segal / the forest and the trees: neighborhood-based clinical social work 5 even social work—despite our unique brand of systemic, contextual thinking—falls prey to the american tendency to polarize ideas, to go to extremes. during my first year of social work graduate school, various debates (concrete services versus individual treatment, ecosystems versus medical model, community organizing versus psychotherapy) shaped my belief that our profession has strayed from its original commitment to social justice, vulnerable populations, and a person-in-environment focus. yet i continued to feel certain that, while i applauded community organizing and case-to-cause advocacy, my talents and interests ultimately lay in casework. that was when the cognitive dissonance set in: is it possible to specialize in clinical social work without abandoning our profession’s mission and values? i began to see that extreme positions preclude possibilities for social work practice that draws upon sophisticated clinical insights and interventions yet remains contextual and empowernment-based. for example, it is hardly useful to demonize the medical model when basic knowledge of psychopathology often sheds light on human behavior. on the other hand, it seems counter-productive to suggest that clients faced with multiple, interacting problems are best served by manualized interventions designed for clinical populations. another polarity: by renouncing casework altogether, proponents of community organizing fail to recognize that “it might be necessary to provide skilled, patient interpersonal help to some families on a long-term basis” (halpern, 1999, p. 244). yet when clinical social workers insist that advocacy and concrete service provision are beyond the scope of therapy, they rarely meet their clients’ needs. during my second year of social work school, i was lucky enough to encounter a community-based family support center that offers a “third tthehe fforestorest andand thethe ttreesrees:: nneighborhoodeighborhood-b-baasedsed cclinicallinical ssocialocial wworkork erin segal social work education gives lip service to systems-based, integrative approaches to practice, yet the profession tends to create unnecessary polarities between clinical practice and social work’s original commitment to vulnerable populations, person-in-environment, and social change. the author describes a model of community-based family services that bridges this gap. columbia university journal of student social work volume 1, number 1 6 space” between polarities (kemp, 2003). like the early settlement houses, the center for family life provides comprehensive, non-stigmatizing, neighborhood-based services: after-school arts programs for children, youth development, summer camp, parent education, an employment center, an advocacy clinic, and a program that meets families’ emergency needs for food, clothing, and financial support. by organizing these components around a core family counseling program, the center also draws on the best of contemporary professional clinical social work, thus attaining a “unique combination of community rootedness and clinical sophistication” (hess, mcgowan & botsko, 2003). instead of placing “bio,” “psycho,” and “social” aspects of clients’ experiences side by side, social workers at the center for family life seek integration, offering students a rich—and rare—representation of systems-based practice that receives so much lip service in social work education. not surprisingly, the clinical program’s focus is not the individual, but the family. by avoiding labels and prescriptive treatments, practitioners acknowledge the uniqueness of each family member and minimize social distance between themselves and families. overwhelmingly, social workers believe that their role is to support and enhance family functioning throughout all phases of development. in refusing to differentiate between therapy and case management, they honor the inextricable connections between environment and psychology and recognize that therapeutic work (for example, modeling or creating a holding environment) often occurs beyond the pale of psychotherapy. caseworkers keep abreast of social justice issues and participate in advocacy efforts undertaken by the agency. unlike therapists in traditional mental health settings, social workers at the center for family life count on in-house resources—therapeutic groups, after-school programs, an emergency food program, and housing subsidies—as they develop individualized treatment plans. this is not to say that counseling at the center for family life survives on service-brokering alone. rather, it remains grounded in professional clinical social work values and methods. all caseworkers hold masters’ degrees in social work. journal articles and descriptions of continuing education circulate freely at casework meetings. staff members are articulate and thoughtful as they discuss their work in terms of object relations, countertransference, the therapeutic alliance, group work theory, cross-cultural issues, and so on. yet interventions are not informed by an over-reliance on a single theoretical perspective; instead, in the spirit of general systems theory, the therapeutic process is flexible and open to creativity (janchill, 1969). such flexibility—along with the horizontal nature of the issues at stake—hardly seems to lend itself to traditional methods of program evaluation, which rely on neat, pre-determined outcomes. nevertheless, a recent evaluation suggests that children and families who take part in the center’s programs do indeed achieve positive changes (hess, mcgowan & botsko, 2003)— a testament to the effectiveness of the center’s staff. i emphasize the accomplishments of center for family life’s casework staff to stress that these frontline workers are creative, thoughtful, competent and kind. to me, it’s quite clear that clinical social work’s identity crisis— call it “psychiatry envy” if you will—is part of a search for legitimacy in the eyes of a society that undervalues our profession. of course social workers choose private practice, policy analysis, and program development over community-based social services—note the differential in salary and prestige! yet unfortunately, our profession’s response to its identity crisis is a retreat to polarities: at one extreme, repudiating the notion that social work should incorporate elements of psychotherapy; at the other, relying all too heavily on managed care’s short-term therapeutic prescriptions for alleviating human suffering. instead of going to extremes, why not revitalize our profession and support our frontline workers by sharing more examples, more stories, and more dialogue about possibilities for operationalizing systems approaches to clinical social work? the center for family life’s flexible, comprehensive model of casework offers a marvelous point of departure. references halpern, r. (1999). fragile families, fragile solutions. new york: columbia university press. hess. p., mcgowan, b., & botsko, m. (2003). nurturing the one, supporting the many: the center for family life in sunset park, brooklyn. new york: columbia university press. janchill, sister m. p. (1969). systems concepts in casework theory and practice. social casework, 50, 74-82. kemp, s. (2003). “preface.” in hess p., mcgowan, b., & botsko, m. nurturing the one, supporting the many: the center for family life in sunset park, brooklyn. new york: columbia university press. erin segal is a second-year ms student at the columbia university school of social work concentrating in clinical practice with families, children and youth. she is currently an intern at center for family life in brooklyn, new york. she holds a ba in american studies from amherst college. segal / the forest and the trees: neighborhood-based clinical social work 7 cameron / a case of trickle-down feminism 21 this spring, the most skilled golfers in the world met at a prestigious golf club in georgia to play in the masters golf tournament. the club, augusta national, does not allow women to be members. recently, the national council of women’s organizations (ncwo) led a public relations campaign to shame the television network that broadcasted the event and the event’s numerous corporate sponsors into pressuring the private club to accept women as members. the ncwo (2003) has declared that these sponsors “sanction sex discrimination” and that “the club has a moral obligation to open its doors to women.” this attempt by the ncwo to break down a gender barrier only reinforces a socio-economic one. there is a waiting list to join augusta national golf club and an undisclosed initiation fee for new members. the ncwo regards augusta national’s policy as a symbol of how women are still denied the opportunity to participate fully in society, and of how men, namely corporate leaders and policy makers, deem this acceptable. i take the ncwo’s initiative as a symbol of the skewed priorities of the feminist movement. this campaign embraces “trickle-down feminism,” the idea that a benefit given to the elite will trickle down the socioeconomic chute to benefit all women. author anna quindlen (2002) uses the term to credit the far-reaching positive effects of feminism in this same manner. i, however, see trickle-down feminism as ineffective. the expectation that feminism will trickle down to benefit all women is unrealistic, and excludes those of lower socioeconomic status. it belies that feminism is not integrated in the lives of most women and must flow downward from the privileged top. this is precisely the problem i have with the ncwo’s campaign against augusta national; its highbrow criticism draws energy and attention from the more appropriate goal of working to earn equality for all members of our a ca caasese ofof ttricklerickle-d-downown ffeminismeminism kari kendall cameron “trickle-down feminism,” a notion that rights and privileges enjoyed by an elite group of women will trickle down and benefit the majority of women, is wholly ineffective in promoting positive social change. it should be replaced by the principles of equalism, a belief in the value and responsibility of all people. social workers, through our professional experience and knowledge of family dynamics, can play a pivotal role in promoting equalism over trickle-down feminism. columbia university journal of student social work volume 1, number 1 22 society. social workers can appreciate the rich heritage of the feminist movement and benefit from its concrete gains. however, the natural evolution of ideas suggests that we become much more than feminists. demanding more social, personal, and political freedom for women to make their own choices is still relevant and necessary and has been a hallmark of feminists’ aims. yet, only one-quarter of women identify themselves as feminists (hymowitz, 2002). perhaps a new designation is necessary: one that is inclusive and captures the essence of the quest for fair opportunities and equitable choices for both sexes, across socioeconomic status. those who acknowledge and respect the importance of equality in our society, as well as support policy initiatives to strengthen it, may call themselves “equalists.” the call for equalism as an alternative to feminism is beginning to gain momentum in popular culture as a means of clarifying the often contradictory and confusing connotations of the term “feminist” (minx, 1999). for those men and women disillusioned by the association of feminism with the practice of trickle-down feminism, the concept of equalism could serve as a unifying remedy. the ncwo’s agenda includes many legislative initiatives that aim to improve the quality of life for millions of americans; however, the attention showered on augusta’s policy has defined the purpose and mission of ncwo for the public at large. it is striking how much media attention the ncwo’s campaign has received and how many of the organization’s resources have been put into it. in business, wise investments generate capital and poor investments set a company back. this is also true with political capital. the ncwo has squandered resources that could be used to advance the rights of members of our society. equalism, rather than the elitist approach of trickle-down feminism, is more in line with a utilitarian approach to facing problems that keep socioeconomic segments of our society separate. attacking a prestigious golf club’s membership policy ultimately benefits only a handful of wealthy women. equalists must protect the underrepresented and underserved. social change drawn from the spirit of equalism reflects an inherent respect for men and women in all segments of society, a level of respect that is already a part of our social work heritage. equalist social workers know the power of labels and language. they resist labeling problems as “women’s” or “men’s.” an equalist social worker acknowledges the common etiology of a problem, draws solutions from men and women, and does not try to address social problems affecting both genders by only looking at half of the equation. mary wollstonecraft (1792), the 18th century feminist philosopher, included in her book, a vindication of the rights of woman, her opinion of cameron / a case of trickle-down feminism 23 national education: “it is not for the benefit of society that a few brilliant men should be brought forward at the expense of the multitude” (p. 168). her view that educational rights should not be limited to a few also applies to the civic and social rights we wish for women to enjoy. our clients will not realize the benefit of a female millionaire playing golf at a private club, yet we are spending precious political capital on this campaign. our future is not at a golf course for the wealthy. in fact i, and many women, want no part of the effort. it simply has no relevance in the lives of most women. in addition to the practice of trickle-down feminism, the pervasive notion of “women’s issues” undercuts the commonality we share as humans. we are discounting our inter-gender relationships and reinforcing a segregated world. by labeling such things as childcare, reproductive health, and welfare as “women’s issues,” we are severing men’s vested interest in these issues and, in effect, absolving men of their roles and responsibilities. social workers know the dynamics and interconnections of male and female members of the family. we see the family in its entire ecosystem, and have a duty to present the integrated nature of problems affecting families we serve. a grieving father, brother, or son facing the loss of his mother, sister, or daughter to breast cancer would not consider it only a “woman’s issue.” men and women are in this society together, and the struggles of one will be felt by the other. trickle-down feminism should be replaced by an agenda that carries the traditions of the trail-blazing feminists who contributed much to our society and touched people of all socio-economic levels. another classic example of trickle-down feminism is the movement to ratify the equal rights amendment. the agenda should instead include a long-run lobbying effort to see the confirmation of supreme court justices who will rightfully interpret “all persons” as written in the 14th amendment of our constitution. according to simon (1994), “social workers’ empowernment is, in part, contingent upon recognition by the public and its officials of the contributions being made to the social whole by members of the profession” (p. 192). as social workers, we are a crucial part of an informed debate, working and witnessing the dynamics of individuals and families in hospitals, public health clinics, foster care agencies, and countless other critical social service organizations. our profession has the knowledge and experience to contribute to social policy instead of once again being sidelined as others dictate the direction of key policies affecting our clients. trickle-down feminism will not perpetuate the changes necessary to advance all members in our society; moreover, it disregards those who are on the front lines of discrimination. social workers in all capacities are critical to the promotion of equalism. allowing women membership in the augusta national golf club will be columbia university journal of student social work volume 1, number 1 24 an easy way out of responsibility for the influential men in the club. they will have offered this symbolic accommodation while continuing the clubby, restrictive culture that permeates too many companies, public agencies, and organizations. they will succeed in placating a few vocal feminists with an empty gesture void of any meaningful social change. feminists would be no less complicit in this sham. real social change cannot be sold for a membership card at a millionaires club. references hymowitz, k. s. (2002). a new feminism? public interest, 149, 116121. minix, m. (1999, october 21) equalism, not feminism. indiana daily student. retrieved april 13, 2002 from the world wide web:http://idsnews.com/news/10199/opinion/102199feminism.html national association of social workers (1996). code of ethics of the national association of social workers. washington, d.c.: nasw. national council of women’s organizations (2003). www.womensorganizations.org quindlen, a. (2002). transcript of speech at women and girl’s third annual grant awards luncheon. fairfield county community foundation, april 10, 2002. simon, b. l. (1994). the empowernment tradition of american social work. new york: columbia university press. wollstonecraft, m. (1996). a vindication of the rights of woman. mineola, ny: dover publications. kari kendall cameron is a second-year ms student at the columbia university school of social work concentrating in clinical practice within the world of work. she is currently an intern at the musician’s assistance program, local 802 afm in new york city. she holds a bs from georgia southern university in education and english. microsoft word understanding female genital cutting in the united kingdom within immigrant communities.docx © 2015 onwu. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. understanding female genital cutting in the united kingdom within immigrant communities christelle n. onwu the age-old tradition of female genital cutting (fgc), most commonly known as female genital mutilation (fgm), is a coming-of-age ritual practiced in some countries in africa, the middle east, asia, and latin america. it is also practiced in the immigrant communities that migrate from these regions to western countries. there are a multitude of physical and mental health issues associated with fgc, including chronic infections, infertility, anxiety and depression, complications during childbirth, and death. in 1985, the united kingdom criminalized the practice of fgc in order to eliminate it. however, evidence suggests that criminalization has been ineffective and that immigrant communities continue to practice fgc without proper medical training and equipment. this paper proposes that replacing criminalization with harm reduction programs will allow policy makers to obtain accurate data on fgc in the uk in order to inform the development of future programs that will ultimately eradicate the practice. introduction he united nations, the world health organization, and other advocacy groups declare that female genital cutting (fgc) is a human rights violation and an act of gender-based violence (world health organization, 2015). many countries support the eradication of fgc, including countries where it is commonly practiced, such as the central african republic, egypt, eritrea, ethiopia, kenya, and uganda. furthermore, eighteen african countries and several western countries, including the united kingdom, france, and canada, criminalize the procedure (human rights watch, 2010). seeking to eliminate a culture’s intergenerational practice can be challenging, especially when it is deeply rooted in the culture’s traditions. the criminalization of fgc in the uk has been ineffective for two primary reasons. first, when fgc is performed in the uk, the procedure is done in private locations without medical personnel, so there is no official documentation (nhs choices, 2014). second, young girls are frequently transported back to their country of origin to have the procedure completed in order to bypass the uk’s criminalization laws (nhs choices, 2014). as a result, evidence of fgc is lacking, making it difficult to prosecute those involved and to obtain accurate numbers of the prevalence of fgc in the uk. over the past decade, an increasing number of africans have fled their countries to seek asylum in the uk, and it is likely that the incidence offgc will rise accordingly (topping, laville, & carson, 2014). in order to fully protect young girls from the physical and psychological ramifications of fgc, it is essential that the uk government reexamines the criminalization of fgc and establishes a more effective policy. to successfully eliminate fgc in the uk, it is necessary for the government to first accurately measure the scope of the issue. this may be achieved by implementing a harm reduction approach that decriminalizes fgc for girls under the age of sixteen. decriminalization will reduce avoidable negative health outcomes associated with the practice and allow victims and those involved in fgc to feel safer discussing their experience without fear of prosecution. obtaining this data will allow researchers and policy makers to collect adequate information and be better equipped to create programs and policies that more effectively address fgc. background information there are three types of fgc that are frequently practiced. type i is a clitoridectomy, during which the clitoris is partially or fully removed; type ii is partial or complete removal of the clitoris and inner labia and may include removal of the labia majora; and type iii is the removal of the external genitalia and the narrowing of the vaginal opening (nhs choices, 2014). while all types of fgc are harmful, types i and ii t © 2015 onwu. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. are considered least invasive. women who undergo type iii are especially at risk of developing health issues (desert flower foundation, 2015). it is estimated that over 20,000 girls in the uk under the age of 15 are at risk of fgc every year (united kingdom government, n.d). girls considered “at risk” are members of communities that practice fgc and are therefore more likely to undergo the procedure. however, these numbers are approximations, as researchers are unable to measure the exact number of women who have undergone fgc in the uk. regardless of the fact that fgc is considered a human rights violation, many cultures continue to perform fgc on girls before they begin menstruation as a symbolic ritual for the entrance into adulthood (chalabi, 2013; althaus, 1997). in the uk, fgc is primarily performed by first generation immigrants and asylum and refugee seekers (nhs choices, 2014). some african immigrants perform fgc to culturally define themselves in contrast to western norms. in certain communities, un-cut women are considered “unclean” and not fit to marry (althaus, 1997). this is a common belief in communities that practice type iii circumcision because a woman is able to demonstrate her virginity (althaus, 1997). moreover, many communities perform fgc to reduce a female’s sexual desire by removing what is considered the most masculine part of female genitalia (the clitoris and labia), which, in turn, is meant to enhance obedience and fertility (althaus, 1997). traditionally, a midwife who has little or no medical training performs fgc. anesthetics and antiseptic treatments are not generally used, and the practice is often carried out with knives, scissors, scalpels, and pieces of glass or razor blades (nhs choices, 2014). all three types of fgc may lead to infections postsurgery, pain during sex, and, in some cases, death (toubia, 1994). type iii can cause chronic pelvic and urinary tract infections that could potentially result in kidney damage, small and large tumors forming along scar tissue, infertility, painful menstruation, and complications during and after childbirth (toubia, 1994). additionally, health problems frequently result from the unsanitary conditions and lack of mental and physical health information provided to women before and after the procedure, as well as from the nature of the procedure itself (toubia, 1994). criminalization of fgc in the united kingdom: has criminalization been effective? although the aim of criminalizing fgc is to protect young girls and ultimately eliminate the practice, the uk has yet to make a conviction despite evidence suggesting that the practice still occurs. one study conducted in september 2014 found that 467 women sought medical treatment in the uk due to complications originating from fgc procedures within a one-month period (vissandjée, denetto, migliardi, & proctor, 2014). over the past decade, the uk has increased its efforts to arrest individuals involved in fgc, including offering a £20,000 reward for information on fgc, hosting fgc helplines, and performing airport searches during summer “cutting seasons” (ridley, 2015). while efforts have been effective in identifying cases for inquiry – with investigations occurring for 41 cases in 2013, compared with 25 in 2012, and 8 in 2011 – the cases lacked evidence for trial (ridley, 2015). mak chishty, the national police commander in charge of investigating fgm in the uk, acknowledged the difficulty in prosecuting fgm cases: “if you haven’t got a compliant victim, or when and where the offence occurred, or any of the complexities we need to prove beyond reasonable doubt, there can be difficulties” (ridley, 2015, p.2). the low conviction rate of those who perform fgc is due in part to the lack of reporting from those who have undergone the procedure, as fgc is frequently performed by friends or relatives of the victims (kern, 2013). the lack of fgc-related arrests and convictions, despite the glaring evidence that fgc is being performed in the uk, suggests that the criminalization of fgc has not been effective. harm reduction as an alternative to criminalization © 2015 onwu. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. harm reduction is an approach that decreases the health risks associated with certain behaviors by promoting safer options if complete abstinence is unattainable (shell-duncan, 2001). over the last decade, harm reduction has gained increasing popularity in the field of public health, especially as a substance abuse intervention. the effectiveness of the harm reduction approach is evident in the needle exchange and drug education programs that emerged in response to the aids epidemic (shell-duncan, 2001). as discussed in strathdee and vlahov (2001), an international comparative study found that cities with needle exchange programs had a 5.8% decrease per year in the incidence of hiv in contrast with a 5.9% yearly increase in the incidence of hiv in cities that did not have established needle exchange programs. similarly, rather than criminalizing fgc, using a less punitive approach to eliminate the practice could prove beneficial. harm reduction and educational outreach programs that are culturally appropriate would likely be more acceptable and influential within immigrant communities. shell-duncan (2001) argues that using medicalization as a harm reduction approach is a more effective way to improve women’s health in instances where eliminating the procedure entirely might not be possible. a harm reduction strategy could reduce risk of medical complications by improving hygienic conditions, providing preventive medical measures, and the skill level of the cutter, subsequently lowering the amount of cutting, and presumably, risk of complications (shell-duncan, 2001). although decriminalization does not align with the zero tolerance policy of fgc adopted by many countries, studies have found that when medical services-using sterilized instruments, anti-tetanus injections, and prophylactic antibiotics-are used during the fgc procedure, negative health outcomes, such as infections, are effectively reduced by as much as 70% (shell-duncan, 2001, p.1019). additionally, research by ruderman (2013) supports the assertion made by shell-duncan (2001) that harm reduction is significant – if not essential – in decreasing medical complications that result from fgc. reducing medical complications saves money and other resources that would otherwise be used on medical treatments incurred by complications from undergoing fgc (ruderman, 2013). thus, decriminalizing the procedure might both increase the safety of women at risk of fgc and save government funds (ruderman, 2013). in addition to helping women at risk of fgc, adopting a harm reduction approach may also reduce the harm experienced by women who have undergone the procedure, as they would be more likely to seek medical treatment when complications arise. studies have shown that women in some regions of sudan hide fgc complications for fear of legal repercussions (shell-duncan, 2001). furthermore, as a result of a rise in infection and health-related complications, indonesia overturned the 2006 ban on fgc, as it forced individuals to perform the procedure in secret, unhygienic conditions (ruderman, 2013). evidence from these case studies suggests that decriminalizing fgc for consenting adults over the age of sixteen in the uk would allow women with complications to seek treatment without fear of punishment. this would both reduce the overall harm experienced by victims of fgc and simultaneously help researchers obtain accurate data on the prevalence of the practice in the uk. a culturally sensitive approach a policy that aims to ultimately eliminate fgc within immigrant communities in the uk must consider culture and tradition. in addition to decriminalizing fgc, the uk should implement educational outreach campaigns to reduce the demand for fgc procedures (vissandjee et al., 2014). in kenya, for example, forums that educate on the risks fgc and encourage collaboration to create alternative coming-of-age rituals proved effective when led by village members (tenoi, 2014). the success of these campaigns relies heavily on ensuring that outreach agents come from within the community and understand the history and cultural meaning of the practice. a similar approach to educational outreach might be effective in immigrant communities in the united kingdom as well. © 2015 onwu. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. a kenyan woman, sarah tenoi, successfully reduced fgc in her community by 20% through the introduction of a new alternative to fgc as a rite of passage (tenoi, 2014). although kenya outlawed fgc, some still practice the procedure, as it is deeply rooted in their cultural values. having been a victim of female circumcision herself, tenoi understood the needs of her village and collaborated with the community to educate them about the dangers of the practice. tenoi’s message was not to change the culture of her fellow men and women, but to alter one aspect of the culture that resulted in negative outcomes for women. she stated: circumcision in maasai culture marks the transition from girlhood to womanhood … to move away from female genital cutting we have developed an alternative rite of passage, in which the girl experiences all the elements of the ceremony but is not cut. (tenoi, 2014, p.2) utilizing tenoi’s success as a model, the uk government could collaborate with women who have undergone fgc to reach out to their communities within the uk. conclusion while it is well documented that serious physical and mental health issues originate from fgc, the practice cannot be eradicated overnight. because the criminalization of fgc in the uk has not been effective and data is not available to accurately analyze the scope of the issue, policy makers must take a different approach. such alternatives include a harm reduction approach that decriminalizes types i and ii while developing outreach programs with members from the community. advocating for decriminalization does not, in principle, align with many human rights documents that condemn gender-based violence and have a zero tolerance policy for fgc. yet with decriminalization and harm reduction, researchers and policy makers will be able to gather accurate information on the prevalence of fgc in the uk, allowing for the creation of policies and programs that utilize actual data as evidence. additionally, to work toward eventual elimination, the uk must establish a culturally sensitive outreach campaign that educates immigrant and refugee communities on the risks of fgc and possible alternatives to the practice. references althaus, f. a. (1997). female circumcision: rite of passage or violation of rights? international family planning perspectives, 23(3), 130-133. retrieved from http://www.guttmacher.org/pubs/journals/2313097.html chalabi, m. (2013, june 24). female genital mutilation: how prevalent is it? the guardian. retrieved from http://www.theguardian.com/news/datablog/2013/jun/24/female-genital-mutilation-prevalence-uk desert flower foundation. (2015). what is fgc? retrieved from http://www.desertflowerfoundation.org/en/what-is-fgm/ human rights watch. (2010). q&a on female genital mutilation. retrieved from http://www.hrw.org/news/2010/06/10/qa-female-genitalmutilation kern, s. (2013, may 9). uk: the crisis of female genital mutilation. retrieved from http://www.gatestoneinstitute.org/3705/uk-female-genital-mutilation nhs choices. (2014). female genital mutilation. retrieved from http://www.nhs.uk/conditions/ femalegenital-mutilation/ pages/introduction.aspx ruderman, r. (2013). female circumcision: the effects of harm reduction policies. michigan journal of public affairs, 10. retrieved from http://mjpa.umich.edu/files/2014/08/2013-ruderman-femalecircumcision.pdf ridley, l. (2014, february 9). fgm trial: why has no-one ever been convicted in britain despite the practice been illegal for 30 years. the huffington post. retrieved from http://www.huffingtonpost.co.uk/2015/02/04/fgm-police-lead-mak-chisty-convictions-charges-evidenceillegal_n_5747672.html shell-duncan, b. (2001). the medicalization of female ‘circumcision’: harm reduction or promotion of a dangerous practice? social science & medicine, 52(7), 1013-1028. doi:10.1016/s0277-9536(00)00208-2 strathdee, s., & vlahov, d. (2001). the effectiveness of needle exchange program: a review of the science and policy. aidscience, 1(16). retrieved from http://aidscience.org/articles/aidscience013.asp toubia, n. (1994). female circumcision as a public health issue. new england journal of medicine, 331(11), 712-716. doi:10.1056/nejm199409153311106 tenoi, s. (2014, february 6). an alternative to female genital mutilation that prevents girls suffering. the guardian. retrieved from http://www.theguardian.com/commentisfree/2014/feb/06/alternative-to-circumcision-prevents-girls-suffering-kenya topping, a., laville, s., & carson, m. (2014, february 6). fgm is banned but very much alive in the uk. the guardian. retrieved from http://www.theguardian.com/ society /2014/feb/06/ female-genital-mutilation-foreign-crime-common-uk united kingdom government. (n.d.). female genital mutilation: the facts. retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/300167/fgm_leaflet_v4.pdf © 2015 onwu. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. vissandjée, b., denetto, s., migliardi, p., & proctor, j. (2014). female genital cutting (fgc) and the ethics of care: community engagement and cultural sensitivity at the interface of migration experiences.” bmc international health and human rights, 14(13). doi:10.1186/1472-698x-14-13. world health organization. (2015). classification of female genital mutilation. retrieved from http://www.who.int/reproductivehealth/topics/fgm/overview/en/ christelle n. onwu is a second year student at columbia university school of social work with a concentration in policy and field of practice in international social welfare for services to refugees and immigrants. she is currently interning at safe passage project at new york law school.   18 | columbia social work review, vol. vii columbia social work review, vol. vii | 19 a narrative inquiry of charter school social work and the “no excuses” behavior model allison balogh neoliberal education reform has resulted in a growing number of charter schools across the country, many of which are concentrated in low-income communities of color (kahlenberg & potter, 2014). charter schools serving these demographics often practice a “no excuses” pedagogy featuring two components: (1) universal, precise behavioral expectations and (2) systematic rewards for compliance and penalties for disobedience (golan, 2015; goodman, 2013; whitman, 2008). this article examines overlooked consequences of the “no excuses” model by presenting a narrative inquiry involving 3 social workers from charter schools in harlem, new york. individual, semi-structured interviews were conducted about professional background, roles and responsibilities, the school community, and the political context of charter schools. the collective narrative that emerged from this framework describes how participants have met their concern that a “no excuses” model creates traumatic or unsupportive environments for marginalized students with evidence-based advocacy. this article serves to foster the community of charter school social workers who wish to critique the “no excuses” model within their schools and on a broader scale. neoliberal education reform and narrative inquiry publicly funded, privately managed charter schools have become a major tool of neoliberal education reform, the system of market-based policies that have increasingly governed america’s public schools in the past several decades (kahlenberg & potter, 2014). shiller (2011) argues that the relationship between charter schools and the marketplace is twofold: they explicitly aim to prepare students for the workforce, and they model their structure on the market itself. in this system, schools are commodities that rely on academic data to prove themselves a worthy choice for parents to send their children. neoliberal reform’s data-driven, academic-focused climate has privileged the voices of educators, policy makers, and business leaders, while devaluing contributions from school social workers. narrative inquiry, the process of collecting and presenting the meaning of personal experiences within a body of research (schwandt, 2007), is a promising methodology for incorporating social workers’ perspectives into the conversation about charter schools. connelly and clandinin (1990) argue that narrative inquiry is frequently used in educational research because stujourn typewritten text © 2016 balogh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 20 | columbia social work review, vol. vii columbia social work review, volume vii | 21 a narrative inquiry of charter school social work and the “no excuses” behavior model balogh educational phenomena are constructed by the personal stories of learners, teachers, and researchers. narrative researchers often shape their reports’ underlying structures around participants’ life experiences, as opposed to a traditional literature review or theoretical paradigm (wiebe, 2009). by leaving the organization and representation of personal stories to the researcher, narrative inquiry capitalizes on their complex, nonlinear, and often contradictory nature (clandinin & connelly, 2000). school social work, carried out through interpersonal relationships that inherently share these characteristics, is particularly suited for narrative study. recruitment convenience sampling was used to recruit social workers from 3 charter schools in harlem, new york, which houses almost 70 percent of charter schools in manhattan (new york city charter school center, 2015). a columbia-affiliated third party facilitated the recruitment of two participants, whose schools will be referred to as metro institute and keystone prep. the researcher independently recruited a third participant, whose school will be referred to as character academy. because of logistical constraints and an initial open-ended framework—which did not call for saturation—data collection concluded after three interviews. methodology at the beginning of each individual interview, social workers were asked to address four topics: professional background, professional roles and responsibilities, the relationship between their school and the community, and the political context of charter schools. the terms “community” and “political context” were left open to each social worker’s interpretation to foster a degree of collaboration between researcher and participant characteristic of narrative inquiry (connelly & clandinin, 1990). the rationale for this structure drew from studies about the diverse roles school social workers embody, including clinician, advocate, and policy practitioner, as well as their responsibility to employ an ecological perspective (constable, 2009; monkman, 2009). the collective narrative on “no excuses” the primary narrative that emerged from this framework describes each participant’s ethical conflict and call to action regarding school practices unsupportive to students receiving counseling, those with diagnosed disabilities, or those who have experienced trauma. in metro institute and character academy, students were expected to constantly sit, speak, walk, or have items arranged on their desk in a specific way that reflected their school’s culture; otherwise they would face disciplinary action. maintaining stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 20 | columbia social work review, vol. vii columbia social work review, volume vii | 21 a narrative inquiry of charter school social work and the “no excuses” behavior model balogh the methodology of narrative inquiry, this article organizes each participant’s stories into a collective chronology (creswell, 2013). before elaborating on individual results, it is worthwhile to contextualize these behavior models. aforementioned behavioral expectations reflect what the literature increasingly refers to as the “no excuses” pedagogy used by a subset of charter schools (kahlenberg & potter, 2014). “no excuses” schools are known for universal and precise behavioral expectations with a system of merits for obedience and punishments for disobedience, an extended school-day and year, a culture of college preparation, a rejection of street culture, very high standardized test scores, and frequent data-driven assessment (golan, 2015; goodman, 2013; whitman, 2008). they are often concentrated in lowincome communities of color, such as harlem, and operate under the notion that poverty is “no excuse” for failing schools (kahlenberg & potter, 2014). part one: ethical conflict the social workers from metro institute and character academy discussed their concerns that universally rigid behavioral expectations unconsciously perpetuate the disenfranchisement of marginalized students, such as students of color, those diagnosed with adhd, or those who have experienced trauma: metro institute: it sickens me sometimes to feel like we replicate something that can bring up something very traumatic for a student of color or a student of trauma. so if you’re a student who has been disenfranchised, felt isolation, felt rejected, not necessarily felt heard for whatever outside reason, and you can come into this school and on some level we replicate that—not on a conscious level, on an unconscious level…i tend to believe because also we get students of color who racially have felt a lot of stuff, that even brings up even more stuff for them…they battle this idea of “i have no voice. why do i have to sit in this damn room for eleven hours? why can’t i operate this particular way?” (personal communication, november 4, 2015). character academy: my training and practice teaches me that the way to support children with certain diagnoses is not aligned with those behavioral expectations…a lot of the children with adhd were repeatedly spending a lot more time in the dean’s office than they were in the classrooms because they were physically unable to meet those expectations without scaffolding “the primary narrative...describes each participant’s ethical conflict and call to action regarding school practices unsupportive to students receiving counseling, those with diagnosed disabilities, or those who have experienced trauma.” 22 | columbia social work review, vol. vii columbia social work review, volume vii | 23 a narrative inquiry of charter school social work and the “no excuses” behavior model balogh them to get there. and it was significantly impacting their self-esteem and i was repeatedly hearing in sessions—and adhd is just one example—that they were bad and couldn’t do good (personal communication, december 9, 2015). the social worker from keystone prep was not concerned about her school’s overall behavior model, which she described as progressive. however, she noted that, with keystone prep entering its first year of standardized testing, recent organizational changes (e.g., a new principal and many new teachers) have shifted staff ’s expectations of counseling to yield fast and specific behavioral results: things are very different this year and i feel it in counseling, when i had a meeting last week and [staff] were like “in two weeks we need to know the progress” (personal communication, november 9, 2015). furthermore, each social worker felt compelled to educate staff about how the needs of students in counseling, surviving trauma, or working with disabilities do not always align with behavioral expectations following a “no excuses” ideology. part two: resolution each participant described her process of negotiating her role and advocating for students, particularly by drawing on evidence-based practices. for example, keystone prep’s social worker has chosen to continue counseling students the way she has in previous years, despite facing direct pressure from staff: suddenly i’m going to act different in counseling and i was like ‘no, you know what you’re doing and you’re very purposeful about what you’re doing.’ so i just do it the way i would do it and just explain to staff it takes time (personal communication, november 9, 2015). character academy’s social worker has taken concrete measures (e.g., organizing professional development and creating staff committees on trauma, crisis management, and adhd) to encourage colleagues to consider differentiating behavioral expectations and support. she stressed the importance of presenting evidence to build a united effort among school leadership. similarly, the social worker at metro institute stated that drawing on resources to educate staff has become a major professional responsibility. she noted the shift in how staff have responded after she adopted an assetbased, skill-building model: having the language to articulate specific things that kids need allowed me to be a part of the conversation…as i began to shift their lens through 22 | columbia social work review, vol. vii columbia social work review, volume vii | 23 a narrative inquiry of charter school social work and the “no excuses” behavior model balogh conversation and getting them to try things because i was trying it, people bought into the fact that, “there may be some benefit to what she’s saying, let me try these things within my classroom” (personal communication, november 4, 2015). supported by evidence-based practices, each social worker found that her training in counseling and work with marginalized students provided her with tools to effectively challenge universal behavioral expectations within her school. discussion and implications as the charter school movement expands, school social workers have an ethical obligation to be critical of any practices that cause harm to students (national association of social workers, 2008). to be most effective, critiques must acknowledge the diversity among charter schools. in continued scholarship, researchers must remain cautious about making “no excuses” synonymous with “charter school”—not all charters use this model (kahlenberg & potter, 2014). there is a limitation with the sample of this study, drawn from charter schools already familiar to the researcher, that yields results relevant to mainstream neoliberal reform. within this study, metro institute and character academy may be characterized as “no excuses” schools, while keystone prep is a noteworthy exception. although keystone prep had routinely differentiated its behavioral expectations and disciplinary measures, it crept closer toward a “no excuses” mentality as state testing accountability concerns grew among staff. the implication of this finding along with the academic success of metro institute, character academy, and other “no excuses” schools suggests a clear link between data-driven academic accountability and rigid behavior models. this relationship does not exist in a vacuum, and further study of its manifestation across socioeconomic and racial contexts is critical. proponents of “no excuses” charters use high standardized test scores to argue that public schools cannot justify citing poverty or systemic racism as causes for failure (kahlenberg & potter, 2014). a data-driven environment makes it easy to assume that universal, unwavering high expectations serve all public school students equally in the face of these traumatizing external forces. however, this study demonstrates that focusing on accountability data alone obscures the exclusion and harm done to students on the margins—those who accumulate disciplinary infractions for not fitting the mold believed to serve their best interests. the social workers from metro institute, character academy, and keystone prep illuminate that these students are often those with diagnosed disabilities and trauma stemming from a host of sources, 24 | columbia social work review, vol. vii columbia social work review, volume vii | 25 a narrative inquiry of charter school social work and the “no excuses” behavior model balogh most significantly poverty and racism. beyond the risk to these students, the ethics of a “no excuses” system even towards those who appear to benefit from it are questionable. whitman (2008) argues that “no excuses” schools demonstrate paternalistic, middleclass values, which is valid on the surface due to their rejection of street culture and emphasis on college. however, golann’s (2015) analysis reveals that interactional skills taught to the middle class, such as self-assertion, independence, negotiating authority, and taking initiative, are absent from “no excuses” schools, which instead emphasize submission to authority, rote behavior, and self-constraint. golann (2015) presents the paradox that “no excuses” schools aim to grant working-class students access to middle-class institutions without cultivating the skills students will need to navigate them. when working-class neighborhoods are synonymous with communities of color, as in the setting for this study, it becomes even more crucial to consider the extent to which a “no excuses” model is enabled by systemic racism. among the few studies that have brought us closer to addressing these concerns by examining everyday life in charter schools (carr, 2013; golan, 2015; seider, 2012; shiller, 2011), even fewer have underscored first-hand accounts from social workers. school social workers are not entirely spared from the accountability concerns that grip teachers and administrators when their work is expected to yield results that serve a “no excuses” model. however, they are additionally accountable to the ethical and moral obligations of the social work profession. when they answer the call to uphold these ethics—like the social workers at metro institute, character academy, and keystone prep have—advocacy for students most vulnerable to marginalization when there are “no excuses” is possible and powerful. references carr, s. (2013). hope against hope: three schools, one city, and the struggle to educate america’s children. new york: bloomsbury press. clandinin, d., & connelly, f (2000). narrative inquiry: experience and story in qualitative research. california: josseybass. connelly, f., & clandinin, d. (1990). stories of experience and narrative inquiry. educational researcher 19(5), 2–14. constable, r. (2009). the role of the school social worker. in c.r. massat, r. constable, s. mcdonald, & j.p. flynn (eds.), school social work: practice, policy and research (pp. 3-29). illinois: lyceum book, inc. creswell, j. (2013). qualitative inquiry & research design: choosing among five approaches. los angeles: sage “when working-class neighborhoods are synonymous with communities of color, as in the setting for this study, it becomes even more crucial to consider the extent to which a ‘no excuses’ model is enabled by systemic racism.” 24 | columbia social work review, vol. vii columbia social work review, volume vii | 25 a narrative inquiry of charter school social work and the “no excuses” behavior model balogh publications. golan, j. (2015). the paradox of success at a no-excuses school. sociology of education 88(2), 103-119. goodman, j. (2013). charter management organizations and the regulated environment: is it worth the price? educational researcher 42(2), 89-96. kahlenberg, r., & potter, h. (2014). a smarter charter: finding what works in charter schools and public education. new york: teacher’s college press. monkman, m.m. (2009). the characteristic focus of the social worker in the public schools. in c.r. massat, r. constable, s. mcdonald, & j.p. flynn (eds.), school social work: practice, policy and research (pp. 3-29). illinois: lyceum book, inc. national association of social workers. (2008). code of ethics of the national association of social workers. washington, dc. nasw press. new york city charter school center. (2015). find charter schools in new york city. retrieved december 20, 2015 from http://www.nyccharterschools.org/school-search. seider, s. (2012). character compass: how powerful school culture can point students toward success. massachusets: harvard university press. schwandt, t. a. (2007). the sage dictionary of qualitative inquiry. thousand oaks: sage publications. shiller, j. (2011) marketing new schools for a new century: an examination of neoliberal school reform in new york city. in kovacs, philip e. (ed.), the gates foundation and the future of u.s. public schools (pp. 53–79). new york: routledge. whitman, d. (2008). an appeal to authority: the new paternalism in urban schools. education next, 8(4), 53–58. wiebe, n. (2009). miriam toews; experience of writing a complicated kindness: implications for how writing can be inquiry in narrative inquiry. (unpublished doctoral dissertation). university of western ontario. allison balogh will be graduating from columbia school of social work in may 2016 with concentrations in advanced generalist practice and programming and school-based services. her primary interest is in the power of transformative education to inspire sustainable social change. she is currently a youth development facilitator at the harlem educational activities fund, where she has helped students cultivate social-emotional skills that support academic success and personal growth. 2018-final.pdf columbia social work review, vol. ix | 45 play therapy and youth experiencing homelessness rachel wiskind youth experiencing homelessness suffer both short-term and longterm negative effects: the rate of mental health problems in the united states (u.s.) seems to be higher for youth experiencing homelessness than for the general population (baggerly, 2004), and twenty percent of adults experiencing homelessness were homeless as children (national coalition for the homeless, 1999). child-centered play therapy (ccpt) has been shown to offer positive short-term effects on self-esteem, developmental delays, and other socio-emotional delays of u.s. youth (leblanc & ritchie, 2001). while ccpt shows promise, the benefits of ccpt for youth experiencing homelessness are underexplored. it is imperative that social workers study the potential longitudinal benefits of ccpt specifically for youth experiencing homelessness so that they can continue to provide the most effective therapies to their clients in the short and long terms. introduction homelessness is an increasingly prevalent social issue in the united states (u.s.). according to the national coalition for the homeless (nch) (2016), in january 2016, over 500,000 individuals experienced homelessness on a single night. between approximately 500,000 and 2.5 million youth experience homelessness in the united states each year (interagency working group on youth programs, 2010). according to the interagency working group on youth programs (2010), youth experiencing homelessness have higher rates of truancy, involvement in the juvenile justice system, sexually transmitted infections (stis), and substance use than the rest of the population. reducing rates of homelessness could benefit society by decreasing rates of incarceration, substance abuse, stis, and other concerns. the pathways to homelessness include declines in availability of public assistance, lack of affordable healthcare, domestic violence, mental illness, addiction, and complex interactions between these issues (baggerly, 2003). when looking at ways to serve this population, child-centered play therapy (ccpt) is an option due to its efficacy with children (leblanc & ritchie, 2001). however, the long-term effects of ccpt on youth experiencing homelessness are not known. can ccpt improve the mental health of youth experiencing homelessness and decrease the likelihood that they will become homeless as adults? as homelessness grows to epidemic proportions in new york city, social workers must look at how they can best help youth experiencing homelessness now to avoid the generational impact of also experiencing homelessness in adulthood (nch, 2016). 46 | columbia social work review, vol. ix play therapy and youth experiencing homelessness current issues regardless of the circumstances, homelessness has many negative effects on children’s mental health, causing deficiencies in self-concept, depression, and anxiety (baggerly, 2004). the lack of research surrounding these issues and youth homelessness as a whole is a disservice to youth experiencing homelessness. twenty percent of homeless adults experienced homelessness as children youth (nch, 1999). current youth experiencing homelessness could potentially benefit from therapies to promote improved mental health and a decrease their likelihood of being homeless as adults. ccpt, one such therapy, has been shown to improve the subject’s perception of their own competence, possibly as a result of ccpt procedures such as encouragement, self-esteem building, and responsibility (baggerly, 2004). competence is key for many forms of achievement in the u.s., including academic, social, and career achievement (bandura, 1977). therefore, social workers and other mental health providers in the u.s. must work to improve a sense of worth and competence in youth experiencing homelessness in order to lay the groundwork for these children to have the tools to grow into adults who are not homeless (baggerly, 2004). according to the national association of social workers (2017) code of ethics, social workers are obligated to commit to their clients and promote their well-being. social workers’ commitment to the welfare of youth experiencing homelessness often means providing short-term therapeutic interventions and working to ensure the youths’ long-term success. thus, further research into long-term efficacy of ccpt as a strategy for working with youth experiencing homelessness is imperative. history by understanding how the u.s. has dealt with youth experiencing homelessness in the past, social workers can work towards more sound programs for these youth in the future. the u.s. has a history of pushing children who are homeless aside and has historically treated them as a burden and a nuisance, to be sent away and dealt with outside of mainstream society (hansan, 2011). as social workers, our obligation is to provide services for youth experiencing homelessness that can help these individuals overcome the stigma of homelessness, work to improve their mental health, and work through trauma. current u.s. homeless policy has roots in the establishment of workhouses. workhouses, based on the 16th and 17th century elizabethan poor laws in england, classified the poor into two categories: the worthy poor and the unworthy poor (the workhouse, 2017). generally, the worthy poor, such as orphans, the handicapped, and the elderly, were considered to be poor through no fault of their own, while the unworthy poor consisted columbia social work review, vol. ix | 47 rachel wiskind of people policymakers and government officials considered at fault for their poverty due to defects of virtue or character (hansan, 2011). children, therefore, were considered worthy, while homeless adults were often considered unworthy (hansan, 2011). workhouses were meant to be places where poor, able-bodied individuals could work and live in a stateor locally-run facility. however, many workhouses ended up housing populations who were unable to work but had no one else to care for them: the sick, disabled, elderly, and youth experiencing homelessness (hansan, 2011).workhouses spread to the u.s. in the 19th century (the workhouse, 2017). in 1935, the u.s. passed the social security act, which decreased the use of workhouses in the u.s. (new world encyclopedia, 2013). instead, separate institutions, including homeless shelters and a more developed foster care system, were formed in the u.s. (new world encyclopedia, 2013). relevance to social work much of the available research on the efficacy of ccpt and youth experiencing homelessness is not generalizable to the entirety of homeless youth populations in the u.s. because of several common study limitations. some studies were conducted with small groups of youth experiencing homelessness all residing in the same community, even the same shelter, or did not have a control group due to ethical concerns (baggerly, 2004; baggerly & jenkins, 2009; muro et al., 2006). for example, in baggerly’s (2004) study, researchers changed the original study design from a comparison between a treatment group that received play therapy and a control group that did not to a design that did not include a control group and instead provided therapy to all study participants because the families moved frequently and the dropout rate of the study was high. since the play therapy services were highly desired by teachers and parents and since researchers had sufficient financial funds to include additional children, they chose to provide therapy for all participants rather than having a control group and excluding some children (baggerly, 2004). baggerly & jenkins (2009) experienced similar design challenges, including a shorterthan-anticipated therapy duration and lack of a valid control group due to participant recidivism. however, these research findings can still offer some insight into providing services for youth experiencing homelessness, even if they are not generalizable to the population as a whole, because findings still showed improvements for those receiving treatment (rubin & babbie, 2017). greater research into this subject would increase researchers’ and mental health providers’ knowledge about the long-term benefits of ccpt, as well as the effects of ccpt on larger and different populations than just youth experiencing homelessness. conversely, failing to research further into this area could negatively affect macro-level social work 48 | columbia social work review, vol. ix play therapy and youth experiencing homelessness because future policy would be blind to potentially beneficial treatments, and unresearched treatments might not be funded on a larger scale. many programs in schools, shelters, and community-based organizations attempt to serve homeless populations and communities by supporting individuals experiencing homelessness, healthcare, food security, job training, and other vital services. social workers who are better informed about the efficacy of interventions can streamline these programs to provide more effective and equitable support to this vulnerable population. theory ccpt falls under the umbrella of experiential play therapy in that it uses the principles of dynamic and somatic experience, but it is conducted through a child-led model (baggerly, 2003). experiential play therapy theory is based on the belief that children interact with the world experientially rather than cognitively (schaefer & kaduson, 2006). instead of thinking about what they encounter, children use their senses to take in information. as children develop and continue to move through the world, these experiences serve to create a developmental framework that is used to interpret future encounters. one tenet of this theory is that experiential play therapy can be used to help children resolve trauma (schaefer & kaduson, 2006). this aspect of the theory is of particular interest to the research question at hand. experiential play therapy allows children to work through trauma, the memory of which is a somatic experience, by giving them the ability to move around and use their bodies (schaefer & kaduson, 2006). play therapy can help youth experiencing homelessness to work through trauma and regain a sense of safety, dignity, and control; further research is necessary to apply this therapy to this specific population and determine the positive effects. in teaching to transgress, bell hooks (1994) reminds the reader that “theory is not inherently healing, liberatory, or revolutionary” (hooks, 1994, p. 61). it is not enough for researchers and practitioners to consider and write about experiential play therapy theory as potentially healing for youth experiencing homelessness. social workers must continue to do the work of asking questions and searching for answers, but it is equally important to take what knowledge they do have and apply it to populations they serve, while continuing to name “play therapy can help youth experiencing homelessness to work through trauma and regain a sense of safety, dignity, and control.” “there is much more to learn about its efficacy and potential long-term effects on improving mental health and reducing the likelihood that youth experiencing homelessness become homeless adults.” columbia social work review, vol. ix | 49 rachel wiskind injustices and using that knowledge to fight them. it is imperative that social workers and other professionals working to serve the population of youth experiencing homelessness in new york city continue to explore ccpt. there is much more to learn about its efficacy and potential longterm effects on improving mental health and reducing the likelihood that youth experiencing homelessness become homeless adults. literature review youth experiencing homelessness face greater problems, most notably in school, than children who are appropriately domiciled—whose housing is fixed, regular, and adequate (mckinney-vento homeless assistance act, 1987; baggerly, 2004). according to baggerly (2004), youth experiencing homelessness seem to experience mental health problems at a higher rate than the rest of the general population. baggerly (2003) also noted that youth experiencing homelessness experience psychological, social, and emotional difficulties due to their greater exposure to stressful life events. due to the greater incidence of mental health problems among youth experiencing homelessness, more attention must be paid to this specific population in order to improve their well-being and life achievement through the implementation of targeted services and interventions. further research into the benefits of ccpt for youth experiencing homelessness in new york city can help inform future play therapy interventions for improving emotional health in members of this population. it is important to consider the efficacy of play therapy generally before applying it to populations of youth experiencing homelessness. in 2001, leblanc & ritchie completed a meta-analysis of play therapy outcomes. overall, the study concludes that, compared to non-play therapies, ccpt seems to be equally effective with children. leblanc & ritchie (2001) point out that ccpt has become widely accepted for use with children who are struggling with developmental delays, abuse, and other socio-emotional issues. youth experiencing homelessness frequently experience these issues as well as other psychological, social, and emotional difficulties (baggerly, 2003). since ccpt is just as effective as non-play therapies, it is a useful alternative for children who do not respond to talk-oriented therapy, including children who have experienced trauma (leblanc & ritchie, 2001). leblanc and ritchie (2001) consider abuse and behavioral difficulties in general but do not specifically discuss youth experiencing “due to the greater incidence of mental health problems among youth experiencing homelessness, more attention must be paid to this specific population in order to improve their well-being and life achievement through the implementation of targeted services and interventions.” 50 | columbia social work review, vol. ix play therapy and youth experiencing homelessness homelessness and the potential benefits ccpt can offer this population. nevertheless, play therapy has potential use for youth experiencing homelessness, as youth experiencing homelessness may often display many of the behaviors stated above. there is some conversation in the literature regarding the potential cognitive and behavioral deficits in youth experiencing homelessness as a result of life circumstances and the efficacy of various therapies to combat such negative effects. two studies by baggerly (2004, 2009) address play therapy efficacy in youth experiencing homelessness. several articles address play therapy outcomes in general, sibling play therapy with homeless children, and play therapy with homeless children (hunter, 1993; leblanc & ritchie, 2001; baggerly, 2003). baggerly’s (2004) first study measured the effects of child-centered group play therapy on self-concept, depression, and anxiety in 42 children who resided at a homeless shelter. compared to the general population, researchers found that youth experiencing homelessness suffered from higher rates of mental health problems (baggerly, 2004). they also found that group play therapy appeared to have positive effects on the children’s self-concept, depression, and anxiety (baggerly, 2004). researchers acknowledged that there is a need to continue to examine how effective, if at all, play therapy can be in helping to improve behavior and academic progress among youth experiencing homelessness (baggerly, 2004). baggerly (2003) details the mental health impact of homelessness and the prevalence and causes of homelessness in order to help the reader develop an understanding of play therapy with youth experiencing homelessness. baggerly (2003) makes two conclusions: that there is a great need for play therapists to work with youth experiencing homelessness in addition to other clients, and that it is imperative that practitioners conduct more research on the topic of play therapy and youth experiencing homelessness. in 2009, baggerly conducted another study that examined the efficacy of ccpt on classroom learning processes. researchers found that youth experiencing homelessness who received this therapy showed an improved ability to internalize controls and otherwise succeed in the classroom (baggerly, 2009). both of these studies show potential positive applications of ccpt for youth experiencing homelessness and their mental health, but leave room for future study on long-term positive effects for youth experiencing homelessness. an article by muro, ray, schottelkorb, smith, and blanco (2006) examines the effects of long-term ccpt, but by the researchers’ definition, long-term was considered to be 32 sessions of ccpt in one school year. muro et al. (2006) found that 32 weeks of ccpt for their sample of 23 children ages pre-kindergarten through 5th grade did serve to significantly improve behavior and the child-teacher relationship. these results are promising for the positive effects of ccpt. however, this article does not discuss youth experiencing homelessness and their specific social, columbia social work review, vol. ix | 51 rachel wiskind emotional, and behavioral needs. not only that, but there is room in the empirical conversation for research around the effects of ccpt far into the future, such as positive outcomes in middle school, high school, and adulthood. while play therapy and partuclarly ccpt have been studied, it is necessary for more extensive research to specifically and longitudinally measure the benefits of ccpt for youth experiencing homelessness, months and years after the therapy is received. previous research indicates that youth experiencing homelessness suffer from mental health problems and that ccpt can help with mental and emotional health and behavioral deficits in general (baggerly, 2003; leblanc & ritchie, 2001). other research has shown some positive effects of long-term ccpt, but longterm for muro et al. (2006) was operationalized as 32 weeks of therapy, and that long-term therapy was not conducted with youth experiencing homelessness. it is important for future research to focus on the benefits of ccpt for years after the therapy is conducted to follow up on the youth who receive the therapy to see if benefits for their mental health remain past 32 weeks. in addition, youth experiencing homelessness have specific needs when it comes to their mental health and dealing with trauma (baggerly, 2003). therefore, it is imperative to examine the effects of ccpt for youth experiencing homelessness and not assume that therapies that work for the general population will also work for youth experiencing homelessness. finally, no studies were located that examine the effect ccpt can have on whether youth experiencing homelessness are also homeless as adults – the future research must look at this specific long-term effect of ccpt for youth experiencing homelessness. since 20% of adults experiencing homelessness were homeless as children (nch, 1999), researchers must examine if interventions such as ccpt can have an impact on decreasing this number and helping youth experiencing homelessness to avoid homelessness in years to come. ethics the national association of social workers code of ethics mandates that social workers practice the most effective therapies for the vulnerable populations they serve. by becoming competent in new therapies for targeted populations that have the potential to be effective, social workers can implement the most successful and beneficial therapies available to intervene effectively in the lives of youth experiencing homelessness. in order to improve their mental health in the short-term and decrease their chances of experiencing homelessness as adults in the long-term, it is ethically imperative to research these options further. while youth homelessness impacts affected youth and their loved ones, the lack of research about therapeutic techniques for this population is also a problem for social work practitioners who wish to implement programs to assist 52 | columbia social work review, vol. ix play therapy and youth experiencing homelessness youth experiencing homelessness but have limited knowledge regarding the efficacy of different interventions. central to the practice of social work is the obligation to practice within areas of competence and to work to enhance professional knowledge when it is lacking (code of ethics, 2017). further research is necessary so that practitioners can be competent in potentially effective therapies for youth experiencing homelessness and work in an ethical way. conclusion a longitudinal panel study would be the best approach for future research. according to rubin and babbie (2017), longitudinal studies are the best option for observing processes over time. panel studies observe the same set of people over time, which allows researchers to obtain the most comprehensive data on changes within individuals in that group over time (rubin & babbie, 2017). there are two main disadvantages of longitudinal panel studies that could affect future research: lack of resources and panel attrition. longitudinal studies require a great deal of money and time on the part of researchers, which make these types of studies difficult to carry out. secondly, panel attrition, when people who participated in the beginning of a study drop out or otherwise do not participate in the later stages, is especially common in studies with homeless populations, as these individuals tend to move around frequently, making follow-up more difficult. despite these challenges, a longitudinal panel study is best in order to carry out future research on ccpt and youth experiencing homelessness and follow up with youth experiencing homelessness who participate in ccpt to check in on their mental health and living situations in the future. future research should examine ccpt’s efficacy in both improving the mental health of youth experiencing homelessness and in decreasing the likelihood that the youth experience homelessness as adults. despite potential challenges and concerns, a longitudinal study is the best way to examine the long-term effects of ccpt on mental health among youth experiencing homelessness, as well as the potential that ccpt may have in helping youth experiencing homelessness to be adequately domiciled as adults. columbia social work review, vol. ix | 53 rachel wiskind references baggerly, j. (2003). child-centered play therapy with children who are homeless: perspective and procedures. international journal of play therapy, 12(2), 87-106. baggerly, j. (2004). the effects of child-centered group play therapy on selfconcept, depression, and anxiety of children who are homeless. international journal of play therapy, 13(2), 31-51. baggerly, j., & jenkins, w. w. (2009). the effectiveness of child-centered play therapy on developmental and diagnostic factors in children who are homeless. international journal of play therapy, 18(1), 45-55. bandura, a. (1977). self-efficacy: toward a unifying theory of behavior change. psychological review, 84(2), 191-215. hansan, j.e. (2011). poor relief in early america. retrieved from https:// socialwelfare.library.vcu.edu/programs/poor-relief-early-amer hooks, b. (1994). teaching to transgress: education as the practice of freedom. routledge: ny. hunter, l. b. (1993). sibling play therapy with homeless children: an opportunity in the crisis. child welfare: journal of policy, practice, and program, 72(1), 65-75. interagency working group on youth programs. (2010). homelessness and runaway. retrieved from https://youth.gov/youth-topics/runaway-andhomeless-youth leblanc, m., & ritchie, m. (2001). a meta-analysis of play therapy outcomes. counselling psychology quarterly, 14(2), 149-163. mckinney-vento homeless assistance act. 42 u.s.c. § 1103 et seq. (1987). muro, j., ray, d., schottelkorb, a., smith, m. r., & blanco, p. j. (2006). quantitative analysis of long-term child-centered play therapy. international journal of play therapy, 15(2), 35-58. national association of social workers. (2017). nasw code of ethics. washington, dc: nasw. national coalition for the homeless. (1999). who is homeless? nch fact sheet #2. retrieved october 4, 2017 from http://www.nationalhomeless.org/facts. html national coalition for the homeless. (2016). homelessness in america. retrieved from http://nationalhomeless.org/about-homelessness new world encyclopedia. (2013). workhouse. retrieved from http://www. newworldencyclopedia.org/entry/workhouse rubin, a. & babbie, e. r. (2017). research methods for social work. boston, ma: cengage. schaefer, c. e. & kaduson, h. g. (2006). contemporary play therapy: theory, research, and practice. new york, ny: guildford press. the workhouse: the story of an institution. (2017). introduction. retrieved from http://www.workhouses.org.uk/intro 54 | columbia social work review, vol. ix play therapy and youth experiencing homelessness rachel wiskind is a first year masters of science in social work student at columbia school of social work (cssw). rachel’s current field placement is at community school 44, an elementary school in the bronx, where her responsibilities include supporting students and families who live in temporary housing with counseling, behavioral supports, faculty training, and connection to resources. before attending cssw, rachel worked as the director of youth engagement at a large reform synagogue where she ran an informal youth program for 300+ youth from kindergarten through 12th grade and their families. rachel is from new york and earned her b.s. in psychology at tufts university in medford, massachusetts. 10 | columbia social work review, vol. vii columbia social work review, vol. vii | 11 over the last decade, the visibility of lgbt (lesbian, gay, bisexual, and transgender) families has multiplied greatly, and these families have begun gaining acceptance within american society. compared with even 10 years prior, the number of organizations dedicated to advancing legal protections for lgbt families, producing teacher trainings about lgbt families, including more inclusive language on parental consent forms in school, and even increasing the number of children’s books centering on lgbt families have climbed dramatically. yet, despite the new attention lgbt families have received, an evident hierarchy has emerged with regard to which members of lgbt families are discussed most frequently by researchers and in the media. there have been extensive research studies and publications that address same-sex parenting, including topics of adoption, donor insemination, surrogacy, same-sex stepfamilies, and coming out to your children (goldberg, moyer, weber, & shapiro, 2013; bergman, rubio, green, & padron, 2010; lynch, 2005; vanfraussen, ponjaert-kristoffersen, & brewaeys, 2003; lynch & murray, 2000). families with transgender parents have not received this high level of attention, and far fewer research inquiries have been conducted in this area. yet, of particular importance for this paper is the lack of acknowledgement of the experiences, realities, and identities of those who were raised in lgbt-parented households. as a result of the shortage of research about this population, there is little knowledge about this group proliferating outside of peer communities of those raised in lgbt families. in particular, clinicians are often not presented with information about this population and aspects to consider when working queerspawn on the couch: a guide for clinicians working with youth and adults with lgbt parents megan mcknight support for lgbtq families is on the rise and many research studies have been published proving that children with lgbtq parents fare just as well as children raised by heterosexual, cisgender parents. however, despite the growing acceptance of lgbtq families, much of the literature and many community resources have only focused on the parents. we still know very little about the experiences and development of queerspawn. in particular, many are unfamiliar with the kinds of support queerspawn need, the language they may use to speak about their identity/ies, and their unique relationship to queerness and queer community. the culmination of this paper includes clinical recommendations for providers to consider when working in clinical settings with queerspawn. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text © 2016 mcknight. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 12 | columbia social work review, vol. vii columbia social work review, volume vii | 13 queerspawn on the couch mcknight with these clients. this paper seeks to begin filling that gap by outlining recommendations and considerations for clinicians working with youth or adults raised by one or more lgbt parents. literature review although relatively new, there are multiple terms employed among those with lgbt parents to identify themselves within their communities and to create a way to discuss their social positionality and identities. “queerspawn” is a term used by many members of this community to not only speak to their identity as children with lgbt parents, but to also claim a space within the larger lgbt community (fitzgerald, 2010). the term “colager” is also used as an identifier, particularly among those involved with colage, the only national organization for youth and adults with lgbt parents (fitzgerald, 2010). in addition, “bothie” and “ 2nd gen” are used to mark subset identities within the queerspawn community. “bothie” refers to someone who was born into a heterosexual relationship in which the parents later both came out as lgbt or applies to instances in which lgbt people came together to create their own families, such as a lesbian couple and a gay male friend who decide to conceive together (kuvalanka & goldberg, 2009). those who identify as “2nd gen” are queerspawn who are lesbian, gay, bisexual, transgender, or queer themselves (kuvalanka & goldberg, 2009). some queerspawn with transgender parents also use the abbreviation “kot,” meaning “kids of trans” (colage, 2008). unfortunately, the bulk of literature about children with lgbt parents has been organized around the idea of “proving” that children raised in same-sex households are no different than children raised in heterosexual households, and that being raised in lgbt families does not negatively affect the wellbeing of these children (bos, gartrell, peyser, & van balen, 2008; lick, tornello, riskind, schmidt, & patterson, 2012; marks, 2012). studies have also sought to show that children with lgbt parents are not more prone to identify as gay themselves (marks, 2012). the use of this narrow scope to understand children in lgbt families is a direct reaction to assertions and previous flawed studies from conservatives suggesting that same-sex couples and trans people should not be allowed to parent (clarke, 2001). this debate has shown up in many research studies in the last 25 “this narrow scope is actually harming lgbt families by determining one’s right to parent based on the successes of one’s children and continues to measure the ‘wellbeing’ of queerspawn by heteronormative standards and norms.” stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 12 | columbia social work review, vol. vii columbia social work review, volume vii | 13 queerspawn on the couch mcknight years and recordable studies continue to show that children raised in lgbt families fare as well as children raised by heterosexual parents. although studies like these were needed in the past to shift public opinion, that time has passed. now, this narrow scope is actually harming lgbt families by determining one’s right to parent based on the successes of their children and measuring the “wellbeing” of queerspawn by heteronormative standards and norms. this has left many issues pertaining to children of lgbt parents unexamined and has allowed little room for queerspawn of all ages to voice their experiences and views of being raised in nontraditional families. more recently, a few studies have surfaced that address more nuanced and real experiences of children with lgbt parents. research looking into the experiences of queerspawn in schools have found that these children often face heightened stigma in classroom environments due to homophobic and transphobic beliefs held by teachers, staff, and other parents (kosciw, diaz, glsen, colage, & family equality council, 2008; lindsay, perlesz, brown, mcnair, de vaus, & pitts, 2006). a lack of inclusion of alternative family structures in curriculums was also noted. queerspawn who were taught such curriculums were found to be more withdrawn or aggressive than those who had inclusive curriculums (kosciw et al, 2008; lindsay et al, 2006). shifting the focus to adolescent experiences, researchers have examined what it is like for adolescents to grow up in lgbt families and how they develop their gender identity and sexual orientation slightly different from most children raised in homes in which both parents are heterosexual and cisgender (davis, 2014; welsh, 2011; istar, 2010). this is due to the decentralizing of heteronormativity and cisnormativity, thus allowing for less rigid gender expectations and opening up the possibility of sexual expression (davis, 2014; istar, 2010). although the literature on queerspawn development is already extremely limited, studies that address adults with lgbt parents are even less common (bourdon, 2013; hart, 2005). these individuals have a unique positionality in society, given their potential to “border-walk” two opposing cultural realities (bourdon, 2013; goldberg, kinkler, richardson, & downing, 2012; goldberg, 2007). now, one may say that lgbt-identified people must also walk the border of queer culture and the dominant, heterosexual culture. however, heterosexual adults with lgbt parents are often raised in the queer community and learn about society through a queer lens first, and then are exposed to the heterosexual culture and its norms later in life.(goldberg et al., 2012; goldberg, 2007). however, unlike someone who is catholic, grows up immersed in catholic traditions and culture, and has the option to still identify as catholic once he or she is an adult, heterosexuals raised in 14 | columbia social work review, vol. vii columbia social work review, volume vii | 15 queerspawn on the couch mcknight queer culture are often unable to access queer space and cultural traditions once in adulthood, even though this community may be a large part of their cultural identity. this type of exclusion is often due to a lack of knowledge in the queer community about queerspawn identity and relations to queerness, particularly in adulthood. thus, heterosexual queerspawn are not seen as queer and are considered either allies or outsiders. to combat this erasure of cultural identity or the “cultural homelessness” experienced by heterosexual adults who were raised in lgbt families, many use the term queerspawn, as well as “culturally queer,” to describe their experience and relationship to this piece of their identity (fitzgerald, 2010). clinical considerations and recommendations as clinicians, it is critical that we develop a level of competency for working with clients from a multitude of backgrounds, identities, and cultures. given that there is not much literature yet on doing clinical work with queerspawn, the hope is that this guide will bring more attention to the importance of understanding this community’s needs. ask them how they identify and validate those identities as with any client, it is important not to assume you know how someone identifies. one must ask how clients identify themselves and how they would like you, as the clinician, to address them. as mentioned earlier, the queerspawn community has a subcultural set of language with which a client may identify, so it is important to understand the terminology. it is equally important to validate this identity, as queerspawn identities are rarely acknowledged and validated in broader society. in addition, many people with lgbt parents may come into your office or attend a group you are facilitating without ever having been exposed to the existence of this terminology and the establishment of any type of collective identity to speak to their experience. it may be helpful to explore this with them in therapy and allow them to “try on” the language and meanings for themselves. acknowledge culture and connections to the queer community many queerspawn articulate a strong affiliation and connection to the queer community, regardless of their own sexual orientation or gender identity. (some of the personal struggles associated with this were mentioned “to combat this erasure of cultural identity or the ‘cultural homelessness’ experienced by heterosexual adults who were raised in lgbt families, many utilize the term queerspawn, as well as ‘culturally queer,’ to describe their experience and relationship to this piece of their identity.” 14 | columbia social work review, vol. vii columbia social work review, volume vii | 15 queerspawn on the couch mcknight above.) it is necessary to allow queerspawn space to discuss in what ways they may experience a sense of bicultural identity, exclusion from queer spaces where they feel most at home and accepted, denial of their cultural identity in adulthood, or their struggles with identifying within the dominant, heterosexual culture. a goal with a client who articulates feelings such as these may be to work on developing a sense of understanding about this bicultural identity, how to discuss it with others (particularly partners) who often do not understand the role of queer culture and traditions in their lives, and how to work through or cope with their feelings surrounding exclusion or isolation. ask how their parents identify and how they refer to their parents do not assume you know the identity of a client’s parent. it is still significant to ask clients how each of their parents identifies and if they have more than two people whom they consider parents. also inquire as to how clients refer to their parents, as there are all sorts of terms that queerspawn may use. in addition, ask what pronouns to use when referring to their parents. this is necessary because although a client may be talking about their father, one should not assume that he/him/his pronouns are appropriate to use when discussing the client’s father. for example, the client may still refer to a father who uses she/her/hers pronouns as “dad.” become educated on the impact of being raised by lgbt parents across one’s life course like any other client, the onus of describing one’s identity and culture should not lie solely on the shoulders of the client. clinicians need to take it upon themselves to become familiar with the experiences of those raised in lgbt families. this includes being knowledgeable about the multitude of ways lgbt families are formed (donor insemination, adoption, foster care, a prior heterosexual relationship, surrogacy, etc.) and the possible clinical implications for each. it also includes an understanding of implications and experiences of queerspawn in schools, particularly during different eras. clinicians should reflect on ways clients may have had to hide their family’s identity, difficulties they experienced “coming out” about their families in school, in their communities, and in their relationships, and how they were affected by heterosexism, cissexism, and discrimination. additionally, clinicians should explore what is it like for queerspawn to transition to adulthood, how their intimate relationships are affected by their identity, how they identify with their queer upbringing, and how they talk to their own children about love and relationships. the questions go on, but they 16 | columbia social work review, vol. vii columbia social work review, volume vii | 17 queerspawn on the couch mcknight make the point that these are areas that clinicians should be researching and coming to understand when working with queerspawn. create outlets for personal narratives to be shared queerspawn are often denied the opportunity to speak for themselves and share their stories and truths, particularly for the many queerspawn whose stories do not align perfectly with the dominant, liberal, and political discourse about queer families. thus, clinicians should think about working with queerspawn on articulating their stories and developing their own voice outside of the narratives they are told about themselves. narrative therapy and creative therapies, such as art and drama therapy, offer modes through which queerspawn can begin to share their narratives. pay attention to silence for queerspawn, there are particular areas in which silence is prevalent and often used to cope. first, do not assume because a client identifies as 2nd gen that they are out to their parents. despite their parent being lgbt, the client may still experience anxiety and pressure causing them to stay closeted. this is often because there is a fear shared by many 2nd gen queerspawn that by being lgbt, they are letting down their parents and community (davis, 2014). one of the biggest fears that those who oppose lgbt parenting voice is that lgbt parents will raise gay and trans children. thus, organizations lobbying for legal protections for and increased visibility of lgbt families tend to counter this assertion by citing statistics that children of lgbt parents are no more likely to be lgbt themselves than those raised in non-lgbt households. however, it is important to consider the impact of this discourse on queerspawns’ comfort or level of social acceptance if they come out as lesbian, gay, bisexual, transgender, or queer. questions to think about: are there fears about the impact of this identity on the perception of their family in their community? what does it mean for their family and the larger community if they do not produce a heterosexual, cisgender child? how does this identity impact the struggle for lgbt family rights at large? why may their truth be stifled within and outside of queer community? similarly, because of the increasingly positive state of public opinion about lgbt parents, abuse in these homes is also often silenced. queerspawn are aware of the possible implications of reporting such behavior reaching far beyond the borders of their own family. even adult queerspawn struggle with telling people that they were abused in any way by their parents. the fear is that sharing may reflect negatively upon all lgbt parents rather than just their parents. even within queerspawn communities, sometimes these 16 | columbia social work review, vol. vii columbia social work review, volume vii | 17 queerspawn on the couch mcknight individuals feel silenced because they may not celebrate or express pride in their family in the way others do. “parentification,” a child’s embodiment of taking on pain or baggage for their parents, is another struggle many young queerspawn experience (fitzgerald, 2010). many queerspawn often keep instances of bullying or discrimination they have experienced in school, in a community group, or from relatives a secret from their parents. they do this as a way of protecting their parents and, in this way, are taking on the parental role of protection. they do not want their parents to blame themselves for the negative experiences they have had navigating a heteronormative society as queerspawn. the effects of this behavior are also worth exploring in therapy. conclusion it is time to move past solely focusing on parents when discussing lgbt families and stop producing studies “proving” child wellbeing to appease conservatives who preach about protecting children from lgbt parents. there was an appropriate time for these studies, but now we need to move forward and begin addressing queerspawn as a community and understanding their unique positionality. it is time to acknowledge how homophobia and transphobia in our society also harm queerspawn, no matter how they may identify. it is time to pay more attention to the truths of queerspawn. specifically, clinicians have the ability to practice this by being open to explore queerspawn identity and how queerspawn view the impact of being raised by lgbt parents. as a first step, clinicians need to educate themselves and learn how to create space for these clients to be heard. references bergman, k., rubio, r. j., green, r., & padron, e. 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(january 01, 2006). stigma or respect: lesbian-parented families negotiating school settings. sociology, 40(6), 1059-1077. lynch, j. m. (2005). becoming a stepparent in gay/lesbian stepfamilies. journal of homosexuality, 48(2), 45-60. lynch, j. m., & murray, k. (2000). for the love of the children: the coming out process for lesbian and gay parents and stepparents. journal of homosexuality, 39(1), 1-24. marks, l. (july 01, 2012). same-sex parenting and children’s outcomes: a closer examination of the american psychological association’s brief on lesbian and gay parenting. social science research, 41(4), 735-751. welsh, m. g. (january 01, 2011). growing up in a same-sex parented family: the adolescent voice of experience. journal of glbt family studies, 7, 49-71. vanfraussen, k., ponjaert-kristoffersen, i., & brewaeys, a. (2003, january). family functioning in lesbian families created by donor insemination. american journal of orthopsychiatry, 73(1), 78-90. megan mcknight is a midwestern transplant living in new york city. she is completing her masters in social work at columbia university and has a bachelor of arts in sociology from depaul university where she also triple-minored in lgbtq studies, women’s and gender studies, and peace, justice, and conflict studies. megan has significant work history supporting lgbtq families and youth in university, community center, and social service settings. how megan conducts her work is greatly informed by her identity as 2nd gen queerspawn, and she dedicates much of her work to creating space for queerspawn inside and outside of the lgbtq community. columbia social work review, vol. viii | 1 the unintended effect in mandatory reporting laws and an increased risk to a protected population stephen johnston insufficient definitions within new york state’s mandatory reporting laws have created a “legal-ethical feedback loop” (johnston, 2015) that can cause an increase in potential victims through the exclusion of certain persons seeking treatment. these non-offending individuals seeking treatment for pedophilia can become subjects of investigations by child protective services because of ambiguous language in the laws, wherein their treatment is jeopardized. this paper will examine how the langue of current new york statutes creates a propensity for over-reporting possible abuse cases when they are unfounded, and potentially risks increasing the number of sexual abuse victims because of a lack of access to or trust in licensed clinicians. this paper proposes several alternatives to closing this “feedback loop” and thereby further protecting one of new york’s most vulnerable populations: children. introduction the state of new york has not always been known as a progressive state, but evidence of its forward thinking can be found decades ago. with the passage of the new york state child protection act in 1973, new york solidified the need to have an official role in the prevention and investigation of child abuse. it was a year later that the federal government passed its own similar law, the child abuse prevention and treatment act of 1974 (42 u.s.c. §5101), requiring states to do as new york and many others already had in legislation. in fact, the need for the protection of children from abuse was so great that most states had already enacted similar legislation by 1967 (myers, 2008, p.456). the new york child protection act (n.y. s.o.s. §411) provided licensed professionals, such as therapists, physicians, and social workers a legal route to breaking confidentiality when there were cases of suspected child abuse occurring, knowledge of which was obtained through communications that were regarded as confidential. the law extends the same privilege to laypersons (unor non-licensed caregivers) concerned with the care of children, such as school teachers and even day care volunteers. social problem addressed by the policy prior to the twentieth century, the extent and severity of child abuse is not easily measured because the collected data showcasing the prevalence of child abuse are sporadic, at best. however, there are several sources that depict the prevalence of child abuse, specifically the sexual abuse of minors. according to mintz (2012) in new york city, between 1790 and 1886, “a third and a half of rape victims were under the age of 19.” in 1894, the most common form of sexual abuse was the “rape of children” (hamilton & godkin, 1894). following events in new york city regarding abused children and the government’s inability or refusal to protect them, the new york society for the prevention of cruelty to children (nyspcc) was formed (myers, 2008, p.451). it is interesting to note that the nyspcc was formed, in part, by the founder of the similarly-named american society for the prevention of cruelty to animals. that a society that was established to protect animals was created before one to protect children speaks to not only how removed the issue of child abuse was to the public, but also to how dire the need for nyspcc was at the time. many other events transpired between the formation of the nyspcc and 1962 that shifted the public’s attention to the issue of child abuse, but it was in that year that what has been described as the “seminal” work addressing the abuse of children was published (gelles, 1996; melton, 2005; myers, 2008). the battered-child syndrome (kempe, silverman, steele, droegemueller, & silver, 1962) brought attention to the common signs and symptoms of children being physically and sexually abused, as seen by medical professionals, to the public. the work of kempe et al. (1962) and his pediatrician colleagues were the catalyst for starting the trend across the nation (at the state level) for passing legislation forming child protective services and mandatory reporting laws that required professionals and laypersons alike to report cases of child abuse. while an in-depth literature review on child abuse is beyond the scope of this paper, there are several known factors that lead up to and contribute to the abuse of children. it is worth mentioning that current mandatory reporting laws do not address the specific causes of child abuse and instead formulates a response to a problem that has already occurred, which is the case with most laws. many commonly accepted causes of child abuse range from (and are in no way limited to) poverty, poor education, marital strife, food insecurity, and inadequate housing (department of human services, n.d.). causes of sexual abuse of children are less understood. previous conjecture stated that individuals who were sexually abused have higher rates of sexually abusing others than non-sexual abuse victims, though recent data shows this may not be the full explanation (ryan, 2013). there is a correlation between individuals who were abused and their future abuse of others; however, causation cannot be confirmed to such experiences and cognitive deficiencies are now being promoted as more likely causes in many cases of sexual abuse (ward, hudson & marshall, 1995). the causes of child abuse, in particular sexual abuse of children, are important to research further, because understanding what elicits such behavior can lead to interventions that reduce the number of offenders, thereby reducing the number of victims. and just as identifying causes could help reduce offenses, if individuals who suffered from a sexual desire for children could be treated before they became offenders, the number of potential victims would be drastically reduced. 2 | columbia social work review, vol. viii policy objctives the objective of the federal child abuse prevention and treatment act of 1974, new york’s child protection act of 1973, and similar acts from other states, is to acknowledge the ongoing abuse of children and prevent future abuse by identifying those who are at-risk. furthermore, the mandatory reporting requirements in n.y. s.o.s. §413 serve to create and promote the framework of reporting abuse and define the roles of the agencies involved in investigating the reports made. according to the new york state assembly, the “purpose of the child protection act and amendments is to encourage more complete reporting of child abuse and maltreatment” (new york state assembly, n.d.). by creating the legal ability to break client confidentiality, the law better protects children by granting the ability to report child abuse of any nature by individuals most likely to encounter evidence or indicators of its occurrence. beyond the clear and concise stated objectives of the law, there is a covert intention of identifying and punishing any suspected abusers. this is not necessarily negative, per se, but when coupled with the law’s failure to address causes of abuse, the law could be interpreted as having an unspoken objective for serving as a punitive instrument for persons attracted to children. in the case of actual abuse, sexual or otherwise, this can be understood. but in cases where abuse did not occur, either because it was stopped prior to its occurrence by confession to a therapist, or no specific child was at risk but a person sought help for pedophilia, this punitive aspect is indeed negative and unnecessarily restrictive. individuals attracted to children are often defined as pedophiles, and pedophiles are colloquially identified as sexual offenders, but this is not always the case (blanchard, 2009). there are individuals attracted to children (the basic requirement for a diagnosis of pedophilia) that do not wish to act on their sexual desires, and their desire to not offend often leads them to therapy. these “minorattracted persons” suffer from a reactionary, punitive aspect of the law that requires the reporting of any abuse, actual or suspected, and herein lies the problem. effects of the policy the list of professionals required to report abuse—i.e. mandated reporters—is exhaustive (n.y. s.o.s. §413). it includes every type of professional that would be qualified to offer any form of psychotherapy to an individual seeking treatment for a sexual attraction to children (pedophilia). again, the distinction must be made that to be considered a pedophile, a sexual act does not have to have been committed, only a sexual attraction or desire (blanchard, 2009). the “amendments” to the new york state child protection act (1973) spoke of by the new york state assembly (n.d.) create a loophole that can preclude minor-attracted persons from obtaining the treatment they need. section 419 of new york state social service law states that an individual required to report abuse under §413 will be immune from “any liability, civil or criminal” that arises from making the report pertaining to child abuse. the effect of this section is to give mandatory reporters a sense of protection in reporting cases that may be unfounded. however, the section requires the report to be made in “good faith” through the execution of their duties. further, section 420 (n.y. s.o.s. §420) goes on to prescribe criminal penalties for any mandated reporter that does not make a report of child abuse when there is “reasonable suspicion” of ongoing or potential abuse. moreover, a professional who fails to report is liable for civil actions resulting from not reporting. what §419 and §420 combine to form is what johnston calls a “legal-ethical feedback loop” (2015). there is a legal (and ethical) obligation to report from the overarching policy, while simultaneously conflicting with the ethical obligation for confidentiality and providing services to the person seeking treatment. the protection from liability if the report is unfounded but made in “good faith”(§419) and the criminal and civil liability of they do not report (§420) combine to form this “feedback loop.” in situations where minor-attracted persons seek treatment and share that they are sexually attracted to children, but have not offended and have no intention to offend, the therapist must consider if the clients pose an actual risk to children. important considerations include proximity through employment, place of residence, and other factors that could potentially place children in harm’s way. their legal obligation is to report if there is a “reasonable suspicion” (§413). their ethical obligation is to the client and the delivery of treatment for their affliction. however, legal obligations now feed-back to the ethical obligations because they are criminally and civilly liable if they do not report and a child ends up being abused. the current design of the law creates a culture of over-reporting for fear of being criminally charged, rather than allowing for more specificity as to when a report should be made and when a provider can be held liable. this unintended effect of current policy is not easily recognized even when a great deal of scrutiny is given to the language of the law because these situations tend to arise in specialized circles of professionals. moreover, each time a nonoffending minor-attracted person is reported, the fact that a report was made can serve to prevent other minor-attracted persons in similar situations from seeking treatment themselves. another unintended effect has been the abuse of the system that allows anonymous reports of child abuse cases to be used begrudgingly during disputes between couples during child custody battles. blaustain (2013) reports an alarming number of false reports being made, resulting in the removal of children because of horrendous claims made via the anonymous hotline. unforeseen effects aside, the intended effect of the policy requires little analysis and its name lends its purpose: the protection of children and the reduction of child abuse incidents. the last two years’ data available, 2008 and 2009, depict a 2% increase in claims made to child protective services, but the actual number of reports, over 164,000, indicates an extensive amount of child abuse reports (new york state office of children & family services, n.d.). given such a large number, and having specified that the cases totaled exclude false reports, it is easily arguable that the policy is having the desired effect of helping promote the reporting of child abuse. columbia social work review, vol. viii | 3 implications of policy the implementation of the law, as written, does not specifically call for reallocation of resources or other benefits from individuals or agencies, aside from budgeting considerations. however, with the “legal-ethical feedback loop” (johnston, 2015), a minor-attracted person under investigation can face problems with current employers or landlords (lanser & kubitschek, n.d.). even if the report is later determined to be unfounded, a minor-attracted person’s employer and landlord may have already been made aware of the investigation. this is especially troublesome for minor-attracted persons that work around or live near children because investigations will more thoroughly explore those areas of the person’s life through a biased lens. the stigma of having had an investigation conducted (and worse if the nature of the investigation was made known) is a consequence that can have far reaching implications for non-offending minor-attracted persons. alternative policies there is no question regarding whether there is a need for a policy obligating professionals to make reports of child abuse. furthermore, an avenue to legally break confidentiality to produce reports of child abuse is necessary and appropriate. the new york child protection act (1973) provides a powerful tool for the prevention and investigation of child abuse. however, the “legal-ethical feedback loop” (johnston, 2015) needs to be closed to better protect the children of new york state by allowing non-offending minor-attracted persons to seek and obtain treatment without fear of being reported. this will enable minor-attracted persons to seek professional treatment needed to help rehabilitate themselves from their current afflictions. by intervening before a person has offended, the number of potential future victims is reduced, which is made possible if the individual seeking treatment feels that disclosing their pedophilia-like desires will not lead to legal ramifications. when there are cases of actual abuse there is no ambiguity as to the course of action for the mandated reporter. by adding more specific language to the policy, specifically §413 and §419, the “legal-ethical feedback loop” johnston (2015) identifies can be eliminated. current language in §413 states that a report should be filed if there is reasonable suspicion “that a child is an abused or maltreated child,” which can be read to mean a specific child, but it can also be interpreted as a “potential” child. specificity this wording would remove the potential for over-reporting when there is no specific child or children that the therapist deems at risk. the immunity granted to mandated reporters in §419 is an invaluable part in ensuring that reports of child abuse are made, even if circumstances are not fully clear. if mandated reporters were fearful of reprisal for making an unfounded report, instances of actual child abuse could escape attention and have negative consequences. however, “good faith” (n.y. s.o.s. §419) should be more clearly defined to specify elements that should be included in determining what is, in fact, “good faith.” language indicating that consideration must be taken into account as to the existence of an actual at-risk child in determining a “good faith” decision would reduce the amount of over-reporting by forcing deliberation on whom, if anyone at all, is immediately at risk. there is a downside to this, in that modifying the language of §419 could bring back a fear of reporting when a case is questionable. the spirit of the law would seem to be over-reporting than under-reporting, and this writer cannot wholly disagree with that for fear of an actual child abuse case not becoming reported. an alternative to modification of would be an additional amendment allowing for the creation of a new form of “quiet” investigation that would be less invasive, but provide for exploration of necessary facts of the report so a determination can be made as to whether a full-fledged investigation should be conducted, including employers and landlords being notified. this would require increased budgetary considerations for manpower and resources, as well as determining the logistics involved in what would be deemed a “quiet” investigation. conclusion while the alternatives to the current policy presented require careful structuring, they can be made to close the “legalethical feedback loop” (johnston, 2015) that currently exists. by preventing minor-attracted persons to seek treatment due to mandated reporting, the policy serves to place children at more risk. the spirit of the law must be considered when deliberating these changes. by treating non-offenders who are attracted to minors under a quiet investigation, we would protect an increased number of children from future harm. the line between many cases, whether suspected or confirmed, need not be so blurry. through refining these essential statutes, by clarifying the language, and circumstances that constitute reporting, we can continue to protect one of our most vulnerable populations, while concordantly reducing the number of potential children victimized. references a guide to new york’s child protective services system. 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(1996). the book of david: how preserving families can cost children’s lives. new york: basicbooks. hamilton, a., & godkin, l. (1894). a system of legal medicine (1st ed.). johnston, s. (2015). a critical evaluation of new york state mandatory reporting laws and the creation of a legal-ethical feedback loop. unpublished manuscript, columbia university school of social work. kempe, c. h., silverman, f. n., steele, b. f., droegemueller, w., & silver, h. k. (1962). the battered-child syndrome. journal of the american medical association, 18, 17-24. retrieved from http://kempeorg.www88.a2hosted.com/wp-content/uploads/2015/01/ the_battered_child_syndrome.pdf lansner, d., & kubitschek, c. (n.d.). clearing your name. retrieved from http://www.lanskub.com/docs/clearing_your_name.pdf melton, g. (2005). mandated reporting: a policy without reason. child abuse & neglect, 29, 9-18. doi:10.1016/j.chiabu.2004.05.005 mintz, s. (2012, july 13). placing childhood sexual abuse in historical perspective the immanent frame. retrieved from http://blogs. ssrc.org/tif/2012/07/13/placing-childhood-sexual-abuse-in-historical-perspective/ myers, j. e. (2008). a short history of child protection in america. family law quarterly, 42(3), 456. retrieved from http://www. americanbar.org/publications/family_law_quarterly_home.html new york state social service law, article 6, title 6, § 411: findings and purpose new york state social service law, article 6, title 6, § 413: persons and officials required to report cases of suspected child abuse or maltreatment new york state social service law, article 6, title 6, § 419: immunity from liability new york state social service law, article 6, title 6, § 420: penalties for failure to report ryan, c. (2013, september 12). can pedophilia ever be “mild”? psychology today. retrieved from https://www.psychologytoday.com/ blog/sex-dawn/201309/can-pedophilia-ever-be-mild statistics child abuse prevention new york state office of children & family services. (n.d.). retrieved from http://ocfs.ny.gov/main/ prevention/statistics.asp ward, t., hudson, s., & marshall, w. (1995). cognitive distortions and affective deficits in sex offenders: a cognitive deconstructionist interpretation. sex abuse, 7(1), 67-83. doi:10.1177/107906329500700107 stephen johnston stephen johnston is a second-year student at columbia university school of social work, where he is specializing in advanced clinical practice. additionally, johnston is pursuing a minor in law conferred in conjunction with columbia law school, focusing on social equality and criminal justice reform. johnston has an extensive history in working with multiple populations, including individuals seeking substance abuse and mental health treatment. moreover, johnston has experience working in legal, non-profit, and medical sectors. johnston’s desire is to apply harm reduction treatments to those suffering from substance use disorders upon graduation, while ultimately procuring a ph.d. in counseling psychology. he has worked in both private treatment centers and public hospital settings, as well as worked with forensic clients exposed to the federal criminal justice system. he is currently heading an initiative that focuses on removing barriers preventing persons returning home from incarceration from rejoining their families in public housing. columbia social work review, vol. viii | 1 lgbtqi-identifying members of the middle eastern-american community nicholas baitoo while the contemporary landscape of sociological and psychological literature boasts nuances that account for many cultural identities, there exists a paucity in research pertaining to the lived experiences of middle eastern-american (mea) members of the lesbian, gay, bisexual, transgender, queer, or intersex (lgbtqi) community within the united states. researchers have investigated the experiences of lgbtqi-identifying individuals and those of meas, but the idiosyncrasies that occur at the intersection of these identities is still a largely unexplored terrain. narrative accounts suggest that this group faces a high risk of adverse quality of life outcomes directly resulting from persecution along axes of race, gender expression, and sexual orientation. moreover, this persecution is bolstered by post-9/11 american societal views, heteronormative middle eastern values, and non-mea members of the lgbtqi community. anecdotal evidence also indicates promise in exploring interventions, such as community building to curb psychosocial pathways that could otherwise result in self-injurious behaviors (including suicide) amongst middle eastern-american individuals who identify as lgbtqi. unfortunately, the lack of research on this topic acts as a barrier to both understanding this extremely vulnerable group and providing its members with culturally competent support. this review will synthesize information germane to the experiences of lgbtqi meas in order to illuminate gaps in literature and indicate areas which further research could better inform social service practices on behalf of this group. defining “middle eastern-american” the term “middle eastern” refers to an ethnic and cultural identity that draws from a constellation of nations located in west asia, central asia, and northern africa. within this identity exists a myriad of ethnicities such as arab, assyrian, and kurdish; religions, such as christianity, islam, and judaism; languages, such as arabic and farsi; and political alignments. as of 2010, counts of individuals in the united states who identified with one of these various ethnicities amounted to approximately 9,981,332, totaling 3.23 percent of the population (sheskin & dashefsky, 2010; united states census bureau, 2012). the middle eastern ethnicities most represented in the united states are jewish and then arab, representing 2.18 percent and 0.5 percent of the total population, respectively (asi & beaulieu, 2013). however, these numbers are only tenuous because, to this day, census forms do not include a discrete category for “middle eastern,” forcing such individuals to select the classification of “white, not of hispanic origin.” this lack of a separate classification came as a result of the group’s absence from political mobilization and participation in mid-20th century civil rights movements, during which other racial and ethnic groups successfully organized into political action leading to minority preference programs (bakalian & bozorghmehr, 2009). this oversight in classification is a barrier to obtaining accurate counts of ethnically middle eastern individuals within the united states, and is an example of the thematic lack of visibility that members of this community experience. middle eastern-americans, 9/11, and islamophobia though middle eastern ethnic communities have existed in the united states since the late 19th century (zong & batalova, 2015), one of the most important incidents affecting the collective mea psyche did not occur until the beginning of the 21st century: the terrorist attack of september 11, 2001. a tremendous spike in enmity towards meas followed this tragedy: only four days after 9/11, balbir singh sodhi, a sikh-american gas station owner in arizona, was murdered by a man whose goal was to “kill a muslim” (saldef, 2011). this marked the first of many documented attacks against middle eastern and middle eastern-appearing americans (bakalian & bozorghmehr, 2009). following this incident, other reports of physical and verbal attacks, de facto socioeconomic restriction, and discriminatory policy began to emerge, particularly at the federal level. proclamations such as the “war on terror,” and legislation such as the uniting and strengthening america by providing appropriate tools required to intercept and obstruct terrorism (usa patriot) act, have come to be criticized as “state-sponsored terrorism” against specific groups (minnite, 2005, p. 182), as they have violated the civil liberties of countless americans (chisthi, meissner, papademetriou, peterzell, wishnie, & yale-loehr, 2003). this coalescence of sociopolitical hostilities against perceivably muslim-americans was dubbed “islamophobia,” and it effectively homogenized and demonized an entire group of people, regardless of their religious affiliation (islamophobia research & documentation project, 2016). understandably, meas experienced a collective identity crisis, marked by competing drives to either distance themselves from any potential associations with muslim extremism or to withdraw into their own ethnic enclaves (beitin & allen, 2005). an interview with an arab-american describes the sociopolitical climate since 9/11: it doesn’t matter if you’re christian or muslim or where you’re from. whether you’re from saudi arabia or palestine, you’re considered an arab, a barbarian. some people see muslim people as the ultimate evil. they don’t want to get to know us. they just see us in supermarkets with our veils and they judge and they whisper…in a way, it was good that people took an increased interest in the muslim faith after 9/11 but it was also bad. it caused even more misunderstanding because people were hearing the media’s version of the muslim faith. (beitin 2 | columbia social work review, vol. viii & allen, 2005, p. 259) in order to examine the lived experiences of lgbtqi-identifying meas, it is vital to first understand the ways in which these social and political contexts interact to create the strenuous landscapes that this group must traverse. middle eastern-american values and the lgbtqi community while a conglomeration of diverse cultural value systems exist in the middle east, islam influences many of these cultures due to its proliferation throughout the region (zeghal & waldman, 2009). d’souza explains that islam describes [lgbtqi] individuals as “‘…people of the wrath of allah,’ and most muslims find the notion of legitimizing what they perceive as sinful conduct to be disgusting and unspeakable (2007).” nearly all middle eastern countries boast criminal laws against “sexual activity by [lgbtqi] people” (human rights campaign, 2016), and at least six of these nations have laws stipulating that sexual acts by lgbtqi individuals can be penalized by death (human rights campaign, 2016). given these heteronormative expectations of society exist across middle eastern cultures, they instigate strong tensions between lgbtqi meas and their ethnic communities (arida & ameri, 2012). lgbtqi-identifying middle eastern-americans narratives of the lived experience though some research exists that describes the experiences of lgbtqi communities in the middle east (sharma, 2007), lgbtqi communities in the united states (stewart, 2014), and middle eastern communities within the united states, there is a glaring absence of research focused on lgbtqi-identifying meas (ikizler & symanski, 2014). however, anecdotal narratives describing those who navigate these seemingly incompatible identities have begun to emerge, and these narratives often take the forms of videos, organizations, news reports, and blog posts. for example, bashar makhay, founder of tarab nyc, describes a life impacted by these converging identities, and his experiences include receiving an ultimatum from his mother to “become straight,” a subsequent separation from his family, a rejection from american society and nonmea lgbtqi spaces, and a longing for community (associated press, 2014). khalida saed, the iranian-american author of on the edge of belonging, utilizes a pseudonym despite coming out as a lesbian for fear of backlash from muslims and middle eastern communities. she also describes the “pain of straddling separate identities” that accompanies the struggle to reconcile two seemingly antipodal cultures (“contemporary gay muslims in america,” n.d.). the difficulties this group faces are best captured in an article from the detroit metro times: as immigrants, they must cope with melding two nationalities; as [middle eastern-americans], they must deal with unbridled, post-9/11 racism in this country; and as gays, they must deal with jokes, harassment, discrimination, and sometimes, the threat of being attacked and beaten — even by their own families. (klein, 2006). emerging themes in lgbtqi-identifying mea experiences though these accounts originate from varying sources in different parts of the united states, two prominent themes emerge: rejection from family and an onerous search for community. lgbtqi-identifying meas face the fear of or actual experience of violence, rejection, or coercive action from family members. for cultures that are historically hostile towards lgbtqi individuals or for communities that originate from nations that actively criminalize lgbtqi identities, it is understandable that this group would be apprehensive of their families’ reactions. second is a longing for community; each of the prior stories portrays individuals being ejected from one community and subsequently rejected by another. this struggle is marked by a sense of loss and confusion as the individual searches for acceptance and understanding, thus underscoring the importance of community for this largely invisible group. isolation and risk for many mea members of the lgbtqi community, being forced to conform to cultural expectations of sexuality, family structures, and social obligations isolates them from their own ethnic communities, and the pervasive islamophobia following 9/11 furthers their distance from other americans. this islamophobia, underpinned by race-based divides within the lgbtqi community (balsam, molina, beadnell, simoni, & walters, 2011), excludes them from authentic community within lgbtqi spaces, further exacerbating the isolation that this population experiences. with their ethnic identities viewed as yet another source of risk, some lgbtqi-identifying meas experience a phenomenon known as the “double closet effect,” which compels individuals in this group to compromise multiple parts of their identities and endure the continuous stress of doing so (gittens, 2009, p. 7). these individuals retreat from their sexual identities while simultaneously divorcing their cultural identities, and this process results in stress, isolation, and shame. this social maneuver, as well as its psychological effects, is consistent with moradi’s “risk hypothesis,” also known as the “double jeopardy” hypothesis, which states that in contrast to white [lgbtqi] individuals, [lgbtqi] people of color endure higher levels of stress resulting from dual pressures of homophobia and racism (as cited in meyer, 2010, p. 447). though research does not exist to confirm the effects of this continued isolation on lgbtqi-identifying meas specifically, data on discrimination against gender, sexual, and racial minorities suggest higher rates of mental health disorders, substance abuse, violence, and suicidality (mereish, o’cleirigh, & bradford, 2014; lavers, 2011; o’donnell, meyer, columbia social work review, vol. viii | 3 & schwartz, 2011). the mea community also carries a historical hesitation to access psychological services (al khateeb, al hadidi, & al khatib, 2014), and as a result lgbtqi-identifying meas are at risk for an incremental compounding of the negative psychological effects spurred by the precarious intersection of their identities (meyer, 2003). this resulting isolation, compounded by multiple layers of cultural incrimination, testifies to a great need for further exploration that will provide nuanced, culturally relevant interventions for members of this specific population. promising practices mea members of the lgbtqi community are forced to navigate an idiosyncratic psychological gambit due to the competing pressures in their daily lives: societal persecution based on their ethnic identities, violence and rejection from their ethnic communities based on their gender and sexual identities, and the invisibility that results from being unable to integrate all facets of their identities. a minority multiple times over, this group experiences extreme isolation as a consequence of prejudice against its unwittingly oppositional identities, and the dearth of research about lgbtqiidentifying meas results in knowledge gaps regarding health outcomes, resiliency models, and community resources available to serve this particular group. this knowledge gap signals a severe research need, as knowledge gleaned from studies of lgbtqi ethnic minorities suggests severe complications in health, mental health, socioeconomic status, and lifespan (balsam et al., 2011). in the absence of such research, this group is at risk for continued isolation and hindrance of quality-of-life outcomes. consequently, service providers are at risk of unintentionally mistreating members of this community and further exacerbating this group’s historic reluctance to access services. research into protective factors for arab-americans suggests that “ethnic density,” which refers to the high concentration of culturally similar individuals in near proximity, curtails socioemotional pathways that typically lead to suicide (el-sayed, tracy, scarborough, & galea, 2011) thereby reinforcing the value of community. for a historically disparate and isolated group such as the mea lgbtqi population, the lack of such density likely contributes to the distress of its members; therefore, this research implies that creating community among this group’s members can mitigate daily distresses and produce a powerful protective factor against suicidality. anecdotal narratives demonstrate the value of community, and organizations such as tarab nyc, assal, and al gamea have emerged as resources through which this community can unite. this value suggests that interventions focusing on community building can be effective protective factors for this group. however, because anonymity is tantamount to safety for lgbtqi meas, community building may pose a daunting task. in the past, the internet has offered a safe space in which members of vulnerable groups can connect with each other (dehaan, kuper, magee, bigelow, & mustanski, 2013; miller, 2012); service providers can leverage the internet to construct online community spaces for lgbtqi meas. although these web-based services could be promising, further research is required in order to determine the efficacy of these or other interventions to mitigate the psychological, social, and emotional stressors that lgbtqi meas experience. differences across axes such as ethnicity, religion, gender, socioeconomic status, and citizenship likely account for variations in experience, so further exploration is also necessary in order to ascertain outcomes along these lines. conclusion there is a great need for research pertaining to lgbtqi-identifying meas, as little investigation has emerged that can strengthen the cultural competencies of service providers who encounter members of this group. such research would provide insight into this group’s numbers, its aggregate psychosocial status, the effects of immigration on middle eastern refugees and asylum-seekers, nuances among ethnic differences among meas, and effective interventions in serving its members. the national association of social workers calls for such cultural competency (national association of social workers, 2017), so it is an ethical responsibility for practitioners and researchers to add to the canon of knowledge on this subject. through conducting such research, this often-invisible group can be better understood, and subsequently, be better served by researchers, mental health practitioners, community organizers, and policy makers. references tal khateeb, j. m., al hadidi, m. s., & al khatib, a. j. 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(2014). interrelationships between lgbt-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities. psychology, health & medicine, 19(1), 1-13. doi:10.1080/13548506.201 3.780129. meyer, i. h. (2003). prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. psychological bulletin, 129(5), 674-697. http://dx.doi.org.ezproxy.cul.columbia.edu/10.1037/0033-2909.129.5.674. miller, a.l. (september 6, 2012). in the middle east, marginalized lgbt youth find supportive communities online. techpresident. retrieved from http://techpresident.com/news/wegov/22823/middle-east-marginalized-lgbt-youth-find-supportivecommunities-online. minnite, l. 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(2011). increased risk of suicide attempts among black and latino lesbians, gay men, and bisexuals. american journal of public health, 101(6), 1055–1059. http://doi.org/10.2105/ajph.2010.300032. sikh american legal defense fund (saldef) (2011). the first 9/11 backlash fatality: the murder of balbir singh sodhi. retrieved from http://saldef.org/issues/balbir-singh-sodhi/#.wmdoohirkrs. sheskin, i., & dashefsky, a. (2010). jewish population in the united states, 2010. mandell l. berman institute north american jewish data bank, center for judaic studies and contemporary jewish life university of connecticut. brandeis university. retrieved from http://www.brandeis.edu/cmjs/conferences/demographyconf/pdfs/dashefsky_jewishpopulationus2010.pdf. stewart, c. (2014). proud heritage: people, issues, and documents of the lgbt experience [people, issues, and documents of the lgbt experience]. santa barbara, us: abc-clio, llc. retrieved from http://www.ebrary.com.ezproxy.cul.columbia.edu. united states census bureau (2012). total ancestry categories tallied for people with one or more ancestry categories reported: 2010 american community survey 1-year estimates. retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/ productview.xhtml?src=bkmk. zeghal, m., & waldman, m.r. (2009). islamic world. in encyclopædia britannica online. retrieved from https://www.britannica.com/ topic/islamic-world. nicholas baitoo nicholas baitoo is the assyrian-american child of iranian parents, and his background as an lgbtqi-identifying first-generation american has a significant influence on his worldview. before attending columbia university school of social work, nick was a teacher, an after school program evaluator, and a counselor for youth experiencing homelessness. he came to the field of social work in order to acquire the knowledge, skills, and connections columbia social work review, vol. viii | 5 needed to empower communities so they can identify and overcome societal oppression. nicholas will be graduating in 2017 with an emphasis in clinical practice, and hopes to leverage his training and experiences to provide direct service to historically marginalized communities, develop empowerment and service programs, generate social policy, and produce research publications. 2018-final.pdf 24 | columbia social work review, vol. ix keep up: aligning policies and practices to optimize telemental health potential angelica frances cullo currently, the united states health care system is undergoing a transformation in health care delivery. innovative strategies are needed to increase access to evidence-based mental health care and make progress on the goals of the health care “triple aim” of reducing per capita costs, improving health outcomes, and increasing patient satisfaction (berwick, 2008 p. 760; mcwilliams, 2016). barriers including a shortage of mental health providers, lack of delivery infrastructure, state licensing limitations, and inconsistent insurance coverage must be addressed before telemental health can become viable. by 2025, social workers are anticipated to experience one of the largest shortages of the mental health provider types (health resources & services administration, 2016). telehealth services have the potential to improve mental health care access, efficiency, and outcomes by reaching people who don’t seek treatment because of distance, cost of transportation, stigma, or disability, and by sharing clinical expertise and medical documentation to more people in less time. with decreasing costs and increasing acceptability by payers, providers, and patients, telehealth is more viable than ever before. social workers are particularly well positioned to make use of telehealth opportunities because their training prepares them to work with individuals marginalized by issues such as stigma, disability, and socioeconomic status. to begin to address this gap in mental health care access, states should pass full parity laws for insurance coverage of telemedicine services so that social workers can provide care to clients regardless of where they are located. background by 2025, shortages are projected of psychiatrists; clinical, counseling, and school psychologists; and mental health and substance abuse social workers (health resources & services administration, 2016). rural areas in particular face persistent shortages in mental health practitioners (hoeft, 2018). rural counties comprise twothirds of all counties and approximately 20% of the united states (u.s.) population but contain fewer than 10% of the mental health workforce “telehealth services have the potential to improve mental health care access, efficiency, and outcomes by reaching people who don’t seek treatment because of distance, cost of transportation, stigma, or disability, and by sharing clinical expertise and medical documentation to more people in less time.” columbia social work review, vol. ix | 25 angelica frances cullo (hoeft, 2018). even when rural location is not a barrier to care, individuals with mental illnesses are not getting the care they need (american psychological association [apa], 2018). among 8.9 million adults with any mental illness and a substance use disorder, 44% received mental health treatment or substance use treatment in the past year, 13.5% received both mental health treatment and substance use treatment, and 37.6% did not receive any treatment (apa, 2018). evidence suggests that travel time, cost, convenience, and stigma may play a role (substance abuse and mental health services administration, 2014). according to the american telemedicine association’s (ata) guidelines, telemental health consists of using video conferencing for mental health care (thomas & capistrant, 2014). services that can be delivered using telemental health include mental health assessment, counseling, substance abuse treatment, medication management, education/training, monitoring, and collaboration (mcwilliams, 2016). mental health care is particularly subject to complex sociocultural factors due to challenges in quantifying mental illness, cultural beliefs about mental health, and attribution of mental illness to personal failures or weaknesses. as such, social workers are uniquely poised to address the limited access to mental health services. telemental health is now making it possible for social workers to provide care to those who encounter barriers such as cost, location, scheduling, language, and other circumstances that perpetuate disparities in access to care. however, historically practitioner reimbursement, particularly from private payers, has limited the viability of telehealth (antoniotti, kenneth, & nancy, 2014). insurance companies are beginning to respond to consumer needs by expanding the services and provider types that they reimburse (aha, 2016). morland et al. (2014) suggest that telemental health is as or more effective than face-to-face (ftf) treatment at monitoring medications and symptoms due to ease of scheduling, reduction of no-show appointments, and communication among other caregivers or family members (hubley, lynch, schneck, thomas, & shore, 2016). a number of studies have also shown the same or higher rates of satisfaction among telemedicine patients as compared to traditional ftf services (morland et al., 2014; o’reilly et al., 2007). telemental health makes accessing mental health care more convenient, allows individuals with physical disabilities or who lack of transportation to more easily receive care, prevents patients from “...social workers are uniquely poised to address the limited access to mental health services. telemental health is now making it possible for social workers to provide care to those who encounter barriers such as cost, location, scheduling, language, and other circumstances that perpetuate disparities in access to care.” 26 | columbia social work review, vol. ix keep up: optimizing telemental health potential having to take off time from work or other responsibilities, and reduces barriers for those who might not get care because of the stigma associated with visiting a psychiatrist or counselor’s office. in addition to delivering services via videoconferencing, social workers can obtain and provide training, supervision, and consultation with specialized mental health providers, such as psychiatrists and clinical psychologists (hoeft, 2018). technology is proving to be such an instrumental part of social work that the most recent revision of the national association of social work code of ethics was revised to incorporate practice guidelines related to the use of technology (nasw, 2017). clinical outcomes there is evidence that telemental health may produce better health outcomes and be more cost-effective than ftf (moraland, 2014). one study comparing utilization data for telemental health appointments and ftf appointments found that patients kept more telepsychiatry appointments than ftf appointments, were less likely to cancel telemental health appointments, and were significantly less likely to noshow (leigh, cruz, & mallios, 2009). remote monitoring of patients via telemedicine has also allowed practitioners to check in with patients more regularly, in some cases providing evening and weekend appointments not traditionally possible for ftf service provision (hubley, lynch, schneck, thomas, & shore, 2016; khasanshina, wolfe, emerson, & stachura, 2008; uscher-pines & mehrotra, 2014). telemental health may be less disruptive to patients’ schedules, more cost-effective because of reduced transportation costs, more appealing to those who feel stigmatized for accessing mental health services, and perhaps even the only option for individuals with disabilities or other physical limitations. while more research is needed to fully understand the causes of improved patient compliance with telemental health when compared with ftf, findings suggest that telemental health patients more consistently utilized mental health services than ftf patients (leigh, cruz, & mallios, 2009). cost telemental health has already proven to be more cost-effective for patients, providers, and the health system as a whole. cost savings include those from reduced travel and lost workdays, appointment cancellations and no-shows, clinical and administrative staff costs, and hospital admissions (rabinowitz, 2010; loh, 2013). according to data from the veterans’ health administration (vha) one of the country’s pioneers in telemedicine the annual cost to fund their telehealth program in 2012 was $1,600 per patient, per year, compared to over $13,000 for traditional care columbia social work review, vol. ix | 27 angelica frances cullo (american hospital association [aha], 2016). some of these savings come from a reduction in the number of required follow-up visits (see figure 1). one study of the california public employees retirement system found that patients seen by a telehealth provider were less likely than those who received their initial consult in the emergency department or a physician’s office to require a follow-up visit (aha, 2016). significantly, data suggest that telemental health increased quality of life adjusted life years (qalys) when compared to ftf services (hubley, lynch, schneck, thomas, & shore, 2016). telemedicine was also associated with a 25% reduction in the number of bed days of care and a 19% reduction in hospital admissions across all vha patients utilizing telehealth. the vha achieved significant reductions in hospitalizations, including over 40% for mental health patients (aha, 2016). the state of vermont saved $63,804 per patient through the use of home-based telehealth and telemonitoring that eliminated expenses related to preventable illnesses and time and travel expenses (aha, 2016). overall, the vha (2016) estimates an average annual savings of $6,500 for each patient who participated in the telehealth program, which translates to nearly $1 billion in system-wide savings. the south carolina department of mental health and the south carolina hospital association established a statewide telepsychiatry network that allows patients, emergency department physicians, and psychiatrists to communicate via video-based and wireless communications. since its inception, the program has resulted in an estimated cost savings of $3,320 per inpatient hospital patient (south carolina telehealth alliance, 2016). these are just a few of the encouraging examples of health care providers already embracing the use of telemental health services as part of the care continuum. percentage of telehealth, physician office, and emergency department visits where follow-up is required for similar condition, april 2012 february 2013 (uscher-pines 2014) telehealth physician office emergency department3% 13% 20% figure 1: telehealth decreases utilization in the long run. 28 | columbia social work review, vol. ix keep up: optimizing telemental health potential current legislation already, states are seeing the value in using telemedicine to fill provider shortage gaps and ensure access to specialty care. medicaid, medicare, and a growing number of third-party payers are beginning to cover telemental health (deslich, stec, tomblin, & coustasse, 2013). private insurers such as aetna, anthem, and united healthcare are incorporating telehealth into their medicare advantage, commercial, and individual benefit packages (aha, 2016). despite progress, however, patients and mental health providers still encounter a patchwork of inconsistent service delivery, legislation, and insurance requirements that make it difficult for both patients and providers to reap the full benefits of telemental health. state licensing regulations remain a barrier to providing telemental health. currently, providers must have separate licenses for each state in which they provide services. in some cases, this is not possible due to conflicting regulations from state to state (thomas & capistrant, 2014). providers and patients bear the burden of informing themselves of legal and financial limitations on practicing across multiple jurisdictions. they also have to consider in which jurisdictions laws apply, which professional codes of ethics apply, and whether the practitioner’s liability insurance covers services provided when the client, practitioner, or agency are in different jurisdictions (barsky, 2017). for instance, if an agency is located in new york, the client is in connecticut, and the social worker is traveling in california, the social worker would have to know regulations and technology policies pertaining to each jurisdiction. according to an analysis of 13 indicators related to coverage and reimbursement, the ata found that more than half of u.s. states received a failing score for the quality of their statewide insurance coverage and reimbursement for telemedicine (thomas & capistrant, 2014). while availability and coverage of telemental health has gained traction, full legal parity with ftf services—defined as insurance coverage for telemental health that is comparable to that of in-person, ftf services—is still lacking and varies across state borders (thomas & capistrant, 2014). encouragingly, full parity has been achieved in 19 states and the district of columbia (dc), and nine states and dc have laws mandating statewide coverage and reimbursement for telemedicine-provided services under their medicaid programs (weinstein et al., 2014). technology other concerns with telemental health are technological privacy and costs. depending on the provider and their setting, initial costs may be several thousand dollars for software, hardware, and other infrastructure. the u.s. federal communications commission’s universal service fund subsidizes high bandwidth telecommunications to rural health care columbia social work review, vol. ix | 29 angelica frances cullo providers, schools, and libraries that require a large network connection and technologies not available for free (mcginty, 2006). if large providers are able to front the technology cost, findings indicate that these expenses can be recovered through long-term telehealth savings. one study found that the threshold at which video conferencing became less costly than ftf was between five and six telemedicine episodes per year (harley, 2006). for others, however, audio-visual conferencing systems that are compliant with the health insurance portability and accountability act (hipaa) such as doxy.me, vsee.com, and polycom can be used at no cost to the provider or patient. most conferencing systems require the patient and provider to have just a computer with a video camera, microphone, and speakers or a headset, and many systems allow providers to access electronic health records while video conferencing (mcginty, 2006). confidentiality concerns can be addressed via encryption technology that enable compliance with hipaa. the use of encrypted codes or the setup of a virtual private network and/or virtual local area networks function to prevent interception of audio, video, and other data during transmission. in the future, facetime and similar applications may even be a viable hipaacompliant option if wpa2-enterprise and 128-bit encryption is used over a wi-fi connection (magno, santos, tucay, flores, & cuyco, 2014). patient & provider satisfaction on average, patient satisfaction with telemental health is the same as or better than with comparable ftf care (khasanshina, wolfe, emerson, & stachura, 2008; hilty, 2013; hubley et al., 2016). satisfaction ratings were higher for both patients and providers in rural versus suburban settings (hubley et al., 2016). this finding further underscores the viability of telemental health for rural regions where mental health disparities are greatest. interestingly, patient satisfaction rates tended to be higher than providers perceived them to be, suggesting that provider concerns about quality of telemental health care are largely unfounded. no significant differences were seen in treatment efficacy and telemental health patients report disclosing the same information they would to a ftf provider (hubley et al., 2016; khatri, marziali, tchernikov, 2014; stubbings, rees, & roberts, 2013). diagnosis accuracy also does not decline for telehealth as compared to ftf services (khasanshina, wolfe, emerson, & stachura, 2008; hubley et al., 2016). although telemental health may not be appropriate for someone in imminent risk of self-harm, it has been shown to be effective for assessing and managing suicidal threats (godleski, nieves, darkins, & lehmann, 2008; jong, 2004). 30 | columbia social work review, vol. ix keep up: optimizing telemental health potential recommendations to help close gaps in mental health care, state legislatures should pass full parity laws that regulate coverage provided by public and private insurers. regional and state government officials should also introduce bills to reform existing parity laws. full parity laws would allow more uniform mental health service provision regardless of parameters such as provider type, health condition, and patient location. barriers to practicing across state lines also need to be reduced. currently, there is no interstate portability agreement surrounding telemental health. social work licensing agencies should offer licensure mobility solutions or a national license, similar to those seen in medical and nurse licensure compact legislation (maheu, pulier, mcmenamin, & posen, 2012; hhs, 2016). national licensure could coordinate standards, yet allow each state to retain their ability to monitor practice and administer disciplinary actions for clinicians who engage in egregious behavior. national licensure could also require demonstration of competence with telemental health technologies and their best practices. lastly, professional associations should provide specific guidelines for using telemental health technologies with varying clinical populations, conditions, and circumstances, as well as standards required for competency (maheu, pulier, mcmenamin, & posen, 2012). discussion/conclusion regions with provider shortages, including rural, low-income, minority, elderly, and disabled communities, are important areas to target for mental health care improvement efforts. travel time, costs, convenience, and stigma associated with seeking many health care services discourage these and other populations from seeking adequate care. a number of states have partial telemental health parity laws. however they limit insurance coverage of telemedicine to certain geographic areas, services, and provider types. while recent efforts signify steps in the right direction, individuals with the highest need will likely not be reached without full parity laws. inclusion of telehealth in value-based payment innovations can help with continued efforts to assess the value of telehealth for health systems working to optimize quality improvement, patient satisfaction, and cost savings. while there is a growing body of evidence to support the idea that telemental health results in cost savings, more data are needed to identify what makes these programs successful so that their practices can be generalized to other places in the u.s. currently, the vha is one of the only organizations that has used telehealth for long enough to have a sizable body of publicly available data about the costs and benefits of columbia social work review, vol. ix | 31 angelica frances cullo telehealth. reflective of a larger challenge in clinical research, studies that examine telehealth treatment outcomes relative to ftf treatments disproportionately sample white individuals (khasanshina, wolfe, emerson, stachura, 2008). future research should focus on clarifying best practices for implementing and sustaining telemental health in populations with diverse backgrounds and mental health needs, including provider training specific to the sociodemographic characteristics of the patient and the provider. sustainable solutions to our nation’s mental health care challenges require improved equity in access to care and quality of care. telemental health represents a highly promising approach to reduce the gap between mental health care demand and access. references american hospital association. 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(2006). economic evaluation of a tertiary telepsychiatry service to an island. journal of telemedicine and telecare, 12(7), 354-357. https://doi. org/10.1258/135763306778682378 hilty, d.m., ferrer, d.c., parish, m.b., johnston, b., callahan, e.j., & yellowlees, p.m. (2013). the effectiveness of telemental health: a 2013 review. telemed j e health, 19(6), 444-54. doi: 10.1089/tmj.2013.0075. 32 | columbia social work review, vol. ix keep up: optimizing telemental health potential hoeft, t. j., fortney, j. c., patel, v., & unützer, j. (2018). task-sharing spproaches to improve mental health care in rural and other low-resource settings: a systematic review. the journal of rural health, 34(1), 48-62. doi:10.1111/ jrh.12229 hubley, s., lynch, s.b., schneck, c., thomas, m., & shore, j. (2016). review of key telepsychiatry outcomes. world j psychiatry, 6(2), 269-282. doi: 10.5498/ wjp.v6.i2.269 jong, m. 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(2014). remote imaging via facetime for potential long-distance diagnosis of suspected cardiac structural and shunt anomalies on contrast echocardiography (the rifle study). asean heart journal, 22(1), 79-98. doi 10.7603/s40602-014-0014-0 maheu, m.m., pulier, m.l., mcmenamin,j.p., & posen, l. (2012). future of telepsychology, telehealth, and various technologies in psychological research and practice. professional psychology: research and practice, 43(6), 613-621. doi: 10.1037/a0029458 mcginty k. l., saeed s. a., simmons s. c., & yildirim y. (2006). telepsychiatry and e-mental health services: potential for improving access to mental health care. psychiatric quarterly, 77(1), 335–42. doi: 10.1007/s11126-006-9019-6 mcwilliams, j.k. (2016). integrating telemental healthcare with the patient-centered medical home model. journal of child and adolescent psychopathology, 26(3), 278-282. doi: 10.1089/cap.2015.0044 morland, l.a., mackintosh, m.a., greene, c.j., rosen, c.s., chard, k.m., resick, p., frueh, b.c. (2014). cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. j clin psychiatry, 75(5), 470-476. doi: 10.4088/ jcp.13m08842 national association for social workers, association of social work boards, council on social work education, clinical social work association. (2017). standards for technology in social work practice. retrieved from https://www.socialworkers.org/linkclick. aspx?fileticket=lctcdshucng%3d&portalid=0 o’reilly, r., bishop, j., maddox, k., hutchinson, l., fisman, m, takhar, j. 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(sma) 14-4887.rockville, md. retrieved december 30, 2017 from http://www.samhsa.gov/data/sites/ default/files/nsduhmhfr2013/nsduhmhfr2013.pdf thomas, l., & capistrant, g. (2014). state telemedicine gaps analysis: coverage & reimbursement. american telemedicine association. retrieved on january 2, 2018 from http://southwesttrc.org/sites/southwesttrc.org/files/50-statetelemedicine-gaps-analysis.pdf uscher-pines, l., & mehrotra, a. (2014). analysis of teledoc use seems to indicate expanded access to care for patients without prior connection to a provider. health affairs, 33(12), 258-264. doi: 10.1377/hlthaff.2013.0989 u.s. department of health and human services. (2016). report to congress: e-health and telemedicine. retrieved from https://aspe.hhs.gov/system/files/ pdf/206751/telemedicinee-healthreport.pdf u.s. department of health and human services. (2016). national projections of supply and demand for selected behavioral health practitioners: 2013-2025. health resources and services administration, bureau of health workforce, national center for health workforce analysis. retrieved from https:// bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/ projections/behavioral-health2013-2025.pdf weinstein, r.s., lopez, a.m., joseph, b.a., erps, k, a., holcomb, m., barker, g, krupinski, e.a. (2014). telemedicine, telehealth, and mobile health applications that work: opportunities and barriers. the american journal of medicine, 127(3), 183-187. doi: 10.1016/j.amjmed.2013.09.032 angelica frances cullo grew up in the hudson valley and is a masters of science in social work candidate in advanced clinical practice at columbia university’s school of social work, where she is also in the dialectical behavior therapy (dbt) training program. angelica received her b.a. from cornell university where she was involved with the mental health community. her first year placement was at the door: bronx youth center where she helped youth earn their high school equivalencies and develop training and skills needed to succeed in the workplace and college. her research interests include increasing access to mental health care through telemedicine and treatment of anxiety, depression, eating disorders, and nssi in adolescents, particularly through the use of dbt. 2 | columbia social work review, vol. vii columbia social work review, vol. vii | 3 hershenson eating disorders have historically been characterized as an illness affecting adolescent, middleto upper-class, able-bodied, white female individuals; thus, early academic research tended to dismiss the prevalence of eating disorders in people who fell outside these categories—such as people with disabilities (striegel-moore & bulik, 2007; striegel-moore & smolak, 2001; tiggeman & lynch, 2001). although studies and clinical observations suggest that individuals with physical disabilities are actually at increased risk for developing eating disorders, there is little awareness of how to treat and prevent eating disorders among this population (gross, ireyes, & kinsman, 2000). unique stressors, such as body-image disturbances due to the disability, feelings of lack of control due to dependency on others, and an emphasis on weight maintenance to sustain mobility, make people with disabilities particularly vulnerable to eating disorders (gross et al., 2000). treatment and prevention, however, are particularly difficult due to accessibility issues, stigma, diagnosis errors, and physical and medical limitations. examining current therapeutic interventions, it is clear that there is a lack of available treatments for individuals with both an eating disorder and a physical disability. music therapy shows promise as an intervention for these comorbid conditions (heiderscheit, 2009; hooper, 2007; weiss, 2013). for both client groups, the most common goal is feeling more in control and improving self-understanding (mcferran, 2010). these goals align with one of the main purposes of music therapy: identity formation (mcferran, 2010). this article seeks to demonstrate that music therapy shows promise as a the promise of music therapy: understanding and treating individuals with comorbid eating disorders and physical disabilities kimberly hershenson research has historically dismissed the prevalence of eating disorders in people with disabilities, yet studies and clinical observations suggest that individuals with physical disabilities are at increased risk for developing eating disorders. due to this discrepancy, there is little awareness of how to treat eating disorders among this population. self-understanding is a key component in treating both individuals with physical disabilities and individuals with eating disorders. with this finding, this article seeks to demonstrate that music therapy is an effective treatment option for those with both an eating disorder and a physical disability due to its focus on self-understanding. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text © 2016 hershenson. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn sticky note accepted set by stujourn 2 | columbia social work review, vol. vii columbia social work review, vol. vii | 3 hershenson valuable technique for treating individuals with both physical disabilities and eating disorders as it addresses goals common to both of these comorbid diagnoses. eating disorders and people with physical disabilities for the purposes of this article, physical disability is defined as “a congenital disease, acquired illness, or trauma that leaves a person with a physical limitation that lasts at least one year” (tsan-hon, pi-sunyer, & laferrère, 2005, p. 321). the fifth edition of the diagnostic and statistical manual of mental disorders identifies three main types of eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder (american psychiatric association, 2013). having a physical disability is often stressful, chaotic, and unpredictable; as such, individuals with disabilities may use calorie restriction as a distraction, stress management tool, or means of control (roosen & mills, 2014). these behaviors are so common that having a physical disability is a higher risk factor for developing an eating disorder than having a mental illness such as depression or anxiety (roosen & mills, 2014). for example, in a survey of 71 women diagnosed with spina bifida or rheumatic illnesses, more than 20% of respondents showed symptomology of eating disorders (gross et al., 2000). in comparison, 9.4% of the united states population suffers from an eating disorder (national eating disorders association, 2014).1 early feeding problems (e.g., difficulty consuming solid foods or liquids due to a physical impairment and/or behavioral issue) are common for those with disabilities and may constitute a risk factor for later eating disorders (schwarz, corredor, fischer-medina, cohen, & rabinowitz, 2001). due to fears and limitations regarding food consumption, children feel isolated and misunderstood, which can have a detrimental impact on the child and may later lead to a diagnosed eating disorder (chatoor, 2009; natenshon, 2016). obesity rates for adults with physical disabilities are approximately 53% higher than for adults without physical disabilities (tsan-hon et al., 2005). more than 50% of adults with physical disabilities have concerns about their weight, often leading to unhealthy eating behaviors such as restricting food intake (roosen & mills, 2014). silber, shaer, and atkins (1999) looked at five individuals diagnosed with spina bifida. they all were overweight prior to their diagnoses and had been advised by their health care professionals to lose weight in order to improve their mobility. dieting and the resulting weight loss they experienced became a source of power for them that could compensate for their neurological limitations and deflect attention from 1according to the national eating disorders association (2014), there are 30 million people in the united states with an eating disorder, out of a total population of 318.9 million as of 2014 (united states census bureau, 2014). stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 4 | columbia social work review, vol. vii columbia social work review, volume vii | 5 the promise of music therapy hershenson social problems associated with their spina bifida diagnoses (e.g., job losses, lack of independence, etc.). eventually, all five individuals were diagnosed with an eating disorder. furthermore, physical disability is often considered a burden, and people with disabilities may therefore feel that they are inconveniencing others (silber et al., 1999). for these people, the pressure to become thinner goes beyond conforming to social norms: it affects whether or not somebody will take care of them (roosen & mills, 2014). karin hitselberger (2013) writes in her blog “claiming crip” that she has often been told to be thin in order to make it easier for others to care for her. she has restricted fluid intake for as long as she can remember because she worries about inconveniencing and feeling dependent upon others for survival. when she was younger, she would not drink fluids at school because she was afraid of untrained aides taking her to the bathroom. today, she says she still restricts fluids, “usually because i’m not sure if the bathroom is going to be accessible, but also because i don’t want to ask my friends for help” (hitselberger, 2013, p. 40). when she started struggling with limiting food intake as well, her therapist dismissed her concerns, saying that as long as she was careful, it was fine. hitselberger could not imagine anybody telling an able-bodied person not to eat or drink, but people such as her therapist often encourage her behavior. because bodies with physical disabilities differ from what many consider mainstream, able-bodied people often have difficulty understanding that those with physical disabilities may also have body-image issues. psycho-social-cultural risk factors individuals with disabilities often discuss two different areas of pressure from society: the culture of thinness, meaning that thin bodies are preferable to fat bodies, and the culture of ableism, meaning that able bodies are preferable to disabled bodies (roosen & mills, 2014). this double stigma often leads to restrictive dieting in order to try to fit in with society (roosen & mills, 2014). the media rarely highlights images and experiences of those with disabilities, and this shortcoming strongly influences body image (minges, 2014). people with disabilities rarely receive positive feedback about their bodies and physical abilities, are aware that their bodies do not fit typical standards of physical ability, and commonly feel inadequacy, body “because bodies with physical disabilities differ from what many consider mainstream, able-bodied people often have difficulty understanding that those with physical disabilities may also have body-image issues.” 4 | columbia social work review, vol. vii columbia social work review, volume vii | 5 the promise of music therapy hershenson disconnection, fear, and shame (minges, 2014). hitselberger (2015) writes: i hated the way my body would jerk and spasm because of my cerebral palsy. i hated the scars left on my body from surgeries meant to fix me. most of all, i hated going to the doctor and hearing what was still wrong with me, wrong with my body….i wanted to blend into the walls and disappear (p. 52). in order to deal with these issues, a person with disabilities may develop an eating disorder or other unhealthy coping mechanisms as a means to gain control and punish the body for failing to function at the same level as an able-bodied individual (minges, 2014). barriers toward diagnosis and treatment most mental health professionals are not familiar with treating people with disabilities (minges, 2014). many individuals with disabilities fear judgment for discussing body image issues and have a history of feeling marginalized, which makes developing rapport a challenging task (froehlichgrobe, nary, vansciver, washburn, & aaronson, 2012; minges, 2014). health care professionals and caregivers must also navigate the individual’s medical and physical limitations (e.g., balancing the disability-related need for an enema with a history of laxative abuse), avoid attendant service errors (e.g., making negative comments about the body), and ensure accessibility (e.g. making treatment centers wheelchair accessible) (froehlich-grobe et al., 2012). many people with disabilities underutilize preventative health care due to such barriers as transportation and finances (roosen and mills, 2014). diagnosing eating disorders in people with disabilities is often difficult. health care professionals often attribute all issues to the physical disability, including weight loss. one common way to diagnose an eating disorder is through body mass index (bmi). however, a person with a physical disability may have bone or muscle loss or be of a short stature, making an accurate bmi reading nearly impossible (roosen & mills, 2014). stigmatization also plays a major role in diagnosing an eating disorder in a person with a physical disability. in accordance with goffman’s (1963) theory of social stigma, in which individuals with disabilities are classified as undesirable, rejected stereotypes, these people possess attributes that discount them from meeting mainstream, socially constructed standards of beauty (roosen & mills, 2014). the resulting false belief is that people with disabilities do not care about their appearance and would never restrict their diet to meet these standards. clinicians need to be aware that clients with physical disabilities may be at risk of developing an eating disorder. this knowledge must influence the quality of nutritional counseling such patients receive and the assessment 6 | columbia social work review, vol. vii columbia social work review, volume vii | 7 the promise of music therapy hershenson of any sudden weight loss they experience (silber, shaer, & atkins, 1999). this author believes that having a physical disability coupled with an eating disorder presents additional challenges that traditional therapy may not effectively address. music therapy for people with physical disabilities unlike an eating disorder, recovery from a physical disability is often impossible. with disability comes a social and political identity and a distinctive worldview and culture (straus, 2014). brown (2013) found that the culture of disability is characterized by “hope, endearment, [and] ability” (p. 1). instead of seeking to normalize people with disabilities, music therapy may enhance their indigenous culture, acknowledge their struggles, and promote self-expression (straus, 2014). music therapy is a successful therapeutic intervention allowing persons with physical disabilities to achieve physical, emotional, and social goals (hooper, 2007). scientific evidence increasingly indicates that rhythm stimulates and organizes muscle responses (weiss, 2013). music may also provide a distraction from pain or discomfort associated with some physical disabilities (hooper, 2007). since music therapy uses musical interaction as a conduit for nonverbal communication, it is a useful technique for individuals who are unable to communicate or verbally express their emotions (gold, voracek, & wigram, 2004). treatment requires empowering people with disabilities by shifting how they view the disability (roosen & mills, 2014). this author believes that an important step in reducing body image issues is to develop a sense of connection with one’s own body. according to hooper (2007), music therapy incorporates different musical formats to achieve individualized treatment goals. musical instruments develop range of motion, hand grasp strength, and nonverbal self-expression. singing improves oral motor skills, pulmonary functioning, breath control, rate of speech, articulation, and pronunciation. analyzing music and lyrics provides opportunities to share personal thoughts and experiences. for a person with disabilities, music therapy is an important way to increase independence, self-confidence, and self-esteem (peters, 1987). music therapy for people with eating disorders just as music therapy is beneficial for individuals with physical disabilities, it is also a useful treatment for eating disorders. eating disorder symptoms are typically a means of coping with stressful or anxious feelings, and music therapy provides new adaptive coping skills (robarts & sloboda, 1994). listening, relaxation, guided imagery, songwriting, music analysis, and active music making are all musical ways of coping. music provides a way for the 6 | columbia social work review, vol. vii columbia social work review, volume vii | 7 the promise of music therapy hershenson individual to discuss emotions and access repressed feelings or experiences while examining his or her sense of self (robarts and sloboda, 1994). heiderscheit (2009) describes several types of music therapy treatment for eating disorders. song analysis helps clients share their stories by listening attentively to a song’s lyrics, tonality, rhythm, instrumentation, and form. another approach, song autobiography, asks clients to select important moments in their lives and identify songs that express these moments, thereby obtaining a better understanding of their lives. in addition, songwriting brings many issues—such as the challenges of an eating disorder, resistance to treatment, and acceptance—to the surface. finally, guided imagery in music helps explore underlying issues. as the music begins, clinicians lead clients through a brief relaxation and then ask what they are experiencing. clinicians then move into imagery, which often includes metaphors that allow clients to feel their emotions and begin to recover. music therapy for people with a physical disability and an eating disorder given the research, music therapy holds intriguing possibilities for individuals struggling with eating disorders and individuals with physical disabilities. as there are no current evidence-based practices addressing treating individuals with both conditions, music therapy seems to be the most promising intervention for this comorbidity at present. the viability of music as a treatment in such cases is even more evident in the following clinical case study of a man diagnosed with both cerebral palsy and anorexia nervosa. case example ryan b. is a 24-year-old graduate student (ryan b., personal communication, july 14, 2015). ryan was diagnosed with cerebral palsy at age 3 and used a walker-frame or scooter to move around. at school, people imitated his walking and called him “crip.” he had no real friends and felt excluded and lonely. as a result, he became very depressed. he dreaded going to school every day and wanted to “disappear.” thinking that if he lost weight his peers would no longer make fun of him, ryan developed an intense fear of eating and getting fat. at age 17, he was diagnosed with anorexia nervosa and soon after was admitted to an inpatient eating disorder treatment center. during his stay, he had regular therapy sessions, but as the “[ryan] attributes his recovery to music therapy because it gave him a way to tell his story. by sharing songs in sessions, he recognized that his cerebral palsy had made him feel out of control of his body, but as he began to lose weight, it felt as if he was somehow reclaiming control.” 8 | columbia social work review, vol. vii columbia social work review, volume vii | 9 the promise of music therapy hershenson only patient with a physical disability, it was difficult for him to talk about the root causes of his eating disorder. after his release from treatment, he continued to struggle and relapsed at age 22. ryan was eventually referred to a music therapist. he attributes his recovery to music therapy because it gave him a way to tell his story. by sharing songs in sessions, he recognized that his cerebral palsy had made him feel out of control of his body, but as he began to lose weight, it felt as if he was somehow reclaiming control. this concept was something he had never been able to verbalize. through continued music therapy sessions, ryan learned new coping skills and now feels that his eating disorder and cerebral palsy have been blessings in disguise. both make him different, which he now realizes is a strength. conclusion individuals with physical disabilities are at an increased risk of developing eating disorders (roosen & mills, 2014). with regard to people with both an eating disorder and a disability, there must be more representation in research, greater competency among health care professionals, and treatment options that better address their experiences. music therapy is an effective treatment option in treating those with both an eating disorder and a physical disability due to its focus on self-understanding, a key component in treating those with this comorbidity (heiderscheit, 2009; weiss, 2013). it is therefore likely that music therapy is a useful intervention for people with a comorbid diagnosis. references american psychiatric association. 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(2013). music therapy for people with disabilities. retrieved from http://www.disabled-world.com/ medical/rehabilitation/therapy/music.php#cite kimberly hershenson began her career as a professional ballerina training with the joffrey ballet. she is a graduate of new york university’s tisch school of the arts. she received her juris doctorate from pace law school, where she served as president of the sports and entertainment law society, and her master of laws in intellectual property from the benjamin n. cardozo school of law. while practicing intellectual property law in new york city, kimberly served as pro bono legal counsel for retorno, the largest jewish rehab center in the world. she was elected 10 | columbia social work review, vol. vii columbia social work review, vol. vii | 11 to the junior board of the national eating disorders association and served as a mentor at mentor connect, the first global eating disorder mentoring community to women in recovery from an eating disorder. in 2015, kimberly was elected as mentor connect’s executive board chair. music will always remain a passion for kimberly, but helping those with addiction issues is her life mission. kimberly will graduate in may 2016 from the columbia school of social work’s 16-month program. she is currently president of the substance abuse and recovery caucus and recently organized a standing-room-only speaking engagement featuring author, iron chef america winner, and recovered substance user jesse schenker. her greatest pride is being a wife to her amazing husband, evan, and a mother to her 1.5-year-old daughter, atara. 2019-cswr_neworder.indd 16 | columbia social work review, vol. x social enterprise: a route to systems change for women formerly incarcerated katherine seibel introduction women who were formerly incarcerated face a number of interrelated inequities and challenges on community reentry, which leads to poor socialemotional outcomes and increases risk of recidivism. these problems, which are compounded for women of color who have been formerly incarcerated and which are ultimately deleterious to individuals, communities, and the economy, are inadequately addressed by micro-level direct-service delivery and traditional solutions like governmental initiatives and nonprofit organizations. because governmental initiatives and nonprofit organizations have become inefficient and ineffective in providing solutions to complex social problems, it has become imperative for social work professionals to investigate alternatives to achieve transformational change for individuals and communities. this paper contends that social enterprise is an emerging alternative best positioned to address complex challenges faced by women who have been formerly incarcerated, especially in mitigating barriers to employment and economic mobility. currently, the rate of women incarcerated in the u.s. is at an historic high, with the rate of women incarcerated calculated to be 133 per 100,000 residents (kajstura, 2018). this rate is likely lower than the true rate of women who are incarcerated due to imprecise data collection, as criminal justice data collection does not always differentiate among individuals based on gender or include categories beyond the male/female binary (kajstura, 2018). further, collecting data on individuals who have been formerly incarcerated can be challenging due to situational and environmental obstacles such as housing insecurity, recidivism, or mental health challenges (western, 2018). a “catch-22” situation emerges after incarceration, as economic resources are necessary for formerly incarcerated people to move forward, and yet safe, adequate employment is often out of reach. while employment is critical to economic wellbeing and stability in our society, people who have been incarcerated often find it is difficult to find employment with a criminal record, particularly in the first year following release, and they also face other structural and complex social, emotional, and environmental difficulties (western, 2018). in a 2015 survey, 75% of participants who had formerly been incarcerated reported that finding employment was “very difficult” or “near impossible” with a criminal record (ajunwa & onwuachi-willig, 2018). indeed, the prison policy initiative estimated that the unemployment rate of formerly incarcerated individuals is over 27%, greater than unemployment during the great depression columbia social work review, vol. x | 17 social enterprise for systems change (couloute & kopf, 2018). moreover, available employment opportunities may be inconsistent or provide income inadequate for supporting oneself or a household without governmental assistance (western, 2018). western (2018) found that within the first year after release, an individual’s median income was nearly half of the federal poverty line amount for single adults, at $6,428. when women who have been formerly incarcerated obtain employment, the work is often highly supervised as a condition of release, which is inextricably entangled with negative societal perceptions about the individual’s moral character (gurusami, 2017). when individuals who have been formerly incarcerated are employed, they may be vulnerable to exploitation in the labor market (gurusami, 2017; zatz et al., 2016). it has been shown that the majority of individuals released after incarceration are motivated to find work and that in cases where an individual finds opportunity for skilled and sustainable employment, economic stability is possible and positive social and emotional outcomes often result (western, 2018). individuals who have a criminal record have a lower rate of job turnover, which could be cost-saving for employers (american civil liberties union, 2017). yet many public programs do not specifically target services to adults who were formerly incarcerated, which makes the reentry process all the more challenging (western, 2018). some of the biggest obstacles to economic security are the constraints in obtaining employment that result from having a criminal record, including disclosure and professional qualification requirements common in both the public and private sectors (ajunwa & onwuachi-willig, 2018). the lack of employment opportunities has negative spillover effects, including increased difficulty obtaining social welfare benefits (seccombe et al., 1998). formerly incarcerated individuals who have been recently released are also 10 times more likely to experience homelessness. women are, on average, more likely to experience greater rates of homelessness than men (couloute, 2018). individuals who have been incarcerated would benefit from multisystem supports, including housing, physical health, and mental health services (couloute & kopf, 2018). given that the majority of individuals recently released from incarceration are motivated to find work (western, 2018), providing wraparound services and improving access to employment opportunities can meet demand and ultimately help expand economic growth. more support and accessible opportunity must be created in order to help improve reentry process and outcomes. women who have been formerly incarcerated face prejudice, discrimination, and barriers to obtaining employment and resources in our society, and these are compounded at the intersection of race and gender (couloute & kopf, 2018; gurusami, 2017). of individuals formerly incarcerated, black women have faced the highest unemployment rate compared with men and white women (couloute & kopf, 2017). in one 18 | columbia social work review, vol. x study that examined the influences of race, gender, and criminal record on the hiring process, race and criminal record appeared to negatively impact the responses that women applicants received to online job applications, whereas there were no significant findings for men in this stage of the hiring process (decker et al., 2014). current barriers to funding systemic social change criminal justice reform is necessary; however, achieving and implementing broad reformation in law and policy is a long, complex, and uncertain process. as we work towards larger-scale reform, something must be done in the interim to address the needs of women who have been formerly incarcerated. examining the historical trajectory of responsibility for direct-service allocation can provide insight into current barriers to systemic change. some economists contend that the u.s. runs on the economic principle that when markets in the private sector fail, the government has the ability or duty to intervene to provide resources that maintain or improve economic stability and societal wellbeing (krugman & wells, 2018). with the implementation of the new deal, the u.s. government provided services to improve the wellbeing of society after the great depression devastated individuals, families, and communities nationwide (gilmore, 2017). however, over time, the government slowly withdrew from providing direct services as this approach fell out of favor as a means of addressing large-scale social problems (gilmore, 2017; kivel, 2017). in response to this change, nonprofit organizations emerged to take on the responsibility of providing direct human services (gilmore, 2017). the shift in responsibility for direct-service provision and the emergence of nonprofit organizations allowed the government to step into a regulatory role that oversees the nonprofit sector’s provision of services (kivel, 2017). the structural shift towards state regulation of nonprofit entities created formalized standards for the nonprofit sector (gilmore, 2017). the formalized relationship between public and nonprofit sectors means that nonprofits must abide by the rules that govern the allocation of public funds (gilmore, 2017). public funds, influenced by politics and legislative cycles, limit and moderate the change that nonprofits can achieve, because restrictions tied to financial support are set by the government and those in power (gilmore, 2017). in the united states, there are currently more than two million nonprofit organizations, which are now commonly considered a leading way to address societal problems and improve access to resources for people who have been marginalized (gilmore, 2017; reilly, 2016). it is estimated that government support makes up one third of a typical nonprofit organization’s revenue (saunji, 2015). moreover, many nonprofit organizations rely on government funding for their free or low-cost services, which is unsustainable (reilly, 2016). traditional nonprofit funding, such as reliance social enterprise for systems change columbia social work review, vol. x | 19 social enterprise for systems change on foundation grants and government resources, can present limitations to macro-level social change due to funding biases, funding requirements, and a tendency to focus on shorter-term, specific projects (kivel, 2017). these restrictions help perpetuate the nonprofit industrial complex, a paradoxical structure that unfortunately and unintentionally upholds the very systems that these organizations set out to change (kivel, 2017). this happens when organizations must rely on funding sources that may support those specific projects but that are opposed to creating systemic social change. as available government support is limited, nonprofit organizations need to find innovative strategies to obtain funding for their services (defourny & nyssens, 2010). kivel (2017) notes that funding regulations limit nonprofit groups to providing direct services without providing resources to achieve transformational, systemic social change. in the same vein, the obstacle of securing funding is often challenging and primarily project-based, with time-consuming and restrictive requirements, which make it less feasible for nonprofit organizations to take action on larger system changes (kivel, 2017). another factor that can inhibit social change work is reliance on funding from private grants and donors (kivel, 2017). individuals with higher amounts of wealth make up only 20% of the population, yet they control 91% of the nation’s wealth (kivel, 2017). typically, individuals in the u.s. with a great amount of financial wealth are able to make larger, and therefore more impactful, financial donations. the professional and owner classes in our society choose where, if at all, to donate their money, impacting which organizations receive funding, how funding is allocated, and what the recipients must do to maintain the funding (kivel, 2017). thus, relying on wealthy donors to provide funding for the common good maintains power disparities. finally, it is pertinent to ask: when funding is received, who controls it? government or donor-provided funding is intended to aid those individuals or groups that a nonprofit serves, but it is usually the case that the people intended to receive the benefit of the funding have no control over it (kivel, 2017). the intended recipients’ lack of opportunities to influence funding decisions is a perpetuation of oppression against groups already marginalized in society. social enterprises focused on work support would have the ability to transfer equity to a more diverse range of recipients and to better empower the individuals they aim to support. if organizations involved in the private sector prioritize making a positive social impact, they have the opportunity to leverage resources to support self-sustaining entities that can make change for the individual and to macro-level systems. still, at its core, capitalism creates marginalization because it often fails to include or prioritize socially conscious considerations or decision-making in the interest of making a shortterm profit (mullaly & dupré, 2018). gurusami (2017) calls attention to 20 | columbia social work review, vol. x social enterprise for systems change intersectional capitalism, the intersection of race and gender identities with the marginalizing forces of capitalism, in regard to formerly incarcerated women of color. through intersectional capitalism, the state uses race and gender to exploit capital from women of color who were previously incarcerated by restricting employment opportunities to low-paid, grueling work that inhibits upward mobility, and then the state attributes individuals’ economic failings to character flaws (gurusami, 2017). in this process, the labor of women of color is molded to fit the state’s desire for low-cost labor, as well as to meet the status quo expectations of race and gender roles (gurusami, 2017). cementing this system’s power is the surveillance over these individuals that threatens reincarceration if conditional-release employment requirements are not met (gurusami, 2017; zatz et al., 2016). systemic change is crucial and timely strong economic arguments can be made for expanding support and employment opportunities for individuals who have been formerly incarcerated, including a recent report that suggests that a majority of consumers want products that are socially conscious and that also suggests that among millennial consumers, how a company makes its profits has become increasingly important (asmus, 2018; nielsen company, 2015). given these trends and the devastating economic and social impact of mass incarceration, this is a critical time for implementing sustainable structures, informed by social consciousness, in private-sector activities in order to advance social justice action and increase access to resources for marginalized populations. increased inclusion of formerly incarcerated individuals in the workforce could increase the u.s. gross national product by an estimated $78 billion to $85 billion (aclu, 2017). the role of social enterprise social enterprise initiatives can effectively address challenges faced by formerly incarcerated women through the creation of safe and supportive employment opportunities (ajunwa & onwuachi-willig, 2018). the goal of social enterprise implementation is to create a sustainable source of revenue, often through commercial market activity, that is used to provide direct services, employment support, or reinvestment in a community or social change goal (kerlin, 2018). developing social enterprises that employ women who have been formerly incarcerated is one way to disrupt systems that limit change to the status quo. social enterprises that offer employment opportunities to women who are formerly incarcerated, alongside holistic wraparound multilevel supports, create sustained opportunity for economic mobility in a way that the government and nonprofit organizations are simply not positioned to do. given that social enterprises move in the for-profit sphere, they are better positioned to take quick, bold action in hiring practices, for example, and to develop supportive services that can be sustainably funded with generated revenue. this approach could create columbia social work review, vol. x | 21 social enterprise for systems change immediate and lasting social change that advances economic opportunities for those who are marginalized by capitalism and who face challenges in accessing economic mobility. initially, it may seem counterintuitive to invite the private sector to address economic and social disparities that the private sector has helped to create. however, social enterprises are legally protected to focus on a social impact goal rather than to prioritize profit or economic returns for their shareholders alone (reilly, 2016). in the u.s., 33 states have already passed social enterprise legislation, predominantly through benefit corporation (b corp) statutes (mirzanian, 2015). social purpose corporations (spc) and low-profit limited liability corporations (l3c) also exist and differ in the extents to which they define their public benefit goals, are held accountable for social impact, are eligible for tax relief, and are evaluated by a third party (mirzanian, 2015). social enterprise frameworks vary across states, which yields pros and cons; implementation and regulation are not uniform, but variation in state economies and culture can promote innovative social enterprise strategies that flourish in different environments. the practical development in each locality and region is best based upon local cultural, economic, and historical factors (kerlin, 2013). by using a multidisciplinary, institutional framework (kerlin, 2013), we can understand how to best use social enterprises in a particular social climate in order to create system change. considerations for social enterprise social enterprise initiatives can effectively address challenges faced by formerly incarcerated women through the creation of safe and supportive employment opportunities (ajunwa & onwuachi-willig, 2018). the goal of social enterprise implementation is to create a sustainable source of revenue, often through commercial market activity, that is used to provide direct services, employment support, or reinvestment in a community or social change goal (kerlin, 2018). developing social enterprises that employ women who have been formerly incarcerated is one way to disrupt systems that limit change to the status quo. social enterprises that offer employment opportunities to women who are formerly incarcerated, alongside holistic wraparound multilevel supports, create sustained opportunity for economic mobility in a way that the government and nonprofit organizations are simply not positioned to do. one must take care to understand oppressive hiring and employment systems when implementing social enterprise initiatives, in order to avoid recreating and perpetuating these dynamics. social enterprises that focus on employment support and economic mobility must be voluntary to prevent coercion, and must have internal policies informed by a person-centered, trauma-informed, and strengths-based approach, with employment opportunities and support at every level of the organization. social enterprises that create employment for formerly incarcerated women 22 | columbia social work review, vol. x social enterprise for systems change should actively work against exploitative intersectional capitalism dynamics and should strategically plan viable, sustainable, stable economic growth for the women employed in a market that has traditionally served to marginalize them in multiple compounding ways. due to the fact that the job opportunities accessible to people with a criminal record can be limited and low paying (gurusami, 2017; ajunwa & onwuachi-willig, 2018), it will be important to set a higher standard for compensation in order to actively work against what have been exploitative environments. in the same vein, social enterprises have great potential to positively impact the job market for formerly incarcerated women. rather than waiting for legislation to create and implement fair and just employment opportunities for formerly incarcerated women, social enterprises can more expediently change hiring policies and implement supportive employment practices within their own entities. because the risk of unemployment is highest shortly after release (couloute & kopf, 2018; western, 2018), integrating proactive outreach, nondiscriminatory hiring policies, and long-term job supports within the social enterprise will be key. another consideration is to institute subsidies meant for wages at social enterprises, similar to the social enterprise models commonly used in spain (fisac & moreno-romero, 2015), that support the social enterprise’s growth, social impact, and ability to fairly compensate employees. as a part of the long-term job support, revenue generated by the social enterprises can fund self-sustaining, quality services that could be used to provide therapeutic, case management, and child care services. such services would be exempt from outside limitations in funding and would help to fill gaps in access to needed social support while making employment more accessible. finally, an internal policy must be in place that provides an opportunity for role and wage development should employees desire growth. social enterprise and like models in practice there are currently more opportunities than ever to harness social enterprise and like models that center the people who receive services, in order to create true systems change. unlocked futures, an accelerator program, invests in criminal-justice-related for-profit and nonprofit organizations that are led by individuals with lived experience in the criminal justice system (klintworth, 2017). unlocked futures has invested in clean decisions, founded by will avila, with its sister nonprofit, changing perceptions, which offers economic opportunity to individuals in the reentry process through employment in a supportive setting with access to free mental health and community supports (klintworth, 2017; clean decisions, n.d.). chrysalis, a social enterprise organization in california, is another exemplary organization that offers tangible and holistic support to people who face barriers to employment. as an organization, chrysalis offers programs for job preparedness, tangible resources necessary for partaking in columbia social work review, vol. x | 23 social enterprise for systems change the job search, mental health services, and women’s empowerment programs, to name a few (chrysalis, 2019). chrysalis enterprises is a transitional job program under the chrysalis organization that provides employment and professional development support as individuals who previously faced barriers to work enter the workforce (chrysalis, 2019). in its most recent annual report available, for the year 2017, chrysalis reported that it had helped 2,800 people to secure employment and that over 70% of chrysalis participants retained employment six months after hire (chrysalis, 2019). outside the u.s., east van roasters in british columbia, canada, is a coffee and chocolate business that supportively employs women who are in a residential addiction recovery program (east van roasters, 2019). the farestart and clubhouse models are not legally defined as social enterprises but can be incorporated into an effective social initiative to serve formerly incarcerated women. farestart is a seattle-based restaurant and job training organization that facilitates job training and placement in the restaurant industry for individuals who are experiencing homelessness or have been incarcerated. all revenue from the restaurant goes directly back to the programs serving the participants (farestart, 2018). david lee, the founder of farestart, reports that consumers expect that businesses will take the lead on creating change and also asserts that this environment enables social enterprises to be a sustainable source of positive change (lee, 2017). another avenue for social change affecting the individual on both a micro and macro level is the clubhouse model. certified clubhouses are spaces for individuals with behavioral health conditions to get involved with community, social, emotional, and vocational opportunities. clubhouse programs have empirically demonstrated their ability to help participants avoid hospitalization or incarceration and to help them achieve their social, financial, educational, and employment goals (clubhouse international, 2018). because farestart and the clubhouse models have a focus on economic opportunity and mobility as well as supportive employment that leads to positive social-emotional outcomes, these models can be platforms for further consideration of how to increase the effectiveness of social enterprise operations. 24 | columbia social work review, vol. x social enterprise for systems change conclusion social enterprises, if held accountable for their goals of social impact, can increase the flow of resources to people who have been marginalized by capitalism. when revenue is generated by the social enterprise, the organization can fund its own quality supportive services for its employeeparticipants in addition to providing employee-participants the benefit of having access to a stable, livable income. self-funded services would give employee-participants an economic stake and influence over the service conception and delivery. engaging in social change through social enterprises will enable populations that continue to experience marginalization and oppression to drive the care they receive and to access tangible benefits with opportunities for economic growth. in sum, we have hope and also have a responsibility to change the status quo for women who are formerly incarcerated, and in social enterprise, we have an actionable path forward to achieving this change. columbia social work review, vol. x | 25 social enterprise for systems change references ajunwa, i., & onwuachi-willig, a. 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(1998). “they think you ain’t much of nothing”: the social construction of the welfare mother. journal of marriage and the family, 60(4), 849–865. doi:10.2307/353629 western, b. (2018). homeward: life in the year after prison. new york: russell sage foundation. retrieved from http://www.jstor.org/ stable/10.7758/9781610448710 zatz, n., koonse, t., zhen, t., herrera, l., lu, h., shafer, s., & valenta, b. (2016). get to work or go to jail: workplace rights under threat (ucla school of law public law research paper no. 16-24). los angeles: ucla institute for research on labor and employment, ucla labor center, & a new way of life reentry project. retrieved from https://papers.ssrn.com/sol3/papers.cfm?abstract_ id=2774528 katherine seibel is a second year, online policy student in the field of child and family services. at her current practicum, she does policy analysis of mental health legislation, tracks bills, and conducts research reviews. journal final revised margins.indd this article examines the risks faced by helping professionals, such as clinical social workers, due to their tendency to be more attentive to clients than to their own needs. it is suggested that clinicians can improve job engagement and minimize burnout risk through increased selfawareness and self-care. using an approach based on giddens’ (1984) structuration theory, the authors provide specific suggestions for selfawareness and self-care, including the concept that workers should improve and exercise their self-advocacy skills as a form of self-care. rescuing the self from selflessness: how we can be better at helping others by helping ourselves steve salee & jonathan sibley there is a long tradition within clinical social work and psychology of considering the importance of self in direct practice (edwards & bess, 1998; guy, 2000; jennings, goh, skovholt, hanson, & banerjeestevens, 2003; kondrat, 1999; skovholt & jennings, 2004). the therapist or clinician plays a key role in therapeutic encounters, and it is thought that a healthy self is a clinician’s most important tool. in addition to considering the advantages of a strong self, this article examines the risks of depleting the self through an unbalanced focus on attending to others – unbalanced selflessness. in the early 1980s, researchers began studying the unique stresses faced by human services workers stemming from the nature of their direct interactions with clients (maslach, 2003; maslach, schaufeli, & leiter, 2001; posig & kickul, 2003). this particular type of occupational stress became known as burnout and is most frequently thought of as a combination of emotional exhaustion, cynicism about the job, and a low sense of personal achievement. burnout has a negative impact on the personal life and work performance of the affected worker, while the presumed antithesis of burnout, job engagement, has a positive impact on the worker’s personal life and work performance (maslach; maslach & goldberg, 1998; maslach, schaufeli, & leiter). this article considers some of the potential vulnerabilities of clinical social workers that may lead to a depleted self, key symptoms of this condition, and steps that can be taken to facilitate self-awareness and engage in self-care behaviors that can both strengthen and maintain the clinician’s self. rescuing the self from selflessness journal of student social work, volume ii 35 this article examines the social worker’s need for self-awareness and self-care, using the concept of person-in-environment, a framework that has been endorsed by the council on social work education and considered a hallmark of good social work practice (council on social work education, 2001; kondrat, 2002; rogge & cox, 2001). in particular, giddens’ (1984) structuration theory, an elaboration of the person-in-environment framework, will also be utilized. this framework develops the concept of bidirectional, recursive interactions between an individual and the individual’s environment and the ways in which this concept supports the notions of human agency and empowerment (giddens; kondrat, 2002). another framework frequently used in social work, bronfenbrenner’s multi-level, ecological systems model, which can be seen as an extension of the personin-environment approach (rogge & cox, 2001), will also be incorporated. bronfenbrenner’s model describes four levels of environment that can affect an individual or family – micro, meso, exo, and macro (bronfenbrenner, 1979). however, this article will forego a complete analysis of each of bronfenbrenner’s levels in the interest of brevity. background on social workers and self-care the tendency to limit or avoid self-awareness and self-care can take a serious toll on the practice and personal life of the clinical social worker. helping professionals appear to be more adept at assessing and intervening with individuals and groups as opposed to assessing and helping themselves. such avoidance could lead to less effective practice, professional impairment, boundary violations, and burnout. in addition, this avoidance could lead to personal relationship problems, depression, substance abuse, and even suicide in extreme cases (brady, healy, norcross, & guy, 1995; gilroy, carroll, & murra, 2002; o’connor, 2001; sherman & thelen, 1998; sussman, 1995b). until recently, few studies focused on distress, burnout, and impairment specifically among social workers. these studies showed mixed results (soderfeldt, soderfeldt, & warg, 1995). however, a 2003 study of social workers in north carolina found that 11% of social workers studied were at serious risk of alcohol abuse, another 22% were at moderate risk of alcohol abuse, and that 53% of those at serious risk reported some kind of professional and personal impairment (siebert, 2003). a recent study of social workers in the united kingdom found that 74% of respondents suffered from borderline to pathological levels of anxiety (lloyd, king, & chenoweth, 2002). although it is unfortunate that recent studies indicate a potential problem with distress, burnout, and impairment among some social workers, it is encouraging that these issues are receiving more attention among researchers. the implications of impairment and boundary violations extend beyond the individual helping professional, as the reputation of the salee & sibley 36 journal of student social work, volume ii helper’s profession can also be tarnished by such acts (sherman & thelen, 1998). while some clinicians suffer from distress, burnout, and impairment, there are other clinicians who have been found to thrive in their profession with therapeutic outcomes that are far superior to other colleagues (brown, dreis, & nace, 1999; okiishi, lambert, nielsen, & ogles, 2003). there appears to be little, if any, research on the specific clinician attributes that lead to positive client outcomes, but there is an increasing body of research that looks at the common attributes among practitioners who are considered to be master therapists, as defined by their peers or by client outcome measures (okiishi, lambert, nielsen, & ogles; skovholt & jennings, 2004). to date, attention to the clinician’s self, through self-awareness and self-care, has been cited as a key characteristic of expert clinicians (guy, 2000; kondrat, 1999; norcross, 2000; schwebel & coster, 1998; skovholt & ronnestad, 1992), and skovholt and jennings (2004) found that master therapists were as skilled at assessing themselves as they were at assessing their clients. additional research is required to identify what degree of selfawareness and/or self-care are directly correlated with therapist wellness and client outcomes. in particular there is a need for longitudinal studies of therapist development (skovholt & jennings) which follow students from school though their professional careers. self-awareness helping professionals are often driven by an intense curiosity about and interest in others (kottler, 2003; spurling & dryden, 1989). as some authors have pointed out, however, it is ironic that the same levels of curiosity and interest are not always present when the practitioners consider themselves (kottler; skovholt, 2001; sussman, 1995b). kottler stated that social workers are encouraged to be reflective but tend not to seek out the same sort of help they provide for and encourage in others. to some degree, social workers are in the business of “disillusionment” (kottler, 2003, p. 23), helping clients to replace their illusions and misperceptions with a more realistic, helpful view of their lives. there are also potential benefits to clients if social workers can disillusion themselves as well. through a more realistic lens, social workers can come to terms with a more balanced view of who they are, what motivates them, and how they behave in their profession, ultimately becoming more effective (kottler). personal therapy, supervision, consultation, and peer support are often-cited approaches to increase self-awareness and personal growth (kottler, 1999; kottler; pieper, 1999; skovholt & jennings, 2004). schools and training programs can also play a key role in encouraging students and trainees to become more self-aware (schwebel & coster, 1998; sherman & thelen, 1998; sussman, 1995b). rescuing the self from selflessness journal of student social work, volume ii 37 it can be important to understand one’s motivations for entering the helping professions to ensure realistic aspirations. this understanding may also serve as a preventive measure against future burnout, impairment, and boundary violations (o’connor, 2001). a number of authors have looked at the motivations of those in the helping professions, including social work (berger, 1995; gilbert, hughes, & dryden, 1989; grosch & olsen, 1995; guy, 2000; kottler, 2003; norcross & guy, 1989; o’connor, 2001; smith, 1995; spurling & dryden, 1989; sussman, 1995a; sussman, 1995b; vincent, 1996). these authors have found that some of the same traits that can lead people to these professions and contribute to their effectiveness as helpers can also be potential vulnerabilities when it comes to taking care of themselves and their clients. in many cases, helpers are driven by a “selfless caring for others” (smith, 1995, p. 785). it is also possible that they are motivated by forces that are further from their awareness and more difficult to accept – a search for intimacy, power, admiration, and even a desire to address issues in others that are also their own (gilbert hughes, & dryden, 1989; pieper, 1999; sussman, 1995a; vincent, 1996). skovholt and ronnestad (1992) found that graduate students studying counseling and therapy believed they understood their motivations for entering the profession, while senior clinicians often stated they had not fully understood their motivations when they were beginning their career. while this was not a longitudinal study and this difference may be explained by the varying cohorts and teaching methods, it is possible that there is an evolution in clinicians’ concepts of their motivations. it is important for social workers to understand their motivations. if they expect, even unconsciously, their clients to serve their own needs, they are likely to care less effectively for their clients and risk frustrating themselves, potentially leading to impairment or burnout (brady, healy, norcross, & guy, 1995; kottler, 2003; vincent, 1996). through self-awareness, social workers can mitigate unrealistic expectations of their clients and their client relationships. through such awareness social workers can recalibrate their expectations of themselves and their clients. another aspect of self-awareness is for social workers to recognize the impact of their personal histories on their choice of profession and how they practice. many who work in the helping professions have played the roles of go-betweens, helpers, caregivers, or mediators in their families of origin (kottler, 2003; ronnestad & skovholt, 2001; sussman, 1995b; vincent, 1996). the positive result of this experience may be that it helped them to develop particular skills and sensitivities toward helping others. however, that focus on the other could mean they have less experience and comfort when it comes to asking for and receiving help themselves. recognizing salee & sibley 38 journal of student social work, volume ii this can allow social workers to counteract such tendencies and seek out the help they need. there are several steps that social workers can take in an effort to increase their level of self-awareness (kondrat, 1999; skovholt & ronnestad, 1992): · notice their own biases. · get feedback from colleagues and clients. · utilize audio and video recording for self-monitoring. · secure good ongoing supervision. · engage in personal therapy. self-care at the individual level at the individual level, self-care is defined as the strategies that one uses to care for himor herself, particularly those that build-up or replenish the self, lowering the risk of impairment, burnout, or simply less effective practice (guy, 2000). maslach (2003) suggests that the three dimensions of burnout are cynicism, exhaustion, as well as a sense of ineffectiveness and lack of accomplishment. while direct client work may lead to quicker burnout, social workers in every discipline need to be aware of and guard against burnout. in fact, kottler (2003, p. 159) has suggested that “rustout” is a more accurate term than burnout “because it better represents the kind of slow, gradual process that eats away at a therapist’s spirit.” in many cases those around social workers may be the best sources of feedback about whether it is time to step up self-care efforts, given the difficulty of identifying the warning signs (kottler). in social work it is often hard to avoid disillusionment related to a sense of ineffectiveness and lack of accomplishment, one of maslach’s (2003) three dimensions of burnout. the greater the imagined success and power, the greater the potential for disillusionment. exhaustion, another of maslach’s dimensions, is also a potential concern for those who work long hours. this is particularly true when there is a great need for services and scarce and diminishing resources with which to help clients. with high, potentially unrealistic expectations for what can be accomplished and inadequate time and resources to achieve constant success, social workers may find themselves becoming cynical, completing maslach’s third dimension of burnout. building self-care into one’s way of life is recommended. just as social workers automatically write progress notes to track client progress or advocate for client social service needs, they also need to build selfcare into their schedules. several possible strategies for individual self-care include (kottler, 1999; mahoney, 1997; sussman, 1992): · maintain strong relationships with significant others. rescuing the self from selflessness journal of student social work, volume ii 39 · eat healthy balanced meals and get 7-8 hours of sleep a night. · get physical exercise at least three times a week. · try a few minutes of meditation in the morning or before seeing clients. · do not lose sight of hobbies such as movies, reading, arts, and museums. · take vacations away from routine schedules, home, and clients. · regularly capture thoughts and feelings in a reflective journal. · set limits and boundaries between work and personal life. · get supervision from peers or others. · embark on personal therapy to better understand motivations and possible sources of countertransference. there are also strategies that could be used within the educational system (schwebel & coster, 1998; sherman & thelen, 1998; sussman, 1992): · screen during the entrance process to ensure that students admitted to the program have a healthy, realistic understanding of their reasons for entering it. · include training on self-awareness and self-care within the curriculum, including family of origin work. · include training within the curriculum on recognizing and dealing with distress and impairment. · use a buddy system or small groups to help students become more self-aware. · ensure that supervisors can provide appropriate support. · continue or expand use of reflective journals and process recordings to ensure that students use these tools to improve their capacity for self-awareness. · encourage students to find an appropriate balance between study and outside interests. self-care at the person and environment levels the degree of fit between an individual and his or her work environment, known as job-person fit, appears to be a major factor in burnout across a broad set of occupations (maslach, 2003; maslach, schaufeli, & leiter, 2001; um & harrison, 1998). self-advocacy – an attempt to improve one’s professional and personal environment – can be seen as a form of self-care and an effective strategy in the quest to both improve job engagement and minimize burnout. as stated previously, the dynamics of exchange between the environment and the individual fit well with giddens’ (1984) model of person-in-environment. social workers may exercise self-advocacy in both salee & sibley 40 journal of student social work, volume ii the workplace and also within and on behalf of the profession of social work. in the workplace, social workers would be interacting with what bronfenbrenner would term the individual’s mesosystem. in advocating for the profession, the worker’s profession would be considered to be part of the individual’s macrosystem. if social workers find that they do not have the resources to do their jobs well, it may be time for increased self-advocacy in the workplace. areas which can be addressed include workload/caseload, paperwork requirements, salary, office environment, amount and type of onsite supervision, alliance building, and the effective marketing of social work services. on a broader level of the profession, using giddens’ (1984) concept of bi-directional, recursive interactions between person and environment, social workers are impacted by the profession’s role in society but also have the potential to contribute to a redefinition of that role. examples of self-advocacy used by social workers trying to impact the profession could include attempts to: · increase salary for all social workers. · improve the public perception of professional competence among social workers. · use and increase the power of the profession to practice at bothmicro and macro levels, practicing both case advocacy and cause advocacy on behalf of clients and others (lens & gibelman, 2000; walz & groze, 1991). strengthening alliances with other professions and practitioners would be of tremendous value to helping social workers and their clients. particularly within the field of social work where the nature of the work can sometimes be isolating, social workers can work more effectively through a greater degree of collaboration with others. by leveraging these resources, social workers will not spend their energy forging a new path of advocacy and support for each additional client. advocating for self-interest may sound antithetical to social work, but when social workers help themselves, they help their clients directly. selye (1974) writes about “altruistic egotism”, suggesting that altruism and egotism do not have to be seen as mutually exclusive. if a client sees that social workers are taking care of themselves, they may receive a positive modeling message of effective self-care. this becomes a useful model of self-advocacy that clients can internalize for their own lives. conclusion only when social workers incorporate an approach that includes self-awareness, self-care, and self-advocacy are they most likely to stay healthfully engaged in their chosen profession and of greatest service to their clients. if social workers begin to lose their self through unbalanced selflessness, they run the previously mentioned risks of impairment and burnout. thus, social workers are faced with a need to rescue the self from pure selflessness so that they may build and maintain their sense of self for their own good and for the good of their clients. rescuing the self from selflessness journal of student social work, volume ii 41 references berger, m. 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(1991). the mission of social work revisited: an agenda for the 1990s. social work, 36(6), 500-505. 44 journal of student social work, volume ii salee & sibley steve salee is a second-year master’s student at the columbia university school of social work concentrating in clinical practice within the world of work. he is currently an intern at the employee assistance program consortium in new york city. he holds a bachelor’s degree from brown university and a mpa from columbia university. his email address is stevesalee@verizon.net. jonathan sibley is a second-year master’s student at the columbia university school of social work concentrating in clinical practice within the world of work. he is currently an intern at the family service league in montclair, new jersey. he holds a bachelor’s degree in psycholinguistics and linguistic anthropology from princeton university and a mba from insead in france. his email address is jsibley@comcast.net. journal of student social work, volume ii 45 rescuing the self from selflessness microsoft word with shoes tied around my neck.docx © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. with shoes tied around my neck: trans-identified exceptionalism and (un)intentional realities for lgb in iran sepideah mohsenian-rahman this paper explores the history and modern-day social relevance of state-sanctioned acceptance and support of transidentified individuals in iran. as a result of a declaration made by supreme leader ayatollah ruhollah khomeini in 1987, gender confirmation surgery (gcs) has become a state-subsidized option for trans-identified persons looking to transition. iran now completes more gcs annually than almost any other nation. additionally, iran furnishes its newly transitioned citizens with new identification, corresponding rights, and other tools to proceed in a gender-segregated society. although these statistics may seem progressive, other alternative expressions of sexual identity are illegal and even punishable by death. research indicates that trans-exceptionalism in iran creates pressure for non-trans-identified men who have sex with men (msm) and women who have sex with women (wsw) to undergo gcs in order to gain legality, safety, and acceptance in iran. furthermore, the social experience of the lgbt community as a whole has not caught up to the progressive policies that some in this community enjoy. introduction n the holy day of ashura in 1987, fereydoon molkara, a 37-year-old iranian man of faith who desperately wanted to gain acceptance as a woman, walked onto ayatollah1 ruhollah khomeini’s compound with shoes tied around his neck and a quran in his hand2, in an act symbolizing a request for shelter. fereydoon utilized this symbolic gesture as he searched for recognition of an identity that he could claim publicly without fear of reprisal. following the historic meeting with khomeini, the single most influential man in iran at the time, fereydoon left the compound waving a historic authorization in the form of a fatwa3, or legal judgment, granting his request for gender confirmation surgery (gcs)4. khomeini addressed the fatwa to the chief prosecutor of iran and to the head of the medical ethics committee, permitting fereydoon to receive a sex change procedure that would align his self-gender identification with his anatomy (mcdowall & khan, 2004). fereydoon, soon to be the transgender woman maryam molkara, was impassioned by the nationalistic fervor brought on by the iranian revolution of 1979. the revolution, led by ayatollah khomeini, provoked strict ideological scrutiny of every aspect of iranian culture, including that of sexual and gender identity                                                                                                                           1 the title “ayatollah’ is given to a high-ranking shiite religious leader in iran who wields considerable legal and political power. ayatollah ruhollah khomeini was the supreme leader of the islamic republic of iran from the iranian revolution of 1979 until his death in 1989. his significance was not only as the most senior leader of the nation, but also as the charismatic leader of one of the most massive revolutions of the 20th century.   2 carrying motifs of religious symbolism depicting request for shelter (shoes, quran) are common rituals conducted during the holy day of ashura. it depicts the heroism of the imam hossein, accepted as the third imam by shi’a muslims, who shi’a believe was martyred on that day.   3 held as binding for the followers of the jurist who proclaims it, depending on their rank.   4 gender confirmation surgery, previously referred to as sexual reassignment surgery, is the current term preferred by advocates.   o © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. (najmabadi, 2011, p. 534, 542). in the years following the revolution, khomeini rose to the position of supreme leader of iran. simultaneously, the critical reassessment and integration of religion into government presented an opportunity for trans-identified people to eventually live as citizens aligned with their government and faith while expressing their self-identified gender. the radical governmental authorization granted by khomeini in 1987 validated fereydoon’s ability to identify publicly as the trans-woman, maryam molkara (tait, 2008). she pursued her own gcs in 1997 after securing support and funds from family and friends (human rights watch, 2010). molkara served as an advocate for gcs within the iranian healthcare system, eventually co-founding an organization with members of the supreme court and judiciary to help individuals with issues surrounding their sexual identity (mcdowell & khan, 2004). she was instrumental in advancing the rights and legal status of trans-identified individuals in iran, not only by securing the fatwa for herself (and others in turn), but also by refusing to accept a society that remains unstructured to fully accept or deny her identity. a confluence of religio-legal jurisprudence, which characterizes iran’s governmental system and molkara’s victory, has created a progressive legal reality for her and for other trans-identified individuals. the legal barrier for same-sex desire in iran however, has not been addressed. a continuing mismatch between legal realities for lgb identified and trans-identified iranians, coupled with the ongoing struggle for social acceptance for the entire lgbt community, marks the strides and shortcomings that define transexceptionalism in iran. status of lgbt individuals in iran traditionally in islam5, individuals who identify as gay or lesbian are reduced only to their sexual behavior (cole, 2006). iranian penal laws are rooted in an interpretation of islam that does not acknowledge same-sex desire as a permanent state. therefore, iranian men who have sex with men (msm) or women who have sex with women (wsw) are penalized for their actions (cole, 2006). the iranian penal code punishes men with death and women with flogging for same-sex sexual relations (human rights watch, 2010; oldershausen, 2012). trans-identified individuals are not specifically addressed in the quran (the safra project, 2014). historical discussions speak to a varied religious discourse, with many followers of the faith choosing to accept trans-identity as normal within islam (safra project, 2014). in 1967, khomeini published a religious fiqh, or islamic jurisprudence that prescribes guidance based on historical experiences, in his tahrir al-wasilah, which validated the rights of trans-identified persons to pursue gcs. khomeini’s progressive fiqh proclaimed that the “prima facie, or al-zahrir, view is contrary to prohibiting the changing sex by operation” (khomeini 1968, p. 753-5). tahrir al-wasilah was a philosophically important document primarily to khomeini’s followers at its time of publication, but it later advanced into national policy when khomeini became the supreme leader of iran. how a fatwa became a national policy the impact of the iranian revolution of 1979 on the landscape of iranian society cannot be overstated. it introduced a series of legal and cultural norms that differed from those of the previous – largely secular – monarchy. during this early period, iranian society underwent a wave of “cultural purification6” (najmabadi,                                                                                                                           5 the unethical nature of same-sex relations arguably reverts to the old testament story of lot in which god condemned men having sex with men (safra project, 2014).   6 iran saw a process of islamification of state institution, which aimed to rid the nation of the western influence that had modernized the nation for most of the 20th century. © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. 2011). some of the most profound facets of this period of islamification related to islamic ethics and ideology. such reforms included an overhaul of the education system in order to accelerate ideological changes, women becoming legally obligated to cover their hair as a symbol of morality and modesty, and sexual minorities, including trans-identified individuals for a short period, becoming criminalized under islamic law (paivandi, 2008; human rights watch, 2010). trans-identified activists confronted the newly institutionalized rejection of trans-identity during the period of “cultural purification” (paivandi, 2008). similar to the regime, they underwent a process of islamification that painted their cause with the color green, the color of islam (najmabadi, 2011). as they advocated for acceptance in the new islamic regime, they reminded the supreme leader khomeini of his own thinking pertaining to the subject that he had published in the tahrir al-wasilah, especially with regard to an individual’s right to live in harmony with his or her gender identification. their advocacy eventually resulted in ayatollah khomeini’s 1987 fatwa, issued on the premise that individuals have certain religious and civic duties they are obliged to perform according to their gender and sex. ultimately, this confirmed that gcs is permitted on a policy level within an iranian interpretation of islam. critical to this fatwa was an understanding that iran enforces gender segregation in many public and private places. furthermore, conformity to one’s identified sex is imperative for participation in many aspects of daily life, such as entering a mosque, sitting in a classroom, dressing in the morning, and even marriage (shakerifar, 2011; tait, 2009). individuals can be penalized if state-monitored conformity to gender norms is not met; public humiliation and incarceration are common reprisals. thus, by allowing individuals to change their anatomy in accordance with their internal gender identity, khomeini’s fatwa sought to reconcile conflicts between gender, sex, and expectations for public behavior. for molkara, khomeini’s fatwa validated her ability to identify with her body and identified gender, her right to a free and peaceful social and public life, and her right to practice her faith in accordance with her gender presentation. globally, the fatwa paved the way for iran to eventually have one of the highest rates of gcs, second only to thailand (human rights campaign, 2013; nelson, 2009). due to the legality and affordability of gcs in iran, many trans-identified individuals from european and arab nations still come to tehran for the surgical procedure. continuing lgbt marginalization from the outside looking in, iran’s acceptance and accommodations speak to “progress for transgender people in iran” (gender across borders, 2009). the progress in policy, however, has not fully carried through to the social experience of trans-identified individuals. the experiences of the trans-identified population and larger queer communities are often conflated, and lgb-identified individuals are pulled into the social complications that trans-identified individuals face. although iranian religio-jurisprudence has initiated a progressive legal reality for trans-identified individuals, legal barriers against same-sex desire remain. as it does for trans-identified individuals, the greater social environment creates further obstacles for gay and lesbian-identified individuals, regardless of the legal rights afforded either. one area in which this can be seen is military service. obligatory service in the military opens many doors for iranian men, especially with the accrual of a document card. upon completion of service, men are given a card that grants them many privileges, including the ability to qualify for a passport, officially buy or sell goods, participate in public sector activities, and gain employment with the government (samimi, 2013). in 2010, the office for the socially harmed at the welfare organization of iran responded to strategic lobbying and activism by trans-identified individuals to reclassify their exemption from the military from “mental disorders clause” (section 33.8) to the “glandular disorders clause” (section 30) (najmabadi, 2011, p.2). this                                                                                                                                                                                                                                                                                                                                                                                                           © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. has, in theory, reduced the amount of discrimination trans-identified men receive when seeking employment as a more socially-permissible exemption is clearly displayed on their identification. gay-identified men and msm, however, must still abide by the “mental disorder clause,” which categorizes them as “moral and sexual deviants” (hrw, 2010, p.24). for them, a card is stamped with the words “sexual deviant” or “behavioral disorder” as a “red-exemption,”7 stigmatizing labels that render the person virtually unemployable (hrw, 2010, p.24). the resulting policy remains a topic that is constantly evolving, with many state leaders continuing to weigh in. today, hasatoleslam kariminia, the cleric responsible for the bureaucratic administration of gender confirmation procedures, states, “the right of transsexuals to change their gender is a human right” (human rights watch, 2010). the rights of lesbian, gay, and bi-sexually-identified individuals, however, are another story, as their experiences remain tied to those of trans-identified individuals. the consequences of gcs for lgb and trans-identified individuals in an environment in which same-sex conduct is criminalized and gcs is state-sanctioned, human rights experts have expressed concern that members of iran’s lgbt communities are being incentivized to undergo surgery to attain a certain level of social acceptability and recognition (hrw, 2010). najmabadi explains, “[f]or legal and medical authorities, sex change surgeries are explicitly framed as the cure for a diseased abnormality, and on occasion they are proposed as a religio-legally sanctioned option for heteronormalizing people with same-sex desires or practices” (oldershausen, 2012). progressive policies towards trans-identified persons are simultaneously capturing other sexual minorities in a harmful web of social and legal isolation, institutional violence, coercion, and oppression. a certification available to trans-identified individuals from the legal medicine organization of iran opens many doors for trans-identified persons, including authorization for gcs, hormonal procedures, stateprovided health insurance, social work support, financial assistance in the form of subsidies for housing and sexual reassignment surgery, exemption from obligatory military service, issuance of new identification records, and the ability to legally wear clothing associated with one’s gender identity (najmabadi, 2011). these doors remain shut without surgery and certification. obtaining the rights afforded by this surgery is critical to survival in iran. nevertheless, policy has not alleviated the fear of social stigmatization and communal discrimination that individuals who have undergone transition harbor. as one 25-year-old trans-woman from tehran explained, “[i]n iran being a transsexual means having no place, no identity, and being treated like a whore. even if one had a sex change, it’s the same” (hrw, 2010). trans-identified individuals experience trauma when they are rejected from their families, are victimized by sexual and gender-based violence, and are unable to hold steady employment due to their gender identity. these factors render such individuals particularly vulnerable to social and state-sanctioned abuse, and can expose them to risk for poverty, homelessness, substance abuse8, hiv9 and other sexually transmitted diseases, and engagement in sex work that similarly heightens these risks                                                                                                                           7 “red-exemptions” refer to the physical color of the card exemptions from obligatory service due to sexual orientation used to be printed on previously (samimi, 2011). section 33 clauses are still viewed as “red-exemptions,” although this no longer has any link to the color of the documentation card (hrw, 2010, p. 24).   8 iran has the highest opium and heroin addiction per capita in the world, with an estimated 200,000 to 300,000 people who inject drugs (pwid). nearly one in seventeen iranians are addicted to some form of opiate (razzaghi, 2006, p.2).   9 two-thirds of iran’s 96,000 hiv+ individuals are intravenous drug users, with the highest concentration in tehran (razzaghi, 2006, p.2). © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. (melendez, bonem, & sember, 2006). these harsh social realities often spill over into the lives of lgbidentified iranians. many employers openly discriminate against people they deem as queer, rendering trans-identified individuals with little financial means. as sex work can be conducted legally in iran through the shi’a notion of a temporary marriage,10 participation in sex work is common and protected. for a trans-identified person who has undergone gcs, it is legal to have a temporary marriage conducted as often as once per hour because there is no chance of pregnancy necessitating future parental responsibilities on the part of the soliciting party (eshaghhian, 2008). this religio-legal loophole gives iran the appearance of a sweepingly liberal state, which belies reality. heart of a lion a cross-sectional study conducted of all gcs performed in iran from 2002 to 2009 indicates that, in proportion to the nation’s total population, the number of female-to-male transitions in iran exceeds the international average (ahmadzad et al., 2011). this finding must be contextualized within a patriarchal sociocultural framework. in pre-modern iran, women who wore men’s clothing to battle for the country or participate in protests were seen as powerful and worthy of honor (najmabadi, 2005) and as having “the strength or heart of a lion” (carter, 2011, p. 815). likewise, women who transition into men gain a myriad of gendered rights. the new gendered responsibilities contribute to the old cultural myths of strength and righteousness of the motherland (carter, 2011). this is why women who transition into men have an arguably easier time in iranian society, and perhaps why there is an exceptionally high rate of female-to-male transitions in iran. conversely, men who transition into women lose many legal rights and social privileges, often finding themselves further ostracized. in patriarchal iran, it is seemingly unimaginable to empathize with intentionally abandoning the rights attributed to men, as doing so may indicate weakness. in one case, due to the heightened estrangement she felt after gcs, a trans-identified woman expressed the desire to either have the surgery reversed, or commit suicide (carter, 2011). policy recommendations in order to complement the strides iran has taken to protect trans-identified individuals through policy, further policy recommendations must address the religious and political abandonment as well as the social stigma present for other sexual minorities. these proposed policy changes encompass a series of inclusive measures to alter the legal, social, and economic landscape for the entire lgbt community. this includes encouraging iran to fully embrace all articles of the universal declaration of human rights— to which it is a signatory— and other relevant conventions (un, 1948). iran must enact policies that value the inherent dignity of all citizens by abolishing laws that criminalize sex outside of marriage and same-sex conduct, sanction arrests under morality laws, and codify such punishments as execution and torture. reforms will also need to include the perpetuation of harmreductionist approach in policing tactics towards people who use drugs, sex workers, and the homeless. recently, the united nations office on drugs and crime hailed iran for being a regional leader in the field of harm reduction (unodc, 2014; tanner, 2013). this harm-reductionist approach must continue.                                                                                                                                                                                                                                                                                                                                                                                                           10 temporary marriages can last from several hours to many years (hrw, 2010, 82). sigeh is a pre-islamic contract traditionally used by arab tribes during long-distance trade (view from outside iran, 2006). sigeh is not validated by many branches of islam.   © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. in addition, iran must demonstrate a commitment to protecting— rather than criminalizing— victims of gender and sex-based violence. by facilitating a cultural environment that does not condone the harassment and persecution of sexual minorities, iranian society may also move towards becoming a freer and more open community both for trans-identified individuals who have a degree of policy protection and for gay, lesbian, and bisexually-identified individuals who do not. role of social workers in future reforms social work education was introduced to iran in 1958 by a u.s.-trained iranian social worker (iran association of social workers, 2014). social work currently holds an established role in post-revolutionary iran, advocating for public health as a social justice issue (hansen, 2012). in 1981, the state welfare organization was founded as an overarching agency responsible for “prevention, rehabilitation, social participation, and social affairs” (padyab & ghazinour, 2013, p. 807). iranian social work training prioritizes empathy, compromise, positive communication skills, peaceful intervention, and social change (padyab & ghazinour, 2013). like their colleagues around the world, iranian social workers aim to meet the needs of and enhance the wellbeing of all individuals as classified in the ethics of the international federation of social workers, the iran association of social workers, and the national association of social workers alike (national association of social work, 2008). currently, a trans-identified individual pursuing gcs in iran receives social work support from the same government departments that provide medical expense subsidies, national health insurance, and housing assistance (najmabadi, 2011, p. 8). social workers assist patients in navigating the “labyrinth of cognition and change” surrounding state-sanctioned transition (najmabadi, 2011, p.6). they are instrumental in helping patients obtain diagnoses, acquire permits to dress in accordance with their gender identity, navigate the bureaucratic path to gcs, and recover from surgery safely (eshaghian, 2008). social workers and naturally, through extension, peer advocates, provide support in ways that complement iranian cultural traditions by reaching out to elders or encouraging trans-identified individuals to cultivate the support of family members prior to undergoing gcs (najmabadi, 2011). at a policy level, social workers should continue to take responsibility for ushering in the changes brought forth through the recent publication of the diagnostic and statistical manual of mental disorders v in a culturally appropriate way. given the societal and familial stigma attached to persons who have undergone gcs, the role of social workers must reach beyond simply connecting people to services. there is little literature focusing on the role of social workers within the trans-identified community. future research must enable social workers to help trans-identified individuals find sustainable employment and cultivate family support, ensure the safety of those with unsupportive families or communities, connect individuals with legal support if necessary, and fulfill the mental health needs of their clients. social workers have a similar obligation to the larger queer community in iran. they hold a unique and progressive position within the government that affords them the ability to catalyze change in entrenched attitudes and beliefs that marginalize and repress the lgb community. social workers must capitalize on the reality that progress is in the hands of iran’s disproportionately young population that is open to confronting historical and social norms. it is imperative that social workers educate the youth and have them serve as advocates for change when confronting policymakers, uniting lgbtq allies and advocates, and enhancing religio-political belief systems to include space and rights for gay and lesbian iranians. conclusion for maryam molkara, iran’s strides towards institutionally validating trans-identity have arguably provided with her safety, purpose, and hope. nearly fifty years of advocacy within a unique religio-political space and time have resulted in exceptional policies for trans-identified persons in iran. the evolution of © 2015 mohsenian-rahman. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. these progressive policies is immensely laudable and must be appreciated on a global stage. still, the unintended consequences these have for gay, lesbian, and bi-sexual identified individuals through heightened stigma and the resulting “sex change or die” vacuum must not go unchanged. further, the social realities for the entire lgbt community leave much to be desired. victories for trans-identified individuals in iran cannot be embraced as a victory for all sexual minorities. with the continued strength, organization, and perseverance exemplified by molkara, however, iran can one day develop into a safe and open place for all. references ahmadzad-asl, m., et. al. 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(2013). epidemiological fact sheet: iran. retrieved september 21, 2013, from http://www.unaids.org/en/regionscountries/countries/islamicrepublicofiran/ united nations. (1948). universal declaration of human rights. retrieved september 21, 2013, from http://www.un.org/en/documents/udhr/ united nations. (2011). human rights committee recommendations of un periodic review of iran. retrieved september 21, 2013, from http://www.iglhrc.org/sites/default/files/544-1.pdf united naitons office on drugs and crime. (2014, feb 17). unodc official praises iranian ngos’ efforts on drug demand reduction. retrieved on november 20, 2014 from http://www.unodc.org/islamicrepublicofiran/en/unodc-official-praises-iranian-ngos.html sepideah mohsenian-rahman received her msw with a concentration in international social welfare and policy from cssw in 2014. prior to graduate school, she worked in international development and global peace building focusing on the middle east and central asia. her time as a student at columbia enabled her to critically assess current policies affecting highly stigmatized communities in these regions. she is currently working at the university of california, santa barbara.   2018-final.pdf 12 | columbia social work review, vol. ix childhood domestic violence trauma impact and coping strategies at a later stage in life: a qualitative exploration ana quiñones studies indicate that over 8.3 million children in the united states are exposed to domestic violence trauma, and results have indicated that exposure to this trauma can have serious developmental effects. this study includes qualitative data collection on six participants who have overcome childhood domestic violence trauma (cdvt). each participant was interviewed, and successful coping strategies were identified in the process. using grounded theory, which interprets the data into collective themes, coping strategies were put into categories and subcategories. after the strategies were organized, the results provided a structured framework for different coping alternatives that could be useful to practitioners who are working with people experiencing or recovering from cdvt in their lives. these results should be adhered to in curriculum-based practice, and can be used as a framework for macro, mezzo or micro application. implications of this study include greater knowledge base for child welfare workers, along with the opportunity for new interventions in working with children struggling with cdvt. furthermore, identification of these interventions can serve to reduce long-term effects of cdvt on children. introduction violence experienced by children in families and its later consequences for children’s personal lives is always a matter of concern. it is estimated that roughly 11.1% of children in the united states have been exposed to physical or psychological violence in the family involving an adult (hamby, finkelhor, turner & ormrod, 2011). exposure to childhood domestic violence trauma (cdvt) has a lasting impact on children and becomes a serious barrier to development even after the children are safe from the domestic violence situation (hardesty & campbell, 2008). studies have shown that exposure to cdvt can lead to behavioral issues in children as they progress through life (moylan, herrenkohl, sousa, tajima, herrenkohl, & russo, 2010). there have been some studies that provide guidelines for coping mechanisms (izaguirre & calvete, 2015). however, further research is needed to determine a wider range of coping mechanisms within people who have been exposed to cdvt. studies indicate that there is a need for more professional strategies to help children who have been exposed columbia social work review, vol. ix | 13 ana quiñones to cdvt (huang, wang & warrener, 2010). furthermore, the earlier the intervention is put in place, the better developmental outcome the child will have (huang et al., 2010). exposure to cdvt in the united states, 5.8% of children revealed that they had witnessed family violence in which one parent assaulted the other (finkelhor, turner, shattuck, & hamby, 2015). children who are exposed to domestic violence are more likely to live in poverty; however, they are also more resilient than “non-poor” (p. 2468) children (yoo & huang, 2012). stressing the numbers of the children who are exposed to cdvt may provide better insight into size of the issue at hand for society. in a recent study, researchers found that children who are exposed to cdvt are more likely to experience emotional, physical, and sexual abuse during the time when the trauma is present in the home than children who do not experience cdvt (holt, buckley & whelan, 2008). this study also found that the emotional effects of trauma are likely to be present even after the children are in a safe environment. calling for a more child-centered approach from professionals could alleviate the suffering of children who have been exposed to domestic violence (holt et al., 2008) and increase their ability to use effective coping skills. behavioral issues behavioral issues arise after cdvt during childhood and well into adulthood. studies show that preschool aged children exhibit long-term detrimental behavioral effects following cdvt (huang et al., 2010). children who focus their attention towards domestic violence are more at risk of developing anxiety issues (briggs-gowan et al., 2015). children may also suffer from severe cognitive deficits, social withdrawal, and limited peer interactions (hildyard & wolfe, 2002). izaguirre and calvete (2015) found that 97% of mothers who have been victims of domestic violence revealed both that their children were indirect victims and that children often tried to interfere in the conflict. it appears that exposure to domestic violence may cause children to think that they have to assume adult roles and responsibilities; alternatively, they sometimes begin to exhibit aggressive behaviors that may be directed towards their mothers as well (izaguirre & calvete, 2015). boys are more at risk of exhibiting externalizing behaviors (e.g. hitting, bullying) and girls are more at risk “exposure to childhood domestic violence trauma (cdvt) has a lasting impact on children and becomes a serious barrier to development even after the children are safe from the domestic violence situation (hardesty & campbell, 2008).” 14 | columbia social work review, vol. ix cdvt impact and coping strategies later in life of internalizing behaviors (e.g. anxiety and powerlessness) due to the fact that boys are more likely to be conditioned at a young age to be dominant while girls are taught to be submissive (blair, mcfarlanne, nava, gilroy, & maddoux, 2015). extensive studies that focus on the repercussions of cdvt have found that adolescents are more likely to fall into delinquency and depression if they have been exposed to domestic violence and/or child abuse than adolescents not exposed to either form of violence (moylan, herrenkohl, sousa, tajima, herrenkohl, & russo, 2010). the social learning theory, which focuses on the pattern-repeating behavior that occurs when an individual learns from his or her environment (bandura, 1973) can be correlated to aggression displays later in life from cdvt. aggression in university students has also been confirmed to be a possible effect of cdvt (feroz, jami, & masood, 2015). coping children who have been exposed to childhood domestic violence exhibit unique coping strategies depending on their family system. external coping strategies indicate the extent to which caregiver support makes an enormous difference in how children respond to stress (hildyard & wolfe, 2002), as caregivers provide a model that children follow for problemsolving, personal control, and predictability (luthar, cinchetti, & becker, 2000). a child’s adjustment is largely reliant on how their parent functions throughout the trauma (graham-bermann, gruber, howell, & girz, 2009). the child’s family as a whole also plays a role in coping for the child. the family stress theory states that a family’s ability to deal with stress is an indicator of how each individual family member will deal with it as well (hardesty, campbell, mcfarlane, & lewandowski, 2008). connecting with supportive loved ones, enacting family rituals, and staying busy are all examples of family coping mechanisms that, according to the family stress theory, can also help the individual child cope (hardesty et al., 2008). in contrast, exposure to intimate partner violence (ipv) can lower maternal warmth (holmes, 2013) and, in turn, affect the children’s ability to adjust after domestic violence trauma. currently, studies surrounding childhood domestic violence experiences lack a strengths-based perspective, and more research is necessary to identify specific coping strategies that were used by participants to transition into adulthood (izaguirre & calvete, 2015). columbia social work review, vol. ix | 15 ana quiñones methodology this qualitative research study had six participants over the age of 25. participants consisted of five women and one man. there were no gender or race-specific requirements for participation. inclusion criteria for the sample included having experienced domestic violence trauma before the age of 18. referral and recruitment were completed through social media sites such as facebook and referrals from department heads at family support services in amarillo, texas. potential participants were given information about the research process and goals. their questions regarding any part of the research were answered truthfully, and deception was not used in any portion of this study. each interview and participant was anonymized through use of codes and pseudonyms for names, towns, workplaces etc. the research was conducted in compliance with institutional review board standards and with approval. this study utilized a qualitative approach to gain a reliable amount of data. the grounded research method was used for the qualitative portion of data collection. the method for this study was an in-depth analysis of interviews and discussions with participants. each participant had one interview with the researcher and on some occasions, two interviews were conducted based on the preliminary data analysis. the duration of the interviews varied based on the quality of the information received. these interviews/discussions included explorative and strength-based questions from the changed lives new journeys (2013) website to help guide the discussion along (appendix a). participants were encouraged to engage in discussion and an in-depth narrative of their trauma and their coping mechanisms. they were also encouraged to submit any additional information that came to mind after the interviews via an electronic form and were allowed to submit any creative work that they might want to share for analysis. the data was collected within a month’s time. a thematic analysis was used for this qualitative research. each interview was transcribed and coded respectively by the primary researcher. line by line coding was used to minimize the exclusion of any vital information to provide a dense analysis (glaser & holton, 2004). the interviews were read and analyzed for sub-themes to later group into main themes. the themes were discussed with co-investigators for analyst triangulation and further modified based on the analysis of the co-investigators. furthermore, the researcher discussed findings with the participants to make sure that the results were trustworthy. 16 | columbia social work review, vol. ix cdvt impact and coping strategies later in life findings the participants in the study identified several coping strategies that were beneficial to them during and while overcoming cdvt. every participant identified physical and emotional trauma occurring in his or her home as a child. all expressed some feeling of helplessness during the trauma. one elaborated: “i really don’t remember a time when anybody actually spoke to me about what was going on; it was always just kind of always happening around me.” (david) the analysis of the participants’ stories of overcoming cdvt led to the identification of coping strategies during three phases. the description of the three phases, coping strategies used, and statements from the participants follow. (for a summary chart, see appendix b). coping strategies during cdvt the most significant coping strategies identified by the majority of participants included school, focusing on having good grades, writing, avoiding conflict when possible, having sibling support, having a positive professional intervention, having role models, and going with the flow. using external resources allowed for a healthy coping process that helped most of the participants define goals to move them towards emotional progress. having role models present in their lives while experiencing the cdvt allowed half of the participants to begin to establish goals for themselves. out of the six participants, all but one identified having positive professional intervention growing up that made a significant difference in how they perceived and coped with the conflict. the experiences range from interactions with social workers, counselors, therapists and law enforcement. a participant explains the impact of having that resource available to her: “the social worker at the rehab center and the counselor at the school were probably the two most vital things in my life that helped me.” (alice) all of the participants identified school as their main coping mechanism during their time experiencing the trauma. it proved to be a distracting factor that allowed them to focus their energy on something besides the negative environment at home. columbia social work review, vol. ix | 17 ana quiñones being focused on school and channeling their energy towards getting good grades was identified as a motivating factor to begin forming values for themselves at a young age. going with the flow and using writing as a way to vent, as 66.6% of the participants did, allowed them to express their emotions in a private manner. “i used to write a lot. especially during that time period, i had journals and journals full.” (angelina) avoiding conflict while growing up was another coping mechanism that allowed participants to emotionally disengage from the negative situation at home. avoiding conflict involved sneaking out of the house, locking themselves in their room, and not getting physically involved. one participant also stressed the importance of sibling support to help get through rough days and avoid conflict: “my sister and i are very close…. a lot of the times when my parents would be fighting or whatever, i would read to my sister.” (claire) coping strategies while breaking the cycle when the participants were old enough to make their own decisions, many were focused on breaking the cycle of abuse, which they defined as wanting to avoid the repetition of the negative behavior patterns they had seen in their parents. coping methods identified by the participants to break the cycle included moving out, setting goals, and focusing on school. moving out as soon as possible from the toxic environment at home was something five out of six participants did. most participants were looking for a safe place away from home and were ready to live a different lifestyle than the one they grew up around. a participant narrates the emotional whiplash of being away from home: “it’s like it wasn’t normal to not have that chaos…. we were so used to the dysfunction.” (alice) soon after, five out of the six participants unexpectedly found themselves in similar dysfunctional relationships after leaving home. one participant revealed the vulnerability of being alone for the first time: “when i ran away initially…i didn’t heal from any of it, you know…. i was probably broken in any way i humanly could be.” (claire) 18 | columbia social work review, vol. ix cdvt impact and coping strategies later in life statements from the five participants who found themselves repeating the negative cycle expressed the importance of becoming aware and setting standards for themselves and their future. one participant shared the desperation felt: “you have no idea what it is to live like that as a child and as an adult, in a situation like that.” (alice) they ultimately found a way to break the cycle and move on to the final phase of coping. coping strategies after cdvt overcoming cdvt later in life proved to be an emotional journey for all of the participants. some of the coping mechanisms mentioned included having a working relationship with the victim and perpetrator of the domestic violence, staying busy, family, and turning negatives into positives. they also identified school, sibling support, support from a significant other, being responsible, talking about the trauma, working with kids, and learning about dv as protective factors. all of the participants in this study received or are in the process of receiving a degree from a higher education institution. school became a portal to learning more about dv, staying busy, and being responsible. learning more about the trauma and the processes involved during cdvt gave all but one of the participants a settling feeling of understanding. one participant shares: “i’m able to understand more of that time, you know, what they must have been going through.” (claire) school was also a helpful way to stay occupied. all of the participants mentioned that getting through school was an important part of overcoming the trauma: “what school really did was put me in my place because it just gave me structure i needed.” (abagail) four out of the six participants explained the resourcefulness of focusing energy towards school instead of “wallowing” in the past. 83.3% of the participants shared that taking on responsibility as a core personal value permitted them to become more objective in their views of the world columbia social work review, vol. ix | 19 ana quiñones and their own life. assuming responsibility for their emotions became a source of strength that contributed a feeling of control in their daily life: “you are in control of your emotions, and that’s really all you have control over.” (abagail) taking opportunities to better themselves for the sake of their loved ones was also significant. more than half of the participants also made points to learn from the mistakes of others. “i had all of the opportunities in the world to be such a horrible person and i—i didn’t.” (angelina) five participants also acknowledged the importance of having support from a sibling or significant other after the trauma had occurred. it gave them the opportunity to voice their feelings and questions to somebody they trust. “having somebody to share it with is something i hadn’t i guess experienced before.” (david) when the participants engaged in a positive relationship with their childhood caregivers from the time of the trauma, they expressed gaining a better understanding of the dv situation. only one participant expressed having forgiven the perpetrator for his or her actions, and at least half of the participants still feel some sort of resentment towards their caregivers but have worked through it by talking about it with them. “it always helps to talk about it.” (angelina) discussion transitioning from a difficult childhood in which violence, manipulation, and stress are common in the household, many children grow up to become caught up in the negative cycle of dysfunction as adults. using silent methods of venting their feelings proved to be an effective way for study participants to stay out of the conflict at hand. moving out of the home environment and having space away from the conflict always proved to be beneficial for the participants, as they found the time to get to know themselves without the environmental stress. “establishing a sense of who they are and having standards for themselves, their significant others, their children, and their lifestyle gave them control over their emotions concerning the cdvt.” 20 | columbia social work review, vol. ix cdvt impact and coping strategies later in life setting up barriers against negative family influence and allowing people back into their lives conditionally was vital in moving forward. establishing a sense of who they are and having standards for themselves, their significant others, their children, and their lifestyle gave them control over their emotions concerning the cdvt. with school as a major driving force and inspiration, the participants were able to set goals and achieve a successful lifestyle that is completely shaped by them instead of their cdvt. establishing a relationship with the dv victim and the dv perpetrator gave them the opportunity to talk about and express the emotions that were ignored as children. limitations one first limitation of this research study is that the participants were all recruited from amarillo, texas, and so the study cannot be generalized to populations beyond those included in the sample. second, the study depended on self-report; therefore, biases and inaccuracy may be present. other research has suggested that professionals who work with clients who have survived cdvt should be thoroughly educated, engage in collaboration, and constantly evaluate their practice (campbell & thompson, 2015; lessard & alvarezlizotte, 2015). some misconceptions that hinder service delivery include believing that the child is not a victim of the domestic violence because there is no physical injury, that if a child did not see the act they have therefore not been affected, or that a particular child might be too young to be affected (campbell & thompson, 2015). these misconceptions lead to gaps in provider education and lessen the strength of service distribution. child welfare workers who interact with these clients should focus on forming positive conversational relationships that allow for more effective engagement strategies (melchiorre & vis, 2012). recommendations a more child-centered approach is recommended in agencies that interact with victims of dv and their children. early positive professional intervention has shown to be a standout resource for 83.3% of participants interviewed. these interventions may not always be formal, but people experiencing or overcoming cdvt should be given the information and tools to be able to find their own way to cope. overcoming cdvt is not limited to formal interventions such as therapy. survivors of cdvt may find comfort in knowing that there are several effective informal resources, “survivors of cdvt may find comfort in knowing that there are several effective informal resources, as outlined by the participants of this study, that they may use to support their well-being.” columbia social work review, vol. ix | 21 ana quiñones as outlined by the participants of this study, that they may use to support their well-being. on a micro level, the coping themes found in this article could be utilized to further counseling outcomes. on a mezzo level, collaboration between disciplines provides a better use of expertise and creates a more unified bridge between ipv and child maltreatment experts to find better solutions for their clients (lessard & alvarez-lizotte, 2015). finally, macro implications of the findings are rooted in keeping the child’s experience in perspective when designing programs or policies aimed at aiding domestic violence victims. children are often overlooked victims who face a lifetime of challenges to overcome the effects of cdvt. the findings of this study show that children have serious and lasting repercussions from experiencing dv in their homes. being that most children remember the events and suffer emotionally in the years afterward, they should be considered valuable players in the dv dynamics that occur in the household. references atkins, m. (2013, october 8). 50 strength based questions. retrieved from http:// www.changedlivesnewjourneys.com/50-first-strength-based-questions bandura, a. (1973). aggression: a social learning analysis. prentice-hall. blair, f., mcfarlane, j., nava, a., gilroy, h., & maddoux, j. (2015). child witness to domestic abuse: baseline data analysis for a seven-year prospective study. pediatric nursing, 41(1), 23-29. briggs-gowan, m. j., pollak, s. d., grasso, d., voss, j., mian, n. d., zobel, e., & ... pine, d. s. (2015). attention bias and anxiety in young children exposed to family violence. journal of child psychology & psychiatry, 56(11), 1194-1201. campbell, a. m., & thompson, s. l. 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(2009). factors discriminating among profiles of resilience and psychopathology in children exposed to intimate partner violence (ipv). child abuse & neglect, 33(9), 648-660. hamby, s. l., finkelhor, d., turner, h., & ormrod, r. (2011). children’s exposure to intimate partner violence and other family violence. national survey of children’s exposure to violence. hardesty, j. l., campbell, j. c., mcfarlane, j. m., & lewandowski, l. a. (2008). how children and their caregivers adjust after intimate partner femicide. journal of family issues, 29(1), 100-124. 22 | columbia social work review, vol. ix cdvt impact and coping strategies later in life hildyard, k. l., & wolfe, d. a. (2002). child neglect: developmental issues and outcomes. child abuse & neglect, 26, 679-695. doi:10.1016/s01452134(02)00341-1 holmes, m. r. (2013). aggressive behavior of children exposed to intimate partner violence: an examination of maternal mental health, maternal warmth and child maltreatment. child abuse & neglect, 37(8), 520-530. doi:10.1016/j. chiabu.2012.12.006 holt, s., buckley, h., & whelan, s. (2008). the impact of exposure to domestic violence on children and young people: a review of the literature. child abuse & neglect: the international journal, 32(8), 797-810. huang, c., wang, l., & warrener, c. (2010). effects of domestic violence on behavior problems of preschool-aged children: do maternal mental health and parenting mediate the effects?. children & youth services review, 32(10), 1317-1323. doi:10.1016/j.childyouth.2010.04.024 izaguirre, a., & calvete, e. (2015). research article: children who are exposed to intimate partner violence: interviewing mothers to understand its impact on children. child abuse & neglect, 48, 58-67. doi:10.1016/j.chiabu.2015.05.002 lessard, g., & alvarez-lizotte, p. (2015). the exposure of children to intimate partner violence: potential bridges between two fields in research and psychosocial intervention: research and interventions often focus on a specific form of violence without considering other forms of victimization. child abuse & neglect, 48, 29-38. doi:10.1016/j.chiabu.2015.05.004 luthar, s. s., cinchetti, d., & becker, b. (2000). the construct of resilience: a critical evaluation and guidelines for future work. child development, 71, 543-562 melchiorre, r., & vis, j. (2013). engagement strategies and change: an intentional practice response for the child welfare worker in cases of domestic violence. child & family. moylan, c., herrenkohl, t., sousa, c., tajima, e., herrenkohl, r., & russo, m. (2010). the effects of child abuse and exposure to domestic violence on adolescent internalizing and externalizing behavior problems. journal of family violence, 25(1), 53-63. yoo, j. a., & huang, c. (2012). the effects of domestic violence on children’s behavior problems: assessing the moderating roles of poverty and marital status. children & youth services review, 34(12), 2464-2473. doi:10.1016/j. childyouth.2012.09.014 ana quiñones received a b.s.w. from west texas a&m university in 2016. she is a masters of science in social work candidate in advanced clinical practice with children, youth and families at columbia university’s school of social work. she is currently employed as a family based specialist for child protective services in the state of texas. columbia social work review, vol. ix | 23 ana quiñones appendix a semi-structured interview: • what age were you when the abuse took place? • what type of abuse was it? (physical, emotional, etc.) • what was the level of relationship between you and the perpetrator? • what type of support was available to you at home? o school? o church? o sports...etc.? • did your primary caregiver provide support? o what type? • was there professional intervention? • what would you say are some of your personal traits that contribute to where you are now? • what are some of your present coping strategies? • what were some of your coping strategies during the trauma? • what do you value about yourself ?* • what do you think helps you bounce back?* • what makes you feel useful?* • what did your transition process look like?* • how do you manage difficult situations in the present day?* • what are some creative solutions you have tried?* • what resources are available to you?* * these questions were inspired and derived from the 50 strength based questions article found on the changed lives new journeys website (atkins, 2013). appendix b columbia university journal of student social work volume 1, number 1 8 introduction on january 13, 1903, the first korean immigrants to the united states arrived in honolulu, hawaii, on the s.s. gaelic. in commemoration, president george w. bush issued a proclamation declaring january 13, 2003 as the “centennial of korean immigration to the united states.” throughout the year, programs, ceremonies, and activities honoring korean immigrants and their descendants have been scheduled to celebrate the contributions of korean-americans over the past one-hundred years. there was a time when i would not have identified with the millions of koreans who risked everything for the hope of a new life in a new land. like them, i was born in korea and came to the united states with the hope of a better life. but unlike them, i did not travel with family or knowledge of my blood roots nor did i have to learn a new culture and language all on my own. my arrival to the united states at the age of three was eagerly awaited; i had become an american through adoption. trends in the field of intercountry adoption it is estimated that between 1955 and 1999, a total of 143,144 korean children were placed for overseas adoptions worldwide (holt korea, 2003). of these children, an estimated 100,008 were adopted by american families (u.s. state department, 2003; gathering, 1999). the first wave of koreanborn children adopted in the aftermath of the korean war were pioneers, paving the way for the thousands of orphaned and abandoned children who are now adopted through intercountry adoption. currently, the practice of intercountry adoption involves the transfer of aaduldultt kkoreanorean iintercountrntercountryy aadopteesdoptees: : a ra resourceesource forfor aadoptiondoption ppracticeractice hollee a. mcginnis the author shares a personal narrative of her efforts to establish an adult intercountry adoptee organization in new york city. these efforts coalesced with a national movement of adult intercountry adopted koreans culminating in the gathering of the first generation of adult korean adoptees, held in washington, d.c. in 1999, and the second gathering in oslo, norway in 2001. the contribution of adult korean adoptees to the field of intercountry and transracial adoption is discussed, with suggestions for how adult adopted persons can be utilized to enhance adoption pracmcginnis / adult korean intercountry adoptees: a resource for adoption practice 9 an estimated 20,000 to 30,000 children from over 50 countries each year, with the united states receiving the largest number of the world’s children (masson, 2001; lovelock, 2000). according to the u.s. state department, the total number of foreign-born children adopted by u.s. citizens has increased by nearly 40 percent, from 8,102 children in 1989, to an estimated 20,099 children in 2002 (table 1). since 1995, the top four countries issuing visas for children migrating to the u.s. for adoption were china (mainland), russia, south korea, and guatemala (u.s. state department, 2003). source: u.s. state department: http://travel.state.gov/orphan_numbers.html in the united states, many of the first waves of korean adopted children are now professionals with a wealth of experience and knowledge to share with the new generation of intercountry adopted children. my efforts as a korean adoptee to establish an adult intercountry adoptee organization in new york city coalesced with a national movement of adult intercountry adopted koreans that culminated in the gathering of the first generation of adult korean adoptees, held in washington, d.c. in 1999, and the second gathering in oslo, norway in 2001. making connections although i always knew i was born in korea and adopted, i was not always conscious of what either meant. growing up, being korean described my physical appearance, explained where i came from, and made me unique from the rest of my family. as a teenager, i was made more concolumbia university journal of student social work volume 1, number 1 10 scious of looking asian because people assumed, based on my physical appearance, that i spoke korean or knew korean culture. however, because i was raised by a non-korean family i did not think of myself as korean. i was a mcginnis. i felt that because of my appearance, people assumed i had knowledge of korean culture. i felt like an imposter: i only knew american culture. despite how american i felt, my family could not tell me where i got my eyes, my artistic talents, or the shape of my face. their love could not shield me from the questions or the puzzled faces of those who did not understand how a white couple could have an asian daughter. living in a society that places a primacy on biology, an adopted person cannot help but feel excluded and cheated for the lack of knowledge of his or her genetic roots. lacking such knowledge, adopted people must find other kinds of connections. my studies as an undergraduate connected me to the history of intercountry adoptions in the united states, which first began after world war ii in response to the humanitarian needs and an altruistic response to displaced war orphans (masson, 2001; lovelock, 2000; riley, 1997). similar sentiments initially led to the adoption of foreign children after the korean and vietnam wars (masson; lovelock). latin america emerged as a significant relinquishing region for intercountry adoptions by the mid 1970s, followed by the former soviet union and china by the mid 1990s (u.s. state department, 2003). also-known-as from my studies, i realized i was not alone. as i sought to reconcile my self-identity based on my adoption experience with the identity imposed by the racial stereotypes of my society, a conflict arose. i was only given two choices: korean or american. the reality for me was that i was both. my korean mother gave birth to my body, but my adoptive mother and father gave birth to my soul. the east gave me life, but the west taught me how to live it. i realized that as an individual i had little power to shift misconceptions regarding adoption, yet as a community, international adoptees could do much to shift perceptions of adoption and racial stereotypes. in forming also-known-as, an organization for adult intercountry adoptees, in 1996, i wanted to gather fellow adult adoptees in order to celebrate our unique experiences and serve the younger generation of intercountry adoptees and adoptive families. gathering as a community we could assert our unique culture as transracial and international adopted people and create a space in which we could embrace our unique identities. the name of the organization is a reflection of our self-identities and human experiences that are not apparent on the surface. i am hollee mcginnis, alsoknown-as lee hwa yong. in establishing the organization, i found a commcginnis / adult korean intercountry adoptees: a resource for adoption practice 11 munity outside of my adoptive family that shared a desire to make a difference with the unique lives we had been given. although we believed intercountry adoptees shared a common experience and sought to include adoptees from all countries, our first effort focused on connecting with korean adoptees, who constitute the largest number of intercountry adoptees in the u.s. our efforts coincided with previous efforts by adult korean adoptees to establish organizations in minnesota and los angeles. however, our organization was unique in that its primary goal was to establish post-adoption services informed by the experiences of adult adoptees. in addition, we were among the first organizations to utilize the internet to connect with adopted people both nationally and internationally. the gathering of the first generation of adult korean adoptees the gathering of the first generation of adult korean adoptees, a three day conference held in september 1999 in washington, d.c., was a momentous culmination in the development of the adult korean adoptee community. this conference, sponsored by holt international children’s services, also-known-as, the korea society, and the evan b. donaldson adoption institue, brought together nearly 400 adults adopted from korea between 1955 and 1985, representing over 30 u.s. states and several european countries (gathering, 1999). this conference was unique in its purpose to provide an opportunity for adoptees to share their experiences, bringing together the past, present, and future of korean intercountry adoptions. to gain greater insight into the experiences of korean adoptees, as well as to plan the conference itself, the evan b. donaldson adoption institute, in conjunction with holt international children’s services, surveyed the participants at the gathering (gathering, 1999). participants discussed, in small groups based on birth years, topics such as reasons for participating in the conference, memories of korea and arrival at their new home, impact of early experiences on adoptees’ lives, discrimination, identity, dating and relationships, relationship to korea, search and reunion, and perceptions of adoption. the conference concluded in the early dawn at the korean war memorial and was a testament to the shared suffering of a generation of koreans who survived a war, were transplanted from their birth culture, and built new lives on foreign soil. since the gathering, korean adult adoptees have continued to meet at “mini-gatherings” throughout the country, new organizations of adult korean adoptees have sprung up, and a plethora of websites now connect korean adoptees throughout the world. a second gathering, focused on bringing together korean adoptees from europe, occurred in oslo, norway columbia university journal of student social work volume 1, number 1 12 in july 2001. future directions despite the increase in the number of intercountry adoptions, research in this field is limited. however, a growing body of work has begun to focus on factors influencing ethnic identity formation and development in intercountry transracial adoptees (fiegelman & silverman, 1984; trolley, hansen & wallin, 1995; huh & reid, 2000; carstens & juliá, 2000; vonk, 2001). these studies of ethnic identity formation have consistently relied on adoptive parents to answer questions regarding the racial awareness and identity formation of their transracially adopted childen. although parents can provide accurate information about much of their children's conduct, it is difficult for them to provide data on all of their children's activities and feelings (feigelman, 2000). in addition, current studies on ethnic awareness have relied on the experiences of young adoptees rather than adoptees who are in adolescence or early adulthood—the age at which racial identification is most salient and recognition of one's racial and ethnic identity becomes most important (feigelman, 2000; hug & reid, 2000). thus, the importance of race may be underrepresented in these studies because of the relationship between racial identification and development. although discussion of the results of the gathering survey is beyond the scope of this paper, it is clear that the inclusion of adult adoptees’ experiences and reflections of their identities would be invaluable to future studies on ethnic identity development over the lifespan. korean adult adoptees have already influenced the development of intercountry adoption practice. for example, also-known-as has a speaker’s bureau where adult adoptees share their experiences of being adopted. while we realize that the experiences of the current generation of intercountry adoptees may be different from our own, we recognize that we have insights into growing up in transracial families that are valuable for prospective adoptive families. research supports that the adoptive family's sociocultural milieu, including minority role models, is a significant factor affecting ethnic identification of transracial adoptees (zuñiga, 1991; carstens & juliá, 2000). thus, we offer a mentorship program for intercountry adopted youth, providing minority role models who are also adopted. adult adoptees have been influential in establishing culture camps and culture days for intercountry adoptive families, reflecting their own desires to have had opportunities to connect with their birth cultures growing up. today, korean adoptees are traveling to korea in unprecedented waves, seeking to experience their birth culture. by sharing their experiences in mcginnis / adult korean intercountry adoptees: a resource for adoption practice 13 film, memoir, and the arts, korean adoptees are redefining what it means to be an adopted person. adult korean adoptees are leading experts into unexpected territories. many korean adoptees are actively searching for—and finding—birth parents, a prospect that many adoption professionals once assumed to be impossible. conclusion agencies need to be responsive to the life-long needs of korean intercounrty adoptees and can do so by partnering with adult adoptee organizations. the formation of these organizations is a response to the unmet needs of adult adoptees. practitioners in the field of adoption often think their work is complete when the child is placed in the hands of a new family; however, this is just the beginning of a life-long journey of self-discovery. references carstens, c., juliá, m. (2000). ethnoracial awareness in intercountry adoption: u.s. experiences. international social work, 43, 61-73. feigelman, w., silverman, a. (1984). the long-term effects of transracial adoption. social service review, 58, 588-602. feigelman, w. (2000). adjustments of transracially and inracially adopted young adults. child and adolescent social work journal, 17,165-183. gathering of the first generation of adult korean adoptees (1999). report retrieved march 6, 2003 from http://www.holtintl.org/pdfs/survey2.pdf holt korea, inc. (2003). the overseas adoption situation (1955-1999). retrieved march 6, 2003 from http://www.holt.or.kr/adop.htm huh, n. s., william j. r. (2000). intercountry, transracial adoption and ethnic identity: a korean example. international social work, 43, 75-87. lovelock, k. (2000). intercountry adoption as a migratory practice: a comparative analysis of intercountry adoption and immigration policy and practice in the united states, canada, and new zealand in the post w.w. ii period. international migration review, 34(3), 907-923. masson, j. (2001). intercountry adoption: a global problem or a global solution? journal of international affairs, 55(1), 141-146. riley, n. (1997). american adoptions of chinese girls: the sociopolitical matrices of individual decisions. women’s studies international forum, 20(1), 87-102. trolley, b. c., wallin, j., hansen, j. (1995). international adoption: issues of acknowledgement of adoption and birth culture. child and adolescent social work journal, 12, 465-479. u.s. state department (2003). immigrant visas issued to orphans coming to the us. retrieved march 6, 2003 from columbia university journal of student social work volume 1, number 1 14 http://travel.state.gov/orphan_numbers.html vonk, m.e. (2001). cultural competence for transracial adoptive parents. social work, 46, 246-255. zuñiga, m. (1991). transracial adoption: educating the parents. journal of multicultural social work, 1, 17-31. hollee a. mcginnis is a second-year ms student at the columbia university school of social work concentrating in international social welfare policy. she is currently an intern at the council on accreditation in new york city. she holds a ba in american studies from mount holyoke college. columbia social work review, vol. viii | 1 developing mental health laws in ghana, kenya, and zambia grace-cecile eya obame mental health has become a national health priority in the west; however, it is still an overlooked issue in most african countries. sixty-four percent of african countries do not have any mental health legislations or fail to adequately promote the rights of people diagnosed with mental illnesses (mental health and poverty project & world health organization, n.d). as a direct consequence, individuals with mental illnesses in african nations often do not receive adequate treatment. this review evaluates the barriers of appropriate development and implementation of mental health laws in ghana, kenya, and zambia. legislative actions that have been taken in these three countries will be examined in an effort to improve mental health laws, via an analysis of strengths and areas of improvement. through these analyses, the author hopes to raise awareness about legislations in africa regarding mental health issues, build a stronger path towards comprehensive mental health laws, and work towards the effective provision of treatment for people with mental health issues in ghana, kenya, zambia, and the rest of the african continent. statement of the problem most african countries appear to adopt a similar attitude towards the issue: mental illness is stigmatized, and little legislation exists to provide improved mental health care services (omar, et al., 2010; bartlett, et al., 2011; faydi, et al., 2011). an estimated 76% 99% of people with serious mental illnesses in africa do not receive adequate services for their conditions, due in part to this pervasive stigma (faydi, et al., 2011; mental disability advocacy center [mdac] & mental health users network of zambia [mhunza], 2014). it is clear that laws and policies are crucial elements in forming priorities for political agendas, obtaining funding, and acknowledging the rights of a particular group of people (mhapp & who, n.d.; omar, et al.; 2010; bartlett, et al., 2011; faydi, et al., 2011). in the context of mental health, laws and policies are of critical importance, as it allows for the rights of individuals with mental illnesses to be protected and can direct the government to provide funding for effective services. laws and policies embody a clear, written government commitment to work towards the improvement of mental health services (faydi, et al., 2011). by 2005, half of all african countries had mental health policies, compared to the early 1990s when only 23% of member states of the african region of the world health organization (who) were reported to have mental health laws (okasha, 2002; omar, et al.; 2010; faydi, et al., 2011). this sudden increase might be due to the diverse projects initiated by international non-profit organizations advocating for improvement in mental health laws (faydi, et al., 2011). despite the significant increase, there are still serious challenges in terms of implementation and dissemination of mental health legislations in countries where these policies have been created. all of the african mental health laws drafted prior 2005 promoted involuntary treatment without consideration of the rights of individuals with mental illnesses (mhapp & who, n.d.; okasha, 2002; omar, et al.; 2010; faydi, et al., 2011). many of these laws did not value informed consent, assuming individuals with mental illnesses did not have the capacity to understand or make decisions for themselves (mhapp & who, n.d.; bartlett, et al., 2011; faydi, et al., 2011). such legislations often failed to consider the dignity, respect, autonomy, and need for protection against discrimination of people with mental illness (mhapp & who, n.d; bartlett, et al., 2011). these legislations also failed to include guidelines against abuse, specifically with regards to involuntary admission and treatment in psychiatric hospitals (mhapp & who, n.d; bartlett, et al., 2011). currently, mental health services available in most african countries are mainly accessible through government funded psychiatric institutions (mhapp & who, n.d; omar, et al., 2010; mdac & mhunza, 2014; walker, 2015). most often these psychiatric institutions are overcrowded and run by one psychiatrist assisted by two or three nurses. bartlett, et al. (2011) found that roughly one psychiatrist is available per million people in africa. the lack of trained mental health providers inevitably leads to poor quality of care, as it is impossible for one psychiatrist to properly serve patients in an overcrowded institution. compounding the problem, the psychiatric hospitals examined are dominated by pharmacologic treatments (mdac & mhunza, 2014). moreover, patients are often overmedicated (bartlett, et al., 2011; faydi, et al., 2011). training in evidence-based interventions such as cognitive behavioral therapy (cbt) is limited, mainly because such interventions require continuous supervision in order to be properly implemented (bartlett, et al., 2011). in addition to involuntary treatment and lack of trained staff, geography has also been a challenge. psychiatric hospitals and mental health providers are mainly concentrated in urban areas (bartlett, et al., 2011). the concentration of mental health professionals in the major cities makes it difficult for patients in rural areas to access care. another major challenge that most african countries face is the limited resources dedicated to mental health care. for the past several years, the african union has encouraged its members to dedicate 15% of their national budgets to health; however, several countries are unable to meet this target. in turn, mental health is only a small part of the overall health budget (bartlett, et al., 2011; drew, 2013). 2 | columbia social work review, vol. viii ghana, kenya, and zambia three different countries were analyzed in this review: ghana, kenya, and zambia. these countries were chosen as subjects of this study for various reasons related to convenience and diversity: 1. accessibility: these three countries all have received increased attention from international non-profit organizations, leading to greater accessibility of data and studies; 2. language: english is the official language for these three countries. language was an important factor for the author’s ability to revise and fully understand the laws enacted, yet also ease the research process; 3. large population: these three countries are among the top 10 anglophone african countries with a large population. the population size was important as the author hoped, to some extent, examine countries that represented significant portions of the african continent population; 4. geography: these three countries are located in very different parts of the continent (west, east, and south). considering the diversity of the african continent, the author hoped to choose countries in different parts of africa to explore the similarities and differences given each country’s location. it is important to note that nigeria and south africa fit some of the criteria. however, the goal of this study is to highlight countries that, unlike these two nations, are not often looked at but still have enough information and data available to allow for more detailed analysis. ghana the republic of ghana is located in the western part of the african continent. in 1957, ghana was the first sub-saharan country to become independent from great britain (adjorlolo, chan, & agboli, 2016). as of 2015, ghana has a population of 27,410,000 (who, 2016). out of the 27 million inhabitants of ghana, it is estimated that 650,000 have a severe mental illness and 2,166,000 suffer from a moderate to mild mental illness (who, 2007; adjorlolo, et al., 2016). about 41% of individuals diagnosed with mental illnesses in ghana are women, although the majority of patients in psychiatric hospitals are men (barke, nyarko, & klecha, 2011; awaf, 2016). zambia zambia is a landlocked country gifted with diverse wildlife in the southern part of africa. zambia was colonized by britain and became independent in 1964 (mdac & mhunza, 2014). in zambia, the number of individuals with mental illnesses is estimated to be high; however, there are no official records of the exact number (mdac & mhunza, 2014). kenya kenya is in the eastern part of africa. it was also colonized by great britain and became independent in 1963 (mdac, 2014). currently, kenya has the largest gdp in central and eastern africa. like ghana and zambia, kenya also has a large number of untreated individuals who have mental illnesses (mdac, 2014; merab, 2016). an estimate shows that about 11.5 million people might one day be diagnosed with a mental health illness in kenya (who, 2007; merab, 2016). stigma, services, and legislations social views and stigma mental illness is stigmatized within families and communities in ghana, kenya, and zambia (mdac & mhunza, 2014; osman, 2016). often, people with mental illness are devalued and isolated. in several countries, individuals with mental illness face extreme discrimination when searching for employment. in the three countries examined, mental illness is often perceived as a spiritual curse (okasha, 2002; omar, et al., 2010; barke, et al., 2011; ame & mfoafo-m’carthy, 2016; awaf, 2016). individuals with mental illness are often viewed as undesirable, or as receiving divine retribution for sins committed in a prior life. people with mental illness are often hidden indoors by families, kept chained outdoors, neglected, or even physically abused (barke, et al., 2011; awaf, 2016; osman, 2016). in addition, lawmakers and governmental officials are reluctant to address mental health due to the stigma attached (omar, et al., 2010; barke, et al., 2011; drew, 2013). in their study examining the views of ghanaian patients toward mental illness, barke et al. (2011) found the southern population of ghana to have a general belief that people with mental illnesses should not be excluded from communities; however, several respondents stated that the presence of persons suffering from mental illness in residential neighborhoods might cause danger. mental health service provision three types of mental health services were identified over the course of this study: psychiatric institutions, communitybased services, and traditional healing. mental health services are mostly provided through psychiatric hospitals (mhapp & who, n.d; omar, et al., 2010; mdac & mhunza, 2014; walker, 2015). at the primary care level, such services are generally non-existent. there are three psychiatric hospitals in ghana, all located in the southern part of the country: the accra psychiatric hospital, ankaful, and pantang (barke, et al., 2011; walker, 2015). these three institutions are the only locations for referrals in ghana. the accra hospital is burdened with overcrowding: it has 800 beds but often accommodates more than 1200 patients (barke, et al., 2011; roberts, et al., 2014). in zambia, there are eight psychiatric institutions, and columbia social work review, vol. viii | 3 in kenya there are fourteen (jenkins, et al., 2010; mdac & mhunza, 2014). although zambia and kenya appear to have more psychiatric institutions, these two countries face challenges similar to those of the psychiatric institutions in ghana (jenkins, et al., 2010; bartlett, et al., 2011). due to overcrowding in psychiatric units, in all three countries, patients are often overmedicated, which leads to a shortage of essential psychiatric medications (bartlett, et al., 2011; faydi, et al., 2011; mdac & mhunza, 2014). in the ghanaian mental health sector, the doctor-patient ratio is one per 1.7 million (awaf, 2016). in the zambian mental health system, there are only five professionals working for a population of more than 13 million (mdac & mhunza, 2014). kenya has 23 psychiatrists in the public service for a population of 40 million (jenkins, et al., 2010; bartlett, et al., 2011). the country produces far fewer mental health providers that are needed. community-based services are scarce in most african countries (mhapp & who, n.d; bartlett, et al., 2011, faydi, et al., 2011). in ghana, the term “community-based facilities” refers to residential facilities that are separate from psychiatric hospitals, regional hospitals, and clinics (roberts, et al., 2014). these facilities are privately funded for the most part, although one was funded by the government. in 2011, there were four community-based facilities in ghana providing 112 beds for admissions. about 46% of the patients admitted were women, and on average most of them spent approximately a year in these facilities (roberts, et al., 2014). no information has been collected on the type of treatment provided in these facilities. in kenya, residents of rural communities volunteer to be “community health workers” (chws) and assist health centers in their local area (jenkins et al., 2010). health centers employ nurses and non-physician clinicians who often do not have proper mental health training, if any (jenkins et al., 2010). there has been a push to provide mental health training to chws in order to ensure better assistance for the staff in health centers, which are usually the first health care stops before patients are transferred to hospitals (jenkins et al., 2010). compared to ghana and kenya, mental health community health services appear to be non-existent in zambia. pilot community care projects have been initiated, however due to lack of funds they were unable to be continued (mdac & mhunza, 2014; who, 2007). according to barke et al. (2011), the ghanaian ministry of health reported that 70 to 80% of ghanaians use traditional healers as their primary care providers, most often in conjunction with modern medicine. research suggests that the lack of mental health services and finances may result in the use of traditional medicine and churches in most african countries (jenkins, et al., 2010; bartlett, et al., 2011; ame & mfoafo-m’carthy, 2016). approximately 45,000 traditional healers and churches currently treat patients throughout ghana (barke, et al., 2011; walker, 2015). many kenyans view mental illness as a spiritual problem rather than a medical one, causing them to turn to religious leaders or traditional healers for a cure (merab, 2016; osman, 2016). in zambia, traditional and spiritual healers have organized and created an association called “traditional healers’ association” (mdac & mhunza, 2014). although traditional healers have attempted to organize and formalize their work, service users have claimed that some of the practices traditional healers use can be physically and mentally harmful. zambian service users have pleaded with the government to better monitor the traditional treatments used in their country (mdac & mhunza, 2014). legislation the ghanaian, kenyan, and zambian legal systems are based on english common law traditions (drew, 2013; mdac & mhunza, 2014; walker, 2015). although the mental health laws currently implemented in ghana, zambia, and kenya have improved, more work is still needed (drew, 2013). first, the revised laws do not present consistent and appropriate language when referencing mental health. zambia defines mental health conditions with the terms “imbecile” and “idiot”, while ghana does not define them at all (mental health decree of 1972; drew, 2013). the lack of concrete, objective, and common definitions leads to ambiguity in the implementation of the laws (drew, 2013). second, the current mental health laws in ghana, kenya, and zambia do not explicitly address the protection of people with mental illnesses’ rights (mhapp & who, n.d.). ghana and zambia both implicitly address the cruel treatment and neglect of individuals with mental illnesses, stating that law enforcement authorities will intervene in such cases (mhapp & who, n.d., ghana’s mental health decree, 1972; zambia’s mental disorders act, 1951; drew, 2013). lastly, there are no explicit and clear guidelines relating to the competence, capacity, and guardianship of individuals with mental illness, reinforcing the stereotype that individuals with mental illness are incompetent and incapacitated (mhapp & who, n.d.; ghana’s mental health decree, 1972; zambia’s mental disorders act, 1951; drew, 2013). in 1989, kenya passed new mental health laws that were insufficiently comprehensive, as the way in which the legislation was written presented challenges for implementation. the issues mainly revolved around funding shortages, which circled the situation back to where it was before: a severe lack of mental health providers and thus the inability to address any mental illness problems in the country (bartlett, 2011). historically in ghana, implementing mental health policies has been challenging for similar reasons (walker, 2015). during the implementation stage, ghana often faces bureaucratic barriers, because its legislative process is often time-consuming (walker, 2015). furthermore, financial restrictions from the government and international donors often have strict conditions (walker, 2015). funds donated are to be used for mandated projects, thus can’t be used for other purposes such as infrastructure (walker, 2015). current initiatives several grassroots nonprofit organizations in ghana, kenya, and zambia are advocating for more effective mental health laws and services. these organizations often work on both macro and micro levels. in kenya, a non-governmental organization named africa mental health foundation (amhf), founded by kenyan psychiatrist dr. david ndetei, aims to 4 | columbia social work review, vol. viii conduct research to inform policymakers and identify the most cost-effective, best practices for individuals with mental health issues (amhf, 2017). initially, ndetei’s objective was to train more psychiatrists in the country. however, he promptly realized that kenyans in low income and rural areas were not benefitting from the increased number of trained psychiatrists, as many psychiatrists provided services in private practices. in 2002, a national tragedy occurred when sixty-seven students died in a school fire. in response, ndetei and some of his colleagues organized and provided free mental health services for the families and the school community. since then, amfh has been advocating for accessible, appropriate, and affordable mental health services to all kenyans through research, policy, and direct services. in ghana, there are eight well-known grassroots nonprofit organizations. most were created by international stakeholders (roberts, et al., 2014). only one, mental health society of ghana (mehsog), was founded by communities in ghana (roberts, et al., 2014). mehsog is a membership-based organization advocating for the rights of people with mental health issues in ghana (roberts, et al., 2014). mehsog offers self-help groups and has an advocacy presence in legislative and legal matters. for instance, in 2015 mehsog advocated for antwi after he made his threat to shoot the former president (awaf, 2016). antwi was confirmed to have mental health issues, yet the court convicted him to a 10-year jail sentence. mehsog argued that antwi should be receiving mental health care, not a jail sentence. in august, antwi’s lawyer, with support from mehsog, succeeded in having his sentence dismissed. nevertheless, antwi was incarcerated until december. upon his release, antwi was finally admitted in the accra psychiatric hospital (awaf, 2016). in zambia, grassroots organizations advocating for mental health are less common. in 2011, the membership-based organization mental health users network of zambia (mhunza) sought help from a united kingdom-based organization named the mental disability advocacy center to create the first comprehensive report analyzing mental health in zambia through a human right perspective (mdac & mhunza, 2014). as per the 2014 report released by mdac and mhunza, mhunza’s mission is to promote and fundamental rights of individuals with mental illnesses and “to promote respect for their inherent dignity” (mdac & mhunza, 2014). amfh, mehsog and mhunza are doing impressive work within their means; however, again, the main obstacle they face is a lack of funding, which minimizes the visible impact they can have. initiatives regarding mental health in africa have also been promoted globally. in december 2006, the general assembly of the united nations (un) passed the convention on rights of persons with disabilities (crpd). the convention aimed to expand mental health community-based service legislations internationally (bartlett, et al., 2011). the crpd laid on the principle that individuals with disabilities, including mental illnesses, have the same rights as everyone else and promoted their non-discrimination and inclusion in society (bartlett, et al., 2011). the crpd was the first international declaration to include the voices of service users and non-profit organizations ran by service users (bartlett, et al., 2011; drew, 2013). the crpd also included countries from developing regions, and as a result 38 african countries signed, including ghana, kenya, and zambia (bartlett, et al., 2011). the crpd holds participating countries accountable by conducting monitoring assessments. the un has created a committee that will publish public report assessing the compliance of the participating countries to the crpd standards (bartlett, et al., 2011). the crpd hopes that the visibility of these reports will create incentives for participating countries to be adherent to the standards (bartlett, et al., 2011). conclusion this article provided an overview of mental health laws and policies in ghana, kenya, and zambia. drafting comprehensive mental health laws is crucial for providing effective legal oversight for programs and services that benefit individuals with mental health issues. understanding the relationship between stigma and policymaking is important for effective strategizing. efforts cannot focus solely on changing perceptions or on changing policies. both need to be addressed and properly understood. three main changes would address both stigma and policy-making: psychoeducation, collaboration with traditional healers, and proportional government spending. 1. psychoeducation: psychoeducation could be an effective way to dismantle stigma towards mental illness. psychoeducation can help communities become familiar with the causes, reasons, manifestations, symptoms, and treatments for mental health issues (lukens & mcfarlane, 2006). once communities become educated on mental illness, members may be more willing to interact with, care for, and support individuals diagnosed with mental health issues in their neighborhoods (ame & mfoafo-m’carthy, 2016). literature shows that psychoeducation results in positive outcomes not only for patients, but for family members as well (lukens & mcfarlane, 2006). one important point to remember is that the culture of communities must be taken into consideration. in ghana, kenya, and zambia, people often believe mental illness is related to spiritual causes (okasha, 2002; omar, et al., 2010; barke, et al., 2011; ame & mfoafo-m’carthy, 2016; awaf, 2016). for psychoeducation to be effective, a strength-based approach should be adopted, meaning that spiritual beliefs should be valued as a resource and included in mental health education for communities. existing beliefs should not be shunned, rejected, and treated as unfeasible. ideally, psychoeducational programs should be designed and run by individuals from the communities. one tangible suggestion regarding psychoeducation is for each country to create a government department dedicated to mental health education. this office would be in charge of integrating mental health educational programs in schools. curricula similar to school sexual health programs can be designed to raise awareness of mental health. to reach adults, there should be a digital platform to help grassroots organizations gain more visibility and offer psychoeducational programs through churches and other community institutions. 2. collaboration with traditional and spiritual workers: given the influence of traditional healers and faith-based practitioners in communities, it is important to consider formally integrating traditional healers in the primary health care system. policies and columbia social work review, vol. viii | 5 regulations should be drafted to address the practices of traditional healers and faith-based practitioners. in zambia, traditional healers and spiritual workers have founded associations (mdac & mhunza, 2014); the government should encourage these organizations to conduct studies to gather evidence about the effectiveness of traditional practices and ensure that they are beneficial. in addition, developing certification programs could ensure that traditional practitioners are performing healthy methods of treatment. ideally, mutual respect between traditional healers and mental health providers would evolve, promoting referrals between the two types of health care systems. 3. proportional government spending: low government spending on mental health is one of the main weaknesses of the mental health systems analyzed in this study. the amount of the health budget spent on the mental health sector should be proportional to the mental health needs of the population. many african countries dedicate less than one percent of their health budget to mental health services (bartlett et al., 2011). in addition, most of the mental health budget is spent on urban psychiatric hospitals (bartlett et al., 2011). to meet the population’s needs, the ghanaian, kenyan, and zambian governments must make an effort to increase the share of the health budget dedicated to mental health services. this a recommendation is in line with the standards of the african union, which has encouraged its members to allocate 15% of their national health budget to mental health (bartlett, et al., 2011; drew, 2013). perhaps the african union can provide incentives to countries that are able to meet the standard, such as selecting them as destinations for the yearly african union summit. while these recommendations are crucial, not all may be feasible. further analysis and research are needed. the process of proportionally allocating parts of the health budget to mental health awareness and treatments requires further exploration. although stigma was identified as one of the main barriers to appropriate government spending towards the mental health system, it might be beneficial to also determine whether there are other obstacles. once they gain a full understanding of the challenges, financial experts and appropriate officials will be in a better position to assist the government and provide suitable recommendations. additional research and analysis of the various traditional and spiritual practices available would also be helpful. further research should examine spiritual practitioners to give them a voice in the way mental health treatment is understood by the people in these countries. as they are often the first to see a person suffering from a mental illness, their inclusion in future research is crucial in helping close the gap between traditional medicine and modern medicine. references adjorlolo, s., chan, h. c. o., & agboli, j. m. (2016). adjudicating mentally disordered offenders in ghana: the criminal and mental health legislations. international journal of law and psychiatry, 45, 1-8. ame, r., & mfoafo-m’carthy, m. (2016). mental health law in ghana: the rights of children with mental disorders. social development issues, 38(1), 1-14. awaf, a.m. (2016). mental health care; ghana among the worst in africa. graphic online. graphic communication group limited. awenva, a. d., read, u. m., ofori-attah, a. l., doku, v. c. k., akpalu, b., osei, a. o., & flisher, a. j. (2010). from mental health policy development in ghana to implementation: what are the barriers?. african journal of psychiatry, 13(3). bartlett, p., jenkins, r., & kiima, d. (2011). mental health law in the community: thinking about africa. international journal of mental health systems, 5(1), 1. barke, a., nyarko, s., & klecha, d. (2011). the stigma of mental illness in southern ghana: attitudes of the urban population and patients’ views. social psychiatry and psychiatric epidemiology, 46(11), 1191-1202. central intelligence agency [cia] (2016). ghana country profile. central intelligence agency. drew, n., funk, m., kim, c., lund, c., flisher, a. j., osei, a., ... & mayaye, j. (2013). mental health law in africa: analysis from a human rights perspective. journal of public mental health, 12(1), 10-20. dhadphale, m., & magu, j. g. (1984). mental health services in kenya. indian journal of psychiatry, 26(1), 37. faydi, e., funk, m., kleintjes, s., ofori-atta, a., ssbunnya, j., mwanza, j., ... & flisher, a. (2011). an assessment of mental health policy in ghana, south africa, uganda, and zambia. health research policy and systems, 9(1), 1 ghana’s mental health decree, 1972 gureje, o., & alem, a. (2000). mental health policy development in africa. bulletin of the world health organization, 78(4), 475-482. jenkins, r., kiima, d., okonji, m., njenga, f., kingora, j., & lock, s. (2010). integration of mental health into primary care and community health working in kenya: context, rationale, coverage and sustainability. mental health in family medicine, 7(1), 37. lukens, e. p., & mcfarlane, w. r. (2006). psychoeducation as evidence-based practice. foundations of evidence-based social work practice, 291, 205-25. mental disability advocacy center [mdac] & mental health users network of zambia [mhunza] (2014). human rights and mental health in zambia. mental disability advocacy center & mental health users network of zambia. mental health and poverty project [mhapp] & world health organization [who]. (n.d). policy brief: developing effective mental health laws in africa. world health organization. merab, e. (2016). health experts warns of mental illness crisis. daily nation. okasha, a. “mental health in africa: the role of the wpa.” world psychiatry 1.1 (2002): 32–35. print. omar, m. a., green, a. t., bird, p. k., mirzoev, t., flisher, a. j., kigozi, f., ... & ofori-atta, a. l. (2010). mental health policy process: a comparative study of ghana, south africa, uganda, and zambia. international journal of mental health systems, 4(1), 1. osman, m. o. (2016). the taboo of mental illness in kenya. al jazeera media network. roberts, m., mogan, c., & asare, j. b. (2014). an overview of ghana’s mental health system: results from an assessment using the world health organization’s assessment instrument for mental health systems (who-aims). international journal of mental health systems, 8, 16. walker, g. h. (2015). ghana mental health act 846 2012: a qualitative study of the challenges and priorities for implementation. ghana medical journal, 49(4), 266-274. 6 | columbia social work review, vol. viii who (2007) ghana: a very progressive mental health law. the country summary series. http://www.who.int/mental_health/policy/ country/ghanacoutrysummary_oct2007.pdf zambia’s mental disorders act, 1951 grace-cecile eya obame grace-cecile eya obame is a french native of african origins who migrated to the united states of america during her teenager years. she is completing her masters of social work at columbia university and received her bachelor of arts in interdisciplinary studies: communication, legal studies, economics, and government from american university in washington, dc. grace-cecile’s undergraduate program provided her with the necessary skills to effectively participate in public affairs decision-making and to examine social problems as public issues. grace-cecile is currently a dialectical behavioral therapy (dbt) intern at rikers island in the women’s facility, where she co-leads dbt skills groups and provides individual psychotherapy. grace-cecile’s clinical interests lie in correctional and global mental health, particularly in the sub-saharan region of africa. grace-cecile hopes to, one day, be able to contribute to the development of the mental health field on the african continent. microsoft word reaching the unreachable.docx © 2015 parekh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. reaching the unreachable: the promise of telepsychiatry in india amrita parekh a 2005 study by the national commission on macroeconomics and health indicated that at least 71 million people in india have a serious mental disorder. despite this alarming statistic, infrastructure as well as manpower for mental health in the country is severely inadequate. furthermore, 70% of the population lives in rural areas, far removed from the majority of mental health facilities. in light of the enormous treatment gap, wherein about 76–85% of serious cases of mental illness in less-developed countries are left untreated, telepsychiatry, defined as “the use of information and communication technology to provide or support psychiatric services across distances,” is a promising delivery method to reach millions of individuals in rural india who are unable to access mental health services and whom the mental health system is currently underequipped to serve (malhotra, chakrabarty & shah, 2013). through an exploration of the history, applications, effectiveness, and challenges of telepsychiatry, this paper makes a case for the potential of telepsychiatry to narrow the treatment gap in india. introduction aya, a 27-year-old woman living in a small village in the pudukkottai district of tamil nadu, india, was discovered chained to the cowshed of her family house. her family members reported that she often spoke to herself and had a tendency to wander off. they worked in agricultural fields throughout the day and felt they had no choice but to keep her restrained for her own safety. maya’s symptoms were present for nine years, during which time her family spent all of their savings on a religious tantric1 in an effort to cure her through traditional healing practices, but to no avail. they later took her to a psychiatrist located three bus rides away, but discontinued treatment as they could not afford the consultation costs and travel expenses. with no results, maya’s family ceased all her treatments and gave up hope for any recovery, keeping her chained for two years (scarf, 2012). maya’s plight is not an isolated case from pudukkottai, but it illustrates the prevailing conditions in much of india, where more than 70% of the population lives in rural areas with limited access to mental health services (prafulla, murthy & ramaprasad, 2010). distance is only part of this problem; although about 6.5% of india’s population lives with a serious mental illness, the country lacks the manpower to address their mental health needs (national commission on macroeconomics and health, 2005). with a population of 1.1 billion people, india has only 0.03 social workers, 0.3 psychiatrists, and 0.47 psychologists for every 100,000 individuals (world health organization, 2011). most of these mental health professionals are located in urban centers, leaving even fewer professionals to care for the needs of the mentally ill in rural india (thara & patel, 2010). in an effort to address the issue of limited access to mental health care, the indian government created the national mental health programme in 1982 and the district mental health programme in 1996, mandating that every district hospital in india have at least one psychiatrist (thara, john & rao, 2008). however, this order has shown to be impractical due to the shortage of trained mental health professionals. in response to this shortage, experts emphasized the importance of integrating mental health services into primary care and increasing the quality and quantity of mental health professionals and infrastructure (malhotra, chakrabarty & shah, 2013). nevertheless, given the logistic issues and length of time associated                                                                                                                           1 practitioner of tantra, a style of hindu or buddhist meditation and ritual that arose in india before the 5th century ad.   m © 2015 parekh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. with implementation, it is crucial to seek alternative and innovative methods of effective mental healthcare delivery in low-resource settings such as rural india. telepsychiatry, defined as “the use of information and communication technology to provide or support psychiatric services across distances,” allows for a unique opportunity to reach the millions of people living in rural india who, like maya, would otherwise have limited or no access to mental health care (malhotra et al., 2013, pg. 3). while telepsychiatry does not increase the number of mental health providers, it is a potential solution for their maldistribution and extends the reach of existing providers, resulting in increased access to care through improved efficiency in the delivery of mental health services. through an exploration of the history, feasibility, and efficacy of telepsychiatry, this paper calls for much needed research into this modality, which has immense potential to narrow the treatment gap in india by providing underserved populations with mental health care through the use of interactive technology. state of mental health care in rural india the number of people suffering from mental illness in india is predicted to rise significantly in the coming decades (chatterjee, 2009; national commission on macroeconomics and health, 2005). despite this projected growth, there is a dearth of government resources devoted to mental health care, particularly with regard to manpower, infrastructure, and finances, deeming mental health services in rural areas grossly inadequate (world health organization, 2011). this is owed in part to the fact that politicians and government officials hardly acknowledge mental health as an important aspect of the healthcare system. for example, in 2011, the indian government allocated only 0.06% of its health budget to mental health services (world health organization, 2011). while the formation of the country’s first ever national mental health policy in 2014 is evidence of a positive shift in the government’s approach to mental health, plans to effectively implement systemic changes remain a key challenge. in addition to limited government support, there are a number of cultural and socioeconomic barriers to seeking mental health services in rural areas of india. the literacy rate among the rural indian population is as low as 68.9%, leading to a lack of awareness and recognition of mental illness and often causing marginalization of and discrimination against mentally ill individuals (census of india, 2011; raguram, weiss, channabasavanna & devins, 1996). consequently, many communities espouse traditional healing beliefs, seeking care from religious leaders or indigenous faith healers as opposed to mental health professionals (sax, 2014). furthermore, more than 75% of those living below the poverty line in india reside in rural areas (census of india, 2011). according to the indian human development survey, the average annual income per capita in rural india in 2005 was estimated to be as low ₹7,101 (approximately $114), highlighting the economic barriers to seeking mental health care in this context (desai, dubey & joshi, 2010). in light of these challenges, it is important for practitioners and policy makers to recognize the limitations of mental health resources in india. exploring new and inventive methods of delivering mental health care, such as telepsychiatry, is necessary in order to reach the millions of people whom the mental health system is currently underequipped to serve. applications of telemedicine and telepsychiatry the first wave of organized telemedicine programs began in the united states in the late 1950s, covering a range of medical disciplines including radiology, dermatology, and ophthalmology (bashshur & shannon, 2009). by the early 1960s, researchers and practitioners in the u.s. pioneered the use of telecommunications technology to connect mentally ill patients with healthcare providers. at its inception, telepsychiatry provided services to military troops on the front lines and personnel on ships and oil rigs, demonstrating early on its utility and crucial role in facilitating access to care (daughten & grainer, 2013; grady, 2012). © 2015 parekh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. health providers in india began implementing telemedicine in 2000 (dutta, 2000). the initial applications of telemedicine were in medical fields that are heavily dependent on image-based diagnoses (sood, 2002). soon, its application spread to the field of psychiatry. today, its use in this field remains in its nascent stages, leading to a dearth of available literature regarding the use and impact of telepsychiatry units in india (thara et al., 2008). in addition to video conferencing, telepsychiatry increasingly incorporates telephone, e-mail, and other modes of internet communication to facilitate mental health care (hilty, yellowlees, cobb, bourgeois, neufeld & nesbitt, 2006). mental health professionals in the united states use videoconferencing to deliver treatments such as cognitive behavioral therapy and group therapy for mood and anxiety disorders (griffiths, blignault & yellowlees, 2006; garcía-lizana & muñoz-mayorga, 2010). moreover, crisis interventions for people with suicidal ideations have been conducted through online counseling, instant messaging, and chat groups (barak, 2007). telepsychiatry can also be used to facilitate home health visits in social work practice, potentially saving a significant amount of time that would otherwise be spent on traveling. one program, launched by the schizophrenia research foundation of india (scarf), has been particularly well documented and deserves attention for its multifaceted model of mental health care delivery through telepsychiatry. the scarf model just when maya’s family gave up hope for her recovery, treatment came to them. sitting inside a little green bus, maya interacted with a psychiatrist located 240 miles away in chennai through skype, who diagnosed her with schizophrenia, provided psychoeducation, and prescribed medications that she collected free of cost at the rear of the bus. today, maya is successfully integrated into her family and immediate community, lives at home, and actively takes on household responsibilities (scarf, 2012). the service she received, scarf telepsychiatry in pudukkottai (step), is an initiative of scarf, a nongovernmental organization based in chennai, india that conducts research and provides rehabilitation and mental health services to individuals with severe mental illnesses. the step program has several components: consultation, medication management, psychoeducation, and awareness creation. patients in villages use a consultation area located inside a bus to communicate with a psychiatrist based in chennai through a television screen and a high-resolution camera over a wireless internet connection (thara & john, 2013). often, the consultation concludes with a recommended prescription, dispensed immediately from the on-board pharmacy, free of cost. this is an important component of the program given most patients’ financial constraints and the rare availability of psychiatric drugs in rural pharmacies (thara & john, 2013). mental health professionals also schedule follow-up appointments with patients. additionally, community health workers, who are trained and supervised by urban-based mental health professionals through video conferencing, provide psychoeducation to families and caregivers. the program also raises awareness about mental illness through street plays, distribution of pamphlets, and screening of psychoeducational films broadcasted on a tv screen at the rear of the bus (thara & john, 2013). currently, this mobile service covers 156 villages with a total population of about 300,000 (thara & john, 2013). it is predicted that over the next three years, an estimated 1,000 people will benefit from this service (2013). while the step program illustrates one possible model of mental health service delivery through telecommunication, it is crucial to examine whether programs like these have been effective, to what degree, and in what kind of contexts. effectiveness of telepsychiatry © 2015 parekh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. existing literature on the effectiveness of telepsychiatry has focused on the reliability of assessments, satisfaction, and clinical outcomes. however, there are few randomized controlled studies that directly compare telepsychiatry with in-person care along these measures (hailey, roine & ohinmaa, 2008). studies focusing on the reliability of clinical assessments have demonstrated varied outcomes, depending on the population being examined. results from cognitive assessments of individuals with a history of alcohol abuse indicated that tele-consultations produced similar results when compared with in-person sessions (jones, johnston, reboussin & mccall, 2001). on the other hand, reliability analyses with geriatric patients indicated that the accuracy of telepsychiatry assessments that require visual observation of behavior were consistently lower than those that require only self-report (yoshino, shigemura, kobayashi, nomura, shishikura, den, wakisaka, kamata & ashida, 2001). moreover, a study examining the use of videoconferencing to conduct psychiatric interviews with patients with schizophrenia found that reliability of this modality was heavily dependent on the bandwidth of the equipment (kirkwood, peck & bennie, 2001). there is a need for more studies that employ standardized structured interviews, examine inter-rater reliability, and determine the reliability of telepsychiatry with regard to specific populations. systematic reviews assessing satisfaction have concluded that overall satisfaction with telepsychiatry is high, and various studies have found no significant difference in patient satisfaction with videoconferencing to deliver mental health services as compared with face-to-face encounters (garcía et al., 2010; bishop, o’reilly, maddox & hutchinson, 2002). thus far, patients have cited reduced traveling time, fewer absences from work, and reduced wait time as reasons for high satisfaction with telepsychiatry (hailey, roine & ohinmaa, 2002; doze, simpson, hailey & jacobs, 1999; mair & whitten, 2000). other potential predictors of patient satisfaction included demographic factors, cost, satisfaction with and availability of local services, provider qualities, and video quality (jones & ruskin, 2001; hilty, nesbitt, hales, anders & callahan, 2000; malagodi & smith, 1999). however, provider satisfaction with telepsychiatry remains less thoroughly evaluated (hilty, marks, urness, yellowlees & nesbitt, 2004). studies assessing clinical outcomes are far fewer in number than those examining reliability of and satisfaction with telepsychiatry (monnier, knapp & frueh, 2003). in one randomized controlled trial of telepsychiatry for adults, 119 u.s. veterans with depression were randomly assigned to six months of outpatient treatment in person or through telepsychiatry, wherein they received medications, psychoeducation, and supportive counseling (ruskin et al., 2004). between groups, no differences were observed in depressive symptoms or adherence to treatment. several other studies have also found no statistically significant differences in clinical outcomes between patients seen via telepsychiatry and those seen in person (zaylor, 1999; nelson, barnard & cain, 2003). while preliminary data suggest that telepsychiatry appears effective, randomized controlled trials would significantly strengthen the evidence for non-inferiority of telepsychiatry over in-person care. studies that show which psychiatric-mental health interventions best serve specific populations would also be useful. additionally, since most studies that address effectiveness of telepsychiatry have been conducted in western countries, findings may not be generalizable to the indian context, underscoring the need for culturally relevant research. challenges of telepsychiatry a key concern amongst critics of telepsychiatry has been cost-effectiveness. it is important to evaluate whether the time and expenses saved on traveling justify the cost of the infrastructure and support staff required to set up a telepsychiatry unit. in a review of 12 studies that evaluated the cost-effectiveness of telepsychiatry based on cost analysis, direct comparison of costs of telepsychiatry and in-person care, cost feasibility, and cost surveys, seven studies deemed telepsychiatry as cost-effective. others found it either financially unviable, comparable in cost to in-person care, or inconclusive due to an unclear business plan © 2015 parekh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. (hyler & gangure, 2003). another such study, which compared treatment delivery via telepsychiatry with face-to-face delivery in veterans with depression, found that telepsychiatry was more expensive per treatment session, but this difference disappeared if the costs of clinicians’ travel to remote clinics were taken into account (ruskin et al., 2004). furthermore, a study conducted in the rural michigan area determined that telepsychiatry was not financially viable for rural outpatients (werner & anderson, 1998). these varied conclusions are indicative of a need for more systematic studies using cost-benefit analyses, especially in the indian context. ethical and legal challenges such as confidentiality and data security also arise when considering the use of telepsychiatry (malhotra et al., 2013). clinicians must ensure strict maintenance of privacy when patient records and other electronic information is stored, transferred, received, or destroyed (stanberry, 2001). a regulatory mechanism or specific law dealing with the delivery of service through telemedicine should be enforced to deal with issues such as informed consent, confidentiality, and the process of conducting assessments through technology. in india, there is currently no legislation that singularly deals with the practice of telemedicine (thara et al., 2008). in 2003, the ministry of communications and information technology issued a document called “recommended guidelines & standards for practice of telemedicine in india,” but as the name suggests, these guidelines are not legally binding. in order to mitigate some of the challenges associated with telepsychiatry and ensure its effective use, it is important for india to have a telemedicine legislation as well as a regulatory authority that will monitor and license practitioners (thara et al., 2008). looking forward the primary objectives of india’s national mental health programme are “to ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population” and “to apply mental health knowledge in general health care and in social development” (national mental health programme for india, 1982). telepsychiatry holds promise to further these objectives and to disentangle the massive and complex issues of underdiagnosing and undertreating individuals with mental illness at a grassroots level (malhotra et al., 2013). the step model not only proposes a practical model for mental health professionals to use as a guideline, but also demonstrates the potential that telepsychiatry has to alter the landscape of mental health in india. the emerging field of global mental health, defined as “the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide,” addresses some of the key issues discussed in this paper through its strong focus on the development of effective, appropriate, affordable, and equitable mental health systems in low-income countries (patel & prince, 2010, pg. 1976). researchers in this field actively study the use of alternative and innovative methods of mental health service delivery to underserved populations like that of rural india. while global mental health has emerged as a significant field within public health, its presence in and penetration into social work is still in its infancy. as professionals who think beyond the medical model and embrace the unique role of identifying and addressing social inequities and structural issues, it is only fitting that social workers take on the responsibility of contributing to this emerging field by adopting a broad and international focus and addressing the issue of mental health delivery systems in low-income countries. one way this can be achieved is by having a stronger presence of global mental health courses in social work curriculums, as well as by forming strong collaborations between schools of social work and schools of public health. furthermore, a thorough evaluation of existing telepsychiatry programs is necessary to gather reliable data for use by policymakers, who are positioned to create and shape national telemedicine policies. a formal regulatory authority and telemedicine act that outlines procedural guidelines and recommendations while © 2015 parekh. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. addressing legal and ethical issues associated with its practice is essential to have in place in order to ensure consistent and effective implementation of telepsychiatry programs in india. finally, randomized controlled studies looking at diagnostic reliability, cost-effectiveness, patient and professional satisfaction, as well as clinical outcomes of existing telepsychiatry programs should be carried out in the indian context (malhotra et al., 2013). much of the research in mental health today is focused on neuroscience and clinical research. while these areas are fundamental and remain crucial to study, it is important to understand that modalities of treatments under development cannot be delivered in the absence of functioning and strong mental health systems. in light of the momentous mental health gap in india, wherein a large proportion of mentally ill individuals are being left untreated, practitioners and policy makers must recognize limitations in resources and take steps toward adopting innovative methods of healthcare delivery in order to reach the millions of individuals in need of mental health care. to this extent, it is imperative that we apprise ourselves with the current state of telepsychiatry, its existing developments and promise – as well as its challenges – and 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(1996) stigma, depression, and somatization in south india. american journal of psychiatry, 153(8), 1043-1049. ruskin, p. e., silver-aylaian, m., kling, m. a., reed, s. a., bradham, d. d., hebel, j. r., … hauser, p. (2004). treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. american journal of psychiatry, 161, 1471-1476. schizophrenia research foundation of india (scarf). (2012). telepsychiatry in padukottai program (stepp): annual report. schizophrenia research foundation of india. sax, w. (2014). ritual healing and mental health in india. transcultural psychiatry, 51(6), 829-849. sood, s. p. (2002). telemedicine in india vol. 1 [government of india’s initiative]. stanberry, b. (2001). legal, ethical and risk issues in telemedicine. computer methods and programs in biomedicine, 64(3), 225-233. thara, r., john, s., & rao, k. (2008). telepsychiatry in chennai, india: the scarf experience. journal of behavioral sciences and the law, 26(3), 315-322. thara, r., & john, s. (2013). mobile telepsychiatry in india. journal of world psychiatry, 12(1), 84-85. thara, r., & patel, v. (2010). role of non-governmental organizations in mental health in india. indian journal of psychiatry, 52(1), 389-395. werner, a. & anderson, l. e. (1998). rural telepsychiatry is economically unsupportable: the concorde crashes in a cornfield. psychiatric services, 49(10), 1287–1290. world health organization. (2011). mental health atlas. yoshino, a., shigemura, j., kobayashi, y., nomura, s., shishikura, k., den, r., wakisaka, h., kamata, s. & ashida, h. (2001). telepsychiatry: assessment of televideo psychiatric interview reliability with present and next-generation internet infrastructures. acta psychiatrica scandinavica, 104(3), 223–226. zaylor, c. (1999). clinical outcomes in telepsychiatry. journal of telemedicine and telecare, 5(s1), 59–60. amrita parekh is a 2014 graduate of cssw in the advance clinical practice method with a concentration in health, mental health, and disabilities. she is currently based in mumbai, india, where she works as a mental health counselor at ummeed child development center. amrita also serves as a consultant to the public health foundation of india, and is involved in research studies within prime, a program that aims to develop mental health care plans in several lowand middle-income countries, including india.   journal final revised margins.indd aarons journal of student social work, volume ii 27 over three million children in the united states are reported to state child protection services as alleged victims of sexual, physical, and emotional abuse and neglect each year. of these cases, approximately 903,000 are substantiated. twelve percent of the substantiated cases involve child sexual abuse. this author provides an overview of the prevalence, risk factors, and symptomology of sexually abused children and critically examines the use of play therapy as an assessment and intervention tool. the use of play therapy with child victims of sexual abuse jamie d. aarons introduction to child sexual abuse over three million children in the united states were reported to state child protection services as alleged victims of sexual, physical, and emotional abuse and neglect in 2003 (us department of health and human services, 2003). of these cases, approximately 903,000 were substantiated. twelve percent of the substantiated cases involved child sexual abuse (kuehnle, 2003). among males, the rate of sexual abuse is .4 per 1000; among females it is 1.7 per 1000 (us department of hhs, 2003). while these abuse and neglect figures encompass children under age 18, over 50% of those children are below the age of eight. childhood sexual abuse is clearly a pressing social problem. research suggests that national incidence figures may represent less than one-third of all occurring cases of maltreated children in america (briere & elliott, 2003; finkelhor, 1994). this may be especially true for boys who are sexually abused, perhaps due to a stigma attached to their accounts. incidents of child abuse during the preschool years are also likely to be underreported (kuehnle, 2003). further variability in national rates may exist because of the diversity of definitions that are employed by individual states. for instance, some states exclude child-on-child sexual abuse from their data. for the purposes of this paper, the definition of child sexual abuse will be that published by cohen and mannarino (1984), which defines child sexual abuse as “sexual exploitation involving physical contact between a child and another person. exploitation implies an inequality of power between the child and the abuser on the basis of age, physical size, and/or the nature of the emotional relationship. physical contact includes anal, genital, oral, or breast contact” (p. 343). children are at an increased risk of sexual abuse when parents are unable to adequately supervise or nurture them, due to factors such as community or domestic violence, substance abuse, poverty, and single-parent status (kuehnle, 2003). in a study by straus, gelles, and steinmetz (as cited in kuehnle), physical or sexual child abuse was found to occur simultaneously in 30 to 70% of two-parent families in which there was domestic violence. other risk factors include early sexual maturation in girls and emotional and physical disabilities. based on general population surveys, abuse by parents and step-parents constitutes between six and 16% of all cases, and abuse by any other relative comprises more than one-third of the cases. in clinical samples, parent figures comprise between one quarter and one third of the offenders, and all other relatives comprise approximately one half (berliner & elliott, 2002). symptomology of child sexual abuse victims sexually abused children may exhibit a wide range of potential symptoms, including low self-esteem, anxiety, depression, anger and aggression, posttraumatic stress, or dissociation. much of the externalized emotional distress comes as a result of the children’s level of hyperarousal, emotional pain, and restimulation of abuse memories; the abuse represents a constant challenge to their coping mechanisms (berliner & elliott, 2002). thus, any external activity that successfully reduces internal tension (e.g., through distraction, self-soothing, or anesthesia) is reinforced and sought out by the child. according to berliner and elliott, negative manifestations of these behaviors include self-mutilatory activities; increased or precocious sexual activity; bingeing and purging; and alcohol or substance abuse. some minors who have been sexually victimized exhibit school-related difficulties, including low time-on-task, acting-out behaviors, and low academic achievement. in a study of adults who had been sexually abused as children, saunders, villeponteaux, lipovsky, kilpatrick, and veronen (1992) found that these adults suffered a wide range of psychiatric disorders and problems, including depression, phobias, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, sexual disorders, and both suicidal ideation and suicide attempts. once sexual abuse has occurred, the child’s functioning is likely to be more positive if the following conditions occur: the child is not closely related to the perpetrator; the child’s mother believes the report and is supportive; the family is stable and without violence; the sexual acts were not violent in nature; and the child endured the abuse for a shorter period of time (kuehnle, 2003). the child will also have an increased likelihood of long-term positive outcomes if he or she utilizes an active/social coping strategy – as opposed to avoidant, internalized, or angry strategies – and does the use of play therapy with child victims of sexual abuse 28 journal of student social work, volume ii not blame himor herself for the abuse (kuehnle). based on the significant impairment that sexual abuse poses to the psychological and behavioral outcomes of children and adults, it is obvious that effective intervention strategies are necessary at an early age. reviews of the treatment outcome literature provide evidence that abuse-specific cognitive behavioral treatments (cbt) are effective for the posttraumatic stress reactions related to child sexual abuse (berliner & elliott, 2002). commonly, this therapy includes psychoeducation, which involves the provision of information about the nature of the abuse and offenders, in addition to anxiety management. children are taught how to identify their emotions and how to use various relaxation and coping strategies. elements from exposure therapy are utilized, involving the gradual exposure to the abuse experience in order to de-condition automatic negative associations and to reduce maladaptive avoidance. this is sought through talking, drawing, or writing about the abuse. finally, cognitive therapy is “used to challenge and replace cognitive distortions about the event or generalized negative attributions about self and others” (berliner & elliott, 2002, p. 67). parents can be included in this treatment with some positive outcomes related to child behavior problems and improved parental support. other potential approaches for this population, such as family therapy, behavioral interventions, and pharmacological treatments, have yet to be thoroughly empirically evaluated for effectiveness in treating sexually abused children. another therapy that has not undergone empirical testing for use with sexually abused children but that may prove effective is play therapy. one reason that play therapy may be a particularly useful approach for sexually abused children is that they have not yet developed the abstract reasoning abilities and verbal skills needed to adequately articulate their feelings, thoughts, and behaviors. “for children, toys are their words, and play is their conversation” (hall, kaduson, & schaefer, 2002, p. 515). play provides a symbolic language that makes communication possible. this paper will provide an overview of play therapy and critically examine its role as an assessment and intervention tool with the population of child sexual abuse victims. defining play therapy play therapy is a general term used to describe a variety of interventions that incorporate the use of play into the assessment and treatment of children and families. there are two basic forms of play therapy: directive and nondirective. directive approaches are those in which the therapist selects the activity and moves the child’s play or discussion toward a specific topic or goal. this structured approach includes cognitive-behavioral play therapy, as described by knell (1999). in nondirective, unstructured play therapy, aarons journal of student social work, volume ii 29 the therapist concentrates on establishing a relationship of unconditional acceptance of the child, within a safe environment, while the child is allowed to choose the play medium, set their own rules, and use the play objects and time as they wish (guerney, 2001). included in this category is the child-centered play therapy (ccpt) method developed by axline (1969), based on the client-centered work of carl rogers, and non-directive puppet therapy (carter, 1987). past research on play therapy in a comprehensive play therapy literature review by phillips in 1985 (as cited in white & allers, 1994), it was concluded that among 200 case studies, anecdotal articles, and empirical research reports that existed at the time, there were inconsistent definitions of play therapy, inadequate definitions of the qualifications and role of the play therapist, and inadequate or flawed statistical design. based on the findings of this author’s research and current literature review, 18 years after phillips’ analyses, the evidence related to play therapy appears nearly identical to that reviewed by phillips, lacking well controlled-studies that could offer meaningful and informative statistics with which to empirically support the use of play therapy. rationale for play therapy with child sexual abuse victims for the past 17 years play therapy has been regarded by numerous clinicians and researchers as a potentially effective intervention tool for use with child victims of sexual abuse. regardless of the specific approach, most of the authors emphasize providing these children with a secure therapeutic setting in which the therapist shows support, acceptance, and perseverance. the authors also emphasize a setting in which the therapist acknowledges the thoughts and feelings expressed within the sessions (carter, 1987; kelly, 1995; knell, 1999; mcmahon, 1992; singer, 1990). psychoanalytic play therapy, which incorporates both directive and nondirective approaches (singer, 1990), aims to alter inner or outer functioning of the child by helping the sexually abused child understand his experiences and feelings. this occurs through the use of verbalization, interpretation, and clarification. a review of studies by casey and berman (as cited in singer) “found good evidence that psychotherapy with children (compared to untreated controls) is at least as effective as with adults . . .” (p. 225). this supports the psychotherapeutic foundation on which child-centered play therapy is based. consistent with the findings of phillips, however, there is no indication that these studies had adequate sample sizes or that they utilized uniformed measurements. in a comparison study of parent therapy, play therapy, group therapy, and behavior modification for a cohort of children with a broad range of behavior problems, psychotherapeutic play therapy proved most effective for those children with internalizing the use of play therapy with child victims of sexual abuse 30 journal of student social work, volume ii behaviors, such as depression, withdrawal, self-doubt, and fears (singer). this could be promising evidence considering that these behaviors are consistent with those of many sexual abuse victims, as described earlier. again, the term “psychotherapeutic play therapy” is used loosely, however, and it is impossible to surmise which aspects of the treatment were effective. the majority of support offered comes, instead, from individual case studies and anecdotes (kelly, 1995; singer). research related to both directive cognitive-behavioral play therapy and child-centered nondirective play therapy provides evidence to support the tenets on which they are based, but does not provide specific empirical evidence proving their effectiveness with sexually abused children. for example, axline’s nondirective approach is based on the empirical and clinical evidence demonstrating support for rogers’ client-centered methods. likewise, in a study by parpel and maccoby (as cited in guerney, 2001), a group of children whose mothers were taught to make supportive statements and to use nondirective approaches during play demonstrated more compliance than children whose mothers followed their own course (p. 14). this data offers support for the potential of child-centered play therapy but certainly does not qualify as empirical evidence to back this clinical approach. literature that devotes specific attention to the use of child-centered play therapy with sexually abused children is limited to case studies and anecdotal clinician and parent reports (carter, 1987; guerney, 2001; mcmahon, 1992). by relaying examples from her own clinical practice, mcmahon suggests a combination of nondirective and focused play techniques to be most effective with this population. she posits that the use of anatomically correct dolls is helpful both as an assessment and treatment tool, but provides no empirical evidence to back this claim. suggested child-centered play therapy goals for the sexually abused child include the restoration of trust, the normalization of feelings, increasing feelings of control, expressing and coping with feelings of anger, fear, disgust and sadness, and enabling the eventual development of normal relationships of mutual sharing and care (mcmahon). like child-centered play therapy, cognitive-behavioral play therapy is grounded in a body of research based on intervention strategies that have been proven effective with adults. modeling, which is useful with adults (bandura, as cited in knell, 1999), is used to improve coping and as a means of psychoeducation with children; role-plays are used to practice problem solving skills and adaptive behaviors. according to knell, “the fact that cognitive behavior therapies for adults have been empirically validated does not mean the same holds true for children” (p. 402). her own evidence in support of cognitive-behavioral play therapy with sexually abused children is in the form of case examples. aarons journal of student social work, volume ii 31 play therapy as an assessment tool aside from the lack of empirical evidence to support the use of play therapy as an intervention tool, multiple authors recognize play as a vital means of assessing the sexually abused child (mcmahon, 1992; norton & norton, 1997; white & allers, 1994). corresponding to the symptoms described previously, children who have been sexually abused may display developmental immaturity, opposition and aggression, withdrawal and passivity, self-destruction or self-deprecation, hypervigilance, sexuality, or dissociation during their play (howard; martin & beezley; terr, as cited in white & allers, 1994). in comparison to a healthy child, the abused child may display a high level of intensity, atypical rigidity in play, or be overly dependent on the therapist for guidance in play. these play behaviors and themes have been shown to be valid and reliable means of identifying and assessing the sexual abuse victim. however, much of the research is based on small sample sizes and there is also a need for variables, such as hypervigilant and aggressive behaviors, to be defined thoroughly and consistently in future research. conclusion child sexual abuse is a disturbing problem within our nation – one that has serious behavioral and psychological ramifications for all involved. play therapy, which may be directive, nondirective, or a combination of the two, is increasingly used for the clinical treatment of sexually abused children. play therapy is the primary intervention model utilized by many social workers with children. supporters of play therapy stand firm in their belief that this is an important clinical technique. most of the research on play therapy and childhood abuse, however, has relied on non-statistical observations using single case or small-group samples. just as phillips (as cited in white & allers, 1994) recommended 18 years ago, research deficits in the field must be addressed if therapists are to provide these children with effective care. now, and in the future, social workers will play a significant role in providing empirical research for the use of play therapy in the treatment of child sexual abuse victims. statistical evidence is needed to show the effectiveness, or lack thereof, of play therapy with this population. evidence is also clearly needed that compares the effectiveness of play therapy to other treatment modalities, including cognitive behavior therapy, family therapy, or nonspecific supportive therapy. the use of play therapy with child victims of sexual abuse 32 journal of student social work, volume ii references american academy of child and adolescent psychiatry. (1998). practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. journal of the american academy of child and adolescent psychiatry, 37(10, suppl.), 4s-26s. axline, v. (1969). play therapy. new york: ballantine books. berliner, l., & elliott, d. m. (2002). sexual abuse of children. in j. e. b. myers, l. berliner, j. briere, c. t. hendrix, c. jenny, & t. a. reid (eds.), the apsac handbook on child maltreatment (2nd ed.) (pp. 55-78). thousand oaks, ca: sage publications, inc. briere, j., & elliott, d. m. (in press). prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. child abuse and neglect. bromberg, d. s., & johnson, b. t. (2001). sexual interest in children, child sexual abuse, and psychological sequelae for children. psychology in the schools, 38(4), 343-355. carter, s. r. (1987). use of puppets to treat traumatic grief: a case study. elementary school guidance and counseling, 21(4), 210-215. cohen, j. a., & mannarino, a. p. (2000). predictors of treatment outcome in sexually abused children. child abuse and neglect, 24(7), 983-994. finkelhor, d. (1994). current information on the scope and nature of child sexual abuse. future of children, 4, 31-53. guerney, l. (2001). child-centered play therapy. international journal of play therapy, 10(2), 13-31. hall, t. m., kaduson, h. g., & schaefer, c. e. (2002). fifteen effective play therapy techniques. professional psychology: research and practice, 33(6), 515-522. johnson, l., bruhn, r., winek, j., krepps, j., & wiley, k. (1999). the use of child-centered play therapy and filial therapy with head start families: a brief report. journal of marital and family therapy, 25(2), 169-177. kelly, m. m. (1995). play therapy with sexually traumatized children: factors that promote healing. journal of child sexual abuse, 4(3), 1-12. knell, s. m. (1999). cognitive-behavioral play therapy. in s. w. russ & t. h. ollendick (eds.), handbook of psychotherapies with children and families (pp. 385-404). new york: kluwer academic/plenum publishers. kuehnle, k. (2003). child sexual abuse evaluations. in a. m. goldstein & i.b. weiner (eds.), handbook of psychology: vol. 11. forensic psychology (pp. 437-460). hoboken, nj: john wiley & sons, inc. mcmahon, l. (1992). the use of play in helping sexually abuse children. in the handbook of play therapy (pp. 154-179). london: routledge. norton, c., & norton, b. (1997). assessing children in the play therapy intake. in reaching children through play therapy (pp. 138-141). denver, co: the publishing cooperative. saunders, b. e., villeponteaux, l. a., lipovsky, j. a., kilpatrick, d. g., & aarons journal of student social work, volume ii 33 veronen, l. j. (1992). child sexual assault as a risk factor for mental disorders among women: a community survey. journal of interpersonal violence, 7(2), 189-204). singer, d. g. (1990). play as healing. in the house of make-believe (pp. 201-229). boston: harvard university press. united states department of health and human services. (2003). child welfare outcomes 2000: annual report. retrieved october 13, 2003, from http://nccanch.acf.hhs.gov/frames/frameset_c.cfm?url=http%3a %2f%2fwww%2eacf%2ehhs%2egov%2fprograms%2fcb%2fpubli cations%2fcwo00%2findex%2ehtm white, j., & allers, c. t. (1994). play therapy with abused children: a review of the literature. journal of counseling and development, 72(4), 390-405. jamie d. aarons is a second-year master’s student at the columbia university school of social work and is enrolled in the dual-degree program at bank street college pursuing a master’s degree in early childhood special education. she is currently an intern at the northside center for child development in the early therapeutic center in new york city. she holds a bachelor’s degree in human development and psychological services from northwestern university. 34 journal of student social work, volume ii the use of play therapy with child victims of sexual abuse buck / social workers of the world unite 25 a call to action social work students are the future of the profession; we are the ones who are to effect change in society, creating a more fair and just world. social work students, however, are ill-equipped to carry out this duty. curricula highlighting social injustice and its effects, illustrated through our clients’ lives, fail to generate action and dialogue on social work school campuses. this political apathy runs counter to the philosophy of social work. social structures need to be changed to remedy social ills through direct action. social work students must turn beliefs and convictions into actions. the social work code of ethics requires involvement social work students have not been sufficiently engaged in social action and discussion. one recent event on campus at columbia university, billed as a discussion on the humanitarian crisis in iraq, was attended by approximately ten social work students. what could have been an opportunity for social work students to inform themselves on issues of global, political, and social importance was, instead, a demonstration of the student body’s apathy toward learning about events outside their immediate practice focus. many social work students are poorly informed about local, national, and international causes and their interconnections. social work students should ssocialocial wworkersorkers ofof thethe wworldorld uunitenite lesley buck social workers begin their professional careers in graduate school. in preparation, students need to educate themselves with regard to relevant social and political issues. the nasw code of ethics stresses the profession’s ethical obligation to actively work on behalf of the goals of social justice and social change. graduate social work programs fall short of preparing students for the progressive role the profession requires. social workers are uniquely positioned to converge various fields relevant to social change. furthermore, social work is a political activity, as it either serves the status quo or the concerns of client populations. students are required to reconcile the ethics of the profession and their graduate training through engaging in political and social action. columbia university journal of student social work volume 1, number 1 26 realize that there is more to social work than what is being taught in graduate schools. social work students have an obligation to engage in social change; it is our fundamental role in society, and mandated by the profession. social justice is one of the core ethical principles of the national association of social workers (nasw) code of ethics. this professional code requires us to act socially and politically to guarantee all people the rights to equity and social justice (nasw, 1999). educational standards exclude social change social work students prepare to enter a professional career, and like all professions, social work has its own educational training (flexner, 1915). a comparison of the code of ethics to the educational standards set by the council on social work education (cswe, 2003) reveals interesting discrepancies. social work schools are not educating their students for future careers as change leaders, as the cswe merely requires that ethics and social justice be infused into the curriculum of graduate programs (cswe). an ethical mission of our profession has been relegated to a non-essential component of our educational requirements. graduate social work education chooses to emphasize certain professional areas over others; it is clear that involvement in social and political justice has not been recognized as an important area for knowledge development (sarri & meyer, 1992). there is little evidence that the current social work curriculum is designed to foster critical social thinking and action. students seldom engage in politically oriented dialogue. in fact, most students and professors take great measures to ensure that discussions are politically sanitized, with students rarely expressing any strong opinions on issues of poverty, racism, classism, or ethics. social workers today have relinquished their roles as social critics and reformers, representing a serious concern for the profession (sarri & meyer). the social work profession has a long history of active political engagement, representing a threat to the status quo. many interested parties would hope the newer generations of the profession would abandon this commitment. in fact, brill (2001) warned of the widening gap between ethics and practice. students are called upon to bridge this gap, which requires more attention and critical thinking to our practice than ever before. social workers have a unique perspective to offer the political and social change debates. as a profession, social work draws upon and connects many fields, including political science, sociology, psychology, and philosophy. social workers perform many duties and operate in many spheres. unfortunately, social work schools may not be doing enough to create professionals suited for the inter-disciplinary work required of social workers. buck / social workers of the world unite 27 social work schools may be training students to take a professional role in the existing structure of society instead of fostering critical thinking and training to create a new and better social structure (sarri & meyer, 1992). social work is political feminists have argued for decades that the personal is political. social workers are positioned, unlike any other group of professionals, to connect personal issues to their social, political, and economic roots (long, 2002). social workers must challenge the status quo by advocating for change to address the structural, economic, and systemic problems from which clients suffer. social justice can be achieved through direct efforts to reform social policy. social work students should be involved in social advocacy on behalf of their client populations. the criteria by which we measure the success of social action must be the change achieved for the deprived communities in which we serve (figueira-mcdonough, 1993). furthermore, many scholars have argued that social work is, a priori, a political endeavor (abramovitz, 1993; long, 2002; freire, 1990). the unifying theme of social work, regardless of the unit of analysis (client interventions, advocacy, community organizing, and policy reform), is amelioration of a social problem. to claim that social work is neutral is to support the existing social structure and ideology and exempt these from diligent scrutiny. long stated that “a decision to act apolitically is a decision to support the status quo” (p. 57). it could be further argued that social workers actually contribute to this status quo by placating the disenfranchised instead of mobilizing them and creating change. apolitical social work absolves the rest of society from action, allowing problems to linger unchallenged. abramovitz argued that social workers need to be educated for change to ensure that the profession does not become an agent of the status quo. the emerging professional’s responsibility to be informed freire (1990) stated, “social workers are conditioned by the structure of the society in which they live, in which they are formed. social workers uncover and make explicit a certain dream about social relations, which is a political dream” (p. 5). the structure of society has changed drastically in the last twenty years. much social progress has been undone through effective political marketing, shifting attention away from domestic and social issues. schools of social work need to sustain an environment where divergent opinions can be expressed, and students need to take initiative to educate themselves about relevant and timely political and social issues. a fundamental problem in the political and social arenas in the united states today columbia university journal of student social work volume 1, number 1 28 is the lack of discourse. citizens are not questioning the political system in the diligent manner that was espoused by this country’s fore founders. the proliferation of social problems in the most recent decades is testimony that many have been victimized by the political system, directly or indirectly. if social workers do not actively work for social and political change on behalf of the most vulnerable populations, who will? if the current generation of social workers fails to embrace the profession’s ethical obligation to achieve social justice, will the profession’s mission evolve to support, instead of oppose, a socially conservative and oppressive political environment? writing in 1953, social worker charlotte towle asserted, “we live in a period of scientific enlightenment and of great technical achievement which, if intelligently used, could render the life of all peoples more satisfactory that even before” (p. 1). social work students must not rely on graduate school curricula to provide all the essential training to accomplish this. the mission and ethics of the profession require a willingness to actively confront social and political injustice on behalf of our client populations. young professionals preparing to enter practice must realize the political nature of their work and reconcile it with the political and social reality they would like to develop. references abramovitz, m. (1993). should all social workers be educated for social change? pro. journal of social work education, 29, (1) 6-11. brill, c. k. (2001). looking at the social work profession through the eye of the nasw code of ethics. research on social work practice, 11(2), 223-234. council on social work education. (n.d.). curriculum policy state ment for master’s degree programs. retrieved february 24, 2003, from http://www.cswe.org. figueira-mcdonough, j. (1993). policy practice: the neglected side of social work intervention. social work, 38(2), 179-188. flexner, a. (1915). is social work a profession? in national conference of charities and corrections, proceedings of the national conference of charities and corrections. chicago: hildmann. freire, p. (1990). a critical understanding of social work. journal of progressive human services, 1(1), 3-9. long, p. (2002). ethical and inescapable: politicized social work. in m. o’melia and k. k. miley (eds.), pathways to power: readings in contextual social work practice (pp. 55-73). boston: allyn and bacon. national association of social workers. (1999). code of ethics of the buck / social workers of the world unite 29 national association of social workers. washington, d.c.: nasw. sarri, r.c. & meyer, c.h. (1992). is social work inherently conservativedesigned to protect the vested interests of the dominant power groups? in e. gambrill and r. pruger (eds.), controversial issues in social work (pp. 39-51). boston: allyn and bacon. towle, c. (1953). common human needs. new york: american association of social workers. lesley buck is a first-year ms student at the columbia university school of social work. she is currently an intern at the boys and girls harbor post-adoption services program in new york city. she holds a ba from new york university in economics and french. 2019-cswr_neworder.indd columbia social work review, vol. x | 1 dance for life: using a resilience model to foster positive body image and prevent body image dissatisfaction cora b. richter and kimone c. coley introduction a substantial majority of women—some 69–84% in the united states— experience body image dissatisfaction (runfola et al., 2013), often beginning from a young age. body image dissatisfaction is an empirically supported predictor of maladaptive eating behaviors such as dieting, bulimic behaviors, and weight gain (bucchianeri, arikan, hannan, eisenberg, & neumarksztainer, 2013). it is also a risk factor for depression (paxton, neumarksztainer, hannan, & eisenberg, 2006) and a mediator of the relationship between body mass index and self-esteem (bucchianeri et al., 2013). accordingly, there is an urgent need for preventative interventions and programs where girls can develop the resilience to maintain healthy body image. body image dissatisfaction is reported at higher rates among females in middle adolescence than among other groups (lawler & nixon, 2011; bearman, presnell, martinez, & stice, 2006), and is argued to be the core component of self-esteem in this population (levine & smolak, 2002). research points to the range of 11–14 years as being a critical age for intervention to promote body image resilience and prevent body image dissatisfaction. gardner, stark, friedman, and jackson (2000) found that body dissatisfaction1 and larger perceived body size predicted elevated eating disorder scores at age 11 and thinner ideal body sizes at age 12. meanwhile, rohde, stice, and marti (2015) found that body dissatisfaction, among other factors, was significantly predictive of eating disorders within four years at age 14. moreover, body image concerns affect millions more women and girls than eating disorders do (choate, 2005)—making body image dissatisfaction a public health concern unto itself and providing an opportunity for researchers and clinicians to positively impact the lives of a substantial swath of the american populace (choate, 2005). in light of this research and the reality of continuing familial, peer, and media-related pressures toward thinness, this paper addresses the need for programs and practices that bolster body image resilience in middle-school-aged girls. this paper has four goals. first, it will review the evidence explaining the sociocultural rise of body image dissatisfaction in adolescent girls. second, it will depict current evidence-based interventions that address body image dissatisfaction and aim to prevent eating disorders and other psychological issues. third, this paper will identify choate’s body image 1 this paper will use “body image dissatisfaction” and “body dissatisfaction” interchangeably. 2 | columbia social work review, vol. x body image resilience program resilience model (2005) as a strengths-based model that implicitly draws on sociocultural theories of body image dissatisfaction to help girls to develop positive body image—and in doing so, help them to understand and address body dissatisfaction—on an individual or community basis. finally, and most importantly, this paper will propose a prevention-intervention program for developing body image resilience, grounded in choate’s body image resilience model, engaging adolescent girls in dance movement therapy (dmt) and their families in discussion of body image issues. we posit that this should be a preferred intervention to address body image dissatisfaction in the target population in schoolor community-based settings. it is argued that addressing body image dissatisfaction in this way could reduce the risk of development of maladaptive eating behaviors and other psychological symptoms. the rise of body image dissatisfaction given the negative effects of body image dissatisfaction, its causes should be explored. multiple explanations for the rise of body dissatisfaction in adolescent populations have been proposed. for example, vartanian and colleagues (2018) theorized a link between body image dissatisfaction and adverse life events, lower self-concept, and greater internalization of appearance. however, the primary explanation for body image dissatisfaction that has been tested in middle-school-aged girls is sociocultural. that is, body image dissatisfaction is associated with the dominant culture’s promoted imagery of the idealized thin and, at times, sexualized female body. taking a sociocultural perspective, thompson, heinberg, altabe, and tantleff-dunn (1999) propose a tripartite model of influence in relation to body dissatisfaction, consisting of the media, peers, and parents. these three influences are mediated through internalization of the thin-ideal and appearance comparison processes. keery, van den berg, and thompson (2004) tested this model on a sample of middle-school-aged girls. keery et al. (2004) found a causative link between the media, peers, and parents’ influences and body image dissatisfaction in this population. in the case of parental influence, this relationship was fully mediated by internalization and appearance comparison. in the case of the media and peer influences, internalization and appearance comparison partially mediated the causative relationship. these results were replicated by schroff and thompson (2011) with a similar sample. peers model appearance norms and play roles in formative conversations about appearance, including those about dieting (jones, 2004; schroff & thompson, 2011). the frequency of these conversations about appearance is causatively linked to an increase in body image dissatisfaction, particularly in adolescent females (clark & tiggemann, 2006; jones et al. 2004). in addition, appearance-based teasing and criticism can also cause columbia social work review, vol. x | 3 body image resilience program body dissatisfaction (lawler & nixon, 2011). teasing and criticism are particularly influential because they apply the sociocultural ideal directly to the individual, which contributes to the process of internalization (lawler & nixon, 2011). in relation to parents, it has been theorized that the family’s appearancerelated culture, that is, the way thinness, eating, and weight are addressed in family contexts, is linked to body image dissatisfaction (kluck, 2010). the impact of parents is observed in multiple domains. first, comments about appearance and expressed attitudes about body size influence children. these comments are impactful regardless of whether they are made in relation to the specific child’s body in the form of criticism or teasing, or to bodies generally (kluck, 2010). second, parents may influence their children by modeling appearance-related behaviors such as dieting or preoccupation with weight and shape, or by encouraging their children to engage in these behaviors (kluck, 2010). research has shown that daughters who are encouraged to diet by their mothers are more likely to be dissatisfied with their bodies (benedikt, wertheim, & love, 1998). in addition, body image dissatisfaction in mothers is linked to body image dissatisfaction in daughters (kichler & crowther, 2001). within the tripartite model of influence, the media is theorized to have the most influence on adolescent body image (levine & smolak, 1996). the media portrays an often unattainable standard of thinness (hargreaves & tiggemann, 2004). studies show that the more adolescent girls are exposed to magazines and television, the higher their rates of body dissatisfaction are likely to be over time (anderson, huston, schmitt, linebarger, & wright, 2001; bell & dittmar, 2011). outside of the traditional mass media, use of the internet is correlated to body image concerns, particularly when social networking sites are used (tiggemann & slater, 2013). part of the reason that middle-school-aged girls are more at risk of body image dissatisfaction may be the amount of time they spend on social media sites and applications that contain images of celebrities, “influencers,” and peers portraying idealized body types (perloff, 2014). these images create “exponentially more opportunities for social comparison and dysfunctional surveillance of pictures of disliked body parts than were ever available with the conventional mass media” (perloff, 2014, p. 366). essentially, the use of social media by middle-school-aged girls means social comparisons can be made quickly, easily, and against multiple sources (myers & crowther, 2009). that is, social media amplifies the thin-ideal that existed already in the dominant culture and that had been created, in part, by mass media. the role of social media in exacerbating the body image dissatisfaction problem underscores the need for proactive efforts to build girls’ body self-esteem—because their social media use seems only to be rising (anderson & jiang, 2018). 4 | columbia social work review, vol. x body image resilience program current approaches to prevention and intervention programs aiming to address body image dissatisfaction in adolescents are targeted (focused on those at risk of disordered eating or other adverse outcomes due to high levels of body dissatisfaction), selective (focusing on demographically high-risk populations such as adolescents or girls), or more universal (applied generally to non-symptomatic participants) (neumarksztainer et al., 2006). in a meta-analysis of published prevention trials, it was found that targeted interventions tend to be more effective than universal interventions (stice, shaw, & marti, 2007). interventions that are interactive and delivered in multiple sessions also have a stronger evidence base (stice et al., 2007). in the domain of targeted and selective interventions, cognitive behavioral programs, psychoeducation, and dissonance reduction have proven effective (levine & smolak, 2006). however, a review of these interventions revealed that, in populations exhibiting body image concerns, the balance of the evidence supports interventions targeting cognitive dissonance (stice, shaw, burton, & wade, 2006). this approach takes a sociocultural perspective. dissonance reduction interventions require adolescent girls to critique negative body image beliefs acquired from peer, familial, and media influences through involvement with verbal, written, and behavioral exercises (stice, rohde, gau, & shaw, 2009). these techniques have resulted in reduction in thin-ideal internalization, body dissatisfaction, dieting attempts, and eating disorder symptoms, persisting through 1-year follow-up (stice et al., 2009). the evidence supporting dissonance reduction interventions has led to these approaches being labeled the “gold standard” prevention approach, which targets the tripartite influence model (atkinson & wade, 2015). meta-analysis reveals that dissonance interventions are one of only two prevention approaches proven to reduce risk of development of eating disorder pathology at 3-year follow-up (the other being an intervention focused on maintaining healthy weight and not specifically targeting body image dissatisfaction) (stice, becker, & yokum, 2013). because of the proven effectiveness of dissonance reduction interventions in targeted populations, it is useful to consider whether this approach could be taken in a universal sample. in a randomized controlled trial, atkinson and wade (2015) compared dissonance reduction interventions to a mindfulness approach in a sample of adolescent girls. importantly, the study was applied to a universal sample, containing participants of all levels of body image concern. the mindfulness approach aimed to address sociocultural factors by teaching participants to refrain from automatically responding to the thin-ideal, while simultaneously reducing the impact of negative affect. negative affect is a risk factor for eating-related dysfunction, thought to coexist with body dissatisfaction columbia social work review, vol. x | 5 body image resilience program (atkinson & wade, 2015). mindfulness interventions resulted in significant reductions in weight/shape concerns, dietary restraint, thin-ideal internalization, eating disorder symptoms, and psychosocial impairment, when delivered by optimally trained facilitators. however, no significant difference was observed between the group receiving the mindfulness intervention and the group receiving the dissonance reduction intervention. the study indicates that both mindfulness and dissonancebased interventions can be helpful in reducing body dissatisfaction in a universal sample of adolescent girls (atkinson & wade, 2015). individual protective factors: a strengths-based model while most researchers have chosen to focus on the risk factors for body image problems (as well as risk factors for clinically diagnosable eating disorders), a few have identified those strengths that allow women and girls to maintain a healthy body image. we will pair the conceptualization of body image issues and interventions found in existing research with choate’s (2005) breakdown of risk factors and protective factors for body image challenges in order to move toward an intervention that can be used by educators, social workers, and other concerned professionals in both clinical and nonclinical settings. choate (2005) acknowledges that women and girls experience pressures as a result of comparison to media representations and their peers. yet she does not find that all groups encounter these pressures to the same degree or in the same way. while acknowledging that eating disorder and body image dissatisfaction rates do not differ substantially among asian, hispanic, and white americans according to many studies, she points to the african american community as one in which women are “buffered” somewhat from the pressure to have an extremely thin physique (choate, 2005).2 warren, gleaves, cepeda-benito, fernandez, and rodriguez-ruiz (2005) point to a possible psychological pathway for such a buffering effect, at least among their mexican american and spanish study participants. they identify the adoption of westernized, thinness-idealizing culture and media as having two components: awareness of the thinness ideals and internalization of those ideals, where internalization is expressed through endorsement and emulation (warren et al., 2005). they suggest that ethnicity mediates the latter component. mexican american and spanish women were found to be significantly less likely to internalize the thin2 research published since laura hensley choate developed her theorization of body image resilience has complicated the narrative somewhat. new studies have found that rates of eating disorders among african americans do not differ substantially from other groups, or that different groups are prone to different types of eating disorders. see smink, van hoeken, & hoek (2012) for a discussion of general epidemiology between different groups; shuttlesworth & zotter (2011) for a discussion of possibly higher binge eating disorder rates among african americans; hoek (2016) for a cross-national perspective and review of the literature; and watson et al. (2013) for a discussion of how black women still internalize the expectations of the dominant white culture despite having some distance from it. 6 | columbia social work review, vol. x body image resilience program ideal, and in turn significantly less likely to experience body dissatisfaction (warren et al., 2005). psychological pathways are complemented by sociological ones. nonwhite or non-northern-european-descent groups’ position outside the dominant white culture is understood to give these groups the ability to more critically evaluate media containing white standards of beauty and to develop their own standards of beauty (choate, 2005). family, peer, and community relationships (especially those between mothers and daughters) reinforce the deviations from the dominant culture and facilitate girls’ sense of self-esteem, strength, and independence (choate, 2005; parker et al., 1995). the curse of marginalization and racism would seem to have the positive collateral effect of allowing communities to develop or maintain their own norms, insights, and practices that can be healthier than those of the dominant culture. choate ultimately identifies “(a) family-of-origin support, (b) gender role satisfaction, (c) positive physical self-concept, (d) effective coping strategies, and (e) sense of holistic balance and wellness” as the key protective factors for body image resilience in women and girls (choate, 2005, p. 325). snapp, choate, and ryu (2012) measured the efficacy of a version of choate’s body image resilience model in a survey study of 301 first-year college females. they found marginal or moderate, but mostly statistically significant, correlations between the different protective factors and “overall wellness,” which they measured using adams et al.’s (1997) perceived wellness survey (snapp et al., 2012). in turn, they found a .31 positive correlation between wellness and body image, which was measured using the body-esteem (be)-appearance subscale of the be scale for adolescents and adults (snapp et al. 2012; see mendelson et al., 2001, for the body-esteem (be)-appearance subscale). other researchers have individually identified the efficacy of each of choate’s (2005) protective factors (if not necessarily with reference to choate). barker and galambos (2003) confirm the importance of family support. other researchers refer to self-esteem (o’dea, 2010), various forms of physical and holistic wellbeing (shisslak & crago, 2001); and selfefficacy as protective factors (shisslak & crago, 2011; see also pelletier, dion, & lévesque, 2004, who refer specifically to the importance of selfdetermination as a protective factor against media). given this broad base of support for choate’s body image resilience model, this paper will use it as a touchstone for designing and evaluating the dmt intervention developed therein. columbia social work review, vol. x | 7 body image resilience program dance for life: a strengths-based intervention for body image resilience while atkinson and wade (2015), among others, have considered empirically supported interventions to address body image dissatisfaction, their approaches are nonetheless limited in that they fail to adequately incorporate protective factors. we propose a program of schoolor community-based dance movement therapy (dmt) that could serve both as a intervention for adolescent girls with body image issues and as a preventative measure for those who do not currently have body image issues but are at risk due to age or demographic factors. given that parents play a crucial role in their daughters’ body image satisfaction levels, per the tripartite model of influence, dance for life would also ideally involve families in a discussion of body image, paired with the dmt sessions and/ or recitals. and while the program would largely shift away from the riskfactors focus of past treatments and toward a strengths-based model, it would also adopt some of the empirically supported, transferable qualities of past interventions, especially the quality of it occurring over multiple sessions (see stice et al., 2007). we call this program “dance for life.” dance movement therapy (dmt) modalities have been used since at least the 1950s (berrol, 1990). while the pairing of dmt with choate’s body image resilience model is new, the idea that various forms of physical activity can promote positive body image is not. versions of the idea appear in many conceptual articles and small-scale studies. choate (2005) herself describes exercise and athleticism as promoting the physical self-concept that in turn promotes healthy body image in her model. pylvänäinen (2003) proposes a model for understanding body image in the context of dance/movement therapy. lewis and scannell (1995) find a positive relationship between experience with “creative dance movement” and approval of one’s body among 112 study participants. in a meta-analysis of the literature on dance and movement therapies, ritter and graff low (1996) describe some positive associations between the therapies and body awareness and acceptance. dmt modalities typically include music, movement, and sensory stimulation (welling, 2014). they can take the form of free-flowing modern dance or expressive, unspecific motion used as nonverbal communication or the basis of a therapeutic alliance (meekums, 1992). dance movement therapists adjust the styles and exercises to the group or individual being served (welling, 2014).3 figure 1 contains the program logic model (plm) for dance for life. the plm serves as a visual aid to map out the program intervention, addresses the need for the development of the program, and illustrates program inputs (i.e. treatments) in relation to desired outcomes for the participants. 3 for a comprehensive description of traditional dmt, please see payne ed. (1992). see hagensen (2015) and green and drewes eds. (2014) for dmt with adolescents. 8 | columbia social work review, vol. x body image resilience program figure 1. program logic model for the dance for life program brief program description: schoolor community-based dance movement program for girls to promote healthful body self-reflection. this program would aim to engage girls to promote healthy physical expression of self and self-love, per the process described by choate’s body image resilience model and the tenets of dmt. problem/need: girls could benefit from implementation of a positive youth-development program to help mitigate the risk of social, emotional, and psychological decline associated with body image dissatisfaction. goals: tackling sociocultural influences on body image dissatisfaction and promoting body image resilience. objectives: using the activity-based youth development program of dancing, groups, and family support to build body image resilience. inputs outputs outcomes impact group counselors or volunteers available space for activities curricula and/ or prompts for dance therapy sessions and family discussion groups screening tools for assessments funding source providers social workers volunteer and group counselors to facilitate dance movement therapy (dmt) groups participants adolescent girls and their families improved health and wellness reduction in body image dissatisfaction familial support for and engagement with positive body image and general wellness while dance as a practice allows people to express themselves through healthy movement, dance for life as a program goes one step further and allows adolescent girls—with the assistance of social workers, other professionals, and the girls’ own families—to build a community and a space for self-love that might be slightly buffered from the pressures of the dominant culture. programmatic dmt utilizes not only choate’s protective factors, but other researchers’ understandings of the psychological and sociological pathways that enable those factors. as noted in the preceding section, researchers have identified marginalization and, by extension, racism as the social forces that enable communities and individuals to build columbia social work review, vol. x | 9 body image resilience program cultures that reject dominant norms, such as the thin-ideal. something as destructive as racial segregation, though, need not be the mechanism for the development of separate cultures where positive body image can flourish. dance for life would ideally give girls an ideological and communal space where they could cultivate their own norms for wellness, beauty, and selflove. while some of these outcomes of dance for life are intangible, certain measures could be used to ensure that dance for life implementations are following best practices. we would recommend using a process evaluation to ensure that the program curriculum is being implemented in accordance with choate’s body image resilience model (2005). specifically, the program would be evaluated on: a) how the program is run; b) whether the services are of high quality; c) whether the program is meeting its targets; d) whether the operations are compliant with applicable regulations and mandates; and e) whether clients are satisfied with the services. program administrators could use a focus group to gather this information. providers could also implement an impact evaluation for all participants, including adolescent girls and their parents. in short, the program would be evaluated based on achievement of the expected outcomes, the impact of the program on the welfare of the adolescents, and whether the program, in fact, promotes resilience towards the development of negative body image. conclusion as a risk factor for eating disorders and depression, body image dissatisfaction is a serious individual and societal problem, especially for girls and adolescents. (we would recommend that more research be conducted to discern the forms that body image dissatisfaction takes in men, boys, and nonbinary individuals, even if those forms may be attenuated in the two former groups.) while individual characteristics have a role in making a young woman prone to body image dissatisfaction, we initially place body image dissatisfaction into its sociocultural context, identifying the role of peers, family, and the media in a tripartite model of influence. we turn toward the individual and personal protective factors, though, when we discuss not just preventing and intervening with body image dissatisfaction, but promoting positive body image. this focus on the individual and her resilience reflects the reality that changing culture such that it promotes body image satisfaction is hard—especially when such a change would target attitudes as diffuse and universal as those that cause body image dissatisfaction. choate (2005) and other researchers point to different ethno-racial cultures that have been resilient to white, westernized standards of thinness and beauty, especially african americans and mexican americans. we duly identify separation from and creation of a socio-ideological space outside the dominant culture as a key pathway for resilience to develop. we adopt choate’s (2005) model of body image resilience, which identifies five key protective factors, as the goal of our 10 | columbia social work review, vol. x body image resilience program intervention. we operate with the assumption that protective factors involving physicality and coping strategies are the easiest to develop in adolescent girls. several empirically supported techniques exist for the treatment of body image dissatisfaction, with dissonance reduction being the most effective. the drawback of these modalities, though, is that these interventions focus largely on risk factors to the expense of protective factors. as an alternative or complement to existing therapies, we put forward dance movement therapy (dmt) as a preventative and interventional program to help girls to develop body image satisfaction, along with resilience toward forces that effectively promote body image dissatisfaction. our dance for life program would use a strengths-based approach to help girls; it would give them the tools that they need to have healthy body image and the space to develop those tools. versions of dmt have been tried broadly within different outpatient and inpatient psychological programs, to address everything from depression to trauma to eating disorders. we believe that as a flexible, arts-based approach, it would fit in well with the span of activities on which many girls spend their time—where those activities include school, extracurriculars, or hanging out with friends. we provide a general template that clinicians, educators, community members, school administrators, or other concerned parties might use to begin implementing a dmt program for body image dissatisfaction. we further propose that body-image-targeting dmt programs for adolescent girls would be accompanied by family discussion series, as well as informal family engagement and involvement—given the potential of family to be either a negative influence on body image or a significant protective factor. as an alternative, arts-based therapy, dmt has proven popular but understudied. given the likely increasing ubiquity of body image dissatisfaction due to social media, researchers, educators, and clinicians should be devoted to exploring new solutions and approaches—especially for diverse populations and for communities not otherwise reached by mental health services. the connection of body image dissatisfaction to eating disorders means that not only could people’s emotional well-being be at stake, but also their lives. columbia social work review, vol. x | 11 body image resilience program references adams, t., bezner, j., & steinhardt, m. 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(2013). eating disorder prevention: current evidence base and future directions. international journal of eating disorders 46, 478–485. stice, e., rohde, p., gau, j., & shaw, h. (2009). an effectiveness trial of a dissonancebased eating disorder prevention program for high-risk adolescent girls. journal of consulting and clinical psychology, 77(5), 825–834. doi:10.1037/ a0016132 stice, e., shaw, h., burton, e., & wade, e. (2006). dissonance and healthy weight eating disorder prevention programs: a randomized efficacy trial. journal of consulting and clinical psychology, 74, 263–275. stice, e., shaw, h., & marti, c.n. (2007). a meta-analytic review of eating disorder prevention programs: encouraging findings. annual review of clinical psychology, 3, 207–231. tiggemann, m., & slater, a. (2013). netgirls: the internet, facebook, and body image concern in adolescent girls. international journal of eating disorders, 46, 630–633. thompson, j. k., heinberg, l. j., altabe, m., & tantleff-dunn, s. (1999). exacting beauty: theory, assessment and treatment of body image disturbance. washington, dc: american psychological association. vartanian, l. r., hayward, l. e., smyth, j. m., paxton, s. j., & touyz, s. w. (2018). risk and resiliency factors related to body dissatisfaction and disordered eating: the identity disruption model. the international journal of eating disorders, 51(4), 322–330. doi:10.1002/eat.22835 warren, c. s., gleaves, d. h., cepeda-benito, a., fernandez, m. d. c., & rodriguezruiz, s. (2005). ethnicity as a protective factor against internalization of a thin ideal and body dissatisfaction. international journal of eating disorders, 37(3), 241–249. watson, l. b., ancis, j. r., white, d. n., & nazari, n. (2013). racial identity buffers african american women from body image problems and disordered eating. psychology of women quarterly, 37(3), 337–350. doi:10.1177/0361684312474799 welling, a. (2014). what is dance/movement therapy? american dance therapy association. retrieved from https://adta.org/2014/11/08/what-isdancemovement-therapy/ body image resilience program columbia social work review, vol. x | 15 cora b. richter, m.a. in psychology in education cora b. richter is currently in her second year of a reduced residency msw program at columbia school of social work in the advanced clinical social work practice track. originally from new bedford, massachusetts, cora received her bachelor’s degree from roger williams university in 2010 and her m.a. in psychology in education from teachers college, columbia university in 2012. for the past 4 years, cora has worked full time for columbia university medical center’s department of psychiatry as program coordinator for the columbia day program, lieber recovery and rehabilitation clinic, and smithers addiction center where she will continue on next year for field placement. cora currently resides in brooklyn, new york. kimone c. coley is a student in the advanced generalist practice program track with a focus in health, mental health, and disabilities. kimone earned her bachelor of arts degree at smith college in massachusetts, where she majored in psychology and minored in applied statistics. born in jamaica, kimone loves to write poetry. body image resilience program 2019-cswr_neworder.indd 36 | columbia social work review, vol. x state reproductive coercion as structural violence gianna dejoy editorial note: the legal landscape in the reproductive justice space is changing rapidly. the information contained in the following article is current at the time of publication and is provided with no guarantees of ongoing completeness, accuracy, or timeliness. introduction violence against women and other marginalized groups takes many forms among individuals and in society. the coexistence of interpersonal and structural violence is especially pronounced in the realm of reproductive autonomy. reproductive coercion, a form of intimate partner violence, finds its structural-level twin in state policies on reproductive health care that are coercive in impact. communities that are already underserved by the health care system and disproportionately affected by anti-choice reproductive health policies—including women of color, young women, lowincome women, and undocumented women—are also the most at risk of reproductive coercion (katz & tirone, 2015). those who experience interpersonal reproductive coercion are additionally burdened by policies that shut down reproductive health care centers and make contraception and abortion care less accessible. moreover, it is arguable that gendered and/or racialized power dynamics permeate many efforts to control a person’s bodily autonomy and reproductive health. the influence of these power dynamics is observable whether control is exerted by a partner perpetrating intimate partner violence or a policymaker creating anti-abortion laws. this paper contends that policies that interfere with an individual’s reproductive autonomy are systems-level manifestations of coercive intimate partner violence, likely influenced by the same power dynamics and desire to exert control, and with outcomes that replicate existing sociopolitical inequities. while state reproductive coercion is a broad phenomenon, and multiple sites of reproductive coercion are considered herein, this paper will examine in more depth the role of reproductive health care centers in coercive reproductive health care policy (see chamberlain & levenson, 2012). reproductive health care centers are the physical and ideological space in which interpersonal and structural levels of coercion collide. for the purposes of this paper, reproductive health care centers will be defined as licensed health care clinics whose primary purpose is the provision of comprehensive reproductive health services, including abortion care. columbia social work review, vol. x | 37 state reproductive coercion reproductive health care centers are primary sites of intervention for victims of reproductive coercion. they are also uniquely threatened by anti-choice policies. this paper is divided into five parts. the first section, reproductive coercion, will provide an overview of interpersonal reproductive coercion. the second section, structural coercion, details federal and state-level policies that reduce access to abortion care and contraception. disparate impacts discusses demographic disparities in access to reproductive health care as well as risk factors for interpersonal reproductive coercion. next, the right to bear children addresses the flip side of this phenomenon, describing the ways in which some populations have faced coercive policies designed to restrict their ability to have children. the fifth section, reproductive health centers: on the front lines, describes the important role that reproductive health care centers can play in screening for and intervening in intimate partner violence, including reproductive coercion. that section will also address the rising tide of policies designed to shut down these clinics. overall, this paper will argue that historical and contemporary u.s. antichoice policies are not simply parallel phenomena to, but also structural manifestations of, interpersonal reproductive coercion, and should be considered forms of violence unto themselves. reproductive coercion reproductive coercion is a form of intimate partner violence characterized by interference in a person’s reproductive health and autonomy as a means of asserting power and control. most commonly, reproductive coercion manifests as a male partner attempting to make a female partner pregnant against her will (thaller & messing, 2016). miller et al. (2010) divide reproductive coercion into three categories: pregnancy coercion, birth control sabotage, and pregnancy outcome coercion. pregnancy coercion includes demanding the partner become or remain pregnant and extends to sexual violence and threats of physical violence. birth control sabotage involves hiding or destroying birth control pills, intentionally breaking condoms or covertly removing a condom during sex, or any other means of ensuring that a partner’s contraceptive method be ineffective (chamberlain & levenson, 2012; miller et al., 2010). pregnancy outcome coercion is interference with an individual’s decision of whether to terminate a pregnancy (miller et al., 2014). as research into the prevalence of reproductive coercion has mainly comprised community sampling, reported rates of this type of violence vary across studies. a review by thaller and messing (2016) found that close to five percent of women in the u.s. reported having experienced reproductive coercion, while results of a 2010 national survey found that 9% of u.s. women had experienced reproductive coercion at some point in their lifetimes (black et al., 2011), and other estimates range up to 16% (kovar, 38 | columbia social work review, vol. x 2018). thaller and messing’s (2016) review reported that between 14% and 74% of teenage mothers and women seeking reproductive health care or domestic violence services reported experiencing reproductive coercion. in their study of family planning clinics in the san francisco area, holliday et al. (2017) reported that reproductive coercion is significantly associated with race (p < 0.001). for all women, other forms of intimate partner violence (defined herein as physical, sexual, or psychological harm by a current or former partner) are strongly associated with reproductive coercion (thaller & messing, 2016). one study of female undergraduate students found an association between contraceptive interference and psychological abuse, physical assault, and sexual assault (katz & sutherland, 2017). experiencing reproductive coercion is also associated with a host of negative sexual health outcomes, including stis (kovar, 2018; davis et al., 2018). there is a strong association between experiencing intimate partner violence and unintended pregnancy (kovar, 2018; moore, frohwirth, & miller, 2010; silverman & raj, 2014; pallitto et al., 2013), which miller et al. (2010) posit may be explained by the co-occurrence of reproductive coercion. structural coercion coercion regarding an individual’s reproductive decision-making is a structural as well as an interpersonal phenomenon (schoen, 2005; solinger, 2007). the u.s. has a long history of laws and policies that assert power and control over childbearing people by interfering with their reproductive autonomy.1 individuals who experience reproductive coercion at the interpersonal level are often additionally burdened by such policies, further compromising their ability to control their own reproductive health and future (heise, moore, & toubia, 1995). since the supreme court’s decision in roe v. wade (1973), a primary issue in the fight over reproductive autonomy has been the de facto rather than de jure right to terminate a pregnancy. an example of reproductive health policy that is coercive in nature—but that does not explicitly defy the law as established by roe v. wade—is the hyde amendment, enacted in 1976, which bars federal funding for abortion except in cases of rape, incest, or life endangerment of the pregnant person (hyde amendment of 1976). the effect of this policy is that a low-income woman experiencing reproductive 1 the legal history of contraception in the u.s. provides a rich illustration of this point. the comstock act of 1873 forbade sending through the mail anything related to preventing conception—a ban that was not lifted until 1938 (act of the suppression of trade in, and circulation of, obscene literature and articles of immoral use of 1873). although the pill was approved by the u.s. food and drug administration for contraceptive use in 1950, many states banned the pill until the supreme court’s 1965 decision in griswold v. connecticut,which ruled that married couples’ right to privacy included the use of this form of contraception (nikolchev, 2010; griswold v. connecticut, 1965). it was not until the supreme court’s 1972 decision in eisenstadt v. baird that the pill was legalized as a form of contraception for all, regardless of marital status (eisenstadt v. baird, 1972). state reproductive coercion columbia social work review, vol. x | 39 state reproductive coercion coercion who becomes pregnant unintentionally would not be able to utilize medicaid to cover abortion care (barot, 2012). the coercive partner may be unlikely to facilitate the termination of the pregnancy. given the frequent, or even near-universal, co-occurrence of financial abuse with other forms of intimate partner violence (adams, 2011), that woman is unlikely to have her own funds available to pay for an abortion out of pocket. in this way, a woman experiencing reproductive coercion in her home is met with the coercive impact of federal policy when she seeks reproductive health care. that is, on both the interpersonal and institutional levels, a woman’s choice as to whether she continues her pregnancy is subject to coercive pressure. many more restrictions on access to birth control and abortion exist at the state level. nineteen states ban abortion after 20 weeks gestation, with varying degrees of exception for conditions that threaten the pregnant person’s life or health (guttmacher institute, n.d., “an overview”). for someone experiencing abuse and/or trying to raise the funds for an abortion, these bans may mean that their abortion is illegal by the time they are able to access it (finer et al., 2006; donohoe, 2005). twenty-six states require a provider to administer an ultrasound or share information about receiving an ultrasound before performing an abortion (guttmacher institute, n.d., “requirements”). twenty-seven states mandate a waiting period of 18 to 72 hours between receiving state-written counseling and the abortion procedure in most cases (guttmacher institute, n.d., “overview”). some states, such as virginia, require that in most cases, the waiting period follow the mandated ultrasound (guttmacher institute, n.d., “requirements”). it is apparent that these policies are designed to inconvenience and dissuade the pregnant person from choosing abortion. much like interpersonal reproductive coercion, these types of laws interfere with an individual’s reproductive health decision-making by causing psychological distress and presenting material barriers (ely et al., 2017). new coercive reproductive health policies are being enacted at a fast rate. for example, new 2018 federal regulations (first introduced as interim final regulations in october 2017) expanded the kinds of exemptions employers can claim from the patient protection and affordable care act’s contraception coverage guarantee (82 fr 47838; sobel, salganicoff, & rosenzweig, 2018). as a result, more people who receive health insurance from their employer or university may not be able to afford contraception (goldstein, 2018; sobel et al., 2018; dreweke, 2018). another example of policies that are coercive in effect is the 2017 reinstatement of the mexico city policy (mexico city policy of 2017). this policy denies federal funding to foreign nongovernmental organizations that provide services or information related to abortion (mexico city policy of 2017). more recently, this “gag rule” has been extended to american organizations (compliance with statutory program integrity requirements, 2019). if upheld by the courts, this rule would restrict domestic, title x-funded organizations’ ability to 40 | columbia social work review, vol. x state reproductive coercion offer information about or referrals for abortion care. this would deny tens of thousands of people vital information on the full range of reproductive health care options available to them (american academy of pediatrics and society for adolescent health and medicine, 2018; new york state office of the attorney general, 2019). in addition, the new rule may have the effect of shutting down some health care centers and influencing the services provided by others, including planned parenthood, due to the requirement of having “physical and financial separation” between institutions providing abortions and those relying on title x funding (compliance with statutory program integrity requirements, 2019). disparate impacts communities most at risk of experiencing interpersonal reproductive coercion are also those most impacted by coercive state policies. a 2012 planned parenthood fact sheet on reproductive coercion reports that women in low-income households, as well as black, indigenous, and immigrant women, experience sexual assault and intimate partner violence at higher rates than white and high-income women (planned parenthood federation of america, 2012). meanwhile, research shows that women of color and teenagers who are pregnant or raising children are at higher risk of reproductive coercion (holliday et al., 2017; miller et al., 2010; thaller & messing, 2016). in one study, 37% of black women, 29.2% of multiracial women, 24% of latina women, and 18.4% of asian, pacific islander, or other non-white women had experienced reproductive coercion, compared to 18% of white women (holliday et al., 2017). dehlendorf, rodriguez, levy, borrero, & steinauer (2010) found that racial and socioeconomic disparities in family planning outcomes are influenced by health system factors, such as the scarcity of abortion providers in rural areas and limits on medicaid funding. reproductive health services, which are already difficult to access for low-income, uninsured, rural, or young patients, are made even less accessible by policies that make abortion and contraception more expensive and reproductive health centers less geographically widespread. for example, the american academy of pediatricians and society for adolescent health and medicine warned that the aforementioned title x “gag rule” would disproportionately impact black, latinx, and young low-income people and exacerbate existing racial and socioeconomic disparities in access to care (aap & sahm, 2018). in other words, many of the demographic risk factors for interpersonal reproductive coercion also signal more vulnerability to reduced reproductive health care access in the face of coercive policies (dehlendorf et al., 2010). when it comes to reproductive health and autonomy, the actions of individual abusers and anti-choice policymakers mutually reinforce one another within a system that burdens certain groups of women more than others. columbia social work review, vol. x | 41 state reproductive coercion the right to bear children while both abusive partners and abusive policies can attempt to force an individual into continuing an unintended pregnancy, interpersonal and structural reproductive coercion can also take the form of preventing healthy pregnancy and childbirth. in relationships where interpersonal reproductive coercion is present, an abusive partner may force a partner who becomes pregnant into having an abortion or may physically abuse them to induce a miscarriage (silverman & raj, 2014). in the united states, state legislatures, judges, and physicians have long held the political and socioeconomic power to prevent those deemed unfit from becoming parents. there is a distinction to be made between the act of coercing one’s partner into ending a pregnancy and policies that mandate sterilization or coerce individuals into long-term forms of birth control; that distinction is the level of power behind the coercion, not the coercive intent. miller and silverman (2010) discuss control of pregnancy outcomes as a form of reproductive coercion, stating: “. . . [o]nce their female partner is pregnant, abusive male partners may enact behaviors to control the outcomes of the pregnancy including violent acts to attempt to induce miscarriage and coercion to . . . terminate the pregnancy” (p. 511). anecdotal research also suggests that abusive partners may force women to get sterilized (hathaway, willis, zimmer, & silverman, 2005). just as abusers may coerce a partner into not getting pregnant or into terminating a pregnancy, the state also has a long history of interfering with an individual’s right to become pregnant and have children. perhaps the most glaring example of this type of interference in reproductive autonomy is the role of eugenics-oriented ideology in u.s. public policy. the american eugenics movement was born in the late 19th century and reached its peak in the 1930s, targeting poor people, people of color, people with disabilities, and people with mental illnesses 2 (washington, 2008). margaret sanger, who was at the time developing the network of family planning clinics that would become planned parenthood, was a vocal and active supporter of eugenics (latson, 2016). by the 1930s, more than 30 states had laws mandating sterilization for people with intellectual disabilities, people receiving welfare, and/or anyone deemed to have genetic defects; these policies were upheld and encouraged by the supreme court in buck v. bell (1927) (washington, 2008). as late as the 1960s, “southern states subjected black patients to medically unnecessary sterilizations in state-run hospitals, and 2 while this period is commonly considered the span of the american eugenics movement, the relationship between reproductive health policy and population control goes back much farther. for example, laws banning abortion throughout the 1800s were motivated by “fears that the population would be dominated by the children of newly arriving immigrants, whose birth rates were higher than those of ‘native’ anglo-saxon women” (national abortion federation, n.d.). 42 | columbia social work review, vol. x state reproductive coercion often informed consent was misleading or absent” (simmons & mclean, 2017, p. 36). the lasting power of this ideology was illustrated by the myth of the “crack baby” during the 1980s crack cocaine epidemic (national advocates for pregnant women, 2018). this moral panic—over the fallacy that fetuses exposed to crack in utero would be born with uniquely severe and lasting defects, including a predisposition towards violence—led to the implementation of mandated long-acting reversible contraceptive (larc) programs, which disproportionately impacted the reproductive freedom of black and/or low-income women who were the targets of the panic’s racist and classist rhetoric (aclu, 1994; sagatun-edwards, 1998). throughout the 1990s, women receiving public assistance, teenage mothers, and women in the court system were compelled to get the larc norplant, a practice with the explicit goal of controlling the growth of “the underclass” (roberts, 1999). women convicted of drug use during pregnancy were frequently presented by judges a choice between jail time or norplant (aclu, 1994). between 1991 and 1993, more than a dozen state legislatures introduced bills intended to coerce certain groups of women into larc use, such as by conditioning receipt of public assistance upon norplant implantation (aclu, 1994). in 1996, the states of south dakota, south carolina, and oklahoma allowed their state medicaid programs to fund the implantation of norplant, but restricted funding for the device’s removal—arguably an overt sterilization initiative for medicaid recipients (arnow, 1996). even while governments were actively pushing larcs, a cautionary appraisal of norplant published in social service review in 1995 asserted: when fertility control resides, at least in part, outside of the woman and her partner’s control, there is a very real risk of coercion on the part of health professionals and other persons in positions of authority who, for whatever reason, might want to limit her ability to conceive and bear children. (gehlert & lickey, 1995, p. 328) that “whatever reason” wondered at by gehlert et al. seems to be the legacy of the american eugenics movement—the belief that some people should not be allowed to decide for themselves whether or when to have children (dixon-mueller, 1993). larcs remain popular among individuals as a powerful tool for controlling their own reproductive lives. what is concerning is that they also remain popular among policymakers and others in positions of power interested in engineering population controls. in 2014, a scholarly commentary on the growing popularity of larcs encouraged “a moment for reflection and reassessment” to avoid repetition of past targeted abuses (higgins, p. 238). higgins compares contemporary larc zeal to the push behind norplant in the 1990s: “as with norplant, policymakers columbia social work review, vol. x | 43 state reproductive coercion have suggested incentive programs in which poor women receive cash in exchange for having a larc method inserted, and such programs may be in practice already” (higgins, 2014, p. 239). despite cautions like higgins’s, the coercion continues. in a 2016 qualitative study, young women reported believing that health care providers disproportionately recommended larcs to marginalized women and that their own preferences for larc selection or removal had not been honored by a provider (higgins, kramer, & ryder, 2016). interrogatory case studies in new york supported findings that physicians may exhibit racial bias both in recommending larcs to their patients and in their willingness to remove such devices (simmons & mclean, 2017). as late as 2017, a tennessee judge ordered that inmates be granted a reduced sentence in exchange for nexplanon implantation (simmons & mclean, 2017). while discussion of reproductive coercion often focuses on individuals forced into unintended pregnancies, the right to choose to get pregnant and safely carry out that pregnancy is an equally essential component of reproductive freedom—one that is infringed upon by policies as well as by partners. reproductive health centers: on the front line as the research involving reproductive coercion indicates (grossman, white, hopkins, & potter, 2014; sonfield, 2011), reproductive health care centers that provide abortions are on the front lines of the sociopolitical fight over reproductive freedom. they are uniquely positioned as intervention points for interpersonal reproductive coercion. if adequately trained and given appropriate resources, reproductive health care providers can be highly effective at screening for reproductive coercion (along with other forms of intimate partner violence) and intervening in it (american college of obstetricians and gynecologists, 2013; miller et al., 2010; miller et al., 2011). this role means that they are also key sites of data collection for research into reproductive coercion as a form of intimate partner violence. where reproductive health care centers exist in adequate supply and are financially accessible, there is great potential for them to act as frontline intervention sites for reproductive coercion (acog, 2013; miller et al., 2010; miller et al., 2011). for example, a 2009 california pilot study randomized four family planning clinics to either provide their patients with an intervention measure or not. among women who reported experiencing intimate partner violence in the preceding three months, patients who received the designated intervention had a 71% reduction in their odds of experiencing pregnancy coercion compared to the control group (miller et al., 2011). the american college of obstetricians and gynecologists (acog) recommends that providers screen for intimate partner violence and reproductive coercion, as well as provide at-risk patients with education 44 | columbia social work review, vol. x state reproductive coercion on reproductive coercion, harm reduction strategies, and the option to use undetectable larcs with which an abusive partner cannot tamper easily (2013). miller et al.’s 2010 study of reproductive coercion among family planning clinic patients concluded with the same recommendations. despite, and perhaps because of, their importance, reproductive health care centers are uniquely at risk under the rising tide of coercive reproductive health policies. policies that shut down these health centers impact research on reproductive coercion, withhold resources for those experiencing intimate partner violence, and deny patients much-needed health services. there are numerous policies being proposed and already in place that limit the existence or capacity of reproductive health care centers. targeted regulations of abortion providers, or trap laws, are one way that governments try to close reproductive health care centers. trap laws are mainly enacted on the state level. a common method that trap laws use to force the closure of reproductive health care centers is to regulate these centers like hospitals by requiring that they have more complex, highrisk surgical capacities. for example, legislators have written trap bills (e.g. alabama’s women’s health and safety act) designating reproductive health care centers as ambulatory surgical centers, meaning that the centers would need hallways wide enough to fit gurneys or particular sprinkler systems (women’s health and safety act of 2016; see also becker, 2014). underfunded community clinics that cannot meet the financial burdens of these licensure requirements are instead forced to close their doors. after the virginia legislature passed a set of trap restrictions in 2013, the virginia department of health estimated that the average cost of compliance would be around $1 million per clinic (guttmacher institute, n.d., “targeted regulations”). in the two years after texas enacted new trap restrictions, the number of women in that state who lived 100 miles or more from an abortion clinic tripled (guttmacher institute, n.d., “targeted regulations”). fewer clinics mean that hassles associated with transportation, child care, or time away from work force pregnant people to wait longer before accessing abortion care (ely, rouland polmanteer, & caron, 2019). this is a significant burden for people with lower incomes; the median cost of an abortion more than doubles between 10 and 20 weeks gestation (guttmacher institute, n.d., “targeted regulations”). reproductive health care centers are the first line of defense for many women experiencing interpersonal reproductive coercion. at the policy level, the first line of defense against structural reproductive coercion must be stopping laws and regulations that force these clinics to shut down, putting reproductive health care out of reach for those who need it. columbia social work review, vol. x | 45 state reproductive coercion conclusion reproductive coercion is a form of intimate partner violence in which an abuser attempts to exclude the victim from participation in decision-making about their own reproductive health and future. at its core, reproductive coercion is about asserting and maintaining power and control by denying the victim their right to reproductive self-determination. when state policies make contraception and abortion care inaccessible to some people, they are, in effect, replicating reproductive coercion on a structural level. those who are likelier to experience interpersonal reproductive coercion at the hands of an abusive partner—mostly members of marginalized populations—are also more likely to face reduced access to contraception and abortion care by dint of being the same groups disproportionately affected by coercive state policies (grace & anderson, 2016). simultaneously, women who are poor, women of color, and women living with disabilities or addiction have long been at the receiving end of eugenic policies that try to deny them the right to have children at all. research has shown that barriers to abortion services may cause or exacerbate trauma for patients seeking such care (ely et al., 2017). policies that reduce access to abortion—and to reproductive health care centers generally—therefore have deleterious mental health impacts in addition to the economic and physiological hardships they impose. the stress and trauma effects of coercive reproductive health policies are yet another parallel between the micro and macro levels of abuse and should further inform our understanding of the harm that these policies can cause. pushing back against coercive policies that impede reproductive autonomy appears to be essential for effecting harm reduction for vulnerable women. reproductive health care centers exist at the intersection of interpersonal and structural reproductive coercion. these clinics can be an invaluable safe space where providers can screen patients for reproductive coercion and intervene if necessary. they prescribe contraception and provide abortion care. they are also important vehicles for advancing research on reproductive coercion. yet anti-choice policies, such as trap laws, aim to shut down these health centers, leaving vulnerable communities without access to a range of health care services and without that front-line intervention for intimate partner violence. the similarities between microand macro-level reproductive coercion outlined here should underscore the urgent necessity that social workers engage in advocacy that addresses not just interpersonal reproductive coercion, but structural coercion as well. as ely and dulmus (2010) point out in their call for social work policy practice around abortion rights, the social work profession has an unparalleled history of commitment to advocacy, including being “the only human service profession with a professional policy statement indicating the support of access to abortion 46 | columbia social work review, vol. x state reproductive coercion services as an important component of social justice” (ely & dulmus, 2010, p. 668). ely and dulmus’s encouragement is only more pressing today. the legal precedents that underpin fundamental reproductive rights in the u.s. are imperiled; the newly majority-conservative supreme court faces a pipeline of cases that could be used to undermine rulings such as roe v. wade (1973) and whole woman’s health v. hellerstedt (2016)3 (haberkorn, 2018). meanwhile, state legislatures are working to reduce access to contraception, close reproductive health care centers, and criminalize abortion. in just one southern state—virginia—more than 170 such policies have been introduced since 2008, including a set of more than 30 trap regulations enacted in 2013 (naral pro-choice virginia, n.d.). as a macro-level incarnation of interpersonal reproductive coercion, restrictive reproductive health policies are structural violence. structural violence should be countered with structural intervention. social workers hold the professional mandate to engage in policy practice around this issue, including promoting proactive protections and opposing coercive policies wherever they appear. 3 in roe v. wade (1973), the supreme court of the united states invalidated a texas law that prohibited abortion except when necessary to save the life of the pregnant person, and in doing so, held that the right to privacy extended to the decision of whether to have an abortion and that governmental interference in that decision is subject to strict judicial scrutiny. the ruling in roe did allow for states to ban abortions after fetal viability except when necessary to preserve the life or health of the pregnant person. in whole woman’s health v. hellerstedt (2016), the court held that two provisions of a texas trap law that threatened to shut down the state’s abortion clinics were unconstitutional as they imposed an undue burden (i.e. impeding access without providing medical benefit) on the right to access abortion care. the court held that in future cases, the benefits of such laws must be weighed against the burdens they impose (naral pro-choice america foundation, 2017). columbia social work review, vol. x | 47 state reproductive coercion references act of the suppression of trade in, and circulation of, obscene literature and articles of immoral use of 1873. 18 u.s.c. § 1461 (1873). adams, a. e. 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(2016). women’s health and safety act of 2016. al code § 26-23e-9 (2016). columbia social work review, vol. x | 53 gianna dejoy is a master of science in social work candidate in accelerated policy practice in the field of health, mental health, and disabilities at columbia university school of social work. she is in the two-year online program and is a 2018-2019 fisher cummings washington fellow. she is currently the policy fellow at naral prochoice virginia where she conducts policy research and advocacy in the state legislature, department of health, and circuit court. gianna received a b.a. in sociology with departmental honors and a minor in women, gender, and sexuality studies, summa cum laude, phi beta kappa, from university of richmond in 2015. she is originally from blue hill, maine, and now lives in richmond, virginia. state reproductive coercion microsoft word employment first.docx © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. employment first* (not only) brittany taylor the origins of employment first o you know your preferred employment outcome? many of you reading this editorial may not have a disability, but if you do and you qualify to receive employment services, your options are being limited as you read this because of a policy known as employment first. this approach sets “community-based, integrated employment – which pays at least the minimum wage – [as] the first option for employment services for youth and adults with significant disabilities” (scaglione, 2015). employment first is a federal policy that has been adopted in many states, and is currently being set in new york state after governor cuomo issued an executive order establishing an employment first policy commission in september 2014 (executive order no. 136, 2014). to understand how this policy has come about, it is crucial that we understand its origins in the evolving definition of inclusion. a landmark in the shift in disability1 policy occurred on june 22, 1999, when the united states supreme court ruled that “unjustified segregation of persons with disabilities constitutes discrimination in violation of title ii of the americans with disabilities act” (united states department of justice civil rights division, n.d.-b). this ruling became known as the olmstead decision, and it set a requirement that services for individuals with disabilities be provided in the “most integrated setting appropriate to their needs” (n.d.-a). it helped to construct a view of inclusion defined by participation in mixed-ability environments. though olmstead specifically addressed a complaint related to institutional versus community treatment programs, media attention has since driven a shift in its application of inclusion through reports about terrible conditions and low pay in sheltered workshops. among these reports have come criticisms of workshop employers such as goodwill, of piece-meal workshops like training thru placement2, and of statewide practices that are alleged to exhibit abuse and neglect stemming straight from the institutional era (adams, 2013; barry, 2014; denson, 2013). this media focus is coupled with a policy catalyst in the form of the workforce innovation and opportunity act (wioa) of 2014, an amendment and reauthorization of the workforce investment act of 1998, aimed at helping american workers navigate employment in a recovering economy (yashchin, 2014). the wioa acknowledges the extremely high unemployment rate among individuals with disabilities and requires states to find ways to lower the barriers to employment (2014). this policy, and a wave of negative media attention, has shifted the concerns over segregation and inclusion that the olmstead decision magnified to the workplace, resulting in a policy known as employment first. employment first is defined by the office of disability employment policy as “a concept to facilitate the full inclusion of people with the most significant disabilities in the workplace and community” (office of disability employment policy, n.d.). it holds competitive pay, inclusion in the community (meaning a community of mixed abilities), and the pride of holding a job as some of the reasons for pursuing employment ahead of other options. as a consequence of this prioritization, other service options – including                                                                                                                           1 disability in this paper will be used inclusively to represent intellectual, developmental, mental, and acquired disabilities   2 see “rhode island settles case on jobs for the disabled,” http://www.nytimes.com   d © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. sheltered workshops – will close. in new york state, funding for new placements in sheltered workshops already dried up in july 2013, and these facilities are mandated to close entirely by 2020 (scaglione, 2015). as employment first continues to grow nationwide and to be established here in new york, the time has come to question the definition of inclusion upon which it is predicated and to question whether employment first truly achieves it. employment first* (not only) at its heart, employment first seeks to expand the concept of inclusion into the workplace, but it does so at the cost of choice. to include all individuals fully in our society, we have to start not with policies that we make on behalf of others, but with policies that allow for the same right to self-determination that we understand in this country as a freedom that is constitutionally assured. to do this, we have to include those individuals in discussions of what inclusion means to them, how they want to live their lives, and where they want to work. for true inclusion to happen, we must amend employment first. we must allow for a policy that pushes a population that has been historically sidelined and ignored to achieve new milestones and which accepts the idea that what this achievement looks like for each individual is his or her own choice. we must adopt employment first* (not only), a title that will be used to reflect a policy that continues to set employment as a primary goal while allowing individuals to pursue work and activity options at their own discretion. new york we can start working toward greater inclusion of individuals by providing choice in new york state, where a task force announced last september by governor cuomo is currently determining employment first policy (executive order no. 136, 2014). presently, the commission that will set this policy by march 2015 is heavily weighted with government officials, but lacks the individuals who will actually face the impact of this policy: the workers themselves (scaglione, 2015). if new york wants to establish a policy that honors true inclusion, it must start by practicing inclusion in the formation of employment policy. individuals with disabilities, their families, advocates, friends, and supporters must have a say in how new york enacts policies of inclusion in the workplace and what options are made available to these workers. without these voices, new york will adopt employment first as a blanket policy that limits the paths of opportunity for this population. if, on the other hand, new york state includes people with disabilities and their friends and allies in shaping employment first, new york could become a model state for a new element in this discussion — choice. sheltered workshops: a thing of the past? sheltered workshops have constituted a dominant model of employment service for many years. in 2010, nearly 27% of the 566,188 individuals receiving employment services nationally worked in sheltered workshops (butterworth et al., 2012). in 2011, that number totaled roughly 8,000 new yorkers (scaglione, 2015). sheltered workshops come in many forms, but the most common is a piece-meal assembly shop where workers assemble items such as simple mechanical objects or provide packaging services for goods manufactured elsewhere. workers are paid below minimum wage based on their production rates and work in a setting where their coworkers are other individuals with a range of disabilities, often both physical and developmental. the drive to eliminate this model is the result of a combination of low competitive employment rates for individuals with disabilities and the view that inclusion in the most integrated setting possible (as laid out in the olmstead decision) should take priority across all areas of living, including employment (butterworth et al., 2012). © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. it must be acknowledged that some sheltered workshops have been the sites of gross neglect and abhorrent conditions. conditions like those described in “the boys in the bunkhouse,” an explosive exposé published in the new york times in march 2014, have been real for many people employed in sheltered sites, which receive little or no oversight. in this example, employees lived and worked on a farm that operated a turkey slaughterhouse. they worked long days slaughtering turkeys— a task that caused severe, and sometimes irreparable, injuries to some workers due to repetitive motions— while earning only enough to buy small indulgences and being forced to live in filthy and unsafe conditions. for others, however, sheltered workshops have been an entirely different experience. they have allowed easy transition from school to work, provided a community with an undeniable and important commonality, and allowed people with disabilities the time and space to master tasks. susan constantino of cerebral palsy association of new york state notes, “…lots of folks found they were doing meaningful work in these programs and getting a pay check” (quoted in scaglione, 2015). many individuals also choose to work in these workshops because they like being in a peer community where all levels of ability and behavior are welcome and normal. another executive director of a new york agency affirms, “[t]hey have friends here…they come to work every day, see people they know, do work that they understand and feel valued” (scaglione, 2015). to fight against the maltreatment and dehumanization that some sheltered workshops have fostered is the right thing to do, but to broadly paint a work model that has been as beneficial for some as it has been awful for others denies individuals with disabilities the full spectrum of experiences. the lessons that we should take from the cases we read about are the importance of oversight and individual choice. stories about workers who love what they do should be as valid as negative cases. further, we must be sure that we have something better to offer to those who want it. if not only to provide options for workers receiving employment services, we should keep other options available until it is clear that “there are sufficient community based, minimum wage paying jobs available for individuals and whether the state is prepared to fund the level of supports that individuals will need to get, learn, and keep those jobs” (scaglione, 2015). new york state’s office for people with development disabilities only aims to cover half of those individuals currently receiving sheltered employment services, if that many can even be placed (scaglione, 2015). what we are doing is tearing down a system without either fully establishing another or consulting at an individual level with those who will be affected. without this knowledge and these voices, employment first could exclude workers from jobs and work communities in an attempt to create a more inclusive policy. what’s missing? the relatively minute influence of voices’ against employment first in the general conversation represents the problem with this policy: it represents only certain voices, who in turn support only certain choices. a case in which workers and families in new jersey rallied together to successfully pressure legislators to keep sheltered workshops open barely received any press (luberman, 2013). another new york state executive director adds, “[i]f you asked individuals working in workshops if they want to give up that job and take a job in the community many would say no. but, the state and cms aren’t asking!” (scaglione, 2015). those voices that have been the primary drivers of employment first have firmly backed this policy as a reaction to examples of exploitive sheltered workshops. even advocacy organizations seem to have become caught up in the wave of negativity and are quick to dissociate themselves from the sheltered employment model. some have gone as far as to create an employment first guiding document, which, while an excellent © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. tool to guide creation and practice of employment services, does nothing to help those who want other options (best buddies et al., n.d.). arguments in favor of sheltered work, such as those presented in a study by de urríes and verdugo (2011) of the experiences of workers in these facilities, provide compelling findings that force us to question whether pursuit of the current definition of inclusion does not come at too high a cost. de urríes & verdugo (2011) found, [t]he percentage of those who state that work satisfaction is very high (93.33%), singling out the task (41.76%) and their fellow workers (30.00%) as what they most like about work, and emphasizing that money is the least attractive feature3 (p. 159) these figures suggest that there is an element of pride in work (seen in extremely high satisfaction rates) present in sheltered workshop workers and that their fellow workers, who also have disabilities, are among the major reasons for this satisfaction in this employment model. given the high ratings of satisfaction and contentment with their work community, how can we continue to argue that other options must be pursued to achieve pride in work or inclusion? some of the few voices that dare to speak out against this policy even argue that framing inclusion around employment creates a valuation system (competitive employment is good; sheltered employment is bad) that is not necessarily accurate. as donald weikle, jr. writes in “achieving community membership through community rehabilitation provider services: are we there yet?,” the assumption that sheltered employment is by definition bad is at best questionable (2008). in the article, weikle (2008) asks the questions that this editorial suggests are not being asked: did anyone ask people working in facility-based or integrated work sites whether they liked those settings? did anyone ask participants if they selected the work location from alternatives during their individual service plan meetings? did [anyone] investigate what i call ‘the boomerang effect’ in supported employment? that is, we help people move from congregate to integrated settings and many come right back. are those individuals telling us something about their values and/or our services? in short, did anyone ask what consumers valued? (p. 58) when it won’t fit, push harder this dogged pursuit of adoption and adherence to employment first, clearly, has prevented even the well-meaning from understanding that this policy does not and cannot work for everyone. it has come out of high-profile negative press and a search for a single solution. this causes us to forget that inclusion in the competitive job market may be inclusion for some, but will mean exclusion for many from the work they want, work they can do, and a community that many cherish. a policy that touts inclusion but defines it so narrowly that it limits an individual’s right to self-determination can only result in exclusion. a policy like employment first is what happens when policymakers forget to include all stakeholders and decide, even out of good intentions, that they know better than the key actors affected by the policy. new york is set to repeat this process by working with only select voices that will champion employment first. nowhere on governor cuomo’s commission is there a seat designated for workers who want to keep this option available, who like what they do and want to remain where they are, and for whom                                                                                                                           3 the issue of subminimum wages merits greater discussion than can be afforded in this editorial. the author will simply note that equal pay should be the goal of any employment program, while also recognizing the difficulty in achieving this.   © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. their work community represents an opportunity to feel safe and included in a group of similar individuals. there is no place for a counterargument or alternative voices. in the same way that policymakers are ignoring those who wish to keep this model, they are ignoring this population’s right to define for itself what they want their community to be. when did it become our choice to determine that an integrated community is the best option, if not the only option? while acknowledging that some may feel comfortable in peer communities because of lack of exposure to larger communities, how can we say with certainty that their desire to remain in their workplace communities is unjustified? if we cannot—and this editorial contends that this is the case— it simply does not make sense to mandate participation in one type of community to achieve a definition of inclusion determined by policymakers. none of us would accept a preferred employment outcome being forced on us so that we could achieve someone else’s idea of inclusion, so why are we asking individuals with disabilities to do so? where do we go from here? currently, employment first is being developed in many states, including new york, and shows no signs of slowing. an employment first action map created in part by the association of people supporting employment first (apse) shows that 32 states have some sort of formal policy action on employment first and that 46 (including new york) have at least some activity related to employment first happening (the research and training center on community living at university of minnesota, 2014). it will likely be adopted by each state over the next few years as media and advocates continue to push it as the preferred employment policy for individuals with disabilities. this editorial makes no attempt to suggest that employment first must be entirely dismantled. employment first is here to stay for the foreseeable future, and in many ways it should. community integration in terms of accessibility and acceptability has certainly not yet been achieved in the united states. employment first puts pressure on states to find ways to foster inclusivity in the workplace, which in its current form continues to stand as a massive barrier to people with a range of disabilities due to demands for specific physical and mental abilities. further, employment first, as it is currently manifesting, will provide the support that many will need to find success in the workplace. as individuals are provided with job coaches and personal aides paid for by the funding that used to go toward sheltered workshops, many will be able to pursue dreams of competitive employment. for too many, however, employment first will take away a valuable option. with the closure of sheltered workshops, the option to move between competitive employment and sheltered employment will be lost. the opportunity to work among peer groups of other individuals with disabilities, and, consequently, to be a part of the norm at work, will be lost. the places that many have woven into their identities as workers and as people, where they have spent years or decades of their life, will be lost. this editorial argues instead that employment first should proceed with an asterisk: employment first* (not only). setting competitive employment as the preferred employment outcome for individuals with disabilities will help those who wish to pursue this avenue to do so and could serve as a supportive push for those who are shy to venture beyond what they have already experienced. it cannot, however, be the only possible outcome. workers who try competitive employment and do not like it, workers who cannot retain such employment, and workers who do not wish to pursue competitive employment for any reason must still be given the option to work in other settings. in an ideal world, funding should be reallocated to sheltered workshops, provided they meet criteria that should be created to review the quality of the workshops as a means to preventing the abuses that media has highlighted that occur in some settings. in reality, though, this continued financial support for sheltered © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. workshops is unlikely to happen. a compromise would be for workshops to convert to alternative models. workshops could also pursue non-government funding if efforts could be made to change the public opinion of this model enough that it would be socially safe for private giving to occur. finally, workshops could potentially splinter into smaller entities employing a small number of workers to get around the size limit that determines status as a sheltered workshop. with any of these options, it is imperative that workshops that employ workers in a safe, meaningful, and fulfilling way using proper oversights and find a way to remain open and remain an employment option for individuals with disabilities. in order to make changes such as these, policy makers, the media, and the public will need to step back from the reactive loops in which they have been operating to reevaluate the prevailing interpretation of inclusivity and integration. for the typically-abled american population, our rights are often encapsulated by the single maxim, “the right to life, liberty, and the pursuit of happiness.” these rights, collectively, exemplify the right to choice. if this is the right that we as a country hold in highest regard, then an interpretation of inclusivity and integration must include choice as an integral part of these definitions. inclusivity in this framework might mean inclusivity in whatever community that an individual wants to be a part. integration might signify a society that creates ways for this population to participate in daily and community life if they so choose. an integrated and inclusive society founded on individual choice might not look like we think it should, but if we allow each individual to determine for him or herself what he or she wants in life, it will become a society that reflects each person’s wishes. we can start to move toward this by reimagining employment first in new york by making a seat at the decision table for all stakeholders and by setting policies that allow maximal options for individuals. we can start by demanding employment first* (not only). references adams, s. (2013, july 7). does goodwill industries exploit disabled workers? forbes. retrieved from http://www.forbes.com barry, d. (2014, april 8). rhode island settles case on jobs for the disabled. the new york times. retrieved from http://www.nytimes.com butterworth, j., smith, f. a., hall, a. c., migliore, a., winsor, j., domin, d., & timmons, j. (2012, winter). state data: the national report on employment services and outcomes. retrieved from state data book 2011 website: http://www.statedata.info/statedatabook/img/statedata2011_fweb.pdf denson, b. (2013, april 11). kitzhaber orders shift from sheltered workshops for people with disabilities. the oregonian. retrieved from http://www.oregonlive.com de urríes, f. b., & verdugo, m. a. (2011). sheltered employment centers: characteristics and users’ perception. work, 38(2), 155–161. exec. order no. 136, 3 c.f.r. (2014). luberman. (2013, july 30). developmental disabilities in the news: n.j. saves sheltered workshops. [web log post] retrieved from http://disabilitiesnews.blogspot.com/2013/07/nj-saves-sheltered-workshops.html office of disability employment policy. (n.d.). disability employment policy resources by topic: employment first. retrieved from http://www.dol.gov/odep/topics/employmentfirst.htm the research and training center on community living at university of minnesota. (2014). retrieved, from the research and training center on community living at university of minnesota website: http://public.tableausoftware.com/shared/ny84rwnt6?:embed=y&:showvizho me=no&:host_url=http%3a%2f%2fpublic.tableausoftware.com%2f&:toolbar=yes&:animate_transition=yes&:display_static_image=yes &:display_spinner=yes&:display_overlay=yes&:display_count=yes&:loadorderid=0 best buddies, the national association of councils on developmental disabilities, national council on independent living, paralyzed veterans of america, national organization on disability, & respectability. (n.d.). disability employment first planning tool. retrieved from respectabilityusa website:http://respectabilityusa.com/resources/disability%20employment%20first%20planning.pdf scaglione, f. (2015, february 12). transition collides with transformation i/dd sector faces “perfect storm” of systematic reforms. new york nonprofit press. retrieved from http://www.nynp.biz united states department of justice civil rights division. (n.d.-a). olmstead: community integration for everyone. retrieved from http://www.ada.gov/olmstead/ united states department of justice civil rights division. (n.d.-b). olmstead: community integration for everyone: about olmstead. retrieved from http://www.ada.gov/olmstead/olmstead_about.htm weikle, d. w. (2008). achieving community membership through crps: a reaction to metzl et al (2007). intellectual and developmental disabilities, 46(1), 58–60. doi:10.1352/0047-6765(2008)46[58:acmtca]2.0.co;2 © 2015 taylor. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. yashchin, a. (2014, july 17). understanding the workforce innovation and opportunity act. the huffington post. retrieved from http://www.huffingtonpost.com brittany taylor is an msw candidate at columbia university and an executive editor of the columbia review. her experience working with individuals with i/dd in sheltered settings inspired her research on this topic and have informed her opinion that providing individual choice is paramount in creating policies that are effective. brittany is from portland, or.   2018-final.pdf columbia social work review, vol. ix | 1 lesbian, gay, bisexual, transgender, queer, asexual, intersex et al. (lgbtqai+) health access disparities in female-identified clients jennifer hand though they recently received legal legitimacy, the lgbtqai+ community faces discrimination through deeply entrenched heterosexist social systems, which amplify inequities for women and gender minorities. social workers must advocate for expansive policy interventions to promote economic and health equity for female-identified members of the lgbtqai+ community. practical policy interventions for the promotion of health equity include provider training programs, anti-discrimination protections, the collection of comprehensive demographic data, and youth education curricula. introduction: codifying basic rights to address lesbian, gay, bisexual, transgender, queer, asexual, intersex et al. (lgbtqai+) health policy, we must consider the historical context of the population in the united states.1 within the last twenty years, the legal system codified basic safety and fundamental rights for lgbtqai+ citizens. the legal system makes change slower than most other systems in order to preserve the rule of law from the tidal waves of popular opinion, and law often follows and codifies established policy. in the united states, there is great discrepancy in social attitudes towards this community that the creation of anti-discrimination laws beget new policies across all areas of social systems (harrison & michelson, 2017). consequently, new antidiscrimination laws prescribe the conscientious and meticulous undoing of systemic bias in all of our social services, from housing to health care. according to martos, wilson, & meyer (2017), lgbtqai+ health care was born out of self-advocacy and self-determination from the beginning. in the mid-20th century, underground lgbtqai+ activism groups began emerging, effectively birthing identity politics for the community (martos et al., 2017). after the compton’s cafeteria riot in san francisco in 1966 and the more widely known stonewall riot in 1969, during which the police raided queer spaces to humiliate and criminalize the community, organizers 1 until obergefell v. hodges (2015), the community was denied the right to marriage. this decision is significant in that the right to marriage is not the right to love unencumbered, but the right to retain financial and other benefits through the formation of a legally recognized partnership. until lawrence v. texas (2003), the united states criminalized sex acts between two consenting adults. again, this case illuminated the legal discrimination against a marginalized group and attempted to protect the community from government intrusion into personal affairs. lastly, romer v. evans (1996) was the first federal case law protecting the lgbtqai+ community from state-sanctioned “bare animus”—the intent to harm a politically unpopular group. 2 | columbia social work review, vol. ix jennifer hand mobilized to carve out intentional queer spaces including community-based health organizations—in urban centers around the country. following these advocacy efforts and the removal of homosexuality from the dsm in 1973, care centers focused on lgbtqai+ health emerged en masse in the 1970s (martos et al., 2017).2 due to rampant homophobia and transphobia among the medical and other care professions, the standard of care for lgbtqai+ individuals was low, to the point where individuals would not feel comfortable disclosing lifestyle and health habits to providers for fear of discrimination. as a person’s lifestyle intersects very closely with his or her health care provision and health outcomes, this is an unacceptable discrepancy. this hesitancy to discuss care with providers due to stigmatization—and thus harm reduction practices—may indeed be a key reason the hiv epidemic decimated this population in the 1980s and 1990s (king, 2011).3 nearly fifty years after the riots sparking organizing efforts, and about twenty years after the initial case law identified them as an “unpopular political group” (romer v. evans, 1996), the lgbtqai+ community continues to work aggressively towards undoing homophobia, transphobia, biphobia, heterosexism, and sexism in every area of social services. as lgbtqai+ service provision is still an emerging area of law, policy, and health care for a high needs population, service delivery has much room for improvement (martos et al., 2017). lgbtqai+ disparities in health access as heterosexism, homophobia, transphobia, biphobia, and misogyny become less overtly enacted on lgbtqai+ identified individuals due to statutory intervention,4 members of the community still experience 2 at the same time, gender identity disorder was codified in the dsm and opened the transgender community up to discriminatory medical practices (martos et al.). 3 discussion of the hiv epidemic and its impact on lgbtqai+ health policy with due diligence would require more words than permitted by this submission and is not entirely germane to the subject matter of smw health disparities. 4 on september 29, 2017, the united states voted against a ban on the death penalty for samesex relations at a united nations conference. similarly, the united states department of justice filed an amicus brief—legal support which may influence case law—for masterpiece cakeshop v. civil rights commission on september 6, 2017. this case is before the supreme court of the united states regarding the tension between first amendment rights of business owners and legal discrimination against the lgbtqai+ community in the contracting of “due to rampant homophobia and transphobia among the medical and other care professions, the standard of care for lgbtqai+ individuals was low, to the point where individuals would not feel comfortable disclosing lifestyle and health habits to providers for fear of discrimination.” columbia social work review, vol. ix | 3 lgbtqai+ health access disparities in female-identified clients structural inequities, which may limit their quality of life and cause long-term damage to their well-being (eckstrand, lunn, & yehia, 2017). lgbtqai+ populations experience higher barriers to healthcare than heterosexual populations (eckstrand et al., 2017). the population also experiences an “increased incidence of sexually transmitted infections, mood and anxiety disorders, and intimate partner violence” as compared to heterosexual and cisgender populations and experiences poorer health outcomes across the lifespan (lunn et al., 2017). lunn (2017) estimates that 2.4% of the general population is lgbtqai+ identified and represents a cross-section of the general population. though already disadvantaged, the community—due to its diversity across age, gender, socioeconomic status, ethnicity, and race— reflects the systemic inequities prevalent in the greater population (krehely, 2009). minority stress, often linked to poor health outcomes due to internalization of isms and externalized discrimination, is intensely compressed in these populations (mule et al., 2009). notably, lgbtqai+ individuals of color are simultaneously pathologized as disease-carriers yet denied access to health care, culturally competent representation, and care provision (lassiter, 2017). for the purposes of this paper, i choose to isolate the social problem of lgbtqai+ health access disparities to the intersection of gender and sexual minority status, which is simultaneously broad enough to produce illuminative disparities in the way marginalized communities gain access to health care, yet discrete enough to provide specific examples of how care is out of reach for the most vulnerable in ways that transcend racial and ethnic identity. structural issues for sexual minority women lgbtqai+ individuals who are female-identified (sexual minority women, smw) experience higher barriers to health care and poorer long-term health outcomes than their heterosexual or male counterparts across race, ethnicity, and ability (lunn et al., 2017). smw experience poorer long-term health outcomes and higher barriers to health care than male-identified members of the lgbtqai+ community or cisgender heterosexual women (eckstrand et al., 2017; lunn et al., 2017). smw are less likely than gay or bisexual men to have a primary care provider and health insurance (lunn et al., 2017). smw are more likely to have chronic health conditions, such as obesity or substance use disorder (lunn et al., 2017). additionally, smw are less likely to enroll in traditional business services. despite great strides for sexual and gender minority inclusivity under the obama administration, homophobia and transphobia may be on the rise under this administration. for the purposes of this paper, i will operate under the assumption that society has made and is making great strides towards equity, which cannot be undone in a few, inelegant legal maneuvers. 4 | columbia social work review, vol. ix jennifer hand employment, requiring them to secure insurance outside of the workplace (lunn et al., 2017; eckstrand et al., 2017). consequently, the population as a whole is not likely to be engaged in workplace diversity initiatives and wellness programs, which help moderate risk behaviors (eckstrand et al., 2017). smw are also less likely to enroll in spousal health care due to lower rates of marriage among the population (blosnich, 2017). even when smw enroll in healthcare, they are less likely to experience quality of care and culturally-competent service provision (blosnich, 2017). on the whole, smw report lower satisfaction rates with primary care provision than their heterosexual or sexual minority male counterparts (baldwin, dodge, schick, sanders & fortenberry, 2017). lower satisfaction rates and lack of culturally competent service provision lead to difficulties in securing a continuum of care, which addresses chronic health issues and provides preventative care (baldwin et al., 2017). most indicative of structural inequity, the needs of smw are not adequately reported or measured by researchers (patterson et al., 2017). people with means have access to quality health care (marmot, 2005). in the united states, economic inequity rests at the heart of health care disparities (fiscella & williams, 2004). women are economically disadvantaged as compared to men, after lower entry-level salaries and gross income disparities (hegewisch & williams-baron, 2018; national women’s law center, 2017; kirkpatrick, 2018). and—even after obergefell v. hodges—sexual minorities are less likely to enjoy the stabilizing economic benefits of marriage, such as dual-income households, spousal health insurance, domestic workload sharing, or provision in the event of illness (eckstrand et al., 2017). despite reports suggesting that smw receive an earnings premium compared to heterosexual women, smw make less than men, so smw couples experience a compounding of the gender wage gap (alexander & ravani, 2016; national women’s law center, 2017). the earnings premium is marginal at best and does not undo the exorbitant gender wage gap. indeed, poverty rates among female-identified same-sex couples are approximately eight percent, which is higher than poverty rates among heterosexual couples (s.k., 2016). lastly, workplace discrimination destabilizes job security and then disrupts health insurance and continuation of care (badgett et al., 2007). consequently, health insurance mandates such as those advocated by the affordable care act represent the single greatest barrier removal to health access (housel & harvey, 2017). though the health insurance mandate is a promising start, the disproportionately low rate of health access for this population necessitates additional protections across all practice areas, such as provider training for culturally competent care, the expansion of anti-discrimination provisions, government collection of demographic data to track and assess population health outcomes, and youth education curricula. columbia social work review, vol. ix | 5 lgbtqai+ health access disparities in female-identified clients interventions in advocacy and training lgbtqai+ affirmative laws improve health outcomes because they legitimize individuals, improve societal attitudes, and—most importantly— lessen minority stress (buffie, 2011). because the community has only recently been legitimized through legal avenues—and thus has only recently been identified as a valuable data point to track in health care— there is a dearth of relevant research for interventions and health outcomes (patterson et al., 2017). policy interventions exist at various system intersections. continued legal legitimacy is a necessity. in 2017, sexual orientation and gender identity are still not protected classes (foti, 2017).5 providing government oversight of discriminatory practices and establishing a department or team to oversee these rules of law would improve equity (mule et al., 2009). mandating sexual orientation and gender identity inclusion in research collection would generate the data necessary to provide adequate health care to these populations by observing trends and practice solutions (patterson et al., 2017). provider education including training providers on asking the right questions appropriately, and encouraging more lgbtqai+ individuals to enter care services would ensure that practice is inclusive, accessible, sensitive, and equitable (lassiter, 2017; mule et al., 2009). in addition, creating programming that builds self-esteem, body autonomy, and self-advocacy skills—such as those taught in many youth programs and gender and sexualities alliance groups—may improve health outcomes through the creation of self-advocates and conscious consumers of medical care (poteat et al., 2013). anti-discrimination protections and data collection though the lgbtqai+ community has still not achieved protected class status and there is much room for improvement, health policy has evolved to be more inclusive and sensitive to the specialized needs of the population. as funders and governments continue to promote evidencebased practice (durso, 2017), social workers must push for sound evaluative processes and data collection to provide visibility to the population and create policies that reflect the true landscape of the lgbtqai+ client experience. we must continue to work towards macro-level policy changes at all levels of government, protecting the community from discrimination and wage disparity, and providing avenues for compliance and enforcement. 5 the equal employment opportunity commission (n.d.) released an anti-discrimination doctrine for sexual orientation and gender identity, which provides supportive policy to stabilize the workforce for this population, and thus economic security and access to health care. 6 | columbia social work review, vol. ix jennifer hand to date, 47% of the lgbt population live in states that protect them from gender or sexual orientation discrimination in the workplace or in public accommodations (movement advancement project, 2018). the establishment of localized lgbt government agencies—such as those developed in philadelphia, d.c., and san francisco—promotes civil rights policy, coordinates services across cities, develops infrastructure for culturally competent training, collects outcome data, and enforces high standards of service delivery (city of philadelphia, 2018; dc mayor’s office, 2018; san francisco human rights commission, 2018). similarly, the creation of an lgbtqai+ serving bureau at the department of human health services (hss) would serve as the appropriate tool for collecting data, enforcing policy, and making recommendations for future protections. in 2010, hss recommended the collection of lgbt data collection through the healthy people 2020 initiative (hss, 2018). while doing so is an adequate step, mandating data collection in medical, u.s. census, and american community survey records would further legitimize the population and ensure that pertinent data points are studied and reviewed—a critical step because much of the current reporting on lgbtqai+ health comes from provider conversations and anecdotal evidence (durso, 2017). we cannot know the true disparity without concrete quantitative data to support qualitative research. providing trainer programs lgbtqai+ visibility in health care settings requires disclosure (rondahl, innala & carlsson, 2006). smw “look like everyone else...act like anyone else, and possess no identifiable or unique characteristic” (willes & allen, 2014). disclosure of sexual identity or sexual practice is the gateway to informed care and selection of services (smith & turell, 2017). sexual and romantic practice intertwine so closely with our physical and mental health that refusal to acknowledge them in health care is detrimental to the whole person approach to service delivery (willes & allen, 2014). and yet, the burden for quality care currently rests on the client’s selfdisclosure, self-advocacy, and protection of one’s own health information (smith & turell, 2017). many providers do not ask their clients’ sexual orientation because they assume heterosexuality, feel uncomfortable including sexual orientation in the psychosocial model of care, or do not consider it necessary due to their heterosexist lens and a misunderstanding of their clients’ experiences (rondahl et al., 2006; talan et al., 2017; spiekermeier, 2017). worse yet, many smw feel misunderstood or aggressed upon by their providers, or else forcibly outed, so much so that they do not want to engage in services again (martos et al., 2017). this failure to deliver culturally competent, or even culturally aware, care by requiring clients to carry the burden of disclosure creates a fissure between the client and their care team, further exacerbating health disparities. columbia social work review, vol. ix | 7 lgbtqai+ health access disparities in female-identified clients enacting direct service policies that standardize best practice would help interrupt health care disparities from the ground up (spiekermeier, 2017). as with all high-needs populations, a solution can revolve around investment in standardization of services, creation of treatment plans for specific needs, and empathic communication of care (mehta, 2017; spiekermeier, 2017; eckstrand et al., 2017). training providers on best practice, continuing professional education, and implementing standardized protocols would serve as a mezzo-level intervention for the protection of the community in direct practice (spiekermeier, 2017). service models that privilege flat affect, open-ended questions, non-judgmental questioning, and requesting permission in the delivery of care may yield the best results (eckstrand et al., 2017; mehta, 2017). youth health education curricula lastly, in micro practice, social workers can promote early intervention by engaging youth in appropriate health education (poteat et al., 2013). young people who are more informed about their bodies and health outcomes tend to adopt healthier lifestyles (da silva vilelas janeiro et al., 2013). affirmative health curricula teaching bodily autonomy build selfesteem and respect for persons, and prime participants to be conscious consumers of medical care (keuroghlian et al., 2017). for children, this type of intervention can result in self-sufficiency and self-determination, and act as a protective factor over the lifespan. family is the first point of contact for youth in providing vocabulary and understanding body function and expression. additionally, family members may act as gatekeepers to health services for youth. this dynamic may present a barrier for lgbtqai+ identified youth who need to rely on their families for determination and care, which may be at odds with the youth’s identity, expression, or behavior. consequently, youth health education incorporating gender and sexual orientation may further legitimize identity and promote clarity for youth (keuroghlian et al., 2017). conclusion equity rests at the heart of social work practice (national association of social workers, 2017). equity requires the fair distribution of services and resources, especially in a health setting (omrani-khoo et al., 2013). although the concept of fairness is subjective, the modern understanding “...a solution can revolve around investment in standardization of services, creation of treatment plans for specific needs, and empathic communication of care (mehta, 2017; spiekermeier, 2017; eckstrand et al., 2017).” 8 | columbia social work review, vol. ix jennifer hand of equity means that we push services and resources towards those who need it most to maintain average—if not basic—access to social and economic survival. when working with people and communities that have been greatly disenfranchised, social workers are required by the code of ethics to consider the intersectional identities and experiences that restrict access to resources (national association of social workers, 2017). though the lgbtqai+ community has been greatly disenfranchised, and is only just receiving the legal protection it deserves, cis and trans women in the community experience enormous inequity in the provision and distribution of social services, health care, and employment. we must consistently provide interventions at the macro, mezzo, and micro levels to promote economic and health parity for female-identified members of the lgbtqai+ community. references alexander, k. & ravani, s. 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(2011 june). public health implications of same-sex marriage. american journal of public health, 101(6): 986-990. doi: 10.2105/ ajph.2010.300112 blosnich, j.r. (2017). sexual orientation differences in satisfaction with healthcare: findings from the behavioral risk factor surveillance system, 2014. lgbt health, 4(3): 227-231. doi: 10.1089/lgbt.2016.0127 coston, b.m. (2014). women’s health, health care service utilization, and experience of intimate partner violence in the united states. in v.l. harvey & t.h. housel (eds.). health care disparities and the lgbt population. ch. 9, lanham, maryland: lexington books. “we must consistently provide interventions at the macro, mezzo, and micro levels to promote economic and health parity for female-identified members of the lgbtqai+ community.” columbia social work review, vol. ix | 9 lgbtqai+ health access disparities in female-identified clients da silva vilelas janeiro, j.m., salvado de oliveira, i.m., rodrigues, m.h.g., de jesus maceiras, m., rocha, g.m.m. (2013). sexual and contraceptives attitudes, the locus of health control and self-esteem among higher education students. revista brasileira em promocao de saude, 26(4): 505-512. dc. (2018). mayor’s office of lesbian, gay, bisexual, transgender and questioning affairs. retrieved from https://lgbtq.dc.gov department of health and human services. 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(2017, april 10). will sexual orientation finally be a protected class? forbes. retrieved from https://www.forbes.com/sites/insider/2017/04/10/willsexual-orientation-finally-be-a-protected-class/#37666d8d5ab9 harrison, b.f. and michelson, m.r. (2017). listen, we need to talk: how to change attitudes about lgbt rights. oxford scholarship online. doi:10.1093/ acprof:oso/9780190654740.003.0001 harvey, v.l. & housel, t.h. (2014). an introduction to the loosely knit patchwork of lgbt health care. in v.l. harvey & t.h. housel (eds.), health care disparities and the lgbt population. lanham, md: lexington books. retrieved from proquest. hegewisch, a. & williams-baron, e. (7 march 2018). the gender wage gap: 2017 earning differences by race and ethnicity. institute for women’s policy research. retrieved from https://iwpr.org/publications/gender-wage-gap2017-race-ethnicity keuroghlian, a.s., ard, k.l., makadon, h.j. 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(2016, feb 15). why lesbians tend to earn more than heterosexual women. the economist. web. retrieved from https://www.economist.com/blogs/ economistexplains/2016/02/economist-explains-8 lassiter, j.m. (2017). introduction: for us, by us. in l.d. follins & j.m. lassiter (eds.). black lgbt health in the united states. 1-10. lanham, maryland: lexington books. lawrence v. texas. 539 u.s. § 558. (2003). retrieved from westlaw. lunn, m.r., cui, w., zack, m.m., thompson, w.w., blank, m.b., yehia, b.r. (2017). sociodemographic characteristics and health outcomes among lesbian, gay, and bisexual u.s. adults using healthy people 2020 leading health indicators. lgbt health, 4(4): 283-294. doi: 10.1089/lgbt.2016.0087 marmot, m. (march 2005). social determinants of health inequalities. the lancet, 365(9464): 1099-1104. doi: 10.1016/s0140-6736(05)71146-6 martos, a.j., wilson, p.a., & meyer, i.h. (2017). lesbian, gay, bisexual, and transgender (lgbt) health services in the united states: origins, evolution, and contemporary landscape. plos one, 12: 1-18. doi: https://doi.org/10.7916/ d8j3953v mehta, s. (april 2017). making the healthcare needs of lgbt patients a priority. primary health care, 27(4): 30. doi: 10.7748/phc.2017.e1233 movement advancement project. (2018, february 7). non-discrimination laws. retrieved from http://www.lgbtmap.org/equality-maps/non_discrimination_ laws mule, n.j., ross, l.e., deeprose, b., jackson, b.e., daley, a. … moore, d. (2009). promoting lgbt health and wellbeing through inclusive policy development. international journal of equity in health, 8:18. doi:10.1186/1475-9276-8-18 national association of social workers. (2017). nasw code of ethics. retrieved from https://www.socialworkers.org/about/ethics/code-of-ethics/code-ofethics-english national women’s law center. (19 sep 2017). the wage gap: the who, how, why, and what to do. retrieved from https://nwlc.org/resources/the-wage-gapthe-who-how-why-and-what-to-do obergefell v. hodges. 576 u.s. (2015). retrieved from westlaw. office of the assistant secretary for health (oash). n.d. access to healthcare: affordable care act. u.s. department of health & human services. web. accessed from https://www.hhs.gov/programs/topic-sites/lgbt/ accesstohealthcare/affordablecareact/index.html omrani-khoo, h., lofti, f., safari, h., jame, s.z.b., moghri, j. (nov 2013). equity in distribution of health care resources: assessment of need and access using three practical indicators. journal of public health, 42(11): 1299-1308. patterson, j.g., jabson, j.m., bowen, d.j. (2017). measuring sexual and gender minority populations in health surveillance. lgbt health, 4(2): 82-105. doi: 10.1089/lgbt.2016.0026 poteat, v.p., sinclair, k.o., digiovanni, c.d., koenig, b.w., russell, s.t. (2013). gay-straight alliances are associated with student health: a multischool comparison of lgbtq and heterosexual youth. journal of research on adolescence, 23(2): 319-330. doi: 10.1111/j.1532-7795.2012.00832.x romer v. evans. 517 u.s. § 620. (1996). retrieved from westlaw. rondahl, g., innala, s., carlsson, m. (november 2006). heterosexual assumptions in verbal and non-verbal communication in nursing. journal of advanced nursing, 56(4): 373-381. doi: 10.1111/j.136502648.2006.04018.x columbia social work review, vol. ix | 11 lgbtqai+ health access disparities in female-identified clients san francisco human rights commission. (2018). lgbt initiatives. retrieved from http://sf-hrc.org/lgbt-initiatives smith, s.k. & turell, s.c. (september 2017). perceptions of healthcare experiences: relational and communicative competencies to improve care for lgbt people. journal of social issues, 73(3): 637-657. doi: 10.1111/ josi.12235 spiekermeier, m. (sep 2017). lgbtq education: earn your “a.” the journal for nurse practitioners, 13(8): 580-581. doi: 10.1016/j.nurpra.2017.05.091 talan, a.j., drake, c.b., glick, j.l., claiborn, c.s., seal, d. (2017). sexual and gender minority health curricula and institutional support services at u.s. schools of public health. journal of homosexuality, 64(10): 1350-1367. willes, k. & allen, m. (2014). the importance of sexual orientation disclosure to physicians for women who have sex with women. in v.l. harvey & t.h. housel (eds.). health care disparities and the lgbt population. lanham, md: lexington books. retrieved from proquest. jennifer hand, located in san francisco, is a masters of science in social work candidate in the social enterprise administration program at columbia university’s school of social work. the sea program provides training across all three levels of social work practice, with emphasis on management and policy. her field of practice is health, mental health, and disability. for her second-year placement, jennifer works at the mayor’s office of economic and workforce development where she researches and assesses programs to promote equity and improve data collection. additionally, jennifer works as a gender and sexuality health educator and chairs the lgbtq community services and education committee at the san francisco planning department. prior to attending columbia university, she worked in the legal industry, small business management, and created a workforce navigator model for professionals managing severe mental illness. she attended stony brook university in new york for her b.a. in english and education. singh / the utilization of mental health services by south-asian immigrants 15 introduction south asians—people from india, pakistan, bangladesh, nepal, and sri lanka—are one of the fastest growing immigrant groups in the united states. according to the immigration and naturalization services (2001) the second largest number of legal immigrants to the u.s. came from india, totaling 70,290 and constituting 6.6% of the total u.s. population. this paper examines why south-asian immigrant communities, as compared to other ethnic groups, underutilize mental health and social services. it is important to note that this paper looks at general characteristics of traditional south-asian families; the information presented cannot be applied to all south asians. while it is important to avoid homogenizing south asians, it is arguable that traditional families share a common set of values, beliefs, and practices. due to the apparent lack of research on south asians and mental health utilization, one can look to the research on asian immigrant populations— which arguably hold values similar to those of south asians—to gain a sense of how much this group utilizes services. one study looking at the utilization of outpatient mental health treatment by individuals who identify as asian american (futa, hsu & hansen, 2001) was conducted over a fiveyear period in the los angeles area. this area has a significant asian population, yet of the 230,441 clients utilizing outpatient mental health treatment, 3.1% were asian american, whereas european americans constituted 43%. asians are not only underrepresented in their utilization of mental health services, but also report being, in general, less satisfied with their therapists and reportedly terminate therapy after an average of only 2.35 therapy sessions. tthehe uutilizatilizationtion ofof mmententalal hhealealthth sserviceservices byby ssouthouth--aasiansian iimmigrantmmigrant ccommunitiesommunities inin thethe uunitednited ssttaatestes meher singh south asians are one of the fastest growing immigrant groups in the united states. this paper identifies possible reasons why south asians in the u. s. underutilize mental health services compared to other immigrant communities, and offers suggestions regarding how mental health services can be tailored to better meet the needs of this particular ethnic group. columbia university journal of student social work volume 1, number 1 16 importance of family and family pride family is arguably the single most important characteristic of southasian culture. traditional south-asian families are composed of nuclear and extended families, as well as the community in which they reside. the relationships between these three systems are extremely close-knit; each is interrelated and intertwined with the other. a related characteristic is the value of family pride. when contemplating personal decisions, individuals are expected to make choices that will benefit—and reflect positively on—the larger family and community. engaging in activities outside of what is culturally or socially appropriate, particularly if these behaviors negatively impact the family, is discouraged. in their discussion of child sexual abuse, futa, hsu, and hansen (2001) illustrate this value, stating that the issue of abuse often remains hidden because of fear that it will shed negative light on the family. the importance of family in south-asian culture can influence mental health service utilization both positively and negatively. it is undeniable that strong family ties provide individuals with tremendous support, particularly in a new country. however, the importance placed on familial relationships and family pride may restrict individual choices and hinder the making of independent life decisions. through my work with south-asian teens, i have discovered that these youth are highly influenced by their parents’ expectations regarding career choices, favoring careers with high salaries and status. coping with stress south asians handle life stressors differently than other ethnic groups. if an individual is faced with a problem, he or she is expected to employ the assistance of family or to cope with it on his or her own. an individual who seeks assistance outside of the family would likely be perceived as having a weak character and going against the value of family pride. in the eyes of a traditional south-asian family, speaking to therapists about individual or family problems would bring unwanted negative attention to the family (futa, hsu & hansen, 2001). a primary reason south asians do not seek assistance—particularly outside of the family unit—is because this is not a socially-accepted nor socially-respected means of solving one’s problems. ow and katz (1999) state that “secret keeping is a strategy at the other end of the disclosure continuum in the management of distressful information that may be potentially disruptive to the group” (p. 2). although this article focused on chinese families, the notion of protecting the family cuts across most asian cultures. singh / the utilization of mental health services by south-asian immigrants 17 stigma of mental illness the stigmatization of mental illness in south-asian culture directly impacts utilization of mental health services. because families are so concerned with hiding this problem from the community, individuals with mental illness often remain untreated. “seeking help for psychiatric problems usually occurs only in severe cases and may start with the pursuit of indigenous treatment modalities in the community” (ahmed & lemkau, 2000, p. 95). some families may first attempt to use herbal remedies and prayers prior to seeking professional help. the final decision regarding treatment, however, would most likely be dependent on the family’s religious background. non-verbal expression & gender roles interpersonal characteristics, like self-expression, impact south-asian use of mental health services. “although direct eye contact is highly valued in american culture as a sign of honesty and engagement, south asians usually avoid eye contact in relationships where they feel deference and respect” (ahmed & lemkau, 2000, p 91). in addition, south asians tend to swing their heads horizontally instead of nodding to mean “yes. ” a practitioner’s familiarity with culturally-based communication patterns can facilitate effective work with south-asian clients, breaking down barriers and enhancing the client’s level of comfort. in this author’s experience, south asians are more likely to express affection through actions than through words. for example, a father may show love for his children by providing them with a college education rather than by saying “i love you. ” this lack of verbal expression makes it difficult for south asians seeking mental health treatment to adjust to traditional modes of psychotherapy, which focus on the client’s verbal expressions and feelings. south-asian families have rigidly defined gender roles, with males at the top of the hierarchy in all aspects of life—familial, social, and political. understanding this patriarchal hierarchy is relevant to mental health treatment because providers may find that south asians prefer to receive treatment from male clinicians. because traditional south-asian culture views females as subservient, female clinicians may not be given the same level of respect as male clinicians. acculturation and adaptation the u.s. is becoming increasingly diverse, and immigrating to this country can be overwhelming. to cope with this stressful transition, some southasian immigrants choose to live in neighborhoods that are predominantly south-asian because they provide a “safety net. ” families that have lived columbia university journal of student social work volume 1, number 1 18 in the u. s. for a longer time can provide support and information to make the transition easier. acculturation has an enormous impact on south-asian immigrants. some immigrant families come to the u. s. with the aim of making money. many, however, soon find themselves in low-wage, unskilled jobs, struggling to make ends meet. this causes a huge strain on an individual’s health as well as on the family unit. children of immigrants face unique issues, as many find themselves caught between the world of their parents and that of their peers, resulting in serious intergenerational conflict. immigrant children often assimilate more quickly than their parents because they are exposed to american culture on a day-to-day basis in school. in order to assimilate, some children may begin adopting similar ways of dressing and behavior as their non-south-asian peers. the stresses associated with immigration and assimilation point to some reasons why south-asian immigrants might benefit from mental health treatment. ahmed and lemkau (2000) emphasize the seriousness of this issue, stating that “this culture shock is a form of transition shock, with symptoms ranging from anxiety, depression, and helplessness to full-blown physiological stress reactions, paranoia, and psychosis” (p. 92). utilizing the family in treatment researchers have suggested that mental health practitioners utilize a family-based approach when working with south asians as a more appropriate method of dealing with the problems of this ethnic group. hong (1988) suggests that having ongoing interaction with one clinician who can be looked upon as a resource to consult when a family faces difficulties has many benefits. this approach requires no actual termination of treatment; the practitioner would be available to the family indefinitely and on an as-needed basis, becoming increasingly familiar with all members of the family and gaining their trust. furthermore, the flexibility of this treatment may not be as threatening to south-asian families. the lack of formality in this model— the fact that there is no beginning or end to treatment—enables south-asian families to feel more comfortable seeking help and less like they are being “treated” for an illness. one downfall of this approach, however, is that some family members may not feel comfortable seeking the assistance of the clinician if the issue involves another family member. this could conceivably happen during times of intergenerational conflict. it would be imperative for the practitioner using this approach to discuss rules of confidentiality with the family so that individual family members feel comfortable seeking assistance. therapists would also have to be careful not to sympathize with one family singh / the utilization of mental health services by south-asian immigrants 19 member over another. as hong (1988) states, “the therapist might become overly identified with or sympathetic to a particular client and lose objectivity when other family members are seen” ( p. 8). community-based services using a “grassroots” approach to encourage utilization of mental health services is one effective way of reaching the south-asian community. if planned well, outreach can reduce stigma against mental illness and mental health treatment. for example, outreach should be spearheaded by someone respected in the community, such as a male, south-asian doctor. a nonthreatening method of outreach could provide the community with some kind of educational services; a physician, for instance, could provide a lecture on how the strain of acculturation can lead to depression. normalizing stressful problems and acknowledging that many people experience similar difficulties may reduce an individual’s hesitation to seek services. another way to increase mental health utilization is to have communitybased clinics staffed with culturally competent, bilingual providers. for some, it may feel less intimidating and less “institutional” to visit a clinic in one’s neighborhood rather than going into a large hospital. conclusion the stress south asians face as a result of coming to the u.s. clearly points to a need for mental health services. however, there are a myriad of reasons why south asians do not utilize services as much as other ethnic groups. mental health practitioners can increase south-asian utilization of services by tailoring treatment to the needs of this particular group. this could mean trying new modes of therapy or starting a community-based practice. while these ideas are feasible, community outreach is arguably the most important method of increasing utilization of services. providers need to go into the community, gain the trust of the people they are trying to serve, and slowly begin reducing stigma around mental health and mental illness. references ahmed, s. & lemkau j. (2000). cultural issues in the primary care of south-asians. journal of immigrant health, 2, 89-96. futa k., eugenia, h., & hansen d. (2001). child sexual abuse in asian-american families: an examination of cultural factors that influence prevalence, identification, and treatment. clinical psychology, 8, 189-220. greene, roberta r. (1999). human behavior theory and social work practice. hawthorne, ny: aldine de gruyter. columbia university journal of student social work volume 1, number 1 20 hong, george k. (1988). a general family practitioner approach for asian-american mental health services. professional psychology: research and practice, 19, 600-605. keum-hyeong, c. & wynne, m. (2000). providing services to asianamericans with developmental disabilities and their families: mainstream service providers’ perspective. community mental health journal, 36, 589-595. ow, r. & katz, d. (1999). family secrets and the disclosure of distressful information in chinese families. families in society, 80, 620-628. saleebey, d. (2001). human behavior and social environments: a biopsychosocial approach. new york, ny: columbia university press. shonfeld-ringel, s. (2000). dimensions of cross-cultural treatment with late adolescent college students. child and adolescent social work journal, 17, 443-454. meher singh is a first-year ms student at the columbia university school of social work. she is currently an intern at soundview throgs neck community mental health center in the bronx, new york. she holds a ba in women’s studies from the university of massachusetts at amherst. columbia social work review, vol. viii | 1 effectiveness of skills groups for adolescents in correctional settings a scientific systematic review charlotte jones lucy nonas-barnes according to the office of juvenile justice and delinquency prevention (2014), approximately 50,821 adolescents are held in residential placement facilities on any given day in the united states. data suggests that about 20% of these adolescents suffer from mental health issues (shelton, et al., 2011). this paper reviewed studies of three different group work-based treatment interventions: mindfulness, cognitive-behavioral therapy, and dialectical-behavioral therapy. the analysis will examine whether these interventions can effectively reduce maladaptive cognitions and decrease self-destructive behaviors, and whether they can be applied to adolescents aged 12-19 in correctional settings. five studies met inclusion criteria; however, due to limitations including small sample sizes, a lack of follow up, a variety of behaviors being measured, and a range of different types of skills groups, several were excluded. for the purposes of this review, the term “residential setting” will refer to correctional settings, inpatient psychiatric settings, and residential settings, and the terms “youth,” “juveniles,” and “adolescents,” will be used interchangeably. introduction the vast number of juveniles under the age of 18 involved in the united states criminal justice system means that there is a significant need to better understand effective treatments for this specific population. in 2008, research found that 75% of youth involved in the criminal justice system had experienced trauma  (ko et al., 2008). youth who are exposed to adverse experiences are more likely to adopt risky and deviant behaviors, such as aggression (baron, 2003). youth who display these behaviors typically struggle with emotional and behavioral regulation. emotional dysregulation can present in multiple ways, such as depression and anger, while behavioral dysregulation is characterized by a lack of inhibition and the inability to use socially desired behaviors to obtain one’s goals.(linehan, 1993a). because these behaviors are primarily learned patterns, dysregulation can be attributed to a failure to acquire the necessary skills throughout childhood development (goldstein, 1999). justice-involved youth often miss out on opportunities for socialization, such as attending school and engaging with peers, which are necessary for development and future endeavors. moreover, trauma and the extreme stress associated with being placed in a correctional setting can contribute to more self-destructive behaviors and recidivism post-release. the relationship between trauma and delinquent behavior indicates there is a critical need to provide treatment for this population (ko et al., 2008). although correctional facilities offer enrichment and therapeutic programs, therapists and counselors face barriers in developing and modifying effective and appropriate modalities (mccann, ivanoff, schmidt, & beach, 2007). for example, a comprehensive treatment model can be costly to implement, there is a lack of extensive clinical training for providers, and service providers have limited access to clients (banks, kuhn, & blackford, 2015). due to the barriers associated with this setting, there is a critical need for more evidence-based treatment adapted to meet the needs of this population (banks, kuhn, & blackford, 2015). this systematic review analyzes the use of skills group interventions with incarcerated juvenile or justice-involved youth in correctional settings and the relevance of these practices to future interventions and research. trauma, adolescents, and the justice system trauma is a common factor among youth involved with the juvenile justice system. childhood trauma occurs when a child or adolescent is exposed to a situation that overwhelms his or her ability to cope with the experience, and it can adversely affect psychosocial development (putnam, 2006). adolescents who have been exposed to trauma may exhibit a range of symptoms such as physically and verbally aggressive behaviors, self-harm, suicidal and homicidal ideations, destruction of property, and engagement in delinquent behaviors (fasulo, ball, jurkovic, gregory, miller & alec, 2015). in addition, research indicates that victims of trauma are less likely to complete their education or maintain employment, and are more likely to have serious legal problems (putnam, 2006). youth in the juvenile justice system express more post-traumatic stress disorder (ptsd) symptomatology compared to their counterparts in the wider community (fasulo et al., 2015). young people who display these maladaptive and difficultto-manage behaviors are often stigmatized as delinquent and often do not have opportunities to have their trauma histories and symptomatic behaviors assessed and successfully treated. maladaptive coping skills the development of effective coping skills is critical during adolescence due to the attachment bonds created during this time (putnam, 2006). justice involved adolescents often cope with serious stressors, such as poverty, family separation, abuse and neglect, and substance abuse—not to mention the normative changes and challenges that occur for all adolescents 2 | columbia social work review, vol. viii (smith & carlson, 1997). like other functions, coping skills follow a developmental trajectory: some are present at birth, while others are shaped and influenced by learning during childhood (shelton, kesten, zhang, & trestman, 2011). many factors influence the way behavior is shaped, including personal experiences, modeling, emotional vulnerability, and pressure from peers (shelton, kesten, zhang, & trestman, 2011). it is important when developing treatment to be aware of how adolescents cope with serious stressors in their environment when developing their treatment plans. evidence-based interventions for adolescents involved with the justice system tackle the idea that due to the development of less effective coping skills, youth will revert to engaging in aggressive and delinquent behaviors (shelton, kesten, zhang, & trestman, 2011). correctional settings exacerbate maladaptive coping skills, such as emotional instability, anger management problems, aversive affect, interpersonal dysregulation, self-damaging behaviors, cognitive disturbances, cognitive rigidity, and self-dysfunction (mccann, ball, & ivanoff, 2000). one likely cause is that the criminal justice system incorporates practices, such as the use of pathological labels and mass punishment, that conflict with the recommendations of treatment providers (mccann, ball, & ivanoff, 2000). in addition, within correctional settings are often environments where engaging in  delinquent and aggressive behaviors is most effective  (personal communications, november, 2016; personal communications, december, 2016). in practice, these deficient skills and challenges may lead to the accumulation of behavioral violations, which may in turn lead to more legal issues. this negative feedback cycle further underscores the need for an appropriate treatment model specifically for adolescents in correctional settings, in order to better assist them in managing the developmental and environmental stressors they face. skills groups skills training groups have been associated with moderately effective improvements in social and community functioning skills, as well as a decrease in aggressive and disruptive behaviors (farmer & chapman, 2016). the goals of skills training in a correctional context are to increase effective behaviors and to decrease the ineffective externalizing and internalizing behaviors often exhibited by justice-involved adolescents. skills training is applicable to several areas of life, including anger management and depression (farmer & chapman, 2016). the term “skill” is conveyed to mean using one’s existing knowledge and learning, often to reach the desired outcome (linehan, 1993a). skills training involves acquiring skills, strengthening skill knowledge and ability, and generalizing skill use in all areas of a person’s life (linehan, 1993a). the goals of skills training in a correctional context are to increase effective behaviors and to decrease the ineffective externalizing and internalizing behaviors often exhibited by justiceinvolved adolescents.  skills training groups have been associated with moderately effective improvements in social and community functioning skills, as well as a decrease in aggressive and disruptive behaviors (farmer & chapman, 2016). it is a cost-efficient  treatment, and in past studies correctional mental health staff have reported that it is highly effective and easy to implement (mccann, ivanoff, schmidt & beach, 2007). method the following research was developed using multiple databases and online catalogs. sciencedirect, jstor, psychinfo, pubmed, scopus, and proquest were all used. multiple replications of the same studies were found on different sites. there was little difference in the search results for “adolescents,” “youth,” and “juveniles.” all terms were used because of an apparent colloquial shift in the use of these terms after the 1990s from the term “juveniles” to now using the term “adolescents” or “youth” when describing people under the ages of 25 (benekos, merlo, & puzzanchera (2011). there were a total of 20,186 hits from the databases examined. articles had to meet the following criteria to be included in the review: 1. the sample size could not be less than 10. 2. the article had to be published in a peer-reviewed journal. 3. the study could not include adult populations. these criteria narrowed the results of the search to 5 studies. study results in our search five studies met the criteria. apsche, bass, & houston (2006) examined the effectiveness of mode deactivation therapy (mdt) versus the effectiveness of dialectical behavior therapy (dbt) in a residential treatment center. this analysis will focus on the dbt aspect of the study. the study evaluated 10 adolescent males aged 15-18. participants were randomly assigned to either dbt, mdt, or a control group. in dbt, clients attended weekly individual therapy sessions and one dbt skills group per week. the beck depression inventory (bdi-ii) and the reynolds suicidal ideation questionnaire (siq) were administered as outcome measures for preand post-test assessments. daily behavior reports and behavior incident reports, which indicate the number of aggressive acts and other crises a participant is involved in, were evaluated preand post-study. the results revealed that all participants in the dbt group benefited from treatment, as evidenced by a reduction in daily behavior reports and behavior incident reports. bdi-ii showed a decrease in rates of depression, and the siq showed a reduction in depression and suicidal ideations. columbia social work review, vol. viii | 3 leonard, et al. (2013) employed a cognitive behavioral therapy/mindfulness training (cbt/mt) intervention in their randomized control trial. they used the power source intervention (ps), which is a group-based cognitive-behavioral/ mindfulness meditation intervention created for youth in the criminal justice system by casarjian and casarjian (2003). the ps intervention uses the theoretical framework of “the process model of emotion regulation,” which identifies five points where emotions can be regulated: situation selection, situation modification, attention deployment and appraisal, cognitive change, and response modulation (leonard, et al., 2013). leonard, et al. (2013) used multiple self-reporting measurements, including the self report of offending and a computer-assisted self-interviewing format as well as the attention network test, which measured focus preand post-test. these tests did not have statistically significant results. leeman, gibbs, and fuller (1993) examined the effectiveness of equipping youth to help one another (equip) with incarcerated adolescents. equip is a multicomponent group treatment program that incorporates social skills training, anger management, and moral education. leeman, et al. (1993) evaluated 57 justice-involved adolescent males between 1518 years old who were incarcerated at a medium-security correctional facility. the equip group was compared to the control groups and showed gains in both mediating variable and behavioral outcomes, and was shown to be effective in increasing social skills as well as reducing recidivism (helmond, et al., 2012). for the purpose of this study, mediating variables included moral judgement and social skills. the sociomoral reflection measure-short form (srm-sf) measured moral judgement and the inventory of adolescent problems-short form assessed social skills. behavioral outcomes were measured by preincarceration archival data, post-incarceration disciplinary incident reports, and self-reported questionnaires concerning pre-intervention delinquent behavior and institutional misconduct. social skills, moral judgement, and self-reported institutional misconduct measures were administered preand post-intervention. however, scores on mediating variables were not statistically significant. helmond, overbeek, & brugman (2012) also examined the effectiveness of equip with incarcerated adolescents. the study included 115 males and females with a mean age of 16 years old. helmond, et al. (2012) measured the social skills, moral value, and moral judgment for both the equip group and the control group. social skills were measured via the inventory of adolescent problems-short form objective. the srm-sf was also adapted into a shorter measure, the sociomoral reflection measure-short form objective (srm-sfo) to measure moral value evaluation and moral judgment. this study did not find any significant increase in social skills or moral development, but did find that the equip intervention group’s scores for both remained stable while the control group’s scores decreased (helmond, et al. 2012). shelton, kesten, zhang, and trestman (2011) authored a secondary data study from a larger study of adults and youth using an adapted version of the dialectical behavioral therapy-corrections modified (dbt-cm) intervention developed by trestman, gonillo, and davis in 2004. the purpose was to examine the effectiveness of dbt-cm with difficult to manage, impulsive, and/or aggressive incarcerated male adolescents. the study evaluated 26 males aged 16-19 and sought to address whether dbt-cm showed a reduction in aggressive behaviors, lowered impulsivity, and improved coping skills. participants received dbt-cm skills groups for 16 weeks. the overt aggression scale-modified and the brief psychiatric rating scale were used for pre-test assessments. the buss-perry aggression questionnaire (bpaq), ways of coping checklist (wccl), and positive and negative affect scales (panas) were administered as outcome measures for pre-and post-test assessments. disciplinary ticket information was collected 12 months prior to treatment and six months after treatment was terminated. there was a significant reduction in disciplinary tickets preand post-test. there were slight improvements on the panas and wccl, but not enough to be statistically significant. the bpaq showed statistically significant improvement post-test. limitations the treatments delivered in the studies were not initially developed for adolescents who are in correctional settings. therefore, the researchers made adaptations to the treatments to fit the population. this is a limitation because the adaptions effect treatment validity. small sample size, implementation, and feasibility issues arose in each study with regard to limitations imposed by correctional facilities, the length of time a participant spent in a certain facility (either because of transfer, sentencing, or released), and/or resources available to be used. helmond, et al. (2012) was the only study to evaluate adherence to treatment. four out of five studies lacked follow-up assessments or data showing the lasting results of the interventions. shelton, et al. (2011) also reported that the assessment instruments they used were not designed for the populations being treated. finally, leonard, et al. (2013) had difficulty identifying the specific mechanism for outcomes, and the effect the subsystems of the groups and the facility had on the participants. discussion and recommendations there are increasing numbers of adolescents involved in the criminal justice system who exhibit significant mental health and behavioral problems, yet few evidence-based mental health treatment programs have been designed for this population. although there is a looming number of adolescents held in some form of correctional settings, the data on effective treatment is limited. some research demonstrates that group treatment can be cost-efficient for correctional administrators (mccann, et al., 2007). skills groups have been shown to be associated with medium effect in improving behavior among group participants (farmer & chapman, 2016). to date, the most effective treatment includes some form of cognitive-behavioral treatment focused on decreasing behavioral deficits and increasing adaptive coping skills. due to a lack of empirical research and the limitations of existing studies, it is difficult to point to the effectiveness of skills groups with incarcerated youth. one reason for this scarcity is the difficulty in administering randomized control 4 | columbia social work review, vol. viii trials in correctional settings (personal communication, ivanoff, 2016). more appropriate measurement tools must be identified or developed in order to enhance the validity of research outcomes. furthermore, professionals must develop trainings in intervention methods found to be successful. it is also important that follow-up assessments be completed to test the lasting quality of the treatments. due to the limitations, additional research with larger sample sizes and follow-up data are needed to determine if these findings are essential for developing adequate treatment in juvenile settings. given our research we found shelton et al. (2011) had the greatest effectiveness in reducing behavioral incidents and therefore, we suggest the future research continues to implement dbt-cm with adolescents who are incarcerated. studies should also continue to examine the impact of trauma on justice involved youth to better inform correctional staff. it would be beneficial for scholars to complete other systematic reviews on this topic within the next few years and include the many dissertation studies on skills training groups with incarcerated adolescents published in peer-reviewed journals. the implementation of skills groups is a promising intervention for healthy adolescent skill development. in turn, acquiring skills would help justice-involved adolescents better navigate everyday life in their communities and avoid further involvement with the criminal justice system. references apsche, bass, & houston. (2006). a one year study of adolescent males with aggression and problems of conduct and personalities: a comparison of mdt and dbt. international journal of behavioral and consultation therapy, 2(4), 544-552. banks, kuhn, & blackford. (2015). modifying dialectical behavior therapy for incarcerated female youth: a pilot study. journal of juvenile justice, 4(1). baron, s.w. (2003). street youth violence and victimization. trauma, violence, & abuse, 4(1), 22-44. brown, s.a. (september, 2015). trends in juvenile justice state legislation: 2011-2015. washington, d.c.: national conference of state legislatures. farmer, r.f. & chapman, a.l. (2016). behavioral interventions in cognitive behavior therapy: practical guidance for putting theory into action (2nd ed.). washington, d.c.: american psychological association. fasulo, ball, jurkovic, gregory, miller, & alec (2015). towards the development of an effective working alliance: the application of dbt validation and stylistic strategies in the adaptation of a manualized complex trauma group treatment program for adolescents in long-term detention. american journal of psychotherapy, 69(2) 219-239. ford, hartman, hawke, and john (2008). traumatic victimization, posttraumatic stress disorder, suicidal ideation, and substance abuse risk among juvenile justice-youth. journal of child & adolescent trauma, 1(1), 75-92. goldstein, a.p. (1999). low level aggression: first steps on the ladder to violence. champaign, il: research press. *helmond, p. overbeek, g., & brugman, d. (2012). program integrity and effectiveness of a cognitive behavioral intervention for incarcerated youth on cognitive distortions, social skills, and moral development. children and youth services review, 34, 17201728. ko, s. j., ford, j. d., kassam-adams, n., berkowitz, s. j., wilson, c., wong, m., ..., & layne, c.m. (2008). creating trauma-informed systems: child welfare, education, first responders, health care, juvenile justice. professional psychology: research and practice, 39(4), 396. *leeman, l. w., gibbs, j. c. and fuller, d. (1993), evaluation of a multi-component group treatment program for juvenile delinquents. aggressive behavior, 19(4), 281–292 *leonard, n. r., jha, a. p., casarjian, b., golsarran, m., garcia, c., cleland, c. m., ... & massey, z. (2013). mindfulness training improves attentional task performance in incarcerated youth: a group randomized controlled intervention trial. frontiers in psychology, 4, 792. linehan, m.m. (1993a). cognitive-behavioral treatment of borderline personality disorder. new york: guildford press. mccann, r.a., ivanoff, a., schmidt, h., & beach, b. (2007). implementing dialectical behavior therapy in residential forensic settings with adults and juveniles. in dimeff, l.a. & koerner, k. (eds.) dialectical behavior therapy in clinical practice: applications across disorders and settings (112-138). new york: the guilford press. mccann, r.a., ball, e.m., & ivanoff, a. (2000). dbt with an inpatient forensic population: the cmhip forensic model. cognitive and behavioral practice, 7, 447-456. putnam (2006). the impact of trauma on child development. juvenile and family court journal, 57(1), 1-11. rohde, p., jorgensen, j. s., seeley, j. r., & mace, d. e. (2004). pilot evaluation of the coping course: a cognitive-behavioral intervention to enhance coping skills in incarcerated youth. journal of the american academy of child & adolescent psychiatry, 43(6), 669-676. *shelton, d., kesten, k., zhang, w., & trestman, r. (2011). impact of a dialectic behavior therapy—corrections modified (dbt-cm) upon behaviorally challenged incarcerated male adolescents. journal of child and adolescent psychiatric nursing, 24(2), 105-113. smith, c., & carlson, b. e. (1997). stress, coping, and resilience in children and youth. social service review, 71(2), 231-256. charlotte jones charlotte jones, from oakland, california, is a current participant in the dialectical behavioral therapy training program at columbia university’s school of social work. the dbt program is a 12-month program which incorporates a focused academic curriculum and dbtbased field placement. for her second-year field placement, charlotte is working as a mental health intern at riker’s island. the population she works with is incarcerated males between the ages of 16-17. prior to attending columbia university, she completed the youth villages’ 360 career development program in memphis, tn. while there, charlotte worked with female clients between the ages of 14-21 suffering from severe emotional columbia social work review, vol. viii | 5 and behavioral problems at the girls center for intensive residential treatment, a level-4 secured facility. she attended clark atlanta university, in atlanta, georgia, for her bachelor of arts in psychology. lucy nonas-barnes lucy is a native new yorker, a former dancer, and about to be a graduate of the columbia school of social work (cssw). lucy has been working within the juvenile justice/criminal justice systems for the past seven years across the country, starting while getting her bachelors at the university of michigan. lucy then moved to southern california where she worked in group homes, school, and correctional facilities. lucy spent her first year of graduate school at the university of pennsylvania, in philadelphia, where she also worked at the philadelphia county prison. for the past year, lucy has been trained in dialectical behavior therapy (dbt) through the dialectical behavior therapy training program at cssw and has been working as a mental health intern at rmsc on riker’s island. lucy has worked in public policy, research, community organization, mental health services, and behavior management with people between the ages of eight and seventy. lucy’s future interest lie in evidence-based practice and research, specifically related to dbt. lucy plans to earn her phd and continue to work with incarcerated and at-risk populations and to work towards reforming the criminal justice system. 2019-cswr_neworder.indd 28 | columbia social work review, vol. x inclusion and readiness: in support of lgbtq-affirming military health care adam pierson milano author’s note: for the purposes of this paper, the acronym lgbq (lesbian, gay, bisexual, queer) is used to discuss policy that does not specifically address transgender service members. the acronym lgbtq (lesbian, gay, bisexual, transgender, queer) is used when individuals who identify as transgender are impacted by the policy or culture discussed. as the author, i recognize and respect that even lgbtq does not incorporate all sexual orientations and gender identities. mercurial policy shifts concerning the gender identity and sexual orientation of individuals serving in the united states military have adversely affected the quality of health care offered to service members who identify as lesbian, gay, bisexual, transgender, or queer (lgbtq) directly impacting unit readiness. a lack of lgbtq-affirming services within the military health care system compromises the health and well-being of lgbtq service members, which is symptomatic of the exclusionary, heteronormative culture fostered by decades of discriminatory policy. the historic inequity within the military and its impact on the relationship between lgbtq service members and military health care providers (mhcps) must be addressed to rectify the ongoing health care disparity. moreover, policies and lgbtq-affirming practices that empower service members and foster inclusivity must be implemented to strengthen the military as a whole. the history of lgbtq service policy during world war i, the u.s. military criminalized sodomy and explicitly prohibited “homosexual conduct” by service members (connell, 2017). the first outright ban of lgbq service members was imposed during world war ii, when the surgeon general of the u.s. army classified homosexuality as a justification for disqualification from military service (bérubé, 1990; bailey & barbato, 2011). after world war ii, lesbian, gay, bisexual, and queer (lgbq) service members were discharged under a pseudo-psychological pretext known as a “blue discharge” (bailey & barbato, 2011). at this time, the military did not address transgender identity in its policies. in 1962, a new policy facilitated the discharge of service members based on assumed homosexual identity, regardless of whether they had engaged in sexual activity with a member of the same sex (connell, 2017). the discharge of service members was left to the discretion of commanding officers. beginning in 1981, the department of defense’s standard protocol columbia social work review, vol. x | 29 lgbtq health care in the u.s. military was to discharge all service members who engaged in homosexual acts (connell, 2017). the don’t ask, don’t tell (dadt) policy, an effort to promote inclusivity within the armed forces, was enacted in 1994, despite fierce opposition from the senate and military leadership (bailey & barbato, 2011). dadt allowed lgbq individuals to serve in the military, provided that they did not disclose their sexual orientation. this repeal did not apply to individuals that identify as transgender. in actuality, discharging service members remained common practice upon reveal of their actual or perceived nonheterosexual orientation (bailey & barbato, 2011; goldbach & castro, 2016). this policy bred a “witch-hunt” mentality, in which service members could report to superiors any service member suspected of being lgbq (bailey & barbato, 2011). this practice negatively impacted unit cohesion because it undermined the value of teamwork inherent to the military. the don’t ask, don’t tell repeal act of 2010 overturned dadt and allowed lgbq service members to serve openly, meaning they were able to be honest about their personal lives with their units. prior to this repeal, service members would often have to lie about their social lives, live off-post, and avoid bringing partners to military functions. this repeal did not apply to service members who identified as transgender. shortly thereafter, the department of defense began offering family benefits to same-sex spouses (department of defense, 2013). current policy the ongoing debate regarding lgbtq service policies specifically impacts the transgender community. in 2012, the department of defense released formal instructions barring individuals with a history of psychosexual conditions, “including, but not limited to, transsexualism, exhibitionism, transvestism, voyeurism, and other paraphilias” from enlisting in the military (department of defense, 2012). this ban on transgender service was officially repealed in 2016 by the obama administration, which emphasized that transgender individuals are fit to serve and already do so in other countries (connell, 2017). the department of defense is actively recruiting, training, and retaining transgender service members despite continued efforts to prohibit their service, including the trump administration’s efforts to reinstate the ban (shane, 2018). transgender individuals enlist at twice the rate of their cisgender counterparts, which some researchers and personal accounts attribute to a desire to embrace the societal construct of masculinity (connell, 2017; goldbach & castro, 2016; herzog & orabona, 2014; kemp & del monte, 2017). the reinstatement of the 2012 ban would limit which transgender service members are permitted to serve based on the length of time each individual has identified as transgender and on potentially necessary medical accommodations related to gender identity (seck, 2018). 30 | columbia social work review, vol. x lgbtq health care in the u.s. military opponents of the ban question the justification for its implementation. some high-level military leaders, bolstered by pseudoscience, claim that the inclusion of lgbtq service members has a negative impact on morale (bailey & barbato, 2011). contrary evidence shows that, in fact, a ban on transgender service would adversely affect unit morality, retention, and readiness, as evidenced by the “witch-hunt” culture during the period of dadt (barnes, 2018; bailey & barbato, 2011). this policy battle has perpetuated confusion among the ranks regarding the state of current regulations and has created a daunting environment for transgender service members. for instance, service members who identify as transgender and who have recently disclosed their gender identity may fear negative repercussions if the trump administration were to reinstate the ban. implications for health care though dadt has been repealed, lgbtq service members’ distrust of military health care providers (mhcps) remains. mhcps serve in the dual roles of clinicians and officers. as officers, mhcps are required to report medical findings that disqualify patients from service eligibility. under the dadt policy, if a patient informed a mhcp of their lgbtq identity, the mhcp was required to report the patient and, in some instances, to classify them as unfit for service (biddix, fogel, & black, 2013). considering that the ban on transgender service may be reinstated, it is likely that many transgender service members will be reticent when interacting with mhcps, as being open about their gender identity can disrupt their ability to serve (goldbach & castro, 2016). in a study examining comfort levels of lgbq service members with regard to the military health care system, 30% reported feeling discomfort when discussing their gender identity, sexual orientation, or sexual health with their mhcp (biddix et al., 2013). the study found that 44% of gay and bisexual male participants believed sexual orientation was a factor in the care they received from the military (biddix et al., 2013). many lgbtq service members waited several years after the repeal of dadt to come out to their units, for fear of bullying, denial of promotion, or discharge (bensahel, 2012). one notable study revealed that 45% of lgbtq service members chose not to disclose their sexual orientation to mhcps and 75% believed that their mhcp presumed that they were heterosexual (stebnicki, persko, & thomas, 2015). many lgbtq service members also reported that they avoided seeking health care for fear of discrimination (stebnicki et al., 2015). notably, lgbtq service members are likely to have poorer physical and mental health—including increased risk of conditions such as depression, posttraumatic stress disorder, and alcohol and/or other substance use—than the health of their heterosexual and cisgender counterparts (stebnicki et al., 2015; shrader et al., 2017). further, lgbtq service members attempt suicide at a rate 2.5 times higher than non-lgbtq columbia social work review, vol. x | 31 lgbtq health care in the u.s. military service members (national defense research institute, 2010). new recruits may be drawn to enlist because of the alluring, comprehensive military health care benefits to which they are entitled during and after service. however, until the repeal of dadt, service members who were entitled to full retirement benefits—accrued over 20 years of service—but who were discharged for being lgbtq would have to reenlist to receive benefits. likewise, if a ban on transgender service is reinstated, transgender individuals who lose their active duty or reserve status would be denied military health insurance until a policy change allows them to reenlist. the nature of their discharge may also negatively impact their right to receive lifelong health coverage from the veterans health administration (vha) (bailey & barbato, 2011). should the military continue to employ transgender service members, lgbtq-affirming measures must be expanded to cover all lgbtq service members, both active and veteran, across all military facilities. recommendations transgender service members face unique barriers in receiving quality health care. an estimated 250,000 lgbtq service members and veterans utilize vha services, including roughly 5,000 who identify as transgender (kauth & shipherd, 2016). in 2018, the veterans administration (va) issued a directive to use inclusive language, providing more deferential care to veterans who identify as transgender or intersex by addressing patients by their preferred names and gender pronouns (department of veterans affairs, 2018). though this policy cannot completely assuage the discomfort of many lgbtq service members in vha environments, it is a step in the right direction and should be adopted by the entire military health care system in order to support and care for lgbtq service members (stebnicki et al., 2015). mhcps and military social workers play an integral part in changing the way the military supports lgbtq service members; both roles have the unique capability to engage at multiple levels of the military and to positively change how lgbtq service members receive care. military social workers are trained to provide necessary support, counseling, and education to military personnel and their families; however, there is room for improvement in how to sensitively and effectively work with lgbtq service members. while seminars and ethics training may provide a foundation, lgbtq service members deserve care from those who are specifically trained to meet their needs. strebnicki et al. (2015) provide several suggestions that can be adapted specifically to social work supervision, including seeing lgbtq patients regularly during internships and post-education training, ensuring that supervision includes discussions about lgbtq experiences, and learning directly from those who have been 32 | columbia social work review, vol. x lgbtq health care in the u.s. military the recipients of this care in the past. a standard of care should then be established to ensure that all service members are receiving the highest possible level of support, regardless of where they are stationed. mhcps and social workers must then address the distrust between lgbtq service members and mhcps. the therapeutic alliance between clinician and service member must be rooted in mutual trust, which has been eroded in the military by the former policies that mandated mhcps to report evidence of lgbtq identity. moving forward, in order to provide affirming care, mhcps must acknowledge the historically problematic power dynamics of the relationship and allow this awareness to shape the ways in which they interact with and provide care for lgbtq service members. for example, not assuming service members’ sexuality or gender identity and changing the language around health care can provide a more welcoming hospital environment and thus healthier lgbtq service members. each unit of mhcps should also include a subject matter expert on anti-oppressive practice to allow for direct peer-to-peer education. furthermore, improving health care outcomes for lgbtq service members may also occur outside of the medical department. due to social work officers’ unique position within military structure, they are able to engage directly with unit leadership. they should take the initiative to conduct anti-oppressive trainings for these leaders, therefore prioritizing and normalizing the inclusion of lgbtq service members. educating all members of the military in anti-oppressive best practices could help to mitigate negative mental health outcomes for lgbtq service members that are rooted in living and working in environments that contain unaddressed stigma, stereotyping, and homophobic undertones (stebnicki et al., 2015). if both commissioned and enlisted leaders incorporate inclusive language into their daily lives, the rest of the unit, and thus the culture, will follow. conclusion in conclusion, vacillating policy changes have had negative effects on readiness and inclusion within the u.s. military. the whims of politicians should not negatively impact the health care provided to service members and veterans, regardless of their sexual orientation and gender identity. while society at large has made great strides toward acceptance and inclusion of the lgbtq community since the dadt era, the military community and government policy still lag behind. under the obama administration, the military took steps toward greater inclusivity with the repeals of both dadt and the ban on transgender service, yet current political leaders are working to revert to an earlier era by reenacting previous bans that were discriminatory and detrimental. however, there is hope for the future of lgbtq service members. vha health directives prioritize inclusivity and work towards providing the care that veterans may columbia social work review, vol. x | 33 lgbtq health care in the u.s. military not have been able to access during their active duty service, and continuous advocacy by military social work officers can help to change military culture both within and outside of the medical tent. perhaps the next administration, alongside congress, will ally with this rising generation of social workers to facilitate the establishment of a more inclusive military, propelled by health care professionals who are educated and committed to lgbtq-affirming practices and sustained by those who will never stop fighting for the care they deserve from the country they love. 34 | columbia social work review, vol. x lgbtq health care in the u.s. military references bailey, f. (producer and director), & barbato, r. (producer and director). (2011). the strange history of don’t ask, don’t tell [motion picture]. united states: hbo documentary films. barnes, r. (2018, november 23). trump administration asks supreme court to immediately take up transgender military ban. washington post. retrieved from https://www.washingtonpost.com/politics/courts_law/trumpadministration-asks-supreme-court-to-immediately-take-up-transgendermilitary-ban/2018/11/23/6cf11b32-ef39-11e8-8679-934a2b33be52_story. html?noredirect=on&utm_term=.be9bfe17e75e bensahel, n. (2012). after repeal: lessons from foreign militaries. in j.f. huffman & t.s. schultz (eds.), the end of don’t ask, don’t tell: the impact in studies and personal essays by service members and veterans (pp. 2–17). pittsburgh, pa: marine corps university press. bérubé, allan (1990). coming out under fire: the history of gay men and women in world war two. new york: penguin. biddix, j. m., fogel, c. i., & black, b. p. (2013). comfort levels of active duty gay/ bisexual male service members in the military healthcare system. military medicine, 178(12), 1335–1340. doi:10.7205/milmed-d-13-00044 connell, c. (2017). now that we can ask and tell: the social movement legacy of the dadt repeal. sociology compass, 11(9). doi:10.1111/soc4.12506 department of defense. (2012, july 2). instruction number 6130.03. medical standards for appointment, enlistment, or induction in the military services. office of the secretary of defense. retrieved from https://www.med.navy. mil/sites/nmotc/nami/arwg/documents/waiverguide/dodi_6130.03_ jul12.pdf department of defense. (2013, august 14). dod announces same-sex spouse benefits [press release]. retrieved from http://archive.defense.gov/releases/release. aspx?releaseid=16203 department of veterans affairs. (2018). providing health care for transgender and intersex veterans ( vha directive 1341). r e t r i e v e d f r o m h t t p s : //w w w. a l b u q u e r q u e .v a . g o v /d o c s / providinghealthcarefortransgenderandintersexveterans.pdf goldbach, j.t., & castro, c.a. (2016). lesbian, gay, bisexual, and transgender (lgbt) service members: life after don’t ask, don’t tell. current psychiatry reports, 18(56). doi:10.1007/s11920-016-0695-0 herzog, m., (producer, director) & orabona, s. (director). (2014). lady valor: the kristin beck story [motion picture]. usa: herzog and company. kauth, m.r., & shipherd, j.c. (2016). transforming a system: improving patient centered care for sexual and gender minority veterans. lgbt health, 3(3). doi:10.1089/lgbt2016.0047 columbia social work review, vol. x | 35 lgbtq health care in the u.s. military kemp, p. (producer), & del monte, m. (director). (2017). transformer [motion picture]. usa: storystream creative. national defense research institute. (2010). sexual orientation and the u.s. military personnel policy: an update of rand’s 1993 study. santa monica, ca: rand corporation. rubin, a., weiss, e. l., & coll, j. e. (2013). handbook of military social work. hoboken, n.j.: john wiley & sons. seck, h.h. (2018). new trump transgender military policy bars those with gender dysphoria. retrieved from https://www.military.com/dailynews/2018/03/23/new-trump transgender-military-policy-barsthose-gender-dysphoria.html shane, l. (2018, march 23). new trump order would ban most transgender troops from serving. military times. retrieved from https://www.militarytimes. com /news/your-army/2018/03/24/trump-order-would-ban-mosttransgender-troops-from-serving/ shrader, a., casero, k., casper, b., kelly, m., lewis, l., & calohan, j. (2017). military lesbian, gay, bisexual, and transgender (lgbt) awareness training for health care providers within the military health system. journal of the american psychiatric nurses association, 23(6), 385–392. doi: 10.1177/1078390317711768 stebnicki, m.a., persko, p.j., & thomas, j.f. (2015). best practices in the healthcare of lgbt military service members, partners and families. journal of military and government counseling, 3(3), 150–171. adam pierson milano is a two-year student on the clinical track with a focus in health, mental health, and disabilities. adam created his current field placement as the life skills instructor at the naval academy preparatory school in newport, ri. he received his bachelor’s degree from middlebury college and is originally from new jersey. adam serves in the 443rd civil affairs battalion, u.s. army reserves. 34 | columbia social work review, vol. vii columbia social work review, vol. vii | 35 program description this evaluation focuses on the legal aid society program called the parole revocation defense unit (prdu). specifically, the study focuses on the written mitigation drafted by social workers at prdu and its impact on preventing parole revocation. written mitigation is a powerful tool that details a client’s personal life and relevant history. it humanizes the client so judges can see the human being beyond the alleged crime (the legal aid evaluating the success of written mitigation in reducing prison sentences and achieving alternatives to incarceration for parole violations nnenna onyema, jaime buseman, and carrie maldovan it is estimated that 2.4 million individuals are incarcerated in federal, state, and county prisons and jails in the united states, the largest number seen in the developed world (flatow, 2014). in addition, there are an estimated 4.75 million, or 1 in 51, adults under community supervision in the united states (herberman & bonczar, 2014). this includes individuals on probation, parole, and other forms of post-prison supervision. there are issues with the mass incarceration system in the united states that extend beyond the sheer number of individuals incarcerated. for instance, people of color make up 30% of the population but 60% of those imprisoned (kerby, 2012). for the about 850,000 on parole, many face struggles adapting to society and attaining basic needs such as health care, housing, and employment. these factors, among many others, lead these individuals to violate parole and become re-imprisoned, creating a cycle of perpetual contact with the legal system. the parole revocation defense unit at the legal aid society provides services for those who have had their parole revoked or face parole revocation. social workers work together with lawyers to provide comprehensive plans to reduce sentences and recommend alternatives to incarceration. one tool, known to be powerful within prdu at the legal aid society, is written mitigation, a process used to advocate for and provide holistic presentations of clients. this paper evaluates the benefits of written mitigation by looking at the sentencing for 20 cases before and after written mitigation. the findings show that written mitigation was helpful in reducing sentences and resulting in alternatives to incarceration with statistical significance. this information learned contributes to the larger discussion of the relevance of social workers in legal settings to provide holistic services and broader conversations of criminal justice reform and elimination of institutions that produce outcomes that do more harm than good. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text © 2016 onyema, buseman, and maldovan. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 36 | columbia social work review, vol. vii columbia social work review, volume vii | 37 evaluating the success of written mitigation onyema, buseman, and maldovan society, 2012). a major aim of written mitigation is to reduce sentences issued by judges compared with those they would have given without mitigation. the shortterm objective is that clients are released from jail into the community to begin recommended treatment and programs. the mid-term objective is for clients to successfully complete parole supervision. the long-term objective of prdu is for clients to adjust to society with more opportunities for selfsufficiency and fewer interactions with the criminal justice system. study aims because written mitigation is one of the few tools prdu social workers use to advocate for reduced sentences, it is important to explore its effectiveness. the original sentences judges intended to give are compared with their final decisions to identify any changes. the level of efficacy in reducing sentences through written mitigation can assist social workers in improving their work and achieving better outcomes for clients. given the prison system’s extensive costs to society , it is necessary to investigate the role of prison in reducing crime and rehabilitating inmates. in a comparison of two studies on recidivism, ostermann (2013) found that a cohort of released inmates from 1983 had a rearrest rate of 62.5%, a reconviction rate of 46.8%, and a return-to-custody rate of 41.4% compared with a cohort of released inmates from 1994, of whom 67.5% were rearrested, 46.95% were reconvicted, and 51.8% returned to custody. this study suggests recidivism and subsequent rearrest, reconviction, and return to prison appear to increase over time. additionally, a study by bales and piquero (2011)—controlling for sex, race, age, current offense, and prior record—found that overall, imprisonment leads to higher recidivism when compared with a non-incarcerative alternative. nagin (2009) also found that compared with noncustodial sanctions, incarceration appears to have a null or mildly criminogenic effect on future criminal behavior. therefore, findings suggest that prison actually contributes to the likelihood of future criminal behavior for previously incarcerated people. given the findings on the ineffectiveness of prisons to reduce recidivism, parole supervision has been used as another avenue to reduce future criminal behavior. ostermann (2013) found that the predicted likelihood of recidivating differed by about 5% between supervised (parole) and unsupervised (nonparole) groups in the 6-month and 1-year periods; however, parolees who were actively supervised for at least 3 years were estimated to recidivate at an 8% lower rate. while this finding is significant, the incidence of recidivism among parolees continues to be high. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text 36 | columbia social work review, vol. vii columbia social work review, volume vii | 37 evaluating the success of written mitigation onyema, buseman, and maldovan based on previously incarcerated people’s high incidence of recidivism, the limited effects of parole alone, and the evidence that prison contributes to future criminal behavior, the effectiveness of the traditional criminal justice system has been called into question (zhang, roberts, & callanan, 2006). alternatives to incarceration (ati) are one promising solution. ati have grown in recent years in response to failures in the traditional criminal justice system. these programs, which generally include aspects such as community service, rehabilitative services, and restitution, are less costly, less disruptive to families and communities, and helpful in maintaining stability and encouraging accountability among offenders (pew center on the states, 2009). according to the legal action center (2012), alternative programs such as drug courts reduce future crime by as much as 35%, while intense community supervision combined with rehabilitation services reduces recidivism by up to 20%. mitigation provided by prdu is the gatekeeper between clients and either prison sentences or alternative programs. therefore, the aim of the evaluation study is to investigate the effectiveness of mitigation in contributing to a reduced prison sentence or the offer of alternative-program sentences. methodology the sample consisted of 20 individuals who allegedly violated parole during the period from july 2013 to january 2014. the age and ethnicity of these individuals vary, but the individuals are mainly middle-aged men who are either african american or latino. their alleged crimes include both violent and nonviolent offenses. since this evaluation used the existing agency data, there was no recruitment process and the sample was convenient. because agency records were used and no new data were collected, the study design of this program evaluation was secondary data analysis. additionally, this is a retrospective study that examines and further analyzes client records based on the differences in sentences administrative law judges gave clients before and after social workers provided mitigation. the methodology used in this evaluation is quantitative analysis based on the existing data about the individuals who have allegedly violated parole. the study compared the judges’ sentencing of the 20 clients before and after mitigation to determine its effect in decreasing prison/jail-time sentences or offers of ati, such as completion of a program. in addition, this study includes a brief analysis of the potential effects of other variables—including type of offense, gender, ethnicity, mental health status, chemical addiction, or “mitigation provided by prdu is the gatekeeper between clients and either prison sentences or alternative programs.” 38 | columbia social work review, vol. vii columbia social work review, volume vii | 39 evaluating the success of written mitigation onyema, buseman, and maldovan educational levels—on sentencing outcomes. in terms of data collection procedures, the program evaluation is based on client records from a 6-month period from july 2013 to january 2014, including written mitigation provided by the legal aid society. since all the client records used in the study already existed, there were neither interviews nor surveys conducted, and clients had no incentives to participate in this study. consent was obtained from the legal aid society. no personally identifiable information, including names, was used. for the measurement and data analysis plan, a paired-sample t-test was used to compare sentencing decisions given to the clients before and after written mitigations to see if there was any improvement. using 3 months as the unit of time, there were 14 values of the dependent variables (coded as “original offer” and “final offer”) ranging from a community program sentence (best outcome) to a 36-month jail sentence (worst outcome). a p value less than .05 showed the change in sentence was statistically significant, meaning the written mitigation improved offers for the clients. another data analysis method used was chi-square, which was used to determine any associations or correlations between the following other variables and the changing outcomes: instant offense (valued as nonviolent or violent crimes), educational levels (less than high school, high school/ged, some college, unknown) , and mental health status (presence of self-reported diagnosis or not), all of which were categorical. the changing outcomes were valued as no change of outcome, less jail time, and zero jail time. results the findings based on the quantitative data of this program evaluation included the demographic information, the results of the paired sample t-test result explaining whether mitigation improved the outcome of the 20 clients, and the association between other variables and the final outcome. the sample contained 20 clients—17 male and 3 female. ages ranged from 19 to 71. half the sample—10—identified as african american, while 3 individuals identified as latino/a, 2 as white, 3 as two or more races, and 2 individuals’ races were unknown. in terms of educational level, 2 of the clients had attended some college, while 6 had a high school diploma or ged, 9 did not graduate from high school, and 3 had an unknown education level. this information indicated that the sample had a low level of educational attainment compared with the general population. mental illness was prevalent within the sample, with 18 of 20 clients reporting a diagnosis. additionally, 15 out of the 20 individuals reported substance abuse or dependence. of the sample, 11 individuals committed a violent crime. 38 | columbia social work review, vol. vii columbia social work review, volume vii | 39 evaluating the success of written mitigation onyema, buseman, and maldovan the number of parole violations ranged from 1 to 14; however, only 2 of the individuals violated parole more than 2 times. to determine whether the mean differences were statistically significant, which would indicate that written mitigation was effective in improving a client’s offer, this evaluation used a paired sample t-test. the results of the test are shown in appendix a. figure 1 indicated a significant decrease in the means of time offered by the judges after the written mitigations, which decreased from 5.25 to 2.75. this reduction means that sentences decreased from an average of 10 months to an average of less than 3 months or a program. additionally, the difference between “original offer” and “final offer” was statistically significant at a p value of .005, shown in figure 2 and 3 in appendix a. as a result, there was a statistically significant decrease in offer scores from “original offer” (m=5.25, sd=3.23) to “final offer” (m=2.75, sd=2.61), t(19)= 4.80, p<.0005 (two tailed). the mean decrease in offer scores was 2.50 with a 95% confidence interval ranging from 1.41 to 3.59, shown in figure 3. therefore, the results from the paired sample t-test revealed that the written mitigation from social workers at prdu improved the final sentences of the clients, either lessening their jail time or getting them another program. additionally, we performed the chi-square test to see if there was an association between different variables and the final outcome. the variables we highlighted were educational level and instant offense. more specifically, the chi-square test was used to determine whether violent or nonviolent offenses would be associated with an improved offer, and whether educational level of the clients would be associated with a change in the final offer. however, because the sample size was very small, the lowest frequency in some cells was less than 5, which means that an association cannot be proven using the chi-square test. the results of the chi-square analysis are shown in appendix b. discussion statistical, practical, and clinical significance the results show a statistical significance between written mitigation and improved sentences for individuals accused of violating parole. more practically, this illustrates the importance and effectiveness of advocating for vulnerable populations, such as individuals with a prior offense. humanizing individuals involved with the criminal justice system is helpful in reducing or avoiding prison sentences and increases referrals to potentially effective programs. this is one aspect that highlights how social workers are invaluable within a legal setting and provide such unique services to clients involved 40 | columbia social work review, vol. vii columbia social work review, volume vii | 41 evaluating the success of written mitigation onyema, buseman, and maldovan with the criminal justice system. furthermore, the results suggest that social workers should complete mitigation for legal matters more often, as it has an effect on outcomes for clients. the results suggest many individuals who are on parole may need mental health and addiction services, as the majority of the sample was diagnosed with a mental illness and many had chemical addictions . this is an opportunity for social workers to intervene and help decrease recidivism at the clinical level. this study is also a reminder that social workers must provide holistic services and take into account environmental factors and other macro-level issues that may lead an individual to commit a crime. limitations while the study did show statistically significant results in terms of the effectiveness of mitigation in decreasing a client’s sentence, there were significant limitations. because of restraints on data collection, a sample of only 20 clients was obtained. this is a very small sample, especially for the use of paired sample t-tests which typically require a sample of 30 or more individuals . furthermore, the sample was non-random, as clients whose information was accessible were used for the sample. additionally, all clients in the sample received written mitigation, so there was no control group. if the study were to be replicated, a larger, random sample of the client population would be preferable. the study also did not address variations in the mitigation that may have affected the outcome, such as the proposed alternative and the particular details about the client’s life as presented by the social worker. further analysis should examine different types of written mitigation to see which were more or less effective. looking at variations between social workers in order to identify the most effective aspects to include in written mitigation could also prove beneficial. the greatest challenge faced was collecting the data about pre-mitigation offers from the judges, as this information was not readily available in client files. it was difficult to identify more individuals for the sample. a larger random sample would have been preferable in order to get more valid results in the study. “humanizing individuals involved with the criminal justice system is helpful in reducing or avoiding prison sentences and increases referrals to potentially effective programs. this is one aspect that highlights how social workers are invaluable within a legal setting and provide such unique services to clients involved with the criminal justice system.” 40 | columbia social work review, vol. vii columbia social work review, volume vii | 41 evaluating the success of written mitigation onyema, buseman, and maldovan implications the implications of this study for practice and research are very significant. the findings show that written mitigation provided by social workers is effective in improving client outcomes, leading to either reduced jail time or an alternative to incarceration. it may be beneficial to include social workers in other departments at the legal aid society and potentially in other organizations involved with the criminal justice system that do not employ social workers. as social workers, it is important for us to evaluate the programs in which clients receive treatment to confirm that they are effective. when clients are released from programs, there is rarely any follow up. the results of this study suggest that social workers should provide services not only during clients’ exposure to the criminal justice system but after program completion as well, as the unique problems that clients face do not end once a case is closed. social workers should communicate with parole officers, family, medical staff, and any other individuals in clients’ lives to ensure the best possible outcomes are consistently achieved. while written mitigation is helpful, it does not solve the macro-level issues. recommendations with the current statistics and literature revealing that incarceration is not cost-effective and can actually contribute to recidivism (vera institute of justice, 1996, 2012), and other research showing that ati are increasingly effective (legal action center, 2012; ostermann, 2013; zhang, roberts & callanan, 2006), it is important to continue investigating the effectiveness of mitigation, especially for individuals who have violated parole. therefore, further research should be conducted using random sampling and larger samples to further investigate the effectiveness of mitigation in increasing the use of alternatives to incarceration. because written mitigation utilized by prdu is an effective intervention to promote ati for individuals who violate their parole, a suggestion is to replicate this program in the hope of increasing the use of ati. additionally, replication of this study within other legal settings may demonstrate a need to increase the number of programs such as prdu that seek ati, which will limit the number of individuals given prison sentences for violating parole or probation, as well as prevent or reduce initial prison sentences. further studies could also provide valuable information needed to create and implement more successful programs such as prdu and improve the effectiveness of written mitigation. while written mitigation is not unique to prdu, studying its efficacy in other organizations can further increase awareness regarding the importance of social workers and written mitigation 42 | columbia social work review, vol. vii columbia social work review, volume vii | 43 evaluating the success of written mitigation onyema, buseman, and maldovan in legal settings. references bales, w. and piquero, a. (2011). assessing the impact of imprisonment on recidivism. journal of experimental criminology, 8(1), 71-101. flatow, n. (2014, september 17). the united states has the largest prison population in the world and it’s growing. retrieved from http://thinkprogress.org/justice/2014/09/17/3568232/the-unitedstates-had-even-more-prisoners-in-2013/ herberman, e. j., & bonczar, t. p. (2014, october). probation and parole in the united states, 2013. retrieved from http://www.bjs.gov/content/pub/pdf/ppus13.pdf kerby, s. (2012, march 13). the top 10 most startling facts about people of color and criminal justice in the united states. retrieved from https://www.americanprogress.org/issues/race/ news/2012/03/13/11351/the-top-10-most-startling-facts-about-people-of-color-and-criminaljustice-in-the-united-states/ legal action center. (2012). alternatives to incarceration factsheet. retrieved from http://lac.org/wpcontent/uploads/2014/07/ati_factsheet.pdf legal aid society. (2012). the parole revocation defense unit. retrieved from: https://www.legal-aid.org/en/ criminal/criminalpractice/parolerevocationsdefenseunit.aspx nagin, d. (2009). imprisonment and reoffending. crime and justice. 38(1), 115-200. ostermann, m. (2013). active supervision and its impact upon parolee recidivism rates. crime & delinquency. 59(4), 487-509. pew center on the states. (2009, march). one in 31: the long reach of american corrections. h t tp ://www.pewt r us t s.o rg/~/med i a/ l eg acy/up loaded f i l e s/pcs_a s se t s/2009/ pspp1in31reportfinalweb32609pdf zhang, s. x., roberts, r. e., & callanan, v. j. (2006). preventing parolees from returning to prison through community-based reintegration. crime & delinquency, 52(4), 551-571. doi:10.1177/0011128705282594 vera institute of justice. (2012). the price of prisons: what incarceration costs taxpayers. retrieved from http://www.vera.org/sites/default/files/resources/downloads/price-of-prisonsupdatedversion-021914.pdf. vera institute of justice. (1996). the unintended consequences of incarceration. retrieved from http:// www.vera.org/sites/default/files/resources/downloads/uci.pdf nnenna onyema is a 2015 graduate of the columbia university school of social work from new jersey. her concentration was policy practice, and during her time at columbia, she was selected to be a law minor and washington dc fisher-cummings fellow. after graduating from columbia, nnenna served as a graduate research assistant at columbia university’s school of social work where she examined the mental health effects that police brutality and the media exposure of such abuses have on people of color. in her current role as a project manager with the national initiative for building community trust and justice, nnenna works with executivelevel leadership to oversee project implementation and provide strategic advice to national initiative partners and pilot sites. prior to joining the national initiative, nnenna worked at the legal aid society connecting incarcerated individuals to alternatives to incarceration at rikers island. in addition, at the vera institute, she co-managed survey research efforts for a nij grant looking at the relationship and challenges between public defenders and their clients with mental illness diagnoses. nnenna graduated from rutgers university magna cum laude with a ba in sociology 42 | columbia social work review, vol. vii columbia social work review, volume vii | 43 evaluating the success of written mitigation onyema, buseman, and maldovan and minor in business administration. jaime buseman is a 2015 graduate of the columbia university school of social work. her concentration was social enterprise administration with a focus in health, mental health and disabilities. prior to attending columbia, jaime volunteered as a pennsylvania certified sexual assault counselor for victim services center and as a hospice volunteer for caring hospice services while attending gwynedd-mercy university and graduating cum laude with her ba in english literature and a minor in human services. during her years at columbia, jaime worked as a school social worker at democracy prep charter middle school and alongside the community social work manager at metropolitan jewish health system hospice (mjhs). currently, jaime is back in her hometown in pennsylvania and is working on the hr team at teva pharmaceuticals that provides human resources support to over 8,000 us and canadian employees. carrie maldovan is a 2015 graduate of columbia university school of social work, where she concentrated in international social enterprise administration. prior to obtaining her master’s degree she lived and worked in tanzania, consulting with nonprofit organizations and leading the social impact strategy at a tourism company. currently, she serves as the manager of programs and operations at the adventure project, an organization working to end extreme poverty by creating jobs in developing countries. carrie is the co-founder of a responsible and sustainable tourism company, above safaris, that creates jobs, supports local businesses, and channels profits into sustainable community development projects in tanzania. 44 | columbia social work review, vol. vii columbia social work review, volume vii | 45 evaluating the success of written mitigation onyema, buseman, and maldovan appendix a : paired sample t-test figure1: paired samples statistics mean n std. deviation std. error mean pair 1 original offer 5.25 20 3.226 .721 final offer 2.75 20 2.613 .584 figure2: paired samples correlations n correlation sig. pair 1 original offer & final offer 20 .701 .001 figure3: paired samples test paired differences t df sig. (2-tailed)mean std. deviation std. error mean 95% confidence interval of the difference lower upper pair 1 original offer final offer 2.500 2.328 .521 1.410 3.590 4.802 19 .000 44 | columbia social work review, vol. vii columbia social work review, volume vii | 45 evaluating the success of written mitigation onyema, buseman, and maldovan appendix b: chi-square tests mental illness & final offer mental illness * the final improvement of the outcome cross tabulation the final improvement of the outcome total less jail time no jail time no improvement mental illness yes count 3 10 5 18 % within mental illness 16.7% 55.6% 27.8% 100.0% % within the final improvement of the outcome 100.0% 100.0% 71.4% 90.0% % of total 15.0% 50.0% 25.0% 90.0% no count 0 0 2 2 % within mental illness 0.0% 0.0% 100.0% 100.0% % within the final improvement of the outcome 0.0% 0.0% 28.6% 10.0% % of total 0.0% 0.0% 10.0% 10.0% total count 3 10 7 20 % within mental illness 15.0% 50.0% 35.0% 100.0% % within the final improvement of the outcome 100.0% 100.0% 100.0% 100.0% % of total 15.0% 50.0% 35.0% 100.0% 46 | columbia social work review, vol. vii columbia social work review, volume vii | 47 evaluating the success of written mitigation onyema, buseman, and maldovan chi-square tests value df asymp. sig. (2-sided) pearson chi-square 4.127a 2 .127 likelihood ratio 4.628 2 .099 linear-by-linear association 2.937 1 .087 n of valid cases 20 a. 4 cells (66.7%) have expected count less than 5. the minimum expected count is .30. symmetric measures value approx. sig. nominal by nominal phi .454 .127 cramer's v .454 .127 n of valid cases 20 46 | columbia social work review, vol. vii columbia social work review, volume vii | 47 evaluating the success of written mitigation onyema, buseman, and maldovan educational level & final offer education level * the final improvement of the outcome cross tabulation the final improvement of the outcome total less jail time no jail time no improvement education level less than high school count 1 6 2 9 % within education level 11.1% 66.7% 22.2% 100.0% % within the final improvement of the outcome 33.3% 60.0% 28.6% 45.0% % of total 5.0% 30.0% 10.0% 45.0% high school diploma or ged count 0 2 4 6 % within education level 0.0% 33.3% 66.7% 100.0% % within the final improvement of the outcome 0.0% 20.0% 57.1% 30.0% % of total 0.0% 10.0% 20.0% 30.0% some college count 0 1 1 2 % within education level 0.0% 50.0% 50.0% 100.0% % within the final improvement of the outcome 0.0% 10.0% 14.3% 10.0% % of total 0.0% 5.0% 5.0% 10.0% unknown count 2 1 0 3 % within education level 66.7% 33.3% 0.0% 100.0% % within the final improvement of the outcome 66.7% 10.0% 0.0% 15.0% % of total 10.0% 5.0% 0.0% 15.0% total count 3 10 7 20 % within education level 15.0% 50.0% 35.0% 100.0% % within the final improvement of the outcome 100.0% 100.0% 100.0% 100.0% % of total 15.0% 50.0% 35.0% 100.0% 48 | columbia social work review, vol. vii columbia social work review, volume vii | 49 evaluating the success of written mitigation onyema, buseman, and maldovan chi-square tests value df asymp. sig. (2-sided) pearson chi-square 10.947a 6 .090 likelihood ratio 10.437 6 .107 linear-by-linear association 2.897 1 .089 n of valid cases 20 a. 12 cells (100.0%) have expected count less than 5. the minimum expected count is .30. symmetric measures value approx. sig. nominal by nominal phi .740 .090 cramer's v .523 .090 n of valid cases 20 instant offense & final offer original felony * the final improvement of the outcome cross tabulation the final improvement of the outcome total less jail time no jail time no improvement original felony violent count 2 6 3 11 % within original felony 18.2% 54.5% 27.3% 100.0% % within the final improvement of the outcome 66.7% 60.0% 42.9% 55.0% % of total 10.0% 30.0% 15.0% 55.0% nonviolent count 1 4 4 9 % within original felony 11.1% 44.4% 44.4% 100.0% % within the final improvement of the outcome 33.3% 40.0% 57.1% 45.0% % of total 5.0% 20.0% 20.0% 45.0% total count 3 10 7 20 % within original felony 15.0% 50.0% 35.0% 100.0% % within the final improvement of the outcome 100.0% 100.0% 100.0% 100.0% % of total 15.0% 50.0% 35.0% 100.0% 48 | columbia social work review, vol. vii columbia social work review, volume vii | 49 evaluating the success of written mitigation onyema, buseman, and maldovan chi-square tests value df asymp. sig. (2-sided) pearson chi-square .683a 2 .711 likelihood ratio .686 2 .710 linear-by-linear association .601 1 .438 n of valid cases 20 a. 5 cells (83.3%) have expected count less than 5. the minimum expected count is 1.35. symmetric measures value approx. sig. nominal by nominal phi .185 .711 cramer's v .185 .711 n of valid cases 20 journal of student social work, volume iii 25 a deconstruction and critique of the female intervention team anita nabha over the past decade, there has been a significant increase in female juvenile offenders resulting in a growing interest in how to best address delinquent girls. in response to the changing demographics of juvenile offenders, the office of juvenile justice and delinquency prevention (ojjdp), a part of the department of justice, has called for “gender-specific” services. in this paper i will take one particular gender-specific intervention lauded by the ojjdp as a best practice in the field, the female intervention team (fit), and deconstruct the theories and beliefs that ground the intervention. this paper argues that fit is problematic for three main reasons: first, fit essentializes being female; second, fit constructs girls as victims; and finally, fit places too much emphasis on the individual girl’s agency at the cost of ignoring how structural forces contribute to and affect her reality. girls’ involvement in juvenile crime has grown consistently over the past decade (acoca, 1999). along with this rise in female juvenile offenders, there is a growing interest in how to best deal with delinquent girls. this changing demographic in the juvenile justice system has contributed to a new call for “gender-specific” services. some researchers suggest that girls follow a distinct pathway to offending and have different developmental needs that require interventions specifically tailored for the female offender (acoca; chesney-lind & sheldon 1991; peters, 1998). gender-specific programming involves a set of core principles that emphasize nurturing female identity and supporting girls’ needs for “positive healthy relationships” (daniel, 1999, p. 4). in this paper, i will take one particular gender-specific intervention, the female intervention team (fit), and deconstruct the theories and beliefs that ground the intervention. i will begin with a brief historical overview of the key theoretical developments that have shaped the social understanding of girls in society. i will then analyze three assumptions embedded in fit about female offenders. finally, i will argue that fit is problematic for three main reasons. first, fit essentializes being female, or attempts to create an understanding of being female that is universal 26 journal of student social work, volume iii female intervention team for all girls and encapsulates all that is defined by being female within a bounded category. second, fit constructs girls as victims. finally, fit places too much emphasis on the individual girl’s agency at the cost of ignoring how structural forces contribute to and affect her reality. historical overview biological theories were one of the first explanations for female criminal behavior. the classic delinquency text by lombroso and ferrero (1895) proposed that criminals were less evolved from normal law-abiding citizens and displayed certain primitive body traits. building on the theories that emphasized female biology as central to women’s nature, further exploration into female delinquency focused more specifically on female sexuality. the emphasis on female sexuality set the foundation for many future theories on female delinquency. however, some theorists who examined the problem of female sexual deviance saw the potential to protect these “problem girls.” the beginnings of a modern theory of female delinquency used the concept of gender roles to suggest that differential gender role socialization encouraged girls to pursue success through relationships (marriage) and males to achieve success through accomplishments (artz, 1998; grosser, 1952; morris, 1963). grosser was one of the first authors to relate this concept to female delinquency. he suggested that female delinquency was “relational” and reflected an aspect of female subculture similar to the way violent and aggressive behavior in men reflected male subculture (p. 120). although socialization theorists acknowledged that much of their research failed to support these ideas, they continued to promote a stereotypical understanding of gender and female identity (artz, 1998; grosser, 1952; morris, 1963). the theories were based on two assumptions: first, that female delinquency was primarily sexual and interpersonal in nature while male delinquency was primarily aggressive and violent. second, they assumed that girls and boys experience different socialization processes in their early development. these socialization processes play a central role in the development of personality characteristics that make females less inclined to delinquent behavior. ironically, although they differ on where essential female qualities originate, socialization theories seem to come to the same conclusions as biological theories regarding female delinquency. in response to theories that emphasized female difference from males, liberal feminists (friedan, 1965; wollstonecraft, 1975) challenged that women were similarly capable of reason and rational thought as men. nabha journal of student social work, volume iii 27 they argued that women were not by nature intellectually inferior, more prone to hysterics, or more emotional or relational. they suggested that in the absence of social and economic equality, women were subjected to oppression and marginalization that rendered them more vulnerable to poverty and discrimination, which could explain a turn to deviant behavior (chesney-lind & sheldon, 1991). these feminists demanded equality as a solution to the problem of being denied agency and rights. when the second wave of feminism emerged, these new radical feminists pushed the equality argument in a different direction (chodorow, 1978; gilligan, 1982). they countered that the sameness doctrine that emphasized how women and men were equals obscured the social realities of women’s experiences as mothers, daughters, partners, and the myriad other roles they held (chodorow; gilligan). out of this understanding of the distinct social reality of women, radical feminists created a difference doctrine that emphasized women’s unique voice as caring and nurturing beings (gilligan). two centuries after the first theories on female delinquency suggested that females were inherently different from males, and that their maternal role and nurturing capacities were central to their identity as women, the second wave of feminism continued to support many of these assumptions. in fact, this feminism was not that radical after all. the female intervention team the female intervention team is one example of an intervention that has come out of the radical feminist movement to acknowledge the “universal experience of womanhood” (daniel, 1999, p. 14). fit is a program designed by the maryland juvenile justice system to work specifically with girls in baltimore city’s juvenile justice system. all of the participants in fit were adjudicated as delinquents in baltimore and would have been alternatively placed in secure confinement. their crimes range from drug offenses and theft to simple assault and gang related violence. the female intervention team’s mission is to “restore hope to young women who have lost their direction and focus and lack goals” (daniel, p. 4). it accomplishes this through a variety of programs and services designed specifically for the female offender (daniel). there is not a universal female perspective one of fit’s core programs is called rites of passage. this program is designed to help girls “make a positive transition to womanhood” (daniel, 1999, p. 19). through the program girls learn to “celebrate womanhood with symbols, rituals and spiritual awareness” (daniel, p. 19). the idea of celebrating womanhood is somewhat new in the treatment of female juvenile offenders. historically, the onset of puberty and menstruation has been stigmatized as something that is impure and causes females to be more hysterical (birke, 1986). however, the idea of embracing and celebrating the “passage to womanhood” places the female adolescent experience of puberty as a defining point in a young women’s identity formation. the rites of passage program attempts to honor the female perspective, yet little is said in the program to explain what is involved in a female perspective (daniel). this idea is grounded in many of the earliest biological theories that began to study female delinquency. by creating a binary of male and female that presumes these are the only two sexes that exist, girls are forced to act within the confines of the female sex, however female is defined by society (butler, 1990). delinquency has traditionally been constructed as a male activity. when girls act delinquently, theorists have argued they were acting male and rejecting their female nature. programs such as the rites of passage, with its emphasis on celebrating womanhood, assume that when these problem girls were engaging in delinquent acts, they were rejecting their core femininity. female adolescence poses girls with unique challenges the female intervention team designed its programming to work only with girls because the task force and staff believed that girls face “distinct challenges during adolescence because of their gender” (peters, 1998, p. 5). the intervention emphasizes female sexuality as a central component of female difference and delinquency. the female intervention team also is reminiscent of the early 19th and 20th century movements to save deviant women. the program provides a safe space for girls, removed from their home environments, where they can learn how to avoid negative peer influences and become more resilient (daniel, 1999). the female intervention team assumes girls are controlled by their sexuality; however, by providing a “female friendly environment that promotes positive change” (daniel, p. 22), fit attempts to undo the effects girls experience from their environments. females need relationships for positive development during staff training and designing of fit programs, professionals were keenly aware of the idea that “relationships are central to girls’ lives” (daniel, 1999, p. 7). the idea that girls are relational is another component of the assumption that there is an appropriate way to act female. staff attempted to model healthy relationships for the girls and female intervention team 28 journal of student social work, volume iii required mandatory participation in a conflict resolution class (daniel). this class attempted to teach the girls how to “get along in their families, neighborhoods, and communities” (daniel, p. 19). the female intervention team’s programs suggest that those females who lacked certain female characteristics such as the ability to nurture and maintain healthy, positive relationships, were at risk of becoming more delinquent. this assumption is gender-biased and suggests that delinquency is inherently masculine. negative aspects of the intervention the problem of a universal woman the rites of passage program is a clear example of how fit privileges one understanding of womanhood. although the program description does not offer an explanation for how fit defines the experience of womanhood that the participants are supposed to embrace and celebrate, the underlying concept is that there is an essential woman. establishing a category of femaleness is problematic on many levels. for girls who feel unable to fit their experience of what it means to be female into the constructed understanding of femaleness, this category may feel exclusive and confining. the female intervention team’s attempt to address the issue of female delinquency by creating a program that is “responsive to girls’ needs” places gender at the center of the female identity (daniel, 1999, p. 9). ironically, while interventions such as fit seek to challenge and move past the stereotypical constructions of girls and female deviancy that were posited throughout much of the 19th and 20th centuries, fit does not stray far from the traditional constructions of girlhood. indeed, the theories behind fit reify many of the stereotypes about girls its creators hoped to defeat. prominent post-structuralists such as brown (1995), hooks (1984), and lorde (1985) question why it is necessary to insist on a single, static construction of “female” subjectivity. as brown argues: after all, the most ardent feminist poststructuralists do not claim that women’s pervasive economic subordination, lack of reproductive freedoms, or vulnerability to endemic sexual violence simply evaporates because we cannot fix or circumscribe who or what woman is or what it is that she wants. certainly gender can be conceived as a marker of power, a maker of subjects, an axis of subordination, without thereby converting it to a center of selves understood as foundational (p. 41). nabha journal of student social work, volume iii 29 the model of gender-specific programming is flawed because it succumbs to pressure from the liberal tradition to reveal and rely upon a universal truth. in order to garner recognition for gender bias in juvenile court and a paucity of alternatives to detention services for girls, advocates and practitioners have resorted to a limited definition of what it means to be a girl (kempf-leonard & sample, 2000). gender-specific programming places gender at the center of a girl’s life and constructs meaning out of a girl’s behavior and life experiences based upon her gender. yet, theorists such as butler (1990) have suggested alternative ways of understanding gender. butler writes, “gender is the repeated stylization of the body, a set of repeated acts within a highly rigid, regulatory frame that congeal over time to produce the appearance of a substance, of a natural sort of being” (p. 33). while it may seem threatening to the girls’ rights movement within the juvenile justice field to suggest eliminating the notion of a universal female, the possibilities for understanding girls’ experiences are much broader when subjectivity is constructed as a constantly varying and dynamic process. victimization and dependency after gender-specific programs such as fit create an essential female for girls to aspire to and celebrate, the program model teaches girls about productivity and dependency. on the surface, the creators of fit purport to be teaching girls to be self-sufficient through educational interventions and to be productive by encouraging work, skills training, and the value of contributing to society (daniel, 1999). however, careful analysis of the program reveals the creators’ understanding of emotional dependency as acceptable and financial dependency as unacceptable. the emphasis on teaching girls to be in healthy, positive relationships suggests that relationships are important to society and that females have a responsibility to maintain relationships in both families and communities. if only the model of gender-specific programming valued the liberal, rugged individual, it would not place so much importance on girls’ ability to successfully maintain relationships with adults. clearly, society has a vested interest in producing a girl who is not only productive but also caring and nurturing. as evidence of this interest, during the early stages of designing the intervention, the department of juvenile services (djs) reported that they must “view these girls not only as individual teenagers but also as mothers and potential mothers” (djs, 1992, p. 5). djs viewed the fit program’s responsibilities as going beyond treating the girls but also molding their children and future children. a female intervention team 30 journal of student social work, volume iii key component of the teen parenting group was teaching the girls how to nurture (daniel, 1999). raising young women who are caring and nurturing towards their children and families serves society well. these girls may grow up to care for their elderly parents, maintain intact families without public assistance, and pass along the value of taking care of one’s own to their children (folbre, 2001; peterson, 2001). as folbre notes, “high quality care creates benefits that extend well beyond the immediate recipients…parents who raise happy, healthy and successful children create an especially important public good” (folbre, p. 50). folbre and peterson suggest that society is not only interested in producing productive citizens (individuals who have jobs and can support themselves financially), but is also interested in producing citizens who care and nurture. it is important to note that the individuals who advocate for genderspecific services are in fact well-intentioned people who are using these constructions to serve society. their motivations are not only to produce a certain type of female, but also to create sympathy for this often invisible population (acoca, 1999). the practitioners of fit unfortunately fall prey to the double-edged sword of having to construct this population as victims in order to justify state intervention. in many ways, the identity politics employed by radical feminists calls for a universal womanhood and also relies upon victimization to garner support. brown (1995) applies the example of consciousness raising or other confessionals that attempt to convey the woman’s experience as a way of using a collective identity to legitimize victimization. structure, agency, and rational choice while gender-specific programming does construct the girls as victims, the model of intervention also identifies the girls as individuals with agency to change their position in society and make better choices (daniel, 1999). for example, one component of the fit program is the use of simulated baby dolls in the pregnancy-prevention program; young mothers are also invited to talk to the participants about the hardships of balancing work, school, and family at such a young age. the stated purpose of the intervention is to “provide girls with information they can use to make choices” and “to help girls decide if they are ready to be parents” (daniel, p. 7). the program is problematic because it presumes teenage pregnancy is the result of a rational choice. the idea is that if fit staff provides girls with information they will make better choices, such as to avoid sexual activity and pregnancy. the model of gender-specific programming attempts to teach girls to make choices that do not drain society financially, which nabha journal of student social work, volume iii 31 female intervention team 32 journal of student social work, volume iii allows them to produce public goods both economically and socially by providing care and support to both family and community. little consideration is given to the role societal structures play in constructing the lives of the fit participants. conclusion returning to the original mission of fit to “restore hope to young women who have lost their direction and focus and lack goals” (daniel, 1999, p. 15), this analysis shows that fit had very specific ideas in mind for which direction the girls’ lives should follow and what goals the girls should have. the idea of providing better services for girls may be a noble one, but social workers must be wary of what exactly these services entail. gender-specific services for girls in the juvenile justice system are spreading throughout the country with the endorsement of the federal government. however, many questions are still left unanswered. are we certain the services defined as needed for girls would not also be useful for boys? what effect does constructing girls as relational, sexual, and maternal beings have on our understanding of masculinity and male juvenile delinquency? social work practitioners who work with delinquent girls must move beyond the rigid stereotypes that have been used throughout the last two centuries to understand female delinquency. social work should acknowledge all girls as unique individuals and examine how society’s expectations should or should not influence girls’ sense of what it means to be successful or complete human beings. references acoca, l. (1999). investing in girls: a 21st century strategy. juvenile justice journal vi (1), washington, dc: office of juvenile justice programs, u.s. department of justice, office of juvenile justice and delinquency prevention. artz, s. (1998). sex, power, & the violent school girl. toronto, canada: trifolium books. birke, l. (1986). women, feminism and biology: the feminist challenge. new york: methuen. brown, w. (1995). states of injury: power and freedom in late modernity. princeton, nj: princeton university press. butler, j. (1990). gender trouble: feminism and the subversion of identity. london: routledge. nabha journal of student social work, volume iii 33 chesney-lind, m. & sheldon, r. (1991). girls, delinquency, and juvenile justice. pacific grove, ca: brooks cole. chodorow, n. (1978). the reproduction of mothering. berkeley, ca: university of california press. daniel, m. (1999). the female intervention team. juvenile justice, 6(1). department of juvenile services (djs) (1992). department of juvenile services (djs). (1992). female population report, 1992. baltimore, md: department of juvenile services. folbre, n. (2001). chapter 2: the care penalty. in the invisible heart, (pp. 22-52). new york: the new press. friedan, d. (1965). the feminine mystique. london: penguin. gilligan, c. (1982). in a different voice: psychological theory and women’s development. cambridge, ma: harvard university press. grosser, g. (1952). juvenile delinquency and contemporary american sex roles. unpublished doctoral dissertation, harvard university. hooks, b. (1984). feminist theory: from margin to centre. boston: south end press. kempf-leonard, k. & sample, l. (2000). disparity based on sex: is gender-specific treatment warranted? justice quarterly, 17(1), 89127. lombroso, c. & ferrero, w. (1895). the female offender. new york philosophical library. lorde, a. (1985). i am your sister: black women organizing across sexualities. new york: kitchen table: women of color press. morris, r. (1963). comparison of female and male delinquency. unpublished doctoral dissertation, university of michigan. peters, s. (1998). guiding principles for promising female programming: an inventory of best ractices. retrieved march 31, 2004, from http://www.ojjdp.ncjrs.org/pubs/principlescontents.html peterson, p. (2001). a graying world. the dangers of global aging. harvard international review, 23(3), 66-70. wollstonecraft, m. (1975). vindication of the rights of woman. london: penguin. anita nabha is a second year master’s student at cussw concentrating in the advanced generalist practice and programming method within the contemporary social problems field of practice. her current field placement is at sanctuary for families, where she works with battered women and helps facilitate the mentors program, an outreach and advocacy program for former clients. she holds a bachelor’s degree in law, jurisprudence, and social thought from amherst college. her email address is an2119@columbia.edu. microsoft word raise the age.docx © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. raise the age: legislation reform for the juvenile justice system laura pearl spivack juvenile justice policies in new york state put adolescents at risk for experiencing trauma in the criminal justice system. as a result of their precarious stage of development and limitations in brain functioning, adolescents face grave consequences when prosecuted and sentenced as adults. adolescents need to be given sustainable solutions through rehabilitation in order to discourage recidivism upon release. juvenile justice is not accomplishing its goals of lowering crime rates, nor is it working to reduce recidivism. these realities, in addition to theory, help to prove that reform is necessary. he u.s. is the only country in the world in which youth offenders can be sentenced to life in prison without the possibility of parole (rothchild, 2013). the goals of the juvenile justice system are to decrease recidivism, reduce crime rates, and dissuade juveniles from committing crimes (rothchild, 2013). in order to accomplish such goals, the new york state government decided that harsh punishment would be the ultimate deterrent. in reality, these goals have not been met, as the crime rate for all ages is increasing (state trends, 2010), and both juvenile and adult prisons are experiencing overcrowding (state trends, 2010). the challenges to the current system are further compounded by high costs and ineffectiveness (state trends, 2010). the juvenile justice system places heavy reliance on containment and punishment, which in turn removes adolescents from their families, peers, and social contexts. this lack of positive influence during an important transition period is compounded further by the collateral consequences of being in the juvenile justice system. adolescents must deal with the developmental consequences of isolation, punishment, and relationships with dysfunctional peers, in addition to a permanent record that may limit future academic or employment opportunities (bonnie et al., 2013). these factors delay brain development and often leave adolescents susceptible to impaired decision-making. this impairment can increase the likelihood of incarceration and be further exacerbated through incarceration, because juveniles are no longer able to learn from pro-social peers (bonnie et al., 2013). in order to achieve the best practice in the criminal justice system, it is crucial to limit recidivism and foster the development of socially conscious adolescents. by raising the minimum age of juvenile offenders to be tried as adults to 18, legislation should integrate evidence-based theory about adolescent brain development. in addition, statutory amendments should be created that would require all juvenile cases to be seen in family court (lazarow, 2012). history of the juvenile offender act the creation of juvenile justice legislation was based upon the belief that adolescents and children are inherently good and that services addressing their transgressions should focus on treatment rather than punitive measures (lazarow, 2012). the first juvenile court opened in new york city in 1922, and by 1925, the majority of states had adopted legislation creating a separate court for juvenile offenders. this process was often less harsh than its adult counterpart and helped to delineate the adolescent delinquent from being labeled as a criminal. in 1962, the new york state family court act was passed, which stated that juvenile offenses would be adjudicated in family court alongside child protection cases and custody disputes (lazarow, 2012). in 1978, the juvenile offender act was established. this legislation came about as a result of public outcry surrounding the case of willie bosket, a 15-year-old who murdered two strangers in the subway. in this case, the defendant was adjudicated as a juvenile offender and was sentenced to a juvenile detention facility for five years (lazarow, 2012). the public felt that the sentence was too light and that willie bosket t © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. deserved to be tried as an adult. the juvenile offender act created a new category of juvenile offenders, defined as individuals between the ages of 13 and 15 who were charged with a crime that the legislature considered sufficiently serious enough as to require the child’s prosecution in criminal court. as a result, the potential consequences for such crimes increased dramatically and placed more emphasis on punitive measures rather than treatment (lazarow, 2012). current policies the new york penal code dictates that 16 is the age upon which an individual may be held criminally responsible (n.y penal law § 30.00(1)). as a result of this legislation, individuals over the age of 16 can be prosecuted as adults in criminal court, but receive youthful offender status (n.y. penal law § 30.00(1)). youthful offenders, according to this characterization, will be deemed criminally responsible for their behavior, unlike their juvenile offender counterparts, who fall under the jurisdiction of family court. according to the juvenile offender act, individuals between the ages of 13 and 15 will be characterized as juvenile offenders (ny criminal procedure law § 1.20(42)). these youth are deemed criminally responsible due to the severity of the act they are charged with committing. this category applies to youth charged with committing any of the violent felonies listed in new york penal law (n.y. penal law § 10.00(18)). cases involving juvenile offenders in new york city are prosecuted by new york city law department’s corporation counsel, but sentences are served through the administration of children’s services (ny penal law § 70.05.) under new york penal law, individuals between the ages of 16 and 18 will be considered criminally responsible and will be prosecuted by the district attorney in the adult criminal justice system. if convicted, these individuals serve their sentences in adult correctional facilities. children between the ages of 16 and 18 who are convicted in adult criminal court may be eligible for the court to grant youthful offender status, which subsequently replaces a criminal conviction and provides a lesser sentence while sealing the individual’s criminal record (ny criminal procedure law § 720.10.) youthful offender status is only available to individuals who have not committed class ai or aii felonies and do not have any previous felonies (ny criminal procedure law § 720.10 (2&3)). raise the age adolescents—as individuals who are growing and forming identities, adapting to various stimuli, and in a precarious stage of brain development—can be considered a vulnerable population (lambie & randell, 2012). in addition to the already difficult processes of adolescent development, the psychosocial factors of incarceration further hinder a healthy transition into adulthood. brain development of adolescents adolescents are distinguishable from adults in numerous ways. they are more likely to be influenced by mass media and peers (lambie & randell, 2012), display relaxed attitudes towards risk, maintain a decreased ability to plan for the future, and have a lower capacity for self-management. it appears more difficult for adolescents to manage stressors and expectations with the same ability as their adult counterparts due to marked differences in emotional, physical, and psychological maturity (steinberg & haskins, 2008). it is difficult for adolescents to regulate mood, impulse, and behavior (lambie & randell, 2012). the adolescent brain is in a constant period of maturation. as the individual grows older, the brain progresses in a series of dramatic changes. the structure and the function of the brain in adolescence may affect the way that an individual can process and react to information and various stimuli (state trends, 2010). the region of the brain most affected by this developmental transition is the one that controls goal-oriented thinking, rational decision making, long-term planning, impulse control, insight, and judgment. without these crucial aspects of © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. the brain functioning at full capacity, adolescents may experience difficulty understanding the repercussions of their actions. anatomical changes in the brain occur throughout adolescent development and often peak in early-tomiddle adulthood. these changes often bring on the creation or improvement of self-regulation, reward processing, processing of social information, lowered levels of sensation seeking and impulsivity, better anticipation of future consequences, and development of psychosocial maturity (lambie & randell, 2012). adolescents are more likely to seek immediate gratification in the form of social rewards and peer approval. lambie and randell (2012) believe that this reality can heavily influence behavior and that delinquency may be a direct consequence of this phenomenon. the inability to clearly regulate impulse and understand consequences are clear demonstrations of childlike thinking (dahl, 2004), making it ineffective for such individuals to be treated as adults by the criminal justice system (rothchild, 2013). when considering adolescent brain development, dahl highlights numerous changes related to puberty that affect the brain and development. as an example, a pubertal hormone called the beta-estrogen receptor is linked to mechanisms prompting behavioral and emotional change. in a period of flux and change, adolescents may experience internal confusion. dahl labels this phenomenon as internal “dys-synchrony,” which is characterized by a process of internal confusion and external acting-out of behavioral outbursts (dahl, 2004). as such, adolescents are more likely than any other age group to engage in risky behaviors. this may be attributed to the emphasis put on exploration and experimentation during adolescence (hayford & furstenberg, 2008). the delay in development of the beta-estrogen receptor makes adolescents more likely to experience a disconnect between emotional regulation and external acting-out of delinquent behaviors (dahl, 2004). impact of incarceration on adolescent development excessive punishment of adolescents may, in fact, increase the likelihood of adolescents further committing crime (bonnie et al., 2013). relevant literature suggests that three conditions are particularly salient for healthy psychological development: the presence of a parental figure who is involved with the adolescent and concerned with their wellbeing, the inclusion of a pro-social peer group that values and models pro-social behavior and academic success, and activities that enable the adolescent to develop critical thinking and autonomous decision making (bonnie, johnson, chemers & schuck, 2013). prison limits the conditions that facilitate healthy psychological development. incarceration generates a major stress response in the brain. adolescents face this situation with the added disadvantage of immaturity, which may make it harder to cope with stressors they encounter in the prison system (shulman & caufman, 2011). incarceration separates adolescent offenders from their social networks family, friends, and community at a crucial time in which adolescents perceive their relationships to be of major importance. this loss may compound the social isolation of being incarcerated, putting the adolescent at risk for psychological disorders or stress (shulman & caufman, 2011). youth incarcerated in adult facilities face atypical and highly stressful experiences that heavily affect future outcomes of emotional development, and often result in responses of trauma (shulman & caufman, 2011). juvenile offenders may be vulnerable to adverse consequences such as deeply immersing themselves in the criminal justice system as they move away from any pro-social involvement in society (lambie & randell, 2013). when adolescents are housed in adult prisons, they face a substantially larger risk of physical and sexual abuse. in order to prevent these dangerous situations, adolescents have been segregated or confined in solitary units for their own safety, which, in turn, can foster or exacerbate mental health problems (state trends, 2010). studies have shown that the suicide rate of juvenile offenders in adult prisons is 7.7 times higher than that of their counterparts serving sentences in juvenile detention centers (justice policy institute, n.d). © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. psychosocial factors sentencing structure does not take into account the psychosocial factors that may have brought individuals into the criminal justice system in the first place. social structures such as low-income neighborhoods and schools that do not promote high levels of engagement enable risk-taking behaviors to become the norm during adolescence. the majority of youth offenders come from backgrounds of family dysfunction, exposure to violence, and low socio-economic status (lambie & randell, 2012). measurable disproportionality has been observed for youth across racial boundaries (bonnie et al., 2013). in 2008, the criminal processing for cases involving black youth was significantly higher (8%) than for white youth. for drug cases, black youth were 16% more likely to be formally processed than white youth. twenty-five percent of black youth were detained in 2008 in comparison with 19% of white youth. in all cases, those involving black youth were 16% more likely to be detained out of home for minor drug offenses than white offenders of the same crime (bonnie et al., 2013). juvenile justice has not been able to account for sociological contexts in its attempt to be egalitarian. because of policies like stop and frisk, certain groups of adolescents are continuously over-represented and stigmatized. weaknesses of the juvenile offender act there is no evidence that confinement of juvenile offenders in adult prisons or juvenile correctional institutions reduces the likelihood of subsequent reoffending (bonnie et al., 2013). it is necessary to focus efforts on preventive services and use mental health counseling as a rehabilitative approach to avoid longstanding punitive consequences for an individual’s future (saltaris, 2001). inappropriate interventions the primary cornerstone of juvenile justice legislation is accountability. legislation was created for juvenile offenders to be held responsible for their actions and to become accountable for the crimes they have been charged with committing (bonnie et al., 2013). the mechanisms for juvenile justice too closely mirror those of adult criminal justice through the use of lengthy confinement, condemnation, and punishment (bonnie et al., 2013). procedures specifically designed to hold adolescents accountable should promote positive legal socialization, reinforce prosocial identity development, and facilitate compliance with laws. in contrast, the current practice of harsh interventions facilitates negative interactions between the youth population and the criminal justice system. these negative interactions can foster discontent and undermine respect for legal authority as well as reinforce social dissatisfaction (bonnie et al., 2013). an inquest by the department of justice cited the heavy reliance on using restraints on youth with mental health issues, poor diagnosis of mental health conditions, poor administration of medication and treatment plans, and poor chemical-dependency programming for youth suffering from substance abuse issues (bohland, 2011). the oversight in interventions has led to prolonged mental health concerns in juvenile offenders in addition to exacerbated levels of substance abuse upon return to the community (bohland, 2011). lambie and randell (2012) cite a study in which they found that up to 95% of detained youth have at least one dsm iv diagnosis, with the possibility of co-existing or co-morbid mental health problems. rates of substance abuse within this population are extreme, affecting approximately 70% of juvenile offenders. juvenile offenders also have multiple special education needs, as many are evaluated below their chronological age level in terms of reading comprehension, writing, and cognitive abilities (lambie & randell, 2012). these deficiencies, when compounded by detainment and incarceration, may lead to major deficits in functioning as the adolescent develops into adulthood. the implications of this may lead to impairments in employment, impairments in attaining higher education, and more reliance on criminal activity (lambie & randell, 2012). lack of subjectivity © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. regular cultural forces in society make the process of coming into the criminal justice system increasingly subjective, which subsequently makes objectivity in the courtroom impossible. there is no single risk-marker strongly associated with serious delinquency. risks are generated across developmental stages and differ in social and geographical contexts. programs are more likely to have positive impacts when using evidencebased treatment models and using multi-faceted, community-based interventions (bonnie et al., 2013). juvenile justice depends on state law and local practices, and the availability of certain interventions depends on the adolescent’s geographic location. more diversionary programs may be available in affluent suburban areas than in communities with lower socio-economic status, which may be the source of discrepancies in recidivism (bonnie et al., 2013). collateral consequences criminal records mark adolescents for the rest of their lives and inhibit success in the academic and career realms. these limitations increase the likelihood of becoming a career criminal (steinberg & haskins, 2008). when taking this factor into account, it is necessary to limit the possibility of re-offending, and doing so would likely include limiting sentences of incarceration of juveniles in adult prisons (steinberg, 2012). the consequences of prosecuting and sentencing youth in the adult system follow the youth throughout their development. adult conviction limits a youth’s opportunity for employment for the rest of their life due the release of adult convictions to public record (state trends, 2010). the role of social work when considering the implications of the criminal justice system on juvenile offenders, it is necessary to also consider the implications for social work practice. theory provides an important framework for the necessity of raising the age of qualification for juvenile offenders. social workers should consider the type of interventions that promote the best learning and promote healthy development for adolescents that come in contact with the criminal justice system. the use of power to change behavior prison is a prime example of an institution that fosters coercive power between law enforcement and offender. coercive power relates to the relationship between two people, in which the less powerful individual must submit to the more powerful person in order to avoid punishment (dr. ronald feldman, ph d., class lecture 2014). adolescents are least receptive to coercive power. this type of punishment, commonly found in juvenile justice facilities and adult prisons, often fosters contempt and does not promote motivation towards positive change (dr. ronald feldman, ph d., class lecture 2014). adolescents are most affected by expert and referent power (dr. ronald feldman, ph.d., class lecture 2014). these types of power, respectively, deal with the subject wanting to gain the knowledge of the person in the powerful position and the subject wanting to emulate the powerful person’s behavior. these types of power relationships could be more readily accessed within a community setting. these environments would be more likely to have a focus around rehabilitation and education rather than crime and punishment, thus making referent power the more likely type of relationship between offender and educator. this turbulent relationship between educator and offender has been researched in different cases throughout the united states. vinter and janowitz (1959) studied correctional facilities in michigan. in their research, they determined that the facility with the worst overall response from juvenile inmates was “dick,” a facility that was the most restrictive with prison cells (dr. ronald feldman, ph d., class lecture 2014). respondents voted that “dick” had the highest rates of disempowerment of inmates and lowest rates of focus on positive change. at the opposite end of the spectrum was “inland,” a facility focused on rehabilitation. “inland” was rated as having highest levels of inmate satisfaction and had the highest number of respondents who reported being helped (dr. ronald feldman, ph d., class lecture 2014). © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. social learning theory social learning theory is important when considering how to develop pro-social behaviors as a means to reduce recidivism and subsequently decrease crime rates. this theory contends that an individual’s behavior is heavily influenced by the person’s environment and is based upon the following principles (dr. ronald feldman, ph d., class lecture 2014): expectations for behavior are shaped by the individual environment principles that govern learning of pro-social behaviors are the same as those for learning anti-social behaviors learning new behaviors depends on modeling, identification, and imitation the goal of juvenile justice legislation is to address dysfunctional behaviors and prevent them from reoccurring. a highly restrictive environment such as an adult prison, however, would inevitably lead to difficulty for adolescents in accessing positive modeling from pro-social peers, or authoritative figures. an environment like the aforementioned “dick” or “inland” would have an important effect on an adolescent’s development. the call for reform in order to move juvenile justice in a positive direction, massive and widespread reform must be undertaken. a change in legislation would be required to raise the age at which a 16-year-old offender could be prosecuted in adult criminal court. research dictates that effective treatments must be focused on the principles of risk, need, and responsibility (lambie & randell, 2012). interventions and programming should be spearheaded through community-based programs that focus on the use of evidence-based treatment options that facilitate rehabilitative modalities and social learning (lambie & randell, 2012). the center for court innovation in new york city is currently researching and undertaking numerous opportunities for juvenile offenders to seek alternatives to the traditional criminal justice model (barbieri, 2014). their innovative youth justice framework provides an important outline for the legislation and overarching reform that needs to take place in juvenile justice today. some examples of their efforts include: the alternative to detention program, which uses mentorship, support, and supervision to ensure that the adolescent can remain in the community while awaiting court decision on charges; the adolescent diversion program, which works with legal systems to create non-criminal dispositions so that adolescents can avoid permanent criminal records that can impair the re-entry into society from being successful and productive; and the aim program, which provides young people on probation with supportive programming that works on healing trauma, providing support, and providing advocacy for youth as they return to their communities (barbieri, 2014). if the true goals of the juvenile justice system included rehabilitation, then treatment modalities and intensity should account for the risk that the offender poses to society, the societal stigma associated with their crime, and the various difficulties that individual will face upon returning to the community. it is also necessary to facilitate effective use of resources and success in addressing target treatments. in order to do so, the offender’s learning style should be considered (lambie & randell, 2012). taking into account the delays in adolescent brain development, the structural differences between adolescents and adults, and the role of intergenerational trauma, it simply makes sense to shift the focus to preventing justice system involvement (barbieri, 2014). given the low age of legal responsibility in new york compounded with the stringent criteria to qualify for juvenile offender status, the majority of individuals are deprived of the opportunity to take advantage of evidence-based programming and treatment (carriero, 2012). in order to affect change for future generations, decrease recidivism, and foster safe communities, it is crucial to amend the current juvenile offender act. amendments should include the policy that all juvenile cases, without exception, should be seen in family © 2015 spivack. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. court. this amendment would ensure that all adolescent offenders are treated equally under protection of the law, and as a result may not face harsher punishment due to widespread oppression, discrimination, or bias. the age for juvenile offender adjudication must be raised to the minimum age of 18. finally, services must be in place to provide adolescents with necessary treatment, including programming such as counseling, restorative justice, and education in order to prevent offenses from reoccurring. references barbieri, r. (2014, january 1). youth justice programs. retrieved january 27, 2015, from http://www.courtinnovation.org/sites/default/files/documents/principles of youth justice programming.pdf bohland, c. (2011). no longer a child: juvenile incarceration in america. capital university law review 39(1),193-230 . bonnie, r. j., johnson, r. l., chemers, b. m., & schuck, j. (eds.). (2013). reforming juvenile justice: a developmental approach. national academies press. corriero, m. (2012). judging children as children: reclaiming new york’s progressive tradition. new york law school law review, 56, 1413-1430. dahl, r. (2004). adolescent brain development: a period of vulnerabilities and oppurtunities. annals new york academy of science 1021, 1-24. dr. ronald feldman, ph d., class lecture 2014. hayford, s., & furstenberg, f. (2008). delayed adulthood, delayed desistance? trends in age distribution of problem behaviors. society for research on adolescence 18(2), 285-304. lambie, i., & randell, i. (2012). the impact of incarceration on juvenile offenders. clinical psychology review 33, 449-456. lazarow, k. (2012). the continued viability of new york’s juvenile offender act in light of recent national developments. new york law school review, 57 (1) 595-635. the penal code of the state of new york (2014). new york state law. rothchild, j. (2013). childhood without life, life without childhood: theological and legal critiques of current juvenile justice policies. journal of the society of christian ethics, 33(1), 83-103. saltaris, c. (2001). psychopathy in juvenile offenders can temperament and attachment be considered as robust developmental precursors? clinical psychology review, 22(1), 729-752. shulman, e., & caufman, e. (2011). coping while incarcerated: a study of male juvenile offenders. journal of research on adolescence, 214(4), 818-826. sobie, m. (2010). pity the child: the age of delinquency in new york. pace law review, 30(3), 1-29. campaign for youth justice. (2010). state trends: legislative victories from 2005-2010 removing youth from the adult criminal justice system. retrieved november 1, 2014, from http://www.campaignforyouthjustice.org/documents/cfyj_state_trends_report.pdf steinberg, l., & haskins, r. (2008). keeping adolescents out of prison. the future of children, 1-7. retrieved november 1, 2014, from http://www.campaignforyouthjustice.org/documents/nr_keepingadolescents.pdf the risks juveniles face when they are incarcerated with adults. (n.d.). justice policy institute. retrieved november 1, 2014, from http://www.justicepolicy.org/images/upload/97-02_rep_riskjuvenilesface_jj.pdf vries, a., & liem, m. (2011). recidivism of juvenile homicide offenders. behavioral sciences and the law, 29(1), 483-498. laura pearl spivack received her bachelor of social work degree from mcgill university, and will be graduating from columbia university in may 2015 with a master of science in social work. she is in the advanced generalist practice and programming track with a concentration in contemporary social issues. laura pearl is currently engaging in an internship at brooklyn defender services, working with individuals and families affected by the family and criminal justice systems. laura pearl continues to be passionate about the intersection between law and social work and how specific social work theories can impact the application of legislation.   2018-final.pdf 56 | columbia social work review, vol. ix proposals for improving the reintegration process of american soldiers edward chan studies have consistently found high prevalence rates of veterans who experience difficulties reintegrating into civilian life, ranging between 50-61%. this paper assesses the current limitations of america’s reintegration methods for military veterans. commonly identified issues include difficulty finding employment, challenges with readjusting to daily life with family members, and stigma associated with seeking mental health services in military culture. this paper explores three proposals for how social workers can address these limitations in a way that would significantly improve veterans’ reintegration processes. the first proposal aims to improve employment rates by creating a market economy exclusively for retiring service members. the second proposal aims to improve service members’ ability to reintegrate with their family members by placing a stronger emphasis on this domain in the transition assistance program, a mandatory program that all retiring service members must undergo before being discharged. the third proposal aims to increase veterans’ use of mental health services by promoting the use of these services as early on as boot camp. by implementing these proposals, the united states could significantly reduce the prevalence rate of veterans who have difficulty reintegrating. introduction “people are going to find this weird, but i miss iraq every single day.” -nicholas johnson nicholas johnson was a proud former specialist deployed to iraq from 2006 until 2007. today, he suffers from a broken back, “can’t get a good job,” and can’t “give [his] kid the life he deserves” (flournoy, 2014). scenarios like johnson’s occur far too often. a study conducted by university of southern california found that 61% of veterans have trouble adjusting to civilian life (castro, kintzle, & hassan, 2015). another study conducted by the washington post and kaiser family foundation found that 50% of iraq and afghanistan veterans polled had difficulty transitioning back into civilian life (flournoy, 2014). in addition, the united states department of veteran affairs (va) (2016) “estimates that post traumatic stress disorder (ptsd) afflicted 31% of vietnam veterans.” research is consistent with regard to the high prevalence of reintegration issues faced by veterans. columbia social work review, vol. ix | 57 edward chan this article will propose ways to improve current strategies social workers and the military use to reintegrate service members into civilian life. more specifically, empirical research will be used to support proposals aimed at reducing both the severity and prevalence of issues accompanying reintegration. with such staggering prevalence rates, it is imperative that we address the factors that contribute to reintegration issues. factors that contribute to veterans’ reintegration are complicated by a variety of issues. upon reintegrating, a service member is essentially changing not only his or her occupation, but also his or her daily routine, purpose in life, responsibilities, and much more almost overnight (wegner, 2011). social work initiatives combined with the military’s involvement can substantially facilitate a smoother transition. this article will provide three proposals for social work initiatives that aim to improve the reintegration process of american soldiers. the reintegration process is complicated by many risk factors, such as the maladaptive use of alcohol and drugs (wegner, 2011). due to these risk factors, veterans are more at risk than the civilian population of severe legal and mental health consequences, ranging from incarceration to homelessness to suicide (wegner, 2011). one study found that 96% of 754 veterans surveyed “expressed interest in services to re-adjust to civilian life” (sayer, noorbaloochi, frazier, carson, gravely, & murdoch, 2010, p. 589). with such a high demand for additional assistance from reintegration resources, it is imperative to evaluate the military’s current reintegration process and its limitations. historical development in order to understand the current limitations of the military reintegration processes, it is important to examine their historical development. the american military reintegration process has roots extending back to the civil war (rubin, weiss, & coll, 2013). however, mental health has only recently been considered an important part of reintegration efforts. in 1918, the red cross employed the first psychiatric social worker, but it wasn’t until 1942 when the military “allowed service members to work as psychiatric social workers” (rubin, weiss, & coll, 2013, p.5). this slow historic progress illustrates the delayed infusion of mental health services into the military. cultural stigmas within the military that associate seeking mental health services with weakness further exacerbate the issue (sharp et al., 2015). a meta-analysis found that a staggering 42.9% of service members surveyed about seeking mental “due to these risk factors, veterans are more at risk than the civilian population of severe legal and mental health consequences, ranging from incarceration to homelessness to suicide (wegner, 2011).” 58 | columbia social work review, vol. ix improving the reintegration process of american soldiers health assistance did not do so because they “might be seen as weak” (sharp et al., 2015, p.144). while progress in combating this stigma is slow, modern advances, such as a push to hire more mental health professionals and train them to treat common issues that veterans face (e.g., traumatic brain injury and ptsd), have a greater impact on infusing mental health care into reintegration services (munsey, 2007). another significant factor that has historically affected reintegration is the relationship between veterans and their family members (rubin, weiss, & coll, 2013). the military has come to realize the importance of maintaining a healthy family dynamic for service members, as it directly affects both soldiers’ mission performance and their reintegration process (rubin, weiss, & coll, 2013). while it is understood that families play a vital role in every service member’s life, society has long failed to acknowledge the lasting impacts of service on family members. service members’ deaths and injuries can have lasting emotional and financial consequences for families. early organizations launched initiatives towards improving family dynamics. the american red cross, empowered by social workers, strongly pushed for family care services as early as 1917. during world war ii, there was an expansion of military family programs, including the emergency maternal infant care program, due to the large number of young, self-supporting women serving in the military. the air force aid society, a u.s. air force operated charity that provides services such as loans and base community programs for service members and their families, was established in 1942 (rubin, weiss, & coll, 2013). family care has grown to play an important role in military reintegration initiatives today (albano, 1994). throughout the history of the united states military, mental health services and family care services have developed into important aspects of the reintegration process for service members. implications for social workers social workers who serve veterans have the potential to further enhance reintegration methods by improving upon the military’s current mental health and family care services. from a clinical perspective, social workers have the skill set to administer a wide range of therapeutic treatments that combat minor to severe mental health issues. issues facing service members can range from mild depression to severe ptsd (national veterans foundation, 2016). in addition, social workers are trained to assess clients from a multifaceted perspective, thus creating a holistic “while it is understood that families play a vital role in every service member’s life, society has long failed to acknowledge the lasting impacts of service on family members.” columbia social work review, vol. ix | 59 edward chan picture of the micro and macro factors that impact an individual, such as family dynamics (micro) or governmental policies (macro). furthermore, social workers are proficient in advocating for the services veterans desire, deserve, and require. social workers in the military should play a critical role in improving current reintegration methods as they are trained to advocate on behalf of their clients and clinically treat their clients’ internal and external stressors. the current american reintegration process in order to examine how social workers and the military can have a positive influence on the veteran reintegration process, it is necessary to examine the military’s current initiatives and their shortcomings. there are a number of military-operated transition programs—including the transition assistance program (tap), the disabled transition assistance program (dtap), wounded warriors, and the system care department— within the va (koeman, 2008). tap and dtap take a proactive approach by providing veterans with “employment assistance and training information within 180 days of separation from the military service” (rubin, weiss, & coll, 2013, p. 282). these programs offer benefits such as “access to family support services, veteran health care benefits, home loans, home care, vocational rehabilitation, and assistance with job searching” (rubin, weiss, & coll, 2013, p. 283). these programs are designed to be accessible and effective in reintegrating all separating service members. the veterans opportunity to work and hire heroes act of 2011 (vow act) mandates that all retiring service members must attend the tap training so that they are aware of these readily available resources (guina, 2012). furthermore, the department of defense created a virtual tap curriculum online so that this compulsory reintegration assistance program can be more accessible. tap’s curriculum consists of a five-day workshop, with optional additional days depending on personal interests. the first three days are dedicated to “going over personal finances, family adjustments, va benefits, and mentorship.” the following two days are dedicated to job preparation services ( department of labor, 2002). in addition to the tap program, additional factors for successful reintegration of military members include the use of obligatory pre and post psychological screenings and information sessions (rubin, weiss, & coll, 2013). higher education is also made more accessible by the post-9/11 gi bill, which provides “substantial financial packets for veterans to attend college” (rubin, weiss, & coll, 2013, p. 289). these resources, coupled with “in order to examine how social workers and the military can have a positive influence on the veteran reintegration process, it is necessary to examine the military’s current initiatives and their shortcomings.” 60 | columbia social work review, vol. ix improving the reintegration process of american soldiers the mandatory policy safeguards, are some of the major ways in which the military currently attempts to successfully reintegrate veterans back into civilian life. limitations while the resources offered by the military help veterans successfully adjust to civilian life, there are still many limitations and complications that limit the military’s role in reintegration. more specifically, as time elapses, the family, service member, and the surrounding environment have often drastically changed from the way they functioned prior to military service (marek et al., 2016). feelings such as resentment, frustration, and indifference can decrease a veteran’s desire to effectively reintegrate into civilian life (wegner, 2011). the abundance of resources provided by the military are useless if individuals are so overwhelmed that they do not take advantage of these opportunities. the military’s ability to successfully reintegrate service members is limited and complicated by the individual’s willingness to accept help. another major limitation concerns employment. there are many ways employers can circumvent laws that prohibit discrimination against physical and mental disabilities (flournoy, 2014). while being interviewed by the washington post, nicholas johnson stated, “to fill out a [ job] application i have to be upfront and say i have a torn up back” (flournoy, 2014). despite his transferable leadership skills gained abroad, the factories in topeka continue to deny him the opportunity to work (flournoy, 2014). discrimination against physical disabilities is just one factor that inhibits veterans’ ability to effectively transition back to civilian life. mental disabilities acquired in the course of duty are the invisible wounds that society does not see, acknowledge, or adequately account for (flournoy, 2014). according to johnson, “between the pain injury from his back and, the god knows, the torment from ptsd, you don’t necessarily look the part, but you still suffer and your life is changed” (flournoy, 2014). johnson’s story is only one of many examples in which, despite the numerous employment and reintegration resources available, veterans who have put their life on the line for freedom are still denied access to fair employment opportunities. proposals to improve the american reintegration process now that some of the most pressing issues with the nation’s current reintegration programs have been identified, the following section will describe three proposals targeting a more effective reintegration process in the following domains: a veteran’s career, family life, and mental health. throughout these proposals, the specific roles social workers would play in columbia social work review, vol. ix | 61 edward chan each scenario will be highlighted. these three domains have been selected because they are areas in which current reintegration methods do not adequately provide assistance. a proposal for a veteran exclusive market economy the first proposal concerns how to improve veterans’ ability to find employment after retiring from the military. for many veterans, managing physical and mental injuries, experiencing rapid cultural changes, and going from an active duty service membership to being unemployed can be very difficult (rubin, weiss, & coll, 2013). the military should create a large number of jobs in a variety of fields exclusively for veterans. while the vow act does allow preferential hiring for veterans in federal positions, there are no government initiatives aimed at hiring or reserving positions only for veterans (guina, 2012). in addition, a significant limitation to this act’s preferential hiring process concerns the fact that many federal positions are already highly sought after by the civilian population. in this proposal to create a veteran market economy, social workers would serve as advocates and supportive resources for veterans in both seeking and maintaining a job. employment opportunities could range from low-skilled jobs to high-skilled jobs, physically demanding to nonphysically demanding, etc. by creating a marketplace hiring only previous military personnel, career opportunities would be guaranteed and culture shock would be reduced, as all coworkers would also be veterans. physical and mental impairments could be properly addressed by social workers providing assistance. perhaps the biggest disadvantage of this proposal is that it would require an extreme initial overhaul in military budgeting. furthermore, institutions that would house these jobs would have to be developed. however, if the government can spend $718 billion on “defense and national securities initiatives” in 2011 alone, the military should at least be able to spend an equal amount on ensuring that veterans have a sustainable job following their service (plumer, 2013). in addition to fulfilling moral obligations, this new marketplace would eventually generate substantial revenue for the american economy as a result of a larger number of veterans contributing to the gross domestic product. social workers would play vital roles in this initiative, as advocacy and support services are critical components of the plan’s success. 62 | columbia social work review, vol. ix improving the reintegration process of american soldiers a proposal for emphasizing family reintegration in the tap program the next proposal attempts to facilitate the reintegration of veterans in family life. as mentioned earlier, tap does provide family support services (rubin, weiss, & coll, 2013). however, word “family” is not mentioned in the entire tap manual’s table of contexts (department of labor, 2002). reintegrating service members into their families deserves far more attention than it currently receives. tap’s mandatory training should be redesigned by social workers to help veterans develop critical skills that would assist in creating healthier relationships with their families. these skills include, but are not limited to, techniques aimed at improving coping mechanisms, stress management, and other emotional and behavioral based assets. social workers would also play a vital role in personally helping veterans develop these skills. in addition, the tap program should be extended to be longer than five days in order to provide veterans with a greater amount of time to develop these critical skills. extending the duration of this program would also allow veterans to receive continuous support in family life, as well as other domains. disadvantages of this proposal include veterans possibly not wanting to undergo a longer mandatory program, additional costs for ongoing treatment, and a huge design overhaul of the tap initiative. despite these disadvantages, these program adjustments would place a more appropriate focus on preparing veterans to reintegrate with their loved ones while obtaining ongoing support and working towards selfimprovement. a proposal for destigmatizing mental health the last proposal attempts to significantly reduce mental health injuries sustained from service, thus improving upon veterans’ overall reintegration process. the phrase “mental health,” or any synonym, is also not mentioned in the table of contents section of the tap manual (department of labor, 2002). the tap manual should be revised by social workers to incorporate mental health as an integral part of reintegration service. in order to reduce mental health issues during reintegration, it is necessary to change the way the military has long stigmatized mental health (acosta et al., 2014; kime, 2015). while the stigmas surrounding mental health issues are decreasing, the rates at which barriers are being broken down are far too slow (kime, 2015). strategies aimed at reducing mental health stigma “strategies aimed at reducing mental health stigma must begin during a service members’ earliest phase of training (i.e., boot camp), thus destigmatizing mental health issues from the beginning of a service member’s career.” columbia social work review, vol. ix | 63 edward chan must begin during a service members’ earliest phase of training (i.e., boot camp), thus destigmatizing mental health issues from the beginning of a service member’s career. it is hypothesized that an introductory program that emphasizes the importance and acceptability of mental health support would decrease the development of mental health issues during and following active duty services. challenges facing this proposal include the deeply rooted negative associations mental health has in the military and securing additional funding for these programs (sharp et al., 2015). nevertheless, no price exceeds the importance of maximizing service members’ mental health during and following their service. conclusion proposals for addressing the needs of veterans have been articulated and examined for strengths and weaknesses, and the roles of social workers in these proposals have been thoroughly discussed. based on this assessment and supporting literature, the advantages of these proposals appear to outweigh the disadvantages. these proposals possess the potential to have a significant impact on service members’ reintegration processes. today, nicholas johnson continues to work at an unfulfilling job, suffer from severe ptsd, and experience difficulties within his family dynamic (flournoy, 2014). he and many other veterans like him deserve far better than the existing reintegration resources. the proposals discussed in this article would begin to address the current service limitations that affect veterans who struggle with reintegration. through a market economy that exclusively hires veterans, veterans would be able to more seamlessly find suitable employment following discharge. through a redesign of the tap program, veterans will be better prepared to reacclimate to civilian life, particularly healthy family functioning. through efforts to destigmatize mental health within the military community, service members and veterans would experience increased quality of life. in conclusion, these proposals have the potential to improve veterans’ quality of life by creating appropriate employment options, improving care for veterans and their families, and beginning to create a military culture that values mental health as much as physical health. references acosta, j., becker, a., cerully, j., fisher, m., martin, l., vardavas, r., . . . schell, t. (2014). mental health stigma in the military (pp.7-14) santa monica, ca: rand corporation. albano, s. (1994). military recognition of family concerns: revolutionary war to 1993. armed forces & society, 20(2), 283-302. castro, c., kintzle, s., & hassan, a. (2014). the state of the american veteran. usc school of social work. doi:10.18411/a-2017-023 64 | columbia social work review, vol. ix improving the reintegration process of american soldiers department of labor. (2002). tap manual. retrieved march 3, 2018, from https://www.dol.gov/vets/programs/tap/tapmanualmar06.pdf flournoy, m. a. (2014, april 02). we aren’t doing enough to help veterans transition to civilian life. retrieved march 3, 2018, from https://www. washingtonpost.com/opinions/we-arent-doing-enough-to-help-veteranstransition-to-civilian-life/2014/04/02/d43189e2-b52a-11e3-b89920667de76985_story.html?utm_term=.d0328047f03e frere, e. (2015). 61 percent of veterans have difficulty adjusting to life after war. retrieved november 16, 2016, from http://abc7.com/society/61-percent-ofveterans have-difficulty-adjusting-to-life-after-war/525846 guina, r. (2012). vow to hire heroes act of 2011 gi bill for unemployed veterans. retrieved march 20, 2018, from https://themilitarywallet.com/ vow-to-hire-heroes-act-gi-bill-for-unemployed-veterans kime, p. (2015). panel: stigma obstacle mental health care. retrieved december 8, 2016, from http://www.militarytimes.com/story/military/benefits/health care/2015/09/10/panelstigma-obstacle-mental-health-care/72013618/ /.latest_citation_text koeman, b. (2008). military veterans ets transition resources. retrieved january 28, 2018, from http://www.operationwearehere.com/ets.html marek, l., hollingsworth, g., d’aniello, c., o’rourke, k., donna-jean, b., moore, l., . . . wiles, b. (2012). returning home: what we know about the reintegration of deployed service members into their families and communities. retrieved march 3, 2018, from https://www.ncfr.org/ncfr-report/focus/militaryfamilies/returning-home munsey, c. (2007). transforming military mental health. retrieved march 3, 2018, from https://www.drdarienzo.com/wp-content/uploads/2011/12/military. pdf national veterans foundation. (2016, september 11). veteran mental health: facts and stats that need to be addressed. retrieved january 27, 2018, from https://nvf.org/veteran-mental-health-factsstatistics plumer, b. (2013, january 07). america’s staggering defense budget, in charts. the washington post. rubin, a., weiss, e. l., & coll, j. e. (2013). handbook of military social work. hoboken, nj: john wiley & sons. sayer, n., noorbaloochi, s., frazier, p., carlson, k., gravely, a., & murdoch, m. (2010). reintegration problems and treatment interests among iraq and afghanistan combat veterans receiving va medical care. psychiatric services, 61(6), 589-597. doi:10.1176/appi.ps.61.6.589 sayer, n., noorbaloochi, s., frazier, p., carlson, k., gravely, a., & murdoch, m. (2010). reintegration problems and treatment interests among iraq and afghanistan combat veterans receiving va medical care. american psychiatric association, 61(6), 589-597. retrieved march 20, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/20513682. sharp, m., fear, n. t., rona, r. j., wessely, s., greenberg, n., jones, n., & goodwin, l. (2015). stigma as a barrier to seeking health care among military personnel with mental health problems. epidemiologic reviews, 37(1), 144-162. doi:10.1093/epirev/mxu012 u.s. department of veterans affairs. (2013, august 15). ptsd: national center for ptsd. retrieved march 3, 2018, from https://www.ptsd.va.gov columbia social work review, vol. ix | 65 edward chan united states census bureau. (2015). fff: veteran’s day 2015. retrieved march 3, 2018, from https://www.census.gov wegner, b. (2011). the difficult reintegration of soldiers to society and family after deployment. essai, 9(41), 1-6. retrieved november 17, 2016. edward chan earned a b.s. in applied psychology with a minor in chinese from new york university in 2016. while completing his undergraduate degree, he worked for the mayor’s office to combat domestic violence, the door, child mind institute, upward bound, and rikers island single stop. edward’s previous work experience led him to pursue a masters of science in social work from the columbia university school of social work. while completing his degree, edward has gained experience interning at gouverneur hospital and new york state psychiatric institute. his insatiable passion for helping people has allowed him the opportunity to serve a diverse population ranging from children with anxiety disorders to incarcerated persons. journal final revised margins.indd a brief review of issues in ptsd research following the september 11 tragedies the attacks on the world trade center (wtc) on september 11, 2001 resulted in the largest loss of life due to terrorism that the united states has ever encountered. terrorism often results in pronounced numbers of post traumatic stress disorder (ptsd) cases. following the september 11 attacks, many research studies reported increases in ptsd, post traumatic stress symptoms (ptss), and stress reactions; however, the inconsistency in the methods used to gather and analyze data poses problems in comparing and interpreting these results. a brief review of the methods used in trauma-related research following september 11 is presented. guidelines for interpreting this research are also presented. the attacks on the world trade center (wtc) on september 11, 2001 were devastating, killing 2,797 people (american red cross, 2003). concerns over widespread trauma both nationally and internationally have been at the forefront of the mental health agenda since that time. ongoing research regarding the shortand long-term effects of traumatic events is crucial for evidence-based social work practice and the provision of mental health services. however, a critical analysis of the methodologies used in research studies is needed before conclusions regarding the prevalence of post traumatic stress disorder (ptsd) or other mental health outcomes can be made. currently no common methodology for studying reactions to wide-scale disasters exists, making it difficult to compare studies and establish the validity of research results (north & pfefferbaum, 2002). in this paper, the use and interpretation of trauma questionnaires as well as the terminology used in describing ptsd symptomatology will be explored so that researchers and clinicians alike may be more informed consumers of trauma-related literature. social workers, other mental health professionals, and researchers need to be able to differentially identify and properly diagnose ptsd. in the first two weeks of the world trade center health registry, more than 10,000 people worldwide enrolled for assessment through a health survey gauging the mental and physical health problems resulting from the september 11 attacks (new york city department of health and mental hygiene, 2001). this response indicated the large number of persons impacted by the disaster. the american red cross (2003) reports that sarah s. jeon & terra k. marroquin a brief review of issues in ptsd research journal of student social work, volume ii 17 their organization provided as many as 240,000 mental health contacts immediately following the attacks. it was critical, therefore, that mental health professionals were able to identify persons who were likely to develop ptsd so as to offer appropriate treatment to these large populations. diagnosing ptsd according to the diagnostic and statistical manual of mental disorders, fourth edition, text revision (american psychiatric association [apa], 2000), a diagnosis of ptsd is dependent upon exposure to an event that involves “actual or threatened death or serious injury” to one’s self or loved one or the witnessing of such an event which causes a sense of “intense fear, helplessness, or horror” (apa, p. 464). symptoms, including re-experiencing the event, avoidance and numbing, and increased arousal, must last longer than one month and cause significant impairment or distress. frequently, following a traumatic event an individual may not meet criteria for ptsd but may have acute stress disorder (asd) or post-traumatic stress symptoms (ptss). asd symptomatology matches that of ptsd but occurs within 30 days of a traumatic event (apa, 2000). people suffering from ptss may have some characteristics of asd or ptsd and may experience significant distress, yet do not meet full dsm-iv-tr criteria for either disorder. while practitioners must carefully adhere to dsm-iv-tr criteria to diagnose ptsd, prevalence studies following mass trauma like the events of september 11 are rarely able to draw diagnostic conclusions. using a clinical interview, a clinician can conduct a thorough assessment by gathering information on the duration and extent of the impairment, gauging the client’s prior history of trauma and psychiatric illness, and assessing for co-morbidity of other psychiatric illnesses. researchers use brief questionnaires like the ptsd checklist (pcl) (weathers, litz, herman, huska & keane, 1993) to make statements about the prevalence of ptsd symptoms. although such checklists are the most efficient way to uniformly collect data from large samples, they do not measure impairment of functioning or duration of symptoms, which are crucial for a dsm-iv-tr diagnosis. research studies often do not conduct thorough assessments, and, when misrepresented or misinterpreted, may lead to inflated statistics about the true number of ptsd cases. increasing the knowledge base concerning the data collection, analysis, and interpretation methods used in trauma research is necessary to provide a clearer picture of prevalence rates, responses to traumatic events, and the design of effective interventions for practitioners. trauma, terrorism, and ptsd research prior to september 11, the national institute of mental health (2001) reported that 3.6% of adults in the united states (5.2 million people) had ptsd during a given year. while many of the studies of the psychological jeon & marroquin 18 journal of student social work, volume ii impact of trauma due to terrorism in the united states were conducted on individuals exposed to the oklahoma city bombing (north et al., 1999), more recent studies of terrorism and ptsd in the united states focus on september 11. several of these studies reported a surge in ptsd-related symptoms amongst persons living in new york city following the attacks (bascarino, galea, ahern, resnick, & vlahov, 2002; sattler, 2002; schlenger et al., 2002; schuster et al., 2001). galea et al. (2002) found that 7.5% of a sample of adults living south of 110th street in manhattan showed symptoms consistent with ptsd. south of canal street, the prevalence rate was reportedly 20%. schlenger et al. estimated that there could be more than 500,000 cases of ptsd as a result of the event in the new york metropolitan area alone and reported a rate of 11.2% of probable ptsd cases found in their study of new york city residents. such results, however, must be considered carefully given that the methods used to interpret findings of ptsd symptoms vary from study to study. the events of september 11 were distinct in nature due to both the large-scale destruction akin to a natural disaster and the component of intentional harm inflicted by one human towards another. natural disasters have traumatic effects due to large losses of life and property (cao, mcfarlane, & klimidis, 2003). however, it has been found that intentional harm inflicted by one human towards another has even longer-lasting effects in the development of ptsd (breslau, chilcoat, kessler, peterson, & lucia, 1999; norris, byrne, eolia, & krzysztof, 2001; thabet, abed, & vostanis, 2002). according to the code of federal regulations (as cited in the federal bureau of investigations, 1998), terrorism is defined as “…the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.” terrorism, as viewed from a mental health perspective, is particularly damaging and has resulted in a pronounced number of cases of ptsd (bleich, gelkopf, & solomon, 2003; north et al., 1999; schlenger et al., 2002). additionally, a single-event terrorist attack such as september 11 may be as traumatic as repeated exposure. bleich, gelkopf, and solomon conducted a study on a representative sample of the population in israel, a country where frequent terrorist acts occur, and found that 9.4% of israeli individuals met symptom criteria for ptsd (bleich, gelkopf, & solomon). this is comparable to 7.4% (galea et al., 2002) and 11.2% (schlenger et al.) found in new york city following the september 11 attacks. these results are noteworthy considering that much of the sample gathered in israel had experienced 19 months of repeated terrorist attacks prior to their study. however, the methodologies used for each of these studies were different, as were the sources of exposure considered, the subjects’ proximity to the events, and the sampling methods used. journal of student social work, volume ii 19 a brief review of issues in ptsd research approaches to research the inconsistent application of questionnaires to conduct research on the prevalence of ptsd poses problems in comparing and validating results of research studies. most studies utilize one of two major ptsd scales—the pcl or the diagnostic interview schedule (dis), which is based on the dsm-iii-r (apa, 1987). although comparisons between the two instruments are difficult to draw, the more distressing issue is the lack of consistency in interpreting results from the same measure. three different methods noted in major studies of ptsd following the september 11 attacks illustrate this point. in the studies reviewed here, schuster et al. (2001) opted to present ptsd symptoms according to levels of symptom severity; schlenger et al. (2002) portrayed “probable ptsd” as a dichotomous variable, in which an individual met criteria through the tallying of symptoms; and galea et al. (2002) grouped symptoms according to dsmiv-tr criteria and determined whether the person met threshold numbers in each category. while these methods are useful as screening devices for potential ptsd cases, they can lead to inflated prevalence statistics. researchers who conduct large prevalence studies usually understand the inherent difficulties in diagnosing ptsd through scales and brief measures, rarely stating outright that they are measuring ptsd. instead, they employ tentative language, carefully choosing their words to reflect the uncertainty of a clinical diagnosis. below, the language used in each research study reviewed will be examined. levels of symptom severity one of the largest studies conducted after september 11 was by schuster et al. (2001) and has been cited extensively (bleich, gelkopf, & solomon, 2003; north & pfefferbaum, 2002; schlenger et al., 2002). in this study, 560 adults participated in telephone interviews three to five days after september 11 that focused on their stress and coping responses. the researchers used the term “stress reactions” throughout their article. this careful use of terminology reflects the fact that ptsd cannot be diagnosed for at least one month after the event. although assessing for stress reactions provides a measure of general distress, it does not discern which reactions are sufficient for a full dsm-iv-tr diagnosis of ptsd. the term “stress reactions” also seems to appropriately indicate that the use of cutoff scores for ptsd symptoms does not necessarily mean that the person meets a full dsm-iv-tr diagnosis of ptsd (north & pfefferbaum). schuster et al. (2001) used the ptsd checklist (pcl) to determine levels of symptom severity. the pcl is a 17-item checklist directly based on ptsd symptoms listed in the dsm-iv-tr. it was initially tested on combat veterans, and then adapted for civilians (pcl-c). it has been tested on vicjeon & marroquin 20 journal of student social work, volume ii a brief review of issues in ptsd research tims of non-combat and non-assaultive traumas (blanchard, jones-alexander, buckley & forneris, 1996). based on participant responses to the pcl’s 5-point likert scale, schuster et al. reported that 44% of respondents had at least one substantial stress symptom (a rating of 4 or higher), 68% had one symptom “moderately” (3 on the likert scale), and 90% had at least one symptom “a little bit.” their claim that a high percentage of respondents demonstrate stress symptoms “a little bit” may be misleading when based on a mark of two on a five-point scale. likert scales offer an ordinal level of measurement without guidance as to the distinction between the choices. in addition, this method of classifying ptsd symptoms is based on the selfreport of the individual of his/her apparent symptoms. the choices made are completely subjective, since one cannot know how each individual interprets his/her symptoms or what the distinction between a rating of 2 or a rating of 3, for example, means to each participant. in addition, as schuster et al. note, though baseline measures exist for ptsd prevalence rates, none are available for stress symptoms. having “a little bit” of insomnia, or increased physiological arousal could easily have been pre-existing and incorrectly attributed to september 11. hence, it is not possible to objectively determine the effects of september 11 on ptsd or ptss through this method. the tallying of symptoms some researchers have tallied symptoms to derive a diagnosis of ptsd or “probable ptsd” (schlenger et al., 2002; simeon, greenberg, knutelska, schmeidler, & hollander, 2003). schlenger et al. based this procedure on a report by weathers, litz, herman, huska, and keane (1993) who state that a pcl cutoff score totaling 50 or greater has strong diagnostic utility for ptsd. this has encouraged the use of the pcl in ptsd research studies. however, schlenger et al., in agreement with north and pfefferbaum (2002), are careful to note that only clinical assessments can definitively diagnose ptsd. schlenger et al. use the phrase “probable ptsd” to discuss their findings. furthermore, it has been appropriately recommended that the pcl be used only as a screening device (blanchard, jones-alexander, buckley, & forneris, 1996). although the pcl is efficient for data collection and has good diagnostic utility, it does not measure the duration and impairment criteria, which are crucial for a clinical diagnosis (north & pfefferbaum). in addition, tallying alone fails to determine whether each individual meets the threshold requirements for each symptom cluster, according to dsm-iv-tr criteria. dsm-iv tr symptom clusters the dsm-iv-tr (apa, 2000) criteria for ptsd include three symptom clusters (b, c, and d) in addition to the requirements for exposure journal of student social work, volume ii 21 (criteria a), duration (criteria e), and impairment (criteria f). criteria b symptoms are the intrusive re-experiencing of the event through flashbacks, nightmares, and physiological reactions to reminders. criteria c symptoms are avoidance and numbing, including detachment from others, loss of interest, and avoiding reminders of the event. criteria d symptoms indicate hyperarousal and include insomnia, irritability, and hypervigilance (apa). the dsm-iv-tr requires at least one b symptom, three c symptoms, and two d symptoms in order to qualify for a diagnosis of ptsd. in an attempt to more closely imitate the requirements of a dsm-iv-tr diagnosis, some researchers interpreting data from brief inventories have adhered to requirements for the number of symptoms in each symptom cluster (galea et al., 2002; piotrkowski & brannen, 2002). galea et al. used items from a modified diagnostic interview schedule for ptsd to determine “symptoms consistent with current ptsd” by noting the presence of symptoms meeting these threshold requirements. although the symptom cluster method still fails to measure duration and impairment criteria required for definitive diagnosis, this method most closely approximates a dsm diagnosis. in addition, research reveals that the numbing and avoidance symptoms of the c category are the markers of ptsd (north et al., 1999). north et al. found that 94% of subjects who met criterion c also met the criteria necessary for a full ptsd diagnosis. researchers who cluster symptoms may predict those cases likely to qualify as full ptsd by noting the participants who report three or more c symptoms, offering a more accurate assessment of ptsd prevalence. a consequence, however, of more closely simulating a dsm diagnosis is that the symptom cluster method can disregard significant but sub-clinical distress that the other methods detect. discussion there is no common practice for measuring ptsd and stress symptoms in research studies. the nature of large empirical studies precludes the use of thorough assessments by trained clinicians, the only way to conclusively diagnose ptsd. ptsd cannot be definitively identified through the use of brief questionnaires (north & pfefferbaum, 2002). hence, studies that use cutoff scores or categorize levels of symptom severity are susceptible to gross overestimation of the prevalence of ptsd. even categorizing symptoms according to dsm-iv-tr criteria is insufficient, as checklists such as the pcl are subjective and often leave out the duration and impairment criteria, inaccurately reflecting the individual’s mental health. an issue parallel to accurately assessing ptsd is detecting significant distress that may not reach a dsm-threshold level. brett (1996) argues that the classification of disorders through the dsm-iv-tr leaves out many clinically relevant characteristics. therefore, although categorizing levels of symp22 journal of student social work, volume ii jeon & marroquin tom severity and tallying scores may not be sufficient for determining ptsd prevalence, they do reflect the presence of distress, whether sub-clinical or qualifying for dsm diagnosis. these studies offer information important for gauging mental health and need not be framed strictly in relation to ptsd. conclusion careful interpretation and application of published research on studies that include post traumatic stress disorder (ptsd), acute stress disorder (asd), and post traumatic stress symptoms (ptss) following traumatic events is necessary due to the wide range in study methods currently employed. we suggest that consumers of such research take careful note of three points. first, investigate the use of terminology for ptsd. the authors of trauma research articles may use the terms ptsd, asd, and ptss, each of which have very different meanings. the correct use and interpretation of these terms is critical in making any further interpretations of such studies. second, the use of measures cannot take the place of a clinician’s diagnosis. conclusions drawn through the use of standardized measures must be considered merely a part of a complex set of responses to traumatic events. third, the dsm-iv-tr, on which the most commonly used measures and clinical diagnoses are based, may fail to recognize persons who are, in fact, suffering severely but do not meet the designated criteria. such classification systems may also exclude important information that may be addressed by more extensive and holistic means of studying individuals, such as a personin-environment system assessment that includes their social role, environmental, mental, and physical problems (williams, karls, & wandrei, 1989). the role of research studies in informing helping professionals is crucial in an environment increasingly focused on evidence-based practice. media publications have an ethical responsibility to accurately report and disseminate knowledge about trauma study findings to the public. in addition, advocates for and funders of mental health services must be aware of the potential range of post-trauma outcomes when seeking and offering funding. all consumers of research should strive to be informed and must tread carefully when extrapolating results from studies of traumatized populations. references american psychiatric association. (1987). diagnostic and statistical manual of mental disorders: dsm-iii-r (3rd ed.). washington, dc: american psychiatric association. american psychiatric association. (2000). diagnostic and statistical manual of mental disorders: dsm-iv-tr (4th ed.). washington, dc: american psychiatric association. american red cross. (2003). the american red cross joins nation in journal of student social work, volume ii 23 a brief review of issues in ptsd research remembering 9/11 victims. retrieved march 12, 2004, from http:// www.redcross.org/pressrelease/0,1077,0_314_1563,00.html bascarino, j. a., galea, s., ahern, j., resnick, h., & vlahov, d. (2002). utilization of mental health services following the september 11th terrorist attacks in manhattan, new york city. international journal of emergency mental health, 4(3), 143-156. blanchard, e. b., jones-alexander, j., buckley, t.c., & forneris, c.a. (1996). psychometric properties of the ptsd checklist (pcl). behavior research and therapy, 34(8), 669-673. bleich, a., gelkopf, m., & solomon, z. (2003). exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in israel. journal of the american medical association, 290(5), 612-620. breslau, n., chilcoat, h., kessler, r., peterson, e., & lucia, v. (1999). vulnerability to assaultive violence: further specification of the sex difference in post-traumatic stress disorder. psychological medicine, 29(4), 813-821. brett, e. a. (1996). the classification of posttraumatic stress disorder. in b. a. van de kolk, a. c. macfarlane & l. weisaeth (eds.), traumatic stress: the effects of overwhelming experience on mind, body, and society. new york: guilford press. cao, h., mcfarlane, a. c., & klimidis, s. (2003). prevalence of psychiatric disorder following the 1988 yun nan (china) earthquake. social psychiatry & psychiatric epidemiology, 38(4), 204-212. federal bureau of investigation. (1998). terrorism in the united states. washington, d.c.: national security division. galea, s., ahern, j., resnick, h., kilpatrick, d., bucuvalas, m., gold, j., & vlahov, d. (2002). psychological sequelae of the september 11 terrorist attacks in new york city. new england journal of medicine, 346(13), 982-987. national institute of mental health. (2001). facts about post-traumatic stress disorder. retrieved september 30, 2003, from http://www.nimh. nih.gov/anxiety/ptsdfacts.cfm new york city department of health and mental hygiene. (2003). more than 10,000 people from 47 u.s. states have signed up for the world trade center health registry in its first two weeks. retrieved march 12, 2004, from http://www.ci.nyc.ny.us/html/doh/html/public/press03/ pr130-0923.html norris, f. h., byrne, c. m., eolia, d., & krzysztof, k. (2001). 50,000 disaster victims speak: an empirical review of the empirical literature, 1981-2001. retrieved october, 15, 2003, from http://obssr.od.nih. 24 journal of student social work, volume ii jeon & marroquin gov/activities/911/attack.htm north, c. s., & pfefferbaum, b. (2002). research on the mental health effects of terrorism. journal of the american medical association, 288(2), 633. north, c. s., nixon, s. j., shariat, s., mallonee, s., mcmillen, j., spitznagel, e. l., et al. (1999). psychiatric disorders among survivors of the oklahoma city bombing. journal of the american medical association, 282(8), 755-762. piotrkowski, c. s., & brannen, s. j. (2002). exposure, threat appraisal, and lost confidence as predictors of ptsd symptoms following september 11, 2001. american journal of orthopsychiatry, 72(4), 476485. sattler, d. n. (2002). the september 11th attacks on america relationships among psychological distress, posttraumatic growth, and social support in new york. boulder, co: university of colorado boulder, natural hazards research applications information center. schlenger, w. e., caddell, j.m., ebert, l. b., jordan, b.k., et al. (2002). psychological reactions to terrorist attacks: findings from the national study of americans’ reactions to september 11. journal of the american medical association, 288(5), 581. schuster, m. a., stein, b.d., jaycox, l.h., collins, r.l., marshall, g.n., elliott, m.n., et al. (2001). a national survey of stress reactions after the september 11, 2001, terrorist attacks. new england journal of medicine, 345(20), 1507-1512. simeon, d., greenberg, j., knutelska, m., schmeidler, j., & hollander, e. (2003). peritraumatic reactions associated with the world trade center disaster. american journal of psychiatry, 160(9), 1702-1704. thabet, a. a., abed, y., & vostanis, p. (2002). emotional problems in palestinian children living in a war zone: a cross-sectional study. the lancet, 359(9320), 1801. weathers, f. w., litz, b.t., herman, d.s., huska, j.a., & keane, t.m. (1993, october). the ptsd checklist: reliability, validity, & diagnostic utility. paper presented at the annual meeting of the international society for traumatic stress studies, san antonio, tx. williams, j. w., karls, j. m., & wandrei, k. (1989). the persons-inenvironment (pie) system for describing problems of social functioning. hospital and community psychiatry, 40, 1125-1127. journal of student social work, volume ii 25 a brief review of issues in ptsd research sarah s. jeon is a second-year master’s student at the columbia university school of social work concentrating in advanced generalist practice and programming within the family, youth, and children’s services field of practice. she is currently an intern at the lower east side family union in new york city. she holds a bachelor’s degree from yale university in psychology. her email address is ssj2011@columbia.edu. terra k. marroquin is a second-year master’s student at the columbia university school of social work concentrating in clinical practice within the contemporary social problems field of practice with a minor in research. she is currently an intern at the survive community project in new york city. she is hold a bachelor’s degree from the university of california at berkeley in psychology and social welfare. her email address is tkm2005@columbia.edu. 26 journal of student social work, volume ii jeon & marroquin columbia social work review, vol. viii | 1 preventing the re-traumatization of individuals who are arrested for prostitution by implementing trauma-informed practices in the criminal justice system leila ostad-hashemi most literature suggests that at least half of those who engage in prostitution have a history of physical or sexual abuse. individuals who have experienced trauma are constantly re-traumatized during their sex work. standard procedures used in arrests of people engaging in prostitution can have profoundly triggering effects on individuals with histories of trauma. to reduce re-traumatization and promote rehabilitation, it is critical to create trauma-informed practices within law enforcement and the criminal justice system to better serve individuals arrested for prostitution. specific trauma-informed training for law enforcement officers and legal counsel staff who work with people charged with prostitution can be created using components from several existing trauma-specific models which this paper will address in detail. introduction with the creation of websites and apps like eros, backpages, the erotic review, and sugar sugar, prostitution, the type of sex work where one performs sexual acts for compensation (hutto & faulk, 2000), has shifted from the streets to indoor locations such as massage parlors, residential brothels, hotels, and strip clubs (farley, franzblau, & kennedy, 2013). even though there are now websites that help buyers and sellers meet, prostitution is still illegal in all but two states. according to federal bureau of investigation arrest statistics, approximately 57,000 people were arrested for prostitution in 2012 (national center for juvenile justice, 2014). with the use of new websites and apps, the field of prostitution has become easier to enter; all one needs is a computer and a few photos to begin such work. as a result, only 10 to 20% of all those who engage in prostitution today in the united states meet buyers, or johns, on the street as opposed to online (weitzer, 2012). regardless, the constant threat of physical and emotional harm caused by the industry exist no matter where and how prostitution takes place (hutto & faulk, 2000; farley, cotton, lynne, zumbeck, spiwak, reyes, alvarez,& sezgin, 2008). most literature suggests that at least half of those who engage in prostitution have a history of physical or sexual abuse (silbert & pines, 1982). trauma-focused programs need to be implemnted in the criminal justice system as an effort to prevent the re-traumatiziation of these individuals. case study hailey,1 a 22-year-old female who describes her childhood as “awful,” experienced events that “no child should ever have to experience.” hailey grew up with her mother and two siblings in the “projects”. her mother was an alcoholic and crack cocaine user. child services were called to the home several times, but hailey and her siblings lied about their mother’s substance abuse to avoid being taken away. hailey’s mother was physically and emotionally abusive and neglectful towards her children. hailey was sexually abused by a relative from the ages of 10 to 12. she ran away from home at 16 and lived on the street where other homeless juveniles introduced her to prostitution. hailey reports that she has been working as a prostitute for six years. during this time, she has been raped on multiple occasions and stabbed and left for dead. she has been diagnosed with complex posttraumatic stress disorder (ptsd), schizoaffective disorder, and depression. hailey has been posting ads on backpages to find potential johns. one night, hailey was hired by an anonymous man, and she agreed to meet him at his hotel room. upon entering the room, the man asked hailey to undress. while she undressed, the man discussed the sex acts he wanted to engage in, in graphic detail. immediately after hailey undressed, several undercover police officers burst through the door and pushed hailey, only in her underwear, to the ground, causing her to get a bloody lip. they put her in handcuffs and walked her out of the hotel. while putting hailey in their van, the officers laughed and called her derogatory names. when she asked if the handcuffs could be loosened because they were hurting her wrists, they ignored her requests and said, “shut up and do not speak until spoken to.” clinical work i met hailey while i was working as a counselor for individuals charged with prostitution at an alternative sanctions court program in midtown manhattan. hailey’s story was not unique. even though the specific circumstances my clients found themselves in varied, most of them experienced a great deal of trauma before and during their time engaging in prostitution. while i had expected to hear stories about neglect, abuse, and childhood sexual assault, i was surprised to learn about the re-traumatization they endured during the process of their arrests and court hearings. during one of my first meetings with my supervisor, i expressed how shocked i was at the number of clients i met who identified their arrests as re-traumatizing. she stated that this was an extremely common occurrence for the people we served (m. goodman, personal communication, july 12, 2016). in most states and courts, a prostitution offense comes with fines and/or jail time. however, the court where i worked offered individuals an alternative sanction: an option to meet with a therapist for five counseling sessions. this option was the 1 client’s name was changed for anonymity. client was arrested for prostitution and mandated to five counseling sessions with a social worker at midtown community court, an alternative sanctions court, in exchange for a dismissal of her charges. 2 | columbia social work review, vol. viii preferred choice for many people convicted of prostitution. according to the united states department of justice’s bureau of justice statistics, 43,190 women and 19,480 men were arrested for prostitution in 2010 alone (snyder, 2012). in an effort to better serve these individuals, it is useful to understand their common life experiences. with a better understanding of these experiences, more tailored criminal justice programs can be put into place to help individuals avoid re-traumatization during the processes of being arrested, detained, and going through court proceedings. life expectaions and prostitution motivation and predisposing factors when designing programs to prevent the re-traumatization of survivors of violence, it is imperative to think about the impact of predisposing factors such as abuse. 55 to 90% of those working in prostitution report a history of childhood sexual abuse (belton, 1992; farley & barkan, 1998; simons & whitbeck, 1991). silbert and pines (1982) found that 62% of a sample of women working as prostitutes had experienced physical child abuse; 60% were survivors of incest and sexual abuse from the ages of three to sixteen, and 70% reported past emotional abuse. in a study of 130 people working as prostitutes in san francisco, 57% reported that they had been sexually assaulted as children, and 49% reported that they had been physically assaulted as children (farley & barkan, 1998). similarly, silbert and pines (1981) noted that 60% of the prostitutes interviewed in their study had experienced childhood sexual abuse, and bagley and young (1987) found that 73% of their sample of former prostitutes in canada encountered sexual assault as children. in addition to physical and sexual abuse, parental neglect, problems in the home, and unsatisfactory filial relationships have all been noted as factors that predispose people to entering the field of sex work (choisy, 1961; maerov, 1965; esselstyn, 1968; davis, 1971; gray, 1973). while studies correlating the sexual abuse and sex work are numerous, contemporary social work scholars should ask the following question: what in particular about childhood abuse leads some people to work in prostitution? to answer this question, one must be able to understand the dynamics of sexual abuse and the feelings that accompany such violence. grooming most sexual abuse is defined by a gradual process in which perpetrators gain the trust of the person they are targeting and his or her caregivers by “grooming” them. this process begins when an abuser identifies a victim, builds rapport with them, and breaks down their defenses (national center for victims of crime, 2012). after the perpetrator gains access to the person they are targeting by creating a false sense of trust, they initiate sexual contact with the victim. there are several reasons abusers are able to specifically exploit children, the main one being that they hold the power in the relationship based on their adult status, experience, size, and strength (national center for victims of crime, 2012). the process of grooming helps the abuser acquire continuous contact with the victim and develop a relationship grounded in secrecy (mcalinden, 2012). this secret relationship may cause the survivor to feel “dirty,” guilty, or ashamed (munro, 2012). research reveals that the experience of sexual abuse often dominates a person’s identity and significantly informs how they experience and perceive the world (bass & davis, 1988). identity constructions associated with abuse include themes of invisibility, inherent badness, guilt, and shame (bass & davis, 1988; courtois, 1988; matsakis, 1996). those who work in prostitution feel a lack of identity and power; this perception of inadequacy often guides an individual into sex work (silbert & pines, 1982). accordingly, engaging in sex work is often how a prostitute forms their identity after experiencing a loss of power due to childhood abuse (silbert and pines, 1982). some children and adolescents run away from home to escape the hands of abusers, and living on the street makes runaways more susceptible to being swept up in the world of sex work (walker & quraishi, 2014; kramer, 2003). re-traumatization re-traumatization during prostitution individuals who have experienced trauma are constantly re-traumatized during sex work (hutto & faulk, 2000). numerous studies have found that people who work as prostitutes are frequently raped and physically assaulted (farley, et al., 2003; hunter, 1994; miller, 1995; silbert & pines, 1982). silbert and pines (1982) reported that 70% of women were raped while engaging in prostitution, with 65% having been physically assaulted by customers. farley and barkan (1998) found that of 130 people working as prostitutes in san francisco, 82% had been physically assaulted and 68% had been raped while working. in a study of 854 people working as prostitutes in nine different countries, it was found that 71% were physically assaulted and 63% were raped while engaging in prostitution (farley, cotton, lynne, zumbeck, spiwak, reyes, alvarez, & sezgin, 2008). miller (1995) concluded that 94% of those working in street prostitution have experienced sexual assault and 75% have been raped by one or more johns. furthermore, giobbe (1993) found that customers use methods of coercion and control, including minimization and denial of physical violence, verbal abuse, threats and intimidation, physical violence, sexual assault, and captivity. people who work in prostitution commonly report feeling sadness, shame, anger, worthlessness, and anxiety (kramer, 2003; valera, et al., 2001). sex workers may also experience mental health problems such as depression, a lack of memory, and suicidal ideation (valera et al., 2001). farley, baral, kiremire, and sezgin (1998) found that of 475 individuals working in prostitution, 67% met diagnostic criteria for ptsd, and the mean ptsd severity in the sample was even higher than that found in treatment-seeking vietnam veterans in the united states. similarly, in an extension study performed ten years later, farley, et al. (2008) found that of 854 people working in prostitution, 68% met diagnostic criteria for ptsd. in columbia social work review, vol. viii | 3 both studies, high rates of experiencing physical and sexual violence from involvement in prostitution were also reported. the severity of ptsd symptoms has been strongly associated with the number of different types childhood trauma, family instability, and lifetime sexual and physical violence experienced by sex workers (farley et al., 2008; mckenzie, marks, & liness, 2001), and the intensity of involvement in prostitution (vanwesenbeeck, 1994). re-traumatization during current criminal justice procedures the standard procedures used in arrests of people found to be engaging in prostitution can have profoundly triggering effects on individuals with histories of abuse, trauma, and mental illness. (human rights watch, 1996). a trigger is something that sets off a memory or a flashback and mentally transports individuals back to the event of their original trauma (herman, 1992). in addition to setting off triggers, custodial misconduct during arrest and detainment have been documented in many forms, including verbal degradation, rape, sexual assault, unwarranted visual supervision, denial of goods and privileges, and the use or threat of force (human rights watch, 1996). human rights watch (1996) explains that “grievance or investigatory procedures, where they exist, are often ineffectual, and employees continue to engage in abuse because they believe that they will rarely be held accountable, administratively or criminally”. many of the individuals i counseled while working at the community court spoke of similar problems with law enforcement. some of the more commonly mentioned problems were related to their arrest, the processing procedures after they had been arrested, and their interactions with attorneys and judges. while the exact arrest circumstances varied from client to client, most individuals explained how police officers spoke down to and laughed at them, arrested and took them to the precinct while they were only partially clothed, and sexually harassed them. in addition, many of the people i saw spoke of being restrained tightly – to the point of having physical bruising, swelling, and pain. after arrest, an individual is taken into police custody and “booked,” or “processed.” during booking, police officers ask personal questions, confiscate clothing and personal property, and complete a full body search of the person they have arrested (findlaw, 2013). the purpose of this full body search is to discover contraband that may be hidden in one’s body, and requires the removal of all clothing and a full visual inspection of all body parts (drapkin, 2011). after this process, the person is placed in a holding cell to await trial or the posting of bail (findlaw, 2013). the process of being booked can be very triggering for someone who has a history of abuse or assault. one client spoke of her experience while in the booking area and awaiting trial as feeling “like i was a kid again, being yelled at and beaten by my father. i had to just stand there and do what i was told while i was berated. it was a terrible experience.” another possible trigger point could occur when clients interact with their legal counsel. several clients told me they felt their counselor did not listen to what they said, their questions were never answered, and they were told what they should plead. they often did not even have the contact information or name of their attorney. importance of trauma-informed care these issues have implications for service providers, correctional administrators, and court staff. in an effort to reduce re-traumatization and help promote rehabilitation, it is critical to create a trauma-informed practice mandate within law enforcement and the criminal justice system to better serve individuals arrested for prostitution. according to the substance abuse and mental health services administration’s national center for trauma-informed care (samsha’s trauma and justice strategic initiative, 2014), this form of care is an approach that recognizes the presence of trauma symptoms in clients and acknowledges the role that trauma has played in their lives. trauma-informed practice, which is a strengthsbased approach, is a treatment framework that responds appropriately to the effects of all types of trauma and examines how services are delivered and the ways in which service systems are organized (samsha’s trauma and justice strategic initiative, 2014). incorporating trauma-informed practice into current law enforcement systems will help clients feel safe and empowered, and doing so will prevent re-traumatization. trauma-informed practices enable sex workers to begin to regain control of their lives and validate their experiences. related policy recommendations the high percentage of those arrested for prostitution who have experienced trauma suggests that the triggering ways in which people are arrested, questioned, booked, and counseled directly impact the experience of perpetuated psychological harm for many individuals. according to munetz and griffin (2006), there are several intercept points where traumainformed practices can be implemented, as explained in figure 1. with the increase in alternative sanctions court programs2 that provide different sentencing options to incarceration, the first and second interception points are of the most interest because they happen regardless of whether or not court programs are implemented. 2 alternative sanctions, also known as “intermediate sanctions,” “intermediate punishments,” and “sentencing alternatives,” usually include probation, community service, fines, restitution, and rehabilitative programs, with the exact range of alternative sentencing options varying by jurisdiction. these alternative sanction programs may offer interventions that give individuals a chance to understand the impact of trauma in their lives, heal, and learn to thrive despite past wounds. however, although these types of programs have been found to be more helpful than jail time in terms of rehabilitation and lower numbers of recidivism, they do not help with the re-traumatization a person may encounter during the actual arrest, initial detainment, and court hearings (yan, 2015). 4 | columbia social work review, vol. viii figure 1 sequential intercept mode; five intercept points: openings for change at the first intercept, to create a more trauma-informed process, mental health professionals and law enforcement should work together to meet, evaluate, and refer a person to mental health treatment. after the second intercept, a more trauma-informed process could include screening for trauma, mental health and/or substance use prior to the initial hearing. questions for those arrested could be formulated in trauma-specific formats, such as “what happened to you?” deferred prosecution, deferred sentencing, or probation could be used as diversion instead of jail time and/or fines. there are also several ways trauma-informed practices can be utilized during booking processes, or the third intercept. to become more trauma-informed, the officers completing these processes should explain what will happen during the full body search before and while the search is happening. additionally, if an officer notices that an individual is frightened or not responding, the officer should take extra steps to bring the individual back to the current moment by offering grounding techniques to them. grounding techniques help a person reorient to the present situation if he or she is intensely anxious or feeling triggered and dissociated from the current environment (cordes, 2014). some easy grounding techniques include instructing the person to concentrate on his or her breathing and reminding them to take deep breaths, or asking the person to name things they see in their surroundings (quayle, 2015). jails should also avoid the use of restraints and seclusion, which could also be triggering for people with histories of trauma. because such a high percentage of those arrested for prostitution have backgrounds rooted in trauma, ways to ensure psychological and physical safety must be provided. specific trauma-informed training for law enforcement officers and legal counsel staff who work with people charged with prostitution can be created using components from several existing trauma-specific models including seeking safety, risking connection, and the forensic experiential trauma interview (feti). in addition to providing trauma-focused procedures and protocols to staff, these models can also be used to create new specific trauma-focused interventions. seeking safety seeking safety is an evidence-based counseling model that was created to help people attain safety from trauma and/ or substance abuse (najavits, 2002). any provider can conduct it, even without formal training, as it is easily accessible to practitioners. specific components that may be most useful for working with people arrested for prostitution include getting to know individual clients and building rapport, understanding their case management needs, learning how to look for signs of danger and safety, and understanding ptsd and other long-term associated problems (najavits, 2002). columbia social work review, vol. viii | 5 risking connection risking connection is another trauma-informed model aimed at mental health, public health, and substance abuse staff (saakvitne, gamble, pearlman & lev, 1999). there are several practitioner-specific adaptations of the model available, including ones for people who work in state and local agencies. risking connection emphasizes the concepts of empowerment, connection, and collaboration. this model provides a framework to guide sessions with survivors of traumatic abuse and specific intervention techniques to use. it also includes five separate modules, one of which covers understanding trauma and the effects of traumatic events on human adaptation. risking connection also includes a 10-step program for crisis intervention (saakvitne, gamble, pearlman & lev, 1999). the forensic experiential trauma interview (feti) according to police commissioner james o’neill, new york police department (nypd) trafficking investigators are currently being trained in feti techniques (tcholakian, 2017). commissioner o’neill’s hope is that after learning feti techniques, nypd investigators will be able to interview trafficking survivors in ways that will help build and collect evidence for cases without further traumatizing the survivors (tcholakian, 2017). aspects of this program can help those who work with people in prostitution. feti is used to help trauma victims feel safe and understood, to maximize recall, and to an overall enhancement of the investigative process overall by increasing victim cooperation and participation (strand, n.d.). a portion of feti training is geared towards helping the listener or interviewer learn skills that can help him or her demonstrate concern and empathy towards the interviewee. these skills are used to help foster a sense of psychological and physical safety during the interview process (strand, n.d.). conclusion it is important to note that more than half of sex workers engaging in prostitution report a history of childhood sexual abuse (belton, 1992; farley & barkan, 1998; simons & whitbeck, 1991), and that such individuals who have experienced previous trauma are constantly re-traumatized while working (hutto & faulk, 2000). moreover, numerous studies have found that people who work as prostitutes are frequently raped and physically assaulted (farley, et al., 2003; hunter, 1994; miller, 1995; silbert & pines, 1982). due to the fact that a large percentage of people working in prostitution have experienced sexual and physical abuse, it is important to put measures into place to try to prevent any further traumatization of this population. trauma-focused programs need to be utilized in the criminal justice system to prevent further re-traumatization of individuals are arrested for prostitution. elements from seeking safety, risking connection, and feti can be used to create more trauma-informed staff, practices and procedures. references bagley, c., & young, l. 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(1994). prostitutes’ well-being and risk. amsterdam, amsterdam, the netherlands: vu university press. walker, k., & quraishi, f. (2014). from abused and neglected to abused and exploited: the intersection between the child welfare system and child sex trafficking. national center for youth law. retrieved from https://www.wearethorn.org/wp-content/ uploads/2015/02/csec-child-welfare-report.pdf wayne, t. k., & banner, l. w. (2015). volume 4: third-wave and global feminisms (1990-present). in women’s rights in the united states: a comprehensive encyclopedia of issues, events, and people (pp. 199-202). santa barbara, ca weitzer, r. j. (2013). legalizing prostitution: from illicit vice to lawful business. new york, ny: new york university press. yan, s. (2015). search for the hidden punishments: an alternative approach to studying alternative sanctions. journal of quantitative criminology. doi:10.1007/s10940-015-9275-4 leila ostad-hashemi leila ostad-hashemi graduated from rutgers college with a bachelor of arts degree in psychology and minor in biological sciences. while at rutgers college, she completed a honors research project examining the serotonin transporter gene and its relation to depression following trauma. she earned her master of science degree in biomedical science at the university of medicine and dentistry of new jersey where she studied brain development following trauma. currently, leila is pursuing a master of science in social work degree at columbia university school of social work with an advanced clinical practice focus. while at cssw, leila’s placements have been at the federal defenders of new york, center for court innovation, and new york-presbyterian/cornell medical center. throughout her placements, leila has provided psychoeducation about trauma, case management, community outreach, and counseling. in her spare time, leila enjoys volunteering with her therapy dog, rufus, to provide comfort to those in need. journal final revised margins.indd the battle for effective sexuality education the debate over sexuality education reveals important issues regarding government regulation of personal behavior and the role of values in social welfare policy. while often regulated to the realm of public health, the promotion of effective approaches to sexuality education is closely aligned with social work’s mission to empower clients and increase their access to resources and information. this article will cover historical trends in sexuality education, the current federal policy and alternatives, and discuss the limitations and subsequent consequences for future policy. additionally, this article will highlight the important implications of the sexuality education debate for the social work profession. sexuality education for young people is no longer confined to awkward family discussions or whispered conversations in the school hallway. the rise in teenage pregnancy, legalization of abortion, and the spread of hiv thrust adolescent sexual behavior into the realm of policy makers and government officials. sexuality education emerged as a potential mechanism for targeting these public health issues; however, a divisive battle over appropriate content and structure has led to inconsistent implementation of sexuality education programs for american youth. while the programs seek to curb teenage pregnancy and prevent the transmission of sexually transmitted diseases (stds), the debate over what kind of sexuality education best achieves this goal illuminates crucial issues regarding the role of values and personal behavior regulation in social welfare policy. this article will cover historical trends in sexuality education, the current federal policy and alternatives, and discuss the limitations and subsequent consequences for future policy. additionally, this article will highlight the important implications of the sexuality education debate for the social work profession. in response to a growing decline in the health status of adolescents in the united states, the national association of social workers (nasw) has called for an increased focus on adolescent health issues and comprehensive prevention services, particularly around adolescent sexual behavior (nasw, 2004). in light of social work’s commitment to self-determination and access to reproductive health resources, the nasw recently declared jennifer friedman friedman journal of student social work, volume ii 7 8 journal of student social work, volume ii the battle for effective sexuality education its intentions to co-sponsor the march for women’s lives in april 2004 (nasw, 2004). given the increasing role that reproductive health and sexuality will play in the upcoming political arena, it is essential that social workers be informed about sexuality education policy and effective interventions. the sexuality education debate is complicated, as it includes concern over the impact of sexuality education on youth sexual behavior and the efficacy of such programs in preventing pregnancy and hiv/stds. the concerns are important: one in five adolescents have had sex prior to age 15, half of all 17 year olds are sexually active, and nearly 850,000 teenagers become pregnant each year (health education advocate, 2003). since the progressive era, sex education has mainly been a function of schools; 89% of public school students will take sex education sometime between grades seven to 12 (luker, 1996; kaiser family foundation, 2000). but the policy debate also affects secular and religious organizations that provide sex education and stretches beyond moral and social prerogatives; nearly $100 million in government funding is available to schools and community-based organizations that implement federally-approved sex education programming. current policy dictates that available funding must be used for abstinence-only education programs, which seek to prevent premarital sexual activity and convey the message that abstaining from sexual activity until marriage is the “morally correct option” (advocates for youth, 2001, p.7). the policy focus on abstinence and the increase in funding has impacted the nature of sex education; in 1999, 23% of secondary schools taught abstinence compared to 2% in 1988 (darroch, landry, & singh, 2000). schools and organizations that do not receive federal funding are free to pursue alternatives to abstinence education, frequently described as comprehensive sexuality education. in 1990, the sexuality information and education council of the united states (siecus) developed guidelines that cover the six main concepts of comprehensive sexuality education: human development, relationships, personal skills, sexual behavior, sexual health, and society and culture (seicus, 1996). comprehensive programs emphasize abstinence, but also provide information about contraception and disease prevention in addition to education on adolescent development, relationships, sexual orientation, and other life issues. a 1999 survey conducted by seicus and advocates for youth found that 93% of americans supported comprehensive sexuality education (advocates for youth, 2001). history and policy development the current sex education policy battle and conflict over funding reflects the historical ambiguity of american attitudes toward teenage sexual behavior. over the last thirty years, the growing awareness of teen pregnancy, the abortion controversy, and the reemergence of political and religious conservatism have significantly impacted sexuality education politics (goodson & edmundson, 1994; wilcox, 1999). teen sexual behavior moves to the forefront in the 1970s in the 1970s, the rates of abortion increased, as did the numbers of women having children outside of marriage. while adolescents represented a small percentage of these trends, the combination brought teen sexual behavior into the forefront. a 1976 report by the alan guttmacher institute further heightened awareness around adolescent sexuality and the “epidemic” of teenage pregnancy (wilcox, 1999; luker, 1996). the policy approach in the 1970s embraced the provision of family planning services and contraception; in 1970, congress passed the family planning services and population research act under title x of the public health services act. the act did not originally target adolescents, but as a result of the growing awareness of teen sexual activity, congress specified that adolescents should receive targeted family planning services under title x. the support for family planning also stemmed from a political consensus that preventing adolescent pregnancy and childbirth would aid efforts to prevent poverty and decrease welfare expenditure (wilcox, 1999). focus shifts to abstinence education in the 1980s support for increasing adolescents’ access to contraception and family planning resources was short-lived. by the early 1980s, a more conservative administration and a growing anti-abortion movement shifted the focus to abstinence education. opponents of the family planning approach claimed that support for contraceptive services encouraged sexual promiscuity and thus sought to replace these services with programs that would prevent sexual activity (luker, 1996). furthermore, proponents of abstinence education argued that the prescriptive nature of abstinence programs would place sex within the context of committed, monogamous relationships (goodson & edmundson, 1994; olsen, weed, nielsen, & jensen, 1992). in 1981, the first full-fledged federal policy mandating abstinence education was passed. the adolescent family life act (afla) was passed in an effort to create programs that develop “strong family values” and promote “selfdiscipline” (title xx, as cited in the office of population affairs, 2003b). the afla supports demonstration projects that develop and implement abstinence curricula, or provide support services for pregnant and parenting adolescents to “ameliorate the effects of too-early-childbearing for teen parents” (office of population affairs, 2003a). the act promotes adoption as the preferred option for pregnant teens and prohibits funding for programs that provide abortions or abortion counseling/referral (title xx as cited in the office of population affairs, 2003b). while funding for afla decreased during the clinton administration, the program friedman journal of student social work, volume ii 9 10 journal of student social work, volume ii has seen a revival during recent years. in 2000, the afla received $19 million — three times the funding it received in 1994 (brindis, 2002). the afla has faced significant challenges, most notably the lawsuit filed in 1983 by the american civil liberties union (aclu). the aclu argued that the afla was a violation of the separation of church and state, as much of the initial funding was used to support religious-based programs that explicitly promoted religious values (saul, 1998). a u.s. district judge found in favor of the aclu, but the u.s. supreme court reversed the decision in 1988. the court however, remanded the case for further fact-finding, which uncovered constitutional violations in the afla’s administration. as a result, in 1993, a five-year settlement reformed the grant administration process and required all afla grantees to submit curricula for review of the material’s content and accuracy (saul, 1998). increased funding for abstinence education in the 1990s in spite of constitutional concerns over the afla and abstinence programs, the legislature continues to increase funding for abstinence education. the 1996 welfare reform legislation contains a specific entitlement program for abstinence-only-until-marriage education, allocating $50 million per year for five years beginning in 1998. states receiving funds are required to match every four federal dollars with three nonfederal dollars, thus creating a total of nearly $500 million in spending for abstinence education (general accounting office, 1998; wilcox, 1999). the legislation dictates the parameters of acceptable abstinence-only programming using a strict eight-point definition, which includes teaching that non-marital sexual activity is likely to have harmful psychological and physical effects (advocates for youth, 2001). wilcox notes that the legislation did not originally allocate any funds for evaluation; after reproductive health advocates protested, congress allotted an additional $6 million for evaluation purposes. the funding provided under the welfare reform act is having a significant impact on the nature of sexuality education. in its first year of funding, all fifty states applied for grants under the abstinence-only-until-marriage provision (advocates for youth, 2001). some states reported concern over the restrictive nature of the abstinence programs, and difficulty in matching federal funds without decreasing funding for existing comprehensive programs (general accounting office, 1998). despite these concerns, funding for the program was reauthorized in 2002 (smith, 2002). states channel these funds for programs in school districts, community-based organizations, and faith-based institutions (advocates for youth, 2001). while these programs have a range of messages and some are also privately funded, many have religious affiliations and include material that directly refers to specific religious beliefs (trevor, 2001). the influence of religious values on sexuality education policy is frequently debated; goodthe battle for effective sexuality education son and edmundson (1994) argue that abstinence-only approaches were promoted in response to concern over the “value-free” character of previous sexuality education approaches. the intersection between religious values and approaches to sexuality education raise powerful questions about whether adolescent sexuality is a public health issue or a moral concern. support for comprehensive sexuality education in spite of the government’s success in promoting abstinence education, there are many who feel abstinence-only programs are fundamentally flawed and support alternative ways to promote responsible sexual behavior among youth. supporters of comprehensive approaches to sexuality education argue that abstinence-only education programs promote a specific set of values, use fear and shame to influence young people’s sexual behavior, and contain biased information about family structure, sexual orientation, and abortion (advocates for youth, 2001; trevor, 2001). supporters also point to european approaches and policies towards sexuality education. darroch, frost, and singh (2001) report that countries such as sweden, france, and the netherlands have significantly lower rates of teenage pregnancy and abortion, despite similar levels of sexual activity among youth. unlike the u.s., however, these countries mandate comprehensive sexuality education. in france and sweden, research has shown that positive attitudes about sexuality and clear expectations for behavior in sexual relationships contribute to more responsible teenage sexual behavior. in addition, adolescents in europe have greater access to contraceptive services and the media is used to promote positive sexual behavior. despite limited support in the united states government, promoters of comprehensive sexuality education often refer to the surgeon general’s 2001 call to action, which states that adolescents need accurate information about contraceptive methods and that providing sexuality education in the schools is crucial for providing youth with a basic understanding of sexuality (office of the surgeon general, 2001). in light of these alternatives, the family life education act (h.r. 3469, 2001) was introduced to the 107th congress in december 2001. the act called for the appropriation of $100 million each year for five years to fund block grants to eligible states for family life education programs, “including education on both abstinence and contraception for the prevention of teenage pregnancy and sexually transmitted diseases, including hiv/aids” (h.r. 3469, 2001). the requirements for the program stated that funding could not be used to teach or promote religion and that information on adolescent development, healthy life skills, and interpersonal skills must be included in program content. in addition, the bill stipulates an extensive evaluation procedure including a national evaluation of sample family life programs as well as state evaluation (h.r. 3469, 2001). the bill currently has 89 sponsors in the house, friedman journal of student social work, volume ii 11 12 journal of student social work, volume ii but remains in the subcommittee on health (advocates for youth, 2003). limitations of current policy the current policies regarding sexuality education in the u.s. are problematic. first, despite the implementation of federal funding and policy for abstinence education, there is no coherent agenda for sexuality education. most education policy remains under the jurisdiction of state and local governments; as a result, states may have multiple policies governing sex education, leading to tremendous variation in the structure and content of programs. sex education programs may also vary among communities depending on local preferences, values, and policies, particularly in schools (general accounting office, 1998; kaiser family foundation, 2000). geographic location also dictates young people’s access to information and resources pertaining to sexuality. second, federal sexuality education policy has been implemented with little debate and away from the spotlight. both the afla and abstinence education provision of the welfare reform legislation passed without extensive discussion (saul, 1998). such legislative tactics may be necessary to the success of the legislation, as recent polls show that only 18% of americans support teaching only abstinence until marriage (kaiser family foundation, 2002). advocates for comprehensive sexuality education found there was increased discussion about sexuality education during the recent welfare legislation reauthorization process; however, open public discussion is necessary for a more informed debate (smith, 2002). lastly, the effectiveness of sexuality education is still open to debate among health and social service professionals and policy makers, largely as a result of limited evaluation efforts. in summary of the world health organization’s review of program effectiveness, grunseit and aggleton (1998) state that the success of hiv and sexuality education programs hinges on whether the programs have the capacity to change behavior, whether the programs cause unintended or negative outcomes, and whether the programs have been adequately evaluated so that outcomes can be relied upon. there is an overall need for increased evaluation funding and sound evaluation methodologies, particularly for abstinence education programs (kirby, 2002; grunseit & aggleton, 1998). the general accounting office (1998) report on teen pregnancy prevention programs found that evaluation was often focused on process rather than outcome; state evaluations measured changes in knowledge, attitude, and behavioral intentions rather than sexual and contraceptive behavior. in spite of these limitations, research has shown that comprehensive sexuality and hiv education programs do not increase the sexual activity of young people, nor do they hasten the onset of sexual behavior. in fact, the literature demonstrates that some programs increase condom the battle for effective sexuality education journal of student social work, volume ii 13 or contraceptive use among sexually active youth and may even delay sexual activity for some youth (grunseit & aggleton, 1998; kaiser family foundation, 2002; kirby, 2002). kirby also identified ten characteristics of curricula effective at reducing unprotected sex, which included, among others, using theoretical approaches to behavior change, incorporating clear messages about sexual activity and contraceptive use, and providing modeling and practice of communication skills. given the available research on comprehensive sexuality education and the limited information on the efficacy of abstinence education, it is significant that current federal policy solely supports abstinence-only-until-marriage programs. such policy positions raise questions over the government agenda and whether intentions are to reduce teen pregnancy or to regulate behavior and “legislate morality” (ehrhardt, 1996, p.1524). among states receiving federal funds for abstinence programs, the lack of evidence-based research was cited as a concern (general accounting office, 1998). a report by the national campaign to prevent teen pregnancy found only three published evaluations of abstinence-only programs that were rigorous enough to be included in its literature review (kaiser family foundation, 2002). kirby (2002) cautions that the lack of evidence should not be taken as a generalization about the effectiveness of abstinence-based education; there are a diverse range of abstinence-only programs and further evaluation could demonstrate an impact on youth sexual behavior. however, until more comprehensive research efforts are completed, it is essential that programs be based on accurate information and realistic notions of adolescent sexuality (ehrhardt, 1996). conclusion in general, concerns over the effectiveness of sexuality education programs are largely focused on behavior – what will adolescents do as a result of receiving such education (grunseit & aggleton, 1998). for supporters of abstinence-only education, the desired aim is the prevention of sexual activity until marriage. as an alternative to this limited scope, michelle fine (1988) argues that sexuality education should offer an “empowering context in which we listen to and work with the meanings and experiences of gender and sexuality revealed by the adolescents themselves” (p.36). this would include providing a safe space for exploring sexuality and discourse on desire (fine, 1988). ehrhardt (1996) adds that adolescent sexuality is always presented in the context of risk behavior, rather than focusing on positive notions of sexual behavior and feelings as part of normal human development. as in other areas of educational policy, the goal should be to help young people become sexually competent individuals (ehrhardt, 1996). this emphasis is important for social workers since the profession’s values promote the importance of human relationfriedman 14 journal of student social work, volume ii references advocates for youth. (2001). toward a sexually healthy america. washington, dc: author. retrieved november 20, 2003, from http://www.advocatesforyouth.org/publications/abstinenceonly.pdf advocates for youth. (2003). action alert. retrieved november 26, 2003, from http://www.capwiz.com/advofy/issues/alert brindis, c. (2002). advancing the adolescent reproductive health policy agenda: issues for the coming decade. journal of adolescent health, 31(6), 296-309. darroch, j.e., landry, d.j., & singh, s. (2000). changing emphases in sexuality education in u.s. public secondary schools, 1988-1999. family planning perspectives, 32(5), 204-211. darroch, j.e., frost, j.j., & singh, s. (2001). teenage sexual and reproductive behavior in developed countries: can more progress be made? occasional report no.3, november 2001. retrieved november 26, 2003, from http://www.guttmacher.org/pubs/eurosynth_rpt.pdf ehrhardt, a.a. (1996). editorial: our view of adolescent sexuality-a focus on risk behavior without the developmental context. journal of public health, 86(11), 1523-1525. fine, m. (1988). sexuality, schooling and adolescent females: the missing discourse of desire. harvard educational review, 58(1), 29-53. the battle for effective sexuality education ships and enhancing an individual’s ability to meet his or her own needs. as practitioners, social workers can effectively provide a safe space for adolescents to explore issues of sexuality and make informed choices. while the future of sexuality education in the u.s. rests largely on improved evaluation methods and demonstration of effectiveness, the values debate cannot be ignored. the ability to demonstrate effectiveness can help guide policy decisions towards evidence-based programming rather than value-laden agendas; however, even evaluation efforts are rarely valuefree. in addition to evaluation, it is also important to examine the underlying goals of social welfare policy — is the goal of sexuality education policy to prevent and educate or to restrict personal behavior? as social workers, we must understand the impact of such policies and work to support policies that promote self-determination and individual well-being. rather than regulating and dictating behavior through abstinence only programs, comprehensive sexuality education programs seek to educate and empower young people and increase their access to resources. in this light, it is imperative that social workers advocate for comprehensive approaches to sexuality education, both by staying informed about local and community policies and lobbying national legislators to support comprehensive approaches to sexuality education such as the family life education act. general accounting office. 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(1998). whatever happened to the adolescent family life act? the guttmacher report, 1(2), 1-5. sexuality information and education council of the united states. (1996). guidelines for comprehensive sexuality education: k-12. retrieved december 3, 2003, from http://www.siecus.org/pubs/guidelines/ guidelines.pdf. smith, w. (2002). reasons for optimism about comprehensive sexuality education. seicus report, 30(2), 35-36. trevor, c. (2001). what abstinence-only-until-marriage education looks like in communities today. siecus report 29(6), 17-21. wilcox, b.l. (1999). sexual obsessions: public policy and adolescent girls. in n. johnson and m. roberts (eds), beyond appearance: a new look at adolescent girls (pp.333-354). washington, dc: american psychological association. jennifer friedman is a first-year master’s student at the columbia university school of social work and is enrolled in the dual-degree program at the columbia university school of public health. she is currently an intern at st. luke’s roosevelt hospital in the adult inpatient psychiatric unit. she holds a bachelor’s degree in latin american studies from brown university. her email address is jf2116@columbia.edu. the battle for effective sexuality education 16 journal of student social work, volume ii columbia social work review, vol. viii | 1 factors that contribute to intimate partner violence in same-sex relationships with hiv/aids jason freeman samuel gilbert aviva raskin darwin rodriguez the proposed study is designed to begin research into the impact of hiv/aids status on intimate partner violence (ipv) in same-sex couples. by comparing ipv in gay men’s relationships in which hiv/aids is present and relationships in which it is not, the proposal asserts that this research is necessary to further research and create prevention interventions in the lgbtqia communities that take intersectionality into account. the proposal theorizes that hiv/aids status should be looked at as a correlate to ipv, in addition to the factors previously identified as correlates such as: socioeconomic status, substance use, relationship history, and other psychological and emotional factors. introduction the primary goal of this proposed study is to explore the impact of human immunodeficiency virus/ acquired immune deficiency syndrome (hiv/aids) status on intimate partner violence (ipv) in same sex couples. by comparing ipv in gay men’s relationships in which hiv/aids is present to relationships in which it is not, we wish to set the stage for more research into ipv in the greater lgbtq community. doing so will allow professionals including social workers, clinicians, and physicians to create specific interventions that are uniquely targeted to serve these marginalized and underserved community. research on ipv in same-sex relationships is usually neglected, in contrast to research on heterosexual relationships (houston & mckirnan, 2007; merrill & wolfe, 2000). according to the center for disease control’s 2010 national intimate partner and sexual violence survey, the lifetime prevalence of rape, physical violence, or stalking by an intimate partner for men who engage in intercourse with men was 26 percent for gay men and 37.3 percent for bisexual men versus 29 percent for heterosexual men. these numbers indicate a pressing need for ipv prevention and intervention in the gay male community, especially as stigma often leads to under reporting. at present, the unique characteristics and impacts of ipv in same-sex couples and the particular needs of these couples are still relatively unknown (mcclennen, 2005). perpetrators of ipv may use their own or their partner’s hiv/aids status as a weapon of coercion. they may also fake illness or threaten to reveal the victim’s hiv/aids status (“domestic violence and hiv/aids nys opdv”, 2017). little is known about the prevalence and clinical associations between hiv/aids and ipv; this intersection needs to be thoroughly examined. the national coalition of anti-violence program’s (2015) report indicates that 44 percent of lgbtq and hiv-affected survivors of ipv who requested shelter services were rejected; 71 percent attributed the reason to gender identity. members of the lgbtq community experience minority stress in addition to relationship stress, which can manifest in various forms of abuse and violence when there is a high level of emotional dependency between intimate partners. when this dependency is present and there is also emotional enmeshment between partners in a relationship, violent behaviors can become a way to compensate for emotional imbalances (balsam & szymanski, 2005). literature review ipv is a relatively new area of research, and the major focus is on heterosexual relationships. prior to the 1970s, ipv was deemed a private matter that should be kept at home; it was not considered a federal crime until 1975 (hoyle & sanders, 2000). ipv gained visibility through the feminist movement in the 1970s, which helped many heterosexual women. the movement, however, largely left out the gay1 population. it is only recently that the campaign against ipv became more inclusive of such relationships. in 2002, an extensive study was done on the relationship dynamics of gay relationships in which domestic violence was present (mcclennen, summers & vaughan, 2002).. this study suggested that regardless of sexual orientation or gender, survivors chose not to leave their relationships because they loved their abusers. according to the findings, dependency, jealousy, power imbalances, and substance use are all factors correlated with ipv in the gay male population. from this discovery, one may conclude that ipv can affect anyone, no matter their gender or sexual orientation. this study broadened the scope of what was considered to be ipv and allowed the movement against ipv to start focusing on the pattern of power and control within a relationship rather than the person’s gender or sexual orientation (mcclennen, summers & vaughan, 2002). in 2005 and 2007, two studies looked at psychosocial factors in same-sex relationships. in the first study, researchers investigated minority stress as it affected relationship quality, as well as both lifetime and recent experiences of ipv. researchers found that sexual orientation and where one falls on the gender spectrum did not play a role in relationship 1 we are using this term to predominately refer to men who have sex with men, however it is generally inclusive of all same-sex relationships in this paper. 2 | columbia social work review, vol. viii quality or experiences of ipv in gay relationships (balsam & szymanski, 2005). the second study found a significant relationship between unsafe sex and ipv. researchers theorized that ipv impacted psychosocial characteristics and health issues among gay and bisexual men (houston & mckirnan, 2007). these studies show that a homosexual identity is critical to a person’s psychosocial development, and both argue that societal homophobia and heterosexism paired with internalized homophobia play a key role in ipv in homosexual relationships (balsam & szymanski, 2005; houston & mckirnan, 2007). additional studies have explored the prevalence, clinical associations, and impact of ipv on the gay male population. these studies sought to explain associations between ipv and available sociodemographic and psychological factors, clinical status, and both hiv/aids-related and unrelated hospitalizations. they found that, given the prevalence of ipv within the gay population, there is a demonstrated need for targeted services and intervention. in addition, when patients reported past and/or present ipv, they had significantly worse health-related quality of life outcomes (siemieniuk, et al., 2013). ipv was also associated with an increased progression rate from hiv to aids (siemieniuk, et al., 2013). the impact of ipv on people living with hiv/aids was clinically relevant due to the increased frequency of interruptions in care (houston & mckiernan, 2007). the study conducted by siemieniuk, et al. (2013) brought hiv/aids status into the conversation in a quantitative manner and showed that it needed to be further examined as a contributing factor toward ipv. conceptual framework disempowerment theory examines ipv from the perpetrator’s perspective and considers a broad range of characteristics that relate to the patterns of abuse in a relationship. the current research proposal will utilize disempowerment theory and three of its major domains – economic, psychological, and social – to explain the association between risk factors and ipv in same-sex relationships with hiv/aids. in line with disempowerment theory, individual characteristics, intimate relationship characteristics, and family of origin factors place individuals at risk for perpetration of ipv (mason et al., 2006). when an abusive partner feels as if their control is threatened, they may use violence or other abusive tactics to impose their will upon their partner (archer, 1994). see figure 1 as follows: figure 1 conceptual framework of the study of hiv/aids status and the factors that contribute to intimate partner violence (ipv) in same-sex relationships. methodology research design and sampling the populations of interest for this proposal are self-identified black, caucasian, and latino men living with hiv/aids and attend an hiv/aids clinic in nyc. all participants must meet the aforementioned criteria we will utilize a cross-sectional study approach for our research. the sampling frame will be obtained by handing out surveys in hiv/aids clinics in new york city. columbia social work review, vol. viii | 3 this study will use cross-sectional methodologies to provide a comprehensive picture of the present environment. our data analysis will include 300 participants: 100 caucasian, 100 black, and 100 latino. examining three different groups allows us to see any patterns that exist within the groups as well as compare any that emerge. data collection methods and measures the survey will be offered at clinic check-in to all patients, not just the target population to provide additional privacy, during routine visits. patients will be given a voluntary informed consent form to read and sign. both the survey and consent form will be subject to institutional review board approval. patients who voluntarily complete the survey will be offered consultation services by a social worker with ipv and hiv/aids expertise. sociodemographic and clinical variables including age at ipv screen, location of original diagnosis, self-reported ethnicity, income level, living arrangements, housing, and history of incarceration will be recorded at the initial visit and updated as appropriate. sections of the standard ipv screening tool wast (woman abuse screening tool, see appendix i) will be adapted for the survey. the wast is a series of eight questions that screens for emotional, physical, and financial abuse. a screening tool developed in 2013 for gay and bisexual men (see appendix ii) will also be incorporated into the survey, however whether it has ever been implemented widely is unknown (stephenson, hall, williams, sato, & finneran, 2013). we will analyze the data per the criteria laid out in our sampling methods, based on how the participants self-identify on the survey. the data collection will take one to two years and require six participating hiv/aids clinics. clinics will be recruited by invitation. we will analyze ipv in same-sex relationships among individuals living with hiv/aids via univariate, bivariate, and multivariate statistical procedures and compare it to data for those living without hiv/aids. first, we will conduct descriptive analyses to produce the profile of the 300 participants in the study sample. second, we will use bivariate analyses to examine hiv/aids status and ipv among the participants. third, we will employ multivariate analyses to identify factors associated with ipv among same-sex couples with hiv/aids. table 1 – measure of variables independent variables measures socio-demographics & history of participant gender identity female = 0; male = 1 ; non-binary = 2 age age of person income level tiered levels of income 0-10,000 = 0; 10,000-30,000 = 1; 30,000-50,000 = 2; 50,000-75,000 = 3; 75,000-100,000 = 4; 100,000-250,000 =5; 250,000+ = 6 ethnicity white/caucasian = 0; african american/black = 1; hispanic/latino = 2; asian pacific islander = 3; other = 4 sexual preference female = 0; male = 1; either = 2; other = 3 receiving public assistance no = 0; yes = 1 living arrangement alone = 1; cohabitating with partner or others = 2 housing homeless = 0; supported temporarily= 1; stable = 2 history of incarceration no = 0; yes = 1 history of childhood abuse no = 0; yes = 1 frequency of social calls (support) in a month: never = 0; rarely = 1; sometimes = 2; often = 3; frequently; 4; everyday = 5 4 | columbia social work review, vol. viii mental and physical health hiv/aids diagnosis no = 0; yes = 1 location of original diagnosis variable depression prior to hiv diagnosis no = 0; yes = 1 hiv psychiatry appointment in past year? no = 0; yes = 1 psychiatry appointment ever? no = 0; yes = 1 other mental health diagnosis no = 0; yes = 1 substance use alcohol use never = 0; rarely = 1; infrequently = 2; sometimes = 3; often = 4; almost day = 5; everyday = 6 illicit substance use (including marijuana in locations where it has been legalized) no = 0; yes = 1 smoker current = 0; former = 1; never = 2 socio-demographics of participant’s partner sex female = 0; male = 1 age variable income level tiered levels of income 0-10,000 = 0; 10,000-30,000 = 1; 30,000-50,000 = 2; 50,000-75,000 = 3; 75,000-100,000 = 4; 100,000-250,000 =5; 250,000+ = 6 ethnicity white/caucasian = 0; african-american/black = 1; hispanic/latino = 2; asian pacific islander = 3; other = 4 living arrangement alone = 1; cohabitating with participant = 2 illicit substance use no = 0; yes = 1 alcohol use no = 0; light drinker = 1; moderate drinker = 2; heavy drinker = 3 frequency of social calls in a month: never = 0; rarely = 1; sometimes = 2; often = 3; frequently; 4; everyday = 5 dependent variables measures intimate partner violence *”yes” or “no” responses were collected. relationship (ipv experienced within)* only current = 0; only previous = 1; both current and previous = 2 columbia social work review, vol. viii | 5 type of abuse* emotional = 0; physical = 1; sexual = 2; intimidation (using hiv) = 3; financial = 4; isolation = 5; neglect = 6 number of abuse types experienced * one = 0; two = 1; three = 2; four = 3; five = 4; six = 5; seven = 6 discussion & conclusion several limitations of this study should be taken into consideration. first, using a cross-sectional method will not allow us to determine causality (balsam & szymanski, 2005; houston & mckiernan, 2007). because our participants will be actively engaged in services through hiv/aids clinics, the study sample cannot be considered representative of the entire population of interest, as one of the hallmarks of ipv is isolation from and lack of engagement in services (herman, 2015). this study is limited to a single same-sex population in new york city, so the gay male population in rural areas and in other cities will be neglected, in addition to the rest of the lgbtq community. additionally, we will look at three generalized racial groups in our study. other groups and associated communities may show results that differ from those of the groups included in this study. expanding the scope of the study to include other sexual orientations, identities, or hiv negative couples would add additional insight into the impact of fixed variables on overall ipv. future potential studies should address these concerns and issues of ipv. there are technical limitations to this study in that there is not a well-established and researched measure for ipv in the lgbtq communitiy, much less one that takes into account the intersectional nature of human experience. for example, the standard eight-question wast tool that is used to rapidly assess whether someone is in an abusive relationship is woman centered (herman, 2015). in addition, many of the studies treat the lgbtq community as one homogenous group, and sometimes assume that what is applicable for one subset of the population applies to another and not as a diverse population. individuals in the lbgtq communities already experience oppression and discrimination in their day-to-day lives (harper & schneider, 2003). the lack of services tailored to the unique needs of the survivors of abuse in same-sex couples with hiv/aids is a further injustice. professionals – including social workers, clinicians, and physicians – should be educated about the specific needs of the different populations they serve to provide or advocate for the appropriate resources. due to the stigmas attached to being gay, having hiv/aids status, or being an ipv survivor, clients who have experienced ipv are likely to be reluctant to disclose experiences of abuse (carvalho et al., 2011; national sexual violence resource center, 2008). professionals would benefit from an understanding of the unique factors of ipv in same-sex couples while conducting assessments and interventions so they can design strategies for this population. references balsam, k. f., & szymanski, d. m. 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(2013). towards the development of an intimate partner violence screening tool for gay and bisexual men. western journal of emergency medicine, 14(4), 391-401. doi:10.5811/westjem.3.2013.15597 umberson, d., anderson, k., glick, j., & shapiro, a. (1998). domestic violence, personal control, and gender. journal of marriage and family, 60(2), 442-452. doi:1. retrieved from http://www.jstor.org/stable/353860 walters, m. l., chen, j., & breiding, m. j. (2013). nisvs: an overview of 2010 findings on victimization by sexual orientation. retrieved october 24, 2016, from http://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_victimization_final-a.pdf waterman, c. k., dawson, l. j., & bologna, m. j. (1989). sexual coercion in gay male and lesbian relationships predictors and implications for support services. the journal of sex research, 26(1), 118-124. 2015 report on lesbian, gay, bisexual, transgender, queer, and hiv-affected intimate partner violence avp: the anti-violence project. (2015). retrieved october 14, 2016, from http://avp.org/resources/avp-resources/554 samuel gilbert samuel gilbert is a columbia university student from minnesota. as an openly gay man from rural minnesota, he learned first-hand what it feels like to be oppressed and disenfranchised. this ostracizing feeling fueled his passion to help others like him. in his undergraduate career at st. cloud state university, he studied applied sociology. sociology helped him continue to develop his passions for social justice. samuel began working with the lgbtq+ community on campus, the intimate partner violence campus program, and undocumented immigrants in the surrounding area. in the future, his goal is to continue doing research that focuses on the intersection between lgbtq+ relationships and intimate partner violence. jason freeman jincong q. freeman (jason) received his bachelor’s degree in economics from the university of minnesota-twin cities in 2014. he is currently a firstyear graduate student at columbia university school of social work. he focuses on advanced clinical practice with the field of practice in health, mental health, and disabilities. jason interns at selfhelp community services, where he works with senior adults in applying government benefits. he is also a research assistant for dr. elwin wu at social intervention group, where he studies hiv prevention and intervention among black/ african american men who have sex with men. jason expects to graduate in may 2018 and plans to apply for ph.d. programs after graduation, so he can continue to pursue research in population health and hiv/aids prevention intervention related topics. aviva raskin aviva f. b. raskin received her bachelor’s degree in linguistics from reed college in 2009. she is a dualdegree msw/mph candidate at columbia’s mailman school of public health and school of social work. she conducted original research for her b.a. on japanese women’s language. this lead her to investigate ipv in japanese society. her interest in hiv/aids came from growing-up in the bay area in the early 1990s where she watched her favorite teacher pass away from aids. prior to graduate school aviva volunteered in dv shelters as a peer/community advocate, worked on dv hotlines, and as a casa. aviva is currently working with dr. elwin wu on hiv prevention and intervention among black/ african american men who have sex with men. darwin rodriguez darwin earned a ba in international business (2005) and a ms in international management (2013), but his passion for helping people led him to transition into social work. he is currently a first-year student at columbia school of social work (cssw). however, his involvement with social justice started in his native venezuela at the age of nine when he was a unicef ambassador for his community. he is concentrating in advanced clinical practice and is interested in counseling survivors of trauma within the lgbtqia community. darwin is currently working at year up (new york city) where he contributes to a program aspiring to empower low-income young adults to go from poverty to professional careers. appendix i woman abuse screening tool (wast) columbia social work review, vol. viii | 7 1 in general, how would you describe your relationship? a lot of tension, some tension, none 2 do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty? often, never, sometimes 3 do arguments ever result in you feeling down or bad about yourself ? often, never, sometimes 4 do arguments ever result in hitting, kicking, or pushing? often, never, sometimes 5 do you ever feel frightened by what your partner says or does? often, never, sometimes 6 has your partner ever abused you physically? often, never, sometimes 7 has your partner ever abused you emotionally? often, never, sometimes 8 has your partner ever abused you sexually? yes, no rabin, r. f., jennings, j. m., campbell, j. c., & bair-merritt, m. h. (2009). intimate partner violence screening tools. 36(5). appendix ii screening tool for gay and bisexual men 1 have arguments in your relationship escalated into any of the following: destruction of property, grabbing, restraining, pushing, kicking, slapping, punching, threats of violence or other acts of physical intimidation? yes, no 2 has your partner pressured or forced you to do something sexual that you didn’t want to do? examples may include any of the following: oral or anal sex, having sex with others, having sexual partners outside the relationship, or any other sexual activity that made you feel uncomfortable. yes, no 3 has your partner pressured you to have sex without a condom after you asked to use a condom? or do you suspect that your partner has lied to you about their hiv status, or intentionally tried to transmit hiv to you? yes, no 4 has your partner insulted, criticized, threatened or yelled at you in any way? examples may include the following: using slurs, calling you names, calling you fat, criticizing your sexual performance, criticizing your clothing, asking you to act more masculine or threatening to out you yes, no 5 has your partner prevented you from communicating with or seeing your friends/family/coworkers? or monitored or demanded access to your cell phone, email, social networking sites, finances or spending? yes, no 6 have you ever felt afraid, threatened, isolated, trapped or like you were walking on eggshells within your relationship? or have your friends or family raised concerns about your safety within your relationship? yes, no stephenson, r., hall, c., williams, w., sato, k., & finneran, c. (2013). towards the development of an intimate partner violence screening tool for gay and bisexual men. western journal of emergency medicine, 14(4), 391-401. doi:10.5811/westjem.3.2013.15. 2018-final.pdf 34 | columbia social work review, vol. ix mass incarceration: overview of its effects on black and brown individuals, with policy recommendations using family engagement to address recidivism durrell malik washington black and brown men are negatively impacted by the criminal justice system and have been incarcerated at higher rates than any other group in the united states (knafo, 2013). the united states criminal justice system is built on punishment and exploitation rather than rehabilitation, resulting in higher rates of incarceration and recidivism compared to other developed nations (gilligan, 2012). countries such as norway and the united kingdom take a more humane approach to their criminal justice system, resulting in low recidivism rates (sterbenz, 2014). implementing policies that aim to keep families connected with individuals who are incarcerated is a major way to reduce recidivism rates (clarke, 2013). using new york state as a case study, this paper will propose extending conjugal visits beyond medium and low-security prisons and implementing skype technology in prisons and jails as policy solutions to promote the well-being of people who are incarcerated and keep them from returning to prison once they are released. social workers can play a vital role in efforts made to shift the united states’ criminal justice system from a culture of punishment towards a restorative model. introduction we live in a nation of incarceration. the united states has only 5% of the world’s inhabitants, but 25% of the world’s prisoners the largest prison population in the world (rabuy, 2017). when asked to describe mass incarceration using one word, slavery is apt. over the course of its history, the united states has repeatedly developed new systems and strategically implemented policies to marginalize and oppress individuals of color (butler, 2017). slavery was made illegal in 1865 (frundt, 2011). however, with the slave system in demise, oppression under the new name of “law and order” was born (alexander, 2012 p. 40). the united states criminal justice system is known for disproportionally targeting and imprisoning black and brown bodies (gilligan, 2012). the system is supposed to be built on rehabilitation; however, it has become an institution established on punishing those who are incarcerated and exploiting them for the economic gain of outside vendors (butler, 2017). not only are black and brown bodies locked up, but many policies also keep them completely cut off from contact with the world outside of prison walls (national research council, 2014). columbia social work review, vol. ix | 35 durrell malik washington instead of rehabilitation, individuals can become institutionalized to the point that they are no longer able to cope and re-adjust to life on the outside (butler, 2017). once released, formerly incarcerated people have stigmas attached to them because of their record and are stripped of their natural born rights of access to healthcare, employment, housing, and education (national research council, 2014). these barriers contribute to high rates of recidivism amongst formerly incarcerated individuals in the united states. how can we use the unjust system currently in place to help individuals of the carceral state? this paper will address the effects mass incarceration has both historically and presently had on black and brown people while also suggesting how policies to connect families with incarcerated loved ones can enhance the chances of keeping individuals from becoming repeat offenders. effects of mass incarceration on black and brown individuals within the u.s. constitution lies the 13th amendment, which prohibits slavery and involuntary servitude “except as a punishment for crime whereof the party shall have been duly convicted” (u.s. const. amend. xiii). this portion of the amendment has been used to legally justify enslaving black and brown bodies and stripping them of their natural rights (king, 2016). similarly to the days of slavery, incarcerated people are often shackled from their hands down to their feet. they are forced into harsh labor conditions with minimal if any, financial reciprocation. they are subjected to substandard living conditions, as well as mental, physical and sexual abuse. once released, they are stripped of the rights and freedoms that are supposed to extend to all people in society (florio, 2018). they are now stigmatized, becoming even more marginalized and oppressed because of their criminal record (national research council, 2014). incarceration is one of the many ways marginalized, and oppressed bodies are kept at lower class status (butler, 2017). laws, policies, and platforms evolve over the decades to continuously target and push people of color into the criminal justice system and keep them at or below the poverty line (rikken, 2018). phrases such as “jim crow” and “black codes” are historical reminders of how a larger system has viewed people of color “how can we use the unjust system currently in place to help individuals of the carceral state?” “they are forced into harsh labor conditions with minimal if any, financial reciprocation. they are subjected to substandard living conditions, as well as mental, physical and sexual abuse.” 36 | columbia social work review, vol. ix mass incarceration: effects and policy recommendations throughout history (bundles, 2015). the implementation of legalized segregation in the past placed limits on the places people of color could go, the education they could receive, and the jobs they could hold (hansan, 2011). after the official end of segregation, the “war on drugs” became its replacement, sparking the mass incarceration of black and brown individuals into the newly created prison industrial complex (fornili, 2018). one in three black males and one in six hispanic males will go to prison within their lifetime. those numbers far outweigh incarceration rates for any other group in the u.s. (knafo, 2013). the effects of these larger policies can have detrimental effects on a person (national research council, 2014). however, we do not always look at incarceration as a holistic entity that affects not only the person who is incarcerated but also the many different systems to which that person belongs. families of incarcerated people can suffer from psychological, emotional and financial problems as a result of one’s incarceration (arditti, 2016). when an individual goes through a period of incarceration, it is essential to look at them within their broader environment and assess the behavior related to the alleged crime, as well as factors that might have triggered the behavior (visher et al., 2014). factors such as the community where a person comes from, his or her mental health status, and his or her family functioning can be helpful in understanding what may have led to incarceration. understanding what led up to the behavior is important because it can shed light on ways to prevent similar action in the future (national research council, 2014). a criminal justice system that financially gains off of the trauma and exploitation of people should be reformed. this country has been built off of the labor of, and profiteering off of people of color for centuries (bell, 2007). the systematic oppression enforced by mass incarceration has been disguised using policies such as the “war on drugs” and “stop and frisk,” which are targets on black and brown bodies in order to continue a narrative that is displayed through media and other outlets labeling people of color as criminals (fornili, 2018). effects of family engagement policies on recidivism people released from prison face many different obstacles that can make it hard for them to readjust upon release (visher et al., 2014). these include homelessness, unemployment, and substance abuse (visher et al., 2004). not only did the number of prisoners quadruple between the 1970s and early 2000s, so did the number of people reentering communities once released from prison (sabol et al., 2009). to dismantle the prison industrial complex, one step to take is reducing recidivism rates. recidivism is a person’s relapse into criminal behavior (cohen, 2017). over the years, columbia social work review, vol. ix | 37 durrell malik washington many policies and initiatives have been implemented to reduce recidivism rates. many of these policies address different factors that can either cause or prevent incarceration, such as mental health programs, substance use programs, and restorative justice programs (roberts, 2012). promoting family engagement for individuals while they are incarcerated can also ease transitions back into the community upon release. implementing family engagement policies could reduce recidivism rates, impacting individuals of color who are recurring offenders (clarke, 2013). nationwide, prison visitation policies are implemented in some form (sterbenz, 2014). however, some of these policies can be problematic. duwe and clark (2011) state that “visitation policies can actually inhibit visits from family, friends… offenders are primarily responsible for conveying visitation rule if a visitation is denied, it is the prisoner’s responsibility to relay that information” (duwe & clark, 2011, p. 4). nevertheless, research has demonstrated over the years that visits from family members improve behavior and lower the likelihood of recidivism (clarke, 2013). one of the first studies done on prison visitation and recidivism found that only 2% of individuals who had visitors within their final year of incarceration returned to prison, compared to more than 12% of those who did not (duwe & clark, 2011). as prison sentences have increased, incarcerated individuals have had a more difficult time maintaining social support networks (lynch & sabol, 2001). removal from their families for an extended period can cause individuals to feel incredibly isolated while incarcerated. this isolation can affect behavior while incarcerated, as well as behavior once released (friedmann, 2014). having a connection to one’s family correlates with lower crime and lower recidivism rates (lavigne et al., 2005). in the following sections, i will examine current policies aimed at connecting families with loved ones who are incarcerated, as well as policy changes that could improve the system. effects of family contact according to the vera institute, a nationally recognized research and policy organization, maintaining a connection between family members and incarcerated people is essential (friedmann, 2014). the primary ways imprisoned people stay connected with their families are through prison visits, letters, and phone calls. most prison institutions have policies in place to facilitate family contact through these three methods; however, these systems need to be revamped. independent evaluations of family contact policies have shown that many of them can be problematic (giovanna, 2013). 38 | columbia social work review, vol. ix mass incarceration: effects and policy recommendations letter writing writing letters can be an efficient way for people to stay in contact with family members. maintaining family ties has been correlated with helping an incarcerated person to succeed once they are released (sakala, 2013). however, some letter writing policies can be deemed unfair. some prison institutions do not allow individuals or their families to send letters bigger than a piece of paper the size of a postcard (friedmann, 2014). limiting how much a person can write does not allow individuals to express themselves openly and effectively when trying to communicate with a loved one. nevertheless, because individuals who are incarcerated may be located far distances from their families, letter writing is a significant tool of communication between them. visitation access to family visitation has been shown to affect recidivism rates. being able to interact with one’s family has been heavily correlated with positive behavior both while incarcerated, as well as upon release (clarke, 2013). a 2011 study by the minnesota department of corrections followed over 16,000 ex-prisoners over five years, examining differences in recidivism rates between those who received prison visits and those who did not (clarke, 2013). results demonstrated that any level of visitation lowered the risk of recidivism. felony re-convictions were 13% lower for those who received prison visits. visitation had an even more significant impact on technical violation revocations, which were 25% lower.visitation can, however, be unpleasant. there are often long wait periods, invasive searches, limited visitation times, and other unfair or burdensome rules. for example, a report from the vera institute describes: one female attorney said she was told by prison officials that she could not visit a prisoner because her underwire bra set off the metal detector. after leaving, removing her bra and then returning, she was told she could not visit because she wasn’t wearing a bra” (friedmann, 2014). there are also prisons that only allow visitation on the weekends (sims, 2017). continuous obstacles in the way of staying connected with loved ones who are incarcerated can make visitation undesirable, which can prevent family members from wanting to partake in visits due to some of these rules (giovanna, 2013). phone calls regular phone conversations also can reduce recidivism rates among formerly incarcerated individuals. however, evaluations of phone policies in prisons and jails have revealed that inflated phone rates have resulted columbia social work review, vol. ix | 39 durrell malik washington in barriers to contacts between prisoners and their families and friends. people from low-income families cannot afford to continuously pay for phone calls at increasing rates. in order for phone calls to be an effective form of family contact, they have to be made more affordable (friedmann, 2014). international efforts internationally, many countries seem to be more advanced in their efforts to reduce recidivism than the united states. when looking abroad, the literature illustrates a more humane approach. many foreign justice systems, particularly those in europe, emphasize rehabilitation rather than punishment. for example, germany builds normalization into their policies: the experience while incarcerated is as close to life on the outside as possible. some of these policies have helped to keep other countries’ recidivism rates low (sterbenz, 2014). in the united kingdom, there are many opportunities for family visitations, including prison visitation centers in england. in canada, incarcerated people are provided with an opportunity to have private family visits in separate areas that have access to a kitchen and living space; these visits can last up to 72 hours at a time and can occur every two months. denmark has instituted policies in which, every third weekend of the month, prisoners can leave for the weekend to be with their families. these policies have not resulted in increases in crime. many international criminal justice systems rehabilitation efforts are reflected in their low rates of recidivism (sterbenz, 2014). new york state visitation policy issues new york state governor andrew cuomo’s 2017-2018 budget contained a proposal to reduce visitation days at maximum security correctional facilities (sylvia rivera law project, 2017). governor cuomo states that the visitation reduction is intended to cut costs and to align maximum-security policy with medium-security facilities (abraham, 2017). however, as previously discussed, prison visits have already shown the ability to reduce recidivism (clarke, 2013). it is counterintuitive to make prison visits more difficult. family members of incarcerated people often have to travel far distances to remain connected with their loved ones. restricting the days during which they can visit may reduce someone’s chance of even having visitors at all. (abraham, 2017). policy change may also lead to congestion problems during visitations because of restricted days (rivera, 2017). 40 | columbia social work review, vol. ix mass incarceration: effects and policy recommendations policy recommendations a lack of family reunification programs can be a root cause of high recidivism rates. in addition to facilitating visitation in prisons, as discussed throughout this paper, other policies intended to keep individuals connected with their families can be strengthened or implemented. specifically, i propose two policies aimed at lowering recidivism through family engagement programs: (1) inmate conjugal visits implemented in all jails and state prisons. (2) inmate access to skype video chats in conjunction with telephonic communication. these policies can be applied in to all jails and prisons in new york state. inmate conjugal visits implemented in all state prisons and jails new york is one of only four states (the others being california, connecticut, and washington) that allow conjugal visits. however, these programs are currently only allowed in medium and low security prisons (dopplr, 2017). one major policy change would be to extend conjugal visits to all correctional facilities throughout the state. if a prison is large enough, administrators could designate specific sections for hosting families. otherwise, external trailers could be purchased for this purpose. although pushback would not generally be expected, there might be opposition around conjugal visits for inmates serving time for certain offenses, such as sexual assault (lochrie, 2014). eligibility restrictions could be applied if necessary, allowing the majority of incarcerated people to still benefit. access to skype video chats in conjunction with phone calls phone calls are a major means of maintaining family contact, but they can also be problematic. in 2013, the fcc proposed a plan to impose rate caps and lower intrastate phone rates to keep costs down for people who were incarcerated (marimow, 2017). in response, a number of corrections officials filed objections to the plan (friedmann, 2014). prisons and jails nationwide have thus far received hundreds of millions of dollars in kickbacks from prison phone companies, resulting in inflated phone rates that create financial barriers to communication between prisoners and their family members (friedmann, 2014). implementing policies that allow prisoners to communicate via skype would make up for current faults in established policies (stroud et al., 2015). doing so would save money for both families and institutions, and columbia social work review, vol. ix | 41 durrell malik washington prisoners would be able to use commissary money to pay the prison, as opposed to paying phone companies directly. instead, the prison could pay a monthly internet fee to supply the prison with broadband access, enabling electronic communication. prisons in st. louis have implemented this policy, yet phone companies continue to try to take the majority of profits (stroud & brustien, 2015). by installing internet connections, the main financial compensation would be kept in-house. this innovation would be beneficial to family members who may have to travel extensive amounts of times, or simply do not wish to be subjected to prison searches, to save money (stroud & brustien, 2015). importance of social workers role in this work social workers can play a significant role in revamping the scope of the criminal justice system in the united states. social work is based on an ethical framework that emphasizes fighting for social justice and empowering oppressed and marginalized individuals in society (national association of social workers, 2008). social workers can lead research initiatives, create programs, propose policies, and advocate on behalf of incarcerated individuals to help end injustices, by advocating for policies that promote family engagement for people while they are incarcerated. conclusion allowing individuals who are incarcerated a means to stay connected with the outside world is just one of the many ways to reduce recidivism and promote community. a system that aims to rehabilitate individuals should focus on developing ways in which behavior can be changed, and opportunities can be provided. punishment has shown to be a method that does the opposite. the benefits of the policy proposals to extend conjugal visits to all jails and prisons and to allow prisoners access to skype telecommunication extend not only to incarcerated individuals and their families, but also to correctional staff. more humane policies can help lower recidivism and keep staff safe. efforts should continue to be made in order to strengthen these policies in order to benefit everyone. references abraham, r. 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(2017, december 09). the end of american prison visits: jails end faceto-face contact– and families suffer. retrieved march 20, 2018, from https:// www.theguardian.com/us-news/2017/dec/09/skype-for-jailed-video-callsprisons-replace-in-person-visits 44 | columbia social work review, vol. ix mass incarceration: effects and policy recommendations sterbenz, c. (2014, december 11). why norway’s prison system is so successful. retrieved november 14, 2017, from http://www.businessinsider.com/whynorways-prison-system-is-so-successful-2014-12. stroud, m., & brustein, j. (2015, april 29). ‘prison skype’ squeezes out in-person visits, soaking inmate families. retrieved november 26, 2017, from http:// www.stltoday.com/business/local/prison-skype-squeezes-out-in-personvisits-soaking-inmate-families/article_34e133d4-b0a7-5aa6-b7e8d75707f154d4.html sylvia rivera law project. (2017, april 15). tell cuomo that visits matter! retrieved february 07, 2018, from https://srlp.org/action/tell-cuomo-thatvisits-matter u.s. const. amend. xiii. visher, c. a., la vigne, n., & travis, j. (2004). returning home: understanding the challenges of prisoner reentry. maryland pilot study: findings from baltimore. washington,dc: urban institute, justice policy center. durrell malik washington is a second-year advanced standing student at the columbia university school of social work. at columbia, durrell interns in the safe lab which is a research initiative focused on examining the intersections between social media and violence. under the supervision of dr. desmond patton, durrell supports ongoing qualitative research using social media and other forms of technology to understand the context behind online language. durrell also assists in developing linguistic algorithms, to equip an artificially intelligent chatbot (wysa), specializing in cognitive behavioral therapy, with the ability to serve as an intervention tool for youth of color. durrell is a beyond the bars fellow. the fellowship is built around helping students and community members develop a deeper understanding of mass incarceration and social change. durrell’s interest centers on criminal justice reform, and the different nuances that leads to people of color entering the carceral state. 46 journal of student social work, volume ii spissinger paradigm of rural homelessness: a case study of clinton county, new york rural homelessness is a social problem that has drawn limited scholarly attention in the social work field. this case study of clinton county, new york, examines the existing service structure to address homelessness while highlighting challenges universal to rural homelessness as a widespread phenomenon. this paper considers possible long-term solutions to rural homelessness, and argues for a structurally based approach to understanding homelessness, either in an urban or rural setting. jessica spissinger understanding homelessness prior interventions to address homelessness have sprung from the belief that homelessness is a personal problem (koegel, 1996). this paper leans toward understanding homelessness as the result of larger, structural problems, including: the lack of affordable housing; lack of a decent, living wage; restricted access to transportation; and lack of affordable childcare and health care. under a structural framework, it is clear that beyond housing, a multitude of factors contribute to an individual’s state of homelessness (jencks, 1994). as social workers, it is imperative to look critically at the macro level and understand how larger, economic conditions and policies have directly influenced the current paradigm of homelessness. clinicians, generalists, administrators, as well as researchers must advocate to fight the growing trend of poverty in this country – in rural, as well as in urban settings. homelessness in a rural setting with approximately 40,000 homeless people on a given night (new york city department of homeless services, 2004), new york city has made a powerful mark on society’s perception of homelessness. an entire city government sector – new york city’s department of homeless services – is dedicated to the homeless, and service providers from other cities have examined new york city’s services as a model for helping the homeless on their own streets (campbell & mccarthy, 2000). marked as an urban issue, homelessness is not often associated with the country or rural areas. in fact, rural homelessness is a problem that appears to be much smaller in size due to smaller population densities (aron & fitchen, 1996). in urban regions, the street homeless constantly encroach upon public spaces, whereas homeless people who are utilizing shelters more readily blend into the mainstream. likewise, in a rural setting, the problem of homelessness altogether escapes the public eye, due to the less concentrated proximity of small towns and distant rural settings. homelessness in a rural setting is defined by substandard housing, doubling up/overcrowding, squatting in abandoned buildings, and utilizing campgrounds as a year round domain (fitchen, 1992). because homeless populations in rural settings are more likely to live in sparse settings, outreach efforts are difficult. the issue of rural homelessness becomes a catch-22: since most of the rural homeless population are unaware of the services provided, there is not a large request for services. due to this lack of request for services, many local departments of social services have not identified homelessness as a major problem (aron & fitchen, 1996). thus, there are few services available due to the false conclusion that they are not needed. among scholars, rural homelessness is a subject that has not drawn widespread attention. many research reports on homelessness, such as the national survey of homeless assistance providers and clients (the urban institute, 1999) conclude that homelessness is predominantly an issue for urban areas to address. according to the report, 70% of the united states homeless population live in cities and 20% live in suburban areas. because only 10% of the national homeless population live in rural areas, such areas are written off and the problem of homelessness is widely overlooked. yet drawing the conclusion that homelessness is marginal in rural areas is flawed, as it does not factor in the ratio of homeless to non-homeless to realistically compare the proportion of people who are living in extreme poverty. in a study on rural homelessness in iowa, the rate of homeless people in rural counties compared to urban areas was much higher in rural regions. new york city had an average of 5.09 homeless per 1000 people, compared to appanoose county in iowa where the number of homeless was 9.7 per 1000 people. similar comparisons from other rural areas reveal an incidence of homelessness much greater than in urban areas (lawrence, 1995). comparable to urban environments, rural poverty results from similar structural causes. fitchen (1992), an avid researcher of rural homelessness in upstate new york in the early 1990s, lists numerous factors that create a population in rural areas who are perpetually at risk of homelessness. these factors include dilapidated and overcrowded housing such as deteriorating trailers and converted farmhouses; the intergenerational cycle of poverty; limited access to public transportation; and lack of job opportunities, all of which are abundant in clinton county, new york. the major difference between rural and urban poverty and homelessness is that in rural areas, paradign of rural homelessness journal of student social work, volume ii 47 48 journal of student social work, volume ii spissinger poverty and homelessness are spread out, making widespread appeals to the issue much more difficult to form. rural homelessness varies tremendously depending on state, county, and locality. despite the fact that new york state is considered a highly urbanized state, 44 of its 62 counties are classified as rural (merwin rural services institute, 2001). fitchen based her research on a sampling of approximately eight rural counties in new york state. honing in further on rural new york state, this paper will examine clinton county, a mid-sized county classified as rural. clinton county: an economic overview clinton county is the most northeastern county in new york state, bordering lake champlain on the east and quebec, canada on the north. the adirondack mountain region lies just south and west of the county border. the total population of clinton county is 79,894 (new york state, 2003) divided among 29,423 households (national low income housing coalition, 2003). the clinton county housing needs report, compiled by the clinton county housing committee in 2003, highlights the most pressing problems in clinton county and outlines current methods utilized to address them. considering a structural understanding of homelessness, three issues stand out in clinton county: economic opportunity; public transportation; and affordable housing. clinton county is similar to many rural counties nationwide that suffer from slim economic opportunities. the majority of residents in clinton county find work in the city of plattsburgh, often at the state university of new york, champlain valley physicians hospital medical center, or bombardier transportation. while these institutions provide gainful employment for some, over 10,000 people in clinton county live in households with an annual income below the poverty level (clinton county housing committee, 2003). with the new york state minimum wage holding to $5.15 an hour, many full-time workers at this level are still unable to pay necessary expenses. single women with children present the highest rate of poverty in clinton county (clinton county housing committee). access to reliable transportation is imperative for people who reside in rural areas to commute to and from work and run routine errands. lack of access to transportation can be a major barrier for a person obtaining employment, thus resulting in poverty or homelessness. approximately 10% of households in clinton county and 20% of residents in the town of plattsburgh do not have access to a vehicle (clinton county housing committee, 2003). the only local transportation system, clinton area rural transit, offers limited bus routes into plattsburgh. affordable housing, while available, is starting to diminish. much of the lower-rent housing which exists – mobile housing, low-rise apartments, and single-family homes – is substandard and often ill-suited to shut out the harsh winters. one of five residents in clinton county lives in mobile homes (clinton county housing committee, 2003). many mobile home renters deal with numerous complications with their housing, often brought about by their landlords, causing the trailers to be in substandard condition. some of the common complications include leaking septic systems, abandoned or dilapidated neighboring trailers, non-potable water supply, and hazardous electric wiring. these conditions are so prevalent, that approximately 25% of mobile home parks in clinton county did not pass the department of health inspections during 2002 (clinton county housing committee). homelessness in clinton county as with many rural areas, the precise number of homeless and duration of homelessness in clinton county are difficult figures to determine. from january to june 2002, approximately 400 people utilized emergency housing services, including temporary shelters and supportive services such as food and transportation, throughout clinton county (clinton county housing committee, 2003). of these, roughly one-third were families. an estimate of 800 people becoming homeless each year amounts to roughly .01% of clinton county’s population. though this may appear small, it is larger than the percentage in new york city, where the estimated average population of homeless is .005% of the total population. the clinton county department of social services (dss) has responded to emergency housing needs by providing shelters, intensive case management, and at times placing people in local motels or hotels through the local crisis center (clinton county housing committee, 2003). there are also a few non-profit agencies that provide further resources for emergency housing. while emergency housing services are in place, the clinton county housing committee estimates a 20-bed deficit for emergency shelter in the region, meaning the existing beds are continually at full capacity. this forces the dss to utilize private motels to service the overflow. one major challenge to the clinton county area is that it has received less state and federal dollars to support affordable housing than other similar counties throughout new york state (clinton county housing committee). again, this inadequate funding points to the catch-22 of rural housing: a lack of knowledge of existing services among homeless leads to less usage, and less usage leads to the legislative conclusion that the services are not needed. when translating the number of homeless into the cost to provide emergency shelter, costs are approximately $400,000 per year. supportive costs to keep children in school or day care, provide transportation, and obtain needed medical care and food quickly drives the costs past the half-million dollar mark. while this number may seem low compared to paradign of rural homelessness journal of student social work, volume ii 49 50 journal of student social work, volume ii spissinger urban areas that have multi-billion dollar budgets, the clinton county dss resources are strained to provide this assistance. as the dss addresses additional needs of homeless families beyond immediate shelter, costs will clearly escalate. solutions to rural homelessness during the 1980s and early 1990s, a nationwide surge of public awareness toward urban homelessness led to rapid construction of shelters to solve the problem. the contemporary perspective supported by researchers points to three levels to address homelessness: improve existing emergency shelter and prevention efforts for those on the verge of becoming homeless; provide transitional and permanent housing placements; and attack the underlying causes of homelessness through policy changes (campbell & mccarthy, 2000; fitchen 1991; fitchen 1992; koegel, 1996). an emphasis on continuum of care supportive services at all three levels is pointing to increased outcomes of successful transitions out of homelessness (baron, 2003). while rural homelessness does not compete in sheer numbers to urban homeless, it constitutes a problem with uniquely rural issues to address. these issues are not served by following an exclusively urban model. the three-level approach described above was developed for an urban model and ought to be changed to address rural differences. one over-arching modification to develop when considering a rurally focused service model is the definition of homelessness. since the homeless populations in rural settings are more likely to live in a physical shelter such as substandard housing or campsites, the lack of visible street homeless in rural areas such as clinton county diffuses any momentum that might exist to address the problem on a local, state, or national response. by changing the definition of homelessness in rural areas, two immediate changes would occur: a dramatic increase in homeless numbers and recognition by legislators and tax-payers that homelessness is a problem in their area. this would hopefully lead to motivation to respond to the problem. as the rural response to homelessness is still in a period of development, modification from the urban service model is possible and necessary. whereas new york city and other urban areas underwent largescale construction of shelters to improve emergency shelter (campbell & mccarthy, 2000), the rural response to homelessness could instead focus on preventative interventions. structural improvements on existing housing classified as substandard and the creation of new housing stock to improve the lack of affordable housing in the area would address a crucial aspect of the problem. such rehabilitation and construction could be financed under a national housing trust fund, such as h.r. 1121 and s.1411, currently in committees in the house of representatives and the senate. unlike urban areas that are pressed for the space and affordability, building in rural areas is generally an affordable endeavor due to lower property value and abundant space to build. creation of affordable housing and supportive housing is an economic stimulus, which might lead to the creation of jobs in the area. supportive housing is a trend that is successful in both rural and homeless areas (baron, 2003) and with federal, state, and local support, could be dramatically helpful in keeping people from becoming homeless. a continuum of care program has demonstrated success in urban areas, and would likely do well in rural areas, as it supplements preventative measures by supporting those who are at risk of becoming homeless. call for action among social workers social workers can play an important role in addressing the problems of rural homelessness through work as clinicians, advocates, researchers, and educators. clinical social workers in rural areas who see the face of poverty directly can provide advocacy information to their clients and encourage them to make their voices heard. for rural homelessness to be addressed at the policy level, legislators must hear from concerned citizens. social workers in positions of community activists, administrators, and policy advocates can begin organizing within local areas to bring more attention to the problem of rural homelessness. further research in affordable housing and homelessness in rural areas is broadly needed and has been especially bypassed by social workers in particular. in addition, social work educators need to introduce more information on affordable housing and rural issues into the curriculum at schools of social work. the silence surrounding rural homelessness is surprising considering that stable housing is the foundation of personal independence. for social workers to truly start where the client is, affordable housing is an area that can no longer afford to be overlooked or be viewed from an exclusively urban perspective. references aron, l. & fitchen, j.m. (1996). rural homelessness: a synopsis. in j. baumohl (ed.), homelessness in america (pp. 81-85). phoenix, az: the onyx press. baron. l.m. (2003). when a roof isn’t enough. journal of housing and community development, 60(1), 21-24. campbell, g.j. & mccarthy, e. (2000). conveying mission through outcome measurement: services to the homeless in new york city. policy studies journal, 28(2), 338-349. clinton county housing committee. (2003). clinton county housing needs report. report provided by j. lepage, commissioner of the paradign of rural homelessness journal of student social work, volume ii 51 clinton county department of social services. fitchen, j. m. (1991). homelessness in rural places: perspectives from upstate new york. urban anthropology, 20(2), 177-210. fitchen, j.m. (1992). on the edge of homelessness: rural poverty and housing insecurity. rural sociology, 57(2), 173-193. jencks, c. (1994). the homeless. cambridge: harvard. koegel, p.m. (1996). the causes of homelessness. in j. baumohl (ed.), homelessness in america (pp. 24-33). phoenix, az: the onyx press. lawrence, m. (1995). rural homelessness: a geography without a geography. journal of rural studies, 11(3), 297-307. merwin rural services institute. (2001). county indicators—agriculture. retrieved january 21, 2004, from http://www.potsdam.edu/mrsi/ ruralnyprofile.html national low income housing coalition. (2003). out of reach—america’s housing wage climbs. retrieved december 3, 2003, http://www.nlihc. org/oor2003/ new york city department of homeless services. (2004). daily census for february 2, 2004. retrieved february 2, 2004, from http://www. nyc.gov/html/dhs/home.html new york state (2003). county information—clinton county profile. retrieved december 3, 2003, from www.nysegov.com/map-ny.cfm the urban institute. (1999). homelessness: programs and the people they serve. washington, dc: us department of housing and urban development printing office. jessica e. spissinger is a second-year master’s student at the columbia university school of social work concentrating in advanced generalist practice and programming within the contemporary social problems field of practice. she is currently a policy associate intern at help usa in new york city. she holds a bachelor’s degree in writing and literature from wheaton college. her email address is jes2105@columbia.edu. 52 journal of student social work, volume ii spissinger microsoft word ipv restorative justice.docx © 2015 andruczyk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. intimate partner violence: restorative justice and trauma-informed care malwina andruczyk the social work profession is positioned to play a critical role in redefining services for responsible parties in intimate partner violence. the traditional approaches to intimate partner violence services, which focus on confrontational rehabilitation rather than therapy, are due to undergo a shift. models of trauma-informed care and restorative justice are promising alternatives for responsible parties and harmed parties alike. by building on the transformative work advocates have already done around intimate partner violence for harmed parties and focusing on the inclusion of the diverse identities of those we serve, we can begin to form a nuanced response to a nuanced social issue. from traumainformed care, we can learn to make space for the personal trauma histories of survivors as well as those who have harmed them. from restorative justice, we can learn about techniques that have helped bring a sense of justice and healing to individuals, families, and communities affected by intimate partner violence, including those who have perpetrated that violence. ork around intimate partner violence (ipv) has been evolving for a long time. we know that ipv can take many forms and that a person can be violent without ever physically hurting someone (national center on domestic and sexual violence, 2014). we also know that ipv affects every gender identity, sexual orientation, and relationship style (anti-violence project, 2014). scholars, advocates, and others who work to better understand ipv are doing tremendous work to increase that visibility. from my experience working with queer survivors of ipv, i have had the opportunity to be in an environment that was conducive to reimagining and queering some of the frameworks that guide conventional ipv work. this is one example of rethinking traditional models around abusive relationships to better serve harmed parties, responsible parties, and their communities. research and practice show that abusive relationships are heavily nuanced. ipv counselors are taught the importance of balancing assessment and honoring self-identification. in assessing for ipv between two people, a pattern of behavior emerges within the relationship to where the needs of one partner are more attended, while the other partner’s options are limited. this is often described through power and control, in the sense that one partner may have developed tactics of emotional, psychological, physical, or other violence to continue having their needs met while neglecting the needs of their partner (gay men’s domestic violence project, 2010). in clinical work, the ability to appreciate the complicated nature of ipv work is a sign of a competent counselor. thus far, clinical efforts to understand how nuanced the responsible party’s role in abusive relationships can be do not meet these standards. the responsible party is essentially labeled and then abandoned by social services. but what might it look like if, through our services, we tried to understand the nuances of the responsible party as well? in order to more fully understand the complicated layers of ipv, it is important to consider the problem of a lack of services for responsible parties and what actions we can take to address this problem. would more social services for responsible parties move us beyond a social response limited to reaction and toward a prevention model? this issue warrants action as ipv continues to occur and social services for harmed parties are empowering for individuals at their best, but retraumatizing for harmed parties and shifting away from social justice at their worst (samimi, 2010). the traditional approach to ipv services is due to undergo a shift. models of trauma-informed care, as well as restorative justice, are promising alternatives for responsible parties and harmed parties alike. a little bit about language w © 2015 andruczyk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. one subtle way in which we can track the evolution of ipv work is to consider the language around it. language is powerful and carries a lot of history, but it also reveals to us the present world we are living in. to start, i use the term “intimate partner violence” rather than “domestic violence” since the word “domestic” implies that this violence is occurring both within the confines of a home and within a relationship where partners are living together. additionally, it carries a heteronormative assumption of which relationships are legitimate and which are not (gmdvp, 2010). in this vein, i also elect to use the genderneutral pronoun “they” rather than “he or she” when referring to non-specific persons throughout this paper. this is done to be inclusive of the gender identities both responsible parties and harmed parties hold, as well as to move away from the binary thinking which teaches that there are two genders rather than a continuum. this non-binary thinking can also be useful in approaching dimensions of intimate partner violence. within abusive relationships, it is useful to typify common behaviors of the people involved; however, this also inevitably creates a binary (klein, 2013). katz provides a powerful analysis of how we talk about violence as a women’s issue by shifting from describing it with phrases such as “john beat mary” to “mary was beaten by john” to “mary is a battered woman.” our focus shifts away from john and onto mary (katz, 2012). overgeneralization about gender aside, the shift goes from holding the responsible party accountable to focusing on the harmed party and their identity as “the battered.” this type of language is reflected in the way social services are provided (klein, 2013). terms like “batterer” and “battered woman” reinforce sexist assumptions about who is able to harm and who is harmed in a relationship and serve as a barrier to all those who do not identify within those roles, often leaving out members of the lgbtq community, harmed parties who identify as male, and others who do not see themselves or their relationship types represented in the language used to describe their experiences. terms such as “abusive partner” or “primary aggressor” and “victim” or “survivor” shift away from specifying a gender or specifying that violence needs to be physical. less specific terminology is more inclusive, yet it also creates a particular identity. for many people, identifying as a survivor after experiencing ipv is very empowering. however, after some time, this identity can take less and less priority in a person’s life. what would it look like to move away from labeling people with identities that do not resonate with them? what would it look like to move away from the label of “abusive partner” and focus on the behavior? available services in writing about alternative approaches to serving responsible parties, i want to begin by acknowledging the work that the movement to end ipv has done. in dealing with ipv, the priority is to ensure the safety, security, and humanity of harmed parties. it is only because of all the work toward visibility and voice for victims and survivors of ipv that there is room to examine responsible parties and what their options look like for interventions. taking a look at the history of the battered women’s movement provides some insight into how social services have been shaped. a sexist and heteronormative culture led to heterosexual women organizing around intimate partner violence1, and years of activism have yielded a shelter system, orders of protection, and mandatory arrests (national resource center on domestic violence, 2011). those social services came out of self-preservation; everyone deserves to feel safe and those services were the way to gain safety when the rest of society was not standing in solidarity with the harmed party in an abusive relationship. however, we now know that mandatory arrests can also escalate situations in abusive relationships, and orders of protection are often described as “nothing but a piece of paper” (van dernoot lipsky & burk, 2009).                                                                                                                           1 even while a great deal of organizing to create women’s shelters was done by lesbians. (taylor & whittier, 1995).   © 2015 andruczyk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. programs that support the movement to end intimate partner violence through targeting the role of the responsible party outside of arrests and orders of protection are lacking. despite new york city’s ample social service resources, there are still only a handful of programs with services available to responsible parties in abusive relationships. the coalition on working with abusive partners (or cowap) has the most thorough directory, listing programs that work with responsible parties, harmed parties, and collaborate with the criminal justice system. they describe their mission as, “to identify effective strategies for addressing the complex factors contributing to abusive behavior, to encourage and support behavior change while simultaneously holding abusive partners accountable, and to support service providers and community members in their efforts to prevent and intervene in intimate partner violence” (cowap, 2014). programs that work to help the responsible party include bridge back to life, the children’s aid society, the pac program, and steps to end family violence, as well as center for court innovation, new york university center on violence and recovery, and voices of women organizing project, which work with criminal justice involved responsible parties who are mandated (cowap, 2014). the programs vary in their levels of inclusiveness. for example, the pac program is the only organization that works with responsible parties who do not identify as male or are in same-sex relationships. additionally, while some of the programs provide thoughtful interventions including education, support groups, and therapy, most only offer anger management in the form of cognitive behavioral therapy, an intervention that research has deemed not to have any significant impact for this population (babcock, green & robie, 2004). examining the available services reveals that programs for the responsible party are designed through a cognitive behavioral therapy model providing “here-and-now” treatment that can shift the focus away from the root of a behavior, limiting the treatment’s effectiveness (butler, chapman, forman, & beck, 2006; babcock, green, & robie, 2004). this response affects public policy, public opinion, and funding, as it suggests that if services are limited, it is better to focus on the harmed party more than the responsible party (van dernoot lipsky & burk, 2009). a sign of good clinical care is a situation in which the clinician provides the client with options and choices for their treatment plans. what would it look like if this standard were replicated in working with the responsible party in an abusive relationship? we should make efforts to go beyond behavioral therapy and value the root of the identified problem as something to be explored. case example of a social service response in a case example from my ipv work , i will explore some of the barriers to community involvement. in my experience, when a community learns of ipv, members of the community often gather around the harmed party to protect them, and in that process, shift away from the responsible party. while this is a service to the harmed party, the responsible party is not given space to be held accountable, reflect, and transform. earlier this year at the anti-violence project, a caller contacted our hotline. the caller identified herself as a “former abusive partner” who had been in an accountability process and was interested in speaking about her experience with other responsible parties to better support them. as an agency, we respond to the needs of harmed parties, and i therefore realized that we were not trained to provide the support that would best serve her needs. after consulting with supervisory staff with many years of experience, i realized we were limited in the useful referrals we could offer her. at most, we could refer her the pac program. if this were an isolated incident, i would not think much of it. however, people who consider themselves the responsible party often contact our office and have been referred by other agencies who could not help in their search for assistance or an accountability process (intimate partner violence counselor, personal communication, november 20, 2014). this reveals that there are a significant number of responsible partners seeking help in a © 2015 andruczyk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. system of services that focuses almost exclusively on their punishment rather than a therapeutic process (babcock, green, & robie, 2004). the outcomes of these situations could be much more beneficial if a restorative and trauma-informed approach was more widely available for responsible partners. i will move to discuss ways in which this and other situations of ipv could be better addressed. restorative justice and trauma-informed care: changes that could result in better outcomes burk describes the criminalization of ipv as a process by which advocates in the movement began to focus on goals related to the criminal justice system and moved away from community-based responses that were also happening (van dernoot lipsky & burk, 2009). this led to important levels of visibility and legal protections that harmed parties had not had previously, but also narrowed the scope of the movement. one drawback for the harmed party and the responsible party is, “as advocates spread the message that people who batter are fundamentally criminals, friends and families become increasingly hesitant about getting involved. as a result, it grew harder to undermine the isolation of abuse.” (van dernoot lipsky & burk, 2009). as a result, both the harmed party and the responsible party become more isolated. restorative justice2 is guided by the principles that “crime causes harm and justice should focus on repairing that harm. the people most affected by the crime should be able to participate in its resolution. the responsibility of the government is to maintain order and of the community is to build peace” (prison fellowship international, centre for justice and reconciliation, 2014). in a restorative justice program focused on criminal justice, what may happen is that the person who commits a crime and the person harmed by the crime are offered the opportunity to go through a restorative process. in restorative justice, the terms used are “the harmed party” and “the responsible party” (pfi, 2014). this offers the acknowledgement and validation that harm was done and remains non-judgmental. these labels also have more plasticity than traditional terms, making it possible for the identities to be less permanent. if ipv service providers started to adopt the language and terminology of restorative justice processes, it could encourage positive changes in the ways services are provided. in thinking about the process of criminalization within the ipv movement, there is also a hope that the work of restorative justice within the criminal justice system can start to collaborate with traditional batterer intervention programs. what can we learn from some of the innovative ways we are working with other responsible parties who have committed violent or harmful acts? author, professor, and executive director of the center on violence and recovery at new york university, linda mills, is pioneering this work. her relationship with some ipv advocates is controversial, as she has come off to some as victim blaming by placing undue responsibility on the harmed party (intimate partner violence counselor, personal communication, january 26, 2015). however, in her current work, she has adapted a model of restorative circles to ipv. in a 2013 study with court-mandated clients, this model was compared with standard batterer intervention programs and was found to be at least equally, if not slightly more, effective (mills, barocas & ariel, 2013).                                                                                                                           2 within the model of restorative justice, there is also a little to say about language. some who practice this type of model prefer the term “transformative justice”. while both are meant to provide harmed and responsible parties with things like accountability, catharsis, and closure, restorative justice models can be at times co-opted by the criminal justice system and turn into something that does not meet its own goals (partnership for safety and justice, 2003). transformative justice seeks to “transform” rather than “restore”—questioning whether restoration is a realistic goal. in considering trauma work models and applying some of those principles to the issue of intimate partner violence, transformative justice aligns with the idea of a “new normal” after trauma, while restoration implies that it is possible and desirable to go back to how things were before.   © 2015 andruczyk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. generally, restorative circles draw from historic indigenous traditions practiced commonly in north america to repair, heal, work through difficult issues and symbolize transitions, among other goals. they do this by giving participants the opportunity to speak without interruption and listen in deeper ways (greenwood, 2005). mills’ model is one way restorative justice can work with responsible parties. the circle can involve both the harmed party and the responsible party. for example, the model could include a third party within the circle identifying the abuse and harm, relieving some of the responsibility of the harmed party to do so, as well as lessening the risks associated with retaliation from the responsible party. another restorative justice model could involve the responsible party participating in a circle with members of their community, but not with the harmed party, with the goal of resolution and healing between the responsible party and their community. a parallel restorative circle could also be happening with the harmed party, in which they have a space to tell their story to their loved ones and community members with the goal of lessening their isolation and providing a sense of justice in the knowledge that the responsible party is going through this process and being held accountable by their shared community. trauma-informed care is guided by principles of safety, trustworthiness, choice, collaboration, and empowerment (fallot & harris, 2008). a common theme is shifting the question from, “what is wrong with you?” into “what happened to you?” while trauma-informed care comes out of work with clients whose adaptive behavior was often being misunderstood and pathologized, it has not yet reached work with responsible parties within ipv situations. this differs from traditional models by working toward understanding what might be contributing to violent behavior and encouraging personal exploration and growth rather than working with responsible parties in a distrustful and directive manner. miller and rollnick describe acceptance as necessary for work with a client in whom we want to inspire some kind of change. they define acceptance as something that encompasses the understanding of someone’s absolute worth and autonomy as well as communicating using accurate empathy and affirmation (miller & rollnick, 2012). this aligns with trauma-informed and client-centered work, but does it align with the current models of batterer intervention programs? trauma-informed care for both partners in abusive relationships could make an important impact. to show individual or institutional care for a perpetrator of violence is not intuitive. often, this becomes a barrier between responsible parties and their providers and makes it particularly complicated to know how to practice trauma-informed and anti-oppressive social work with both harmed parties and responsible parties. (stanford, 2009). the lack of care consequently begins a dehumanizing process that can act as a tool of oppression (freire, 1970). as service providers, we should work to create, extend, and maintain a better balance of care across the spectrum to both harmed and responsible parties. in a recent training on trauma, dr. andrew levin posed the question, “what if we had intervened earlier?” referring to adults who harm others and have experienced trauma. this idea is very important for bringing a person-in-environment perspective to our clients. trauma as a root cause of anger and violence was explored by dutton and starzomski (1993) and creates space for ideas on how to link responsible parties with effective methods of treating trauma. while we will not find that, with every responsible party, trauma is the root of their abusive behavior, there are those for whom it will have an important impact. this in particular may be valuable when working with responsible parties who are members of historically marginalized communities, for whom oppression and the trauma connected to it may have an impact on the ways control is regained within daily life. conclusion interventions for responsible parties in ipv currently encompass many contradictions. abusive personality development is often linked with trauma, and while much therapeutic teaching emphasizes the need to discover the root of the trauma (lawson, 2001), this notion seems completely lost in work with © 2015 andruczyk. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. responsible parties. what would it look like if an incident of intimate partner violence could lead the responsible party to heal from trauma rather than engaging them with systems that focus on rehabilitation and punishment? restorative justice is empowering and healing for both the responsible party and the harmed party (partnership for safety and justice, 2003). this makes it a good option when compared with the injustice and lack of safety found in traditional models (van dernoot lipsky & burk, 2009). although this has long been seen as a contradiction, it is possible to prioritize a harmed party’s safety while the responsible party is held accountable in a restorative manner. it is possible to believe that processes of both healing and justice are possible for the harmed parties, the responsible parties, and their communities. references anti-violence project. (2014). mission, vision & goals. retrieved from http://avp.org/about-avp/mission-vision-a-goals babcock, j. c., green, c. e., & robie, c. (2004). does batterers’ treatment work? a meta-analytic review of domestic violence treatment. clinical psychology review, 23(8), 1023-1053. bograd, m., & mederos, f. (1999). battering and couples therapy: universal screening and selection of treatment modality. journal of marital and family therapy, 25(3), 291-312. butler, a. c., chapman, j. e., forman, e. m., & beck, a. t. (2006). the empirical status of cognitive-behavioral therapy: a review of meta-analyses. clinical psychology review, 26(1), 17-31. coalition on working with abusive partners. (2014). about. retrieved from http://cowapnyc.weebly.com/about.html coalition on working with abusive partners. (2014). core principles. retrieved from http://cowapnyc.weebly.com/core-principles.html dutton, d. g., & starzomski, a. j. (1993). borderline personality in perpetrators of psychological and physical abuse. violence and victims, 8(4), 327337. fallot, r. d., & harris, m. (2008). trauma-informed approaches to systems of care. trauma psychology newsletter, 3(1), 6-7. freire, p. (1970). pedagogy of the oppressed, trans. myra bergman ramos. new york: continuum. gay men’s domestic violence project. (2010). domestic violence/intimate partner abuse. retrieved from http://gmdvp.org/domestic-violence/domesticviolence/ greenwood, j. (2005). the circle process: a path for restorative dialogue. retrieved from http://www.cehd.umn.edu/ssw/rjp/resources/default.asp katz, j. (2012, november). jackson katz: violence against women – it’s a men’s issue [video file.] retrieved from http://www.ted.com/talks/jackson_katz_violence_against_women_it_s_a_men_s_issue?language=en klein, r. (ed.). (2013). framing sexual and domestic violence through language. palgrave macmillan. lawson, d. m. (2001). the development of abusive personality: a trauma response. journal of counseling & development, 79(4), 505-509. miller, w. r., & rollnick, s. (2012). motivational interviewing: helping people change. guilford press. mills, l. g., barocas, b., & ariel, b. (2013). the next generation of court-mandated domestic violence treatment: a comparison study of batterer intervention and restorative justice programs. journal of experimental criminology, 9(1), 65-90. national center on domestic and sexual violence. (2014). power and control wheel. retrieved from http://www.ncdsv.org/images/powercontrolwheelnoshading.pdf national resource center on domestic violence. (2011). the battered women’s movement: transforming our vision to meet women’s needs. retrieved from http://www.vawnet.org/advanced-search/print-document.php?doc_id=719&find_type=web_desc_nrcdv partnership for safety and justice. (2003). restorative and transformative justice: a comparison. retrieved from http://www.safetyandjustice.org/story/restorative-and-transformative-justice-comparison prison fellowship international, centre for justice and reconciliation. (2014). domestic violence. retrieved from http://www.restorativejustice.org/press-room/07kindscrimes/domestic-violence samimi, j. c. (2010). funding america’s nonprofits: the nonprofit industrial complex’s hold on social justice. columbia social work review, 1(1), 17-25. stanford, s. (2009). ‘speaking back’ to fear: responding to the moral dilemmas of risk in social work practice. british journal of social work, bcp156. taylor, v., & whittier, n. (1995). analytical approaches to social movement culture: the culture of the women’s movement. social movements and culture, 4, 163-187. van dernoot lipsky, l. & burk, c. (2009). trauma stewardship: an everyday guide to caring for self while caring for others. berrett-koehler publish. malwina andruczyk is a student at columbia school of social work, where she is pursuing a master’s degree with a clinical concentration and a field of practice in contemporary social issues. her primary interests include working with the lgbtq community, criminal justice-involved individuals, and homeless individuals using anti-oppressive, anti-racist and trauma-informed methods. she was motivated to write an article on intimate partner violence, restorative justice, and trauma-informed care by working with survivors of intimate partner violence and seeing that current responses to intimate partner violence do not fully and effectively meet the needs of survivors or the persons who caused harm.   10 columbia social work review, volume v stepping out of the shadows: non-suicidal self-injury as its own diagnostic category lindsay cohen non-suicidal self-injury (nssi) is the repetitive and intentional act of causing injury to one’s own body without suicidal intent. nssi is an extremely prevalent and pervasive phenomenon, affecting between 13.0 to 23.2% of individuals in the general population. there are significant negative outcomes that may result from engaging in nssi including risk of serious physical injury, becoming addicted to the behavior, experiencing stigmatization and social rejection, and an increased risk for suicidality. there is also sufficient evidence in the literature supporting the distinction between nssi and suicide as well as nssi and borderline personality disorder (bpd). creating a distinct diagnosis of nssi in the dsm has many positive clinical implications such as developing a tailored treatment for individuals who engage in such behaviors, stimulating further research about nssi, improving communication regarding behaviors of self-injury, and bringing awareness to this widespread behavior. this article evaluates each of these benefits to demonstrate that nssi deserves to be a distinct diagnostic entity in the dsm. introduction mary, a 14-year-old female, spends most of her time with her friends and boyfriend, steve. on monday, steve cancelled on her, claiming that he was sick and wanted to go home and sleep after school. on the way home from school, mary saw steve walking down the block holding another girl’s hand. when she arrived home, mary ran through the kitchen, ignored her parents’ greeting, and went straight upstairs to her bedroom. she locked the door and took out the razor blade that she had hid in her bottom drawer. mary knew that she was not supposed to cut her arms, but it seemed like the only way to escape from the horrible knot inside her chest. she held the razor blade to her arm and sliced deeply into her skin, watching the bright red line slowly materialize. mary felt an immediate warm sense of release, as if all of her anger and pain were bleeding out of her. columbia social work review, volume v 11 cohen non-suicidal self injury (nssi) is defined as the purposeful hurting of oneself without the conscious intent to die (jacobson & gould, 2007). the majority of individuals report that the function of nssi, such as self-scratching or self-cutting, is to reduce tension and regulate emotions, such as anxiety, depression, fear, or anger (favazza, 1998; nixon et al., 2002; ross & heath, 2003). as illustrated by mary’s behavior in the case study, interpersonal difficulties often lead to nssi. a study by adrian, zeman, erdley, lisa, and sim (2011) found that interpersonal difficulties in the family and peer context increase the frequency and severity of nssi through emotional dysregulation. interpersonal influence, the use of self-injury to manipulate people in the environment, also has been found to contribute to nssi (klonsky, 2007). a minority of individuals assert that their motivations for engaging in nssi are to arouse feelings when none exist and to terminate feelings of depersonalization (jacobson & gould, 2007; klonsky, 2007). when the american psychiatric association composed the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5), nssi was proposed for inclusion as its own diagnostic category. ultimately, nssi was added to section iii of the dsm-5 as a condition for further study, which means that criteria sets need to be further studied before nssi can become an official diagnosis (in-albon, ruf, & schmid, 2013). given (a) the prevalence and pervasiveness of nssi; (b) the problems that stem from engagement in such behaviors; (c) evidence in the literature distinguishing nssi from both suicidality and borderline personality disorder (bpd); and (d) the clinical utility of having nssi as its own diagnosis, nssi deserves to be a diagnostic category in the dsm. furthermore, nssi meets the criteria for a mental disorder according to the dsm-5. prevalence and pervasiveness of nssi nssi often starts during early adolescence, with an average age of onset of 12-14. nssi peaks in mid-adolescence and decreases into adulthood. prevalence of nssi in males and females is nearly equivalent, and it is unclear whether there are ethnic differences in its incidence (jacobson & gould, 2007). in their critical review of nssi literature, jacobson and gould (2007) found that the lifetime prevalence of the behavior in the general population ranges from 13.0%23.2%. an 12 columbia social work review, volume v non-suicidal self-injury adolescent community study, which used the proposed criteria for the dsm-5, found the prevalence of nssi to be 6.7% among adolescents (in-albon et al., 2013). in the inpatient population, approximately 21% of adults and 30%-40% of adolescents engage in nssi (hamza & willoughby, 2013). for individuals who have engaged in nssi, the behavior is extremely pervasive. in a study that examined the frequency of nssi over the lifetime, it was found that out of a sample of 171 people who had engaged in nssi at some point during their lives, over 55% selfinjured at least once a week (turner, chapman, & layden, 2012). the high prevalence of nssi in the population and the pervasiveness of this behavior in individuals’ lives is a chief reason why nssi is a behavior significant enough to be a distinct diagnostic category in the dsm. adverse consequences of engaging in nssi while nssi provides relief from negative emotions in the moment, it can create long-term problems. first, nssi may be a habitforming behavior. individuals who engage in nssi report difficulty in controlling the urge to self-injure. a person can become physically addicted to self-harm as a result of the involvement of the endogenous opioid system. this system regulates pain perception and levels of endorphins, which are released when the body is injured and result in a feeling of pleasure. repeated activation of this system may lead to a tolerance effect whereby individuals who self-injure develop a decreased sensitivity to pain while self-injuring over time (mental health foundation and camelot foundation, 2006; the cornell research program on self-injury and recovery, 2013). social consequences, including peer rejection and stigmatization, are also important repercussions of nssi (favazza, 1998). society’s negative views of self-injurious behaviors cause people to avoid individuals who engage in such behaviors. healthcare workers also possess stigma towards individuals who engage in nssi, such as beliefs that people who self-injure are manipulative, attention seeking, untrustworthy, and uncooperative. evidence suggests that this stigma may negatively impact services and treatment outcomes and lead to a growing sense of alienation amongst individuals who self-injure (law, rostill-brookes, & goodman, 2009). the stigma present in the general columbia social work review, volume v 13 cohen population, the stigma among healthcare professionals, and the selfstigma that individuals possess towards themselves often discourage individuals from disclosing their nssi behavior and seeking help. resulting feelings of secrecy and the inability to reach out generate shame and guilt (raymond, 2012). another adverse consequence of nssi is the risk of physical injury. infection and scarring often result from nssi. people sometimes inflict more harm upon themselves than was intended, which can lead to severe and potentially life-threatening injuries that may require medical attention and cause lasting disfigurement (turner et al., 2012). lastly, individuals who practice nssi have an increased likelihood of suicidal behavior when compared to individuals who do not practice nssi (hamza & willoughby, 2013). studies of older individuals who engaged in nssi in the past indicate a greater risk for subsequent suicidal behavior (hawton & fortune, 2008). according to joiner (2005), increased engagement in nssi raises an individual’s capacity for suicide via habituating the individual to the fear and pain linked with taking one’s own life. increased frequency and greater time spent engaging in nssi, using multiple methods to inflict nssi, and engaging in nssi alone are all associated with a greater risk of future suicidality (hamza & willoughby, 2013). these many adverse consequences demonstrate why nssi is significant enough to warrant its own diagnostic category. nssi and suicide as distinct concepts nssi is often wrongly viewed as a manifestation of suicidality. this has made it difficult for researchers, clinicians, and the general public to view nssi as a valid and distinct entity. while in the past suicidality and nssi were seen as two points on the same continuum, recently, research has found a high prevalence of nssi in individuals who clearly distinguish this behavior from suicidality (jacobson & gould, 2007). this growing research base is forcing researchers and clinicians to rethink their perspective and to begin to view nssi and suicidality as distinct concepts. the major difference between nssi and suicide attempts is the intent of the behavior. while nssi is a maladaptive behavior, it is a form of coping, and coping is a confirmation of a desire to live, not a desire to die. typically, when individuals engage in nssi, they have cognitions 14 columbia social work review, volume v non-suicidal self-injury centered on temporary relief while individuals engaging in suicidal behaviors have cognitions of permanent relief via death. additionally, people engage in nssi more frequently and with more diverse methods compared with suicidal behavior (jacobson & gould, 2007). while nssi is a risk factor for suicide, these are distinct behaviors that do not necessitate the presence of the other. this differentiation between nssi and suicide supports the diagnostic validity of nssi. differentiating nssi from bpd some clinicians argued that nssi is primarily a function of bpd. however, while nssi and bpd are frequently comorbid, they also frequently occur independently–a point that is largely misunderstood and overlooked. a growing number of adolescents do not meet the diagnostic criteria for bpd, are nonetheless distressed, exhibit nssi, and are in need of help. in a recent study by in-albon et al. (2011), it was found that 80% of the adolescents with nssi did not fulfill the criteria for bpd. results from a study conducted by glenn and klonsky (2013) indicate that the comorbidity of nssi with bpd is comparable to that of bpd with mood and anxiety disorders. substantial overlap has been found between nssi and depressive disorders, anxiety disorders, post traumatic stress disorder, conduct disorder, and substance misuse disorders (jacobson & gould, 2007; wilkinson & goodyer, 2011). in addition, many individuals who engage in nssi have no associated psychiatric diagnoses (wilkinson & goodyer, 2011). thus, while nssi and bpd do commonly overlap, nssi is distinct from bpd, as evidenced by its frequent presence in the absence of symptoms of bpd. misconceptions about the relationship between nssi and bpd lead to the assumption that nssi does not have clinical significance beyond the context of bpd. many studies have found that, on its own, nssi is linked with clinical impairments such as depression, anxiety, suicidality, emotion dysregulation, and loneliness (glenn & klonsky, 2013; wilkinson & goodyer, 2011). the fact that nssi frequently occurs independently of bpd and has clinical significance outside the scope of bpd, provides compelling evidence that nssi is, in fact, a distinct condition that is not simply a symptom of bpd. columbia social work review, volume v 15 cohen clinical utility of including nssi as a diagnosis in the dsm creating a distinct diagnostic category for nssi has significant clinical benefits. in the absence of an accompanying psychiatric diagnosis, there currently exists no place to record nssi. it is especially difficult to provide treatment to individuals without a formal diagnosis within today’s healthcare system, which will not pay for services provided to individuals without a diagnostic label. to ensure insurance reimbursement in the current healthcare system, many individuals are misdiagnosed with other psychiatric disorders without meeting the full criteria. if nssi were an official diagnosis, insurance companies would reimburse for the treatment of nssi, and the primary objective of psychotherapy could be treatment of nssi (in-albon et al., 2013). imparting dsm status to nssi will help individuals who engage in such behaviors to receive appropriate treatment before they begin to demonstrate suicidality. the presence of an nssi diagnosis would provide a researchbased definition that would prevent clinicians and researchers from confusing nssi with bpd or suicidal behavior. furthermore, it would enhance inter-professional communication and communication between professionals and patients regarding this behavior (in-albon et al., 2013). the presence of a separate diagnostic category would encourage nssi research, particularly on nssi-specific treatments. unfortunately, there is scant research about the treatment of nssi, probably in large part because it has not been its own diagnostic entity. most research studies look at the treatment of nssi under the umbrella of bpd and suicidality. in this regard, dialectical behavior therapy (dbt) has been found to reduce the frequency and severity of nssi. dbt was originally designed to treat bpd, and its use has been expanded to treating adolescents with suicidal tendencies (linehan et al., 2006; washburn, gebhardt, styer, juzwin, & gottlieb, 2012). as discussed above, nssi is distinct from bpd and suicidality, and therefore, approaches specific to nssi must be studied. last, creating a distinct diagnostic category for nssi would elevate the visibility of this behavior, bringing awareness to the issue and ensuring that clinicians treat it seriously (wilkinson & goodyer, 2011). all of these clinical benefits present further support for the addition of nssi as a disorder in the dsm. 16 columbia social work review, volume v non-suicidal self-injury does nssi meet all the dsm requirements of a mental disorder? dsm-5 working definition for a mental disorder the dsm-5 working definition defines a mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (american psychiatric association, 2013, p. 20). additionally, mental disorders cannot be an expectable or culturally accepted response to stress or loss or socially deviant behavior that is primarily a conflict between the individual and society (american psychiatric association, 2013). nssi is a disturbance in behavior that involves repetitive selfinjuring. this behavioral pattern reflects an underlying psychological dysfunction, which centers on difficulties regulating emotions as well as preoccupation with self-injury and urges to self-injure (in-albon et al., 2011; klonsky & glenn, 2008). there are possible biological correlates, such as altered serotonergic function and endogenous opiate function, which may increase an individual’s chance of engaging in nssi by affecting responses to stress and levels of pain tolerance (jacobson & gould, 2007). this behavior pattern is also associated with significant distress as evidenced by all of the problematic consequences that result from engaging in nssi. it is important to note that nssi is associated with levels of distress and impairment comparable to levels seen in individuals diagnosed with other axis i disorders (selby et al., 2012). furthermore, it is not an expectable or culturally sanctioned response to stress or loss. therefore, nssi fulfills the criteria of a mental disorder according to the dsm-5. benefit versus harm of creating an independent diagnosis in proposing the creation of a separate diagnostic category for nssi, it is important that the potential benefits of doing so outweigh the potential harms. the creation of nssi disorder has many benefits, including motivating new research and improving patient care through more targeted diagnosis and treatment (selby et al., 2012). in addition, the creation of this new diagnostic category would help to further distinguish behaviors of suicidal intent from behaviors of self-injury. http://www.psychologytoday.com/basics/cognition http://www.psychologytoday.com/basics/emotion-regulation columbia social work review, volume v 17 cohen the misclassification of nssi as suicidal in nature, which is commonly reported by adolescents, leads to inappropriate and potentially unnecessary responses such as hospitalization. clearly differentiating nssi from suicide would result in decreased hospital admissions for individuals engaging in nssi (glenn & klonsky, 2013). a possible disadvantage of creating this new diagnosis is the potential for increased stigmatization of self-injurious behaviors (zetterqvist, lundh, dahlstrom, & svedin, 2013). while this is possible, individuals who engage in nssi already experience stigma. creating a new diagnosis will likely bring increased attention and awareness to the condition in the community at large. a second disadvantage is that by defining the condition as “non-suicidal,” people may begin to perceive nssi as less severe or important, decreasing the significance of treatment. however, it is also likely that the presence of an independent diagnostic category for nssi will increase awareness, leading to improved assessment and treatment (wilkinson, 2013). thus, the potential benefits of creating a diagnosis of nssi greatly outweigh the potential harms, further strengthening the case for the creation of a distinct diagnostic category for nssi. conclusion recently, nssi has gained attention in regards to its legitimacy as a diagnosis in the dsm. as discussed above, there are many reasons why nssi deserves to be a distinct diagnostic entity: (a) the prevalence and pervasiveness of nssi is extensive; (b) many problematic outcomes stem from engagement in nssi; (c) nssi is distinct from suicidal behaviors; (d) there is significant research indicating that nssi is often present in individuals not diagnosed with bpd; (e) there is considerable clinical utility to having nssi as its own diagnosis; and (f) nssi meets the standards for a mental disorder according to the dsm-5. while more research is needed regarding the specific diagnostic criteria, there is no reasonable doubt that nssi should be a diagnosable disorder. the addition of nssi as a diagnosis in the dsm has immense implications for the field of social work. this change in diagnosis would largely impact the work of clinical social workers that work with adolescents in psychiatric settings, as this is the population most likely to present with nssi. it will bring awareness to and stimulate new research regarding nssi, which will increase social workers’ understanding of the 18 columbia social work review, volume v non-suicidal self-injury disorder. additionally, establishing a diagnosis of nssi will encourage research regarding nssi-specific treatments. this will increase social workers’ competence in regards to diagnosis and treatment, resulting in improved patient care. according to the nasw code of ethics “the primary mission of the social work profession is to enhance human well being” (national association of social workers, 2008). creating an independent diagnostic category for nssi in the dsm would be a crucial step in fulfilling this goal. references adrian, m., zeman, j., erdley, c., lisa, l., & sim, l. (2011). emotion dyregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls. journal of abnormal psychology, 39(3), 389-400. doi: 10.1007/s10802-010-9465-3 american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). arlington, va: american psychiatric publishing. favazza, a. r. (1998). the coming age of self-mutilation. the journal of nervous and mental disease, 186(5), 259-268. doi: 10.1097/00005053-199805000-00001 glenn, c. r., & klonsky, d. e. (2013). nonsuicidal self-injury disorder: an empirical investigation in adolescent psychiatric patients. journal of clinical child & adolescent psychology, 0(0), 1-12. doi: 10.1080/15374416.2013.794699 hamza, c. a., & willoughby, t. (2013). nonsuicidal self-injury and suicidal behavior: a latent class analysis among young adults. plos one, 8(3), 1-8. hawton, k., & fortune, s. (2008). rutter’s child and adolescent psychiatry (5th ed.). malden, ma: blackwell publishing, inc. in-albon, t., ruf, c., & schmid, m. (2013). proposed diagnostic criteria for the dsm-5 of nonsuicidal self-injury in female adolescents: diagnostic and clinical correlates. psychiatry journal. doi: 10.1155/2013/159208 jacobson, c. m., & gould, m. (2007). the epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review columbia social work review, volume v 19 cohen of the literature. archives of suicide research, 11(2), 129-147. joiner t. e. (2005). why people die by suicide. cambridge, ma: harvard university press. klonsky, e. d. (2007). the functions of deliberate self-injury: a review of the evidence. clinical psychology review, 27(2), 226-239. klonsky, e. d., & glenn, c. r. (2008). resisting urges to self-injure. behavioral and cognitive psychotherapy, 36, 211-220. law, g. u., rostill-brookes, h., & goodman, d. (2009). public stigma in health and non-healthcare students: attributions, emotions and willingness to help with adolescent self-harm. international journal of nursing studies, 46(1), 108-119. leibenluft, e., gardner, d. l., & cowdry, r. w. (1987). special feature the inner experience of the borderline self-mutilator. journal of personality disorders, 1(4), 317-324. doi: 10.1521/pedi.1987.1.4.317 linehan, m. m., comtois, k. a., murray, a. m., brown, m. z., gallop, r. j., heard, h.l.,…lindenboim, n. (2006). two year randomized trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaiors and borderline personality disorder. archives of general psychiatry, 63, 757-766. mental health foundation and camelot foundation. (2006). the truth about self-harm.retrieved from http://www. mentalhealth.org.uk/content/assets/pdf/publications/ truth_about_self_harm.pdf national association of social workers. (2008). code of ethics of the national association ofsocial workers. retrieved from http://www.naswdc.org/pubs/code/code.asp nixon, m. k., cloutier, p. f., & aggarwal, s. (2002). affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. journal of the american academy of child and adolescent psychiatry, 41(11), 1333-1341. raymond, c. m. (2012). non-suicidal self-injury: the movie industry’s influence on its stigma. mcnair scholars research journal, 5(1), 147-166. ross, s., & heath, n. (2003). two models of adolescent self mutilation. suicide and life threatening behavior, 33(3), 277-287. http://www.mentalhealth.org.uk/content/assets/pdf/publications/truth_about_self_harm.pdf http://www.mentalhealth.org.uk/content/assets/pdf/publications/truth_about_self_harm.pdf http://www.mentalhealth.org.uk/content/assets/pdf/publications/truth_about_self_harm.pdf 20 columbia social work review, volume v non-suicidal self-injury selby, e. a., bender, t. w., gordon, k. h., nock, m. k., & joiner, jr., t. e. (2012). non-suicidal self-injury disorder: a preliminary study. personality disorders: theory, research, and treatment, 3(2), 167-175. the cornell research program on self-injury and recovery. (2013). is self-injury addictive? retrieved from http://www. selfinjury.bctr.cornell.edu/about-self-injury.html#tab8 turner, b. j., chapman, a, l., & layden, b. k. (2012). intrapersonal and interpersonal functions of non suicidal self-injury: associations with emotional and social functioning. suicide and life-threatening behavior, 42(1), 36. washburn, j. j., gebhardt, m., styer, d. m., juzwin, k. r., & gottlieb, l. (2012). co-occurring disorders in the treatment of nonsuicidal self-injury: an evidence-informed approach. journal of cognitive psychotherapy, 26(4), 348-364. wilkinson, p., & goodyer, i. (2011). non-suicidal self-injury (nssi). european child and adolescent psychiatry, 20(2), 103-108. wilkinson, p (2013). non-suicidal self-injury. european child and adolescent psychiatry, 22, 875-879. zetterqvist, m., lundh, l., dahlstrom, o., & svedin, c. g. (2013). prevalence and functions of non-suicidal self-injury (nssi) in a community sample of adolescents, using suggested criteria for a potential nssi disorder. journal of abnormal child psychology, 41, 759-773. 55 end of life debate the role of social workers in the end-of-life debate although many articles and books discuss the ethics of end-of-life issues, few publications are written specifi cally for social workers and social work students. the lack of relevant literature is problematic because social workers have different ethical obligations than other health care professions who work with clients who are contemplating assisted suicide. this paper will analyze the ethical dilemma that social workers face in end-of-life issues by reviewing the material available to social workers such as the nasw code of ethics and the relevant nasw policy statement. this paper fi nds that the different sources of information provided by nasw do not fully address the complexities surrounding the social work profession and end-of-life issues. additional training and continuing education courses should be offered and a stronger policy statement is needed that explores the complexities faced by social workers in endof-life care. dvances in medical capabilities and technology have recently made it possible to extend life through artifi cial means (nasw, 2002). the national association of social workers (nasw) acknowledges that, “unwanted utilization of medical technology may lead to a lessened quality of life, loss of dignity, and a loss of integrity for patients” (nasw, 2002, p.60). social workers are being called upon to deal with quality of life issues as well as choices related to assisted suicide. because of its recent and sudden growth mixed with the unavailability of clear guidelines, end-of-life care is an area of practice that many social workers are unprepared and unable to deal with effectively (csikai & raymer, 2003). to determine the appropriate course of action for end-of-life care, social workers must examine the pertinent resources, including nasw policy statements, available state guidelines, and the nasw code of ethics. reviewing the available material for social workers reveals that current policy and resources for social workers are inadequate and the issue needs to be addressed further. jennifer zaleski a 261809_columbia 01-72 sec1:55261809_columbia 01-72 sec1:55 4/5/07 2:12:31 pm4/5/07 2:12:31 pm 56 journal of student social work, vol. v nasw policy statement the nasw frequently publishes policy statements to help guide social workers in ethical dilemmas not specifi cally covered in the code of ethics. the nasw policy statement, “client self-determination in end-of-life decisions,” states that client self-determination is “the right of the client to determine the appropriate level, if any, of a medical intervention and the right of clients to change their wishes about their treatment as their condition changes over time or during the course of their illness” (2003, p. 59). the appropriate role of social workers in end-of-life care is to help patients express their thoughts and feelings, to facilitate exploration of alternatives, and to deal with grief and loss. this policy statement justifi es social workers’ facilitation of a client’s end-of-life decision making process, although it allows a caveat for those social workers who wish not to participate when it states that “social workers are permitted to participate in assisted suicide depending on their personal beliefs, attitudes, and value systems” (nasw, 2003, p. 61). the oregon death with dignity act because oregon is the only state where physician-assisted suicide has been legalized, the death with dignity act is a model through which the role of social workers in the end-of-life debate can be explored. whereas a doctor is committed to the benefi cence of the patient, social workers in oregon are committed to fostering the client’s self-determination by providing information about assisted suicide, answering questions, and forming a trusting relationship, thus empowering the client to make autonomous decisions about how to live out his or her fi nal days (ganzini, et al., 2004). the values and mission of social work distinguish social workers from other professions; therefore, social workers must handle assisted suicide differently than members of other professions. the death with dignity act legalizes physician-assisted suicide (ganzini, et al., 2004) for terminally ill oregon residents who are 18 years or older with a life expectancy of six months or less, as diagnosed by a primary physician and a consulting physician. the death with dignity act enacts procedural safeguards to determine eligibility for a lethal prescription. in order to be considered for this lethal dose, a patient must have a terminal illness with only six months to live, make a written request for a prescription, and two oral requests, which must be separated by at least 15 days (werth & wineberg, 2005). je n n if e r z a l e sk i 261809_columbia 01-72 sec1:56261809_columbia 01-72 sec1:56 4/5/07 2:12:32 pm4/5/07 2:12:32 pm 57 the prescribing physician must inform the patient about alternatives to lethal medication, as well as request that family members be notifi ed of the patient’s decision. it is also the responsibility of the prescribing physician to assess whether the patient’s decision is informed and voluntary, and two additional people are to serve as witnesses. physicians are required to establish patient competency and complete a patient assessment prior to prescribing a lethal prescription. eligibility for a lethal prescription under the death with dignity act also requires that the patient’s competency be established. competency is usually assumed unless a court has declared the person incompetent or a mental illness raises doubts about competence (farrenkopf & bryan, 1999). a patient can establish mental capacity by showing he or she can make clear choices, is able to understand and accurately apply medical information to his or her condition, and can demonstrate internally consistent reasoning (farrenkopf & bryan). if a physician fi nds the patient’s judgment impaired, they must refer the patient to a psychologist or a psychiatrist for a more thorough assessment (werth & wineberg, 2005). during this assessment, the patient should demonstrate his or her understanding of information relevant to his or her decision, such as the consequences of the decision and the risks and benefi ts of alternatives. nasw code of ethics service “social workers elevate service to others above self-interest. social workers draw on their knowledge, values, and skills to help people in need and to address social problems” (nasw, 2000, ethical principles, para 2). social workers are obligated to respect a client’s right to self-determination, even when the client’s goals confl ict with the worker’s individual moral framework. those opposed to the act may argue that the principle of service is limited to those acts which pose no harm to the client or others. john stuart mill (1975) justifi es interfering with autonomy only if it prevents infl iction of harm upon others, not oneself, when he stated, “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others … over himself, over his own body and mind, the individual is sovereign” (p. 11). supporters for the death with dignity act also assert that a client’s sense of “human worth” increases if he or she is able to gain control over the dying process (farrenkopf & bryan, 1999). je n n ife r z a l e sk i end of life debate 261809_columbia 01-72 sec1:57261809_columbia 01-72 sec1:57 4/5/07 2:12:32 pm4/5/07 2:12:32 pm 58 journal of student social work, vol. v social justice “social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice” (nasw, 2000, preamble, para 2). it is the responsibility of social workers to help meet the needs of all populations, especially those who are vulnerable and oppressed. critics of the death with dignity act have expressed a fear that people who choose physician assisted suicide would be uneducated, poor, uninsured, or receiving inadequate end-of-life care (csikai & manetta, 2003). some critics have suggested that people would turn to assisted suicide so as to not burden their families. however, palliative care is covered through the oregon health plan. as a result, people do not have to worry about bankrupting their loved ones (werth & wineberg, 2005). in addition, 98% of those who have utilized physician assisted suicide have had private insurance or were covered by medicare or medicaid. while these reports suggest that the death with dignity act does not target the poor, the issue needs to be examined in more depth. dignity and worth of a person at the forefront of arguments surrounding social workers and the death with dignity act is the dignity and worth of a person. it is the responsibility of social workers to “promote clients’ socially responsible self-determination” (nasw, 2000, ethical principles, para 4). physician collected data has highlighted the importance of self-determination on end-of-life decisions. patients have expressed that their reasons for choosing physician assisted suicide include future loss of control, being a burden, being dependent on others for personal care, loss of dignity, being restricted to bed more than 50% of the time, and experiencing severe depression (csikai & manetta, 2002). the values of the social work profession refer to strongly-held beliefs about the individual’s right to free choice and opportunity (hepworth et al., 2003). supporters maintain that the law is benefi cial even to those terminally ill people who do not utilize a lethal prescription, because they gain peace of mind from knowing that the end-of-life is under their control (greenhouse, 2005), illustrating the importance of autonomy on client satisfaction. “social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others” (nasw, 2000, social workers’ ethical responsibilities to clients, para 2). this statement asks social workers to limit clients’ self-determination in some cases, je n n if e r z a l e s k i 261809_columbia 01-72 sec1:58261809_columbia 01-72 sec1:58 4/5/07 2:12:33 pm4/5/07 2:12:33 pm 59 but there is no clear distinction as to what actions will pose imminent risks for clients. social workers have previously been advised that upholding the client’s right to self-determination is a pillar of social work, but are now being instructed that upholding the benefi cence of the client may now take precedent. competence “social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certifi cation, consultation received, supervised experience, or other relevant professional experience” (nasw, 2000, 1.04 competence, para a). nasw does not defi ne at what point social workers have an obligation to participate in end-of-life care, or at what point one is considered competent in a given area. “when generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps to ensure the competence of their work and to protect clients from harm” (nasw, 2000, 1.04 competence, para c). reamer (1998) suggested that social workers take into account a number of resources when encountering an ethical challenge: ethical theory, literature on ethical decision making strategies, social work practice theory and research, relevant laws and regulations, agency policies, and other relevant codes of ethics. the nasw also calls for state chapters to encourage their members to participate in local, state, and national level committees and task forces to study the issues of end-of-life care, in order to better inform themselves (csikai & manetta, 2002). in the absence of generally recognized standards, social workers should refer to the guidelines and principles listed in the code of ethics. recommendations practice recommendations working with clients who are making end-of-life decisions is an area of discomfort to many people, including social workers. social workers should be aware of any confl icts between personal and professional values and deal with them responsibly (nasw, 1996). social workers should be informed of current federal and state legislation, and have an understanding of how this legislation intersects with their own values and beliefs. neither the code of ethics nor the policy statement addresses the relative importance of values surrounding the end-of-life debate. in one study, many social workers expressed views that were inconsistent with the policy j e n n if e r z a l e s k i end of life debate 261809_columbia 01-72 sec1:59261809_columbia 01-72 sec1:59 4/5/07 2:12:33 pm4/5/07 2:12:33 pm 60 journal of student social work, vol. v statement that defi nes end-of-life decisions as, “the choices made by a person with a terminal condition” (manetta & wells, 2001). over half of the participants in this study favored physician assisted suicide even in situations where there was no fatal illness present, which is inconsistent with the death with dignity act. this study illustrates how social workers’ personal beliefs and values can be inconsistent with nasw standards or state guidelines, and it demonstrates the importance of addressing this issue in greater detail. policy recommendations although oregon is the only state with physician-assisted suicide, it is important for social workers in all other states to advocate for the increased quality of care of patients at the end of their lives. social workers should specifi cally advocate for public policy that respects clients’ rights to self-determination. some of the most critical barriers to optimal end-of-life care are limited availability and coverage, ineffective service delivery, and poor provider communication (yabroff & mandelblatt, 2004). a large part of overcoming these and other barriers should be achieved through continuing education and training. social workers need more guidelines and guidance to determine the proper course of action when working with clients who are contemplating assisted suicide. a stronger policy statement is needed that explores the complexities faced by social workers in end-of-life care, rather than simply exploring the issue of assisted suicide. this policy statement should outline in greater detail the role and responsibilities of social workers, formally address the confl ict between social workers’ professional and personal values, and mandate that social workers receive more education and training in order to improve their competency in end-of-life issues. conclusion social workers have a different role in end-of-life care because of their unique purpose and perspective. in order to make ethical decisions, social workers must examine state guidelines, nasw policy statements, and the code of ethics, as well as their own values and beliefs. the resources available to social workers for ethical dilemmas, such as the code of ethics and nasw policy statements, can further complicate decision-making rather than help to distinguish the ‘right’ answers. a stronger and clearer policy statement is necessary to address the complexities surrounding end-of-life issues. je n n if e r z a l e s k i 261809_columbia 01-72 sec1:60261809_columbia 01-72 sec1:60 4/5/07 2:12:33 pm4/5/07 2:12:33 pm 61 training should be offered to social workers entering the fi eld of aging, and more continuing education courses should be mandated for social workers who are continuing in the fi eld. social workers can no longer afford to have only a vague understanding of prevailing ethical standards (jayaratne et al., 1997). references callahan, j. (1994). the ethics of assisted suicide. health and social work, 19(4), 237-244. csikai, e.l. & manetta, a. (2002). preventing unnecessary deaths among older adults: a call to action for social workers. journal of gerontological social work, 38(3), 85-97. csikai, e.l., & reamer, m. (2003). the social work end of life care education project: an assessment of educational needs. insights. retrieved november 22, 2005, from http:www.nhpco.org/fi les/public/insightsissue2_2003social_worker_pp8-9.pdf. farrenkopf, t. & bryan, j. (1999). psychological consultation under oregon’s 1994 death with dignity act: ethics and procedures. professional psychology: research and practice, 30(3), 245-249. ganzini, l. & farrenkopf, t. (1998). mental health consultation and referral. in k. haley & m. lee (eds.), the oregon death with dignity act: a guidebook for health care providers (pp. 30-32). portland, or: task force to improve care of terminally ill oregonians. ganzini, l., harvath, t., jackson, a., goy, e.r., et al. (2004). experiences of oregon nurses and social workers with hospice patients who requested assistance with suicide. palliative medicine, 18(8), 685-691. greenhouse, l. (2005). justice explores u.s. authority over states on assisted suicide. new york times. new york, n.y.: oct 6, 2005. pg. a.1 hare, j. & skinner, d. end-of-life care: an explanation for wisconsin’s citizens attitudes towards legalization of physician-assisted suicide. wisconsin medical journal, 98, 39-43. hepworth, d.h., rooney, r.h., & larsen, j.a. (2003). direct social work practice: theory and skills (6th ed). belmont, ca: wadsworth. jayaratne, s., croxton, t., & mattison, d. (1997). social work professional standards: an exploratory study. social work, 42(2), 187-198. manetta, a. & wells, j. (2001). ethical issues in the social worker’s role in physician-assisted suicide. health & social work, 26(3), 160-165. mill, j.s. (1975). on liberty. new york: norton. originally published in 1859. j e n n if e r z a l e s k i end of life debate 261809_columbia 01-72 sec1:61261809_columbia 01-72 sec1:61 4/5/07 2:12:34 pm4/5/07 2:12:34 pm 62 journal of student social work, vol. v national association of social workers (2005). standards for palliative and end of life care. washington, dc: nasw press. national association of social workers (2003). client self-determination in end of life decisions. social work speaks: national association of social workers policy statements, 2003-2006 (6th ed., pp. 46-49). washington, dc: nasw press. national association of social workers (2002). client self-determination in end-of life decisions. american behavioral scientist, 46(3), 434-438. national association of social workers, (1996). code of ethics. washington, dc: author. proctor, e., morrow-howell, n., lott, c.l. (1993). classifi cation and correlates of ethical dilemmas in hospital social work. social work, 38(2), 166-177. reamer, f.g. (1998). the evolution of social work ethics. social work, 43(6), 488-499. werth, j.l., & wineberg, h. (2005). critical analysis of the oregon death with dignity act. death studies, 29, 1-27. yabroff, r.k. & mandelblatt, j.s. (2004). the quality of medical care at the end-of-life in the usa: existing barriers and examples of process and outcome measures. palliative medicine, 18, 202-216. jennifer zaleski is a second year master’s student at cussw within the policy practice method, in the international social welfare fi eld of practice. she is currently an intern at the department for economic and social affairs of the united nations. she holds a bachelor’s degree in psychology from the university of california, los angeles. her e-mail address is jmz2107@columbia.edu. je n n if e r z a l e s k i 261809_columbia 01-72 sec1:62261809_columbia 01-72 sec1:62 4/5/07 2:12:34 pm4/5/07 2:12:34 pm this paper examines some of the challenges the social work profession faces in expanding the field at the international level. defining what we mean by international social work is a fundamental issue to provide greater recognition for the field in order to recruit new students and expand the presence of social workers in international organizations. one of the main avenues for pursuing these goals is to strengthen the international social work curricula at universities. the paper looks to social work values in defining the field’s strengths in international work and uses this as a base to provide suggestions for deepening international social work curricula. sara van gunst in today’s increasingly globalized world the social work profession is looking to expand its role to meet emerging demands at the international level. such a monumental task poses substantial challenges. because social work is geared toward working within the context of people and their environment, broadening social work education to the international level requires comprehensively evaluating the transferability of the field’s approaches across cultures. this paper will examine one of the main challenges to this growth, defining what social workers mean by international social work, and will provide suggestions about better structuring international social work programs in the united states (u.s.) to best prepare future practitioners. defining international social work as midgley (2001) points out, two of the greatest challenges in developing strong international social work curricula are both the lack of a common definition of what international social work is and, therefore, coherent professional goals. definitions of international social work are inordinately broad, ranging from a practice area that affords practitioners skills that can be applied internationally, to a global awareness that 2� journal of student social work, volume iv defining international social work for the purpose of strengthening curricula in social work graduate schools enables social workers to view their own role and issues within a broader international context (midgley). part of the problem is that international social work can involve many different roles, including clinical work, policy, social administration, or generalist practice. in my experience, it is also unclear in talking with professors whether international social work should be a practice method or a field of practice. however, if social work is to move forward in establishing international competence, there must be a more coherent and cogent definition of the domain of international social work and how the goals are advanced by the different methods as a whole. a sound definition of international social work is critical since social work is competing for students across a variety of other disciplines with strong international identities, such as political science, law, public policy, and area studies. in addition, social work must gain the trust of agencies working in international development. currently, many international agencies do not recognize social work’s strengths and, as a result, social work does not have a strong presence in the international development field outside of academia (caragata & sanchez, 2002). through an articulation of social work’s relevance to international development, social work can attract both more students interested in international work and also increase the presence of the profession in the field. taylor (1999) argues that social work should abandon clinical work to psychologists and psychiatrists and instead focus on community development and advocacy. this argument may be too drastic a move in the domestic arena, but it possesses merit when applied at the international level. for example, many argue that clinical casework is culture specific, both in terms of effective interventions and in its function as a luxury rather than a necessity in well-developed countries. these well-developed countries have the resources to focus on the psychological health of the population instead of on the struggles facing many developing countries, such as the acquisition of the more basic needs like food and shelter (drucker, 2003; taylor). one way of addressing this dilemma is to examine the profession’s value system to determine what is most appropriate for international work. social work’s values can be divided into two categories: fundamental, or primary, values and secondary, or instrumental, values. fundamental values represent overarching humanitarian concerns of the profession, while secondary values pertain to the social, cultural, economic, and political conditions that impact how fundamental values are enacted (mullaly, 1997). taylor (1999) argues that fundamental values are more applicable to the international arena van gunst journal of student social work, volume iv 2� than are secondary or instrumental values. she proposes that social work’s fundamental values of “helping others, preventing harm and social justice” (p. 311) are transferable to other cultures, as well as social work’s dedication to empowerment, “both as a state of mind (feeling worthy or competent or perceiving power and control) and as exercising control over the course of events in the socio-political arena through social and political influence” (p. 311). however, the social, cultural, economic, and political environment of individual countries should determine how these fundamental values can be realized. starting with more commonly shared or transferable values, such as social justice, may be an effective way to unite social workers around the globe in common interests and may also be more appropriate in terms of the most pressing international needs. even more importantly, these values maximize social work’s relative strength in working at the grassroots level as compared to other disciplines. this is not to minimize the importance of sharing successful clinical interventions on the international level, but perhaps practitioners need to tie clinical work more closely to the goals of social justice and carefully examine which interventions are most transferable to the international context. based on these arguments, the case can be made for a more narrow and targeted definition of international social work. one of the earliest definitions of international social work emphasized it as a field of practice that hones the skills and knowledge needed to work in international agencies (midgley, 2001). while this definition can seem a bit confining at first, my personal experience in international development has taught me that most americans working abroad in the field do so through international non-governmental organizations (ngos), multi-lateral agencies, or government agencies, and this is, therefore, the most likely arena in which social workers would be employing their skills. this definition can be further refined to clarify the type of skills and knowledge most appropriate to international work. thus, international social work may be delineated as a field of social work practice that hones the skills and knowledge needed to work in international agencies around issues of social justice and empowerment. because of the unique set of skills required for work in this field, international social work should continue to be included as a field of practice, but careful consideration should be given to the nuances of working abroad for individual methods, such as clinical, policy, or generalist practice. defining international social work 2� journal of student social work, volume iv establishing criteria for evaluating international social work curriculum in applying this new definition, which focuses on the skills needed for work in international agencies, it is important to review the role that international social work schools play in fostering relevant skills for international practice through appropriate topics of study. healy has developed a continuum of internationalization by which to assess how well social work schools have internationalized their programs as outlined below (johnson, 2004). the continuum provides a good starting place, but can be expanded to consider other critical aspects of the social work education process. first, the continuum needs to clarify what “well-articulated curriculum” means and should assess the depth of the curriculum. the following questions may be addressed: how many classes are offered? what do the courses cover and do they sufficiently prepare students for the nuances and unique challenges posed by international social work? what particular skill sets are taught to students through the curriculum and is this appropriate given the field’s definition of what international social work is and how the profession seeks van gunst journal of student social work, volume iv 2� tolerance responsiveness commitment • unsolicited presence of foreign students • individual faculty doing international work • offering an occasional elective • occasional international field placement for a student who initiates it • doctoral dissertations • independent study with international focus • well-articulated program through program of study and independent work • international field placement program with adequate preparation • school-maintained program with specified purpose and accountability to assert itself in international development programming? in order to refine the curriculum, it is important to identify the unique role social workers can bring to the international development arena and form courses around these topics. while there are many options to work towards this goal, based on the more narrow definition of international social work proposed above, a starting point might be the following: bottom-up approach social work takes a grassroots approach that focuses on community organizing to foster social change. many recent program models in the civil society area focus on a community mobilization model rather than funding large, national-level agencies or organizations (usaid, 2005). social work can help take the lead in developing appropriate approaches in this area. empowerment social work takes an empowerment or strengths-based approach to working with individuals and communities by identifying existing resources to solve problems rather than focusing on weaknesses and deficiencies (taylor, 1999). the issue of empowerment has become a common theme in the international development field, and social work is well positioned to offer approaches and tools to give the concept real meaning in practice. ecological perspective because social work focuses on the person and community within its own context, the profession has the skills to go beyond promoting a particular political ideology, such as free-market democracy, as an answer to a country’s development needs. this perspective provides the profession with important tools to avoid cultural imperialism and the creation of solutions that are not appropriate in other countries. social justice social work values place particular importance on social justice and reducing poverty, arguably two of the most urgent international development needs. while other disciplines address these issues, they are central themes in social work and form the foundation of the profession. while much work needs to be done to create a comprehensive list of social work’s international strengths, educators need to carefully direct defining international social work �0 journal of student social work, volume iv the type of specialized courses provided to students, rather than rely on a haphazard selection of international courses within other departments. for example, at columbia university school of social work (cussw), there is only one required course offered for those choosing the international social welfare immigrant and refugee services field of practice. to fulfill the remaining requirements for the field of practice, students take courses at other programs within columbia university. in order to avoid reliance on other departments, international social work curricula should be a practice method, rather than just a field of practice, which would help to deepen the curricula and provide students with a more in-depth training in the nuances of working in international settings and how to responsibly employ western or u.s. models of practice in the international context. establishing international social work as a practice method would require that social work schools recruit and retain a committed group of professors with a strong international background, including experience conducting international research and projects, publishing articles in international social work publications, collaborating with international social work professionals, and maintaining contacts with international development agencies and organizations. comprehensive international social work curricula should also consider the diversity of the student body and faculty. a committed international social work program should include an institutionalized international exchange component that actively recruits students and professors from around the world. for example, cussw’s partnership with the open society institute brings central asian students to cussw to receive their master degrees in social work. the u.s. state department bureau of educational and cultural affairs (eca) funds many international exchange programs that could also be tapped for attracting professors and professionals to teach and conduct research at u.s. universities. the contemporary issues fellowship program, which is currently coming to a close, recruited professionals across a broad array of fields, including social welfare, for four-month research positions at u.s. universities (irex, 2005). the fulbright program’s hubert h. humphrey fellowship program is another active eca program that brings talented mid-level professionals to the u.s. for a year of study at selected host universities (u.s. department of state, 2006). most costs for the program are covered by the government, making it a viable option for social work programs that may not have sufficient funds available to cover the costs of frequent international exchanges. van gunst journal of student social work, volume iv �1 it is essential that committed international social work programs institutionalize opportunities for international learning and practice that extend to both research and field placements. while the healy continuum does include international placements (cited in johnson, 2004), more emphasis should be placed on the permanence and structure of this component. international field placements should not only be available, they should be an integral part of the degree process (cited in johnson). schools must have standards for international experience among students majoring in international social work and require international field placements for those not meeting the set standards. sufficient international, experiential learning is critical for students to develop the necessary cultural awareness and sensitivity to apply social work’s models effectively. boyle, nackerud, and kilpartrick (1999) make a valuable point that too little emphasis has been given to the importance of experiential learning in fostering cross-cultural skills in social work students. they explain that experiencing culture shock helps students understand themselves better and develop new sensitivities. this experience is hard to simulate in the classroom, so cultural immersion programs are critical to gaining cultural competence. opportunities to participate in international research projects are also invaluable for helping students gain a deeper understanding of international social work and examine the nuances of applying social work interventions and approaches around the world. in order to develop both international placements and research, it seems that social work programs would greatly benefit from institutional agreements and contracts with other schools abroad. having an established agreement in place, which outlines a formal relationship between universities, could help to break down bureaucratic barriers to collaboration on grant-funded or school-funded programs. agreements could also contribute to clarifying expectations and setting goals for future collaboration, which can create a more solid, sustainable relationship. finally, the healy continuum (cited in johnson, 2004) does not address the need for programs to form ties to the professional international development community, including international ngos, multi-lateral organizations, and government agencies. it is important to make the distinction between ties with agencies in terms of field placement arrangements and active collaboration at the institutional level that includes sharing professional expertise on common projects. institutional connections with the professional community defining international social work �2 journal of student social work, volume iv have many advantages. they can lead to collaborative partnerships on international grant projects that open doors for more international research and field placement possibilities (usaid, 2005). in addition, links to the international community can raise the profile of the social work field and provide practitioners and academics with a stronger voice in setting priorities for international development programs. how well do u.s. universities currently prepare students for international social work? many of the ideas posed above can be considered ideal scenarios and there may be realistic concerns about meeting these goals based on funding constraints. however, research indicates that social work programs have a long way to reach even the responsiveness level in the healy continuum (cited in johnson, 2004). caragata and sanchez (2002), for example, reviewed international social work curricula at u.s. and canadian schools and found significant deficiencies. of the u.s. schools interviewed, only 11% demonstrated linkages with other institutions or agencies in developing countries. similarly, only 11% of u.s. schools had research projects in developing countries. a slightly higher number, 14%, of schools noted individual faculty members with research projects in developing countries. twenty-seven percent of schools had international field placements which, in one case, included a summer course in mexico. on a brighter note, 66% of schools at least had linkages or connections with international projects, although only 39% of the cases included formal relationships. twentythree percent of u.s. schools invite international students and teachers to visit or teach within their programs. while more research needs to be done to examine the effectiveness of international social work programs, these statistics point to a serious lack of progress on the part of many schools to internationalize their curricula. conclusion while social work faces many challenges in establishing itself in the international arena, there is great potential for the field to play a key role in shaping international policy and intervention. the field must first establish a clear identity for international work by settling on a focused definition of the subfield and then move to evaluate social work programs to test how van gunst journal of student social work, volume iv �� well they prepare students. a superficial international focus combined with the general curricula cannot adequately prepare students for the myriad of challenges they will face in an international setting. social work programs must establish more rigorous criteria if the field is to develop more capable professionals. the best way to prepare students is to develop a more focused curriculum that focuses in on social work’s strengths for international development, rather than covering a broad spectrum of issues. social work has much to offer the international development arena and social work schools play an important role in providing that connection. references boyle, d., nacherud, l., & kilpatrick, a. (1999). the road less traveled: cross-cultural, international experiential learning. international social work, 42(2), 201-214. caragata, l., & sanchez, m. (2002). globalization and global need: new imperatives for expanding international social work education in north america. international social work, 45 (2), 217-238. drucker, d. (2003). whither international social work?: a reflection. international social work, 46(1), 53-81. international research & exchanges board (irex). (2005). contemporary issues fellowship program (ci). retrieved october 31, 2005, from http:// www.irex.org/programs/ci/index.asp johnson, a. k. (2004). increasing internationalization in social work programs: healy’s continuum as a strategic planning guide. international social work, 47(1), 7-23. midgley, j. (2001). issues in international social work: resolving critical debates in the profession. journal of social work, 1(1), 21-35. mullaly, r. p. (1997). structural social work: ideology, theory, and practice. new york: oxford university press. taylor, z. (1999). values, theories and methods in social work education. a culturally transferable core? international social work, 42(3), 309 318. u.s. agency for international development (usaid). (2005). u.s. higher education community: doing business with usaid. retrieved october 31, 2005, from http://www.usaid.gov/university/ u.s. agency for international development (usaid). (2005). moldova citizen participation project. retrieved november 2, 2005, from http:// www.usaid.kiev.ua/moldova_act.shtml#irex defining international social work �� journal of student social work, volume iv u.s. department of state. (2006). hubert h. humphrey fellowships program. retrieved march 13, 2006, from http://exchanges.state.gov/education/hhh/ sara van gunst is a first year student at cussw. she holds a bachelor’s degree in international relations with a focus on countries of the former soviet union from the college of william & mary and a master’s degree in russian studies from indiana university at bloomington. she has over 5 years of experience developing and implementing civil society programs in the international development division of the international research & exchanges board (irex) in washington, dc and moscow, russia. after finishing cussw, sara plans to work with immigrant communities in the united states and explore social work opportunities abroad. her email address is sev2107@columbia.edu. van gunst journal of student social work, volume iv �� private practice social work might be argued to be a cure for a wealthy man’s worries, or more simply, a cure for the worried well. this type of social work can have a higher earning potential and is generally available to those who have insurance or can afford to pay for the services. social workers’ participation in private practice has the potential to draw criticism and debate regarding social work’s mission and ethics. has social work in fact deviated from its historical definition and abandoned its mission to serve the underprivileged, or does private practice represent a logical and worthwhile modern progression, one reflecting the current social and political climate? this paper will examine some of the stereotypes and perceptions about public and private social work practice. it will explore how this dichotomy may be the newest incarnation of an old social work schism between whether the profession should focus on change at the community level or focus on change at the individual level. in addition, this paper will highlight how the two approaches to social work, historically and today, are not irreconcilable. on the contrary, healthy debate is critical to the ongoing development of the profession. journal of student social work, volume iv �� since the 1980s, social workers have increasingly left the service of the public sector and entered into private practice. a substantial number of today’s social workers practice for-profit client-based therapy rather than agency-based public service. these recent changes are causing critics to question whether social work’s new focus on for-profit services has deviated from social work’s original purpose to forge allegiances with the poor, the disadvantaged, and the oppressed. is this change in focus an abandonment of social work’s historical principles? or is it simply a modern and logical evolution? this paper examines the debate between private and public social work practice. it describes how social work historically emerged and evolved on two interconnected fronts, one with a focus on change at the community level, and one with a focus on change at the individual level. this paper posits that the two approaches are not irreconcilable and that healthy debate has led, and continues to lead, the profession forward. jenna benn the privatization of social work: a deviation or a logical progression? social work’s professional development and debates in the 19th century, social work emerged and evolved with two purposes in mind — to combat and change societal injustices, and to help individuals who directly suffer from the oppression of these systems. jane addams, founder of the settlement house movement, approached social work from a paradigm that emphasized grassroots social change within the community and larger society. she primarily focused on societal injustice rather than on individual maladjustment (mclaughlin, 2002). her contemporary, mary richmond, founder of the charity organizational society, used a social work case model that focused on the improvement of the family and the individual. richmond primarily focused on the study, diagnosis, and treatment of casework on an individual and familial level, as distinguished from the betterment of the masses (mclaughlin). together, these different schools of thought created the foundation for today’s practice of social work. it is important to note that although jane addams shaped early social work efforts and inspired some of the modern social work methods, such as groupwork (goldstein, 1973), the settlement house movement for which she is most famous ultimately dissolved. in contrast, mary richmond’s model of casework continued to largely set the stage for modern social work practice. the tradition of community work and social justice seems to have often taken a secondary role in social work, perhaps in part because of social work’s strivings to be recognized as a full profession and compete with related disciplines for resources and clients. since the profession’s emergence, heated debates have ensued regarding social work’s definition and purpose. in 1915, abraham flexner, assistant secretary of the general education board, pronounced that social work was not a full and legitimate profession (austin, 1983). he asserted that although social work was a useful social activity, particularly as it helped link individuals with problems to resources, it did not fulfill the criteria to be a formally recognized profession (austin). flexner’s argument came at a critical point in the early development of social work and social work education. his earlier criticism of medical education triggered important changes in that field. however, flexner’s criticism of social work as a full profession ultimately seemed to, in response, cause social workers to question their own legitimacy and rethink the purpose and mission of social work. his standards for becoming a full profession included becoming more specific in purpose and developing a distinct body of presumably scientific the privatization of social work �� journal of student social work, volume iv knowledge; mary richmond’s more individual-centered and medicaloriented model seems to have been more likely to forward this cause, and the reverberations can still be felt today. schools, such as columbia university’s school of social work, seem to be largely dominated by students who focus on clinical, rather than community or policy practice. the latest incarnation of this division between individual focused versus society or community focused social work methods may be private versus public social work practice. today 60% of social workers practice private clinical social work (kassan, 1996). with this high level of participation in privatized social work, critics might argue that social work has abandoned its mission to serve the poor and oppressed, and failed to focus on broader contemporary social problems. therapists in private practice primarily work with the individuals and families who are able to afford their services or have insurance. medicaid and medicare recipients, as well as individuals and families with restrictive insurance plans, are only eligible for a limited amount of treatment coverage, requiring in some cases that therapists restrict therapy when patients cannot pay out of pocket. the goal of treatment may only be to stabilize the problem, which may not be therapeutically adequate or beneficial for the patient over the long run. in contrast, the affluent are better able to pay for more comprehensive treatment. today’s restrictive insurance plans may ultimately stunt the opportunity for successful private therapy for a large segment of the population. critics may also take issue with the average earnings of private practice therapists. on average, clinical social workers at public agencies earn between $42-45,000 a year (linsley, 2003). in 2000, private practice social workers earned a median annual income of $55,512 (linsley). therapists in private practice can make a significantly higher income that can increase with years of experience. private practice social workers who have more than 25 years of experience earn an average income of $79,600, nearly 1/3 more than social workers in the public sector (nasw, 2001). there is a perception among some that social workers who engage in private practice reflect a new wave of self-indulgence and radical individualism that has shifted social work’s mission to the treatment of the individual at the expense of the collective (herron & welt, 1992). some social workers may hold up icons like jane addams, who believed in living with the poor as neighbors, as a means to further our understanding of the implication of societal problems and may assert that private practice social work departs from these romantic ideals in two significant ways. benn journal of student social work, volume iv �� first, the therapist who commands high prices serves a less impoverished population. second, private practice workers’ pursuit of higher salaries greatly reduces the possibility that they will live among, and ultimately serve, such a population. there seems to be a perception among some social workers that living among clients, and even struggling to survive on meager pay, is the best way to experience empathy for the populations they serve. however, in private practice, just as in any method of social work, the focus is on the worth and dignity of the person. private clinical social workers are strongly committed to helping the individual negotiate environmental stress, regardless of economic background (herron & welt, 1992). moreover, these private practitioners may also serve clients who are stuck in the middle: those who do not have enough money or lack the insurance to afford the services of more expensive professionals, such as psychiatrists or psychologists, yet do not qualify for government benefits, such as medicaid or medicare. clinical social workers argue that it is idealistic to try to change the world and more realistic to change one person at a time (van heugten & daniels, 2001), and social work has a long tradition of individual-oriented practice. studies indicate that 15% of the population needs mental health services, and only 2% of the population receives them (herron & welt, 1992). there is a significant gap between those needing services and those receiving them. this reinforces the need for more social workers to treat mental health. private practice, while often serving those who may have access to relatively more services, plays an important part in meeting this need. people of all economic backgrounds have legitimate issues that deserve attention. critics may scoff at serving people with economic means, however they are not immune to pressures and hardships. people who are relatively well-off can and do suffer from mental health issues that can be just as serious and, at times, be associated with worse outcomes (luthar, 2003). dismissing or marginalizing this population in favor of serving people who have what may have judged to be “real” problems, seems to run counter to social works’ mandate to serve suffering community members regardless of economic status. in addition, not all private practitioners exclusively serve the upper classes. often therapists are willing to accept no fee or a low fee so the poor may access services (herron & welt, 1992). social workers, more so than private psychologists, may be more likely to offer their clients options like sliding scale fees exactly because of their commitment to social justice, and thus open the door for clients to receive the benefit of a service that might the privatization of social work �� journal of student social work, volume iv otherwise be unreachable. proponents of private practice do not feel that therapists are selling out to the bourgeoisie or dominant class in society, but rather look at private practice as a career phase. more often than not, private clinical social workers return to the public sector at a senior or managerial level with skills gained through private clinical experience as a means to exert influence on the workplace and professional direction (van heugten & daniels, 2001). in addition, social workers in clinical private practice may supplement their income by working concurrently at a public agency. social workers returning to the public sector after private practice, or simultaneously working in both, are not necessarily neglecting a specific population but rather providing services to many varied populations. in addition to serving wealthy and non-wealthy clients at some point in their career, social workers might question whether or not the trend toward privatization is a reflection of society’s capitalistic system co-opting the field. some argue that criticism should be levied at the monetarily driven culture of the united states rather than pointing fingers at private practice (van heugten & daniels, 2001). it is possible that the desire for a higher salary in private practice is a reflection of the highly individualized, money-oriented nature of a capitalistic society like the united states. social workers, just like other human beings who must operate within the existing social structure, are arguably just as likely to be affected by socialization. privatization of life is a product of a society highly focused on, and dominated by, private individuals, private spaces, and private institutions. this privatization has reshaped the context in which social workers live and practice (fisher & karger, 1997). reconcilable differences perceptions, warranted or not, can spur debates that assume strong points of contention and criticism. in reality, it is not important to choose a side, but rather to create a common ground that includes and unites both schools of thought. instead of seeing social work as a dichotomy between clinical social work and social action, or framing it as a choice between serving the wealthy versus the poor, it is more productive to recognize how both practices have a place under the social work umbrella. jane addams and mary richmond, though differing in philosophy and practice, both practiced social work. their foundations of social work established two approaches, but one common goal remains that still resonates today, “...to enhance human well-being and benn journal of student social work, volume iv �� help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. and in addition to... pay attention to the environmental forces that create, contribute to, and address problems in living” (national association of social workers, 1999). social work problems occur on the individual and societal level (mclaughlin, 2002) and among all economic classes. although dichotomous thinking, pitting one extreme side against the other, may be a useful tool for highlighting the core issues, it also oversimplifies the debate. instead, there should be recognition of the critical interplay between society and individual functioning, and vulnerability and suffering among all communities. private troubles are public issues and vice versa. social workers, no matter where they practice and with whom, should not look at social problems and ignore the individual, and cannot examine the individual without looking at the lasting effects of social issues (mclaughlin). leading the profession forward the conflict between the differing philosophies and approaches of social work’s public and private sector has the potential to encourage the growth and evolution of the profession. today we may continue to be haunted by abraham flexner’s ghost. his belief that social work was not a profession continues to challenge the purpose and legitimacy of the field (austin, 1983). similar to the controversy and eventual professional growth that ensued after flexner’s statement, the field’s current reevaluation of purpose and practice propels the profession forward. professional insecurity, stemming from historical and current debates, is forcing the field to critically reexamine its ethics and mission, and inevitably make change (mclaughlin, 2002). the changing face of social work is not a deviation from its historical mission, but rather a modern logical progression that will continue to evolve and change on interconnected fronts in years to come. what is needed is a blending of social work’s versatile objectives toward an improved quality of life for all (mclaughlin). social work’s greatest challenge, its diversity of method and focus, has arguably been its greatest strength. it is important to focus on the mission of the profession and ethical commonalities that unify us all, both in the public and private sectors, under a common professional identity. the privatization of social work �� journal of student social work, volume iv references austin, d. m. (1983). the flexner myth and the history of social work. social service review, 3(11), 358-375. fisher, r. & karger, h. j. (1997). social work and community in a private world: getting out in public. white plains, ny: longman. goldstein, h. (1973). social work practice theory: an historical perspective. in h. goldstein (ed.). social work practice: a unitary perspective. chapel hill, north carolina: university of north carolina press. herron, w., & welt, s. (1992). money matters: the fee in psychotherapy and psychoanalysis. new york: the guilford press. kassan, l. (1996). shrink rap: sixty psychotherapists discuss their work, their lives, and the state of their field. new jersey: jason s. aronson inc. luthar, s. s. (2003). the culture of affluence: psychological costs of material wealth. child development, 74, 1581-1593. linsley, j. (2003). social work salaries: keeping up with the times? the new social worker, 10(1), 1-7. mclaughlin, a. m. (2002). social work’s legacy: irreconcilable differences? clinical social work journal, 30(2), 187-200. national association of social workers (nasw). (1999). code of ethics of the national association of social workers: preamble. retrieved october 10, 2005, from http://www.socialworkers.org/pubs/code/code.asp national association of social workers (nasw). (2001). practice research network of the national association of social workers. retrieved october 10, 2005, from http://www.naswdc.org/naswprn/default.asp van heugten, k., & daniels, s. (2001). social workers who move into private practice: the impact of the socio-economic context. british journal of social work, 31(5),739-755. jenna benn is a first year master’s student at cussw within the social enterprise and administration practice method, in the world of work field of practice. she is currently placed at weston united supported housing in harlem, new york. she holds a bachelor’s degree in history and a double minor in psychology and jewish studies from mcgill university in montreal, quebec. her email address is jeb2127@columbia.edu. benn journal of student social work, volume iv �� journal of student social work, volume iii 43 changes in american family structure – including a rising divorce rate, increasing numbers of single parents, and growing numbers of same-sex couples with children – are some of the most frequently discussed issues in social welfare policy today. scholars often assert that family structures other than the “traditional” family (headed by two married, heterosexual parents) are potentially detrimental to children’s well-being. some research has found a correlation between parental marriage and positive outcomes for children, especially decreased child poverty rates (brown, 2004; mclanahan & sandefur, 1994). based on this association, some policy-makers have concluded that social problems such as child poverty are at least partially caused by the declining marriage rate. for example, the conservative heritage foundation states on its web site that “the collapse of marriage is the principal (sic) cause of child poverty in the united states” (heritage foundation, 2004). the rise of single parenthood has also been blamed for social ills ranging from high school dropout rates to drug use among youth (fagan, rector, johnson, & peterson, 2002). child poverty is a very complex problem, posing questions to which there are no clear-cut answers. however, i would like to present some concerns about using marriage as a primary strategy for addressing this problem. in this article, i will discuss the proposed healthy marriage initiative (hmi), a policy that is intended to reverse the trend of rising single-parenthood and improve children’s well-being on all counts. i will focus on the hmi’s relationship to child poverty, one of the primary targets is the healthy marriage initiative really healthy for families?: a critical analysis the healthy marriage initiative is a government proposal to expand programs promoting marriage, particularly among low-income families and welfare recipients. in this paper, i examine the implications of this proposal as it applies to child poverty. i argue that contrary to the claims of its proponents, the healthy marriage initiative would not substantially reduce child poverty rates, would increase as many unhealthy as healthy marriages, and would intrude inappropriately into the lives of poor men and women. meg yardley 44 journal of student social work, volume iii is the healthy marriage initiative really healthy? of this initiative. finally, i will argue that hmi programs will have limited effectiveness in decreasing child poverty and that they are inappropriately intrusive and coercive in the lives of poor men and women. background historically, it is not new for marital status to be a consideration in the awarding of social benefits. for example, the widows’ pensions that existed in many states prior to the social security act of 1935 were not always extended to non-widowed single mothers and could be denied if a home was considered “unsuitable” (trattner, 1994). however, proponents of marriage promotion policies claim that recent welfare policy has actually benefited single parents, thereby functioning as a disincentive to marry, and contributing to the decline of marriage (besharov & sullivan, 1996). for this reason, the promotion of (heterosexual) marriage has been a stated goal of welfare programs since the 1996 “welfare reform” that replaced aid to families with dependent children with the temporary aid to needy families (tanf) program. in addition, some individual states have chosen to use tanf money to promote marriage (chase-lansdale & pittman, 2002). the proposed healthy marriage initiative would set aside $100 million annually from tanf funds to be used by states for the following activities: (a) public advertising campaigns on the value of marriage and the skills needed to increase marital stability and health; (b) education in high schools on the value of marriage, relationship skills, and budgeting; (c) marriage education, marriage skills, and relationship skills programs, that may include parenting skills, financial management, conflict resolution, and job and career advancement for non-married, pregnant women and nonmarried, expectant fathers; (d) pre-marital education and marriage skills training for engaged couples and for couples or individuals interested in marriage; (e) marriage enhancement and marriage skills training programs for married couples; (f) divorce reduction programs that teach relationship skills; (g) marriage mentoring programs, which use married couples as role models and mentors in at-risk communities; and (h) programs to reduce the disincentives to marriage in means-tested, aid programs (acf, 2004a). the policy also provides for an additional $102 million annually for “research, technical assistance, and demonstration projects” related to the above activities (acf, 2004a). congress has not yet approved funding for the healthy marriage initiative (which is part of the 2006 tanf reauthorization bill). however, tanf funds are already being used for journal of student social work, volume iii 45 yardley marriage promotion in many states (white & kaplan, 2003). marriage and child well-being the debate over the hmi and other marriage promotion policies generally revolves around three questions: first, whether higher marriage rates would improve children’s well-being; second, whether government policy is able to affect marriage rates; and third, whether government has the right to intervene in favor of marriage. research in the social sciences has established a clear correlation between single parenthood and increased poverty rates (mclanahan & sandefur, 1994). however, the causal direction of this correlation is not clear. for one thing, poverty itself can be a factor in marital success; as roberts (2004) points out, stressors associated with poverty may contribute to marriage breakups. in addition, a number of researchers hypothesize that many of the apparent benefits of marriage are actually brought about by selection, or differences between those who choose to marry and those who do not. based on her review of the research, roberts estimates that about half of the alleged economic boost from marriage can be explained by selection. similarly, acs and nelson (2004) found that “50 to 80 percent of the differences in child well-being between cohabiting and married families can be explained by differences in family characteristics, such as parental age, education level, and race” (p. 1). sigle-rushton and mclanahan (2002), examining data from the fragile families study, conclude that differences in human capital between married and unmarried adults translate into differences in poverty level. the authors note that proponents of marriage “are substantially overstating its benefits when they compare the earnings or poverty rates of single-mother families to those of married, two-parent families” (p. 20). even many authors who believe marriage has beneficial effects acknowledge that these effects may not be very large. according to statistical simulations, if all single parents were to marry someone of a similar background to their own, the child poverty rate would fall 3½-4 percentage points (acs & nelson; roberts). although this difference is not insignificant, it is based on the highly unrealistic scenario of all single parents choosing to marry (and staying married) and is therefore not particularly helpful in guiding policy. in addition, the type of family structure may not be as important as the quality of relationships in the family. marriages marked by high levels of conflict or domestic violence clearly have negative effects on children’s emotional well-being. one study that compared married parents and 46 journal of student social work, volume iii is the healthy marriage initiative really healthy? divorced parents found a strong relationship between parental conflict and children’s well-being, but none between family structure and children’s well-being (vandewater & lansford, 1998). although hmi proponents claim the initiative wants to increase only healthy marriages, it is unclear whether their proposed activities would be able to increase healthy marriages without increasing unhealthy ones as well. many currently funded marriage promotion projects offer marriage skills training (acf, 2005a). this type of program might reduce conflict in some marriages but would not offer a solution to relationships marked by domestic violence and might even be harmful to victims trying to leave such a relationship. thus we can see that, based on the available research, increased marriage rates might create some improvement in children’s economic well-being. however, it would probably not be a very large improvement, and it might have negative side effects such as increasing children’s exposure to conflict or domestic violence. policy effectiveness turning to the question of whether government programs and policies will really be able to create the desired change, there is very little empirical evidence one way or the other. in particular, there appears to be very little research documenting the effectiveness of the above-mentioned marriage skills trainings and similar activities among low-income welfare recipients. moore, jekielek, and emig (2002) note that although there are “promising insights” from research, “there is not yet a proven approach for building strong marriages” (p. 7). for example, the authors cite one study that found positive short-term results from a marriage skills improvement program. however, participants in this study were primarily white, were not economically disadvantaged, and were already married prior to the program. therefore, it is not clear whether similar programs would be generalizable to the tanf recipients who would be targeted by hmi programs. an aspect of the hmi that has received a lot of research attention is the use of changes in welfare benefits to favor married couples, changes which have been implemented in some states (white & kaplan, 2003). one program with positive findings in this area is the minnesota family investment program (mfip), in which a subsidy of employment earnings (without any explicit marriage promotion initiatives) brought about a small increase in marriage rates (ooms, 2002). however, this type of employmentrelated subsidy is not part of the proposed hmi. most research does not tend to support the claim that benefit changes have an effect on the marriage yardley journal of student social work, volume iii 47 rate of welfare recipients. for example, a national poverty center working paper states that generally, “research has found little to no effect of welfare policies on family formation decisions” (seefeldt & smock, 2004, p. 10). preliminary analysis of data from the fragile families study indicates that more generous welfare benefits correlated with higher rates of cohabitation, but had no effect on marriage rates (mincy & dupree, 2001). besharov and sullivan (1996), supporters of marriage promotion, were surprised to find that new jersey’s benefit changes had little or no effect on marriage rates among women on welfare. these findings should not be particularly surprising when we consider the research on which factors influence expectations of marriage. for example, in communities with high rates of joblessness, partners with low earning potential may not be seen as “marriageable.” in waller’s (2001) study of unwed parents, low expectations for marriage were highly correlated with factors such as a partner’s drug or alcohol problems, frequent conflict, and physical violence in the relationship. under such circumstances, the author notes, encouraging marriage may “not only be inappropriate, it may also be detrimental to parents and their children” (p. 482). despite these and other findings, policy-makers continue to rally around the claim that the marriage choices of single mothers can – and should – be shaped by welfare benefit policy. government intervention finally, we must ask: does the government have the right to intervene in the marital choices made by individual welfare recipients? united states government welfare policy has a history of discriminating against particular groups in order to coerce recipients into valued behaviors (as in the earlier example of widows’ pensions); however, this does not mean it is right. the hmi web page asserts that the hmi is not coercive because americans already value marriage: “more than 93% of americans say marital success is important to them” (acf, 2005b). as mentioned earlier, studies have shown that welfare recipients’ reasons for not marrying are often factors such as the partner’s drug addiction, abusive behavior, or infidelity (waller, 2001), rather than a lack of marriage values. however, administration official wade horn has asserted that the goal of marriage promotion is “to reinstate marriage as an ideal in low-income communities” (1997, p. 43, emphasis added), revealing the hmi’s true agenda: to impose specific values onto welfare recipients, who are perceived as being anti-marriage. in addition, the hmi web site insists that it only wants to help people 48 journal of student social work, volume iii is the healthy marriage initiative really healthy? “who choose marriage for themselves [to] acquire the skills and knowledge necessary to form and sustain healthy marriages” (acf, 2005b). this argument seems disingenuous, given that the hmi would be directed toward welfare recipients, who are vulnerable to government coercion. also, many existing marriage promotion programs recruit participants who are not married or engaged. for example, some healthy marriage projects currently funded by the administration for children and families recruit unwed parents from hospitals through the paternity establishment process (acf, 2004b). in addition, the hmi would not be simply a supplement to alreadyexisting services for tanf recipients, but rather would divert tanf funds from other services. furthermore, the ideological underpinning of marriage promotion policies is marked by an insistence on traditional gender roles; these policies encourage job training opportunities for men (to make them more “marriageable”) while attempting to move women back into the home. for example, besharov and sullivan (1996) admiringly describe how if welfare benefits are lowered, “a mother who prefers to stay home with her children rather than work might trade her now lower-value benefit package for the role of housewife, caregiver to her children, and, perhaps, part-time worker” (p. 94). in essence, these authors implicitly argue that “mothers should trade dependence on welfare for dependence on a husband” (p. 92). ultimately, it is not the government’s duty – or its right – to dictate family structure. it is the government’s function to provide as much support as possible for all families so that children’s (and adults’) well-being will be improved. the healthy marriage initiative inappropriately attempts to take charge of individuals’ private decisions about family formation. alternative policy options many other policies could be more directly supportive of family and child well-being. welfare benefits could be marriage-neutral (rather than privileging marriage, as encouraged by horn & bush, 1997), which would allow family structures to be determined by individual families. marriage could also be made available to same-sex couples, who represent a significant percentage of cohabiting couples with children (parke, 2003). universal availability of quality child care would go a long way toward reducing poverty among low-income families. with quality child care easily accessible, the availability of job training for both men and women would allow partners to decide whether one or both of them would choose to work. the government could also supplement employment earnings, as in the yardley journal of student social work, volume iii 49 mfip. based on research findings, sigle-rushton and mclanahan (2002) suggest that it might be more cost-effective to focus on employment than on marriage promotion as an anti-poverty strategy. these are just a few examples of the types of policies that would support families and help raise children out of poverty, without coercing families into what politicians believe they should be. if tanf funds were used for such policies, extensive evaluation should occur to ensure that they were actually having positive effects on children’s well-being. outcomes should be measured by children’s financial, physical, and emotional health, not by whether or not more parents are getting and staying married. policies that support working families of all kinds would be likely to have beneficial effects on children’s economic well-being. in addition, once parents are able to provide basic economic support for themselves and their children, their own improved well-being will give them greater resources to focus on parenting their children and creating healthy relationships. in contrast, implementation of the healthy marriage initiative would take away funding from resources like child care, job training, and other services, which are desperately needed by working families (including single, cohabiting, and married parents). although the hmi might increase healthy marriages, it might also increase the incidence of marriages plagued by conflict or domestic violence, and its effect on child poverty rates might be minimal. far from bringing about its stated goal of reducing poverty, the hmi would be likely to further stigmatize single parents and to intrude coercively into the lives of poor men and women. references acs, g. & nelson, s. (2004, may). what do “i do”s do?: potential benefits of marriage for cohabiting couples with children. new federalism: national survey of america’s families policy brief no. b-59. retrieved january 18, 2005, from urban institute web site: http://www.urban.org/url.cfm?id=311001 administration for children and families (acf) (2004a). healthy marriage initiative: healthy marriage matters. retrieved january 18, 2005, from http://www.acf.dhhs.gov/ healthymarriage/about/factsheets_hm_matters.html administration for children and families (acf) (2004b). currently funded healthy marriage projects: office of child support enforcement. retrieved february 26, 2005, from http://www.acf.dhhs.gov/healthymarriage/funding/child_support.html 50 journal of student social work, volume iii is the healthy marriage initiative really healthy? administration for children and families (acf) (2005a). healthy marriage initiative: funding opportunities. retrieved january 18, 2005, from http://www.acf.dhhs.gov/healthymarriage/funding/index. html administration for children and families (acf) (2005b). healthy marriage initiative: myths and facts about the healthy marriage initiative. retrieved february 26, 2005, from http://www.acf.dhhs.gov/healthymarriage/about/myths_facts.html besharov, d. j. & sullivan, t. s. (1996). welfare reform and marriage. public interest, 125, 81-94. brown, s. l. (2004). family structure and child well-being: the significance of parental cohabitation. journal of marriage and family, 66, 351-367. chase-lansdale, p. l. & pittman, l. d. (2002). welfare reform and parenting: reasonable expectations. the future of children, 12(1), 167-185. fagan, p. f., rector, r. e., johnson, k. a., & peterson, a. (2002, april). the positive effects of marriage: a book of charts. retrieved february 26, 2005, from heritage foundation web site: http://www.heritage.org/research/features/marriage/ heritage foundation. (2004). issues 2004: marriage promotion. retrieved january 18, 2005, from http://www.heritage.org/research/ features/issues2004/marriagewelfarepoverty.cfm horn, w. f. & bush, a. (1997). fathers and welfare reform. public interest, 129, 38-49. mclanahan, s. & sandefur, g. (1994). growing up with a single parent: what hurts, what helps. cambridge, ma: harvard university press. mincy, r. b. & dupree, a. t. (2001). welfare, child support, and family formation. children and youth services review, 23(6/7), 577-601. moore, k. a., jekielek, s. m., & emig, c. (2002, june). marriage from a child’s perspective: how does marriage affect children, and what can we do about it? research brief. washington, dc: child trends. retrieved february 27, 2005, from http://www.childtrends.org/files/ marriagerb602.pdf ooms, t. (2002). marriage and government: strange bedfellows? center for law and social policy, couples and marriage series, brief no. 1. retrieved january 18, 2005, from http://www.clasp.org/ publications/marriage_brief1.pdf parke, m. (2003, may). are married parents really better for children?: what the research says about the effects of family structure on child well-being. center for law and social policy, couples and marriage series, brief no. 3. retrieved march 1, 2005, from http:// www.clasp.org/publications/marriage_brief3.pdf roberts, p. (2004, august). i can’t give you anything but love: would poor couples with children be better off economically if they married? center for law and social policy, couples and marriage series, brief no. 5. retrieved january 18, 2005, from http://www. clasp.org/publications/marr_brf_5.pdf seefeldt, k. s. & smock, p. j. (2004). marriage on the public policy agenda: what do policy makers need to know from research? national poverty center working paper series no. 04-2. retrieved january 18, 2005, from http://www.npc.umich.edu/publications/ workingpaper04/paper2/index.shtml sigle-rushton, w. & mclanahan, s. (2002, july). for richer or for poorer?: marriage as an anti-poverty strategy in the united states. center for research on child wellbeing, working paper #01-17ff. retrieved march 1, 2005, from http://crcw.princeton.edu/papers. html trattner, w. i. (1994). from poor law to welfare state: a history of social welfare in america (5th ed.). new york: free press. vandewater, e. a. & lansford, j. e. (1998). influences of family structure and parental conflict on children’s well-being. family relations, 47(4), 323-330. waller, m. r. (2001). high hopes: unwed parents’ expectations about marriage. children and youth services review, 23(6/7), 457-484. white, d. & kaplan, j. (2003, june). the states’ role in supporting marriage and family formation. welfare information network, issue notes, 7(8). retrieved february 27, 2005, from the finance project web site: www.financeprojectinfo.org/win/ famformation.asp meg yardley is a second year master’s student concentrating in the advanced clinical practice method. her field of practice is family, youth, and children’s services. she is currently placed at the brooklyn child and adolescent guidance clinic of the jewish child care association. she holds a bachelor’s degree in comparative literature from smith college in northampton, ma. her email address is mby2101@columbia.edu. yardley journal of student social work, volume iii 51 microsoft word women in conflict-1.docx © 2015 arnett. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. women in conflict robin arnett this article focuses on female combatants serving in armed conflicts in africa, south america, and asia, profiling their time engaged with these forces as well as the realities they face upon their return to civilian life. women play a significant role in these conflicts, sometimes constituting up to 30% of the armed forces, although they are often overlooked. when they are acknowledged, women are frequently regarded as helpless victims rather than active participants. through statistics and country profiles, the groundwork is laid to develop a fuller picture of female participation in conflict in terms of their numbers, the ways in which they become involved, and the various roles that they play. conditions women commonly face upon returning from war are explored, including stigma, psychological and physical health issues, and a lack of options to provide for their own livelihoods. the article specifically notes the deficiencies of disarmament, demobilization, and reintegration (ddr) programs in serving female populations. the article concludes with analysis and recommendations for improvements to ddr programming, specifically as it relates to serving women and girls, and noting the precedent set by international human rights law for gender mainstreaming in ddr. ortrayals of conflict in the developing world commonly represent women and girls as victims suffering at the hands of violent men (coulter et al., 2008). it is true that conflict often disproportionately victimizes women and girls; they are at increased risk of sexual violence, are more likely to be pulled out of school, bear increased care burdens, and face decreased access to resources (buscher, 2009). research by mckay and mazurana (2004) reveals that armed conflicts tend to escalate sexism and intensify gender roles. however, what is often overlooked is women and girls’ active participation in war. women and girls represent a substantial minority of active participants in global conflicts, playing diverse roles within militaries, paramilitaries, militias, and armed opposition groups. women come to these organizations through abduction, as a survival strategy, or voluntarily. their experiences are complex and become even more so in the aftermath of conflict. this paper examines the participation of women and girls in armed forces in the developing world, highlighting specific cases from africa, latin america, and asia, including civil conflicts in nepal, colombia, sierra leone, ethiopia, uganda, and mozambique. the fate of these women when they return to their home communities is specifically addressed, with particular concern for disarmament, demobilization, and reintegration (ddr) programs. finally, the paper concludes with analysis and recommendations for improvements in programming.1 women in war girls and women join military forces in a variety of ways. many are abducted, while others enlist voluntarily, or as a survival strategy (coulter et al., 2008). according to specht (2006), approximately one third of female ex-fighters in the civil conflicts in liberia were forcibly recruited. most who volunteered cited survival and protection as their primary motivation, while others joined due to economic concerns, a desire for revenge, or a chance for equality with men. according to research on post-independence wars in several                                                                                                                           1 throughout this paper, the terms “young women” and “girls” will be used interchangeably. a detailed analysis of the differing experiences for women and girls, disaggregated by age, is beyond the scope of this paper, but deserves scholarly attention.   p © 2015 arnett. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. african nations, girls who enlisted often did so to escape domestic violence, abuse, and poverty (coulter et al., 2008). “home life was difficult. my father [stepfather, in fact] was a heavy drinker, he didn’t work….i left because he beat us, he drank, and then he took me as his wife. i preferred to die in the war rather than to stay at home and to keep on suffering.” vanessa, drc (brett & specht, 2003, p. 88) motivations rooted in ethnic identity and religion were rarely cited, as is more common for young men and boys who join liberation struggles in this region (coulter et al., 2002). however, this is not universally the case. although not all female members of the maoist movement in nepal joined freely, many young women from marginalized ethnic groups and lower castes joined the movement of their own accord – first as political supporters and later as combatants. their decision was inspired by a number of grievances that later developed political focus as they received ideological training (centre for peace studies, 2012). interviews with these women revealed motivations rooted in a desire for social, economic, and political emancipation, as well as self-defense and revenge. although nepal does not adhere to a rigidly gendered social structure, women who joined the mobile militia units and people’s liberation army (pla) still made a difficult and costly decision that significantly countered cultural norms (centre for peace studies, 2012). these women had a clear idea of what they hoped to gain. this case demonstrates that some women who participate in armed movements make deliberate, empowered choices that they believe can bring new freedoms and opportunities. life in combat female participation in armed conflict is strongly characterized by the variety of roles they play (coulter et al., 2008). wide variation in roles may exist even within the same country. in the mozambique liberation front (frelimo) and the mozambican national resistance (renamo), some women were forced into domestic labor and sexual slavery, while others were given more traditionally masculine assignments as fighters, recruiters, trainers, intelligence officers, spies, and weapons experts. nepalese girls and women in the pla shared the same duties and responsibilities as men, although they were expected to conform to new, more masculine gender norms (centre for peace studies, 2012). women were given new, “revolutionary” names and cut off their long hair, which had historically symbolized their femininity. typically, these roles tend to reinforce gender norms (brett & specht, 2003). for example, an international labour organization study of child soldiers in the philippines found that all girl soldiers, and no boys, were assigned to feminized, caretaking jobs such as nurses and medics. other common roles for women and girls in military groups include agricultural food cultivation, cooking, and cleaning (coulter et al., 2008). when afforded equitable treatment, many women have experienced some degree of empowerment as combatants. in these cases, war appears to provide opportunities to take on leadership roles and develop new skills (coulter et al., 2008). female fighters have reported that carrying arms gave them a sense of power, pride, status, and control, and that they were able to gain self-confidence and a sense of belonging through their military roles. still, mckay (2004) asserts that true gender equality has not been possible in african wars, even for women in high-ranking positions. in spite of opportunities for empowerment, female combatants are highly vulnerable to rape and gender-based violence at the hands of their male counterparts (mackay & mazurana, 2004). in their study of girls in fighting forces in northern uganda, mozambique, and sierra leone, mckay and mazurana (2004) found that girls associated with fighting forces almost universally reported experiencing sexual abuse. sexually transmitted infections, especially hiv/aids, are of particular concern to these women and their children. even women who are able to eventually achieve prominent positions face sexual abuse and gender discrimination on their path up the chain of command. return to civilian life © 2015 arnett. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. while their military experiences differ widely, all female ex-combatants face significant obstacles to their successful reintegration into civilian life. whether former combatants are welcomed back into their communities depends on several factors including the nature of the conflict, the societal structure, and the roles that the women played in the armed forces, with tremendous case-by-case variation. for example, female maoist combatants in nepal were generally welcomed back without hostility, because of community support for the movement and relatively liberal gender norms (centre for peace studies, 2012). however, returning child soldiers in colombia, many of whom are voluntary recruits, are regarded with fear and hatred because of the atrocities committed during wartime, especially as the conflict in that country continues (y care international, 2008). coming home can be especially difficult for girls who become mothers during their time away and for those who have “bush husbands”2 from their time in combat, especially if these husbands are considered enemies of the community (mckay & mazurana, 2004). for women who experienced empowerment as active combatants, being forced to fit back into highly oppressive societies can be extremely arduous. even women who had taken part in gender-equal liberation movements found themselves back within patriarchal societies once the fighting ended (coulter et al., 2008). women in the eritrean people’s liberation front (eplf) expressed that they had felt respected and equal during wartime, but that this was lost as their country began to shift into a normal civilian structure. mckay and mazurana (2004) find that, in the aftermath of war, communities and outside organizations attempt to push female ex-combatants back into traditional gender normative roles rather than capitalizing on valuable strengths and skills developed during combat. as a result, many female combatants – even those who had been abducted, abused, or kept as sex slaves – have stated that wartime was actually preferable to the life that came afterwards (coulter et al., 2008). according to one woman, sarah, who fought against pro-government forces in sierra leone, her situation after the war was considerably worse than it had been during the conflict: “now i live with war stigma and trauma…in our community, decision making is not an active ingredient in the life of women…they are nothing but property. even the affluent struggle to take part in decision making.” (mackenzie, 2012, p. 81). marriage and conjugal relations can be particularly intractable issues for women and girls returning from combat (coulter et al., 2008). the men in their communities regard them as having lost their femininity, and even male combatants who married fellow fighters often discard their wartime wives in favor of civilian women. consequently, many female soldiers return without partners and are left alone to support children born during the war (mckay & mazurana, 2004). women who had enjoyed equitable conjugal relationships during the war often saw their husbands change upon return to civilian life and faced highly gendered expectations from in-laws. despite sharing labor equally in the past, husbands now expected their wives to fit into more traditional roles. “i and my husband…had shared the same daily tasks in the cantonments, but when we came home my husband totally changed. i had to work at home and on the farm from 4 o’clock in the morning to 11 o’clock at night while my husband used to [spend the day] chatting about his war experiences with others...” – nepalese female ex-combatant (centre for peace studies, 2012, p. 13) most of the women who returned from war in nepal, married or not, were regarded by their elders as morally corrupt for having cohabitated (and presumably engaged sexually) with members of the opposite sex (centre for peace studies, 2012). for reasons such as this, girls and young women try to return home quietly, drawing as little attention to themselves as possible (mckay & mazurana, 2004). they often attempt to                                                                                                                           2 “bush husbands” are, for female combatants, from either forced or consensual marriages made within the context of war.   © 2015 arnett. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. reintegrate with their own families first. if rejected, they may turn to strategies such as sex work or seeking the help of an ngo. some female ex-combatants have been able to ease back into society through cleansing rites, which can be part of a healing process for both combatants and communities (bouta, frerks, & bannon, 2005). cleansing rituals may be designed to drive away evil spirits, protect the community, connect with ancestors, and welcome ex-combatants home. mckay and mazurana (2004) have observed that in uganda, sierra leone, and mozambique, such rituals help girls heal and reintegrate upon their return from conflict. these rituals take on various forms, from stepping on an egg to symbolize the beginning of a new life in northern uganda, to taking a special herb bath in mozambique (schirch, 2005). some rites are female-specific, as in mozambique and sierra leone, where special rituals were designated for sexually abused girls (bouta et al., 2005). stark (2006) found positive psychosocial results for girls in sierra leone who had undergone such ceremonies. they experienced greater acceptance from their families and communities and were able to heal through the supportive process of the ritual itself. these girls were also able to shed the spiritual contamination that they felt had been acquired through the war. nevertheless, cleansing rites are still primarily restricted to men, and women may have a great deal of difficulty gaining access (schroven, 2006). furthermore, while cleansing rituals may have tremendous benefits, they often focus on reestablishing patriarchal gender roles. some can even be dangerous to women’s health and wellbeing, such as female genital mutilation (bastick, grimm, & kunz, 2007). programs to address the needs of female ex-combatants should integrate cleansing ceremonies into their approaches, taking advantage of effective components and mitigating the risks. disarmament, demobilization, and reintegration ddr programs in post-conflict zones have overwhelmingly failed to address the needs of female excombatants. generally, ddr programs have three primary goals: (1) to collect, register, and destroy all conventional weapons; (2) to demobilize combatants; and (3) to reintegrate combatants into society (coulter et al., 2008). benefits can include health care, counseling, cleansing rituals, education and vocational training, and aid in community reconciliation (mckay & mazurana, 2004). however, ddr programs tend to be severely underfunded and poorly designed. multiple studies have found deficiencies within demobilization programs worldwide due to the gendered nature of the reintegration process (coulter et al., 2008). in fact, women overwhelmingly do not participate in these programs at all. one of the main reasons that women avoid ddr programs is out of fear of identification as combatants (coulter et al., 2008). commanders, peers, or relatives may tell women that it is not appropriate for them to disarm because of the association with masculine roles and actions that disarmament implies. furthermore, women are mostly excluded from post-war political structures and militaries, and they are often refused access to land. for many, the risks are not worth what the ddr programs have to offer. women who do participate in ddr programs often find that their needs are unmet. they are explicit about the importance of accessing education and training in skills that will allow them to develop sustainable livelihoods (mckay & mazurana, 2004). unfortunately, however, the funding decisions of the global development industry have played a key role in confirming existing gender stereotypes (mackenzie, 2012). vocational programs typically offer training only in traditionally feminine fields such as dressmaking and cosmetology (y care international, 2008). in sierra leone, failure to conduct a local market assessment resulted in an overabundance of women trained in gara tie dying (mackenzie, 2012). in this case, inappropriate allocation of funds wasted valuable resources in training women for a trade that not only failed to support their livelihoods, but also reinforced typical gender stereotypes and disregarded skills and strengths that they had developed during their time in combat. © 2015 arnett. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. analysis and recommendations the most effective ddr programming for female ex-combatants is comprehensive, market-based, and empowering. noting the barriers listed above, ddr programmers must reach out specifically to female excombatants and provide services in a way that is both safe and private. women should have access to femaleonly facilities and services without being forced to reveal their status as ex-combatants. the failure of ddr vocational training in sierra leone demonstrates the critical importance of marketbased approaches to livelihoods provisioning (mackinsey, 2012). before implementing any programming, ddr programmers must conduct needs assessments and market analyses in order to understand the desires, needs, fears, and strengths of the people they are serving. furthermore, data collected must be disaggregated by age and gender. women need equal access to all training, not just stereotypical trades with limited upward mobility. ideally, the skills and strengths learned in wartime would be seen as such and applied to livelihoods strategies based in economic realities. for example, a former recruiter might be trained in marketing, advertising, networking, and business. additionally, all ex-combatants should have access to educational programming that allows them to provide materially for themselves and their families. many female ex-combatants are dealing with serious mental health concerns, especially post-war trauma (coulter et al., 2008). effective programming will also address their psychological needs. while it may not be feasible to provide individual counseling to all, female ex-combatants should be encouraged to form support groups, where they can share their experiences of war and return. these groups have the potential to ease psychological burdens and build community and solidarity, especially if facilitated by skilled practitioners. war is a tragedy wherever it occurs, and practitioners working in post-war settings must be better equipped to serve the needs of female fighters. doing so requires that they understand the duality of these experiences, keeping in mind female ex-combatants’ special needs, addressing trauma, and empowering them toward brighter futures. ultimately, ddr programs should build upon the confidence and liberation these women may have developed while at war. references buscher, d. (2009). women, work, and war. in martin, s. f. & tirman, j. (eds.), women, migration, and conflict: breaking the deadly cycle (pp. 87-106). new york: springer. brett, r. (2002). girl soldiers: challenging the assumptions. geneva: united nations quaker office. brett, r. & specht, i. (2003). young soldiers: why they choose to fight. geneva: international labour office. centre for peace studies – university of tromsø. (2012). post-war moral communities in somalia and nepal: gendered practices of exclusion and inclusion. tromsø: bleie, t. coulter, c., persson, m., & utas, m. (2008). young female fighters in african wars: conflict and its consequences (policy dialogue no. 3). stockholm: the nordic africa institute. delgado-kling, p. (2009). child soldiers. literary review, 52(2), 163-174. retrieved from: http://ezproxy.cul.columbia.edu/login?url=http://search.proquest.com/docview/222108557?accountid=10226 keairns, yvonne e., (2002). the voices of girl child soldiers, new york: quaker united nations office. mackenzie, m. h. (2012). female soldiers in sierra leone: sex, security, and post-conflict development. retrieved from: http://site.ebrary.com/lib/columbia/reader.action?docid=10602435 mazurana, d. & carlson, k., (2004). from combat to community: women and girls of sierra leone. washington dc: women waging peace policy commission. mckay, s., (2004). reconstructing fragile lives: girls’ social reintegration in northern uganda and sierra leone. gender and development, 12(3), 19–30. mckay, susan, 2007, “girls as ‘weapons of terror’ in northern uganda and sierra leonean fighting forces”, studies in conflict and terrorism, 28:5, 385–397. mckay, s. & mazurana., d. (2004). where are the girls?: girls in fighting forces in northern uganda, sierra leone, and mozambique: their lives during and after the war. québec: rights and democracy. schirch, l. (2005). ritual and symbol in peacebuilding. bloomfield, ct: kumarian press, inc. specht, i. (2006). red shoes: experiences of girl-combatants in liberia. geneva: international labour office. united nations entity for gender equality and the empowerment of women. (1995). beijing declaration and platform for action: report on the fourth world conference on women, a/conf.177/20/rev.1 (4-15 september 1995), available from http://www.un.org/womenwatch/daw/beijing/pdf/bdpfa%20e.pdf © 2015 arnett. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. united nations security council resolution 1325, s/res/1325 (31 october 2000), available from http://undocs.org/s/res/1325 veale, a. (2003). from child soldier to ex-fighter: female fighters, demobilisation and reintegration in ethiopia. pretoria: institute for security studies: http://www.issafrica.org/uploads/mono85.pdf women’s refugee commission. (2015). wrc fact sheet. retrieved from: https://womensrefugeecommission.org/about/how-we-work y care international. (2008). overcoming lost childhoods: lessons learned from the rehabilitation and reintegration of former child soldiers in colombia. london: thomas, v. robin arnett is a dual-degree student with columbia’s school of social work and the school of international and public affairs studying for an mssw and an mpa. she graduated from vanderbilt university in 2009 with a ba in political science. since then, she has worked for two multi-national consulting companies and spent a year in ecuador as a volunteer english teacher. she currently interns in the children and youth services department at sanctuary for families, an agency focused on issues related to domestic violence in new york city. her areas of interest include women’s empowerment, economic development, human trafficking, and immigration.   50 | columbia social work review, vol. vii columbia social work review, vol. vii | 51 shan and sandleraddressing the homelessness crisis in new york city: increasing accessibility for persons with severe and persistent mental illness leeann shan and matt sandler homelessness continues to be a persistent and highly visible public health issue in new york city. new york/new york iii, the current initiative that aims to expand supportive housing services for new york city’s chronically homeless mentally ill population, will expire in june 2016. in the context of shifting policies reflecting the growing popularity of the housing first model, the authors of this paper call attention to the unique needs of the severely and persistently mentally ill (spmi) homeless population. the authors propose that the current and future states of homelessness initiatives are inadequate in their levels of funding, coordination, and regulation, thereby negatively affecting new york city’s most vulnerable residents. drawing on evidence from the literature, we compare the housing first and traditional housing readiness models in new york city, the latter of which has become increasingly controversial in recent years. the authors provide suggestions for bridging the current gaps in research, policy, and practice in hopes of increasing accessibility and prioritizing housing for this population. homelessness continues to be a persistent and highly visible public health issue in new york city. in 2013, the number of people sleeping in city shelters each night reached its highest level since the great depression, with homeless families and children making up 78% of this population (markee, 2013). approximately one-third of all homeless individuals suffer from at least one serious mental illness, and 50% to 70% of homeless mentally ill individuals also suffer from concurrent substance use disorders (groton, 2013). homeless shelters are projected to cost new york city close to $1 billion in 2015, a 62% increase in the last eight years (bekiempis, 2015). these numbers reflect a serious problem in current service delivery and homelessness prevention methods. new york/new york iii, the current initiative that aims to expand supportive housing services for new york city’s chronically homeless mentally ill population, will expire in june 2016. on january 13th, 2016, governor andrew cuomo issued a new initiative to create 20,000 new supportive housing units in new york state over the next 15 years. this initiative adds to mayor bill de blasio’s prior commitment to fund 15,000 units in the city over the same time period (rought, 2016). in the context stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text © 2016 shan and sandler. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. stujourn typewritten text 50 | columbia social work review, vol. vii columbia social work review, vol. vii | 51 shan and sandler of these new developments and shifting policies reflecting the growing popularity of the housing first model, the authors of this paper call attention to the unique needs of the severely and persistently mentally ill (spmi) homeless population. the authors propose that the current and future states of homelessness initiatives are inadequate in their levels of funding, coordination, and regulation, thereby negatively affecting new york city’s most vulnerable residents. drawing on evidence from the literature, we compare the housing first and traditional housing readiness models in new york city, the latter of which has become increasingly controversial in recent years. in doing so, the authors provide suggestions for bridging the current gaps in research, policy, and practice in hopes of increasing accessibility and prioritizing housing for this population. a brief history modern homelessness in new york city has roots in two important historic events: the deinstitutionalization movement and the decline of the single-resident occupancy housing market (baxter & hopper, 1982; cite: coalition for the homeless). the deinstitutionalization movement, which began in new york state in the 1950s, facilitated the discharge of thousands of psychiatric patients from state hospitals and other inpatient facilities into the general community. this policy stemmed from new psychopharmacological developments and studies advocating for less restrictive, community-integrated approaches to treatment (durham, 1989; talbott, 2004). over the next few decades, negative public opinion toward inpatient treatment strengthened the movement, largely shaped by popular media depicting abhorrent hospital conditions (e.g., the 1962 novel one flew over the cuckoo’s nest). as a result of deinstitutionalization, the number of resident patients in new york state psychiatric centers fell by 68% between 1965 and 1979 (coalition for the homeless, 2015). lack of follow-up services meant that many newly released individuals were left without any treatment or community support. with limited resources and inadequate follow-up services, the patients sought housing in low-cost, single-resident occupancy (sro) units. during this era, from 1955 to 1975, restrictive zoning ordinances and changes in new york city housing regulations essentially prevented the creation of any new sros (dennis et al., 1991). in addition, gentrification and property tax policies financially incentivized owners of existing sro buildings to convert sro units into higher-priced rental housing, cooperatives, or condominiums (coalition for the homeless, 2015). these events led to a rapid decline in the 52 | columbia social work review, vol. vii columbia social work review, volume vii | 53 addressing the homelessness crisis in new york city shan and sandler sro housing stock, which continued for several decades and severely limited both access to and availability of housing. adverse political, economic, and social contexts perpetuated modern homelessness. for individuals who struggle with mental illness, the impact of homelessness is especially consequential. compared with their non-mentally ill counterparts, such individuals generally remain homeless for longer periods of time, have fewer social supports, poorer health outcomes, and experience more barriers to employment (tessler & dennis, 1989). homelessness impedes continuity of care, which further exacerbates these problems. past supportive housing plans in new york were a response to the ubiquity of conspicuous homelessness on city streets. the origins of city and state coordination on supportive housing date back to 1990, when mayor david dinkins and governor mario cuomo entered an agreement called new york/new york to create 5,000 supportive housing units for chronically homeless new yorkers. the agreement has since been renewed twice, first in 1999, when 2,000 units were added [new york/new york ii], and again in 2005, when the city and state agreed to create 9,000 units over a 10-year period through the new york/new york iii initiative (office of the public advocate, 2015). housing first as a way of tackling homelessness for this most vulnerable and chronic mentally ill population, sam tsemberis, the founder of the new york-based organization pathways to housing created the housing first model in 1992 (tsemberis & asmussen, 1999). the model’s philosophy states that access to housing integrated with appropriate and ongoing support services is of immediate concern and should not be contingent on commitment to mental health and/or substance abuse treatment. housing first aims for harm reduction, in contrast to a housing readiness approach, which emphasizes that psychiatric treatment and/or sobriety should be a precondition to stable housing (tsemberis, gulcur, & nakae, 2004). evidence of housing first’s effectiveness has been demonstrated in multiple research studies, set within a variety of contexts (goering et al., 2011; tsai, mares, & rosenheck, 2010; stefancic et al., 2013; stefancic & tsemberis, 2007). it is important to note, however, that most studies investigating the effectiveness of the housing first model have had a strong research affiliation with the agencies being evaluated (groton, 2013). thus, it is possible that this bias could have influenced more favorable study outcomes. in a 5-year longitudinal study, tsemberis and eisenberg (2000) compared 52 | columbia social work review, vol. vii columbia social work review, volume vii | 53 addressing the homelessness crisis in new york city shan and sandler housing retention rates among new york city individuals housed through the pathways to housing program with those who were housed through standard care, treatment-first programs. as predicted, housing first tenants maintained significantly better housing tenure over the duration of the study—88% remained housed, compared with 47% of the control group (tsemberis & eisenberg, 2000). housing stability has also been linked to positive health outcomes for individuals with mental illness, as evidenced by lower rates of hospital utilization (kyle & dunn, 2008), and improvements in overall neuropsychological functioning (seidman et al., 2003). in addition to individual benefits, the housing first approach also promises improvements on a macro scale. in terms of cost effectiveness, increased access to permanent housing and services means decreased risk of contact with the criminal justice system and lowered use of costly acute care services such as emergency shelters and hospital emergency rooms (dennis et al., 1991; gulcur, stefancic, shinn, tsemberis, & fisher, 2003). in a 2013 randomized controlled trial on five major canadian cities that adopted the housing first program, it was found that the approach was both effective in reducing homelessness and economic impact—“government savings were even greater for those who used services the most, with three dollars saved for every two dollars spent” (tsemberis & stergiopoulos, 2013, p.1). continuum of care the continuum of care was first implemented by the united states department of housing and urban development (hud) in 1995 and prescribed a housing readiness model (o’connell, 2003). unlike the housing first approach, the housing readiness approach used in the continuum of care system centered on the idea that homeless individuals, including those diagnosed with mental illness, must pass through a series of temporary residential programs (e.g., emergency shelters, transitional housing) with varying levels of care prior to attaining permanent, independent housing (gulcur et al., 2003). as a result, hud allocated funding to those housing organizations that followed such a model. for the subset of spmi individuals who may not be equipped to care for themselves in an independent setting, the requirements of this kind of graduated model—which often include psychiatric medication compliance, participation in psychotherapy, and/or psychosocial rehabilitation—offer the structure and support not necessarily emphasized in housing first programs. although the majority of spmi adults report a preference for living in as independent and normative a setting as possible (yamada, korman, 54 | columbia social work review, vol. vii columbia social work review, volume vii | 55 addressing the homelessness crisis in new york city shan and sandler & hughes, 2000), and consumers that live under these conditions report higher levels of satisfaction (wilson, 1992), it is important to remember that subjective satisfaction alone does not eliminate the risk of returning to homelessness. in fact, yamada and colleagues (2000) found that consumers who were placed in group homes or supported housing with “appropriate structure and support” (p. 36) were able to remain in the community for twice as long as those living independently. consumer self-determination is a key component of the housing first model that should not be negated. however, social isolation—a significant predictor of psychiatric relapse (hultman, wieselgren, & öhman, 1997)— continues to be a reality for spmi adults, as community integration can prove extremely challenging. individuals with severe mental illness living in independent housing report significantly more social isolation than those living in group settings or supportive housing with on-site visits by staff (friedrich et al., 1999). for these reasons, the new york/new york supportive housing agreements successfully created different levels of supportive housing to include custodial and therapeutic services to meet the variety of needs for chronically homeless individuals and families. in addition, ensuring housing in beneficial neighborhoods with well-maintained buildings has been linked to lower costs of mental health services for spmi adults (harkness et al., 2004). housing first has evolved to satisfy these unique needs of the populations it serves through different levels of supportive housing. in 2013, hud changed its continuum of care guidelines and began prioritizing funding for localities whose service providers use the housing first model (u.s. department of housing and urban development, n.d.) to address chronic homelessness. this change in policy is a major step forward in recognizing the efficacy of providing housing stability as the cornerstone to successful treatment for spmi and other chronically homeless populations. this prioritization, though, while supported by many service providers, also came with unintended consequences. service providers in new york city provide mostly transitional housing services in the form of emergency shelter. given the number of homeless in the city, shelter remains an important safety net. under the new continuum of care guidelines that prioritize housing first, “this change in policy is a major step forward in recognizing the efficacy of providing housing stability as the cornerstone to successful treatment for spmi and other chronically homeless populations.” 54 | columbia social work review, vol. vii columbia social work review, volume vii | 55 addressing the homelessness crisis in new york city shan and sandler service providers that run shelters stand to lose some hud funding. new york/new york iv: a lost opportunity the lost funding opportunities and increased number of homeless individuals in shelters and on the street made an updated new york/new york supportive housing agreement even more crucial. what should have been a matter of course—an agreement between city and state to fund a new crop of supportive housing units—turned into a political tug-of-war between mayor de blasio and governor cuomo over cost sharing. under previous new york/new york supportive housing agreements, the state paid 50% of capital expenses while covering 80% of service costs (stewart, 2015). the mayor began negotiating an agreement by seeking 12,000 units in new york city. the governor responded by offering 3,900 units and changing the previous funding scheme from the state covering 80% of service costs to an even 50-50 split (see: editorial board). the impasse resulted in the mayor and governor each announcing his own independent plan for creating more supportive housing; new york city will create 15,000 units of supportive housing over the next 15 years, and the state will create 20,000 units in the same time. on a positive note, the political spat resulted in a one-upmanship that created more supportive housing than either city or state initially offered. the independent announcements from the mayoral and gubernatorial administrations demonstrate a significant increase in resource allocation to supportive housing. however, these plans function independently of one another and are not a coordinated new york/new york iv agreement. this is significant, as the independent initiatives abandon the efficiency of previous coordinated efforts between the city and state. past agreements allocated resources and processes for capital financing and service delivery in concert. now, with two separate initiatives, nonprofits charged with creating new units of supportive housing will likely encounter administrative hassles. a new coordinated new york/new york agreement would be a more efficient strategy to reduce chronic homelessness, as well as a more financially responsible approach. the new york city department of health and mental hygiene estimated in 2013 that the new york/new york agreements resulted in public savings of $10,100 annually per unit (coalition for the homeless, 2015) through decreased use of emergency services. conclusion supportive housing is appropriate for the chronically homeless and makes 56 | columbia social work review, vol. vii columbia social work review, volume vii | 57 addressing the homelessness crisis in new york city shan and sandler financial sense for the city and state because of the high cost of care otherwise associated with individuals and families who use emergency services at a high rate. it is important, though, to consider that the chronically homeless are a subpopulation of a larger whole. nearly one-third of individuals and heads of household in the new york city shelter system have earned income (iverac, 2015), and would not qualify for supportive housing. the city and state can partner to make rental subsidies, such as the living in communities (linc) subsidy introduced in 2014, viable options for these individuals and families. the two can also work together to help prevent homelessness by working together to increase funding for the solutions to end homelessness program (stehp). these issues must be tackled in a partnership between the city and state, and this requires a coordinated effort between the mayor and governor. although it is encouraging that more supportive housing will be created over the next 15 years, it is disappointing that these units could not build upon the legacy of a new york/new york agreement. the success of housing first supportive housing under the banner of a new york/new york iv housing agreement could be monumental. a robust housing plan to curb chronic homelessness in the country’s largest city would certainly be a notable achievement. a plan of this nature would signal the joint commitment to providing stability and services to the vulnerable subpopulation of spmi individuals and families. in the meantime, we welcome the independent plans and look forward the city 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(2000). predicting rehospitalization of persons with severe mental illness. journal of rehabilitation, 66(2), 32-39. leeann shan is currently a second-year student at cussw and executive editor for the columbia social work review. she is concentrating in advanced clinical practice, with a focus on health, mental health, and disabilities. she is currently placed at new york state psychiatric institute, where she works on the inpatient research unit with adults with severe mental illness. leeann is also a research assistant at columbia’s experimental psychopathology laboratory, where she studies the treatment and prevention of schizophrenia and schizophrenia-spectrum disorders. leeann plans to apply to ph.d programs after graduation, so she can continue to pursue research into these topics. matt sandler is a senior editor at the columbia social work review and an ms candidate in his second year at the columbia school of social work. his field of practice is in public policy, with an academic concentration on contemporary social issues related to poverty. matt has worked extensively in homeless services, directly with clients, and in coalitions with providers. journal2011 ! 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(2:=+&!*&&:2>>2>!:24!@/%>@2-=>!+:9!2=a*-+&!-a+&&2:?2>c! >-#+.'%#&$)+/!j699$1+)<!ul5!tvn"c! .%:?5!$c5!;+3*9>%:5!\c5!s-u&+>a+:5!jc5!u2/>%:5!1c5!s+&+>@*:+5! ;c5!k!$%/-%/+:5!$c!flmmzgc!$%(@+/+)&2!b+(*&<!)'/92:!*:! b+(*&*2>!%b!-&*:*-+&!a*?ae/*>0!+:9!/2-2:=e%:>2=!@><-a%>*>! @+=*2:=>c!m/&92!q)1$&5$)1+')*!+)!;*2-#+/1&2<!h<!l"xvlxnc!! h':?5!dc!1c5!s-u%//<5!yc!;c5!s-p+/&+:2!5$c!dc5!8+-0>%:5!]c!8c5! y+==%:5!uc!$c5!k!1+00+/5!dc!fn##xgc!s%:*=%/*:?!+:9!-+/2! %b!<%':?!@2%@&2!+=!*:-*@*2:=!/*>0!%b!@><-a%>*>c!>-#+.'%#&$7 )+/!j699$1+)<!hh<!lztvtmtc!! h':?5!dc!1c5!i2&>%:5!ec5!ja%(@>%:5!d!c;c5!k!.%%95!,c!8c!flmnmgc! ,a%'&9!+!/*>0!><:9/%(2!b%/!@><-a%>*>!)2!*:-&'929!*:!=a2! ;,se6m!>-#+.'%#&$)+/!o$*$/&-#<!lhp<!`vn"c!! h':?5!dc!1c5!ya*&*@>5!\c!8c5!s-u%//<5!yc!;c5!s-p+/&+:25!$c!dc5! p/+:-2<5!,c5!]+//*?+:5!,c5!2=!+&c!fn##zgc!y/29*-=*%:!%b!@><e -a%>*>c!j&+1+*#!e'6&)/9!',!;*2-#+/1&2<!lth<!ndvlmc!! h':?5!dc!1c5!ya*&&*@>5!\c!8c5!h'2:5!]c!yc5!p/+:-2<5!,c!sc5! s-p+/&+:25!$c!dc5!]+&&?/2:5!sc5!2=!+&cflmmtgc!y><-a%>*>! @/29*-=*%:l!nle(%:=a!b%&&%4e'@!%b!+!a*?ae/*>0! fa@/%9/%(+&bg!?/%'@c!>-#+.'%#&$)+/!o$*$/&-#<!xp<!lnvtlc!! ! ! favaro journal of student social work, volume ii 53 reflections of racial consciousness in social work this article focuses on select reflections of a white social work student’s thoughts on racism within a historical, societal, and systems context. topics discussed include prejudice, privilege, and power differentials within the white as helper, black in need dichotomy. research and personal outlook are interwoven to conclude that as agents of change, white social workers hold a unique responsibility in working towards an anti-racist agenda and confronting their own racist ways of knowing. jamie favaro to-day the ferment of his striving toward self-realization is to the strife of the white world like a wheel within a wheel: beyond the veil are smaller but like problems of ideals, of leaders and the led, of serfdom, of poverty of order and subordination, and, through all, the veil of race. few know of these problems, few who know notice them; and yet there they are, awaiting student, artist, and seer, a field for somebody sometime to discover. –w. e. b. dubois the acknowledgement and unlearning of racism are especially salient to white individuals working within the social work profession. due to an unequal power structure that categorizes whites as helpers and people of color as clients1, whites must be pro-actively cognizant of the way in which societal and interpersonal contexts affect the multiracial practitioner/client relationship. borrowing terminology from belenky, blythe, goldberger, and tarule (1986), this article focuses on a racist way of knowing to describe the distinct way in which whites in the united states have cultivated their own reality and conclusions regarding the intersection of race, power, and privilege. the purpose of this article is to demonstrate that without a conscious understanding of one’s own racist ways of knowing, white social workers are primed to disservice their clients of color through various forms of racism. to embark on this conversation about race, i would first like to acknowledge the simplification of the black/white dichotomy corroborated by this paper when race is, instead, a complex social construct. the following article is by no means designed to function as a review of social work literature or the state of racism in america. rather, it is a heart-mind journey (seldon, 2000) – reflections of unlearning racism, the questions and challenges it has posed in personal experiences and the professional practice of social work. a question of covert repression while working in the south bronx during my first year field placement, i confronted a daily turmoil involving, of all things, hair. in an agency where i was most often the only blonde, blue-eyed individual, i experienced heightened sensitivity to a culturally induced skewed beauty standard2 when male clients would express an allure towards my blond hair in front of their female companions. this experience, which occurred regularly with multiple clients, unleashed an inner dialogue and maelstrom within me. i became exceedingly alert to my own fears toward repressing clients and wondered: is my hair color covertly repressive to a client of color? how does my whiteness affect my practice? this internal argument was the catalyst for an intense and unremitting journey within my consciousness – a journey of reflection on racist identity and privilege. issues of race can be controversial and problematic to self-identity. to be labeled racist invokes defensive fears in all of us. as a white individual, i have come to acknowledge that i am aligned with the perceived class elite and the politically powerful which entitles me to a wealth of privileges regardless of my moral conviction or personal history (steinhorn & diggsbrown, 2000). as mcintosh (1989) suggests, i was socialized to downplay my own racial issues and understand white people’s way of thinking as normative, neutral, and ideal. despite a liberal education that focused on the damaging ideology of hierarchy and oppression, without self-reflection and a personal confrontation of my own racist schemas, i only superficially considered myself part of a racist structure. when we think of white supremacy, visions of klansmen and skinheads may pervade our definition; we rarely think of ourselves as the vehicle for oppression. seldon (2000), however, reminds us that “prejudice + power + privilege = racism” (p. 26). because most of my peers are white, and most of our collective clients are people of color, i have become particularly interested in how race and social work intermingle. in 2000, whites composed close to 70% of social work students enrolled in master’s level social work programs in the united states (lennon, 2002). thus the continuation of the white as helper, black in need dichotomy is something i have had to critically examine to bring an anti-racist agenda into my practice. mcmahon and allen-mearnes (1992) define anti-racist social work as “helping people reflect on their situation so that they can understand the oppressive system they are in and working with them to change it” (p. 538). in contrast, i have chosen to tailor my own model of anti-racism reflections of racial consciousness 54 journal of student social work, volume ii favaro journal of student social work, volume ii 55 in a direction towards the self rather than the client. for me, anti-racism encompasses both pro-active critical examination and recognition of individual and institutional involvement in perpetuating racist structures. it also includes an analysis of the subtlety and complexities of racial dynamics in the historical, political, economic, social, and cultural realms of power structures. to be anti-racist is to move towards incorporating racial and social justice into all facets of personal and professional development. examining whites in the victim role in my opinion, the most interesting race-based conversation among social work students revolves around the fear of the walk from the subway station to their placements. i have been privy to thought processes in which students acknowledge and then minimize the racist undertones of their fears and proceed to externalize racism by suggesting their fears of criminality are statistically founded. in fact, the criminalization of people of color highlights the legacy of slavery inherent within the criminal justice system3. to illustrate this point, we can turn to drug sentencing statistics: “blacks make up 12% of the united states’ population and constitute 13% of all monthly drug users… but represent 35% of those arrested for drug possession, 55% of those convicted of drug possession and 74% of those sentenced to prison for drug possession” (butterfield, 1995, p.a8). additionally, the media disproportionately focuses on crimes committed by black men while the dangers people of color face are rarely highlighted (glassner, 1999; reiman, 2001). in understanding how criminal injustice and skewed media portrayals exacerbate stereotypes about people of color, i am reminded that “a person is evaluated, either favorably or unfavorably, not because he does something, or even because he is something, but because others react to their perceptions of him as offensive or inoffensive” (quinney, 1975, p. 67). to maintain a racist status quo, skewed perceptions supported by criminal injustice and media images fulfill and perpetuate the dominant culture’s need to place themselves in the inculpable position of victim. therefore, students’ fears of walking through a neighborhood with the credence that one is in danger sanctions little need to critically examine negative schemas towards people of color and the poor. focusing on the systematic, institutional structures responsible for the cause and maintenance of crime, poverty, and second class citizenship will make walking through an agency’s neighborhood take on an entirely different meaning. white social workers as averse racists by nature of the liberal principles presented in the code of ethics of the national association of social workers (nasw, 1999), social workers present themselves as socially progressive, and it is against this philosophy to internalize a racist identity or embrace a racist thought pattern. by externalizing one’s own racist lens, however, whites fall into what gaertner and dovido (2000) identify as aversive racism. aversive racists are described as those who “sympathize with the victims of past injustice; support public policies that, in principle, promote racial equality and ameliorate the consequences of racism; identify more generally with a liberal political agenda; regard themselves as non-prejudiced and nondiscriminatory; but, almost unavoidably, possess negative feelings and beliefs about blacks” (gaertner & dovido, p. 289). furthermore, a study of white graduate students showed racerelated guilt to be an evident manifestation when talking about whiteness (arminio, 2001). arminio found that often, guilt was associated with efforts at indemnification; privilege was used to avoid recognizing racist patterns and as justification for not seeing oneself as part of the system. research teaches us that by externalizing racist and negative thought patterns, fears are manifested in apprehension, discomfort, and uneasiness (gaertner & doivido, 2000). considering the impact of racism on the white mentality, white social workers hold a unique responsibility for self-reflection and critical thinking about one’s prejudices, privileges, and the implications of both. by the definition of our work, a great disservice is committed if we do not take a proactive stance towards combating externalized racism and confronting how covert fears present themselves in practice. venturing beyond a one-dimensional reality one of my most disturbing experiences as a social work student occurred during a first year required class, human behavior and the social environment in which the 1986 cbs documentary the vanishing black family: crisis in black america (wolff) was shown. the film showcased african-americans living in newark, nj, depicting young men as irresponsible sex-crazed pimps and two generations of women as quintessential welfare mothers. a student interrupted this video and stated that she was offended with the content of the film. she labeled it “racist propaganda” and was unsure why the class was viewing it. this comment provoked other students to voice disappointment and anger toward the film’s failure to address the root causes of poverty. i remember the professor, outwardly flustered, attempting to conclude the discourse by stating it was taking away from the film’s message, and that we would understand its greater meaning if we continued to watch the entire movie. the film’s agenda was to document the disappearance of the black nuclear family. however, the content did not acknowledge the destruction of the black family as an essential component of american slavery (marable, 2000). without historical connections or context, reality is one-dimensional. reflections of racial consciousness 56 journal of student social work, volume ii favaro journal of student social work, volume ii 57 for social work education to function in a one-dimensional manner, which presents race-based material void of the historical and political contexts, our ability to be critical thinkers is injured. despite one student asking if we could stop the movie to continue the discussion, the class sat agitated while the professor, obviously bothered, fast-forwarded through the two-hour film to make up the time we had lost talking. while the professor did set aside the last twenty minutes of the following class, one week later, to discuss the film, i felt like we were silenced and frustrated from the previous experience. the discussion lacked the original passion and productivity that was generated by the experience of watching the film. one week later, this discussion seemed deflated and decontextualized. i sense that many students yearn to discuss context and impact, but without a catalyst or encouraging environment, conversations dealing honestly and frankly with race are not permitted to exist. i am saddened that my experience of social work education has minimally challenged my understanding of power and inequality. it has demonstrated a general lack of energy in its dialogue, unequivocally ignoring and therefore supporting a white supremacist status quo4. if “a major objective in social work education is to impart knowledge that helps students engage in critical self-reflection about power and inequality” (millstein, 1997, p. 491), then we must welcome the potential volatility of such discourse. white students unable to engage and gain proficiency in race-based dialogue within an academic environment will be less likely to initiate internal reflection or dialogue as professionals. i sometimes listen to social work students’ call for more diverse faculty and student body citing the predominantly white student composition, yet i rarely hear a request for anti-racism class or field assignments. while acknowledging the importance of diversity in thought within any healthy community, i must also highlight that the presence of diversity in itself is not sufficient to imply a lack of racism. academic institutions, such as the smith college school of social work, have challenged themselves to create and implement an anti-racism field assignment, requiring students to recognize racial dynamics within their field practice (basham, donner, & everett, 2001). while this is an intriguing window into the psyche of social work education’s response to the conception of an anti-racism field assignment, i challenge all institutions to continue to question how antiracism assignments could fit into their curriculum, particularly through the full cooperation between faculty, students, and field instructors. if class or field assignments were designed to incorporate anti-racism in their agenda, what would they look like? how would the faculty and field advisors execute and evaluate them? how would the students receive and develop through them? call for anti-racism as a critical component of social work education social work academia as an institution has an obligation to demand reflective, in-depth materials regarding anti-racism as a baseline for students pursuing social work. for cultural competence standards to truly be addressed, existing social work literature must be critiqued for its thoroughness and ability to address concerns in an unveiled, shameless manner. critically examining not only issues of race, but those of class, ethnicity, religion, sex, gender, sexual orientation, disability, and societal definitions of deviance should be what sets social work apart from other professions. while the code of ethics of the nasw (1999) provides multiple principles for the creation and maintenance of a culturally competent practice, the existing social work literature geared toward the promotion of social work’s specific responsibilities in unlearning racism, is at best, inconsistent. i have found texts, such as allen-mearnes & garvin, 2000; burgest, 1985; vacc, devaney, & brendel, 2003; vacc, devaney, & wittmer, 1995, that range from one paragraph on cultural competency to entire chapters on self-awareness. to dedicate a section or chapter to the issue of race perpetuates the illusion that discussion and examination should exist within a designated box or timeframe. mcmahon and allen-meares (1992) believe, “the literature of a profession is the text of what that profession believes is important for knowledge and practice” (p. 537). it would be my hope that future social work literature dealing with issues of race be multifaceted, highly developed, thorough, and seamless in composition. for social work to achieve self-respect, i feel it must aspire to be not only anti-racist but also pro-actively vigilant in the process of achieving racial and social justice. it is for this reason that academic curricula’s treatment of social justice must be examined for integration and thoroughness of anti-racist training and policies. ultimately creating an anti-racist climate. social work must acknowledge that accessing higher education is a privilege that prevents people of color from empowering their own underserved communities. to achieve social justice, social work should confront the institutional structures that contribute to the disproportionate racial composition of its graduates. reflections on racial consciousness like mcintosh (1989), i struggle with my own position within the system of dominance and oppression from which i benefit. it was in social work practice that i first had to confront my own intellectualization of prejudice and meet head-on my own racist ways of knowing. i spent most of my first year of my master’s program attempting to pick up the pieces of a shattered white knowledge base. my sensitization to the complexity of these issues reflections of racial consciousness 58 journal of student social work, volume ii favaro journal of student social work, volume ii 59 endnotes 1 i have chosen to focus on the black/white duality due to a legacy of slavery and white superiority that has economically exploited and politically underdeveloped black america. for the purpose of this paper, the term african-american is used to distinguish the descendants of the north american slave trade from that of black which is used as an umbrella term to include african-americans as well as those who wish to identify as recent generation blacks, caribbean-americans, haitian-americans, and so on. the term “people of color” is used to identify those who are not caucasian or of west european decent. has made them salient in life to the point that i am sometimes alienated by my own awareness. through the equally invigorating and exhausting time i have spent unlearning a history authored by whites, i have increasingly felt more detached from my social work peers. i have come to understand that silence creates a vacuum, and the absence of antiracist awareness personally, politically, and academically signals the presence of covert racism. reflecting on this progress, i acknowledge a previous clandestine discomfort with my own whiteness, which undoubtedly influenced my competency in working with clients of color. through the process of thinking, writing, and editing this article, i have been forced to confront my own fears of defensive intellectualization as well as attempt to enmesh a continually transforming view of my own cultural competence and understanding of racist ways of knowing. during my deepest and most painful thought processes around racism, i often roll around the phrase “ignorance is bliss”. i sometimes think this because i am feeling fatigued, sad, and dejected. i am able to think this because, as a white individual and even as a white social worker, i can survive and thrive unaware as whites have done for generations. however, i feel a profound responsibility to enter into the pain and discomfort of identifying and acknowledging my racist ways of knowing and to welcome and truthfully confront problems that arise interpersonally, politically, and in practice. my personal journey towards an anti-racist ideology has led me to feel more powerful as an individual, and as a social worker, than i ever have before. w.e.b. dubois believed that racism should not just be a burden on the backs of nonwhites but had to be thoroughly acknowledged by progressive whites as well. it would not be until this white awareness, that antiracist politics and attention to the needs of the oppressed could be addressed (1924). social work, as a profession, has dedicated itself to the mission of social change and is therefore obligated to be a leader in anti-racist policies, academia, training, and practice. 2 research highlights the pervasive nature of a distorted beauty standard that favors eurocentric ideals and supports what malcolm x in 1963 referred to as “brainwashed”, “slavemaster worship” (hill, 2002; x, 1999, p. 166). 3 statistics show that 64% of the prison population is people of color and 32% of black men could expect to serve in federal prison at some time in their life (bureau of justice statistics, 2001). 4 i suggest that social work, as a profession, exists under what helms (1990) terms pseudo-independence. in the helm’s model of white racial identity development, pseudo-indepedence exists as a stage which devotes much of its time to helping the other and inadvertently supporting a belief system which perpetuates whites as superior instead of transforming the dominant paradigm. in this stage, whites are used as the normal model, while the focus of interaction revolves around assisting blacks in transforming their lives to look like that of whites (helms). references allen-mearnes, p., & garvin, c. (eds.). (2000). the handbook of social work direct practice. thousand oaks, ca: sage publications, inc. arminio, j. (2001). exploring the nature of race related guilt. journal of multicultural counseling & development, 29(4), 239-252. basham, k. k., donner, s., & everett, j. e. (2001). a controversial commitment: the anti-racism field assignment. journal of teaching in social work, 21(1/2), 157-174. belenky, m. f., blythe, m. c., goldberger, n. r., & tarule, j. m. (1986). women’s ways of knowing: the development of self, voice, and mind. new york: basic books. bureau of justice statistics. (2004). criminal offender statistics. retrieved january 28, 2004, from http://www.ojp.usdoj.gov/bjs/crimoff. htm#prevalence burgest, d. r. (1985). social casework intervention with people of color. lanham, md: university press of america. butterfield, f. (1995, october 5). more blacks in their 20’s have trouble with the law. the new york times, p. a8. dubois, w. e. b. (june, 1924). opinion. crisis, 28, 55-56. gaertner, s. l., & dovidio, j. f. (2000). are racial stereotypes really fading? the princeton trilogy revisited. in c. stangor (ed.), stereotypes and prejudice (pp. 86-99). philadelphia: psychology press. glassner, b. (1999). the culture of fear: why americans are afraid of the wrong things. new york: basic books. helms, j. e. (ed.). (1990). black and white racial identity: theory, research and practice. westport, ct: praeger publishers. hill, m. e. (2002). skin color and the perception of attractiveness among african americans: does gender make a difference? social psychology reflections of racial consciousness 60 journal of student social work, volume ii quarterly, 65(1), 77-91. lennon, t. m. (2002). statistics on social work education in the united states: 2000. alexandria, va: council on social work education. marable, m. (2000). how capitalism underdeveloped black america (2nd ed.). cambridge, ma: south end press. mcintosh, p. (1989). white privilege: unpacking the invisible knapsack. peace and freedom, july/august, 10-12. mcmahon, a., & allen-meares, p. (1992). is social work racist? a content analysis of recent literature. social work, 37(6), 533-539. millstein, k. (1997). the taping project: a method for self-evaluation and “informed consciousness” in racism courses. journal of social work education, 33(3), 491-506. national association of social workers. (1999). code of ethics of the national association of social workers. washington, dc: nasw press. quinney, r. (2000). conflict theory of crime. in p. a adler & p. adler (eds.), constructions of deviance: social power, context, and interaction (3rd ed.). (pp.65-69). belmont, ca: wadsworth publishing company. reiman, j. (2001). the rich get richer and the poor get prison: ideology, class, and criminal justice (6th ed.). boston: allyn and bacon. seldon, h. (2000). the de-radicalization of anti-racism. sage race relations abstracts, 25(1), 26-35. steinhorn, l., & diggs-brown, b. (2000). by the color of our skin: the illusion of integration and the reality of race. new york: plume. vacc, n. a., devaney, s. b., & brendel, j. m. (2003). counseling multicultural and diverse populations: strategies for practitioners. new york: brunner-routledge. vacc, n. a., devaney, s. b., & wittmer, j. (eds.). (1995). experiencing and counseling multicultural and diverse populations. muncie, in: accelerated development. wolff, p. (executive producer). (1986). the vanishing family: crisis in black america. [television documentary]. new york: cbs broadcasting inc. x, m. (1999). the autobiography of malcolm x with the assistance of alex haley. new york: ballantine books. jamie favaro is a second-year master’s student at the columbia university school of social work concentrating in clinical practice within the health, mental health, and disabilities field of practice. she is currently an intern at the upper manhattan mental health center in new york city. she holds a bachelor’s degree in psychology from wells college. her email address is jsf2103@columbia.edu. journal of student social work, volume ii 61 favaro redefining sex work in the republic of georgia the government of georgia, while complying with current international standards to eradicate human trafficking, has inadvertently neglected the needs of female sex workers. by redefining sex work as a profession and an employment option for women in georgia, international policy and programming can reduce harm while confronting women’s economic realities. female sex workers in the republic of georgia encounter discrimination, stigmatization, and now, regulations against sex workers imposed by the international community, despite the fact that sex work is both a legal and a social reality in georgia. the georgian government, faced with pressure to comply with anti-trafficking measures, is forced to adopt regulations dictated by the international community in order to maintain eligibility for monetary aid. as a result, georgia’s criminal laws that address select aspects of prostitution in combination with anti-trafficking legislature have created more harmful conditions for sex workers who already experience social stigmatization. to advocate for this socially and culturally stigmatized population, social workers must be aware of international political developments and international human rights protocols. defining sex work due to the lack of information available on male sex workers in georgia, this paper will define sex workers as women who contract to perform sexual services in exchange for explicitly agreedupon, material payment (kuo, 2002, p. 57). such a definition views prostitution as voluntary and chosen work therefore empowering sex workers by normalizing and legitimizing their work. the abolitionist feminist discourse, which argues that women would not choose sex work if presented with other options, attempts to rescue sex workers from an inherently powerless position (jenness, 1993, p. 78). although power journal of student social work, volume iii 7 ingrida platais 8 journal of student social work, volume iii redefining sex work dynamics and the current economic situation in georgia play a complex role in available employment options for women, accepting that all women in the sex industry are there unwillingly frames the argument in terms of victimization of the poor and denies these women agency and choice (outshoorn, 2004). instead of criminalizing prostitution, policies must protect sex workers, who are often subjected to violence and deplorable work conditions, through harm reduction modalities (doezema, 2000). female sex workers in georgian society after the fall of the soviet union in 1991, the republic of georgia underwent an economic recession when its largely agricultural economy plunged due to the russian financial crisis, drought, and political instability. the interethnic conflicts in abkhazia, south ossetia, and neighboring chechnya resulted in an increase of internally displaced persons, contributing to the economic instability in georgia. light, food, and chemical industries, all traditional places of employment for women in georgia, were directly impacted by the economic downfall, thus causing women to lose jobs and wages (united nations, 1998). women were more likely to be dismissed from work than men due to the persistent societal belief that household and childrearing duties were more important than employment in the public sphere (international helsinki federation for human rights [ihfhr], 2000). by 2002, about 65% of the total population lived below the poverty line, and nearly half of the registered unemployed were female (shioshvili, 2003). in georgian society, women’s roles are primarily defined in a domestic capacity. evidence of this is seen in georgian literature, works of art, and national symbols such as monuments that revere women as heroic mother figures. by promoting such narrowly defined representations of women, georgian society reinforces the notion that a woman’s sexuality is bound to reproductive purposes. a relationship with a man, sanctioned through marriage, normalizes a woman’s social standing while premarital sex, divorce, and extramarital affairs affect women negatively. for example, a recent study noted that divorced women experienced stigmatization and repression as a result of societal pressures (arutinova, berekashvili, berekashvili, berekashvili, & tsihistavi, 1999). in addition, the united nations development program conducted a sociological survey on social changes and family structures in georgia and concluded, “according to universally acceptable social standards, adultery is a forgivable sin for men, while the public opinion in georgia is absolutely intolerant of women’s infidelity” (dourglishvili, 1997). the traditional view of gender roles in georgia directly impacts society’s view on female sex workers. occupational choice is an important element in one’s personal and social identity and if members of society view an occupation as deviant, those groups will be stigmatized (thompson & harred, 1999). the ideal of womanhood is shattered when women sex workers test boundaries of acceptable sexual expression and do not conform to maternal roles as dictated by society. as a result, women sex workers are categorized as “other of other,” creating a subgroup within an already marginalized population (kuo, 2002, p. 69). subsequently, society scapegoats larger-scale problems on subgroups, therefore granting permission to further stigmatize and disenfranchise women sex workers. at a meeting with the committee on human rights in 2002, the georgian government stated that statistics on sex workers do not exist, but they affirmed that there are several hundred sex workers in georgia, mainly in large cities such as tbilisi, georgia’s capital (human rights committee, 2002). in addition, the government attributed poverty as the contributing factor for prostitution and expressed the need for financial support from the world bank to end poverty and thus curb prostitution. since international monetary aid in part depends on a country’s commitment to anti-trafficking legislation, the georgian government hastily attempted to fulfill international anti-trafficking mandates without considering the impact of such changes on the conditions that sex workers face. international anti-trafficking efforts current international efforts to curb human trafficking became prominent in 2000 when the u.n. protocol to prevent, suppress and punish trafficking in persons was adopted to address the protection of human rights of trafficking victims and to provide measures for their physical, psychological, and social recovery. in accordance with the u.n. protocol, the u.s. government enacted the trafficking victims protection act (tvpa) in october 2000, which requires the u.s. state department to submit an annual report to the u.s. congress documenting the status of severe forms of trafficking in persons (office to monitor and combat trafficking in persons, 2004). this report focuses resources on prosecution, protection, and prevention policies and programs, such as platais journal of student social work, volume iii 9 10 journal of student social work, volume iii education programs for groups vulnerable to trafficking, and support programs for the voluntary return and societal reintegration of trafficking victims. it also recommends the establishment of shelters, crisis centers or safe houses, and specialized legal, psychological, and medical services. in addition to prosecution at an individual level, current policy supports ceasing disbursement of monetary aid by international institutions, such as the world bank and the international monetary fund, to ensure state actor accountability. as awareness of human trafficking increased, international and local organizations criticized georgia’s government for the lack of anti-trafficking measures and the high level of illegal migration and trafficking. as part of the u.s. monitoring mechanism, a system of categories was created that placed each country into one of three tiers. tier 1 status demonstrates a country’s full adherence to the tvpa standards, tier 2 status demonstrates a country’s significant efforts to bring itself to full compliance, and tier 3 status demonstrates a lack of any governmental action in the prevention of human trafficking. in 2003, as a result of pressures from international communities, including the u.s. government who threatened tier 3 countries with sanctions, the georgian government enacted a series of anti-trafficking initiatives and raised its classification to tier 2. currently, georgia is placed on a tier 2 watch list for failure to provide evidence of increased efforts to combat severe trafficking from the previous year (office to monitor and combat trafficking in persons, 2004). the effect of anti-trafficking initiatives on sex workers faced with pressure from the international community, the georgian government initiated changes to incorporate anti-trafficking measures. in 2003, the government added several important articles to the georgian criminal code (parliament of georgia, 1999), which, as a result of the additions, prohibited trade and exploitation of persons (women’s human rights program, 2003). the new changes also created contradictory conditions for sex workers. prostitution was not criminalized, but engaging a person in prostitution became unlawful. consequently, a sex worker can offer her services but it is illegal for a customer to hire her. the criminal law also prohibits maintaining brothels. enforcement of such policies drives sex work further underground where abusive practices continue to occur (kuo, 2002). sex work is financially necessary for some women, and despite ambiguous laws, it is practiced openly in redefining sex work georgia (ihfhr, 2000). nevertheless, sex workers, who are already stigmatized by society, face harmful working conditions and inadequate institutional support such as police protection and appropriate health services due to the government’s failure to acknowledge sex work as a profession. violence, especially against women, is an issue of concern in georgia. georgia’s government does not provide statistics on violence against women, citing difficulty in obtaining information due to the unwillingness by the population to discuss such issues openly (human rights committee, 2002). it is estimated that more than 95% of sexual crimes in georgia are unreported (glonti, 2004). several human rights organizations have reported cases of police beating and raping female sex workers, but the georgian government has made no effort to reform curricula used by law enforcement agencies that protect women sex workers’ rights in cases of violence (u.s. department of state, 2001). in a report to the commission on human rights, the united nations special rapporteur also highlighted her concerns regarding police violence against female sex workers (commission on human rights, 2003). non-governmental organizations such as the tanadgoma center for information and counseling on reproductive rights provide counseling and referrals to health care facilities, reproductive health, and hiv/ aids education programs. hospitals and clinics provide health care services to anyone who may seek them. yet, sex workers are reluctant to seek such services due to experiences of guilt and shame that result in social isolation (kuo, 2002). furthermore, lack of trust in police protection creates an obstacle to reporting violent acts (ihfhr, 2000). programs focused on rescuing women, such as the ones recommended by tvpa, may be inappropriate for sex workers who may not seek help for an immediate change in their lifestyles. societal expectations for rehabilitation and reintegration criminalize or victimize sex workers, assuming that women sex workers cannot mobilize for change (jayasree, 2004). when sex workers are regarded as victims of exploitation, this further promotes a sense of stigmatization. it is important to confront the economic reality of sex workers without the distraction of societal definitions of sexuality in order to initiate policy that will improve working conditions for sex workers (platt, 2001). sex work and human rights advocacy it is a state’s responsibility to bring forth the necessary measures to platais journal of student social work, volume iii 11 12 journal of student social work, volume iii prevent individuals or groups from violating the integrity, freedom of action, or other human rights of an individual. it is also the state’s responsibility to address issues of discrimination and stigma rather than overlook these issues while attempting to adhere to international standards that provide international monetary aid. georgia is party to the convention on the elimination of all forms of discrimination against women (cedaw) and the international covenant on economic, social and cultural rights (icescr), effective gender advocacy instruments that address inequalities in social relations and discriminatory practices (office of the high commissioner for human rights, 1966; united nations division for the advancement of women, 1979). cedaw addresses women’s rights as human rights and calls for the end of discrimination against women, regardless of their social standing or choice of work. icescr furthers the notion of the right to self-determination of both genders and provides guarantees that protect the livelihoods of social groups. for example, article 8 and article 9 of the treaty guarantee the right to work in safe and healthy working conditions and the right to form and join unions. by turning a blind eye to female sex workers, georgia’s government is not upholding its obligation to international human rights treaties. while the georgian government must be sensitive to the global crisis of human trafficking, it also must create interventions that are sensitive to sex workers’ needs and lifestyles. although sex work as a profession may not be accepted by society, georgia’s traditional views on gender roles cannot justify the violations of human rights of female sex workers. social workers play a vital role in the global advocacy of marginalized groups such as female sex workers in georgia. according to the national association of social workers’ code of ethics (1999), social workers must promote social justice and social change on behalf of their clients, whether individuals, groups, or communities. it is also a social worker’s responsibility to advocate and promote social justice on the global as well as the local level. a social worker must act as an advocate when international policy, especially policy that carries a caveat of monetary aid, overlooks its negative effects that marginalize and further discriminate against a segment of a society. social work is a way to initiate, stimulate, and raise awareness of a policy’s impact on the rights of all members of a society and to ensure that those rights are upheld locally and globally. redefining sex work journal of student social work, volume iii 13 platais references arutinova, l., berekashvili, d., berekashvili, t., berekashvili, n., & tsihistavi, n. (1999). study of gender stereotypes and hidden female discrimination. retrieved december 7, 2004, from open society georgia foundation web site: http://www.osgf.ge/wie/7.html commission on human rights. (2003). integration of the human rights of women and the gender perspective violence against women. (u.n. doc. e/cn.4/2003/75/add1). retrieved november 23, 2004, from u.n. economic and social council web site: http://www.hri.ca/ fortherecord2003/documentation/commission/e-cn4-2003-75-add1.htm doezema, j. (2000). loose women or lost women? the re-emergence of the myth of white slavery in contemporary discourses of trafficking in women. gender issues, 18(1), 23-50. dourglishvili, n. (1997). social change and the georgian family. in discussion paper series 3, united nations development programme. retrieved december 7, 2004, from http://www.osgf.ge/wie/pub.html glonti, g. (2004). human trafficking: concept, classification, and questions of legislative regulation. organized crime, trafficking, drugs: selected papers presented at the annual conference of the european society of criminology, helsinki 2003, 42, 70-77. retrieved october 14, 2004, from http://www.heuno.fi/uploads/v2t9skuki.pdf human rights committee. (2002). united nations press release: torture, criminal justice reform, religious freedom among issues addressed as human rights committee concludes discussion of georgia’s report. (publication number hr/ct/615). retrieved october 21, 2004, from http://www.unis.unvienna.org/unis/pressrels/2002/hrct615.html international helsinki federation for human rights. (2000). georgia. in women 2000: an investigation into the status of women’s rights in central and south eastern-europe and the newly independent states, 175-186. retrieved october 17, 2004, from http://www.ihf-hr.org/ viewbinary/viewdocument.php?doc_id=2059 jayasree, a. k. (2004). searching for justice for body and self in a coercive environment: sex work in kerala, india. reproductive health matters, 12(23), 58-67. jenness, v. (1993). making it work: the prostitute’s rights movement in perspective. new york: aldine de gruyter. kuo, l. (2002). prostitution policy: revolutionizing practice through a gendered perspective. new york: new york university press. national association of social workers. (1999). code of ethics of the national association of social workers. washington, dc: nasw press. office of the high commissioner for human rights. (1966). international covenant on economic, social and cultural rights. retrieved january 10, 2005, from http://www.unhchr.ch/html/menu3/ b/a_cescr.htm 14 journal of student social work, volume iii redefining sex work office to monitor and combat trafficking in persons. (2004). trafficking in persons report. retrieved january 10, 2005, from u.s. department of state web site: http://www.state.gov/g/tip/rls/tiprpt/2004/ outshoorn, j. (2004). voluntary and forced prostitution: the ‘realistic approach’ of the netherlands. in j. outshoorn (ed.). the politics of prostitution: women’s movements, democratic states and the globalization of sex commerce. new york: cambridge university press. parliament of georgia. (1999). criminal code of georgia. retrieved january 10, 2005, from http://www.parliament.ge/legalacts/2287. htm platt, l. (2001). regulating the global brothel. the american prospect, 12(12), 10-14. shioshvili, n. (2003). economic problems of women in georgia. social policy in georgia, 4, 4-7. retrieved november 23, 2004, from http:// www.west-gcmi.care.org.ge/pdf/spig_eng_04.pdf thompson, w. e. & harred, j. l. (1999). topless dancers: managing stigma in a deviant occupation. in h. n. pontell (ed.). social deviance: readings in theory and research. upper saddle river, nj: prenticehall united nations. (1998). implementation of the international covenant on economic, social and cultural rights. initial report: georgia. (u.n. document e/1990/5/add.37). retrieved december 9, 2004, from http://www.hri.ca united nations divison for the advancement of women, department of economic and social affairs. (1979). convention on the elimination of all forms of discrimination against women. retrieved january 10, 2005, from http://www.un.org/womenwatch/daw/cedaw/ united states department of state. (2001). country reports on human rights practices 2000: georgia. retrieved december 16, 2004, from u.s. embassy stockholm web site: http://www.usemb.se/human/2000/ europe/georgia.html women’s human rights program. (2003). law on amendments and changes to the criminal code of georgia. retrieved november 23, 2004, from minnesota advocated for human rights web site: http://www.stopvaw.org/georgia.html ingrida platais is a first year master’s student at cussw. she is currently an intern at the brooklyn real continuing day treatment program of the jewish board of family and children’s services in brooklyn, ny. she is a graduate of the elliott school of international affairs at the george washington university with a bachelor’s degree in international affairs. her email address is ip2012@columbia.edu. in january 2006, students from cussw and union theological seminary participated in an immersion course entitled, katrina: poverty, race, and social work practice. the aim of the course was to explore experientially the inequality exposed by hurricane katrina and its effect on some of the poorest communities and individuals in the united states. this paper presents an overview of the course development. in addition, the authors describe some of their experiences and observations before, during, and after their travels to the gulf coast and other communities affected by hurricane katrina. the specific focus of the article is on the themes of poverty, racism, violence, governmental irresponsibility and disregard in the wake of this tragedy, and describes some of the efforts made towards supporting social justice in the gulf coast as it rebuilds. gabriella cassandra and natania kremer learning from katrina: student perspectives on poverty, race, and ethics through an experiential course in january 2006, 45 graduate students, faculty, and staff members from union theological seminary (uts) and the columbia university school of social work (cussw) embarked together on an immersion course to the gulf coast titled katrina: poverty, race, and social work practice. the course was designed to give students the opportunity to witness and reflect on the systemic inequalities exposed by hurricane katrina and its effect on some of the poorest communities and individuals in the united states. as participants in the course, we explored poverty and race relations along the gulf coast in towns and cities with displaced hurricane katrina evacuees. throughout the experience, we were struck by the similarity between the systemic issues highlighted by hurricane katrina and the social justice issues with which we struggle as social workers in new york city and across the nation. there is a vividly clear need for an integrated, race-conscious, and class-conscious approach to recovery and change, and this approach must reach beyond the immediate horror of the disaster. the aftermath of hurricane katrina brought poverty, racism, violence, and governmental irresponsibility and disregard into the general �0 journal of student social work, volume iv consciousness of the american public. these realities, however, were too quickly forgotten by the media and, as a result, have largely disappeared from public discourse. race and class injustices were ignored throughout the processes of evacuation, planning, and rebuilding. our goal in writing this paper is twofold. first, we want to share our experience in this uniquely hands-on and codisciplinary immersion course with other social work students. we feel the immersive learning opportunity provided through this course was invaluable, particularly in light of the uniquely raw and overwhelming subject matter, which we feel is difficult to grasp through any medium but experience. second, we have a strong desire, as well as a responsibility, to raise awareness about the ongoing struggles that face many people and communities hit by this disaster and how race and class are inherently embedded within these struggles. we will first present an overview of the course and its development. next, we will describe some of our travel experiences and highlight some of the inequality, trauma, and macro level issues that we witnessed. finally, we will briefly address efforts being made to continue working toward social justice in the gulf coast and nationwide. in writing this paper, we are mindful that the story we tell represents our personal experiences and not the multiplicity of experiences and stories that emerged for other participants in this course. katrina: race, poverty, and social work practice the idea for this course started with students at uts who were angered by the situation in the gulf coast following hurricane katrina. these students approached the poverty initiative i and asked for help leading a community response. uts students then worked in collaboration with the poverty initiative to prepare, plan for, and develop the framework for an immersion course. soon after, social work students from cussw were invited to share in the learning and advocacy experience. as a codisciplinary effort, the course offered a unique perspective on healing, recovery, treatment, and community in the wake of devastation, both natural and human-made, by utilizing both a social work and theological framework. the central questions of the course, which developed out of student i “the poverty initiative at union theological seminary is a student-initiated program that brings poor people into all facets of union’s life – classes, worship, workshops and informal discussions, where they are no longer regarded as objects of charity, but are appreciated as change agents, working for a more just society.” (www.povertyinitiative.org) cassandra & kremer journal of student social work, volume iv �1 discourse, were: what are social workers, religious leaders, and other people of conscience to do in the face of growing poverty, homelessness, and misery? how are we, as a country, responding to the aftermath of natural disasters like hurricane katrina? to explore responses to these questions, we embarked on this immersion experience to fuel ourselves with facts and stories to share with others, so that we would be equipped to publicize and expose the continuing injustices devastating the gulf coast. we documented much of what we observed through writing, audiotaping, videotaping, and photography. this course gave us an opportunity to meet, engage with, offer assistance to, listen to, and learn from many different families, community organizers, and professionals of varied ethnic, racial, and socioeconomic backgrounds. we explored the short and long-term impact of disaster and the ways in which trauma relief was and is delivered. uts students and faculty contacted members of local congregations, community organizations, and other agencies involved in relief efforts to host our group during the week along the gulf coast. specifically, the christian church (disciples of christ), the presbyterian church (usa), the baptist church, the episcopalian church, common ground relief, pastors for peace, and member organizations of the poor people’s economic human rights campaign ii organized forums for dialogue with community leaders who educated us about their own struggles when providing disaster relief. these groups connected us to families and organizations in need of support, as well as to individuals who were willing to share their stories. we traveled with a strong and committed group of people led by liz theoharis and willie baptist of the poverty initiative at uts alongside john robertson of cussw. the social work and seminary students brought their perspectives and experiences to the group, which contributed to the richness of the codisciplinary learning that occurred. we engaged in dialogue to build sensitivity toward and knowledge about the issues of health care, housing, education, food, and living wages. we also examined response efforts to disasters with particular attention to the influence of poverty, homelessness, and racism. throughout this experience, we made efforts to incorporate ii the poor people’s economic human rights campaign is “committed to unite the poor across color lines as the leadership base for a broad movement to abolish poverty. they work to accomplish this through advancing economic human rights as named in the universal declaration of human rights, such as the rights to food, housing, health, education, communication and a living wage job.” (www.economichumanrights. org) learning from katrina �2 journal of student social work, volume iv what we saw and what we learned into our social work knowledge while renewing and deepening out commitment to social and economic justice. new york city: groundwork in new york city, we met for 2 days of intense preparation before our trip to the gulf coast. we began by introducing ourselves to the history and culture of the area, poverty programs in the south and nationally, and the economic and social impact of hurricane katrina and other natural disasters on communities and individuals. through readings and videos, we studied the structure of race and poverty in america, the effects of the hurricane on the poorest communities, and efforts to address short-term needs and longterm empowerment of affected families and communities. additionally, we learned from experts and other professionals as we prepared for our journey to the gulf coast. for example, david billings from the people’s institute for survival and beyond iii provided a helpful framework for understanding the situation in new orleans post-katrina and described some of the experiences of hurricane katrina evacuees in the new york city area. mary ragan, a woman who worked with hurricane katrina survivors as they returned to their neighborhoods and their devastated homes, shared stories and images that she witnessed during her own trip to new orleans. we found that hearing these first-hand accounts and viewing the photographs gave us a sense of what we might encounter on our trip, yet two days of speakers and pictures could not fully prepare us. atlanta, georgia: a people displaced our group had decided to visit atlanta, georgia due to the large number of hurricane katrina evacuees relocated there; we arrived in atlanta on saturday, january 7th. we visited homeless shelters and met with grassroots organizations in the city to critically explore the structural manifestation iii the people’s institute for survival and beyond was created to “develop more analytical, culturallyrooted and effective community organizers. over the past 24 years, the people’s institute undoing racism™/ community organizing process has impacted the lives of nearly 100,000 people both nationally and internationally. through this process, it has built a national collective of anti-racist, multicultural community organizers who do their work with an understanding of history, culture, and the impact of racism on communities. these anti-racist organizers build leadership in and account to the constituencies where they are organizing.” (www.pifsab.org) cassandra & kremer journal of student social work, volume iv �� of racism, classism, and poverty highlighted by the displacement of 200,000 hurricane katrina evacuees. atlanta residents described increases in homelessness, housing shortages, and unemployment. as the federal emergency management administration (fema) winds down its emergency shelter program and plans to drop 20,000 people from its hotel subsidy program, the problems will be compounded. although one could argue that money is better spent directly on housing vouchers rather than hotel subsidies, thousands of people are not receiving emergency housing benefits and are in need immediate shelter. disorganized management of housing assistance is pushing locals and hurricane katrina evacuees into homelessness. some atlanta residents described their concerns about unemployment, fewer job opportunities with living wages, and an increasing number of day laborers who work for substandard pay. we also visited the task force for the homeless shelter, a privately owned and funded shelter that nightly houses between 300 and 500 men – the homeless from atlanta and hurricane katrina evacuees. the shelter was an overcrowded, dirty, and noisy warehouse. the already overburdened shelter system in the city will be further taxed by an influx of hurricane katrina survivors as they lose their housing subsidies. the inadequate government response has pitted the poor against the poor in competition for scarce resources. atlanta had few systemic responses, and little support from the federal government, to address these housing and employment issues. the situation will likely deteriorate as recovery efforts are discontinued and the pervasive problems of homelessness and unemployment are once again deprioritized. pensacola, florida: community in convalescence although our country’s experience of hurricane katrina may have been unique in that it forced many, if only for a moment, to consider race and class inequity, this storm was not the first to wreak havoc on vulnerable people. after 2 days in atlanta, we moved on to pensacola, florida to look at recovery and rebuilding a year and a half after hurricane ivan ravaged the area. as in atlanta, we met with local church leaders, as well as a social worker and a case manager from united ministries, a cooperative crisis assistance effort of many different denominations in pensacola. we discussed needs assessment systems that were used by these individuals and examined the role of social workers in coordination and case management following learning from katrina �� journal of student social work, volume iv hurricane ivan. the social workers and community leaders highlighted the importance of monitoring systems and formal documentation, not only for accessing support but also as a means to establish the extent of the destruction that occurred and the number of lives lost. although many people are aware of the more immediate and tangible impacts of a hurricane, less obvious consequences radiate well beyond the storm and reverberate through already marginalized communities. on several occasions, we were told by church and community leaders that the rates of child abuse, substance use, and domestic abuse significantly increased in the year following the disaster of hurricane ivan. additionally, a pastor who spoke with us shared that due to the high levels of stress and lack of appropriate outlets and support, some individuals were channeling their stress through family violence. in pensacola, even though the local leaders we met had an awareness of these social concerns, they continued to struggle with how best to address post-ivan problems. we became aware of the extent to which a community continues to suffer years after a disaster without adequate supports and resources. post-katrina rebuilding efforts could benefit substantially from the knowledge of what was effective and ineffective in supporting communities in pensacola in the aftermath of hurricane ivan and use this knowledge to anticipate long-term effects in the gulf coast. biloxi, mississippi: inadequate assistance after 2 days in pensacola, we drove by van to mississippi and worked in demolished communities. we were told by residents that the death toll from hurricane katrina in mississippi alone was 5,000, although this number was not found in media reports. as freezer trailers for unidentified bodies were pointed out to us by church leaders acting as our guides, we were struck by the sheer number of people still missing in biloxi. we also saw fema trailer parks throughout the city where people have been living in cramped quarters for months. others have yet to receive their fema trailers due to problems accessing and completing forms. residential areas closest to the water were completely destroyed and laying in ruin. in contrast, the neighboring casinos were rebuilt and fully functioning, seemingly untouched by the storm. residents told us that current casino patrons were primarily locals from mississippi, struggling in desperate attempts to regain some of what was lost. cassandra & kremer journal of student social work, volume iv �� in addition to the homes destroyed along the coastline of mississippi, many houses further inland were also significantly affected by the storm surge that accompanied hurricane katrina. we helped some families gut and remove up to 6 feet of moldy, black sheetrock inside of their homes. they were living in fema trailers on their front lawns while working to make their houses habitable again, which was clearly an emotionally and physically daunting task. we worked with churches in mississippi that were actively providing basic assistance to families in the area. we canvassed communities, providing outreach to residents by asking them about their immediate needs. during our time in biloxi, we saw church groups and social service organizations working with hurricane katrina survivors. we noticed that most of the interventions being provided only addressed their basic needs, as the physical rebuilding of communities had barely begun. in the months that follow our trip, the need for extensive mental health support will increase dramatically as survivors move beyond physical recovery and struggle to recover emotionally from the trauma they experienced. indeed, the extent of the trauma experienced by hurricane katrina survivors became increasingly clear to us as we moved through mississippi and on to louisiana. new orleans, louisiana: abandoned citizens our final 2 days were spent in new orleans. we had the privilege of spending time at the ashé cultural arts center iv where we spoke to local residents and professionals who lived through hurricane katrina and continue to work in the city. throughout our conversations, we took on the role of listener, feeling that these individuals wanted and needed to be heard as we listened to their stories of trauma and survival. many individuals shared stories of how they were affected by the lack of sufficient aid and the woefully inadequate intervention efforts before, during, and after hurricane katrina. most of the stories we heard had undertones of racism and classism. although the new orleans residents with whom we spoke experienced class and race disparities pre-katrina, the disaster reinforced their worldviews that the local and national governments did not value the lives of minorities iv “ashé is an effort to combine the intentions of community development and economic development with the awesome creative forces of community, culture and art to revive and reclaim a historically significant corridor of new orleans’ central city community.” (www.ashecac.org) learning from katrina �� journal of student social work, volume iv and the poor. we were told by a community leader that 80% of new orleans residents had not returned to their city, and those who had returned were predominantly white and wealthy. many residents expressed frustration and anger about the government neglecting to ensure that non-white residents were able to return to their homes, demonstrating a lack of commitment to rebuilding the city for all of its citizens. those who shared their stories with us were each unique in their recounting. the following account by tim, an african american man in his mid-fifties who has lived in new orleans for many years and is a professor of music, provides one example of the many powerful experiences that were shared with us. i tried to leave the city but it was too late. they turned us back. i was stranded with my 3 sons on the bridge in utter blackness for 7 hours with many, many others. i sat on top of them throughout this time to ensure that they were still there with me in the morning. we saw helicopters overhead but could not get them to stop for us. i felt helpless and scared. it has been 5 months since the storm and since the levees were breached, but this is the first time that i have been able to share my story in this way. tim’s story highlights the human experience of disaster and its consequences, but does not begin to describe the work yet to be done. in new orleans we saw the need for extensive rebuilding months after the disaster and the need for repairing and implementing basic systems like water and electricity before survivors could be treated for trauma. relief workers found another body one day after we left the area in mid-january, 5 months after the storm. the city of new orleans remains in a state of emergency with most residents unable to return. local advocates describe how few public housing units have been reopened and landlords intend to evict people in mass numbers upon their return. many residents shared their feeling that the local and federal governments had abandoned them in their recovery just as they were abandoned during the first days of the storm. where do we go from here? upon return from the gulf coast region, our group took time to reflect on the social work implications of the visit and the course. social work cassandra & kremer journal of student social work, volume iv �� students met for three seminar sessions in the month following our return. we continue to encourage each other to value social change and to incorporate racial, cultural, and socio-economic considerations into our practice. this paper is a brief overview and an introduction to our immersion experience in atlanta, pensacola, biloxi, and new orleans through the course katrina: poverty, race, and social work practice. one goal of our trip was to reclaim public attention for the continued plight of hurricane katrina’s survivors as well as the long-standing race and class inequality pervasive along the gulf coast and throughout the united states. we have sought to share our awareness by developing consciousness-raising efforts through presentations, writing articles, displaying artwork and photography, and holding public forums at cussw and outside communities. as we reflect on our experiences, we hope to continue these conversations and inspire others to participate in the dialogue and take action. contacts the poverty initiative union theological seminary 3041 broadway new york, ny 10027 poverty@uts.columbia.edu common ground in new orleans 1415 franklin street new orleans, la 70117 www.commongroundrelief.org volunteer coordination team phone: (504) 218-6613 commongroundvolunteers@gmail.com washington office: 1525 newton st. nw washington, dc 20010 phone: (202) 332-5333 projectsouthdc@earthlink.net national office: 9 gammon ave. atlanta, ga 30315 phone: (404) 622-0602 general-info@projectsouth.org project south: institute for the elimination of poverty and genocide wrfg radio (radio free georgia) 1083 austin avenue, ne atlanta, ga 30307-1940 phone: (404) 523-8989 info@wrfg.org learning from katrina �� journal of student social work, volume iv gabriella cassandra is a second year master’s student at cussw within the advanced generalist practice and programming method, in the family, youth, and children’s services field of practice. she holds a bachelor’s degree in psychology and french from skidmore college. she is currently an intern at a residence for pregnant teenagers at the new york foundling hospital in manhattan, ny. she is interested in trauma intervention. her email address is gsc2102@columbia.edu. natania kremer is a second year master’s student in the dual degree master’s program with bank street college of education for special education and cussw, within the advanced clinical practice method, in the family, youth, and children’s services field of practice. she is a graduate of swarthmore college with a bachelor’s degree in psychology and education. she is currently an intern at the child development center of the jewish board of family and children’s services in manhattan, ny. her email address is nek2104@ columbia.edu. journal of student social work, volume iv �� 26 | columbia social work review, vol. vii is criminalizing re-homing the best solution? a look into safe adoption policy yunqi zhang this paper will examine existing state policies of criminalizing rehoming, and their potential benefits and costs. recommendations are made to mitigate the potential costs of criminalizing re-homing and to prevent families from reaching the point of re-homing their adopted child. introduction of the policy problem: re-homing on september 9, 2013, reuters published a five-part article, the child exchange, (twohey, 2013) to bring attention to a practice widely referred to as “re-homing,” in which parents transfer custody of their unwanted adopted children to non-relative adults or families without informing any professionals or government systems. the article identified several social media platforms, such as yahoo and facebook, where parents post advertisements either of children waiting to be re-homed or wanting to receive re-homed children. because this practice intentionally circumvents authorities and professionals, it appears that the only statistics about rehoming come from the reuters article, which examined messages advertising 261 children in one yahoo! group. the analysis found that offers to re-home children occurred at a rate of one child per week. about 70% of the children offered were adopted internationally between the ages of 6 and 13 (twohey, 2013). according to a report by the government accountability office [gao] (2015), families might choose to re-home a child for three main reasons: lack of preparation to parent a child with special needs, such as postinstitutionalized behavior, attachment disorder, physical or mental health problems particularly for international adoptions; lack of access to postadoption services to help them cope with those challenges or avoid reaching a crisis point in their adoption; and reluctance to seek help due to fear of repercussions and associated stigma. re-homing is an unregulated practice, regardless of the cause or level of parent desperation, which has potentially damaging consequences for children. re-homing creates new opportunities for child traffickers1 (burdick, 1as the definition on unicef’s website indicates, child victims of trafficking are recruited, transported, transferred, harbored, or received for the purpose of exploitation, while rehoming is the behavior of some parents transferring the custody of their children to strangers without professional involvement and court approval. re-homing usually happens when the stujourn typewritten text © 2016 zhang. this is an open-access article distributed under the terms of the creative commons attribution license, which permits the user to copy, distribute, and transmit the work provided that the original author(s) and source are credited. stujourn typewritten text stujourn typewritten text stujourn typewritten text stujourn typewritten text columbia social work review, vol. vii | 27 zhang 2015) and puts adoptive children in great danger for abuse and psychological damage (kunz, 2014). children are given to new parents without any protective measures in place, such as extensive background, health, and financial screenings, or any other preadoption trainings and counseling, which are required by federal or state law before prospective adoptive parents receive a referral (gao, 2015). adoption is a hard process for both the family and the child. several required services before the adoption help the newly formed family units integrate and adjust. background screenings are designed to ensure the eligibility and suitability of the adoptive family. screenings include a check for child abuse history and criminal history related to children. the process also ensures that the adoptive family is prepared emotionally and financially for accepting a new family member. the permanency and sustainability of an adoption is likely to be diminished without these prerequisite screenings. pre-adoption trainings help families prepare for child-specific challenges experienced as a result of adoption and provide information on postadoption services. these services could potentially reduce the risk of failed adoptions and avoid traumatic experiences for adoptive children. re-homing bypasses these helpful steps. there is no effort taken to make sure the child’s best interests are met. unregulated transfers of custody could place children in risky situations. media reports (twohey, 2013; hardy, 2015) cite cases that include re-homed children being verbally, mentally, and sexually abused and exploited, involved in child pornography or child trafficking (cousins, 2015). history and variation of policy addressing re-homing government, at both the federal and state levels, has worked to address re-homing since the media exposed this harmful practice. several states modified, proposed, or enacted new laws and regulations, which include making re-homing illegal and restricting advertising children or potential homes for placement. in april 2014, wisconsin was the first state to respond to the media exposure by passing legislation targeting re-homing (kunz, 2014). wisconsin criminalizes advertising related to adoption as well as the delegation of the care and custody of the child to a non-relative for a period greater than one parents feel incapable of meeting the child’s need, without the intention to sell or exploit the child. but the stranger who receives the child might be a child trafficker with the intention of making a profit from the child. “re-homing is an unregulated practice, regardless of the cause or level of parent desperation, which has potentially damaging consequences for children.” stujourn typewritten text stujourn typewritten text stujourn typewritten text 28 | columbia social work review, vol. vi columbia social work review, volume vi | 29 is criminalizing re-homing the best solution? zhang year without petitioning a court. these criminal sanctions may include up to a $10,000 fine and 9 months in prison (wis. stat. § 48.979 (1m) (g) (2013)). colorado created new legislation on may 22, 2014 (kunz, 2014). the state has not criminalized re-homing—that is, the actual transfer of custody—but it does prohibit advertisement on the internet or through any other public medium to find a child to adopt or to find an adoptive home for a child. authorized services (i.e. fertility clinics, adoption agencies and adoption attorneys) are exempt from the advertising ban. violation of the law, is a class 6 felony (colo. rev. stat. § 19-5-213.5 (4) (2014)). in june 2014, both louisiana and florida passed laws prohibiting the advertisement and the re-homing of a child (kunz, 2014). violation of the laws lead to criminal sanctions. arkansas moved to criminalize re-homing following a scandal in their state legislature. in early 2015, it became public that arkansas state representative justin harris re-homed his two adopted daughters, ages 3 and 6, to a man who allegedly sexually abused one of them. the legislature quickly and unanimously passed a bill making re-homing a felony punishable by up to 5 years in prison and a $5,000 fine (riben, 2015). in june 2015, the maine legislature unanimously overrode governor paul lepage’s veto of a bill to prohibit the re-homing of adopted children. re-homing in maine is a crime subject to the same penalties as abandonment. the legislation also includes an affirmative defense clause to protect people acting in good faith from penalty (hickman, 2015). no federal law specifically prohibits re-homing, although the issue has gained traction with some members of congress. an adoption safety bill was introduced on april 28, 2015 that would make it illegal to “offer to engage or engaging in the transfer of permanent custody or control of a minor in contravention of a required legal procedure” under the category of child exploitation (langevin, 2015). the bill also promotes grants for and the provision of preand post-adoptive support services. this bill was referred to the subcommittee on health on may 1, 2015, but no action has been taken since then. in summary, six states enacted laws to criminalize re-homing, and some impose criminal penalties on the advertisement of adoptive children or potential homes for placement. states’ definitions of “re-homing” vary, but generally include transferring or assisting in a transfer of physical custody of a child to a non-relative without court approval with the intent of avoiding permanent parental responsibility. cost-benefit analysis of criminalizing re-homing 28 | columbia social work review, vol. vi columbia social work review, volume vi | 29 is criminalizing re-homing the best solution? zhang re-homing is a newly identified problem that will require more research into the impacts of the policies implemented at state levels of government. data to measure the success of these newly adopted laws are not yet available. this section will, instead, examine the potential costs and benefits of passing legislation to criminalize re-homing. benefits several potential benefits are derived from the criminalization of rehoming. they include raising public awareness, deterrence, promoting legal ways to terminate adoption, and protecting children. however, there are some limitations that might diminish the benefits in terms of the severity of the punishment and whether the law addresses the underlying problem behind re-homing. public awareness is important because, before the reuters article and subsequent state responses, governments and the public knew little about the practice of re-homing children. parents generally re-home their adoptive children, wishing to find them a more suitable home, but are unable to imagine the destructive results of this practice. the criminalization not only alerts the adoptive families to the dangerous consequences the children might face, but also reminds child welfare agencies, social workers, school teachers, and the public at large to be aware that a child that might be a victim of re-homing. criminalization is also a symbolic denunciation of the practice (frase, 2002). the labeling of re-homing as a crime sends a message of a social judgment and classifies the practice as something that is morally wrong because it harms children. this judgment might reinforce public sentiment, which increases the awareness of this issue and creates a relatively safe environment to reduce the risk of children being re-homed. public awareness and the criminal penalties associated with re-homing are expected to deter families from re-homing adoptive children themselves. conviction and sentencing are likely to reduce the future incidence of the criminalized practice. reductions will likely be achieved through the educational effect of general deterrence (frase, 2002). with the punishment of fines ranging from $5,000 to $10,000 and/or up to 5 years in the prison, re-homing can be deterred and reduced. the penalties associated with criminalization help to promote legal ways to terminate adoptions. even if the goals for adoption are permanency and stability, support and services must be provided for families that decide to no longer parent a child. past practices for terminating an adoption required families to either to re-home the child privately or find an adoption or other child welfare agency to help dissolve the relationship with the adopted 30 | columbia social work review, vol. vi columbia social work review, volume vi | 31 is criminalizing re-homing the best solution? zhang child. the criminalization of re-homing will mean that the only legal way for parents to transfer custody of an adoptive child is to inform proper personnel, such as a child welfare agency or family court, and to be involved in a legal procedure to terminate their parental rights. agency participation in the termination process allows the child welfare system to monitor adoption disruption and dissolution, and provides a resource for data collection. a formalized system for adoption termination ensures the child’s best interest is met and gives researchers increased ability to analyze data and find ways to keep adoptions permanent. protecting children is the primary benefit of criminalizing re-homing. reducing the incidence of re-homing reduces the chances of child exploitation, child abuse, and child trafficking, as mentioned above. while not all children will be exposed to such dangerous and negative situations, the act of placing a child in a new and unfamiliar environment without proper care from the parents and intervention from a social worker or therapist might still traumatize the child, causing lasting impact on the child’s development. this is often the case with re-homing since there is no pre-training for the parents and no professional assistance involved. despite the benefits that could be expected after the criminalization, there are some limitations. when the punishment is not severe enough, the effectiveness of criminalization will be undermined. for example, according to reuters, children with special needs are much more vulnerable than healthy kids to re-homing (twohey, 2013). one major reason for this susceptibility is that the family invests more emotionally and financially on a child with special needs, and does so without much support. the average cost of residential care in tennessee is approximately $65,000 per year, compared with the average adoption subsidy of $4,824 per year (the evan b. donaldson adoption institute, 2010). although the fine is a maximum of $10,000, desperate parents might take the risk to re-home because the cost of child care is much higher. in addition, simply outlawing re-homing does not solve the underlying causes of the problem. to prevent the family from re-homing, it is essential to have parents prepared for adoption and to make access to post-adoption services easier. the accessibility of these services means that when the family finds itself trapped in relational and functional crises during the process, they can quickly identify affordable and effective services that address their challenges, such as counseling and therapy, support groups, respite care, and educational and information resources (child welfare information gateway, 2012). moreover, it also means the parents feel comfortable reaching out to professionals or agencies when they are making a decision about whether to 30 | columbia social work review, vol. vi columbia social work review, volume vi | 31 is criminalizing re-homing the best solution? zhang continue to parent their adoptive child. costs despite the benefits criminalizing re-homing might bring, it is acknowledged that there are also substantial costs to the criminalization of re-homing. criminalization has the potential to scare away prospective adoptive parents and leave more children in the foster care system or worse situations, especially children with special needs. if so, the potential decrease in prospective adoptive parents will result in fewer adoptions, which leaves more children in need in the foster care system and generates considerable financial costs for the government. the foster care reimbursement fee is higher than an adoption subsidy. in a 3-year study, barth, lee, wildfire and guo (2006) pointed out that in north carolina, the average adoption subsidy cost is approximately $9,000. the average long-term foster care reimbursement, conversely, is about $14,893 per child. in another study, the total maintenance (reimbursement fee) and administrative costs per child annually in the foster care system were $25,782; the total of adoption assistance payments and administrative costs per child annually were $10,302 (zill, 2011). adoptive parents are more likely to work full time and are less likely to rely on public welfare (zill, 2011), which costs the government less. other public costs warrant consideration. children who spend time in foster care are more likely to encounter serious challenges later in life. children experiencing more time in foster care are at a higher risk for encountering teen pregnancy, homelessness, incarceration, mental health issues, and are less likely to complete their education or to find employment (center for family representation, 2013), which can add costs to the government. a rule of thumb is that for every 3 months that a young child resides in an institution, the child loses 1 month of development (williamson & greenberg, 2010). these all cost society more. if criminalization discourages prospective adoptive parents, society will likely spend more on children in the foster care system who could have been adopted, although the exact number is not clear yet. criminalization might also disproportionately affect poor families. the demographic information shows that a large proportion of domestic adoptions from the foster care system are relative adoptions involving families of lower socioeconomic status, who might have a higher chance of re-homing their adoptive children due to challenges surrounding family capacity and condition (j. schmidt, personal communication, november 13, 2015). 32 | columbia social work review, vol. vi columbia social work review, volume vi | 33 is criminalizing re-homing the best solution? zhang there are also direct costs to a community in enforcement expenditures and lost opportunity costs. the level of enforcement will vary depending on the nature of the crime, the pervasiveness of the conduct, and the means available to detect it (frase, 2002). however, it is obvious that these costs must include resources devoted to detection and punishment of criminals, such as police surveillance, court costs, and imprisonment. since re-homing is difficult to effectively track, it puts the burden on the police, child welfare system, and other related departments to investigate. the chilling effect of criminalization is another potential cost that might drive people engaging in this behavior further underground. families encountering severe problems might resort to methods outside the confines of the law to re-place the children. they might take the children outside the united states to evade the law, sending them across the border to canada or mexico, making them harder to track as well as putting the children in a far more dangerous situation with few chances to be rescued. the threat of conviction might also make families afraid to seek help. additionally, enacting criminalization laws could worsen the situations of the children who have already been re-homed (i.e. confined at home), because the new family is afraid to let people know their child was re-homed to them. another major cost of criminalization is its effect on the family members, especially children, left in the home. as of 2010, 79% of adoptive families have more than one child in the home. (kreider & lofquist, 2014). arrest, prosecution, and conviction have disastrous effects on both an individual and a family unit (thompson, 1989). fines reduce whatever resources are available to support the family and care for the children. imprisonment means that parents are not available to care and provide for the family. as such, the family’s children may need to resettle with relatives or the foster care system. phillips and bloom (1998) pointed out that children in the care of relatives may have academic, behavioral, and emotional problems. children whose parents are incarcerated may feel abandoned, angry, and worried for their parents, and be anxious about their own future. conclusion adoption is intended to provide children a safe and permanent home to grow and develop healthily and happily. the practice of re-homing potentially puts children in danger by exposing them to non-vetted families. criminalizing this practice is an important step to prevent re-homing because it sends a message to the public, has deterrent and educative effects to regulate parents’ behavior, and protects children in the end. however, it also has substantial limits and costs. for that reason, i recommend that states that criminalize 32 | columbia social work review, vol. vi columbia social work review, volume vi | 33 is criminalizing re-homing the best solution? zhang re-homing take steps to mitigate the costs and target the underlying issue of how to improve the rate of successful adoptions and establish strategies for parents when they encounter challenges. these additional policies could include expanded screening of prospective parents, increased pre-adoption preparation and family training, and increased access to quality post-adoption services. strengthening the preparation and training that families receive prior to adoption finalization can improve parents’ ability to assess their readiness for adoption and build skills needed to meet the challenges of raising children with special needs (children’ bureau, 2015). affordable access to high-quality post-adoption services makes a critical difference in the long-term success of adoptions (congressional coalition on adoption institute, 2013). adoptive families benefit greatly from counseling services, support groups, and respite services (jordan,2015). these pre-adoption and post-adoption services promote better outcomes for both the child and family and help them move toward permanency. references barth, r. p., lee, c. k., wildfire, j., & guo, s. (2006). a comparison of the governmental costs of longterm foster care and adoption. social service review, 80 (1), 127-158. retrieved from http://www.jstor. org.ezproxy.cul.columbia.edu/stable/10.1086/499339?pq-origsite=summon& burdick, l. (2015). five states act to prevent dangerous adoption ‘re-homing’ practice. foster coalition. retrieved from http://www.fostercoalition.com/#!five-statesact-to-prevent-dangerous-adoption-%e2%80%98rehoming%e2%80%99-practice/ c1oq3/5525ea5e0cf2aa1811934463 center for family representation. (2013) foster care facts. retrieved from https://www.cfrny.org/newsblog/foster-care-facts/ child welfare information gateway. (2012) finding and using postadoption services. retrieved from https://www.childwelfare.gov/pubpdfs/f_postadoption.pdf children’ bureau. (2015). responding to rehoming: protecting children & strengthening adoptive families. retrieved from http://voice-for-adoption.org/sites/default/files/final%20joint%20 statement_responding%20to%20rehoming-protecting%20children%20strengthening%20 adoptive%20families.pdf colo. rev. stat. § 19-5-213.5 (4) (2014). congressional coalition on adoption institute. (2013). ccai response to reuters “re-homing” series: an opportunity for reflection and reform. retrieved from http://ccainstituteblog.org/2013/11/15/ ccai-response-to-reuters-re-homing-series-an-opportunity-for-reflection-and-reform/ cousins, c. (2015). bill to outlaw ‘rehoming’ of adopted children to become law. bangor daily news maine. retrieved from http://bangordailynews.com/2015/07/03/news/state/bill-to-outlaw-rehomingof-adopted-children-to-become-law/ frase, r.s. (2002). criminalization and decriminalization. in encyclopedia of crime and justice. retrieved “additional policies could include expanded screening of prospective parents, increased preadoption preparation and family training, and increased access to quality post-adoption services.” 34 | columbia social work review, vol. vii columbia social work review, vol. vii | 35 from http://www.encyclopedia.com/doc/1g2-3403000069.html hickman, c. (2015). hickman’s bill to prohibit rehoming becomes law in maine. retrieved from http:// hickmaninthehouse.blogspot.com/2015/07/hickmans-bill-to-prohibit-rehoming.html hardy, b. (2015). a child left unprotected. arkansas times. arktimes. retrieved from http://www. arktimes.com/arkansas/a-child-left-unprotected/content?oid=3691164 jordan, j. (2015). there’s no place like home: overhauling adoption procedure to protect adoptive children. the journal of gender, race & justice, 18(237). langevin, j (2015). to ensure the safety and well-being of adopted children. h.r.2068. kreider r. m. and lofquist d. a., (2010). adopted children and stepchildren. u.s. department of commerce. economics and statistics administration. u.s. census bureau. retrieved from https://www.census.gov/prod/2014pubs/p20-572.pdf phillips, s., & bloom, b. (1998). in whose best interest? the impact of changing public policy on relatives caring for children with incarcerated parents. child welfare, 77(5), 531-41. retrieved from http://ezproxy.cul.columbia.edu/login?url=http://search.proquest.com/ docview/213804632?accountid=10226 riben, m. (2015). is criminalizing rehoming the best solution? huffington post. retrieved from http:// www.huffingtonpost.com/mirah-riben/is-criminalizing-rehoming-the-best-solution_b_6980944. html the evan b. donaldson adoption institute, (2010). keeping the promise: the critical need for postadoption services to enable children and families to succeed. retrieved from http://aap.uchc.edu/events/ pdfs/keeping_promise_10_20_2010.pdf thompson, e. (1989). the criminalization of maternal conduct during pregnancy: a decision making model for lawyers. indiana law journal. volume 64 | issue 2. retrieved from http://www.repository. law.indiana.edu/cgi/viewcontent.cgi?article=1186&context=ilj twohey, m., (2013). the child exchange. reuters. retrieved from http://www.reuters.com/investigates/ adoption/#article/part1 williamson j. and greenberg a., (2010). families, not orphanages. better care network working paper. retrieved from http://www.thinkchildsafe.org/thinkbeforevisiting/resources/families_not_ orphanages_j_williamson.pdf wis. stat. § 48.979 (1m) (g) (2013) zill n., (2011). better prospects, lower cost: the case for increasing foster care adoption. adoption advocate. no 35. national council for adoption. barth, r. p., lee, c. k., wildfire, j., & guo, s. (2006). a comparison of the governmental costs of long-term foster care and adoption. social service review, 80 (1), 127-158. retrieved from http://www.jstor.org.ezproxy.cul.columbia.edu/ stable/10.1086/499339?pq-origsite=summon& yunqi zhang is an msw student with a concentration in social welfare policy, at the school of social work at columbia university (cssw). she is currently working as a policy intern at hague intercountry adoption department at council on accreditation. yunqi is dedicated to promoting international students’ and asianpacific students’ rights, and improving their learning experience at cssw. she is also committed to child welfare and minority rights in all contexts. she also worked at several human service agencies and ngos both in china and the united states. she is interested in promoting social work education and a social welfare system in china. cswrfinal_4.1.13 columbia social work review, volume iv 24 effective employment of individuals with mental health conditions: harnessing national, state, and local efforts to improve outcomes in new york city camille santistevan according to the national alliance on mental illness (nami), 60% to 90% of individuals with mental health conditions are unemployed. employer stigma toward hiring people with mental illness, a lack of local-level professional coordination, and ineffective legal mandates have all contributed to underwhelming employment for many qualified individuals. employment outcomes of people with mental health conditions may be improved with a two-part, local-level employer awareness and stigma reduction campaign coordinated by social workers and other professionals. this article explores prior and ongoing efforts at the national, state, and local levels, and argues that new york city is a prime location to pilot an employer awareness campaign. recommendations include details for launching such a campaign by building organizational partnerships to harness existing resources. over the past three decades, people with disabilities and their advocates have lobbied for increased access to services and legal protections in the workplace. despite the wide range of programmatic responses and the passage of the american with disabilities act (ada) in 1990, 60% to 90% of individuals with mental health conditions are unemployed, increasingly with the severity of their conditions (ada, 1990; nami, 2010, p. 1). the ada guarantees equal employment opportunity for individuals with physical or mental disabilities and requires that employers use nondiscriminatory hiring practices and make workplace accommodations for qualified workers. the lack of coordination between social workers and other professionals—such as vocational counselors, mental health practitioners, policy makers, and disability advocates—has contributed to high rates of unemployment and may explain why overriding stigma among employers remains a significant barrier to employment for individuals with effective employment of individuals with mental health conditions 25 columbia social work review, volume iv mental health conditions. this is no small matter; approximately 25% of the working age population experiences a mental health condition over the course of a year, causing an indirect cost of 79 billion dollars of lost productivity (u.s. department of health and human services, 1999). this article is a comprehensive analysis that can serve as the foundation for a future mental health awareness and stigma reduction campaign targeted at local employers in new york city. i will begin by defining “mental health condition” and describing the importance of work for individuals with mental health conditions. next, i will describe the strengths and shortcomings of the national response to the issue of unemployment of people with mental health conditions by reviewing the implementation and outcomes of the ada and employee assistance programs (eaps). i will then review programmatic responses in new york city by defining and describing the history of the supported employment (se) movement and highlighting examples of two local direct-service se program models: personalized recovery oriented services (pros) and young adults work opportunities for rewarding careers (ya worc). lastly, i will argue that new york city can maximize the success of se services by launching a targeted awareness and anti-stigma campaign directed at local employers by using resources from the substance abuse and mental health services administration’s (samhsa’s) statelevel anti-stigma initiative. to achieve better employment outcomes, all stakeholders must engage in coordinated campaigns to educate local employers about the prevalence of mental illness and their obligation to accommodate current employees and qualified candidates. defining mental health condition in the context of work for the purposes of this article, an individual with a mental health condition is a person with a psychiatric impairment that disables his or her everyday functioning and may prevent him or her from completing essential work tasks (macdonald-wilson et al., 2011). this definition will encompass the broad spectrum of mental health conditions from minor disorders to severe and persantistevan columbia social work review, volume iv 26 sistent mental illness. recent legal actions have constricted ada protections to only include severe mental illnesses that are not controlled by medication. however, most vocational rehabilitative services are offered to individuals who may or may not be symptomatic or may not be on medication for mental illness. the importance of work decades of research have shown that with proper support services, employment can be an effective component of treatment for people with mental health conditions (akabas, gates, & oransabia, 2006; bond, resnick, drake, xie, mchugo, & bebout, 2001). work allows a person with a mental health condition to become financially independent and can improve the nonvocational realms of an individual’s life. the individual may learn to manage personal finances; live independently; and create meaningful, lasting relationships (akabas et al., 2006). the type of employment also matters—in one study, people with severe mental illness placed in integrated, competitive employment as part of a vocational rehabilitation program showed higher rates of selfesteem, symptom improvement, and quality of life compared with groups receiving sheltered work, minimal work, or no work (bond et al., 2001). integrated, competitive employment refers to jobs in settings with other nondisabled employees that pay at least minimum wage and may be more beneficial than sheltered employment. the primary components of competitive employment include: socialization, routine and structure, and change in role status from unemployed to competitively employed. these components may all work together to explain better employment outcomes. additionally, surveys have consistently shown that people with mental health conditions strongly desire employment and believe that they can work in competitive settings (cook, 2006; nami, 2010). a recent study of 20 high-functioning individuals with schizoaffective disorder and schizophrenia found that work was a crucial factor in supporting symptom management (saks, 2013). one subject in a focus group explained, “work has been an important part of who i am…[w]hen you become useful to an effective employment of individuals with mental health conditions 27 columbia social work review, volume iv organization and feel respected in that organization, there’s a certain value in belonging there” (saks, 2013, para. 10). the subject also reported working overtime because her job distracts her from her symptoms (saks, 2013). the national response the american with disabilities act (ada) at the national level, legislators have acknowledged the benefits of work for individuals with physical or mental health conditions by passing the ada. the protections of the ada were intended to safeguard the civil rights of people with physical or mental disabilities and to improve the poor employment rate of this group. surprisingly, the ada actually led to negative employment outcomes for many. for example, the employment rates of men with disabilities fell more than 7% within the first 5 years after the passage of the ada. employment rates declined because of the perceived costs that employers incur when they hire a person with a disability (deleire, 2000). however, a report by the job accommodation network showed that the median cost to accommodate an employee with a disability was only $500, and 51% of accommodations actually had no cost (deleire, 2000). as a result, the perceived costs of employing people with disabilities may prevent employers from hiring, even though the actual cost is minimal or zero. furthermore, protection under the ada requires disclosure, but people with mental health conditions may be apprehensive to discuss their condition with an employer. their conditions are invisible, making disclosure potentially more complicated than revealing a physical condition (macdonald-wilson et al., 2011). these concerns are not unwarranted; numerous studies have shown that employers consistently rate individuals with psychiatric disabilities lower than people with physical disabilities when all else is equal (dalgin & bellini, 2008; cook, 2006). in a national survey, 32% of people with mental health conditions who disclosed their condition to employers reported negative employment outcomes, including hiring discrimination, firing, lower santistevan columbia social work review, volume iv 28 pay, and fewer opportunities for advancement (cook, 2006). individuals with mental health conditions are often unaware or confused about their rights in the workplace. they may not understand the various ways in which they can strategically time their disclosure, limit disclosure to certain individuals, or limit the amount of information shared (macdonald-wilson et al., 2011). recent legal actions may also undermine the ada protections for people with mental health conditions. the united states supreme court recently ruled that ada protections do not apply to workers with conditions that “are not central to most people’s daily lives” (cook, 2006, p. 1396) or that can be “controlled by medications” (cook, 2006, p. 1396). additionally, claims filed with the equal opportunity commission—the entity that oversees ada compliance—are usually considered low-priority if the claimant has a mental health condition (paetzold, 2005). these low-priority cases made up one fifth of the cases that went to trial in 2004, and 76% were ruled in favor of the employer (cook, 2006). employers’ misperceptions of the ada and subsequent stigma demonstrate how ignorance continues to prevent positive employment outcomes for people with mental health conditions, despite legal supports and the economic benefits for businesses and society. employee assistance programs (eaps) another national response has taken place via large organizations that have developed eaps to mitigate the costs of their employees’ untreated health and mental health conditions. these organizations recognize that they can save money and proactively support their employees by providing flexible scheduling, time-limited therapy, substance abuse counseling, and paid personal days off from work. the costs seem well worth it—a 2010 harvard business review article found that eaps lead to lower healthcare insurance costs, greater productivity, and higher morale among workers (berry, mirabito, & baun, 2010). most eaps, however, are only available in large organizations, because small business owners believe they cannot afford such programs. small business owners are also exempt from the ada— effective employment of individuals with mental health conditions 29 columbia social work review, volume iv businesses with less than 15 employees do not have to comply with ada provisions. (nami-nyc metro, n.d). local programmatic responses in new york city supported employment (se) new york city is a prime example of a targeted, local effort to improve employment outcomes of people with mental health conditions. the se movement began in new york city at the fountain house, a community-based mental health organization that used a work-ordered day to help formerly institutionalized patients adjust to community living (bond & jones, 2005). several decades later, seven main se principles now serve as a foundation for many of today’s direct-service employment programs: (1) services should be integrated, (2) work is an individual choice, (3) ultimate goal is competitive employment, (4) jobsearch and placement begins immediately, (5) job choices are determined by clients’ preferences, (6) on-going support is available, and (7) clients are provided benefits counseling (bond & jones, 2005, p. 375). the success of the se model of service has been demonstrated in several studies, and outcomes are markedly better than alternative programs (bond & jones, 2005; nami, 2010). the city’s department of health and mental hygiene (dohmh) and the new york state office of mental health (omh) have funded vocational programs for adults and adolescents that are based on se principles. personalized recovery oriented services (pros) the new york state omh’s pros program is one example of a direct-service, integrated rehabilitation program founded on se principles that combines clinical treatment with vocational rehabilitation. pros centers use comprehensive, ongoing assessment to adapt the program to any client’s needs through peer support, skill development, and intensive, goal-oriented rehabilitation (office of mental health, 2009). the overarching goal of pros is to “improve functioning, reduce inpatient utilization, reduce santistevan columbia social work review, volume iv 30 emergency services, reduce contact with the criminal justice system, increase employment, attain higher levels of education, and secure preferred housing” (office of mental health, n.d., para. 27). young adults work opportunities for rewarding careers young adults work opportunities for rewarding careers (ya worc) is another example of a local level se program model in new york city that seeks to ameliorate the disheartening employment statistics for young people with mental health conditions. this model is currently being implemented at several nonprofit agencies that operate dohmh’s adolescent skills centers—community-based mental health centers that serve people between 16 and 23 years of age. the ya worc program consists of three components that are derived from se principles: (1) comprehensive initial assessment to determine vocational and nonvocational barriers to employment, gaps in functional capacity, and possible workplace accommodations; (2) career club, a peer support group with a structured curriculum that provides ongoing support throughout the job process; and (3) the development of a labor market strategy, which requires the agencies to consider employers as equal and primary clients (akabas, et al., 2006). the ya worc model acknowledges that partnerships between agencies and potential employers must be made before the job placement process begins so that the agency knows how to best prepare clients for these particular workplaces. recommendations for new york city while pros and ya worc are strong examples of se programs and are effective at preparing their clients for employment, a major shortcoming of both models is their failure to aggressively address existing employer stigma in the hiring process and within the workplace. the ya worc model minimally addresses discrimination by requiring providers to establish relationships with employers, but it ultimately underestimates the power of stigma during the employment process. both models effective employment of individuals with mental health conditions 31 columbia social work review, volume iv assume that people with mental health conditions are willing to disclose their conditions and that employers are willing to hire a person who discloses. earlier attempts to mitigate stigma have been launched primarily at the state level. in 2003, samhsa piloted a broad anti-stigma effort in eight states, called the elimination of barriers initiative. samhsa produced two publications during this initiative: (1) a toolkit entitled, developing a stigma reduction initiative (samhsa, 2006); and (2) a booklet for employers called, workplaces that thrive: a resource for creating mental health-friendly work environments (samhsa, n.d). the success of the initiative in reducing stigma is unknown, because the final evaluation of outcomes is not available. however, research on public service announcements about mental health conditions suggests that social marketing campaigns are more effective when focused on local groups (corrigan, 2012). thus, these publications can be better used in local-level campaigns designed to increase awareness about mental health conditions, reduce employer stigma, and improve outcomes of workers with mental health conditions. in new york city, dohmh can use samhsa’s materials to address employers’ knowledge, beliefs, and behaviors regarding mental health conditions and increase awareness of existing vocational programs, such as pros and ya worc, which are available to employers to support workers. dohmh can also use the community health survey database, epiquery, to prioritize the neighborhoods that are most in need of anti-stigma employer interventions. for example, an epiquery analysis showed that an estimated 34% of people in the bronx who are not in the labor force reported a history of depression in 2010 (dohmh, 2012). dohmh can conduct organizational needs assessments using surveys, focus groups, interviews, and observations at each pros and ya worc center to verify the data found using epiquery and gather additional qualitative details about employer stigma and other barriers to employment in each agency’s catchment area. after identifying the areas of highest need, dohmh can establish coalitions consisting of representatives from the followsantistevan columbia social work review, volume iv 32 ing organizations, as relevant to the particular locations: (1) pros centers, (2) ya worc centers, (3) community-based mental health centers, (4) hospitals with mental health inpatient and outpatient services, (5) professional associations of clinicians, and (6) local-level chapters of advocacy organizations such as nami-new york city metro. next, the coalition can develop a unique, culturally competent marketing plan, targeted at local employers near pros or ya worc centers, that include messaging strategies, communication approaches, outreach materials, an implementation strategy, and an evaluation plan (kotler & lee, 2008). during this stage, it is essential that the materials are contextually appropriate—a marketing plan created to reach a large corporate employer in lower manhattan will likely not have the same impact on a small business owner in queens. if the pilots are successful, different coalitions can be organized by borough or county to develop anti-stigma campaigns targeted at employers in their neighborhoods, using the boundaries of their catchment areas to create lists of employers to target. conclusion the consequences of failing to address unemployment of people with mental health conditions are critical. new york city is strikingly close to increasing the employment outcomes of its residents living with mental health conditions; however, federal legal protections, existing workplace supports such as eaps, state-level public awareness campaigns, and the city’s strong history of se programming can only go so far. social workers and other professionals that serve this population must work together to create targeted, local anti-stigma campaigns to change the beliefs and behaviors of employers toward individuals with mental health conditions. this article contributes to the effort by compiling existing resources and recommending new and more effective local campaigns in new york city. professionals working in the mental health field in new york city must unite to eliminate the stigma faced by people with mental health conditions in the workplace. effective employment of individuals with mental health conditions 33 columbia social work review, volume iv references americans with disabilities act, 42 u.s.c § 12101 (1990). akabas, h. s., gates, b. l., & oran-sabia, v. (2006). work opportunities for rewarding careers (worc): insights from implementation of a best practice approach toward vocational services for mental health consumers. journal of rehabilitation, 72(1), 19-26. berry, l. l., mirabito, a. m., & baun, w.b. (2010). what’s the hard return on employee wellness programs? harvard business review, 88(12), 104-112. bond, g. r., & jones, a. (2005). supported employment. in drake, r. e., merrens, m. r., lynde, d.w (eds.), evidence-based mental health practice: a textbook (pp. 367394). new york, ny: w.w. norton & company. bond, g. r., resnick, s. g., drake, r. e., xie, h., mchugo, g. j., & bebout, r. r. (2001). does competitive employment improve nonvocational outcomes for people with severe mental illness? journal of counseling and clinical psychology, 69(3), 489-501. cook, j. a. (2006). employment barriers for persons with psychiatric disabilities: update of a report for the president’s commission. psychiatric services, 57(10), 1391-1405. corrigan, p. w. (2012). where is the evidence supporting public service announcements to eliminate mental illness stigma? psychiatric services, 63(1), 79-82. dalgin, r., & bellini, j. (2008). disability disclosure in an employment interview: impact on employers’ hiring decisions and views of employability. rehabilitation counseling bulletin, 51, 3-15. deleire, t. (2000). the wage and employment effects of the americans with disabilities act. the journal of human resources, 35(4), 693-715. department of health and mental hygiene [dohmh]. (2012). history of depression by employment status and borough, 2010 (age-adjusted). retrieved from https://a816healthpsi.nyc.gov/sasstoredprocess/guest? program=%2fepiquery%2fchs%2%20fchsindex% santistevan columbia social work review, volume iv 34 20&year=2010 kotler, p., & lee, n. r. (2008). social marketing: influencing behaviors for good. thousand oaks, ca: sage publications. macdonald-wilson, k. l., russinova, z., rogers, e. s., lin, c. h., ferguson, t., dong, s., & macdonald, m. k. (2011). disclosure of mental health disabilities in the workplace. in shulz, i.z. and rodgers, e.s. (eds.), work accommodation and retention in mental health (pp. 191-217). college park, md: springer science & business media llc. retrieved from http://link.springer.com/chapter/10.1007% 2f978-1-4419-0428-7_10 nami. (2010). the high cost of cutting mental health: unemployment. retrieved from http://www.nami.org/ template.cfm?section=about_the_issue&template=/ contentmanagement/ contentdisplay.cfm&contentid=114540 nami-nyc metro. (n.d.). mental health resources for small businesses: employer guide. retrieved from http:// ww.naminycmetro.org/linkclick.aspx?fileticket=% 2b95gow3rof4%3d&tabid=100 office of mental health. (2009). overview of pros program design. retrieved from http://www.omh.ny.gov/omhweb/ pros/program_design.html#b office of mental health. (n.d.). program definitions. retrieved from http://bi.omh.ny.gov/bridges/definitions paetzold, r. l. (2005). mental illness and reasonable accommodations at work: definition of a mental disability under the ada. psychiatric services, 56(10), 1188-1190. samhsa. (2006). developing a stigma reduction initiative (samhsa publication no. sma-4176). rockville, md. retrieved from http://store.samhsa.gov/shin/content/ sma06-4176/sma06-4176.pdf samhsa. (n.d.) business materials for a mental health friendly workplace: executives booklet. retrieved from http:// promoteacceptance.samhsa.gov/publications/ business_execs.aspx effective employment of individuals with mental health conditions 35 columbia social work review, volume iv saks, e. r. (2013, january 25). schizophrenic, not stupid. the new york times. retrieved from http:// www.nytimes.com/2013/01/27/opinion/sunday/ schizophrenic-not-stupid.html?hp&_r=0 u.s. department of health and human services. (1999). mental health: a report of the surgeon general. rockville, md: u.s. department of health and human services, substance abuse and mental health services administration, center for mental health services, national institutes of health, national institute of mental health. retrieved from http://profiles.nlm.nih.gov/nn/b/b/h/s/ journal of student social work, volume iii 15 public policy affecting the social welfare of immigrants is a realization of their impact on society as well as a reflection of the value that society places on them. the personal responsibility and work opportunity reconciliation act of 1996 (hereafter, referred to as “welfare reform”) has had a profound impact on the lives of immigrants and suggests a deeply fundamental shift in our national stance toward immigration. this paper will examine the impact of welfare reform on legal, non-citizen immigrants in the united states. after summarizing the debate over its impact, it will evaluate the merits of the devolution of welfare policies to states, as well as the role of welfare reform in promoting naturalization. ultimately, it will demonstrate that measures taken to ameliorate the harsh effects of welfare reform were insufficient. although not necessarily caused by welfare reform, subsequent anti-immigrant legislation in the united states reinforces a growing social and political climate based on fear and intolerance towards immigrants. discrimination towards immigrants continues to define our post 9/11 social and political environment, posing complex challenges for social workers who provide services and make policies affecting immigrants. welfare reform and immigrants: implications for policy the personal responsibility and work opportunity reconciliation act of 1996 profoundly impacted immigrants and suggested a fundamental shift in our national stance toward immigration. this paper examines the impact of welfare reform on legal, non-citizen immigrants in the united states. it describes how welfare reform restructured the laws that determined the eligibility for benefits among immigrants, discusses changes made to these laws, and summarizes the debate over whether these changes were sufficient. it concludes with implications for policy and policy options that exist within the context of the present laws. ultimately, through welfare reform, the government devalued the role of the immigrant and inverted the ideals of opportunity, equality, and full participation in society that, in theory if not in practice, characterize our national identity. alice kopij welfare reform and immigrants 16 journal of student social work, volume iii background on welfare reform for legal immigrants the welfare reform act passed by president clinton in 1996 included drastic changes in eligibility rules for legal, non-citizen immigrants seeking welfare benefits and various forms of public assistance. specifically, welfare reform renders most legal, non-citizen immigrants, who were living in the united states prior to 1996, ineligible for temporary assistance for needy families (tanf), supplemental security insurance (ssi), food stamps and medicaid programs regardless of their age, disability status, or whether or not they received benefits prior to the legislation (carnegie endowment for international peace [ceip], 2001; kim, 2001). exceptions to these restrictions include immigrants who meet specific requirements relating to work, military service, and refugee or asylee status. in addition, the new laws state that legal immigrants entering the united states after august 22, 1996 are ineligible for tanf, ssi, medicaid, and the state children’s health insurance program (schip) during their first five years in the country (ceip; corderro-guzman & navarro, 2000; fix & haskins, 2002; mautino, 2000). the food stamp program is especially restrictive because legal permanent residents and some groups of qualified immigrants remain ineligible for the program after the five-year residency rule (ceip). such disproportionately severe eligibility restrictions on immigrants lay bare policy distinctions that are based on nationality and citizenship. these divisions have enormous implications for how a nation determines whose welfare is more valuable and, therefore, more deserving of federal resources. welfare reform legislation concerning immigrants, in its original form, ignited a heated debate concerning the status and rights of immigrants and the roles and responsibility of the federal government for their welfare. opponents of welfare reform argue that prior to 1996, immigrants had access to benefits based on the principle that immigrants should be treated like americans since they participate in economic, social, and political activities (fix & haskins, 2002). kim (2001) points out that legal immigrants are expected to be contributing members of society who pay taxes and can be drafted into the military and thus deserve the basic safety net of welfare benefits. opponents also argue that the children of non-citizens, many of whom are u.s. citizens, bear the burden of these laws and suffer the consequences of poverty (fix & haskins; kim). proponents of welfare reform argue that federal policy restricting the rights and benefits of immigrants is nothing new in american public policy (fix & haskins). their justification for restrictions on immigrant benefits also relies on familiar rhetoric of balancing the budget and saving taxpayers’ kopij journal of student social work, volume iii 17 money (fix & tumlin, 1997; rector, 2002). for example, immigration restrictions on welfare would save the federal government $23 billion, or approximately half of their total expected savings from all welfare reform laws (fix & tumlin, 1997). rector also supports welfare reform because the new laws make the immigrant’s sponsor liable for his or her support, effectively shifting the financial burden off of the taxpayer. the effects of welfare reform on immigrants when president clinton signed the welfare act, he acknowledged its severity and agreed to work with congress to restore benefits to society’s most needy members (mautino, 2000). not long after the enactment of welfare reform came subsequent legislation intended to mitigate the harsh effects of welfare reform on immigrants. with these changes came rigorous debate over whether an appropriate safety net that ensured the welfare of immigrants could be adequately provided. some argue that welfare reform created a climate of fear and confusion among immigrants, further reducing their participation in welfare programs. since 1996, many immigrants have chosen not to apply for eligible public benefits out of fear that they will be considered a public charge or face deportation or both (betancourt-swingle, 2000; fremstad, 2000; mautino, 2000). in response to this confusion, in may of 1999, the ins issued a set of guidelines that clearly defined the public charge rule and its relevance for those seeking public benefits (betancourtswingle; fremstad; mautino). this provided clarification and encouraged relatively high participation in public benefit programs for those who qualified under the welfare reform laws. despite the clarification of the public charge rule, cordero-guzman and navarro (2000) describe many concerns felt by immigrants regarding their immigration status and use of benefits after welfare reform. social service providers continue to report panic and misinformation among immigrant clients who have difficulty keeping up with legislative changes and guidelines. those who argue against welfare reform point out that emerging data on the use of public benefits since its passage show significant declines in the number of immigrants on the welfare roles. fix and haskins (2002) also cite evidence from the u.s. census bureau that shows a precipitous decline of non-citizen use of tanf, ssi, food stamps, and medicaid or schip between 1994 and 1999. this report attributes a small portion of the decrease on other factors but concludes that much of it can be ascribed to benefit cuts imposed by welfare reform. in contrast, proponents of welfare reform typically interpret declining welfare roles as a measure of success for the alleviation of poverty (rector & fagan, 2003). those who claim that welfare reform and its subsequent legislation were too harsh on immigrants argue that we need only to look at the lives of the immigrants around us to see the poverty and hardship that they face. cordero-guzman and navarro (2000) used information gathered from immigrant service providers to report that changes in immigration and welfare laws have resulted in noticeable panic among immigrants, less access to health services, decreased food security, loss of medicaid and food stamp eligibility, and fewer immigrants who receive social services. ku (2003) cites a report by the kaiser commission claiming that low-income, non-citizen immigrant children are more likely to lack medical insurance than citizen children and that this disparity has increased significantly since the enactment of welfare reform. conservative arguments claim that welfare reform, in general, has had a positive impact on lessening poverty throughout society. rector and fagan (2003) asserted that, overall, welfare reform has significantly reduced child poverty and rates of childhood hunger, and that decreases in welfare caseloads are the result of increased employment among single mothers. devolution to the states faced with the fear of leaving countless legal immigrants destitute as a result of the new laws, states have been forced to decide if and how they will provide for the welfare of immigrants within their borders. this devolution of immigrant policy from the federal to state level has given rise to a multitude of new policies, challenges, and debates among those who work at state and federal levels of government. proponents of state authority claim that policy stemming from state and local governments is more effective in meeting the needs of specific local populations (fix & tumlin, 1997). state control over benefits also has the potential to be more cost effective in the allocation of resources. furthermore, states’ ability to set conditions for aid gives them the power to make rules that encourage naturalization. opponents of shifting control of benefit eligibility to states argue that this essentially gives states the power to create and place their own value on the meaning of citizenship (fix & tumlin). state control over benefits for immigrants may also cause financial hardships for individual states, especially those who have higher concentrations of immigrants. in addition, states may find that there is a financial incentive to establish less generous benefits, thereby avoiding the welfare reform and immigrants 18 journal of student social work, volume iii possibility of becoming a “welfare magnet” for immigrants from other states. the laws put into effect through welfare reform give states the authority to refuse a wide range of benefits to countless immigrants. states, therefore, have been faced with tough individual choices regarding their policies. they must now establish distinct eligibility criteria for state and federally funded programs, decide if and how they will spend state money to offset the cuts made through welfare reform, and decide how they will enforce restrictions on benefit use as well as the obligations of sponsors of immigrants (fix & tumlin, 1997). instead of facing a crisis of widespread poverty, states are opting to implement policies that address the needs of non-citizen immigrants. by 1997, less than one year after welfare reform, congress passed a law giving states the option of purchasing food stamps from the federal government to provide food assistance to immigrants who were denied food stamp benefits through welfare reform (carmody & dean, 1998). within six months of its passage, eleven states had already passed legislation that allowed for food stamp purchases. in 2002, the farm security and rural investment act was passed, restoring federal food stamp eligibility to legal immigrants who are either disabled, have been in the united states for over five years, or are under 18 years old (capps et al., 2004). while this legislation represents a shift in policy back towards federal responsibility, states still face important choices about how they will publicize new eligibility rules and make social services accessible to language and cultural minorities (gigliotti, 2004). overall, the trend toward devolution of welfare policy to states continues. alabama is now the only state that does not provide tanf to eligible immigrants who entered the country prior to 1996 (zimmerman & tumlin, 1999). by 2004, 23 states relied on state funds to provide medicaid or schip benefits to legal non-citizen immigrants rendered ineligible by welfare reform (fremstad & cox, 2004). although many states appear to be generous towards immigrants, they have also implemented conditions that still prevent many immigrants from accessing benefits. these include limitations on aid for immigrants arriving in the united states after welfare reform enactment, eligibility limitations on certain population groups, and consideration of the income of the immigrant’s sponsor (zimmerman & tumlin). public welfare policy for immigrants, if done correctly, can be created and implemented on a state level. states have the potential to decrease bureaucracy and provide relevant services to those that they identify as the neediest. the federal government position implemented through welfare reform, however, is incongruous with this aim and provides an inappropriate journal of student social work, volume iii 19 kopij context for work at the state level. through welfare reform, the federal government has devalued the role of the immigrant and inverted the ideals of opportunity, equality, and full participation in society that have, in theory if not in practice, helped define our national identity. if states are to assume more responsibility for the welfare of immigrants, they need a federal policy that supports them by passing laws requiring more adequate minimum standards for the welfare of immigrants. left to stand alone, state policies for immigrants will continue to provide safety nets that are inconsistent, inadequate, and ultimately permeable to the complex needs of immigrant communities. the naturalization question states also implement policies for immigrants that encourage naturalization. by helping immigrants become u.s. citizens, states are relieved of the burden of providing benefits to these immigrants, who, as citizens, qualify for federal welfare benefits (zimmerman & tumlin, 1999). examples of state action to encourage naturalization include providing english and civics classes, conducting outreach campaigns, requiring naturalization for state-funded services, and reimbursing immigrants for fingerprints and other required fees. while naturalization may seem to be a solution to restrictive benefit laws, the relationship between naturalization and public benefits is somewhat ambivalent. first, there is evidence that immigrants do not pursue naturalization for the purpose of receiving public benefits. for example, recently naturalized immigrants use public benefits at slightly lower rates than all immigrants who are eligible for benefits. on the other hand, there is some evidence that immigrants are responding to this changed, post1996 political climate by naturalizing. specifically, 1996 marked the end of a long-standing downward trend in naturalization rates among legal immigrants. between 1970 and 1996, the naturalization rates of legal immigrants fell from 64% to 39% (fix, passel, & sucher, 2003). these rates increased sharply in 1996 and have risen to 49% of all legal immigrants in 2002 (fix et al.). explanations for this increase may include welfare reform and other anti-immigrant legislation such as proposition 187 in california and the illegal immigration reform and immigration responsibility act of 1996. rising numbers of eligible immigrants, increased costs for replacing expired green cards, and decreased restrictions on dual nationality imposed by sending countries are also contributing factors to this trend (fix et al.). welfare reform and immigrants 20 journal of student social work, volume iii kopij as more immigrants become citizens after welfare reform, it is increasingly clear that encouraging naturalization is not the panacea for poverty that state policy makers need. social service providers report that their immigrant clients are frustrated by the inefficient and bureaucratic policies of the ins that have caused a backlog of naturalization applications (cordero-guzman & navarro, 2000). increasingly, immigrants have become discouraged by the lengthy process of naturalization, which can take up to 15 months (pinto, 2002). in january of 1999, the application fee for naturalization was raised from $95 to $225 (cordero-guzman & navarro). immigrants applying for citizenship in order to have more access to public benefits are unlikely to be able to afford such high fees. this is supported by findings showing that immigrants who are eligible to naturalize, but have not, are more likely to have limited english skills, lower education levels, and lower incomes than those who have naturalized (fix et al., 2003). pinto (2002) notes the difficult decisions that immigrants are forced to make in order to be eligible for benefits. for some immigrants, their original citizenship helps them to define their identity and remain connected to their families and homelands in spite of all they may have lost in their lives. therefore, an immigrant’s decision to become a u.s. citizen could cause emotional hardship and distress for immigrants and their families. perhaps one of the most salient arguments against state-implemented policies for immigrants impacted by welfare reform is the poverty, marginalization, and exclusion that legal immigrants continue to face. implementing policy that coerces immigrants to become citizens of a country that purposely excludes, devalues, and discriminates against them is unfair. naturalization can be positive because it gives immigrants the right to vote and thus a voice in society. however, making state benefits contingent on naturalization only deepens the divide between immigrants who are able to naturalize and those who cannot. welfare reform in the current context welfare reform continues to adversely impact the lives of immigrants today. its message also has renewed relevance in the political and social context of the post 9/11 era. since welfare reform, legislation such as the usa patriot act, the enhanced border security and visa entry reform act of 2002, and the intelligence reform and terrorist prevention act of 2004 represent a deeper government commitment to the promotion of fear and discrimination towards immigrants. as national security journal of student social work, volume iii 21 interests provide another reason to marginalize immigrants, it is increasingly difficult for citizens and policy makers to come to terms with conflicting notions of our economic need for immigrants and fear of their presence. it is from within this context that social workers, as service providers and policy makers alike, must rise to the challenge to advocate for the well-being of our legal immigrant population. in the end, we all stand to benefit from the physical, economic, and social well being of those who have and continue to make our nation what it is today. 22 journal of student social work, volume iii welfare reform and immigrants references betancourt-swingle, d. (2000). immigrants and august 22, 1996: will the public charge rule clarify program eligibility? families in society, 81(6), 605-610. capps, k., koralek, r., lotspeich, k., fix, m. e., holcomb, p. a., & rearden-anderson, j. (2004, november). assessing implementation of the 2002 farm bill’s legal immigrant food stamp restorations (research report). washington, dc: the urban institute. carmody, k. & dean, s. (1998, july). new federal food stamp restoration for legal immigrants: implications and implementation issues. retrieved on november 10, 2003, from center on budget and policy priorities web site: http://www.cbpp.org/71098fs.htm carnegie endowment for international peace (ceip). (2001). immigrants, their families and their communities in the aftermath of welfare reform. in a. singer (ed.), research perspectives on migration, 3(1), 2-9. retrieved on november 14, 2003, from the ceip web site: http://www.ceip.org/files/projects/imp/rpm/rpmvol3no1.pdf cordero-guzman, h. r. & navarro, j.g. (2000). what do immigrant service providers say about the impact of recent changes in immigration and welfare laws? migration world magazine, 28(4), 20-27. fix, m. & haskins, r. (2002). welfare benefits for non-citizens. policy brief no. 15. retrieved november 14, 2003, from washington, dc: the brookings institution web site: http://www.brookings.edu/ dybdocroot/es/wrb/publications/pb/pb15.pdf fix, m., passel, j. s., & sucher, k. (2003, september). trends in naturalization. (immigrant families and workers: facts and perspectives, brief no. 3). washington, dc: the urban institute. fix, m. e. & tumlin, k. c. (1997, october). welfare reform and the devolution of immigrant policy. retrieved on november 14, 2003, from the urban institute web site: http://www.urban.org/url. journal of student social work, volume iii 23 kopij cfm?id=307045 fremstad, s. (2000, january). the ins public charge guidance: what does it mean for immigrants who need public assistance? retrieved on november 10, 2003, from center on budget and policy priorities web site: http://www.cbpp.org/1-7-00imm.htm fremstad, s. & cox, l. (2004). covering new americans: a review of federal and state policies related to immigrants’ eligibility and access to publicly funded health insurance. washington, dc: kaiser commission on medicaid and the uninsured. gigliotti, k. (2004, august). food stamp access for immigrants: how states have implemented the 2002 farm bill restoration. retrieved on march 10, 2005, from national conference of state legislatures web site: http://www.ncsl.org/programs/ immig/immigrantandfoodstamps1 004.htm kim, r.y. (2001). welfare reform and “ineligibles”: issue of constitutionality and recent court rulings. social work, 46(4), 315-324. ku, l. (2003, october). report documents growing disparities in health care coverage between immigrant and citizen children as congress debates immigrant care legislation. retrieved on november 10, 2003, from center on budget and policy priorities web site: http://www. cbpp.org/10-14-03health.htm mautino, k. s. (2000). welfare reform: an update. journal of immigrant health, 2(1), 1-3. pinto, r. m. (2002). social work values, welfare reform, and immigrant citizenship conflicts. families in society, 83(1), 85-93. rector, r. e. (2002, september). the baucus “work” act of 2002: repealing welfare reform. retrieved on november 15, 2003, from the heritage foundation web site: http://www.heritage.org/research/ welfare/bg1580.cfm rector, r. e. & fagan, p. f. (2003, february). the continuing good news about welfare reform. retrieved on november 16, 2003, from the heritage foundation web site: http://www.heritage.org/research/ welfare/bg1620.cfm zimmerman, w. & tumlin, k. c. (1999, april). patchwork policies: state assistance for immigrants und welfare reform (occasional paper no. 24). retrieved on november 14, 2003, from the urban institute web site: http://www.urban.org/url.cfm?id=309007 24 journal of student social work, volume iii welfare reform and immigrants alice kopij is a second year master’s student at cussw within the policy practice method in the international social welfare and services to immigrants and refugees field of practice with a minor in international social welfare. she is currently a policy research intern at cussw where she studies immigrant children and the school environment. she holds a bachelor’s degree in english and environmental studies from bowdoin college. her email address is ack2101@columbia.edu. columbia social work review, volume v 43 children and the mind/body connection: mindfulness-based practice with children who have cancer claire schoen in recent years, clinicians have increased their use of mindfulness-based practice and have extended its use to the treatment of adults who have cancer. although research has demonstrated the physical and psychological benefits of these practices with adult cancer patients and with children in the general population, there is little research specifically on the use of mindfulness-based practices with children who have cancer. this article first explores existing research on the use of mindfulness-based practices with both adults who have cancer and children in the general population. the article then provides examples of cancer organizations using mindfulness-based practices in the treatment of children who have cancer. last, the author provides recommendations for group mindfulness-based programs designed for children who have cancer in outpatient or community-based settings and discusses the role of social workers in facilitating the research and implementation of such programs. the use of mindfulness-based practice has increased in recent years, as has the research on its physical and psychological benefits (burke, 2010). research points to significant benefits of mindfulness-based practices for adults undergoing treatment for or recovering from cancer (baer-wu, 2010; speca, carlson, goodey, & angen, 2000). researchers also have begun to investigate the positive psychological and social benefits of mindfulness-based practices with children (burke, 2010; greenberg & harris, 2012; hooker & fodor, 2008; napoli, 2004; thompson & gauntlett-gilbert, 2008). yet, research on the effects of mindfulness-based practices with children who have cancer remains limited. it is critical that social workers begin to examine the potential benefits of incorporating mindfulness-based practices into the treatment of children who have cancer. social workers are poised to be leaders in the development, implementation, and evaluation of such holistic programs because of the profession’s tradition of expanding the medical model to incorporate clients’ individual, social, and familial needs. 44 columbia social work review, volume v children and the mind/body connection this article first defines mindfulness-based practice and then explores the existing research on the use of mindfulness-based practices with both adults who have cancer and children in the general population. next, the article highlights existing programs that incorporate mindfulness-based practices in the treatment of children who have cancer. finally, the author provides recommendations for group mindfulness programs designed for children who have cancer in outpatient or community-based settings and discusses the role of social workers in the development and implementation of such programs. mindfulness-based practice: a definition mindfulness can be defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (kabat-zinn, 2003, p. 145). mindfulness-based practice includes both “formal” practices such as yoga, body scans, or sitting meditation and “informal” practices such as daily mindful tasks or breath awareness (kabat-zinn, 2003, p. 148). in mindfulness-based practice there is no outcome or goal; rather, the focus is on remaining present and observing, describing, and acting with awareness (carmody & baer, 2008). mindfulness-based practice also maintains a strong emphasis on nonjudgmental acceptance; all emotions or sensations are observed carefully but not evaluated as good or bad, true or false (baer, 2003). mindfulness-based practice originated in a number of eastern meditation practices, but buddhism is primarily credited with its development (kabat-zinn, 2003). western researchers and clinicians have introduced mindfulness-based practices into mental health treatment programs and, for the most part, are teaching the skills independently of their religious and cultural origins (baer, 2003). increasingly evidence supports a number of modalities, which have stemmed from mindfulness-based practice, including mindfulness-based stress reduction, mindfulness-based cognitive therapy, dialectical behavior therapy, and acceptance and commitment therapy (baer, 2003; carmody & baer, 2008). these interventions have become progressively popular to treat “well” individuals and clients suffering from chronic pain, life-threatening illness, and axis i disorders. research suggests these interventions are successful because mindfulness-based practices incorpo columbia social work review, volume v 45 schoen rate exposure, cognitive restructuring, relaxation, and acceptance, leading to symptom reduction and improved well-being (baer, 2003; carmody & baer, 2008). mindfulness-based practices with adults who have cancer over 75% of cancer patients integrate complementary or alternative medicine into their treatment plans (ang et al., 2005). with new studies linking psychological stress to cancer, more patients are including mindfulness-based practice to address their stress and anxiety (national cancer institute, 2012). through standardized measures and patient self-report, a number of studies have found that mindfulness-based practice reduces anxiety and stress while increasing a patients’ coping abilities and their quality of life during treatment (baer-wu, 2010; national cancer institute, 2012; thompson & gauntlett-gilbert, 2008). similarly, speca, carlson, goodey, & angen, (2000) found that mindfulness-based practices lower mood disturbance and emotional irritability in cancer patients, leading to fewer physiological problems, such as cardiopulmonary and gastrointestinal symptoms. other studies point to mindfulness-based practice’s efficacy in altering brain function and changing thought patterns and attitudes, which can help individuals conceptualize and approach their diagnoses in emotionally healthier ways (davidson et al., 2003; hooker & fodor, 2008). yoga, a form of mindfulness-based practice, has been found to help with recovery from cancer treatments by improving sleep patterns, reducing fatigue, improving flexibility, and increasing energy levels (bower, woolery, sternlieb, & garet, 2005; ivy child international, 2012). research has found that even short-term mindfulness-based programs can be effective in altering immune function, an important component of the health of patients undergoing cancer treatment (davidson et al., 2003). mindfulness-based practice with children the majority of research on the use of mindfulness-based practices, and especially studies with cancer patients, focuses primarily on their efficacy with adults. additional mindfulness studies are limited by 46 columbia social work review, volume v children and the mind/body connection their failure to distinguish between children and adults within their study designs and analyses (greenberg & harris, 2012). despite the paucity of thorough research, extant research demonstrates that mindfulness-based practices are appropriate for and beneficial to younger clients (burke, 2010). the bulk of research on mindfulness-based practice with children has been conducted in schools, which offer easy access to children in the general population. this research suggests that the use of mindfulness, meditation, and yoga can lead to increased attention, academic performance, self-acceptance, and self-understanding and reductions in anxiety and stress (greenberg & harris, 2012; hooker & fodor, 2008; napoli, 2004). research argues that mindfulness-based practices can be beneficial to children because many children are on “autopilot” throughout the day, following the directions given by adults in their lives without really experiencing the day fully. as a result, children are an important population in which to develop greater self-awareness (hooker & fodor, 2008). some scholars have raised concerns that mindfulness is not developmentally appropriate for children because they are not yet capable of abstract thought (greenberg & harris, 2012). yet, other researchers contend that children are highly creative, imaginative, and open to new experiences and opportunities to explore. in addition, young children have “beginners” minds’ and have yet to develop a sense of self-consciousness, allowing them to be open to mindfulness-based practice and be compassionate and non-judgmental with themselves (greenberg & harris, 2012; hooker & fodor, 2008). with further research, mindfulness-based practice with children could complement other forms of work with children that address children’s emotional and physical well-being in child-friendly ways. now is an opportune time to explore the value of mindfulness-based practices with children who have cancer. mindfulness-based practice in pediatric cancer treatment and therapy a number of pediatric oncology outpatient programs and cancer-related nonprofits in new york city already include mindfulness-based practice in their treatment and therapy. memorial sloan-ket columbia social work review, volume v 47 schoen tering cancer center (mskcc) has an integrative medicine team that offers services to complement traditional medical care. for children, some of these offerings have a basis in mindfulness-based practice, including mind/body therapies and yoga. mskcc’s website suggests that these practices can help pediatric cancer patients manage their symptoms and improve their quality of life by lessening pain, nausea, headaches, and insomnia. mindfulness-based practices can also help children manage anxiety, stress, and depression; decrease fears; enhance coping skills; and improve relaxation during procedures, treatments, and long hospital stays (mskcc, 2013). similarly, montefiore medical center has followed other hospitals in the united states by starting a kids kicking cancer program where pediatric oncology patients practice breathing techniques, meditation, and martial arts to help cope with pain and anxiety (kids kicking cancer, 2013). gilda’s club new york city, an affiliate of a nationwide cancer support organization, has a children’s program known as noogieland that incorporates yoga into their workshops for children who have been diagnosed with cancer, have a loved one living with cancer, or have a loved one who died from cancer (gilda’s club, 2013).1 other organizations are developing research-based curricula built entirely around mindfulness-based practice. in may 2012, ivy child international launched a mindfulness program designed originally for pediatric cancer patients. the program is a 16-week certificate program that meets once a week for one hour at a time. classes include 20 minutes of circle time to learn mindfulness-based practices, 20 minutes of yoga postures, and 20 minutes of discussion. additionally a self-assessment feelings chart is collected at every class. ivy child international implements this mindfulness program in early childhood centers and hospitals (ivy child international, 2012). all of the aforementioned organizations are taking vital first steps in integrating mindfulness-based practice into the treatment of children who have cancer. these programs can serve as foundations for further research in the development, implementation, and evaluation of mindfulness-based programs in pediatric outpatient or community-based organizations. 1at the time of this publication, the author worked as an independent contractor for gilda’s club new york city. 48 columbia social work review, volume v children and the mind/body connection recommendations for further research and practice although many existing pediatric cancer treatment programs incorporate mindfulness-based practice there exists a growing need for curriculum-based group mindfulness programs for children who have cancer. each stage of the development, implementation, and evaluation of these programs must be based in methodologically rigorous, evidence-based research and integrate evaluations that can contribute to existing research and help guide future studies. the curricula for such programs should be developed using research, literature, and other similar programs as guides. curricula should combine a mixture of mindfulness practices to engage children in varied and engaging ways, as particular practices might be more efficacious for certain children. each practice should be included purposefully, with all exercises examined in advance to ensure they are developmentally appropriate for each group of children (greenberg & harris, 2012; hooker & fodor, 2008; thompson & gauntlett-gilbert, 2008). curricula should begin with basic mindfulness techniques so that the children can experience success early on and feel encouraged to continue further. for example, beginning with a 1-5 minute meditation exercise would be more effective than asking children to sit still for 10 or 15 minutes (hooker & fodor, 2008). mindfulness practices could include yoga, belly breathing, meditation, daily mindfulness tasks, and body awareness (hooker & fodor, 2008; napoli, krech, & holley, 2005; bower, woolery, sternlieb, & garet, 2005). all practices need to include discussion so that children’s questions, concerns, or discomforts can be addressed (hooker & fodor, 2008). the practice and discussion must focus on acceptance, compassion, and acknowledgment of where each child is in the process of her or his illness and experience in the mindfulness-based practice program. children should be encouraged to accept that they might feel pain or worry during their treatment and that this practice is not intended to deny or pathologize these fears, but rather it is designed to help them cope with their experiences (hooker & fodor, 2008). the programs should be held in outpatient pediatric treatment centers at the hospitals in which the children are receiving treatment or in cancer-focused community-based organizations (thompson & gauntlett-gilbert, 2008). programs should be designed for implementation in columbia social work review, volume v 49 schoen groups of children of similar ages so that the children can provide mutual support when exposed to practices that might be new or uncomfortable at first (thompson & gauntlett-gilbert, 2008). programs should be run by trained facilitators, who can provide instructions for each practice in concrete and clear child-friendly language (greenberg & harris, 2012; hooker & fodor, 2008; thompson & gauntlett-gilbert, 2008). throughout implementation and review, programs should integrate rigorous evaluation processes, including standardized measures for the children to fill out at baseline and at pre-determined intervals (kabat-zinn, 2003). these measures could include standardized anxiety or coping scales, self-report, and teacher or caregiver report. if possible, the evaluations might include analyses of changes in physical health throughout participation in the program, whether through self or caregiver report or through medical records (greenberg & harris, 2012). analyses can also disaggregate data by age and gender, enabling program developers to further hone curricula to maximize benefits to clients. an ambitious program could also evaluate the effects of mindfulness-based programming on family members and caregivers or include a simultaneous caregiver mindfulness group. including caregivers acknowledges caregiver stress and enables caregivers to reinforce the mindfulness-based practices with the children outside of the program and provide additional support and comfort (greenberg & harris, 2012). social work involvement and implications social workers can play an integral role in the scientific study and practice of mindfulness-based practices with children who have cancer. the mission of the social work profession is to serve vulnerable populations through incorporation of the person-in-environment approach in both research and practice (code of ethics of the national association of social workers, 2013). social workers are equipped to advocate for and coordinate the treatment of the whole person in her or his context, which includes not only the treatment of disease, but also attention to psychological, social, behavioral, and spiritual factors involved. this holistic practice is in line with the mind/body connection, a central tenet of mindfulness-based practice. social workers are often members of multidisciplinary teams, either as part of a hospital treatment team of doctors, nurses, and child 50 columbia social work review, volume v children and the mind/body connection life specialists or as part of a community-based organization’s team of psychologists, art therapists, and play therapists. social workers can take the lead in using the expertise of their team members to create holistic mindfulness-based programs with attention to the diversity of a child’s cancer treatment and therapy experience. social workers can also be instrumental in engaging families, who can then help the children apply what they have learned and integrate mindfulness techniques in daily routines. finally, social workers are charged to be culturally aware and conscious of their therapies and interventions (nasw, 2013). with mindfulness-based practices especially, clinicians and researchers must find ways to incorporate the practices into western science and treatment plans, while honoring the integrity of the cultures and religions in which these practices are rooted. social workers must find a balance between respecting the traditions and providing an environment free of cultural, religious, or ideological factors where patients can experiment with ways to relieve suffering of both the mind and body (kabat-zinn, 2003). conclusion promising research, albeit limited in scope, documents the efficacy of mindfulness-based practices with children and adults who have cancer in reducing anxiety and increasing coping skills. thus, mindfulness practices could be effective in treating children who have cancer (greenberg & harris, 2012). more research should be conducted to investigate the effects of mindfulness practices in children. current studies and programs can serve as guides so newly developed programs are designed specifically to meet the unique needs of children who have cancer. a mindfulness-based group program for children who have cancer has the potential to treat both the physical and emotional side effects of cancer and lead to better overall health and quality of life for these children, their families, and their caregivers. medical social workers have the opportunity to engage with members of multidisciplinary teams to integrate traditional medical treatments with innovative therapies. moving beyond a rigid medical model is crucial for building approaches that treat the whole individual. examining the value of mindfulness-based practices with children who have cancer allows for further research that may lead to the incorporation columbia social work review, volume v 51 schoen of these practices with children who have other chronic illnesses. social workers must continue to pioneer creative, researched-based programming in order to best serve clients and their families. references ang, j. y., ray-mazunder, s., nachman, s. a., rongkavilit, c., asmar, b. i., & ren, c. l. (2005). use of complementary and alternative medicine by parents of children with hiv infection and asthma and well children. southern medical journal, 98(9), 869-875. baer, r.a. (2003). mindfulness training as a clinical intervention: a conceptual and empirical review. clinical psychology: science and practice, 10(2), 125–143. baer-wu, s. (2010). mindfulness meditation. retrieved from http://www.cancernetwork.com/oncology-nursing/mind fulness-meditation bower, j. e., woolery, a., sternlieb, b., & garet, d. (2005). yoga for cancer patients and survivors. cancer control, 12(3), 165-171. burke, c. a. (2010). mindfulness-based approaches with children and adolescents: a preliminary review of current research in an emergent field. journal of child and family studies, 19, 133-144. carmody, j. & baer, r.a. (2008). relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. journal of behavioral medicine, 31, 23-33. davidson, r. j., kabat-zinn, j., schumacher, j., rosenkranz, m., muller, d., santorelli, s. f… (2003). alterations in brain and immune function produced by mindfulness meditation. psychosomatic medicine, 65(4), 564-570. engel, g.l. (1977). the need for a new medical model: a challenge for biomedicine. science (196)4286, 129-136. greenberg, m. t.& harris, a. r. (2012). nurturing mindfulness in children and youth: current state of research. child development perspectives, 6(2), 161-166. http://www.ncbi.nlm.nih.gov/pubmed?term=davidson rj%5bauthor%5d&cauthor=true&cauthor_uid=12883106 http://www.ncbi.nlm.nih.gov/pubmed?term=kabat-zinn j%5bauthor%5d&cauthor=true&cauthor_uid=12883106 http://www.ncbi.nlm.nih.gov/pubmed?term=schumacher j%5bauthor%5d&cauthor=true&cauthor_uid=12883106 http://www.ncbi.nlm.nih.gov/pubmed?term=rosenkranz m%5bauthor%5d&cauthor=true&cauthor_uid=12883106 http://www.ncbi.nlm.nih.gov/pubmed?term=muller d%5bauthor%5d&cauthor=true&cauthor_uid=12883106 http://www.ncbi.nlm.nih.gov/pubmed?term=santorelli sf%5bauthor%5d&cauthor=true&cauthor_uid=12883106 52 columbia social work review, volume v children and the mind/body connection gilda’s club. (2013). noogieland. retrieved from http://www.gildasclubnyc.org/membership/noogieland.html hooker, k. e. & fodor, i. e. (2008). teaching mindfulness to children. gestalt review, 12(1), 75-91. ivy child international. (2012). yoga and mindfulness for kids (pre school through grade 12). retrieved from http://ivychild.org/ programs/yoga-mindfulness/ kabat-zinn, j. (2003). mindfulness-based interventions in context: past, present, future. clinical psychology: science and practice, 10(2), 144-156. kids kicking cancer. (2013). our mission. retrieved from http://kidskickingcancer.org/content/about/our-mission/ memorial sloan-kettering cancer center. (2013). pediatric cancer care: integrative medicine & complementary services. retrieved from http://www.mskcc.org/pediatrics/ integrative-medicine-complementary-services napoli, m. (2004). mindfulness training for teachers: a pilot program. complementary health practice review, 9(1), 31-42. napoli, m., krech, p. r., & holley, l. c. (2005). mindfulness training for elementary school students: the attention academy. journal of applied school psychology, 21(1), 99-125. national association of social workers. (2013). code of ethics of the national association of social workers. retrieved from http://www.socialworkers.org/pubs/code/code.asp national cancer institute. (2012). psychological stress and cancer. retrieved from http://www.cancer.gov/cancertopics/factsheet/risk/stress speca, m., carlson, l.e., goodey, e., & angen, m. (2000). a randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. psychomatic medicine, 62, 613-622. thompson, m. & gauntlett-gilbert, j. (2008). mindfulness with children and adolescents: effective clinical application. clinical child psychology and psychiatry, 13(3), 395-407. 52 journal of student social work, volume iii adoptive homes and the meaning of family: implications for gay and lesbian prospective parents restrictions on the adoption rights of gay men and lesbians limit their possibilites to become parents, even as thousands of children wait to be placed in adoptive families in the united states. this article will review past and current policy on gay and lesbian couple adoption in the united states. policy changes are then suggested to expand the definition of adoptive families and to create non-discriminatory adoption guidelines to protect gay men and lesbians as legitimate families. finally, the role of social workers and their responsibility under both the laws and systems of adoption protocol will be explored. alicia erickson zink while thousands of u.s. children eligible for adoption languish in foster care, discriminatory policy and practice continue to restrict the rights of many prospective parents seeking to adopt. the passage of the 1997 adoption and safe families act (asfa) accelerated the termination of parental rights, predictably increasing the number of children waiting for safe and permanent placements (kenyon, chong, enkoff-sage, & hill, 2003). in addition, asfa no longer defines interventions by risk of harm to the child, but by “the best interest of the child” criterion. according to the adoption and foster care analysis and reporting system (u.s. department of health and human services administration for children and families, 2004), there were approximately 118,000 children waiting to be adopted as of august 4, 2004. ricketts (as cited in brooks & goldberg, 2001) noted that there is a widespread recognition that the pool of prospective adoptive parents is dwindling. a viable group of prospective parents, though, has yet to receive adequate, fair, and just governmental consideration under adoption policies. the research is unequivocal that gay men and lesbians are equally qualified to provide adoptive homes for children. however, without a clear definition for the best interest of the child, courts, states, and governments continue to allow homophobia to dictate the future of children’s lives. according to adams, jaques, and may (2004), there are as many as two to ten million gay men and lesbians in the united states who are parents to erickson zink journal of student social work, volume iii 53 an estimated 14 million children. despite these numbers, studies have shown that gay men and lesbians encounter many obstacles throughout the process of becoming prospective adoptive parents. adoption policies affecting gay men and lesbians vary from state to state, county to county, and often judge to judge. due to the absence of federal policy regarding adoption, gay men and lesbians are subject not only to state law but are at the mercy of local judges who base adoption decisions on the broad best interest of the child criterion. these decisions may be influenced by personal bias, discrimination, and political agendas, and continue to perpetuate homophobia in social policies (benkov, 1994). some officials fear that placing children in gay and lesbian homes may not be in the best interest of the child; however, scientific research demonstrates that children who grow up in households with gay and lesbian parents fare just as well in emotional, cognitive, social, and sexual functioning as children whose parents are heterosexual (drucker, 1998; patterson, 1992; perrin, 2002; raymond, 1992; steckell, 1987). it is clear that based on the existing empirical research, gay men and lesbians deserve legal protections to qualify to become adoptive parents to the growing number of children in need of permanent families. gay and lesbian adoption policy adoption laws pertaining to gay men and lesbians are made on a state rather than federal level and are dictated by statutes, agency regulations, and court opinions, which may be fueled by political ideologies (kenyon et al., 2003). while some states completely ban adoption by gay men and lesbians, other states implicitly prohibit gay couples from adopting by requiring that adoptive couples be married, a practice currently prohibited for gay men and lesbians in most of the country. the remaining states that do nothave specific state laws addressing this issue make decisions based on the undefined best interest of the child criterion of the adoption and safe families act of 1997. currently, florida is the only state that categorically prohibits gay and lesbian individuals from becoming adoptive parents through florida statute ch. 63.041(3), which states that: “no person eligible to adopt under this statute may adopt if that person is a homosexual” (appell, 2001, p. 76). according to the american civil liberties union (2005), this statute, first enacted in 1977, has undergone several unsuccessful appeals, the last appeal denied by the supreme court in january 2005. according to the 2002 human rights campaign foundation report (bennett, 2002), new hampshire enacted a law in 1988 to prohibit gay men and lesbians from adoptive homes and the meaning of family 54 journal of student social work, volume iii adopting children or serving as foster parents and barred heterosexual foster parents from having gay or lesbian people spend the night in the same house as the child. this law, though challenged in federal court and repealed in 1999, illustrates how homophobia can influence policies and legislation and continue the cycle of oppression on not only prospective gay and lesbian parents, but also those who are friends or family of gay men and lesbians. as mentioned previously, laws may implicitly deny gay and lesbian couples from adopting through the use of carefully designed but blatantly homophobic language. for example, utah passed a law in 2000 prohibiting adoptions by a person who is cohabitating in a relationship that is not a legally valid and binding marriage under the laws of the state (utah code ann. 78-30-1(3) (b)). according to the families like ours organization (2004), oklahoma adopted a new law in 2004 stating that no office, court, or municipality in oklahoma will legally recognize a joint adoption by two peoples of the same sex from another state or country (10 0.s.2001, §75021.4). despite the many states restricting gay and lesbian adoption, there are some states that explicitly permit joint adoption: california, massachusetts, new jersey, vermont, new york, maryland and the district of columbia (ryan, pearlmutter, & groza, 2004). state by state, the future of children’s lives and the rights of gay men and lesbians are dictated by insidious homophobia. the best interest of the child standard is the primary criterion for approving adoption in those states without specific statutes, although there is a considerable amount of flexibility in the factors that may be taken into account in evaluating an adoptive parent’s suitability (benkov, 1994; national center for lesbian rights, 2004). decisions are often made by court judges and child welfare workers that make recommendations on the resources, strengths, and personalities of the family, as well as the family’s overall motivation for adoption. however, because of the void of formal policy in this area, it can be a subjective process, allowing for the influence of personal bias and prejudice. in pima county juvenile action b-10489, the court denied a bisexual man an adoption petition on the grounds that, “he testified that it was possible that he at some future time would have some type of homosexual relationship with another man” (ariz. ct. app. 1986). the role of personal bias, as shown in this case, heavily impacts the rights of gay men and lesbians to adopt. yet, while there continues to be discriminatory laws against gay and lesbian families, other judges attempt to separate judgments on sexual orientation from parenting capabilities. for example, in adoption of evan, a new york judge ruled, “an open lesbian relationship is not a reason to deny adoption because a child’s best erickson zink journal of student social work, volume iii 55 interest is not predicated on or controlled by parental sexual orientation” (sur. ct. 1992). the cycle of oppression will continue to perpetuate without appropriate policies to prevent decisions based on personal bias, homophobia, or both. those opposing the idea of gay men and lesbians as adoptive parents may use the following arguments to conclude that licensing a home for adoption or foster care is not in the best interest of the child: the child will be harassed or ostracized, the child might become gay or lesbian, the child’s moral well-being may be harmed, and that the child may be molested (adams et al., 2004). empirical research supports that these arguments are unsubstantiated. children of gay and lesbian parents are equally successful in their developmental process compared to the children of heterosexual parents (mallon, 2000; perrin, 2002; sullivan, 1995). for example, mallon found that a child is 100 times more likely to be sexually molested by a heterosexual partner of a relative than by someone who identifies as being gay, bisexual, or lesbian. patterson (1992) noted that studies assessing children born to gay or lesbian parents in twelve different samples showed no disruption in the normal course of their sexual identity development. despite this research, the best interest of the child standard unjustifiably denies adoption to gay men and lesbians. this is evident as judges, child welfare workers, and social workers continue to equate homosexuality or bisexuality with deviant behavior and uphold the current adoption guidelines that perpetuate such notions as acceptable ways of thinking (raymond, 1992). the failure of courts to recognize that gay and lesbian adoptive homes are in the best interest of the child has an adverse effect on those children waiting to be adopted. children remaining in foster care are denied secure attachments (patterson, 1992) and have been found to have low self-esteem, confidence, and overall satisfaction of life (mcdonald, alle, westerfelt, & piliavin, 1996). in a study conducted by taigelman and silverman (as cited in bartholet, 1994), it was found that permanent placements in adoptive homes for those children waiting in foster care are more conducive to the overall well-being of the child. additionally, the failure of the law to recognize gay men and lesbians as viable parents creates a culture of fear and hate, ultimately allowing for homophobia to permeate the lives of children and families in society. for example, children of gay and lesbian families are often subject to teasing and harassment within their peer group (drucker, 1998; patterson; raymond, 1992). patterson states that protection of gay and lesbian families, “demands that courts and legislative bodies acknowledge nontraditional families,” and that the failure to acknowledge adoptive homes and the meaning of family 56 journal of student social work, volume iii these families will pose “great difficulty in serving the ‘best interest of the child’” (p. 1037). it is imperative that policy be created to not only protect the rights of prospective gay and lesbian parents, but also to support children of nontraditional families who are affected by the current policies that allow for homophobic discrimination to continue. proposal for new legislation as cited previously, empirical research is persuasive in demonstrating that there is no significant difference between gay and non-gay parents in emotional health, parenting skills, and attitudes toward parenting and should therefore be considered as suitable families for the growing number of children in foster care. notably, neither the adoption assistance and child welfare act of 1980, nor the newer adoption and safe families act (asfa) of 1997, delineate a useful standard for defining a family. crawford (as cited in kenyon et al., 2003) proposed that by not clearly defining the family, “the interpretation of the appropriateness of nontraditional families is left vulnerable to the values and biases of professionals and communities” (p. 572). according to the u.s. census bureau, by 2010, only 20% of the total number of households nationwide will be comprised of the traditional two-parent heterosexual families (u.s. bureau of the census, 1996). nontraditional families, such as those headed by gay men and lesbians, are increasing within the united states and federal policymakers need to protect the rights of these families. there are many prominent professional organizations that support gay and lesbian families and adoption, such as the child welfare league of america, the american psychiatric association, the american psychological association, the american academy of pediatrics and the national association of social workers (nasw). it is in the spirit of these organizations that new legislation be proposed to redefine “family” as the first step towards assuring full adoptive rights to gay and lesbian families, supporting the welfare of children in foster care, and allowing for equal opportunity within the adoption process. an amendment to the adoption and safe families act should be proposed to clearly define the family so as to accommodate the growing need of adoptive parents and nontraditional families within the united states and to reduce biased interpretations of placing children in gay and lesbian families. family should be defined as any responsible caretaker(s) supporting the well-being of their children both financially and emotionally (adams et al., 2004; benkov, 1994; drucker, 1998; patterson, 1998). in addition, there should also be a clear erickson zink journal of student social work, volume iii 57 definition of the eligibility of adoptive parents. lastly, adoption policies should be bound by the same anti-discrimination laws that set the standards in other facets of society. equal opportunity to apply for adoption and the condition that no one will be subjected to race, gender, sexual orientation, or religious discrimination as criteria for adoption can shape new policies and state decisions on how the best interest of the child clause is interpreted. implications for service delivery to children and families social workers are trained to identify where the needs of society and the individual intersect and to promote change when these needs are compromised (ben-ari, 1998). in the case of gay and lesbian adoption, social workers are called upon to advocate for the rights of gay men and lesbians on an institutional, community, and individual level. agencies and social workers continue to weigh their commitment to multiculturalism when working with gay men and lesbians seeking to adopt (ryan et al., 2004). according to the nasw code of ethics, social workers should not practice any form of discrimination; however, social workers as well as child welfare providers may be bound by laws that allow prejudices or judgments about gay and lesbian families. for instance, in richmond, va, a state senate committee rejected a bill that would have required social workers involved in adoption cases to determine if the applicants are gay. it is critical for social workers to fight against these laws that promote discrimination. however, it is important to recognize that eradication of these laws does not necessarily impact personal views that may influence professional decisions. prejudiced views on gay men and lesbians may continue to stem from several sources including family background, family values, religious beliefs, or other learned negative beliefs and attitudes about homosexuals (sullivan, 1995). in addition to these biases, social workers and child welfare providers who do speak out against discrimination and advocate for gay and lesbian prospective parents also face their own risks. social workers can be subjected to ridicule, ostracism and other career-limiting reactions if homophobia reduction is not respected among colleagues, peers, or supervisors (ryan et al.). in order to increase awareness of personal bias and discrimination, trainings in graduate schools as well as in state welfare and private agencies should be implemented to sensitize workers to the needs of the gay and lesbian community. in a study conducted by ben-ari (1998), social work students exposed to courses on individual, familial, and social aspects of homosexuality changed their attitudes towards gay men and lesbians adoptive homes and the meaning of family 58 journal of student social work, volume iii significantly. ryan (2000) found that training focused specifically on adoptions by gay men and lesbians was the most significant predictor of social worker placement recommendation. through these trainings, social workers and child welfare providers will be able to broaden their perceptions of family and advocate for the rights of gay and lesbian parents and the many children waiting in foster care. conclusion an estimated 25 million individuals, 10% of the population, have identified themselves as having a sexual orientation other than heterosexual (mallon, 2000). excluding 25 million individuals from becoming adoptive parents, solely on the basis of sexual orientation, limits the opportunities for children who are in need of permanent families. despite the many state laws prohibiting gay and lesbian adoption, multiple research studies have confirmed that it is in the best interest of the child to allow gay men and lesbians to be adoptive parents (benkov, 1994). unfortunately, personal bias, discrimination, and homophobia continue to be used systematically to shape policies affecting gay men and lesbians and inadvertently hurt children who wait for loving homes. many of these children waiting to be adopted could find permanent families if laws and policies are inclusive of gays and lesbians and use scientific evidence and reason to set adoption standards. by undoing the unjust boundaries that currently restrict the adoption process, children can have a greater opportunity to find the support and love of a permanent family. references adams, j., jaques, j., & may, k. (2004). counseling gay and lesbian families: theoretical considerations. family journal, 12(1), 40-51. american civil liberties union. (2005). aclu disappointed the supreme court will not hear an appeal in case challenging florida’s anti-gay adoption law. retrieved january 28, 2005, from http://www.aclu.org/lesbiangayrights/ lesbiangayrights.cfm?id=17292&c=104. appell, a. (2001). lesbian and gay adoption. adoption quarterly, 4(3), 75-86. bartholet, e. (1994). race matching in adoption: an american perspective. in gaber, i., & aldridge, j. (eds.), in the best interest of erickson zink the child: culture, identity and transracial adoption (pp. 151-187). london: free association books. ben-ari, a. (1998). an experiential attitude change: social work students and homosexuality. journal of homosexuality, 36(2), 59-71. benkov, l. (1994). reinventing the family: the emerging story of lesbian and gay parents. new york: crown publishers. bennett, l. (2002). the state of the family laws and legislation affecting gay, lesbian, bisexual, and transgender americans. human rights campaign foundation 2002 hrc foundation report. retrieved october 18, 2004, from http://www.hrc.org brooks, d. & goldberg, s. (2001). gay and lesbian adoptive and foster care placements: can they meet the needs of waiting children? social work, 46(2), 147-158. drucker, j. (1998). families of value: gay and lesbian parents and their children speak out. new york: plenum press. families like ours organization. (2004). the hard facts of discrimination in adoption. retrieved october 18, 2004, from http:// www.familieslikeours.org/modules/icontent/index.php?page=56 kenyon, g., chong, k., enkoff-sage, m., & hill, c. (2003). public adoption by gay and lesbian parents in north carolina: policy and practice. families in society, 84(4), 571-580. mallon, g. (2000). gay men and lesbians as adoptive parents. adoption quarterly, 11(4), 1-22. mcdonald, t., allen, r., westerfelt, a., & piliavin, i. (1996). assessing the long-term effects of foster care: a research synthesis. washington, dc: child welfare league of america. national center for lesbian rights. (2004). adoption of lesbian, gay, and bisexual parents: an overview of current law. retrieved october 18, 2004, from http://nclrights.org/publications/adptn0204.htm. patterson, c. (1992). children of lesbian and gay parents. child development, 63(5), 1025-1042. perrin, e. (2002). technical report: coparent or second-parent adoption by same-sex parents. pediatrics, 109(2), 341-345. raymond, d. (1992) “in the best interest of the child”: thoughts on homophobia and parenting. in w. blumenfeld, homophobia: how we all pay the price (pp. 114-130). boston: beacon press. ryan, s. (2000). examining social workers’ placement recommendations of children with gay and lesbian adoptive parents. families in society, 81(5), 517-529. ryan, s., pearlmutter, s., & groza, v. (2004). coming out of the closet: opening agencies to gay and lesbian adoptive parents. social work, journal of student social work, volume iii 59 49(1), 85-96. steckell, a. (1987). psychosocial development of children of lesbian mothers. in f. bozett (ed.), gay and lesbian parents (pp. 75-85). new york: praeger publishers. sullivan, a. (ed.) (1995). issues in gay and lesbian adoption: proceedings of the fourth annual pierce-warwick adoption symposium. washington, dc: child welfare league of america. united states bureau of the census. (1996). national households and family projections. retrieved february 27, 2005, from http://www. census.gov/prod/1/pop/p25-1129.pdf united states department of health and human services administration for children and famlies. (2004). national adoption and foster care statistics. retrieved october 25, 2004, from http://www.acf.hhs.gov programs/cb/dis/afcars/publications/afcars.html. alicia erickson zink will be graduating in may 2005 with a master’s in social work from cussw. she is an advanced clinical practice student with a field of practice in family, youth, and children’s services. she is currently placed at the family service league in montclair, nj, which provides family counseling to individuals, children, and families. alicia also holds a bachelor of science in international business from fairfield university. her email address is age2001@columbia.edu. adoptive homes and the meaning of family 60 journal of student social work, volume iii 42 journal of student social work, vol. v the human immunodefi ciency virus, which causes the acquired immunodefi ciency syndrome (hiv and aids), is a pandemic that militates against public health policy and practice on a global scale. the sex industry is frequently cited as one of the growth factors contributing to increased hiv and aids transmission, as well as the spread of sexually transmitted infections across international lines. therefore, the prevention of hiv and aids among commercial sex workers is a major goal of the public health operations of both u.s. and foreign-based organizations working in the sex sector. as it stands, current u.s. laws and policies that dictate the funding of organizations working with sex workers are deleterious to public health and run counter to best practices that prevent the global spread of hiv and aids, as well as human rights norms. this article is centrally concerned with the public health implications of the anti-prostitution pledge, which requires foreign ngos and u.s.-based ngos working abroad to explicitly oppose the practice of prostitution in order to receive u.s. federal funding for hiv and aids prevention among commercial sex workers. policy prescriptions concerning the public health dimensions of commercial sex work will be offered based on the analysis. perating from the premise that prostitution is conjoined with traffi cking in persons for commercial sex, the u.s. government is prohibiting the award of federal funds to foreign non-governmental organizations (ngos) that appear to promote or support prostitution (the state department’s offi ce to monitor and combat traffi cking in persons, 2004). u.s. legislation and policies like the president’s emergency plan for aids relief (pepfar), leadership against hiv and aids, tuberculosis, and malaria act (aids leadership act), and traffi cking victims protection reauthorization act (tvpra) require that foreign ngos and u.s.-based ngos working abroad make an anti-prostitution pledge, which explicitly opposes prostitution, in order to receive u.s. federal funding for hiv and aids prevention targeted at sex industry workers. the anti-prostitution pledge has negative public health consequences for sex workers at risk of hiv and aids transmission as it taimur khan | devika iyer o the pledge requirement: u.s. anti-prostitution policy and the public health context for people-in-prostitution 261809_columbia 01-72 sec1:42261809_columbia 01-72 sec1:42 4/5/07 2:12:26 pm4/5/07 2:12:26 pm 43 prohibits recipients of u.s. federal funds from using best practices, such as harm reduction and empowerment strategies to prevent hiv among high risk populations. sex workers are defi ned as “female, male and transgendered adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally, and who many or may not consciously defi ne those activities as income-generating” (unaids, 2002). this article will consider aspects of the anti-prostitution pledge, including arguments advanced in support of and in opposition to this policy. recommendations will be offered on the policy level based on the analysis of the global public health implications of the anti-prostitution pledge. best practices in public health and human rights to counter hiv and aids harm reduction model best practices in public health and human rights norms suggest that harm reduction is effective in stymieing the spread of hiv and aids among commercial sex workers (rekart, 2005). harm reduction as an approach to hiv and aids prevention is considered to be a simple, safe, and inexpensive line of response to hiv and aids infection that helps avert risk, mitigate harm, and save lives. according to rekart (2005), hiv and aids infection risks associated with commercial sex are reduced using an empowerment-oriented harm reduction model in public health practice with sex industry workers. harm reduction practices include: occupational health and safety guidelines for brothels, distribution of male and female condoms, training in condom-negotiating skills, and safety tips for street-based sex workers regarding hiv and aids preventative strategies. empowerment: a harm reduction tool empowerment and harm reduction share a synergistic relationship. one of the hallmarks of harm reduction is respect for the individual’s right to selfdetermination, which is also a core concept of empowerment (newman, 2003). the harms associated with sex work can be minimized through the empowerment of sex workers. the goal of empowerment is to provide real opportunities for sex workers through services, such as job training, language skills, access to health services, and protection from violence. human rights framework the view that positive public health outcomes can be produced by the pledge requirement t a im u r k h a n | d e v ik a iy e r 261809_columbia 01-72 sec1:43261809_columbia 01-72 sec1:43 4/5/07 2:12:27 pm4/5/07 2:12:27 pm 44 journal of student social work, vol. v linking global health policy with respect for human rights is gaining increased acceptance (loff, et al., 2000). the relationship between human rights abuses and hiv and aids transmission among sex workers is bidirectional. discrimination and human rights abuses are the cause as well as result of hiv and aids (csete, 2004). many public health interventions, such as the aids leadership act, consider sex workers hazards to society (woffers & beelen, 2003). restrictive policies around sex work, such as the anti-prostitution pledge, increases stigma driving sex work further underground and increases the likelihood that sex workers will avoid state institutions, including those that deliver health care (wolffers & beelen). anti-prostitution laws and policies: pepfar, aids leadership act, and tvpra pepfar pepfar is an executive directive aimed at stemming the spread of hiv and aids throughout the world. president bush recognized hiv and aids as a harbinger of a “severe and urgent crisis abroad” in his 2003 state of the union address and proposed pepfar as a solution (alliance for open society international, inc. & open society institute, 2005). pepfar mandates u.s. funding restrictions on organizations that do not adopt a pro-abstinence approach to the practice of commercial sex work. the executive directive does not consider the human rights standards and best practices in public health discussed above. aids leadership act pepfar has given impetus to the creation of a cluster of laws and policies, one of which is the aids leadership act. in may 2003, the u.s. congress passed the aids leadership act (22 u.s.c. §§ 7601-7682, 2003), which bars the use of federal funds to “promote, support, or advocate the legalization or practice of prostitution or sex traffi cking” (22 u.s.c. § 7631(e), 2003). the law requires organizations receiving u.s. hiv and aids funding to agree with the anti-prostitution pledge and adopt a policy explicitly opposing prostitution and sex traffi cking. organizations that do not denounce prostitution could continue to lose billions of dollars in u.s. federal funding, thus impeding their efforts to prevent the spread of hiv among sex workers and undermining efforts to promote the fundamental human rights of all persons (change, 2005). t a im u r k h a n | d e v ik a i y e r 261809_columbia 01-72 sec1:44261809_columbia 01-72 sec1:44 4/5/07 2:12:27 pm4/5/07 2:12:27 pm 45 the aids leadership act is currently applicable to foreign ngos receiving bilateral u.s. hiv and aids funds and u.s.-based ngos working abroad. although the restrictions of the law do not currently apply to multilateral organizations, there is considerable concern that the extension of the restrictions is inevitable (change, 2005). in may 2005, the centers for disease control implemented funding restrictions on the joint united nations programme on hiv and aids (unaids) and world health organization sub-grantees, which were later abrogated after widespread public denunciation (change). tvpra the tvpra prohibits u.s. federal funding for organizations that tacitly “promote, support, or advocate the legalization or practice of prostitution” (22 u.s.c. §§ 7101-7110, 2003). the funding restrictions mandated by the tvpra bar organizations that work with traffi cking victims from employing a range of modalities to improve the public health of this group using a human rights-based framework. due to the confl ation of prostitution with traffi cking in persons, organizations working to aid and empower victims of traffi cking lose necessary funding to stave off health harms surrounding sex work (ditmore, 2003). proponents of the anti-prostitution pledge in a december 2002 national security presidential directive, the u.s. government adopted an abstinence-based and abolitionist position against legalized prostitution. this position was adopted based upon the premise that prostitution is a harmful and dehumanizing practice that stimulates human traffi cking, and the vast majority of sex workers want to escape from this practice (the state department’s offi ce to monitor and combat traffi cking in persons, 2004). from the vantage point of the u.s. government, legalization of prostitution increases the demand for commercial sex work, thus providing market opportunities for criminals who traffi c people into prostitution. furthermore, the u.s. government contends that legalized prostitution makes it diffi cult for law enforcement offi cials to identify and penalize criminals who engage in traffi cking (the state department’s offi ce to monitor and combat traffi cking in persons). based on this confl ation between prostitution and traffi cking, the u.s. government decided to implement restrictions on hiv and aids funding to organizations that work with sex workers. anti-prostitution pledge advocates, also known as abolitionists, further argue that abstinence from sex and abolition of prostitution should the pledge requirement t a im u r k h a n | d e v ik a iy e r 261809_columbia 01-72 sec1:45261809_columbia 01-72 sec1:45 4/5/07 2:12:27 pm4/5/07 2:12:27 pm 46 journal of student social work, vol. v underpin the hiv and aids prevention efforts of organizations working in the sex sector. abolitionists view sexual commerce as degrading and dehumanizing, characterizing sex work and traffi cking in persons as a form of modern day slavery (the state department’s offi ce to monitor and combat traffi cking in persons, 2004). many ideologues from the christian right, as well as several radical feminists endorse this view of commercial sex work. radical feminists who support the anti-prostitution pledge view prostitution as a coerced form of male-dominated wage slavery, as well as a feminized type of exploitation refl ecting patriarchy, which is harmful to all women (jaggar, 1997). similarly, members of the christian right supporting the anti-prostitution pledge oppose sex work on moral grounds because these members defi ne legitimate sexual contact as relations between two married people of the opposite sex for purposes of procreation only (change, 2004). anti-prostitution pledge advocates assume that all sex workers are perforce victimized, do not choose to engage in sex work, and seek to escape this practice. in addition, they argue that traffi cking in persons is bound up and inextricably linked with the sex trade. furthermore, abolitionists reason that the harm reduction model of prostitution encourages the practice of sex work and increases the market demand for the profession, causing a rise in persons traffi cked into commercial sex on the supply side (the state department’s offi ce to monitor and combat traffi cking in persons, 2004). opponents of the anti-prostitution pledge public health practitioners working with sex workers suggest that the u.s. government’s pro-abstinence, anti-prostitution stance towards hivprevention aid is a paternalistic and unrealistic approach (ditmore, 2005). therefore, pro-anti prostitution pledge arguments require a more complicated and human rights based understanding of sexual commerce. harm reduction approach opponents of the anti-prostitution pledge argue that harm reduction is a best practice and funding should not be eliminated for organizations implementing this approach (change, 2004). as discussed earlier, empirical evidence of public health operations involving sex workers suggests the greater effi cacy of the harm reduction model in countering the spread of hiv and aids among sex workers (newman, 2003). for example, by bringing a harm reduction model to bear on public health interventions in india, the sonagachi project, an t a im u r k h a n | d e v ik a i y e r 261809_columbia 01-72 sec1:46261809_columbia 01-72 sec1:46 4/5/07 2:12:28 pm4/5/07 2:12:28 pm 47 the pledge requirement hiv-prevention program in calcutta, signifi cantly lowered hiv seroprevalence rates among sex workers in the city (newman). the sonagachi project couples harm reduction principles with empowerment strategies to minimize the health risks of sexually transmitted diseases among sex workers. human rights watch estimates that the sonagachi project’s harm reduction approach has impacted more than 30,000 sex workers at risk for hiv and aids (human rights watch, 2005). unaids has also credited the sonagachi project as a best practice model for the proven effects in public health. furthermore, harm reduction is the precipitating factor behind the successful public health outcomes achieved among sex workers in many countries. for example, in brazil, harm reduction and hiv and aids prevention programs have been lauded by the united nations as among the best in the developing world (reel, 2006). current estimates indicate that there are less than 600,000 hiv-infected people in brazil, which is half the number forecasted by the world bank a decade ago. through state-funded sex education and prevention workshops, the distribution of free condoms, and informational pamphlet dissemination, brazil has managed to effectively reduce the hiv and aids rate in the country (reel). international human rights violations opponents to the anti-prostitution pledge contend that this policy is in violation of the fundamental human rights of sex workers and in confl ict with a corpus of international human rights instruments and laws, such as the universal declaration of human rights (udhr) (change, 2005). the rights emanating from the udhr, including the right to “security of person,” freedom from “inhuman or degrading treatment,” and “equal protection of the law,” are eroded by the anti-prostitution pledge (butcher, 2003). whereas international human rights laws lack enforcement power, as their implementation rests on governing bodies, laws and policies issuing from the u.s. federal government compel observance due to the threat of loss in funding. it is evident that multinational institutions, including the united nations and foreign national leaders in hivand aids-affected countries exert little pressure on u.s. federally-funded hiv and aids programs (csete, 2004). through its proscription of harm reduction as an approach to the public health of sex workers, the anti-prostitution pledge counteracts human rights. furthermore, access to healthcare is a fundamental human right as stated in article 25 of the udhr (udhr, 1948) and the constraints wrought by the anti-prostitution pledge deprive sex workers of their basic right to health. the t a im u r k h a n | d e v ik a iy e r 261809_columbia 01-72 sec1:47261809_columbia 01-72 sec1:47 4/5/07 2:12:28 pm4/5/07 2:12:28 pm 48 journal of student social work, vol. v limited range of public health interventions sanctioned by the aids leadership act fl y in the face of best practices and human rights standards forcing recipient organizations of u.s. funding to adopt less effective hiv and aids preventive strategies. u.s. constitutional concerns and challenges opponents of the anti-prostitution pledge raise constitutional concerns about this policy, arguing that it violates the right to freedom of speech enshrined in the first amendment (human rights watch, 2005). by forcing organizations to explicitly oppose prostitution, the anti-prostitution pledge compels speech, thereby violating the first amendment to the constitution by requiring domestic and foreign-based organizations working in public health to align with the u.s. government’s policy position. anti-prostitution pledge advocates also believe that funding restrictions under the aids leadership act violate the first amendment because the vagueness of the pledge requirement allows the law to be applied arbitrarily (open society institute, 2005). finally, organizations working with sex workers contend that the antiprostitution pledge unconstitutionally undermines public health interventions by forcing them to either adopt an anti-prostitution policy or forego federal funding, which may limit the effectiveness of their hiv and aids prevention efforts (alliance for open society international, inc. et al., 2005). public health implications of the anti-prostitution pledge opponents of the anti-prostitution pledge argue that current legislation is antithetical to best practices that promote empowerment (change, 2005). empowerment strategies intended to provide commercial sex workers with economic alternatives to sexual commerce are being affected by the government policy. for example, ngos in cambodia have stopped providing avenues out of sex work, such as english-language classes, for fear they would be seen as promoting prostitution (change). additionally, the intervention strategies of empower thailand, an organization that helps sex workers obtain high school diplomas and employment skills, were jeopardized as a result of the anti-prostitution pledge (change, 2003). in short, the anti-prostitution pledge can be said to have a perverse effect on the public health operations of organizations working with sex workers. furthermore, opponents of the anti-prostitution pledge suggest that the pro-abstinence agenda is myopic insofar as it alienates sex workers, the very population essential to prevent further spread of hiv and aids, by t a im u r k h a n | d e v ik a i y e r 261809_columbia 01-72 sec1:48261809_columbia 01-72 sec1:48 4/5/07 2:12:29 pm4/5/07 2:12:29 pm 49 the pledge requirement stigmatizing commercial sex work and calling for its abolition (change, 2005). implicit in the anti-prostitution pledge is the denial of the lived and embodied experiences of commercial sex workers. the condemnation of sexual commerce that organizations working with sex workers are compelled to adopt under u.s. laws and policies ratchet up the stigma around this line of work (change). policy recommendations in consideration of the sex work harms and public health concerns that this government policy engenders, we offer the following policy recommendations to the federal government of the united states: amendment of the aids leadership act with a view towards greater conformity with constitutional guarantees, human rights norms, and best practices in public health when sex workers are denied access to condoms or any other prevention technology or strategy, it violates both human rights principles and medical ethics (change, 2004). furthermore, a reliance on abstinence will leave millions of people without the knowledge, information, and skills necessary to prevent infections (change). hence, u.s. government commitment is required to maintain funding for condom procurement and delivery to decrease behavioral risk of hiv and aids infection among sex workers globally. revoke the anti-prostitution pledge and have a re-authorization act excluding the opposition to sex work there is concern in policy and public health circles that the pledge requirement undermines hiv and aids prevention programs specifi c to sex industry workers and that organizations working with sex workers will abandon innovative and effective programs for fear of losing funding. as a result, the pledge requirement could further stigmatize commercial sex workers, leading to disastrous consequences for global public health. hence, a revocation of the anti-prostitution pledge is needed. include commercial sex workers affected by laws and policies germane to prostitution in policy decisions concerning the sex trade sex industry workers affected by laws and policies concerning prostitution should be included in policy decisions about transactional sex t a im u r k h a n | d e v ik a iy e r 261809_columbia 01-72 sec1:49261809_columbia 01-72 sec1:49 4/5/07 2:12:29 pm4/5/07 2:12:29 pm 50 journal of student social work, vol. v because they are associated with the transmission and prevention of hiv and aids. the pledge requirement alienates sex workers who are already socially marginalized because of widespread stigma and discrimination. evidence suggests that public health interventions repudiating targeted populations produce ineffective outcomes. including sex workers in policy making about people-in-prostitution reduces social stigma. broad-based consultation with experts across the professional spectrum consult with a broad range of experts including but not limited to social work practitioners, public health professionals, and organizations working in the sex sector, to effectively create an overarching policy that productively stems the spread of hiv and aids. broad-based consultancy ensures transparency in policymaking, consistency with u.s. and international human rights law, and the promotion of best practices in public health (change, 2005). avoid confl ating sex work with traffi cking the u.s. government must avoid confl ating sex work with traffi cking as it ignores other categories of traffi cking, including traffi cking for forced labor. the confl ation between human traffi cking and traffi cking for sex eclipses other forms of internal and cross-border traffi cking, which promotes a narrow view of this transnational activity. linking traffi cking uniquely to sex work is harmful on the policy level as it may encourage situations of abuse for persons traffi cked into other industries to go unnoticed and unaddressed (ditmore, 2002). provision of u.s. funding to organizations working with sex workers that do not espouse a specifi c policy on prostitution retract current funding restrictions in legislation and espouse a harm reduction model and human rights based approach to sex work. specifi cally, amend the tvpra with a greater conformity towards human rights standards and best practices in public health. conclusion productive public health outcomes can be achieved more successfully through human rights and empowerment mechanisms coupled with harm reduction models rather than an anti-prostitution and abstinence-only approach to commercial sex work. hiv and aids is a public health concern of global proportions. as it stands, the aids leadership act will accelerate the t a im u r k h a n | d e v ik a i y e r 261809_columbia 01-72 sec1:50261809_columbia 01-72 sec1:50 4/5/07 2:12:30 pm4/5/07 2:12:30 pm 51 the pledge requirement transmission of hiv and aids, increasing morbidity and mortality rates among sex workers as well as the larger population. therefore, a rethinking of u.s. government policy with regard to hiv and aids prevention is in order. at this writing, several u.s.-based ngos including alliance for open society international, pathfi nder international, open society institute, and dkt international have fi led suit in new york and washington d.c. district courts arguing that the anti-prostitution pledge violates their constitutionally-protected right to free speech (bristol, 2006). district court judges in new york and washington d.c. decreed that enforcement of the anti-prostitution pledge would cause the plaintiff organizations to suffer irreparable harm, thus violating the first amendment of the u.s. constitution (05-cv-8209 (s.d.n.y.)). while this ruling provides plaintiff u.s.-based ngos with a legal remedy, it does not provide legal relief to foreign ngos who do not have u.s. constitutional rights and are potentially gagged by the pledge requirement (bristol, 2006). on february 27, 2007, a federal appellate court for the district of columbia upheld the constitutionality of the pledge requirement overturning the lower court’s decision (brennan center for justice, 2007). circuit judges of a u.s. court of appeals decided that the funding conditionality under the aids leadership act does not compel appellate organization, dkt international, to advocate the government’s position on prostitution and sex traffi cking, but rather communicates the message the government chooses to fund (06-cv-5225 (d.c. cir. 2007)). at this writing, it is uncertain as to whether or not dkt international will appeal the ruling concerning the pledge requirement at issue. the judicial outcome of a separate action brought by the u.s. government appealing the decision of the new york district court also remains to be seen. with more than 40 million hivand aids-infected people worldwide and the loss of funding from the u.s., one of the largest donors of hiv and aids prevention funding globally, implications for the public health of sex workers are disastrous (bristol, 2006; open society institute, 2004). human suffering caused by the scourge of hiv and aids can be more effectively prevented on the local, national, and international level if the pledge requirement is jettisoned for evidence-based, best practices in public health. references alliance for open society international, inc. and open society institute. (2005) civil action no. 05-8209 (vm) (s.d.n.y.). retrieved march 14, 2007, t a im u r k h a n | d e v ik a iy e r 261809_columbia 01-72 sec1:51261809_columbia 01-72 sec1:51 4/5/07 2:12:30 pm4/5/07 2:12:30 pm 52 journal of student social work, vol. v from http://www.aclu.org/womensrights/gen/21210lgl20051109.html brennan center for justice, brennan center statement on d.c. circuit court of appeals decision in dkt international v. usaid, et. al. retrieved march 14, 2007, from http://www.brennancenter.org/press_detail. asp?key=100&subkey=48017 bristol, n. (2006). u.s. anti-prostitution pledge decreed “unconstitutional.” the lancet, 368(9529). butcher, k. (2003). confusion between prostitution and sex traffi cking. the lancet, 361. center for health and gender equity. 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(1997). contemporary western feminist perspectives on t a im u r k h a n | d e v ik a i y e r 261809_columbia 01-72 sec1:52261809_columbia 01-72 sec1:52 4/5/07 2:12:30 pm4/5/07 2:12:30 pm 53 the pledge requirement prostitution. asian journal of women’s studies, 3(2). loff, b., gaze, b., & fairley, c. (2000). prostitution, public health, and human rights law. the lancet, 356(1764) . newman, a. p. (2003). refl ections on sonagachi; an empowerment base hiv preventive intervention for female sex workers in west bengal, india. women’s studies quarterly, 31, 168-177. open society institute. (2005). osi sues usaid over dangerous public health policy. retrieved march 14, 2007, from http://www.soros.org/ initiatives/health/focus/sharp/news/usaid_20050923 reel, m. (2006). where prostitutes also fight aids: brazil’s sex workers hand out condoms, crossing u.s. ideological line. the washington post. retrieved march 14, 2007, from http://www.washingtonpost.com/ wpdyn/content/article/2006/03/01/ar2006030102316.html. rekart, m. l. (2005). sex-work harm reduction. the lancet 366(9503), 2123. the state department’s offi ce to monitor and combat traffi cking in persons. (2004). the link between prostitution and sex traffi cking. global affairs. retrieved march 14, 2007, from http://www.state.gov/r/ pa/ei/rls/38790.htm. traffi cking victims protection reauthorization act of 2003, 22 u.s.c. §§ 7101-7110 (2003) [hereinafter, tvpra]. unaids technical update. (2002). sex work and hiv and aids. unaids best practice collection. united states agency for international development and randall l. tobias. (2007). civil action no. 06-5225 (d.c. cir. feb. 27, 2007). retrieved march 14, 2007, from http://brennancenter.org/dynamic/subpages/ download_fi le_47995.pdf. united states leadership against hiv/aids, tuberculosis, and malaria act of 2003, 22 u.s.c. §§ 7601-7682 (2003) [hereinafter, aids leadershipact] united states leadership against hiv/aids, tuberculosis, and malaria act of 2003, 22 u.s.c. § 7631(e) (barring use of funds to “promote or advocate the legalization or practice of prostitution or sex traffi cking”) universal declaration of human rights. retrieved march 14, 2007, from http://www.un.org/overview/rights.html. weitzer, r. (2006). moral crusade against prostitution. society, 43(3), 33. wolffers, i., & beelen, n. v. (2003). public health and the human rights of sex workers. the lancet, 361, 1981. t a im u r k h a n | d e v ik a iy e r 261809_columbia 01-72 sec1:53261809_columbia 01-72 sec1:53 4/5/07 2:12:31 pm4/5/07 2:12:31 pm 54 journal of student social work, vol. v devika iyer is a second year master’s student at columbia university’s school of international and public affairs, and her focus is economic and political development. she has recently worked as a research intern at the bureau for development policy, undp and at the human development report offi ce, undp. she is a graduate of rutgers university with a bachelor’s degree in psychology. her email address is ds2417@columbia.edu. taimur khan is a second-year master’s student at the columbia university school of social work with a practice method in social enterprise administration. he is also a degree candidate in international affairs at the columbia university school of international and public affairs. currently, he is completing his fi eld placement at the new york resettlement offi ce of the international rescue committee. he holds a bachelor’s degree in english and political science with a french minor from the university of north carolina, greensboro. he is interested in international social welfare. his e-mail address is trk2103@columbia.edu. t a im u r k h a n | d e v ik a i y e r 261809_columbia 01-72 sec1:54261809_columbia 01-72 sec1:54 4/5/07 2:12:31 pm4/5/07 2:12:31 pm columbia social work review, volume v 53 the intersection of corporate social responsibility and the non-profit industrial complex exploitative child labor in côte d’ivoire’s chocolate industry gabrielle cole this article examines the role of the chocolate industry in the exploitation of children on cocoa farms in côte d’ivoire. under the guise of corporate social responsibility (csr), the chocolate industry has used its power in the united states to shape policy and program-level initiatives to address the worst forms of child labor, while protecting its business interests and disregarding poverty as the root cause of the problem. the non-profit industrial complex (npic) limits the ability of international non-governmental organizations (ingos) to effectively implement programs that address poverty. the increasing csr funding to ingos prevents them from holding the chocolate industry accountable. further, this article discusses the unique contribution of the social work profession in creating the social and structural change required to mitigate the negative consequences of the relationship between csr and the npic. corporate social responsibility (csr) is often proclaimed as an important mechanism by which companies can help reduce poverty in the developing world (dansereau, 2010). however, the continuing impact of colonialism and globalization on poverty reduction, as well as the power dynamics between the western world and the developing world, are frequently ignored. international non-governmental organizations (ingos) often provide services or implement programming in developing countries. they primarily receive their funds from western governments, foundations, and/or individuals, as well as multilateral organizations, such as un agencies and the world bank. ingos are plagued by the non-profit industrial complex (npic), which has curtailed their abilities to lead social change because of implicit and explicit restrictions on their funding streams from donors, corporate or otherwise. as a result, ingos fail to adequately address the limitations of csr initiatives, perpetuating global inequalities. this article illustrates the role of the united-states based choc54 columbia social work review, volume v csr and the non-profit industrial complex olate industry, including chocolate companies, chocolate manufacturers, industry associations, and cocoa traders, in the continued exploitation of children on cocoa farms in côte d’ivoire. first, this article uses the chocolate industry to examine the limitations of csr, the significance of the npic in developing countries, and intersection of the two. second, the article will address the unique role the social work profession can play in identifying sustainable solutions that address poverty, the heart of the problem. the exploitation of children in the production of cocoa in 2000, child labor in côte d’ivoire’s cocoa farms entered public consciousness with a series of news reports on exploitative work conditions (ryan, 2011). the us department of state estimated that over 109,000 children work under the worst forms of child labor in côte d’ivoire’s cocoa industry, and that approximately 10,000 are victims of slavery or human trafficking from neighbouring west african countries (international labor rights forum [ilrf], 2008). these children endure long, demanding hours of work in unsafe conditions, use dangerous tools, and often are exposed to dangerous pesticides. some children also suffer violence and cruel treatment at the hands of the farmers (ilrf, 2008). these conditions violate the international labour organization’s convention no. 182 on the elimination of the “worst forms of child labour.” adopted in 1999, the convention’s definition of the worst forms of child labor includes “all forms of slavery or practices similar to slavery, such as the sale and trafficking of children, debt bondage and serfdom, and forced or compulsory labour…. [and] work which…is likely to harm the health, safety or morals of children” (american federation of teachers [aft] & ilrf, 2010, p.2). the underlying cause of exploitative child labor the causes of exploitative child labor are complex and must be examined in the context of global political and economic systems. in the past, agriculture in developing countries often was based on subsistence where farmers would grow food and livestock mainly for their own consumption; however, farmers now focus on cash crops, growing only specific crops for export. the shift from subsistence to cash crop agriculture contributes to the uneven effects of modernization and globalization, columbia social work review, volume v 55 cole which are linked to exploitative work conditions in the developing world (bales, 1999). one important cash crop is cocoa, with 73% of global production based in africa and 40% based in a single country, côte d’ivoire. unlike other western agribusinesses, 90% of global cocoa production comes from individually-run, small-scale farms (world cocoa foundation, 2012). the root cause of exploitative child labor on cocoa farms is poverty (off, 2008; athreya, 2011). cocoa farmers are poor because they receive very little money from the sale of their cocoa beans (off, 2008). often, they neither have access to current information on the world market price of cocoa nor have their own scales to weigh their products. consequently, cocoa farmers bargaining power is very low and middlemen who sell to the international chocolate companies pay them well below the market price. with small revenues, small-scale farmers are forced to cut their expenses and use children as laborers to reduce their production costs, with no possibility of investing in better working conditions (off, 2008; athreya, 2011). the power of the chocolate industry in the united states every year, people around the world consume three million tons of cocoa beans (world cocoa foundation, 2013), and in 2011, global sales of chocolate surpassed $100 billion for the first time. cocoa is an important cash crop for producing countries and a key import for countries that process and consume cocoa (world cocoa foundation, 2012). the us is also an important market for the chocolate industry and 47% of its cocoa imports come from côte d’ivoire (world cocoa foundation, 2011). in 2009, the us imported close to $3 billion of cocoa and chocolate products (world cocoa foundation, 2012). furthermore, for every dollar of cocoa it imports, one to two additional dollars are spent on other domestic agricultural inputs, such as sugar, milk, and peanuts. close to 70,000 jobs are directly involved in manufacturing chocolate and confectionery products in the us, and this number triples when considering jobs related to the distribution and sale of these products (world cocoa foundation, 2011). the size and role of the chocolate industry in the us economy is the fundamental source of the industry’s power in influencing us policy. 56 columbia social work review, volume v csr and the non-profit industrial complex the chocolate industry defends its interests activists in western countries from the fair trade movement who were working in solidarity with local farmers spearheaded claims about the exploitative conditions of child labor in côte d’ivoire’s cocoa production (athreya, 2011). public attention toward child labor, trafficking and slavery-like conditions on cocoa farms quickly spurred the chocolate industry to respond, to minimize decreases in sales (ryan, 2011). media exposure also stimulated the introduction of an agricultural bill amendment in 2001 that would establish exploitation-free labeling requirements on chocolate sold in the us (off, 2008). however, the chocolate industry’s lobbying efforts secured the withdrawal of support for the amendment in exchange for signing a voluntary policy instrument known as the “harkin-engel protocol” (ilrf, 2008). the protocol was supposed to develop and implement a set of standards for public certification of exploitation-free production by 2005 (ilrf, 2008). the industry was successful in convincing both consumers and policymakers that it would handle the problem of exploitative child labor on its own, without government regulation (athreya, 2011). the protocol maintained the industry’s strong position of power and allowed it to dominate the development of strategies in addressing exploitative child labor under the guise of csr. the empty promises of corporate social responsibility csr is defined in many ways, but generally refers to the belief that companies have a responsibility for the impact of their business practices, including its supply chain, on both society and the environment (blowfield & frynas, 2005). csr initiatives are voluntary, distinguishing them from other regulatory frameworks and hindering meaningful monitoring and evaluation (blowfield & frynas, 2005). companies frequently turn to csr because they hope to strengthen their reputations among consumers and increase their profits, or because they need to mitigate the negative impacts of their business practices to prevent a decline in profits (hamann & acutt, 2003). although csr is touted by the world bank as an important route to development for low-income, resource-rich countries (dansereau, 2010), companies do not engage in csr primarily to alleviate poverty in local communities. usually when a conflict arises between columbia social work review, volume v 57 cole the goal of a csr initiative and the bottom-line of business, the default response is clear: prioritize profits while protecting public relations (hamann & acutt, 2003). in 2008, the ilrf released a report concluding that the harkin-engel protocol “failed resoundingly” (ilrf, 2008, p.2). the report found that none of the activities implemented as a result of the protocol attempted to monitor or improve labor conditions in cocoa production. moreover, the report said that all the major chocolate companies, as well as industry associations and cocoa traders, consistently claimed that monitoring or tracking labor conditions was impossible (ilrf, 2008). the harkin-engel protocol is, therefore, a poignant example of the empty promise of csr. proposing the protocol in place of legislation was a sure way for the industry to maintain positive public relations while protecting its economic interests (off, 2008). in 2010, the “declaration of joint action to support the implementation of the harkin-engel protocol” was signed by the governments of côte d’ivoire and ghana, the us department of labor, the international chocolate and cocoa industry as well as us representative eliot engel and us senator tom harkin. it committed the signatories to take steps to reduce the worst forms of child labor in the production of cocoa by 70% before 2020 (child labor cocoa coordinating group [clccg], 2013). however, the framework of action does not implicate or target cocoa farmers who are key stakeholders in the cocoa production process. although the 2010 declaration and its framework of action are signs of progress, the nine years that elapsed since the 2001 protocol illustrate the chocolate industry’s disregard for local communities. moreover, the chocolate industry’s protocols and frameworks are voluntary, allowing for little meaningful oversight or accountability. further, american consumers, who according to csr theory are meant to hold companies accountable, have little knowledge of the realities on the ground and are not positioned to advocate for the interests of the affected local communities. the limitations of csr are more complex in today’s globalized world. strong stakeholder engagement and dialogue are often credited for the success of csr initiatives (blowfield & frynas, 2005). however, stakeholder engagement is fundamentally flawed when those most impacted by a company’s business practices do not directly participate. in the context of the developing world, meaningful participation is complicated by language, education, and cultural differences. often, local 58 columbia social work review, volume v csr and the non-profit industrial complex workers’ participation is ‘ensured’ through proxies such as ingos, which are not in a position to legitimately represent the views and priorities of these local communities and marginalized groups (blowfield & frynas, 2005). the influence of the chocolate industry on programming in local communities with the chocolate industry’s success in shaping the policy response and its powerful position over ingos and local non-governmental organizations, it has also been able to shape programmatic responses on the ground. for example, the international cocoa initiative (ici), established under the harkin-engel protocol as a joint partnership between the industry and civil society, explicitly states in its by-laws that only one-third plus one members of the board of directors must be a representative of civil society (ici, 2012). the board makes all program strategy decisions (ici, 2012) and ici’s funding comes from the chocolate industry representatives on the board (ici, 2010a). thus, it is evident that the balance of power in this organization favors the chocolate industry, which is consequently able to ensure that its interests are reflected in programming. the ici’s program activities do not address the root cause of exploitative child labor, but rather intervene on the secondary impacts of the problem. the ici claims to reduce poverty by enhancing community access to healthcare improving water and sanitation, and teaching techniques to increase cocoa crop yields as well as other vocational skills (ici, 2010a). none of these initiatives address the need for improved bargaining power and access to current information on the world market price of cocoa, which would have a more direct impact on the working and living conditions of those who produce cocoa. furthermore, because increasing crop yields would lead to an increase in the supply of cocoa beans, potentially lowering the market price of cocoa beans and thereby decreasing the income of farmers, these csr initiatives might negatively impact the affected communities. the non-profit industrial complex although ingos are mission-driven, the npic limits their ability to address the systemic root causes for sustainable and long-term columbia social work review, volume v 59 cole change. the npic is a system of relationships that link the political and financial resources of the state and the ruling class to the non-profit sector, thus limiting and controlling social and political movements for change. the npic enables the state and capital interests to use non-profits to “monitor and control social justice movements; … redirect activist energies into career-based models of organizing instead of mass-based organizing capable of actually transforming society; and, allow corporations to mask their exploitative and colonial work practices through ‘philanthropic’ work” (smith, 2007, p.3). ingos are also increasingly dependent on public-private partnerships for funding (athreya, 2011). paired with the effects of the npic, ingos are increasingly limited in their abilities to develop and implement programs that address the heart of the problem of exploitative child labor on cocoa farms–program strategies that may threaten the interests of the chocolate industry. furthermore, the npic tends to place blame on communities in developing countries for their “backwards” attitudes without examining the connections between extreme poverty and white supremacy, colonialism, and globalization (smith, 2007). these implicit victim-blaming messages often come through in programming in local communities. for instance, there are programs funded by the chocolate industry that are designed to promote “better parenting,” based on the assumption that if parents and communities “knew better,” exploitative child labor would end (athreya, 2011). these paternalistic and de-contextualizing interventions can have far-reaching, unintended, and negative consequences (khan, westwood, & boje, 2010). the npic has meant that ingos are complicit in the exploitation of children in cocoa production, and, at worst, are perpetuating racist stereotypes of ignorant african villagers (athreya, 2011). the role of the social work profession the social work profession is uniquely positioned to play a key role in creating structural and social change. these changes are necessary to address the negative consequences of the connection between csr and the npic. the anti-oppression and ecological frameworks used to analyze social issues are critical in understanding the interplay between colonialism, globalization, and poverty. oppression can be found throughout economic and political systems as well as cultural institutions and is experienced through exploita60 columbia social work review, volume v csr and the non-profit industrial complex tion, marginalization, powerlessness, cultural dominance, and violence (hinson & bradley, 2006). in the case of côte d’ivoire, the worst forms of child labor found in cocoa production are symptoms of this oppression. the ecological framework uses a multi-level perspective to understand social issues. it examines individuals, communities, systems, and the interactions among them. the complexities of the causes of the worst forms of child labor require this sophisticated analysis. an anti-oppression lens paired with an ecological approach well-positions social workers to facilitate the identification and implementation of solutions. community organizing is another skill social workers use when working with communities to effect positive social change. community organizing is critical to allow those most impacted by a problem to be the agents of change in their own lives. it is a tool used for building power in a community because the power of individuals depends on their abilities to organize together (kahn, 1991). social workers in western countries do not have a monopoly on these skills, and in many ways, they should take lessons from mass-based social movements in developing countries (de almeida, 2007). nonetheless, community organizing principles are important to integrate into any social change process. recommendations both social and structural change is necessary to address exploitative child labor in côte d’ivoire. the people and government of côte d’ivoire must lead the process of structural change because only through enforced trade regulations will the chocolate industry be forced to reform its practices. côte d’ivoire should invest in the manufacturing process of cocoa in order to increase its value in the supply chain and become a more important player in the world cocoa market (economic commission for africa, 2013). the us government should implement a mandatory certification system for cocoa products because the evidence overwhelmingly shows that voluntary self-regulation is ineffective. this system should include a set of clear standards, an independent verification process, a certification logo, and an independent audit system (ilrf, 2008). ingos need to re-examine their program strategies to ensure that they do not perpetuate the very systems against which they claim to work. focusing on labor conditions addresses fundamental structural issues, like working and living conditions, that are key components of the production process of any industry and has more potential for meaningful columbia social work review, volume v 61 cole change (dansereau, 2010). conclusion the exploitation on the cocoa farms of côte d’ivoire and the flawed strategies employed to address it, illustrate the interconnection between csr and the npic. csr initiatives are becoming increasingly common among companies in the western world. in turn, ingos are becoming increasingly dependent on funding from these companies (athreya, 2011). therefore, it becomes more difficult to identify the competing interests and, in some cases, hidden agendas of these powerful, corporate stakeholders. the intersection of csr and the npic creates an illusion of progress, while those who are most impacted by the exploitation continue to suffer the consequences of inaction. western governments, activists, and ingos need to act as true allies with the people they claim to serve, not speak or act on their behalves. the voices of ivoirians should be heard at the negotiating table. the good intentions of western countries are simply not good enough. references american federation of teachers (aft) & international labor rights forum (ilrf) (2010). united states policies to address child labour globally. retrieved from http://www.laborrights.org/sites/default/files/publications and-resources/child%20labor%20briefing.pdf athreya, b. 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(2007). radical social change: searching for a new foundation. in incite! women of color against violence (ed). the revolution will not be funded: beyond the non-profit industrial complex, (pp. 185-195). cambridge, massachusetts: south end press. economic commission for africa (2013). making the most of africa’s commodities: industrializing for growth, jobs and economic transformation. economic report on africa 2013. retrieved from http://www.uneca.org/sites/default/files/publications/unera_ report_eng_final_web.pdf hamann, r. & acutt, n. (2003). how should civil society (and the government) respond to ‘corporate social responsibility’? a critique of business motivations and the potential for partnerships. development southern africa, 20 (2), 254-270. hinson, s. & bradley, a. (2006). a structural analysis of oppression. grassroots policy project, 1-5. international labor rights forum (ilrf) (2008). the cocoa protocol: success or failure? retrieved from http://www.laborrights.org/sites/default/files/ publications-and-resources/cocoa%20protocol%20 success%20or%2failure%20june%202008.pdf international cocoa initiative (2010a). about the ici foundation. retrieved from http://www.cocoainitiative.org/images/ stories/pdf/ici_leaflets_presentations/ici_information_kit_-_ april_2012_-_about_the_ici_foundation.pdf. international cocoa initiative (2010b). what we do…acting locally. retrieved from http://www.cocoainitiative.org/en/ what-we-do/acting-locally. international cocoa initiative (2012). by-laws of the international cocoa initiative. retrieved from http://www.cocoainitiative. org/images/stories/pdf/ici_charter_and_bye-laws/ ici-bye-laws.pdf kahn, s. 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(2010). ‘i feel like http://www.uneca.org/sites/default/files/publications/unera_report_eng_final_web.pdf http://www.uneca.org/sites/default/files/publications/unera_report_eng_final_web.pdf http://www.laborrights.org/sites/default/files/publications-and-resources/cocoa protocol success or failure june 2008.pdf http://www.laborrights.org/sites/default/files/publications-and-resources/cocoa protocol success or failure june 2008.pdf http://www.laborrights.org/sites/default/files/publications-and-resources/cocoa protocol success or failure june 2008.pdf http://www.cocoainitiative.org/images/stories/pdf/ici_leaflets_presentations/ici_information_kit_-_april_2012_-_about_the_ici_foundation.pdf http://www.cocoainitiative.org/images/stories/pdf/ici_leaflets_presentations/ici_information_kit_-_april_2012_-_about_the_ici_foundation.pdf http://www.cocoainitiative.org/images/stories/pdf/ici_leaflets_presentations/ici_information_kit_-_april_2012_-_about_the_ici_foundation.pdf http://www.cocoainitiative.org/en/what-we-do/acting-locally http://www.cocoainitiative.org/en/what-we-do/acting-locally http://www.cocoainitiative.org/images/stories/pdf/ici_charter_and_bye-laws/ici-bye-laws.pdf http://www.cocoainitiative.org/images/stories/pdf/ici_charter_and_bye-laws/ici-bye-laws.pdf http://www.cocoainitiative.org/images/stories/pdf/ici_charter_and_bye-laws/ici-bye-laws.pdf columbia social work review, volume v 63 cole a foreign agent’: ngos and corporate social responsibility interventions into third world child labor. human relations, 63, 1417 – 1438. doi: 10.1177/0018726709359330. off, c. (2008). bitter chocolate: the dark side of the world’s most seductive sweet. new york, ny: new press. ryan, o. (2011). chocolate nations: living and dying for cocoa in west africa. london: zed books. smith, a. (2007). introduction: the revolution will not be funded. in incite! women of color against violence (ed). the revolution will not be funded: beyond the non profit industrial complex, (pp. 1-18). cambridge, massachusetts: south end press. world cocoa foundation (2011). economic profile of the us chocolate industry. retrieved from http://worldcocoafoundation. org/wp-content/uploads/economic_profile_of_the_us_ chocolate_industry_2011.pdf world cocoa foundation (2012, march). cocoa market update. retrieved from http://worldcocoafoundation. org/wp-content/uploads/cocoa-market-update-as of-3.20.2012.pdf world cocoa foundation (2013). about cocoa: history of cocoa. retrieved from http://worldcocoafoundation.org/about-co coa/history-of-cocoa/ http://worldcocoafoundation.org/wp-content/uploads/economic_profile_of_the_us_chocolate_industry_2011.pdf http://worldcocoafoundation.org/wp-content/uploads/economic_profile_of_the_us_chocolate_industry_2011.pdf http://worldcocoafoundation.org/wp-content/uploads/economic_profile_of_the_us_chocolate_industry_2011.pdf http://worldcocoafoundation.org/wp-content/uploads/cocoa-market-update-as-of-3.20.2012.pdf http://worldcocoafoundation.org/wp-content/uploads/cocoa-market-update-as-of-3.20.2012.pdf http://worldcocoafoundation.org/wp-content/uploads/cocoa-market-update-as-of-3.20.2012.pdf http://worldcocoafoundation.org/about-cocoa/history-of-cocoa/ http://worldcocoafoundation.org/about-cocoa/history-of-cocoa/ cswrfinal_4.1.13 columbia social work review, volume iv 92 the public and the profession’s perception of social work jeffrey olin the social work profession has long been concerned about its mission and perception. the two interests go hand in hand, because to have an effect on how we as social workers are viewed, we must be self-aware about who we are and what we do. this paper will address how social work periodically reflects upon and re-assesses its purpose because of internal considerations, such as the profession’s ethics, and external forces, including the job market and public perception. some of the research conducted over the years into public perception of social work—as well as that of our clients—will be presented and compared. in addition, i review how the media have portrayed the field, and how we as professionals have marketed ourselves. finally, some suggestions will be offered, which can be applied at various levels, including direct practice, program development and evaluation, administration, and branding of the profession as a whole. when counterterrorism police officer lawrence deprimo bought boots for a homeless man in november 2012, the new york police department (nypd) posted a photo to its facebook page. the photo elicited a significant response to nypd’s new online presence, and shortly thereafter deprimo appeared on the “today” show focusing on his heroism and humanity (bell, 2012; goodman, 2012). the tourist who took the photo works in the communications department of the pinal county sheriff's office in phoenix (ruelas, 2012). this was self-promotion to some extent, but the action and response demonstrates a profession reevaluating its mission as well as seeking to enhance its image. social workers serve the homeless population but are rarely featured on national television. we can learn from this story on two counts: by growing in awareness of our mission and by learning how to influence the public perception of social work. many children look up to police officers or firefighters, others strive to become doctors or lawyers, and some endeavor to follow in the footsteps of a teacher; few children, however, aspire 93 columbia social work review, volume iv the public and the profession’s perception of social work to be social workers. culture and gender (liben, bigler & krogh, 2001) and public image and prestige (auger, blackhurst & wahl, 2005) influence desirability of a particular career. the perception of social work is therefore important in attracting highly committed, professional individuals. we must first determine if control over our profession’s image lies more firmly in the hands of social workers or in other outlets like the media. ultimately, “the image of social work” is not simply a cosmetic matter: a positive image is important to the vitality, effectiveness, acceptance, and funding of the profession. “the more that social work is perceived positively, the more likely it is to gain support for its programmes, to have its services utilized, to maintain morale, to attract recruits and to have its voice heard” (kaufman & raymond, as cited in reid & misener, 2001, p. 194). this article will review how the social work profession has reflected upon its mission and perception, consider some of the research into public perception of its work and clients, examine media portrayal, and look at how social work has marketed itself. i will conclude with some suggestions for the profession that can be applied at multiple levels, including direct practice, program development and evaluation, administration, and branding of the profession as a whole. the importance of defining social work social work’s concern for its image must begin with a clear understanding and definition of its role and mission (corvo, selmi, & montemaro, 2003). since its inception, social work has been concerned with “how it is defined, practised and perceived,” undergoing many evolutions that have shaped how it is viewed (staniforth, fouché, & o’brien, 2011, p. 192). social workers’ activities include “direct practice, community organizing, supervision, consultation administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation” (national association of social workers [nasw], 2008, preamble). defining parameters of social work potentiates artificial limitations on the profession (gibelman, 1999). in addition, professionals vary across qualifications, excolumbia social work review, volume iv 94 olin perience, and training levels. the bureau of labor statistics revealed that 70% of social workers in the u.s. either had no college degree (27.9%) or a degree in a field other than social work (44%) (gibelman, 2000). many workers without a social work degree—or any degree at all—find a place in the field because of needs for staff or population-specific expertise. consequently, “in the public mind, all social workers are lumped together – credentialed or not” (gibelman, 2000, p. 466), which can perpetuate misinformation. external factors like the job market or the political atmosphere force our profession to evolve, leading to disparate understandings of social work’s identity over time (gibelman, 1999). sometimes, mid-career social work professionals can lose sight of their original purpose. passion and ideals are constrained by the resulting stress of unmanageable responsibilities, low wages, and little recognition from others. professional self-awareness and its relationship with public perception the social work mission changes over time to meet evolving global needs and establish purpose (baron, as cited in gibelman, 1999). consequently, two somewhat opposing pressures emerge: (a) fidelity to the core values of empowering vulnerable and oppressed populations considering their environmental influences, and (b) openness to the fluidity and dynamic change inherent within “the expansive and expanding boundaries of social work and the difficulty in providing succinct, encapsulated descriptions of a complex and multifaceted profession” (gibelman, 1999, p. 301). staniforth, fouché, and o’brien (2011) argued that social workers throughout all levels of organizations should engage in critical reflection. they should practice self-awareness about the field’s evolving mission, have vigorous discussions about it in supervision and at conferences, and pursue it in research and writings. they contend that all professionals “can sit within a practice framework which holds social justice as an overarching principle” (p. 194). operating under common ethical principles to promote society’s general welfare, empower people 95 columbia social work review, volume iv the public and the profession’s perception of social work and communities, and positively affect the social environment, social workers must evaluate performance internally, debate the aim of the profession, and externally assess how the public perceives their work. silverman (2012) reflected that without self-awareness of our own profession, mission, and professional identity, how can we presume that others will understand us any better? internal exploration of how the field should outwardly present itself is complex because of pressures to serve clients and communities while maintaining confidentiality. yet perception affects financial support of programs and efficacy of our work. a conflict emerges over who defines the social work brand: social workers, the public, and/or the media. when social workers abdicate their responsibility, it allows others to control their image. assessment of the public’s perception the social work profession wants public perception of its mission to align with its core values. despite the profession’s regard for its self-image, there have been few comprehensive efforts to survey public opinion. condie, hanson, lang, moss, and kane (1978) described early surveys that found little consensus about the role of a social worker, but that “a vaguely negative connotation of social work seems to have been the stereotype” (p. 47). only 6% of respondents perceived social workers as “sources of help for emotional problems,” compared with 28% for religious leaders, 26% for psychiatrists, 22% for physicians, and 11% for psychologists (condie et al., p. 51). positive takeaways included an understanding that social workers were more than just caseworkers and showed care for all populations regardless of income level. lecroy and stinson (2004), recognizing changes in social work practice in the 25 years since condie et al.’s (1978) research, sought to reassess public perception. the authors reasoned, “if the general public is confused, uninformed or even hostile toward social work, the profession is less able to fulfill its mission of helping those in need” (lecroy & stinson, 2004, p. 164). finding only limited recent studies, they executed a nationcolumbia social work review, volume iv 96 olin wide survey to assess public sentiment toward social work. they discovered that the public associates social workers with frequent media stories reporting children being taken from their parents, indicating little change since condie et al.’s (1978) study about the role of social workers. strikingly, almost 1 in 5 respondents believed the stereotype that “social workers take advantage of the government” (lecroy & stinson, 2004, p. 169). dennison, poole, and qaqish (2007) explored what incoming college students from various courses of study thought about social work. the authors were curious to learn if the students, though smaller in number and younger than those previously surveyed, reflected more current views of the profession. significantly, students did not completely understand the range of social work activities or the levels of training needed. zugazaga, surette, mendez, and otto (2006) described a study, commissioned by the nasw, which investigated how the public viewed the profession. participants had little direct experience with social workers; their perception of the field was shaped predominantly by the media. they associated social workers with child welfare, the government, and the poor or underprivileged. they had an altogether positive regard for the profession despite the prevalence of negatively portrayed child welfare cases. fall, levitov, jennings, and eberts (2000) presented five case histories of individuals with mental health or relationship challenges to a group of subjects who ranked their confidence in a range of clinical professions. participants consistently expressed a low level of confidence in social workers, almost always by a substantial margin. hodge (2004) discovered how the public might be confused, because the “social worker” title can be purported by a doctoral, master’s or bachelor’s degree in social work, or another degree entirely. if the public is only moderately aware of what social workers do, its hazy perception of social workers is worsened by association; trattner (as cited in tirado, 2006, p. 27), states, “social workers, through no fault of their own, are disliked by the public because they work with (or are perceived to work with) people in society who are feared and/or despised.” the limited research conducted shows that the public often takes a polite view of social workers because of the belief that 97 columbia social work review, volume iv the public and the profession’s perception of social work compassionate work is being done. however, there are also common negative perceptions: (a) an overall ignorance of the extent of social work’s mission (often thought to be predominantly child welfare); (b) a lack of understanding of what social work roles include (often perpetuated by the profession’s lack of clarity); (c) a negative view of social workers’ competence when compared to similar helping professions; and (d) an unfavorable view of some client populations with which social work aligns itself. media portrayal of social work much of the public does not interact directly with social workers, so a large part of the profession’s perception is attributable to depiction in the media. zugazaga et al. (2006) discovered that most social workers believed the media cast a negative image on their profession. freeman and valentine (2004) examined american movies from 1938 to 1998 with a “social work” character. twenty-nine of the 44 movies focused on child welfare. most social workers were women, white, middle-class, and incompetent. they were caretakers in a subordinate position of authority and served as a buffer between oppressed groups and their oppressors. many characters had sexual relationships with a client. overall, the characters reinforced rather than challenged the status quo (freeman & valentine, 2004). gibelman (2004) reviewed three “social work” television characters in the 1990s–2000s. she observed that without consultation from social work professionals, characters reflected no social work education, questionable ethics, and made a mockery of the profession. she argued that in shows featuring lawyers and hospitals, professional qualifications were clearly emphasized, even if their moral character sometimes was suspect. however, social workers were portrayed as “uneducated and bumbling, if not outright laughable” (gibelman, 2004, p. 332), reinforcing stereotypes and denigrating social work. she concluded, “we should be getting the message. television is not kind to social workers” (gibelman, 2004, p. 331). although a survey of 60 newspapers and 399 articles over a 4 1/2-year period by reid and misener (2001) demonstrated a columbia social work review, volume iv 98 olin largely positive image of social work, they concluded that more could be done. the positive stories portrayed social workers as experts, described program innovations and interesting direct practice work, and demonstrated the potential impact of positive publicity. opportunities for enhancing the public’s perception of social work if perception does not match the profession’s stated mission, social workers must learn how to influence public understanding. “social workers themselves are best suited to enhance the public’s knowledge and opinions about the profession… [because] no one else is likely to step forward” to do so (lecroy & stinson, 2004, p. 174). in 2005, the nasw set out to raise the public’s esteem of social work given the stereotypes the profession had endured (nasw, 2004a). this goal, developed in concert with the 50th anniversary of the nasw’s founding (nasw, 2004b), spurred an advertising campaign to increase awareness, which included magazine and newspaper ads, press releases, appearances on radio and television programs, and a new website. moreover, the campaign stimulated efforts to engage social workers in the topic of effecting change in social work’s perception. murdach (2011) cited mary richmond’s classic what is social case work? and richmond’s biography of early social workers as efforts to develop public appreciation of social work (murdach, 2011, p. 92). reid and misener (2001) suggested that social workers learn how to place stories in the media; furthermore, collaboration between social work and journalism schools could provide social workers with strategies, resources, and contacts to produce more positive portrayals. “[s]uch initiative can be directly tied to an important social work function—to educate the citizenry about the needs of its clientele” (reid & misener, 2001, p. 200). then, not only does social work’s image improve, but the needs of clients are highlighted and stigmatizing myths about certain populations and issues can be dispelled. as social workers, we can view efforts to increase selfawareness and enhance positive public perception as a service to 99 columbia social work review, volume iv the public and the profession’s perception of social work self and clients, not an additional burden. this effort can allow for reflection on our original motivation for becoming a social worker and open up a variety of opportunities for intervention. learn how you can broadcast your work. be mindful of doing so in a way that does not glorify yourself or jeopardize confidentiality, but calls attention to the empowering work of your organization. research local media and develop contacts across various media outlets. then, learn how to prepare a press release, place an op-ed, or appear on a local radio or television show. learn from social media experts how your organization can publicize its work through the ever-changing world of social media. most importantly, consider internal and external collaboration, recruiting assistance from the nasw if necessary; advocate for the importance of these efforts in your organization even if you are not the individual to complete the tasks. tower (2000) provided the clearest mandate for action: “[s]ocial workers are responsible for debunking myths when the public is misinformed about the profession and the people served by it” (p. 575). she helped create a social work and the media course at the university of nevada, reno, that taught students about the film production process; students eventually developed documentaries to air on local television and public broadcasting stations. she argued that social work students and professionals need to learn how “to shape the public image of social work through effective use of popular media” (tower, 2000, p. 575). college and university programs can offer similar elective courses intended to produce documentaries. another perception-changing and image-enhancing possibility is interdisciplinary collaboration where social workers partner with other professions to serve a common population. cacciatore, carlson, michaelis, klimek and steffan (2011) presented an innovative intervention in which social workers formed a crisis response team to assist a municipal fire department. social workers served in a direct practice trauma intervention role either with the public or the first responders, allowing for direct engagement with individuals who normally would not interact with social workers. columbia social work review, volume iv 100 olin conclusion returning to the example of officer deprimo, there were two resounding outcomes: (a) police officers and the public reconsidered the role of police officers, and (b) public perception improved. perhaps a few well-placed stories of social work in action could attract the same selfand public awareness of professional mission and image-bending attention that the deprimo case did for the new york police department. the social work field must regularly reflect on its purpose, assessing how its programs and efforts serve clients and communities. gibelman (1999) suggested that we should not lament “the lack of a durable definition of the profession, its practice, and its boundaries,” (p. 308). instead, she reasoned that periodic reexamination reflects positively on the profession’s ability to respond to changing environments. however, becoming more selfaware about our mission is not sufficient. we must engage with society and culture to reflect on our image. when our efforts are poorly received or misconstrued, we must attempt to shift those views. tower (2000) exhorted us: “the image problem is real… and social workers should be concerned. educators who are not convinced that an image problem exists need only ask students if someone close to them disapproved of their decision to enter the social work profession” (p. 584). finally, taking an active approach and defining our role is better than allowing others to speak for us. as one of the taglines from the nasw 2004 campaign proclaimed, “social workers: if you don’t tell your story, who will?” (nasw, 2004a). references auger, r. w., blackhurst, a.e., & wahl, k. h. (2005). the development of elementary-aged children’s career aspirations and expectations. professional school counseling 8(4), 322 329. bell, j. (executive producer). (2012, november 30). today [television broadcast]. new york, ny: nbc news. retrieved from http://video.today.msnbc.msn.com/ 101 columbia social work review, volume iv the public and the profession’s perception of social work today/50024319#50024319 cacciatore, j., carlson, b., michaelis, e., klimek, b., & steffan, s. (2011). crisis intervention by social workers in fire departments: an innovative role for social workers. social work, 56 (1), 81-88. condie, c. d., hanson, j. a., lang, n. e., moss, d. k., & kane, r. a. (1978). how the public views social work. social work, 23(1), 47-53. corvo, k., selmi, p., & montemaro, s. m. (2003). icons of conformity: the marketing of social work education. journal of community practice, 11(1), 85-99. dennison, s. t., poole, j., & qaqish, b. (2007). students' perceptions of social work: implications for strengthening the image of social work among college students. social work, 52(4), 350-360. fall, k. a., levitov, j. e., jennings, m., & eberts, s. (2000). the public perception of mental health professions: an empirical examination. journal of mental health counseling, 22(2), 122-134. freeman, m. l., & valentine, d. p. (2004). through the eyes of hollywood: images of social workers in film. social work, 49 (2), 151-161. gibelman, m. (1999). the search for identity: defining social work – past, present, future. social work, 44(4), 298-310. gibelman, m. (2000). say it ain’t so, norm! reflections on who we are. social work, 45(5), 463-466. gibelman, m. (2004). television and the public image of social workers: portrayal or betrayal? social work, 49(2), 331-334. goodman, j. d. (2012, november 28). photo of officer giving boots to barefoot man warms hearts online. the new york times, p. a22. retrieved from http:// www.nytimes.com/2012/11/29/nyregion/photo-of-officergiving-boots-to-barefoot-man-warms-hearts-online.html?_r=0 hodge, d. r. (2004). who we are, where we come from, and some of our perceptions: comparison of social workers and the general population. social work, 49(2), 261-268. lecroy, c. w., & stinson, e. l. (2004). the public's perception of social work: is it what we think it is? social work, 49(2), columbia social work review, volume iv 102 olin 164-174. liben, l. s., bigler, r. s., & krogh, h. r. (2001). pink and blue collar jobs: children's judgments of job status and job aspirations in relation to sex of worker. journal of experimental child psychology, 79, 346-363. murdach, a. d. (2011). mary richmond and the image of social work. social work, 56(1), 92-94. national association of social workers. (2004a). what is the national social work public education campaign? retrieved from http://www.naswfoundation.org/imagecampaign/campaign/ default.asp national association of social workers. (2004b). firm named to plan public image drive. nasw news, 49(1). national association of social workers. (2008). code of ethics. retrieved from http://www.naswdc.org/pubs/code/code.asp reid, w. j., & misener, e. (2001). social work in the press: a cross-national study. international journal of social welfare, 10(3), 194-201. ruelas, r. (2012, november 30). woman behind kind nypd officer photo appears on ‘today.’ usa today. retrieved from http://www.usatoday.com/story/news/nation/2012/11/30/ woman-behind-officers-kindness-photo-today-show/1736909/ silverman, e. (2012). the branding of a profession: time to re flect. social work, 57(4), 367-369. staniforth, b., fouché, c., & o’brien, m. (2011). still doing what we do: defining social work in the 21st century. journal of social work, 11(2), 191-208. tirado, d. (2006). perception of social workers: an analysis of public knowledge, attitudes, and beliefs in new york city. retrieved from proquest dissertations and theses. (issn 0419-4209) tower, k. (2000). in our own image: shaping attitudes about social work through television production. journal of social work education, 36(3), 575-585. zugazaga, c. b., surette, r. b., mendez, m., & otto, c. w. (2006). social worker perceptions of the portrayal of the profession in the news and entertainment media: an exploratory study. journal of social work education, 42(3), 621-636. 21 women in the middle: the intersection of domestic violence and the child welfare system in families affected by domestic violence, women are typically both the battered party and the parent most likely to be responsible for the caretaking of children. although the domestic violence and child welfare service systems both work towards ending family violence, confl icting goals refl ect the historical tension between the woman-centered battered women’s movement and the child-centered child welfare system. this article considers the overlap between the domestic violence and child welfare service systems and women’s place at the intersection of these two spheres. suggestions to improve policy and practice are made for social workers who serve battered women and children affected by family violence. elizabeth s. brown he overlap of domestic violence and child maltreatment is well established, with numerous studies showing that child abuse and partner abuse are often co-occurring forms of family violence (edleson, 1999a). less recognized, however, is the disproportionate burden women bear at the intersection of the child welfare system and battered women’s services. domestic violence (also called intimate partner violence) most frequently describes violence perpetrated by men against their female partners and ex-partners (humphreys, 1999). as typically both the battered party and the primary caregiver (maxwell, 2000), a mother in a family affected by domestic violence is often subject to the competing demands for keeping herself and her child safe. surprisingly, given the rates of co-occurrence and populations served, the child welfare system and battered women’s movement often operate in different spheres, emphasizing different values and philosophies. although both are designed to protect women and children, the two systems at times work at cross-purposes, an opposition that further victimizes women. new policy and practice methods should consider the intersection of these two systems and develop ways to support women and children from a strengths-based, holistic perspective that does not ignore the gendered dynamic of both systems. women in the middle t 261809_columbia 01-72 sec1:21261809_columbia 01-72 sec1:21 4/5/07 2:12:18 pm4/5/07 2:12:18 pm 22 journal of student social work, vol. v e l iz a b e t h s . b r o w n the scope of the problem the number of children exposed to domestic violence each year is estimated at 3-10 million, and studies suggest that there are both child and adult victims in 30 to 60% of families affected by domestic violence (u.s. dhhs,2003). studies show that the long-term effects of domestic violence on children have serious implications on child development and well-being. children who witness domestic violence are more likely to exhibit signs of social, cognitive, emotional and behavioral problems, and are at increased risk of drug abuse, suicide, and homelessness (park, et al., 2004; edleson, 1999b; onyskiw, 2002; national coalition against domestic violence, 2005). despite progressive policies designed to differentiate between children witnessing and experiencing direct abuse, current child welfare practice often removes children from households with a recent history of domestic violence. if the child welfare system becomes involved with a family affected by domestic violence, women may be compelled to make diffi cult choices about housing, work arrangements, childcare, and child custody. for instance, a battered woman, by leaving her abuser and taking her children with her to live in a shelter or on the streets, may risk removal of her children by the foster care system because of a lack of appropriate housing options (pearce, 1999). predictably, many women choose to deny the presence of domestic violence in order to avoid its social and legal ramifi cations and to prevent the removal of her children into the foster care system. different perspectives on protecting battered women and their children child advocates and battered women advocates alike acknowledge the historical tension between their philosophies as refl ected by the child-centered child welfare system and the woman-centered battered women’s movement (beeman, hagemeister, & edleson, 1999). although the two systems both work towards ending family violence, their goals are sometimes in confl ict. battered women’s advocates criticize the child welfare system for turning a blind eye to domestic violence (pennell & burford, 2000) or, when the presence of domestic violence is evident, holding the woman and not the batterer responsible for the safety and well-being of the child (saunders & anderson, 2000). while some domestic violence service providers acknowledge the co-occurrence of abuse of women and children, many still view women as the primary victims and children as secondary victims (pearce, 1999). 261809_columbia 01-72 sec1:22261809_columbia 01-72 sec1:22 4/5/07 2:12:18 pm4/5/07 2:12:18 pm 23 e l iz a b e t h s . b r o w n women in the middle grounded in a feminist perspective, some domestic violence service providers argue that empowering women ultimately benefi ts children and choose to serve women fi rst and their children collaterally. children’s advocates hold that children have their own needs that are not always met by serving their mothers fi rst or exclusively. the differences between the two systems are echoed even in their outcome goals. child welfare policy, along with the permanency planning required by the adoption and safe families act of 1997 (asfa), uses practice language such as “family preservation” and “family reunifi cation” (pennell & burford, 2000). on the other hand, the battered women’s movement considers options for women that separate her from the batterer, whether psychologically (individual counseling), legally (via protective orders or divorce proceedings), or physically (alternative housing). battered women in the child welfare system a societal bias which views women as primarily responsible for the care of their children is refl ected in the child welfare system. socially and legally, women more often than men are blamed for the poor treatment of their children and are more harshly judged when their children are maltreated, regardless of who commits the maltreatment (saunders & anderson, 2000). while the legal and child welfare systems penalize women for failing to protect their children, these same systems are often criticized for neglecting to pursue punishment of or interventions for the batterer, instead focusing on what the mother’s responsibilities are for keeping her child safe (edleson, 1999a). as one study found, “women are held responsible for both their male partners’ behavior and the protection of their children” (pearce, 1999, p. 112). another study of child protection workers and battered women’s advocates found that child protective service (cps) workers rarely included the male perpetrator of violence in family service plans (beeman, hagemeister, & eldeson, 1999). although asfa emphasizes adoption and permanency planning, which critics of the act contend interferes with family preservation efforts, procedures remain for removing children when doing so is deemed to be in the child’s best interest or in order to keep the child safe (postmus & ortega, 2005; saunders & anderson, 2000). in some cases, if a woman does not leave her abuser, caseworkers may perceive a betrayal of a mother’s inherent responsibility to protect her children and may hold the woman responsible for the abuse by removing the child from her care (magen, 1999). 261809_columbia 01-72 sec1:23261809_columbia 01-72 sec1:23 4/5/07 2:12:19 pm4/5/07 2:12:19 pm 24 journal of student social work, vol. v women’s advocates believe that removing a child from a mother’s care is a second victimization, punishing the mother for her batterer’s actions (beeman, et al., 1999). a landmark new york court case, nicholson v. scoppetta, 344 f.3d 154, 164 (2d cir. 2003), alleged that the administration for children’s services was unduly removing new york city children, who were not otherwise abused, from their families in which domestic violence was taking place and charging their mothers with neglect (postmus & ortega, 2005). the court found that such practice was illegal and, in effect, penalized mothers for being battered. not all states, however, have such a legal precedence and some child welfare practices continue to punish women for their batterer’s abuse by placing their children into foster care. in fact, the law in this area of child as domestic violence witness continues to develop and carries important implications for women including potential legal responsibilities and consequences. children’s exposure to domestic violence battered women are repeatedly confronted with untenable choices. some women feel emotionally trapped, physically threatened, fi nancially constrained, and/or psychologically tethered to their batterer. domestic violence advocates recognize the complexity of these choices and provide services that look to empower and support women. the effects of domestic violence on children, however, are not as well understood, and children’s needs are often subjugated by legal systems that respond to adult demands. in some cases, children are witness to, but not the direct targets of, intimate partner violence. in other cases, children are hurt as bystanders. research shows, however, a signifi cant number of battered women’s children have also been physically or sexually abused themselves (humphreys, 1999), and the abuse may be perpetrated by any primary caretaker, whether male or female. edleson (1999b) found that children of battered women can experience a tangle of emotions as a result of their experiences and are not receiving the services they need to address these complicated psychosocial needs. for instance, children of battered women, in addition to coping with the effects of being witness or subject to violence, may be also struggling with having to move out of their home, separate from a parent and/or other family members, change schools, and reconcile their love for the batterer with their sense of betrayal. child-centered advocates in the movement against domestic violence contend that children have needs that are not always addressed by protecting and empowering women (beeman et al., 1999). viewing children as individuals e l iz a b e t h s . b r o w n 261809_columbia 01-72 sec1:24261809_columbia 01-72 sec1:24 4/5/07 2:12:19 pm4/5/07 2:12:19 pm 25 e l iz a b e t h s . b r o w n women in the middle with agency, they argue, demands that service systems be restructured to assess and address children’s specifi c needs and not just those that derive from their mother. current practice methods the lack of coordination between the child welfare system and battered women’s movement reveals numerous missed opportunities to serve both women and children. for instance, new york state law does not require that cps be notifi ed in domestic violence cases (bent-goodley, 2004) despite the fact that cps workers called to intervene in an at-risk family are in an excellent position to recommend or make referrals to domestic violence services. in fact, a study of battered women served by a new york city child welfare preventative service agency found that battered women want child welfare workers to ask them about current and past incidents of domestic violence (magen, et al., 2000) so that appropriate services can be implemented. additionally, women’s shelters, the populations of which are primarily children, are a unique opportunity to provide children with counseling and other therapeutic services, which are not routinely in place (magen, et al., 2000). studies have found that caseworker perception of domestic violence plays a large role in the services rendered to family members affected by the violence (yoshihama & mills, 2003; postmus & ortega, 2005). consequently, understanding caseworker attitudes towards domestic violence is important to developing sensitive and effective interventions that protect both women and children. for example, humphreys (1999) found that some child caseworkers believe that their guiding mandate is the best interests of the child and do not always perceive themselves to be advocates for battered women. in other cases, studies show that some child welfare workers blame the mother for failing to protect her child by remaining in the abusive household or maintaining a relationship with her batterer (petrucci & mills, 2002; saunders & anderson, 2000). to the contrary, evidence suggests that many women stay in abusive relationships in order to protect their children from potential abuse from the batterer (schecter, & edleson, n.d.). maxwell (2000) argued that corollary institutions serving battered women and their children, such as the courts and welfare programs, also need improved coordination. women receiving welfare assistance may fi nd that they are given competing advice from welfare and child welfare offi cials about, for instance, work requirements that confl ict with the responsibilities a mother has to keeping 261809_columbia 01-72 sec1:25261809_columbia 01-72 sec1:25 4/5/07 2:12:19 pm4/5/07 2:12:19 pm 26 journal of student social work, vol. v her children safe at home (pearce, 1999). more research is needed to explore the interaction between related services that support battered women, including substance abuse services, social welfare programs, and the criminal and civil court systems, so that the provision of services is not in confl ict. implications for domestic violence and child welfare practice numerous studies point to the effi cacy of educating child welfare caseworkers on domestic violence. education and training programs have been found to be successful in changing child caseworker attitudes and in using assessments and interventions in domestic violence situations that do not further victimize women (postmus & ortega, 2005; magen, et al., 2000; saunders & anderson, 2000). petrucci & mills (2002) study found that although most states have some procedures in place that integrate questions about domestic violence into child abuse risk assessment forms, most standardized instruments that screen for domestic violence do so only insofar as the violence affects the child. additionally, battered women’s advocacy organizations might benefi t from training that highlights the need for child-centered assessments and interventions that do not ignore the specifi c effects of domestic violence on children. battered women may benefi t from culturally-relevant education programs that address both the effects of family violence on children and resource availability (schechter & edleson, n.d.). parenting classes, a standard part of family service plans instituted by child protection agencies, can assist women in developing a clear safety plan in a way that empowers women to direct their own choices. at the same time, family service plans should not ignore the batterer’s responsibility to the plan if safe and appropriate (schechter & edleson, n.d.). some battered women may be coping with feelings of guilt as a result of her perceived failure to protect her child from violence or from her child’s removal into the foster care system. other women, who feel powerless against her abuser, may see her role as a mother as one area over which she still has some control and pride. effective parenting classes should be sensitive to such considerations by using a strengths-based perspective that is empowering to women. to supplement caseworker training, implementing concrete protocols can help mitigate the effects of workers’ own feelings about domestic violence on child abuse assessment and intervention. other institutional changes include hiring domestic violence specialists at child welfare agencies (saunders & anderson, 2000). additional promising practices include family group e l iz a b e t h s . b r o w n 261809_columbia 01-72 sec1:26261809_columbia 01-72 sec1:26 4/5/07 2:12:20 pm4/5/07 2:12:20 pm 27 e l iz a b e t h s . b r o w n women in the middle conferencing, an intervention that brings together all members of the family affected by the abuse who collaboratively construct a plan to stop the maltreat ment and keep all family members safe (pennell & burford, 2000). finally, additional research is needed to explore the differential effects of race, culture, and ethnicity on child welfare assessments of family violence so that interventions and services are culturally competent. conclusion battered mothers negotiate the dual role of primary caretaker to their children and abuse victim, balancing at the fulcrum of two social service systems: family violence and child protection. new policy and practice methods that marry the efforts of child advocates and battered women’s advocates support the idea that protecting women and children is not a zero-sum affair. rather, it requires coordination on the part of multiple social service systems and a reframing of historically held philosophies that privilege the safety of either women or children over the other. child welfare training should be sensitive to the complicated position of battered women, while the battered women’s movement should resist considering children as secondary victims of domestic violence. social workers at the confl uence of these systems are in a unique position to assist battered women in creating a safety plan that addresses the woman’s needs as well as the needs of her children. through collaboration, women-centered and child-centered approaches can minimize the bias of the “failure to protect” clauses against mothers, hold batterers accountable, and help domestic violence survivors keep their children safe. references beeman, s., hagemeister, a., & edleson, j. 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(brandwein, r., ed.). thousand oaks, california: sage publications. pennell, j., & burford, g. (2000). family group decision making: protecting children and women. child welfare, 79(2), 131-158. petrucci, c., & mills, l. (2002). domestic violence assessment: current practices and new models for improved child welfare interventions. brief treatment and crisis intervention, 2(2), 153-172. postmus, j., & ortega, d. (2005). serving two masters: when domestic violence and child abuse overlap. families in society, 86(4), 483-490. saunders, d.g., & anderson, d. (2000). evaluation of a domestic violence training for child protection workers & supervisors: initial results. children and youth services review, 22(5), 373-395. schechter, s., & edleson, j. (n.d.) recommendations from the national council of juvenile and family court judges family violence department. retrieved march 5, 2007, from http://www.childrensprogram.org/media/pdf/green_book.pdf u.s. department of health and human services, administration for children and families, children’s bureau. (2003). child welfare information gateway. e l iz a b e t h s . b r o w n 261809_columbia 01-72 sec1:28261809_columbia 01-72 sec1:28 4/5/07 2:12:21 pm4/5/07 2:12:21 pm 29 e l iz a b e t h s . b r o w n women in the middle children and domestic violence. retrieved february 25, 2007, from http://www.childwelfare.gov/pubs/factsheets/domesticviolence.pdf yoshihama, m., & mills, l.g. (2003). when is the personal professional in public child welfare practice? the infl uence of intimate partner and child abuse histories on workers in domestic violence cases. child abuse & neglect, 27, 319-336. elizabeth s. brown graduated from cussw in 2006 with a master’s degree in social work specializing in children, youth, and family policy. while attending cussw, she served on the editorial board of the journal for two years. she holds a bachelor’s degree in rhetoric from the university of california at berkeley. her email address is elizsbrown@gmail.com. 261809_columbia 01-72 sec1:29261809_columbia 01-72 sec1:29 4/5/07 2:12:21 pm4/5/07 2:12:21 pm columbia social work review, volume v 33 undocumented immigrants and policy advocacy: reasserting the activist roots of social work tatum stewart the social work profession is positioned to play a critical role in redefining policies surrounding historically marginalized immigrants in the united states. the creation of the concept of the “undocumented immigrant” reflects an embedded discriminatory aspect of immigration policy, and becomes reinforced in policies that actively dehumanize undocumented immigrants, inhibiting their social integration. when the social origins of law cease to be recognized, the legal concept of the “undocumented immigrant” becomes understood as the result of law-breaking by the individual rather than as a socially constructed concept. undocumented immigrants acknowledge that they have adapted to an american way of life, yet they do not feel they belong. undocumented youth experience a shift from feeling a sense of belonging to feeling marginalized. the code of ethics shared by all social workers provides an ideal foundation for social workers to pursue roles as social justice activists. this paper makes two specific recommendations. first, national social work organizations should emphasize the history of social activism in social work. second, social workers should develop skills to assert political views that embrace policy goals and advance social justice. by enhancing their capacity for policy change, social workers will realign with the profession’s activist roots. immigration policies in the united states have historically marginalized undocumented immigrants (furman, ackerman, loya, jones, & nalini, 2012). this marginalization has only intensified since the events of 9/11 (furman, et al., 2012; nielson, 2009). immigration policies have become less welcoming as policymakers have begun to view immigrants “as potential terrorist suspects first and welcome newcomers second” (tumlin, 2004, p.1175). this attitude has greatly influenced state policies, such as arizona senate bill 1070 and california proposition 187, as well as federal policies, such as secure communities. policies like these target immigrants who enter the united states from its southwest border with mexico (furman, et al., 2012), who the house committee on homeland security (2007) asserted constitute “an ever-present threat 34 columbia social work review, volume v undocumented immigrants and public advocacy of terrorist infiltration,” and “are from countries known to support and sponsor terrorism” (p. 4). as a result of this sentiment, immigration has become increasingly criminalized, particularly for undocumented immigrants (furman, et al., 2012). for example, secure communities allows united states immigration and customs enforcement (ice) to access state criminal databases to screen for undocumented immigrants, who are subsequently incarcerated and deported. ultimately, through such policies, the legal rights necessary for economic and social success are purposefully withheld from undocumented immigrants. policies that criminalize immigrants prevail even in the face of studies that demonstrate greater economic benefits from education rather than deportation and/or incarceration (baum & ma, 2007; meissner, kerwin, muzaffar, & bergeron, 2013; simpson, 2012). the disconnect between policy implementation and research suggests that policymaking in this realm is not always rooted in economic analysis, but in social sentiments. the gulf between policy practice and research results in the dehumanization of undocumented immigrants. the contextualization of their complex human experiences goes unacknowledged, and an immigrant’s criminalized, undocumented status becomes a defining aspect of her or his social identity. the social work profession is positioned to play a critical role in redefining policies and attitudes surrounding historically marginalized immigrants in the united states. this paper will illuminate the social work profession’s capacity for such influence by examining the transformation of social work over time. it will shed light on how social workers can begin to redefine their roles to better aid undocumented immigrants through policy advocacy. this paper will also illustrate the real effects of immigration policy on daily social experiences of undocumented immigrants, and propose suggestions for incorporating these experiences in advocacy to humanize those most affected by immigration policy. immigration policy creating the concept of “undocumented” law is a mechanism that normalizes social sentiment. “law not only reflects society but constitutes it as well…law normalizes and naturalizes social relations and helps to structure the most routine practices of social life” (ngai, 2004, p. 8). the emotional social climate in a particular society informs and influences legality; legal and social forces columbia social work review, volume v 35 stewart mutually aid each other in creating certain norms. consequently, law and policy influence how american society perceives immigrant groups. the creation of the “undocumented immigrant” concept reflects an embedded discriminatory aspect of immigration policy (ngai, 2004). the negative social sentiment becomes reinforced in laws and policies that dehumanize undocumented immigrants, inhibiting their social integration. the normalization of social sentiment through law can be problematic. the possible interpretation of law as independent of social forces, even though social meanings constitute law, presents danger. disassociating law from its social origins may cause social constructions to become embedded in the daily meanings and routines of social life, and the biased, social nature of law may go unrecognized. when the social origins of law cease to be recognized, the legal concept of the “undocumented immigrant” becomes understood as the result of law-breaking by the individual rather than the result of social construction. the combined legal and social exclusion does not necessarily go unnoticed by undocumented immigrants. one way they experience exclusion is through unwelcoming social climates at the community, state, and national levels in the form of political dialogues in the media. ongoing debates on the legalization of undocumented immigrants, in which undocumented immigrants are unable to participate as representatives of their own interests or voice their own experiences, are dehumanizing. other blatant measures of exclusion are laws that openly prohibit undocumented immigrants from legally accessing the workforce, welfare programs, medical services, and other rights, privileges, and opportunities reserved for citizens (gleeson & gonzales, 2012). exclusion undeniably shapes the routines and interactions in many undocumented immigrants’ daily lives, through political processes that leave out their populations and through policies that create barriers to accessing services and claiming their rights. the feeling of being undocumented the ability of undocumented immigrants to feel social belonging in american society is largely influenced by the social reactions of their communities (chavez, 1991). legality is an integral, if unarticulated, part of the definition of social belonging for many americans, and many undocumented immigrants are not accepted into their communities in part because they do not share legal status (chavez, 1991). throughout 36 columbia social work review, volume v undocumented immigrants and public advocacy the 1980s, chavez (1991) conducted interviews with undocumented immigrants in the san diego area and found that their local communities would draw lines of inclusion and exclusion by constructing and reinforcing negative social meanings around undocumented status, utilizing dehumanizing language towards this population. name-calling through words such as “wetback” and “illegal alien” reinforced feelings of hostility and reaffirmed the belief that undocumented immigrants were not legitimate members of american society (chavez, 1991). in recent years, the deportation of almost two million undocumented immigrants during the obama administration has further alienated undocumented immigrants and torn apart families (fineman, 2013). in recent years, more than 200,000 deported undocumented immigrants reported that they were parents to children who are american citizens; many of these children live in constant fear of their parents’ deportations (planas, 2012). the identification of undocumented immigrants by one aspect of their person that holds negative connotations creates difficulty for communities to see immigrants beyond their undocumented status and for immigrants to develop a sense of belonging. oftentimes, undocumented immigrants identify their undocumented status as “the reason they did not feel part of the community” (chavez, 1991, p. 272) and acknowledge that although they have adapted to an american way of life, they still do not feel as though they belong. the experience of undocumented children perhaps best demonstrates how social climate influences feelings of social belonging. oblivious to the hostile social climate toward undocumented immigrants, undocumented children initially have a sense of belonging in american society (chavez, 1991; gonzales, 2011). they go to school, participate in school-based activities, learn to speak english as part of their public presence, and are exposed to popular culture like any other american children (gonzales, 2011). it is not until they are older that they realize american society does not recognize them as legitimate members, and that it views them as undocumented immigrants rather than americans (abrego, 2006; chavez, 1991; gonzales, 2011). undocumented youth experience a shift from feeling a sense of belonging to feeling alienated and marginalized (abrego, 2006; chavez, 1991; gonzales, 2011). there are various catalysts that instigate this shift in undocumented youth from feelings of belonging to alienation. the transition is often triggered when youth are unable to participate in a coming-of-age columbia social work review, volume v 37 stewart event that most legal american youth experience, such as acquiring a driver’s license, applying for a job, or going to college (gonzales, 2011). gonzales wrote, “as [undocumented youth] came to grips with the new meanings of [undocumented] status, they began to view and define themselves differently” (2011, p. 610). after growing up feeling included in american society, the realization of the extent of their exclusion can induce shock. oftentimes, there are two stages of shock (gonzales, 2011). first, the youth experience a multitude of emotions ranging from “confusion, anger, frustration, and despair” (gonzales, 2011, p. 610), after which they feel overwhelmed. the second shock occurs as they realize the permanence of the exclusion from society and that nothing, short of their legalization, can overcome it. previous aspirations are lost and the future begins to look similar to the lives of their parents, who often try to make ends meet in labor-intensive jobs that require little skill and pay low wages. how legal status influences feelings of social belonging not being accepted by their communities denotes the complexity of what it means to be part of american society. social belonging relies on legal status as well as on the social constructions around that status. these meanings establish alienation experienced by undocumented immigrants and can have grave effects on their life experiences. the feeling that comes from losing one’s sense of belonging is described by undocumented youth as, “waking up to a nightmare” and being unable to escape (gonzales, 2011). to address feelings like these, and the situation from which they arise, america needs a political discourse that accurately illustrates the life-altering experience resulting from the social exclusion of undocumented immigrants. a humanizing dialogue that identifies and describes these feelings of alienation and brings visibility to the hopelessness of undocumented immigrants should inform immigration policy. policy advocacy based on integrating the lived experiences of undocumented immigrants holds promise to balance traditional social forces that would otherwise reaffirm their marginalized status. 38 columbia social work review, volume v undocumented immigrants and public advocacy relevance of social work to policy advocacy professionalization of social work inhibits a progressive policy agenda when the national association of social workers (nasw) code of ethics (2008) was established in 1960, it officially held social workers responsible for “pursu[ing] social change with and on behalf of vulnerable and oppressed individuals and groups of people.” the historical context of the social work profession and its legal obligation to marginalized groups provide an exceptional foundation for social workers to serve as policy advocates for the interests of undocumented immigrants. in spite of these attributes, the role of social workers as policy advocates has not been fully realized. abramovitz (1998) has argued that social work as an organized political force has become neutralized over time due to its professionalization. “social work [has] often [been] accused…of serving as a handmaiden of the status quo” (abramovitz, 1998, p. 512). instead of facilitating social change, many social workers have perpetuated an oppressive system by teaching the oppressed how to manage and live within the system rather than create new spaces outside the system, or a new system altogether. this professionalization “pressed social work to narrow its vision and to play it safe” (abramovitz, 1998, p. 518). to be considered a more esteemed profession, social work has, in some ways, conformed to a market economy that requires public and private funders who exert conservative influences on the profession, thereby restricting a socially liberal agenda (abramovitz, 1998; wenocur & reisch, 1989). additionally, the conservative political climate throughout most of the 20th century prevented many progressive social work practices and denounced the few practitioners of such practices as “radicals” (katz, 1996). in many cases, this prevented the establishment of strong, longterm, progressive leadership in the social work profession (katz, 1996). professionalization in this field, however, does not have to continue to compromise social justice ideals. social workers can maintain professional legitimacy and still honor their social activist roots. columbia social work review, volume v 39 stewart recommendations for social workers social workers practice directly with undocumented immigrants and often their citizen children in capacities that address the barriers to employment, medical services, food, housing, and other needs (semple, 2011). furthermore, social workers have historically been perceived as agents of social justice with a duty to uphold values that “emphasize the importance of individual worth and dignity and service to humanity” (bisman, 2004, p. 112; siporin, 1982). the code of ethics shared by all social workers serves to provide an ideal foundation for social workers to pursue roles as social justice activists. as this profession looks forward to its role in the future, it should focus on overcoming oppressive systems by creating the necessary policy foundation through advocacy that establishes a new, humanizing discourse. it must advocate for the voices of undocumented immigrants to emerge. with this vision, social work should always look back to its history as a profession rooted in social activism. based on this underpinning, two specific recommendations for actions social workers should take to strengthen their capacities for policy advocacy can be made. first, national social work organizations, like the nasw, and associated publications should emphasize the history of social activism in social work and release statements in response to contemporary social issues that reaffirm social justice ideology without regard for political reactions (abramovitz, 1998; bisman, 2004). second, social workers should develop skills to assert political views that align with the values of the profession and embrace policy goals that work towards social justice (abramovitz, 1998). the nasw could organize workshops and policy coalitions that develop the necessary skills and organizational base to visibly advocate for social reform. the great advantage of the social work community is its passion, energy, and willingness to actively support social issues. these strengths should be utilized in the form of organized social action for policy reforms. within these recommendations, what is most essential is that social work, as a professional institution, asserts itself as an entity unconstrained by political influences that may otherwise divert it from its social justice vision. although social workers will need to openly support certain policies and political initiatives, it will always be in the spirit of social justice. 40 columbia social work review, volume v undocumented immigrants and public advocacy conclusion undocumented immigrants report an oppressive social experience caused by emotional upset and permanent barriers to opportunity and fulfillment. these barriers cannot be rectified on an individual basis, or negotiated at the micro-level. only through changes in national policy that address the absence of legal status can the marginalization of undocumented immigrants begin to be reversed. the degree to which undocumented immigrants have been alienated through the creation of policy based on exclusionary social forces is a lesson that attests to the power of social sentiment in policymaking. the key to developing policy that establishes legal spaces for undocumented immigrants is to humanize them by bringing out their social experiences as an empathetic social force. social workers, by the nature of their profession, should be an integral part of the creation of this humanizing policy dialogue. the progressive social values that underlie the social work profession and its emphasis on individual human experience, position social workers as ideal advocates for undocumented immigrants in the policy arena. by enhancing their capacity for policy change, social workers will realign with their activist roots. as this profession pushes the boundaries of current social reform to achieve social justice, the ideals of social justice will no longer be just words that compose a professional creed, but rather values that are lived each day through work. references abramovitz, m (1998). social work and social reform: an arena of struggle. social work, 43(6): 512-526. abrego, l. j. (2006). i can’t go to college because i don’t have papers: incorporation patterns of latino undocumented youth. latino studies, 4: 212-31. baum, s., & ma, j. (2007). education pays: the benefits of higher education for individuals and society (report no. 12b-7104). new york, ny: college board. bisman, c. (2004). social work values: the moral core of the profession. british journal of social work, 34: 109-123. doi: 10.1093/bjsw/bch008 chavez, l. (1991). outside the imagined community: columbia social work review, volume v 41 stewart undocumented settlers and experiences of incorporation. american ethnologist, 18: 257-278. fineman, h. (2013, april 24). immigration reform is all about www.huffingtonpost.com/2013/04/24/immigration reform-families_n_3095531.html furman, r., ackerman, a., loya, m., jones, s., & nalini, n. (2012). the criminalization of immigration: value conflicts for the social work profession. journal of sociology & social welfare, 39(1): 169-185. gleeson, s., & gonzales, r. (2012). when do papers matter? an institutional analysis of undocumented life in the united states. international organization for migration. doi: 10.111/j.1468-2435.2011.00726.x gonzales, r. (2011). learning to be illegal: undocumented youth and shifting legal contexts in the transition to adulthood. american sociological review, 76: 602-19. house committee on homeland security. (2007). a line in the sand: confronting the threat at the southwest border. retrieved from http://www.house.gov/sites/members/tx10_ mccaul/pdf/investigaions-border-report.pdf katz, m. b. (1996). in the shadow of the poorhouse: a social history of welfare in america. new york: basic books. meissner, d., kerwin, d., muzaffar, c., & bergeron, c. (2013). immigration enforcement in the united states: the rise of a formidable machinery. migration policy institute. national association of social workers. (2008). code of ethics. washington, d.c.: nasw. ngai, m. (2004). impossible subjects: illegal aliens and the making of modern america. princeton, nj: princeton university press. planas, r. (2012, december 17). deportation: more than 200,000 parents removed who say they have a u.s. citizen child since 2010. the huffington post. retrieved from http://www. huffingtonpost.com/2012/12/17/deportation-more-than 200000-parents-removed-citizen-child_n_2316692.html semple, k. (2011, may 21). illegal immigrants’ children suffer, study finds. the new york times. retrieved from http:// www.nytimes.com/2011/05/21/nyregion/illegal immigrants-children-suffer-study-finds.html simpson, j. (2012). maryland’s question 4: proponents push http://www.house.gov/sites/members/tx10_mccaul/pdf/investigaions-border-report.pdf http://www.house.gov/sites/members/tx10_mccaul/pdf/investigaions-border-report.pdf 42 columbia social work review, volume v undocumented immigrants and public advocacy overly fraudulent dream act cost estimates. accuracy in media. retrieved from http://www.aim.org/aim-column/ marylands-question-4-proponents-push-overtly-fraudulent dream-act-cost-estimates/ siporin, m. (1982). moral philosophy in social work today. social service review, 56(4): 516-38. tumlin, k. c. (2004). suspect first: how terrorism policy is reshaping immigration policy. california law review, 19(4), 1175-1240. wenocur, s., & reisch, m. (1989). from charity to enterprise: the development of american social work in a market economy. urbana, il: university of illinois press. http://www.aim.org/aim-column/marylands-question-4-proponents-push-overtly-fraudulent-dream-act-cost-estimates/ http://www.aim.org/aim-column/marylands-question-4-proponents-push-overtly-fraudulent-dream-act-cost-estimates/ http://www.aim.org/aim-column/marylands-question-4-proponents-push-overtly-fraudulent-dream-act-cost-estimates/ columbia social work review, volume iv 46 in search of the arc: the path to justice for women in the military elizabeth estabrooks “the arc of the moral universe is long, but it bends toward justice.” — martin luther, king jr., 1967 “no, no, we are not satisfied and will not be satisfied until justice rolls down like water and righteousness like a mighty stream.” — martin luther, king jr., 1963 over the past two decades, the epidemic of sexual assault (assault, rape, and harassment) in the u.s. military has garnered increasing media and legislative attention. while activists and survivors have achieved some successes in achieving the passage of stronger policies that address military sexual assault, many of those changes are recent, and much work remains to be done. this paper examines the growth of a social movement over 22 years and seeks to determine how the social movement against military sexual assault contributed to the department of defense’s shift from promises to action. i challenge social workers to examine their responsibility to groups whose voice has been silenced or stolen by trauma. although sexual assault, rape, and harassment in the u.s. military have only come into sharp public focus in the past year, these crimes have grown steadily over the last two decades. this increase has incited the department of defense (dod) and u.s. congress to pass zero-tolerance policies, commission studies, convene task forces, and hold hearings. nevertheless, the rate of military sexual assault (msa) has risen annually since 1991, growing to such alarming numbers that it is now commonly described as an epidemic (kitfield, 2012; slaughter, 2010). from 1991 to 2011, responses to msa by defense secretaries donald rumsfeld and robert gates led to many promises but little change. incidents were met with massive media coverage, but public attention repeatedly waned between each success sive outrage. in january 2012, defense secretary leon panetta’s in search of the arc 47 columbia social work review, volume iv press conference included familiar promises, which, although similar to those of his predecessors, laid the groundwork for change. later that spring, secretary panetta viewed the invisible war (2012) a powerful documentary portraying the lives and stories of msa survivors. with unflinching honesty, this documenttary tells the story of msa survivors and provides damning evidence of the u.s. military’s failure to address sexual assault within its ranks. two days later, secretary panetta, under mounting pressure from advocacy groups and members of congress demanding codification of stronger policies, took concrete steps to move toward protecting service members against msa. follow ing decades of little policy change around sexual assault in the military, the dod appeared prepared to enact lasting measures. this paper seeks to determine how the social movement against msa contributed to the dod’s shift from promises to action. i will outline the scope of the problem of msa and briefly review the major public events from 1991 forward, then analyze these events in relation to efforts by activists and organizations, striving to answer the question: what was the tipping point that brought the issue into full view of a nation in a way that catalyzed policy change? movements such as this one develop in response to the need of a group or population whose voice has been silenced or stolen. i posit that advocacy is a tool that social workers are obligated to use in our efforts to help individuals, groups, and communities regain their power. until justice rolls down like water: problem background according to the sexual assault prevention and response office (sapro) (2012), the most recent report on msa states that there were 3,192 reported msas in 2011 in all branches of the military, a 1% increase in overall reporting from 2010. a 2003 survey conducted by veterans affairs found that 30% of female veterans experienced sexual assault during military service. of this group, 14% had been gang raped and 20% had been raped more than once (hansen, 2005). given estimates that ap proximately 84% of civilian and military rapes go unreported, estabrooks columbia social work review, volume iv 48 sapro (2011) concludes there were close to 19,000 msas in 2010. hansen (2005) reports that the prevalence of sexual as sault was three to ten times higher for females serving in the armed forces than in the general population. estimates of prevalence are in the range of 23% to 33%, and military sexual trauma is more associated with ptsd than any other form of trauma, civilian or military (himmelfarb, mintz, & yaeger, 2006). a 2011 women’s research and education institute chronology identifies 1979 as the starting point for military guidelines covering sexual harassment. however, there is no mention of msa until 1991 when the media broke the las vegas tailhook convention story, where 83 females and 7 males were victims of sexual assault by more than 100 navy and marine corps aviation officers. the tailhook incident was the first highly publicized u.s. msa scandal. what followed was months of front-page headlines and nightly news reports that shocked the nation, building the case that military women were unsafe from our men in uniform. the dod, forced to answer to the taxpayers, was spurred into action. between 1992 and 2003, there were 18 different task forces, reports, and committee hearings on sexual assault, discrimination, and gender-related issues in the military (hansen, 2005). kitfield (2012) summarizes the most widely publicized events of the past 22 years:  1996: u.s. army aberdeen proving ground 1  2003: u.s. air force academy 2  2008: u.s. marines, fort leonard wood, missouri 3  2012: u.s. marine barracks, washington dc 4  2012: u.s. air force lacklund air force 5 1 twelve army officers charged with sexually assaulting female trainees 2 twelve percent of female graduates reported having been victims of rape or attempted rape, and 70% said they had been sexually harassed 3 nineteen non-commissioned officers were charged with various harassment and assault charges against trainees 4 nine women, including two civilians, report sexual harassment, assault and rape from 2009 – 2010 5 thirty-two trainers identified in cases of sexual assault or misconduct with 56 female and three male trainees (christensen, s. 2013) in search of the arc 49 columbia social work review, volume iv in november 2003, congress directed then-secretary donald rumsfeld to commission the defense task force on sexual harassment and violence at the military service academies, which subsequently reported that sexual assault and harassment was military-wide and not limited to the academies. the report’s recommendations included instituting training programs, recruiting more (including higher-ranking) women, and revising the uniform code of military justice (ucmj) to address sexual misconduct. yet without proper guidance for implementation and no apparent follow-up from the dod for enactment, implementation of recommendations did not occur (lancaster, jones, & lipari, 2005). in february 2004, secretary rumsfeld commissioned the task force on care of victims of sexual assaults. the task force made more recommendations and spawned yet another task force called the joint task force for sexual assault prevention and response, “designated as the single point of authority to provide direction, a centralized approach, and overarching guidance to sexual assault prevention and response” (lancaster, jones, & lipari, 2005, p. 6). multiple recommendations and policies were born from the joint task force, yet more than a decade after tailhook, there remained little measurable progress. the military’s own misogynistic culture, which displays continuing hos tile and sexist attitudes toward women (hansen 2005), may well have impeded its progress in policy change and implementation regarding msa. as the u.s. presence in iraq and afghanistan advanced, the u.s. army faced an ever-growing need for recruits and began to relax recruitment standards in order to meet “manning” needs. without addressing clear concerns on the problem of msa, this relaxation of standards allowed waivers for recruits with criminal records. according to lieutenant james mcconico (2009), a 2007 report identified an increase in criminal waivers by 38% from 2001 to 2007. stande, merrill, thomsen, crouch, & milner (2008) report that a naval health research center survey indicated as many as 15% of incoming navy recruits had either committed or attempted rape prior to recruitment. the 2011 sapro report shows a continued increase in msa and that repeat offenders commit 90% of all assaults (2012). did the relaxation of recruitment standards, allowing sex offenders into military ranks, estabrooks columbia social work review, volume iv 50 correlate with the increase in the rate of sexual assault? this is an area for further study in order for policy makers to understand the need to implement and uphold stronger policies related to msa. the long arc bends while the struggle for justice has been difficult, move ment allies have spread across the country, from local communi ties to congressional halls. as with all the congressional caucuses, the caucus for women’s issues (the women’s caucus) works to address and influence legislative matters (u.s. legal, 2013). the women’s caucus has focused on issues related to women and girls since its inception, and the 108th caucus (2003– 2004) continued that legacy by participating in special congressional women’s history month activities. one activity was a hearing on msa, followed by a report of findings to secretary rumsfeld. shortly after, the house passed an amendment, championed by the caucus, requiring the pentagon to adopt policies responding to msa (slaughter & capito, 2005). in september 2004, the women’s caucus met with dod officials, and again in december with pentagon officials, regarding the development of policies on msa (slaughter & capito, 2005). in 2005, representative loretta sanchez (d-ca), made another request for a report from the armed services commit tees, demanding a change in the sexual assault definition to bring the ucmj in line with federal and state sexual assault laws (snowden, 2005). when that request failed to bring results, she introduced the first bill to change msa laws. although the bill did not pass, it opened the door for the ongoing introduction of relevant legislation by other congressional leaders, including congresswomen nikki tsongas (d-ma), jackie speier (d-ca), and carolyn maloney (d-ny) (snowden, 2005). as the 21st century got underway, the number of women in the military grew, paving the way for a challenge to dod policies that silenced victims and did nothing to address msa. while survivors told their stories publicly and privately, the dod found itself under pressure not only to provide answers, but to effect change. katzenstein (1998) states, “feminist organizing (in its most adversarial and even sometimes in its more accommodative in search of the arc 51 columbia social work review, volume iv form) does seek to transform the world” (p. 6). feminist organizers collaborated with existing sexual assault advocates and organizations (e.g., the rape abuse and incest national network [rainn]) and founded new organizations, such as service women’s action network (swan) and protect our defenders, launching a campaign born of injustice, coupled with a desire to bring justice and protection related to msa. from the dreams of many, one over the next decade, advocates and activists coordinated efforts, formed new entities, collaborated with state and national nonprofit organizations, forged professional relationships, and partnered with politicians as allies for change. their fight was strengthened through the added efforts of politically powerful and influential national veterans’ organizations (e.g., the american legion, disabled american veterans, vietnam veterans of america) that have relentlessly campaigned for policy changes to address msa and military sexual trauma. movement participants used a broad repertoire of political actions, media coverage, and public awareness building, regularly speaking before congressional and committee hearings, demanding policy change to protect active duty service members and address the needs of veteran survivors. stories from victims and survivors informed politicians and the public that perpetrators had not been held accountable while victims were silenced, punished, discharged, and disgraced, and it became known that veteran survivors are denied benefits (“military sexual assault litigation,” 2011; anonymous, 2011; bhagwati, 2010; u.s. fed news, 2004). the voices of survivors-turned-activists were heard in congressional chambers, the public square, university classrooms, and on the big screen. the movement strategically used both traditional and social media to provide a platform from which survivors’ voices have traveled across the world as they live their version of soldier up—telling the most deeply painful personal stories. in march 2007, helen benedict published “the private war of women soldiers” in salon magazine. documentary filmmakers kirby dick and amy ziering, influenced by benedict’s (2007) article, estabrooks columbia social work review, volume iv 52 produced the invisible war (2012), which became a touchstone in panetta’s challenge to the status quo. in less than a decade, the efforts of a small group of women had grown into a social movement, the voices of many joining to become one solitary force with a singular goal: safety and justice relating to msa. a bend toward justice although the arc was beginning to bend toward justice, its progress was slow. there was a need for a catalyst—a tipping point—to bring about effective change. by 2011, advocacy had influenced some change, including requiring treatment of sexual assault patients as emergencies in military medical facilities and enhancing training for key personnel (including leaders, victim advocates, and law enforcement) (sapro, 2012). still, these changes lacked substance and real protection. military rules for reporting up the chain of command remained in place, victims continued to be re-victimized by the military system, and sexual assault trainings were questionable (“military sexual assault litigation,” 2011). it is not surprising, then, that in this climate, msa continued to occur at alarming rates. nevertheless, the movement for justice marched forward, and between 2011 and 2012, a confluence of three important events occurred to deliver the perfect political opportunity structure for substantive change: 1. in february 2011, attorney susan burke filed a federal lawsuit against the pentagon on behalf of 15 female and 2 male msa active-duty and veteran survivors (parker, 2011). the lawsuit named then defense secretary gates and former-secretary rumsfeld, accusing them not only of allowing a culture of sexism and misogyny and of fail ing to implement regulations, but also of “prevent[ing] various programs from being fully implemented” (“military sexual assault litigation, 2011”, p. 33). 2. on july 2, 2011, president obama appointed leon panetta secretary of defense. in january 2012, panetta gave his first press conference on the topic of msa, discussing new dod reforms on sexual assault being implemented, in search of the arc 53 columbia social work review, volume iv reforms that advocates and their allies had requested for years (hynes, 2012). 3. on april 14, 2012, following a viewing of the invisible war (2012), secretary panetta met with congresswomen sanchez and tsongas and held a press conference, an nouncing immediate implementation of additional msa policy changes (kitfield, 2012). these policy changes in cluded the removal of reporting sexual assault from the chain of command, the establishment of special victims units, and the enhancement of training programs (kitfield, 2012). there is hope that secretary panetta’s policy changes will decrease the rate of msa and provide redress for those who experienced any form of msa. nevertheless, policies alone will not make real changes in msa. successful change must be systemic and delve into the culture of the military and dismantle the old patriarchal, male-centric attitudes that disdain and denigrate women (flood, 2011). a military that breeds violence against women is a military not only of little moral value in the eyes of the world, but also one that cannot be trusted. and righteousness like a mighty stream this examination of the movement’s 20-year timeline illustrates how far it has come. however, much remains to be done to ameliorate the injustices experienced by thousands of msa victims. efforts must be undertaken to adopt strong policies and to alter the culture surrounding sexual assault in the u.s. military. president obama, in his april 4, 2008 speech commemorating dr. martin luther king, jr., stated, "dr. king once said that the arc of the moral universe is long but it bends toward justice. but what he also knew was that it doesn’t bend on its own. it bends because each of us puts our hands on that arc and bends it in the direction of justice" (the american presidency project, 2013). we are witnessing the bending of the arc by the hands of those who have experienced egregious injustice and by those who would see it replaced with the safety and justice to which our uniformed service members are inherently entitled. estabrooks columbia social work review, volume iv 54 should the dod choose to further commit to reducing sexual assault in their ranks and make justice for victims a priority, eventually the military may become a place where our nation’s defenders no longer must protect themselves from their fellow soldiers. until then, responsibility for change is shared among health and human service workers, medical personnel, and social workers. given the multitudes of victims and survi vors in military and civilian populations, we must recognize that there is a statistical probability our professional work with the military will include sexual assault survivors. ethics require us to do no harm, and as a profession, achieving this means improving our knowledge around sexual assault. it is incumbent upon us to do our part in applying our hands to the bending of the arc toward justice, for if not us, then who? references anonymous. (2011, september 12). justice for women veterans. the new york times. retrieved from http://www.nytimes.com/2011/09/12/opinion/justice-forwomen-veterans.html?_r=0 benedict, h. (2007, march 3). the private war of women solders. salon. retrieved from http://www.salon.com/2007/03/07/ women_in_military/ bhagwati, a. (2010). house committee on veterans’ affairs. statement to the house committee on veterans’ affairs, subcommittee on disability assistance and memorial affairs. congresswoman louise m. slaughter us representatives web sites. (2010). slaughter champions new protections against military sexual assault [press release]. retrieved from http://www.louise.house.gov/index.php? option=com_content&task=view&id=1655&iteite=141 christensen, s. (2013, january 15). 3 men put on the list of sexual victims at lackland. san antonio express-news. re trieved from http://www.mysanantonio.com/news/ military/article/3-men-put-on-the-list-of-sexual-victimsat 4196935.php#ixzz2muy7o5xb. retrieved from http:// in search of the arc 55 columbia social work review, volume iv www.mysanantonio.com/news/military/article/3-men-puton-the-list-of-sexual-victims-at-4196935.php flood, m. (2011). involving men in efforts to end violence against women. men and masculinities, 14(3), 3358-77 . doi:10.1177/1097184x10363995 hansen, c. (2005, september). a considerable sacrifice: the costs of sexual violence in the u. s. armed forces. presented at the military culture and gender conference, university of buffalo, buffalo, new york. himmelfarb, n., mintz, j., & yaeger, d. (2006). posttraumatic stress disorder in female veterans with military and civilian sexual trauma. journal of traumatic stress, 19(6), 837 846. hynes, p. (2012, february 15). reforming a recalcitrant military. truthout, retrieved from http://www.truth out.org/news/item/6713:reforming-a-recalcitrant-military katzenstein. (1998). faithful and fearless: moving feminist protest inside the church and military. princeton, n.j: princeton university press. kitfield, j. (2012, september 18). the enemy within. the na tional journal. retrieved from http:// www.nationaljournal.com/magazine/the-military-srapeproblem-20120913?print=true lancaster, a., jones, a., & lipari, r. department of defense, (2005). u.s. department of defense initiatives related to sexual harassment and sexual assault. arlington, va: defense manpower data center. mcconico, j. l. (2009). ethical imbalance: how the u.s. army overcame its manning crisis. u.s. army war college, retrieved from http://www.dtic.mil/cgi-bin/gettrdoc? ad=ada500883 parker, a. (2011). military personnel say pentagon ignores sexual assaults, harassment. the new york times. retrieved from http://www.nytimes.com/2011/02/16/us/16military.html?_r =0 sexual assault prevention and response office (sapro). 2012. department of defense annual report on sexual assault in the military, fiscal year 2011. washington, dc. estabrooks columbia social work review, volume iv 56 retrieved from http://www.sapr.mil/media/pdf/directives/ dodi649502p.pdf the american presidency project. (2013). “remarks in fort wayne, indiana: ‘remembering dr. martin luther king, jr.’” retrieved from http://www.presidency.ucsb.edu/ws/ index.php?pid=76996 slaughter, l. m. & capito, s. m. (2005). report on accomplishments of the congressional caucus for women's issues in the 108th congress. women’s caucus of the 108th congress. january 2005. washington d.c. snowden, k. (april 21, 2005). lawmaker says sexual assault victims in military need more protections. the orange county register. stande, v. a., merrill, l. l.; thomsen, c. j., crouch, j. l., & milner, j.s. (2008). premilitary adult sexual assault victimization and perpetration in a navy recruit sample. journal of interpersonal violence, 23(11), 1636-1653. united district court for the eastern district of virginia, susan l. burke (va bar no. 27769) (2011, february 15). “military sexual assault litigation.” washington dc. retrieved from http://servicewomen.org/wp-content/ uploads/2011/02/48879866-military-rape-andsexualassault-litigation.pdf u.s. legal. (2013). congressional caucus law & legal definition. retrieved from http://definitions.uslegal.com/c/congressional-caucus/ u.s. fed news. (2004, july 9). pentagon must take immediate action to support military sexual assault victims. knight ridder/tribune news service. retrieved from lexis/ nexis academic, online database. ziering, a. (producer), barklow, t.k. (producer), & dick, k. (director). (2012). the invisible war [motion picture] united states: cinedigm & docurafilms. with the elderly population growing, there is a great need to improve the quality of end-of-life care. traditionally, the healthcare industry has focused on the pathology-oriented medical model when assisting terminally ill patients. this focus can lead to patients feeling depressed, anxious, and hopeless about the dying process. by incorporating spirituality into the dying process, the hospice movement diverged from this medical model, but the role of social workers is often divided between these two very different paradigms. this paper discusses spiritual practice theories that hospice social workers can use to benefit the well-being of terminally ill patients while working within the current health care system. samantha chipetz the hospice movement: spirituality within the united states’ health care system the history of the american hospice movement reveals the importance of spirituality in end-of-life care. in the early hospice movement beginning in the fourth century, care for the dying was almost solely driven by religious communities that promoted spiritual well-being during a patient’s last phases of life. what differentiates the hospice movement today from these earlier efforts is the implementation of modern medicine (garcesfoley, 2003). within this new medical context, a question arises for social workers: how can we effectively work within the current medical model, which places value on curing, deficits, and pathology, and still attend to the patient’s social, emotional, and spiritual comfort in an increasingly secular society? this paper will seek to answer this question by exploring current theories and practices social workers can employ to promote the well-being of patients with terminal illness by focusing on spirituality in hospice care. choosing hospice care today more than 3,200 hospices have been established in the u.s. (“brief history of hospice movement,” n.d.). types of hospice care vary from independent, to nonprofit, and for-profit. the national association for �� journal of student social work, volume iv home care and hospice (nahc) noted that in 2000, one in four terminally ill individuals in the u.s. received hospice care (nahc, 2002). the majority of patients receiving hospice care are elderly, with more than 79% age 65 or older and only 3.9% of hospice patients under the age of 45 (nahc). race and social class play a significant role in identifying patients most likely to use hospice services. nahc (2005) asserted that although utilization of hospice services has increased among all racial and economic groups over the past decade, white, middle-class patients are still more likely to use hospice assistance than other groups. blacker (2004) suggested that many vulnerable populations, including refugees, immigrants, those with severe physical and mental disabilities, and people of color, continue to be underserved during end-of-life situations. barriers to hospice care may include a lack of knowledge concerning end-of-life options and the limited number of hospice services available in some local communities. in addition, different views on death and dying shaped by philosophical, spiritual, and social beliefs often lead to lower rates of hospice use by different cultural groups. for example, sullivan (2001) asserted that many latinos would not choose to be cared for in nursing homes or hospices due to their strong cultural emphasis on familial responsibility, privacy, and modesty. with the growth of hospice care since the 1970s, an increasing number of americans are choosing hospice as an option for themselves and their loved ones. cicely saunders, a social worker and founder of the first modern hospice in 1974, and dr. elisabeth kubler-ross, who wrote the groundbreaking book, on death and dying, both brought the topic of dying to public attention. they did so during a time when the medical community viewed terminal illness as something to be controlled rather than a condition that required relief. saunders and kubler-ross illustrated how the medical community all too often ignored and abandoned the emotional needs of a dying patient, once it became apparent that the patient could not be cured (raymer & reese, 2004). according to tyrer and exley (2005), the most common reasons patients choose hospice care over hospital facilities are the support and care available to families, the patient’s wishes to die at home, and the inability of medical interventions to cure the patient. nahc (2005) also suggested that hospice policies that allow patients to stay with family in the comfort of their own home and policies that encourage family members to take an active role in the treatment of their loved one lead patients to prefer hospice care over hospital or nursing facilities. in addition, when compared to trained nursing and chipetz journal of student social work, volume iv �� hospital services, hospice is a more cost-effective option for eligible patients with a life expectancy of 6 months or less to live (nahc). hospice services are covered by both the medicare hospice benefit under medicare part a, and the medicaid hospice benefit. in addition, most private insurers will cover portions of hospice services. since the majority of hospice recipients are 65 years of age or older, they qualify for entitlement services under the medicare hospice benefit, resulting in almost no out-of-pocket costs to the patient (“caring connections,” n.d.). due to its increased accessibility and cost-effectiveness, hospice use rose 20% from 1992 to 2000 (nahc). today, as a greater number of elderly patients seem to be choosing hospice as the baby boom generation continues to age, a focus on end-of-life care by the healthcare system is imperative (nakashima & canda, 2005). social work practice in hospice care social workers involved with hospice are part of a team of physicians, nurses, counselors, home health aides, clergy, therapists, and trained volunteers (nahc, 2005). together they offer support and emphasize a holistic framework that places attention on palliative as opposed to curative care. the hospice team relies on the skills and knowledge specific to each discipline in an effort to organize a unique and supportive plan beneficial to each patient and family (nahc). blacker (2004) noted that social workers have a unique role on the hospice team, which is to assist patients and families managing complicated psychological, medical, social, legal, and ethical decisions associated with end-of-life issues. also, social workers serve as patient advocates on the hospice team by assisting the patient in navigating through complex medical and social systems. when developing a model for hospice care, saunders conceptualized professionals working as a team comprised of many fields of study, since saunders herself assumed the roles of social worker, physician, and nurse. the current model for hospice care, similar to social work practice, suggests that collaboration is essential for boosting the physical, mental, and social conditions of the patient (parkeroliver, bronstein, & kurzejeski, 2005). although social workers hold a distinct place within the interdisciplinary hospice team, batten (1997) suggested that the social worker’s role in a hospice setting is often variable and unclear (nahc, 2005). while providing patients’ psychosocial and spiritual care is an essential and standard aspect of hospice service, social workers do not exclusively the hospice movement �� journal of student social work, volume iv perform these tasks, but share the responsibilities with nurses, clergy, and volunteers. as reese (2001) explained, “although hospice philosophy holds that all members of the team address spirituality, sometimes spirituality is considered the chaplain’s domain. social workers may do the initial spiritual assessment, but not intervention with spiritual issues” (p. 149). therefore competition may arise between social workers and chaplains regarding their core responsibilities. in addition, turf issues may also surface between social workers and nurses concerning the task of completing psychosocial assessments. often, social workers in hospice settings perceive that nurses are assuming this duty, which is specifically assigned to social workers, creating high levels of frustration and conflict within the interdisciplinary team (parker-oliver et al., 2005). although the role of the social worker is not clearly defined within many hospice settings, social workers’ diverse knowledge of intervention strategies can decrease conflict and motivate change within the hospice team (parker-oliver et al.). by working to assess and respond to the needs of the interdisciplinary team, social workers can improve the cooperation, communication, and success of the hospice team and enhance hospice service to patients and their families. spirituality in end-of-life care nakashima and canda (2005) argued that while the hospice movement has played an important role in improving terminal care by providing a holistic approach, the leading philosophy of patient care is still embedded in a pathology-oriented medical framework. this medical approach can lead patients to feel depressed, anxious, and hopeless about the dying process. the current medical model does not address a patient’s spiritual concerns, such as questions about the origin and purpose of life and the meaning of suffering (reese, 2001). while the hospice setting incorporates different religious and spiritual elements to address spiritual issues, social work as a profession has historically fought traditional religious paradigms that often blame individuals for their problems. as a result, social workers have successfully shifted the profession’s attention to the person-in-environment context (bullis, 1996). therefore, social work in hospice may differ from the current orientation of many in the social work profession. hospice work requires social workers to attend to the spiritual dimension of a person, which is vital in understanding how patients define their environment during their final days (garces-foley, 2003). nakashima and canda maintained that chipetz journal of student social work, volume iv �� spiritual practices offered by social workers in a hospice setting can provide profound support for patients to heal, grow, and feel more comfortable in the last stages of life. transpersonal social work reese (2001) argued that focusing on spirituality when working with the terminally ill can act as a source of strength for patients. reese claimed that, when faced with death, all adult patients can achieve a stage of spiritual growth. this stage, called transegoic, occurs when “ordinary life is infused with a sense of the sacred. heightened empathy, compassion, and moral standards naturally arise as the individual experiences a profound connection with others” (p. 137). although the transegoic level of consciousness is not an automatic development during the last stage of life, reese contended that a smooth shift into the transegoic stage can support a comfortable death by reducing death anxiety and increasing social support. she pointed to the need for hospice social workers to incorporate transpersonal theory as a foundation for practice technique to assist dying patients and their relatives make the transition to the transegoic stage (reese). application of these transpersonal techniques may help patients take full advantage of the time that remains and to live in as much peace as possible during their last phase of life. an example of one transpersonal technique is teaching meditation practice as a way to support spiritual growth and relieve stress. specific meditation techniques include “paying attention” and “intentional breathing” (reese, 2001, p. 152). paying attention supports awareness by encouraging patients to take pleasure in a shower or appreciate each moment with a loved one. intentional breathing is a technique that helps patients to diminish stress by repeating a mantra while concentrating on their breathing. other transpersonal techniques used to help transegoic stage development are movement mediation, group chanting, dream interpretation, music and art therapy, acupuncture, and keeping a journal (reese). focusing on a patient’s resiliency nakashima and canda (2005) conducted a qualitative study that examined the opinions of older adults who had positive experiences during their last stages of life. from their findings, the researchers concluded that in order to promote the psychosocial and spiritual well-being of terminally ill patients, social workers need to create intervention plans to help patients identify their internal and external resources that have helped them cope the hospice movement �� journal of student social work, volume iv with adversity in the past. through this process, patients will re-live past experiences of resiliency, which can lead to a more positive and peaceful death. examples of a patient’s internal and external resources might include spiritual attitudes, unique skills, talents, and relationships with others that can be shared with the social worker through narrating events of past resiliency. by storytelling past positive experiences, patients can create meaningful narratives of living and dying. findings from nakashima and canda’s (2005) study also indicated that strong spiritual or religious relationships in the community strengthen the ability for individuals to cope during stressful situations. a strong connection to the church, involvement in prayer, or attending spiritual rituals all promote spiritual practices and beliefs and strengthen the ability of individuals to thrive and benefit in adverse circumstances (nakashima & canda). buddhist approach to end-of-life care while social workers need to focus on a patient’s resiliency and spiritual strengths to promote the well-being of terminally ill patients, garces-foley (2003) argued that it is also important to create a nonsectarian spiritual language, along with nonsectarian social work practices, to aid in a patient’s positive end-of-life experiences. garces-foley pointed out that over the past 20 years, buddhism and hospice have created a mutually valuable relationship based on the attraction to nonsectarian language of spirituality, the craving for realistic techniques of coping with death, and the potential capacity of buddhism to meet this need. during the 1980s, the american hospice movement was searching for a spiritual language that was not associated with a particular religious denomination and that would be appropriate for clients of different ethnic, religious, or cultural backgrounds (garces-foley, 2003). in addition, hospice was becoming a mainstream option for terminally ill patients. around this same time, buddhism was expanding in popular culture through advocates of buddhist practice who used books, buddhist centers, conferences, and trainings to raise public awareness of buddhist philosophies. through this increased social consciousness, leaders of the hospice movement became aware of buddhist wisdom towards death and dying and discovered that buddhism offered an appropriate nonreligious language to use within hospice practice (garces-foley). within buddhist philosophy, there are many teachings and applicable chipetz journal of student social work, volume iv �� practices that speak specifically to end-of-life issues. as a result, many religious and non-religious people who are searching for supportive practices during the dying process turn to buddhism as a guide to dying and post-death rituals. buddhist teachings present meditation practices for both the patient, whose objective is to begin to let go of life, and the caregiver, whose objective is to develop compassion. for either patient or caregiver, these practices permit the increase of a sense of power in times when people often feel powerless. in contrast to the view of medical institutions, which view death as a failure, buddhist practices present a means to a successful and positive death, which can be accomplished through discipline during meditation practices (garces-foley, 2003). patients who are receiving hospice services may be attracted to buddhist teachings on death and dying, but are not necessarily converting to buddhism. instead, religious and nonreligious hospice providers and patients are borrowing buddhist practices to enhance their own religious ideals and practices. garces-foley (2003) called this type of melding of religious practices “religious mixing or combination” (p. 342). through this process of religious selection, people can maintain their personal religious backgrounds while selecting aspects of buddhism that seem appealing and applicable in their daily spiritual practices. with the establishment of buddhism within the modern hospice movement, social workers have access to a unique spiritual language and applicable meditation practices that support positive spiritual end-of-life experiences for patients of diverse religious backgrounds. the future of spirituality in hospice care in addition to learning spiritual techniques and approaches, there is also a need for hospice social workers to be trained in spiritual assessment and intervention. wesley, tunney, and duncan (2004) suggested that even though the joint commission on accreditation of healthcare organizations includes spiritual assessment in it principles, it does not offer precise guidelines for social workers. furthermore, the social work profession needs to define what constitutes standards of spiritual care, as little social work research exists concerning spirituality and terminal illness (wesley et al.). in addition, reese (2001) suggested that there are inconsistencies among social workers to define, identify, and address spiritual issues. she proposed that social work education needs to focus attention on the various spiritual the hospice movement �0 journal of student social work, volume iv beliefs about dying that exist within our society. social workers also need to come to a consensus and create suitable documentation of spiritual interventions that can effectively monitor and evaluate the effectiveness of various approaches. lastly, reese noted that it is important for social work education to address the social worker’s personal beliefs about death and spirituality, which may influence their willingness to address spiritual matters with clients. conclusion social workers’ use of spirituality in a hospice setting can greatly enhance and promote a patient’s well-being during their last stages of life. as a result of the work of saunders and kubler-ross, the topic of dying has been brought to public attention (“brief history of hospice movement,” n.d.). there is now a critical need for social workers to move away from the current pathology-oriented medical model (nakashima & canda, 2005). hospice social workers need to incorporate spirituality to support patients’ ability to emotionally heal, grow, and feel more comfortable in their last stages of life. transpersonal social work, focusing on the resiliency of terminally ill patients, and incorporating a buddhist approach to death practices are all types of spiritual practice theories that social workers can use to benefit the well-being of people with terminal illness. spirituality training for social workers employed at hospice settings, as well as addressing spirituality and hospice in graduate social work programs, are also necessary to support the hospice movement’s use of spirituality in end-of-life care. even with all of the existing theories and lessons for social workers to understand and apply when working with dying patients, reese (2001) put it simply when she said, “in the end, the people who are dying will teach us these lessons more often than we will teach them” (p. 158). references batten, d. (1997). conceptualizing spiritual care in three diverse hospices: a phenomenological study. ann arbor, michigan: umi. brief history of hospice movement. (n.d.). retrieved october 8, 2005, from http://www.hom.org/movement.asp blacker, s. (2004). palliative care and social work. in j. berzoff & p. silverman (eds.), living with dying (pp. 409-423). new york: columbia chipetz journal of student social work, volume iv �1 university press. bullis, r. (1996). spirituality in social work practice. washington, dc: taylor and fransic. caring connections. (n.d.). retrieved february 13, 2006, from http://www. caringinfo.org/i4a/pages/index.cfm?pageid=3468 garces-foley, k. (2003). buddhism, hospice, and the american way of dying. review of religious research, 44, 341-353. nakashima, m., & canda, e. r. (2005). positive dying and resiliency in later life: a qualitative study. journal of aging studies, 19, 109-125. national association for home care and hospice. (2002). hospice facts & statistics. retrieved february 12, 2006, from http://www.nahc. org/consumer/hpcstats.html national association for home care and hospice. (2005). hospice facts & statistics. retrieved february 12, 2006, from http://www.nahc. org/hospicefands.pdf parker-oliver, d., bronstein, l., & kurzejeski, l. (2005). examining variables related to successful collaboration on the hospice team. health & social work, 30(4), 279-286. raymer, m., & reese, d. (2004). the history of social work in hospice. in j. berzoff & p. silverman (eds.), living with dying (pp. 150-160). new york: columbia university press. reese, d. j. (2001). addressing spirituality in hospice: current practices and a proposed role for transpersonal social work. social thought, 20, 135-161. sullivan, m. (2001). lost in translation: how latinos view end-of-life care. plastic surgical nursing, 21(2), 90-91. tyrer, f., & exley, c. (2005). receiving care at home at end of life: characteristics of patients receiving hospice at home care. family practice, 22, 644-646. wesley, c., tunney, k., & duncan, e. (2004). educational needs of hospice social workers: spiritual assessment and interventions with diverse populations. the american journal of hospice, 21, 40-46. samantha chipetz is a first year master’s student at cussw. she is currently an intern at a public elementary school in bronx, ny. she is a graduate of the university of vermont with a bachelor’s degree in sociology and a double minor in religion and environmental studies. her email address is sc2517@columbia.edu. the hospice movement �2 journal of student social work, volume iv cswrfinal_4.1.13 columbia social work review, volume iv 36 environmental justice and social work: a call to expand the social work profession to include environmental justice dominoe jarvis “what we are doing to the forests of the world is but a mirror reflection of what we are doing to ourselves and to one another.” — mahatma gandhi concern for environmental justice has increased in recent decades. although the environmental justice field is closely linked to social justice, the social work profession has yet to gain a substantive involvement in environmental justice efforts. this article is a call to action for the social work profession and explains why the profession is ideally suited to address issues of environmental justice. it examines how issues of environmental injustice, such as the location of industrial waste facilities in predominantly minority communities, often affect those people who are most afflicted by other forms of injustice. a review of recent literature explains how the social work profession can shift its framework and make important connections to environmental justice. this article also discusses three recommendations for the social work profession to become involved in environmental justice. the critical need for social workers in the environmental justice field in recent decades, there has been a growing concern for environmental justice. the u.s. environmental protection agency’s (epa) definition of environmental justice establishes it as a social justice issue: environmental justice is “the fair treatment and meaningful involvement of all people regardless of race, color, sex, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies” (u.s. epa). social work has a realistic and evidence-based understanding of social justice as well as a commitment to serve society’s most vulnerable populations; however, the profession has yet to gain a substantive inenvironmental justice and social work 37 columbia social work review, volume iv volvement in environmental justice efforts. the social work profession has been slow to respond to environmental concerns and to the devastating effects of environmental injustice on the health of individuals and communities served by social workers, specifically minority and poor communities. environmental destruction and devastation are carried disproportionately by disadvantaged and marginalized groups (gray & coates, 2012). in failing to gain a considerable presence in the environmental justice field, and by not taking advantage of the opportunity to grasp environmental justice as a legitimate professional identity (kemp, 2011), the social work profession is neglecting its ethical responsibility to the individuals it serves. as part of the profession’s ethical principles, social work is responsible for helping those in need, addressing social problems, and confronting social injustice (national association of social workers [nasw], 2008). it is imperative and relevant for the principles of social work to extend to environmental justice through social work’s commitment to vulnerable individuals and communities. forming multidisciplinary partnerships is an important and effective step toward achieving environmental justice. a diverse group of professionals—such as engineers, scientists, business people, urban planners, and those in the legal profession— has focused heavily on environmental concerns within its practice. mainstream social work, however, has concentrated acutely on social issues and has been disconnected from topics concerning the natural and physical environment (coates, 2005). social work often involves inclusive, multidisciplinary efforts to solve problems within communities and to address social justice and, as a result, is well suited to take on a participatory role in the environmental justice movement (freisthler & crampton, 2009; schmitz, matyok, sloan, & james, 2011). yet, the social work profession is missing an important opportunity to close the gap between social and environmental justice concerns and to be recognized as a profession that is nondiscriminatory when it comes to the social justice issues it supports and pursues. social workers can lend critical support to environmental justice work and the time has come for the social work profession to realize its potenjarvis columbia social work review, volume iv 38 tial to make a significant difference in the environmental justice field. social work education must contribute to the available scholarly research and connect social work’s long-established social justice values and commitments with environmental justice issues (jones, 2006). this article explains why the social work profession is ideally suited to address issues of environmental justice. first, it will examine how issues of environmental injustice, such as the location of industrial waste facilities in predominantly minority communities, often affect those most afflicted by other forms of injustice. second, the article will review recent literature that explains how the social work profession can shift its framework and make important connections to environmental justice. lastly, as a means of incorporating environmental justice into the field of social work, the article offers three recommendations for current and future social workers. the inequitable distribution of environmental burdens various studies and literature indicate that environmental pollution disproportionately affects minority and low-income populations (arora and cason, 1999; bullard, 1990; united church of christ, 1987). minority and poor communities bear the burden of environmental problems that are forced upon them by decision makers and more empowered communities that subscribe to the notion of ‘not in my back yard’. according to besthorn and saleeby (2003), this inequality in healthy environments “results in the further marginalization of already disenfranchised people” (p. 9). a 2005 government research project concludes that african americans are nearly 80% more likely to live in close proximity to hazardous pollution sites than white americans (associated press, 2005). african americans are not only exposed to a disproportionate amount of pollutants from industrial facilities but also suffer from higher levels of lead poisoning, a by-product of living close to industrial facilities (adeola, 1994; jones & rainey, 2006). research has shown that exposure to these pollutants is connected to diseases such as asthma and cancer (department of health and human services, 2012). locally environmental justice and social work 39 columbia social work review, volume iv unwanted land uses (known as lulus), such as waste facilities and industrial disposal sites, disproportionately affect minority and poor communities throughout the country (mohai & saha, 2006). the locating of lulus near minority and poor communities is evidence that land-use decisions favor those with more political and economic influence. an example of environmental injustice can be found in new york city within walking distance of the columbia university school of social work. the north river wastewater treatment plant, located in a predominantly minority and low-income neighborhood in west harlem, is a sewage treatment facility that was engrossed in controversy during its decades of planning and even after its completion in 1986. the sewage treatment facility was originally planned to be built near 72nd street, on the upper west side. due to a decision by the new york city planning commission, the facility was relocated to 137th street in west harlem (miller, 1993). the proposed site for the facility was relocated from the affluent upper west side community to west harlem because it was considered “incompatible” with development plans for the upper west side (miller, 1993, p. 709). the coalition that opposed the plant at 72nd street was better funded and better able to lobby the city’s decision makers than those who opposed the plant in harlem. the west harlem community was outraged that a waste treatment facility would be located so close to their homes and schools, yet the facility would be built regardless of disapproval and protest. as a limited compromise, the city built riverbank state park, a twenty-eight acre park on top of the sewage facility (miller, 1993). the riverbank state park was built as “a mitigation measure” (miller, 1993, p. 711) to compensate residents for the wastewater treatment facility being built in such close proximity to their homes. residents soon began to experience foul odors coming from the waste treatment site (severo, 1989). while the residents of west harlem received a new park, they were plagued by a waste treatment facility nearby that affected their daily lives. at 72nd street, the original proposed site for the facility, there are now thousands of units of additional luxury housing and acres of additional parkland. the more affluent community of the upper jarvis columbia social work review, volume iv 40 west side were presented with increased housing and improvement to their parkland, while the poorer neighborhood of west harlem received parkland in exchange for having an odorous facility in their neighborhood. in this particular case, social workers could have helped the west harlem community mobilize and take action to amend this environmental injustice. social workers can use their knowledge of advocacy and community organizing to help individuals and communities facing similar situations. a shift in the social work framework to include environmental justice social work has always been concerned with contemporary social issues and has continually shifted to address and meet the needs of vulnerable people. realizing that the profession needed to adapt to better serve clients, mary richmond pioneered the social work practice of visiting clients in their home environments. she recognized the physical environment as significant to social work, but only in connection to poverty (richmond, 1922). the social work profession has evolved tremendously since richmond’s time and has adapted to address the current needs affecting the many populations served. richmond’s practice of visiting clients in their home environment can be viewed as an early approach to the person-in-environment perspective. today, social work maintains a strong emphasis on the person-in-environment perspective, which considers individuals as active participants in a larger social system. yet the perspective maintains a narrow definition of “environment” that includes the social but disregards the natural environment. excluding the natural environment has perhaps contributed to the profession’s slow involvement in environmental justice. in order to gain substantial involvement in the field of environmental justice, it is imperative that the profession broaden its definition of the person-in-environment perspective to encompass the physical and natural environments. while social work’s practicing professionals are aware of the importance of environmental issues, this has not affected their practice. marlow & van rooyen (2001) embarked on an exploratory study aimed at raising the awareness of environmental issues environmental justice and social work 41 columbia social work review, volume iv with social workers and to begin to develop a framework for social work interventions that are environmentally related. the study asked participants, social workers in both the u.s. and south africa, about their personal concern for the environment and the inclusion of environmental issues within their practices. the study found that 92.8% of respondents described environmental issues as personally important, but only 43.2% actually addressed these issues in their practice (marlow & van rooyen, 2001). perhaps it can be deduced from this study that social workers are aware of environmental issues, but tend to concentrate on the social environment and may lack the training to include environmental concerns into their professional identities. social workers are adept in responding to social justice issues and will be better prepared to address issues of environmental justice after receiving specific training through social work curricula. changes in social work curricula to include the natural environment are essential in establishing the social work profession in environmental research, policy, and practice. it is necessary for the contemporary social work profession to acknowledge the consequences of environmental injustice on vulnerable populations (miller, hayward, & shaw, 2011) and begin to engage in such work, which may lead to a better understanding of the disproportionate effect that environmental degradation has on minority and poor communities. in building research and knowledge about the need for social work’s involvement in addressing environmental concerns, it is imperative that social workers “include an analysis of the tensions between racism, classism, environmentalism, and economic development” (furman & gruenwald, 2004, p. 48). the question in implementing this suggested change to the profession is whether social work will remain committed primarily to the social needs of marginalized populations or heed environmental justice considerations to diversify its commitments and embrace issues that arise from environmental injustice (gray & coates, 2012). the challenge to include environmental justice as part of the profession’s social justice framework is necessary, overdue, and one that social workers should actively pursue in order to maintain relevancy within the field of social justice. jarvis columbia social work review, volume iv 42 conclusion at present, there is a deficit in the current social work education and scholarship in addressing the nexus of environmental justice, social work, and social justice. while there is a growth in awareness of environmental justice, the topic is still under-acknowledged in the social work profession, and there is a lack of available information on the important role and involvement of social work in environmental concerns. it is therefore crucial for social workers, current and future, to start addressing environmental inequality endured by the individuals the profession serves. as a profession that is focused on social justice principles, it is necessary that social work include environmental concerns in its areas of practice. through exploring and incorporating environmental justice in their practices, social workers can begin to help the people they serve by broadening their understanding of environment to include not just the social, but also the natural and physical environment. first, it is important that social work courses and field education offer students the opportunity to study the nexus between environmental justice and social work (dewane, 2011). this is necessary for the future of the profession if social work is to become involved as a serious participant or leader in environmental justice. second, shifts in practice, training, and interventions will be necessary before implementing environmental justice content into graduate social work curricula (freisthler & crampton, 2009). shifts can begin through collaborating with other disciplines to achieve a clear understanding of environmental justice content and allowing the profession to incorporate multidisciplinary ideas. third, further research into environmental justice, the effects it has on marginalized populations, and the beneficial involvement of social workers is necessary. environmental justice is an interdisciplinary field in which social work has been slow to enter. by acknowledging and engaging with the multidisciplinary culture of environmental justice, social work can become more substantial and comprehensive (hoff, 2003). social work research can also bring new ideas to the environmental justice and social work 43 columbia social work review, volume iv field of environmental justice and, likewise, can learn from other disciplines that have already established themselves within the field. incorporating knowledge from other disciplines will allow social work to evolve and determine responses to the present issues pertaining to the environment and its effects on individuals. the profession’s responsibility remains to serve the interests of its clients, who are adversely affected by their environments. social work has the potential to shape and improve the environment and to become not only an active participant in discussions on environmental justice, but also a leader in the environmental justice movement. acknowledgements i wish to thank gideon sorkin (m.s. columbia seas ’12), an engineer, for bringing to my attention the north river wastewater treatment plant. our discussion of the subject is a clear illustration of a multidisciplinary approach to environmental justice. references adeola, f. o. (1994). environmental hazards, health, and racial inequality in hazardous waste distribution. environment and behavior, 26, 99-126. arora, s. & cason, t. n. (1999). do community characteristics influence environmental outcomes? evidence from the toxics release inventory. southern economic journal, 65 (4), 691-716. associated press. (2005). more blacks live in unhealthy, polluted neighborhoods. fox news. retrieved from http:// www.foxnews.com/story/0,2933,178672,00.html besthorn, f. h. & saleeby, d. (2003). nature, genetics and the biophilia connection: exploring the link with social work values and practice. advances in social work, 4(1), 1-18. bullard, r. (1990). dumping in dixie: race, class, and environmental quality. boulder, co: westview press. jarvis columbia social work review, volume iv 44 coates, j. (2005). the environmental crisis: implications for wocial work. journal of progressive human services, 16(1), 25-49. department of health and human services. (2012). hhs environmental justice strategy. retrieved from http:// www.hhs.gov/environmentaljustice/strategy.html dewane, c. j. (2011). environmentalism & social work: the ultimate social justice issue. social work today, 11(5), 20. freisthler, b. & crampton, d. (2009). introduction to environment and child well-being. children and youth services review, 31(3), 346-348. furman, g., and gruenwald, d. (2004). expanding the landscape of social justice: a critical ecological analysis. education administration quarterly, 40(1), 47-76. gray, m. & coates, j. (2012). environmental ethics for social work: social work’s responsibility to the non-human world. international journal of social welfare, 21(3), 239-247. hoff, m. d. (1993). social dimensions of the environmental crisis: challenges for social work. social work, 38, 204-211. jones, p. (2006). considering the environment in social work education: transformations for eco-social justice. australian journal of adult learning, 46(3), 364-382. jones, r. e. & rainey, s. a. (2006). examining linkages between race, environmental concern, health, and justice in a high polluted community of color. journal of black studies, 36 (4), 473-496. kemp, s. (2011). recentring environment in social work practice: necessity, opportunity, challenge. british journal of social work, 41(6), 1198-1210. marlow, c. & van rooyen, c. (2001). how green is the environment in social work? international social work, 44(2), 241-254. miller, s. e., hayward, r. a., & shaw, t. v. (2011). environmental shifts for social work: a principles approach. international journal of social welfare, 21(3), 270-277. miller, v. d. (1993). planning, power, and politics: a case study of the land use and siting history of the north river water environmental justice and social work 45 columbia social work review, volume iv pollution control plant. fordham urban law journal, 21 (3), 707-722. mohai, p., & saha, r. (2006). reassessing racial and socioeconomic disparities in environmental justice research. demography, 43(2), 383-399. national association of social workers. (2008). code of ethics of the national association of social workers. retrieved from http://www.socialworkers.org/pubs/code/code.asp passmore, j. a. (1974). man’s responsibility for nature: ecological problems and western traditions. new york: charles scribner’s sons. richmond, m. e. (1922). what is social case work? new york: russell sage foundation. schmitz, c. l., matyok, t., sloan, l. m., & james, c. (2011). the relationship between social work and environmental sustainability: implications for interdisciplinary practice. international journal of social welfare, 21(3), 278-286. severo, r. (1989, november 30). odors from plant anger many in harlem. new york times. retrieved from http:// www.nytimes.com/1989/11/30/nyregion/odors-fromplant-anger-many-in-harlem.html?src=pm united church of christ. (1987). toxic wastes and race in the united states: a national report on the racial and socioeconomic characteristics of communities with hazardous waste sites. new york: commission for racial justice, united church of christ. u.s. environmental protection agency [epa]. (n.d.). environmental justice. retrieved from http://www.epa.gov/ environmentaljustice/ journal of student social work, volume iv � anger is described as an emotional response to a perceived physical or psychological threat that induces feelings of vulnerability, powerlessness, and anxiety (hollinworth, clark, harland, johnson, & partington, 2005). anger can become a problem in multiple respects if it is experienced or expressed inappropriately. physically, prolonged feelings of intense anger strain certain areas of the nervous system, increase blood pressure and heart rate, and may contribute to such health problems as hypertension, heart disease, and diminished immune system efficiency (reilly & shopshire, 2002). psychologically, anger problems may inhibit psychosocial functioning and contribute to aggressive, anti-social behaviors, such as physical violence and verbal abuse. these behaviors carry many potentially negative consequences, including incarceration, assault, being viewed as untrustworthy, losing the emotional support of family and friends, expulsion from a substance abuse or other community support program, and feeling remorse, shame, or self-loathing (reilly & shopshire). due in part to the rise in demand for mental health services placed upon agencies by the current geopolitical climate, the treatment of problematic anger among veterans is an issue of pressing clinical significance (hoge, anger problems are most evident in veterans who are diagnosed with posttraumatic stress disorder (ptsd) and have been exposed to combat. because of the institutionalized role anger plays in military training, identity, and culture, anger problems are also an issue for former soldiers who have neither ptsd nor combat experience. consequently, anger problems are an issue for many veterans whose inability to manage and express their anger constructively inhibits psychosocial functioning in multiple areas, including personal relationships, employment, self-esteem, and behavioral self-control. empirically supported group interventions addressing this issue adhere to the principles of evidence-based practice and are particularly important given the current geopolitical climate. this paper reviews some of the current literature on clinical interventions for veterans experiencing anger problems and acknowledges the increasingly important role social workers are playing as mental health service providers to veterans with anger problems at institutions such as the department of veterans affairs. scott miller journal of student social work, volume iv � anger and military veterans auchterlonie, & milliken, 2006). anger problems among the members of this population (primarily male, although increasingly diverse) are associated with multiple factors related to military service including combat exposure, military culture, and war-induced psychological trauma (gerlock, 1994). veterans who were exposed to combat and are diagnosed with posttraumatic stress disorder (ptsd) are most likely to suffer from anger problems, although former soldiers who have neither ptsd nor combat experience are also at risk (calhoun et al., 2002; chemtob, hamada, roitblat, & muraoka, 1994; novaco & chemtob, 2002). current treatments used to address this issue follow a group format based upon the principles of cognitive behavioral therapy that is time-limited, goal-oriented, and supported by empirical research attesting to its clinical efficacy (beck & fernandez, 1998; gerlock, 1996; reilly & shopshire, 2002; tang, 2001). the department of veterans affairs uses these interventions because they are congruent with the practical and ethical expectations of evidence-based practice as well as the professional objectives of clinical social work. the etiology and psychosocial implications of anger problems in military veterans prior to 1920, psychological models focused solely on the sexual drive, or libido, as the primary behavioral and cognitive drive among humans (horowitz, 1988). according to these early models, aggression is the result of sexual repression and is evident throughout the course of psychosexual development prior to the successful resolution of the oedipus/electra complex. the identification of aggression as a separate drive element in 1920 introduced the notion that anger is instinctual and part of a natural dichotomy between two inherently opposed impulses: eros, the ego and libidinal instinct for survival, and thanatos, the death instinct. in this paradigm, negative energy displaced onto others to prevent the self-destruction of the individual is considered to be the basis of aggression and is first apparent in the infantile desire to possess and destroy the maternal breast (hinshelwood, 1989). the development of relational models in the 1940s rejected drive theory’s emphasis on aggression as an independent energy source and replaced it with the view that aggression is the behavioral expression of an induced emotional state that occurs due to the inability to achieve primary motivational aims (greenberg & mitchell, 1983). this approach provided the groundwork for the idea that feelings of anger and their subsequent behavioral expressions anger and military veterans � journal of student social work, volume iv are ostensibly elicited by anger-provoking events that trigger thoughts of disappointing and unresolved conflicts. according to this latter perspective, trigger events vary from individual to individual and are dependent upon one’s personal experiences and worldview. similarly, anger cues — or the physical, emotional, behavioral, and cognitive reactions that occur in response to anger-provoking events — vary according to individual, as well as societal and cultural norms. among military veterans, anger problems are associated with trigger events and cues related to specific aspects of military experience, namely combat exposure, combat related psychological trauma, and military culture. anger problems are especially prevalent in those who were exposed to combat and have been diagnosed with ptsd (calhoun et al., 2002); chemtob et al., 1994; novaco & chemtob, 2002). as noted in the diagnostic and statistical manual of mental disorders (4th ed., text rev.: dsm-iv-tr; american psychiatric association, 2000), problematic expressions of anger are a persistent symptom of ptsd, an axis i diagnosis that may develop after one experiences, witnesses, or is confronted with a life-threatening event. combat-exposed military veterans with ptsd are more likely than other veterans to suffer from anger problems that lead to impaired relationships, social isolation, and feelings of helplessness (novaco & chemtob). research conducted by calhoun et al. indicated that combat-exposed veterans with ptsd report more frequent arousals of unchecked anger accompanied by a hostile attitude towards others in a variety of situations. similarly, chemtob et al. reported that combat veterans with ptsd have significantly more incidents of problematic anger towards their partners and are also more likely to experience employment difficulties due to their inability to express anger in socially acceptable ways. veterans who were not exposed to combat and do not have ptsd typically exhibit fewer anger symptoms than those who were in combat and do have ptsd (calhoun et al., 2002; chemtob et al., 1994; iversen et al., 2005; novaco & chemtob, 2002). nevertheless, non-combat veterans, too, are at risk of suffering from anger problems and may seek anger treatment for similar or related symptoms. according to gerlock (1994), this may be due to the role of unchecked anger as an integral part of military culture. anger is presented in the military environment as a necessary element of the idealized version of masculine identity that defines the psyche of the successful combat soldier. military training emphasizes the need to repress feelings such as sadness and fear so that soldiers are psychologically equipped for external miller journal of student social work, volume iv � expressions of aggression (gerlock). for the soldier, anger thus becomes a mechanism that enables him or her to ignore and overcome the emotional challenges inherent to the combat experience without succumbing to the deep and complex psychological reactions associated with such traumatic events as witnessing the death of a comrade. treating anger problems in military veterans current interventions that address anger problems in military veterans generally utilize a treatment plan based upon the principles of cognitive behavioral therapy (cbt) (beck & fernandez, 1998; gerlock, 1996; reilly & shopshire, 2002; tang, 2001). the group format of the cognitive behavioral model postulates that interventions should include five to ten participants and meet once per week for a period of up to 12 sessions. cbt interventions for anger problems are based upon the stress inoculation training (sit) model, which consists of three parts: (1) cognitive preparation, (2) skill acquisition, and (3) application training (beck & fernandez; dwivedi & gupta, 2000). according to gerlock, a typical cbt anger management intervention follows a curriculum that focuses on identifying situational triggers, learning coping skills, and practicing role rehearsal through exposure to anger-provoking stimuli. group sessions are typically divided into two parts. a didactic portion examines cues to anger, learned responses to anger, anger triggers, personal vulnerabilities to anger, and short-term payoffs versus long-term consequences of anger. a practice component included in each session offers structured role-plays and break-out periods during which participants may test their newly learned social skills. experts believe using cbt in the treatment of anger is justified by its effectiveness in achieving desired treatment goals via a time-limited, goaloriented intervention format that empirically evaluates clinical change (beck & fernandez, 1998). for example, tang’s (2001) retrospective quasiexperimental study on the effectiveness of a cbt anger management group for patients with mental health problems used the anger control inventory (aci) and the state-trait expression inventory (staxi) to measure clinical outcomes. the study revealed that the participants experienced a decrease in overall feelings of anger and an increase in anger coping skills as evidenced by reductions in maladaptive cognitions and behaviors, cognitive deficits, and behavioral deficits (tang). interventions involving client samples consisting of current and former anger and military veterans 10 journal of student social work, volume iv members of the military suggest clinical outcomes similar to the results presented by tang (2001) regarding the efficacy of cbt group therapy in the treatment of problematic anger. conducted at a veterans affairs outpatient mental health center, gerlock’s (1994) retrospective quasi-experimental study revealed that an anger management group using a cbt approach leads to significant improvement in anger coping mechanisms and a significant drop in sensitivity to anger provocation as evidenced by significant decreases in respondents’ self-reported feelings of anger. similarly, a 4-session cbt anger management group study conducted by linkh and sonnek (2003) in a setting frequented by current and former members of the military concluded that a brief cognitive behavioral psychoeducational approach to treat anger problems is empirically justified; participants experienced a marked reduction in their subjective experience of anger and in potentially aggressive expressions of anger. strengths and weaknesses of the current approach to treatment cbt anger management groups, such as those tested by gerlock (1994), linkh and sonnek (2003), and tang (2001), are particularly useful in the treatment of the military veteran population because they induce clinical change in clients from all genders, cultures, races, and ethnicities. this is particularly important given the increasingly diverse nature of the military veteran population. according to reilly and shopshire (2002), the strategy of identifying trigger events, cues to anger, and developing personalized coping skills effectuates equally positive clinical outcomes among members of both gender groups. interventions based upon the cbt model can also successfully accommodate the culture-specific needs and situations of individuals from various racial and ethnic groups (reilly & shopshire). finally, cbt anger management groups are valuable because they have been found to be effective in treating clients who have a history of substance abuse or who are diagnosed with co-occurring psychiatric disorders. for such clients, participation in cbt anger management groups leads to clinical improvement so long as participants abstain from drugs and alcohol, adhere to the stipulations of their medication treatment plan, and receive appropriate care for co-occurring disorders (reilly & shopshire). this latter point is especially relevant to treating military veterans, who, as was previously mentioned, often trace their anger problems back to combat experiences that precipitated the onset of psychiatric disorders, such as ptsd. miller journal of student social work, volume iv 11 despite its apparent clinical supremacy, shortcomings exist in the cbt approach that may call into question its position as the intervention of choice for the treatment of problematic anger. these shortcomings relate to cbt’s ability to affect long-term clinical improvement, as well as its capacity to address specific clinical symptoms vis-à-vis other types of interventions. concerning the former shortcoming, durham et al. (2005) suggested that improvements immediately following cbt treatments often fail to translate into lasting results and cannot be maintained by simply extending the cbt treatment. on the other hand, psychodynamic interventions have been shown to effectuate lasting clinical improvement. a study conducted by muratori, picchi, bruni, patarnello, and romagnoli (2003) revealed that participants who received an intervention consisting of short-term psychodynamic psychotherapy were more likely to experience long-lasting clinical improvements than the members of the control group. finally, psychodynamic group interventions have proven to be better able to improve clients’ behavioral control and coping despite cbt’s emphasis on these goals (sandahl, gerge, & herlitz, 2004). these clinical shortcomings call into question the two non-clinical elements that make cbt so appealing, namely its time-limited and costsaving qualities. participants in cbt anger management groups may have to participate in the group multiple times or receive another form of follow-up intervention given the increase in the number of veterans seeking treatment for anger management problems and other forms of psychological trauma. this is a critical point, especially in the wake of operation iraqi freedom and operation enduring freedom, as well as the limited amount of resources available to put towards treatment of veterans. implications for clinical social work practice the need to treat military veterans with anger problems in a way that is clinically effective, ethical, and cost-efficient has never been greater. military campaigns in iraq, afghanistan, and elsewhere mean more troops are being exposed to combat and other stressful situations that put them at risk of returning home with anger problems. a recent study conducted by hoge et al. (2006) indicated that 19.1% of veterans returning from iraq and 11.3% of veterans returning from afghanistan reported a mental health problem. overall, 35% of all returning operation iraqi freedom veterans requested mental health services. as with previous research, this study indicated that anger and military veterans 12 journal of student social work, volume iv combat-exposed veterans are more likely to report and request services for mental health problems than other veterans. given the relationship between combat exposure, psychiatric trauma, and problematic anger, this may mean more veterans will present with significant anger problems that require clinical intervention in the near future. institutions that offer services to returning veterans find themselves under increasing demands to treat more clients with fewer resources. these institutions are simultaneously incorporating elements of evidence-based practice into their institutional culture that are congruent with the ethical demands of accrediting organizations, such as the joint commission on accreditation of healthcare organizations, and the financial realities of managed care. this is particularly true of the department of veterans affairs (va). as one of the nation’s primary providers of medical and psychiatric services to military veterans, the va medical system is the largest integrated health care system in the country; it has a health care budget of approximately $30 billion, employs 196,000 health care professionals, and maintains 1,300 sites of care (department of veterans affairs, 2006). the va provided health care services to over 5 million veterans via its system of inpatient and outpatient clinics and hospitals in 2004. this represents an increase of 22% in the number of patients treated since the end of fiscal year 2001 (department of veterans affairs, 2005). the va is also known for its position as the employer of over 4,000 licensed social workers and for its desire to become the employer of choice for qualified clinical social workers (department of veterans affairs, 2004). social workers at the va fill a variety of roles that reflect the diversity of the social work profession. social work services provided at va medical centers include psychosocial screening and evaluation, pre-admission planning, discharge planning, psychosocial diagnosis and intervention, patient advocacy, end of life planning, and bereavement services (department of veterans affairs). in the realm of mental health, social workers provide a specific array of services using a psychiatric, dsm iv-tr-based assessment, diagnostic, and treatment model. services provided include individual psychotherapy, group psychotherapy, and psychosocial assessments. social workers facilitate their interventions in partnership with other mental health professionals and are considered to be integral members of an interdisciplinary mental health team consisting of psychiatrists and psychologists. miller journal of student social work, volume iv 1� conclusion participation in the military exposes individuals to numerous potentially traumatic situations that can have long-lasting psychological, economic, and social ramifications (dalenberg, 2000; friedman, 2005; iversen et al., 2005; solomon & kleinhauz, 1996). as a result, military veterans face multiple psychosocial stressors, one of the most salient of which is problematic anger. anger problems, which are particularly chronic among combat veterans with ptsd, are believed to be due in part to the socially constructed role of aggression in military identity and culture, as well as combat exposure and war-induced psychological trauma (calhoun et al., 2002; chemtob et al., 1994; gerlock, 1994; novaco & chemtob, 2002). veterans with anger problems are at increased risk of suffering from economic, interpersonal, psychological, and physical problems. multiple studies have illustrated the efficacy of cbt anger management groups in causing clinical change among military veterans who suffer from anger problems (gerlock; linkh & sonnek, 2003; tang, 2001). clinical social workers play an integral role in clinical work with military veterans who have anger problems at such institutions as the va. social workers’ efforts are sorely needed as demands for psychosocial services among military veterans are increasing and more anger-prone veterans are expected to return in dire need of assistance as a result of current military engagements overseas. to improve the odds of effectively helping returning veterans with anger problems, research might be conducted to assess the level of stigma perceived by veterans regarding obtaining mental health services. though beyond the scope of this paper, additional research could look at how women in the military experience anger. research might also address the current racial, gender, and other forms of demographical diversity that exist in today’s military. greater empirical knowledge in each of these areas could be incorporated in culturally competent cbt anger management group interventions that are increasingly cognizant of how veterans with anger problems can be treated in a manner that is ethical, empirically-based, and resource efficient. references american psychiatric association. (2000). diagnostic and statistical manual of mental disorders (4th ed., text rev.). washington, dc: author. anger and military veterans 1� journal of student social work, volume iv beck, r., & fernandez, e. (1998). cognitive behavioral therapy in the treatment of anger: a meta-analysis. cognitive therapy and research, 22(1), 63-74. calhoun, p., beckham, j., feldman, m., barefoot, j., haney, t., & bosworth, h. (2002). partners’ ratings of combat veterans’ anger. journal of traumatic stress, 15(2), 133-136. chemtob, c., hamada, r., roitblat, h., & muraoka, m. (1994). anger, impulsivity, and anger control in combat-related posttraumatic stress disorder. journal of consulting and clinical psychology, 62(4), 827-832. dalenberg, c. (2000). countertransference and the management of anger in trauma therapy. ptsd clinical quarterly, 9(3), 39-45. department of veterans affairs. (2004). clinical social work veterans health administration: twenty-first century employer of choice. retrieved march 5, 2006, from http://www1.va.gov/socialwork/docs/swbrochure 2004.pdf department of veterans affairs. (2005, june). facts about the department of veterans affairs. retrieved october 11, 2005, from http://www1. va.gov/opa/fact/vafacts.html department of veterans affairs. (2006, february). feeley appointed to senior va health care post. retrieved march 5, 2006, from http:// www1.va.gov/opa/pressrel/pressartinternet.cfm?id=1077 durham, r., chambers, j., power, k., sharp, d., macdonald, r., major, k., et al. (2005). long term outcome of cognitive behavioral therapy trials in central scotland. health technology assessment, 9(42), 1-174. dwivedi, k., & gupta, a. (2000). “keeping cool”: anger management through group work. support for learning, 15(2), 76-81. friedman, m. (2005). veterans’ mental health in the wake of war. the new england journal of medicine, 352(13), 1287-1290. gerlock, a. (1994). veterans’ responses to anger management intervention. issues in mental health nursing, 15(4), 393-408. gerlock, a. (1996). an anger management intervention model for veterans with ptsd. ncp clinical quarterly, 6(3), 61-64. greenberg, j., & mitchel, s. (1983). object relations in psychoanalytic theory. cambridge, ma: harvard university press. hinshelwood, r. (1989). a dictionary of kleinian thought. london, uk: free association books. hoge, c., auchterlone, j., & milliken, c. (2006). mental health problems, use of mental health services, and attrition from military service after returning from deployment to iraq or afghanistan. journal of the miller journal of student social work, volume iv 1� american medical association, 295(9), 1023-1031. hollinworth, h., clark, c., harland, r., johnson, l., & partington, g. (2005). understanding the arousal of anger: a patient-centered approach. nursing standard, 19(37), 41-47. horowitz, m. (1988). introduction to psychodynamics: a new synthesis. new york, ny: basic books. iversen, a., nikolaou, v., greenberg, n., unwin, c., hull, l., hotopf, m., et al. (2005). what happens to british veterans when they leave the armed forces? the european journal of public health, 15(2), 175-184. linkh, d., & sonnek, s. (2003). an application of cognitive-behavioral anger management training in a military/occupational setting: efficacy and demographic factors. military medicine, 168(6), 475-478. muratori, f., picchi, l., bruni, g., patarnello, m., & romagnoli, g. (2003). a two-year follow up of psychodynamic psychotherapy for internalizing disorders in children. journal of the american academy of child & adolescent psychiatry, 42(3) 331-339. novaco, r., & chemtob, c. (2002). anger and combat-related posttraumatic stress disorder. journal of traumatic stress, 15(2), 123-132. reilly, p., & shopshire, m. (eds.). (2002). anger management for substance abuse and mental health clients: a cognitive behavioral therapy model. rockville, md: u.s. department of health and human services. sandahl, c., gerge, a., & herlitz, k. (2004). does treatment focus on self efficacy result in better coping? paradoxical findings from psychodynamic and cognitive-behavioral group treatment of moderately alcohol dependent patients. psychotherapy research, 14(3), 388-397. solomon, z., & kleinhauz, m. (1996). war-induced psychic trauma: an 18 year follow-up of israeli veterans. american journal of orthopsychiatry, 66(1), 152-160. tang, m. (2001). clinical outcome and client satisfaction of an anger management group program. canadian journal of occupational therapy, 68(4), 228-36. scott miller is a second year master’s student at cussw specializing in advanced clinical practice in the field of mental health. his current field placement is at the department of veterans affairs/new york harbour health care system, where he provides individual and group psychotherapy to veterans in the outpatient psychiatry unit. he holds a bachelor’s degree in foreign service from georgetown university. his email is swm2106@columbia.edu. anger and military veterans 1� journal of student social work, volume iv journal of student social work, volume iv 1� the majority of children placed into foster care are separated from their siblings upon entering the child welfare system. some research suggests that siblings enjoy more stable home environments and fewer behavioral problems when placed together in care. the sibling relationship may provide stability, consistency, and unconditional positive regard to the children most at risk for poor outcomes such as anxiety, depression, low self-esteem, and loss of identity. this paper argues that foster care and child welfare agencies must institute the changes necessary to make sibling relationships a priority. recommendations for integrating the protection of sibling relationships in the placement process are proposed. the sibling relationship in foster care: policy implications nearly 17,000 new york city children are in foster care (administration for children’s services, 2005). the majority of children in foster care have siblings (herrick & piccus, 2005), yet strong efforts to preserve this critical relationship have yet to be put into practice within most states’ foster care systems. as a result, the majority of children with siblings in foster care are separated from their siblings (herrick & piccus). this paper will outline the arguments for the protection of, and support for, sibling placements in foster care, as well as offer practical recommendations for the child welfare and foster care systems. the sibling relationship a sibling relationship is usually the longest relationship in an individual’s life course (groza, maschmeier, jamison, & piccola, 2003). children who are separated from siblings in foster care face potentially traumatic and long-term effects from this loss. older children are “attachment figures for younger siblings” according to groza et al. (p. 481). children in chaotic homes with inconsistent parenting may come to rely more upon one another than on a parental figure (hegar, 1993) such that the loss of this sibling relationship may, in fact, be more damaging than the loss of the parent. through the sibling relationship, children develop relationship skills journal of student social work, volume iv 1� kate sheehan including how to successfully negotiate, empathize, and communicate emotions. siblings who are separated based on a history of disagreements will learn to retreat from conflict rather than resolve it (groza et al., 2003). siblings placed separately may show more aggression and be more depressed than children who are placed with siblings (smith, 1998). these two factors may be related in that children who have fewer interpersonal skills may experience greater conflict while together and then more aggression or depression when separated from their siblings. it is reasonable to believe that children might benefit by learning new communication skills while remaining with their siblings, even in the face of conflict, and could apply such skills across their life course. the foster care system too frequently acknowledges the importance of sibling relationships for children in care without integrating the necessary supports for the preservation of those relationships into the system’s structure. out of respect for the primacy of this relationship and its duration, new york state regulations mandate diligent efforts toward placing siblings together whenever it does not jeopardize the safety, health, or well-being of one of the siblings (smith, 1996). however, in practice siblings may often be separated in foster care for reasons other than those specified by administration of children’s services (acs) regulations. these issues must be rectified in order to uphold the mandate and best serve children in foster care. similarly, the importance of sibling placement has been recognized on a federal level. the administration for children and families’ child and family service reviews (cfsr), a national effort to monitor state agency compliance with child welfare requirements, also considers sibling placement in its examination of child and family outcomes (administration for children and families, 2004). risks and consequences of separation families facing chronic poverty and its potential stresses including high levels of internal chaos, a lack of clearly defined roles, or a want of parenting and disciplining skills, may be more likely to produce highly stressed and maladjusted children. these lower functioning children are in greater danger of being placed in foster care and, at that time, being separated from siblings due to behavioral or safety concerns. older siblings are particularly at risk since they may have lived in adverse conditions for a longer period of time than their younger siblings and are at increased risk of reactive behavioral the sibling relationship in foster care 1� journal of student social work, volume iv problems (tarren-sweeney & hazell, 2005). these behavioral problems and safety concerns, in turn, are used as arguments for separation of siblings during placement. in a sample of nearly 12,000 children in care, less than half were placed with all of their siblings, while one third were not placed with any sibling (shlonsky, webster, & needell, 2003). according to hegar (2005), the greatest risk factors for separate placements are: age, sibling group size, timing of entrance into care, and the presence of special needs within the sibling group. specifically, hegar found that older children are kept with siblings less frequently, large sibling groups are harder to place, and children entering care at different times are not tracked as a sibling unit but as individuals. children deprived of their sibling relationships may react behaviorally and emotionally, showing signs of guilt, a loss of self-esteem, grief, anger and acting out, anxiety, developmental setbacks (especially in identity formation), and depression (tarren-sweeney & hazell, 2005; herrick & piccus, 2005). the emotional and behavioral symptoms of children who have been separated from their siblings in care may resemble the symptoms of children experiencing the death of a parent or sibling. many children in foster care experience multiple losses, which include the loss of parents, of home, of siblings, of school, of peers, and of their role within the family system. these losses are seldom acknowledged by others, leaving the children with disenfranchised, or, as boss (1999) terms it, ambiguous grief; this is a grief that has no name, no rituals, and sometimes no end. devita-raeburn (2004) warns that such losses, unacknowledged by others, can create a life of ennui ranging from strained relationships and dissatisfaction to self-destructive or even suicidal behaviors. certain demographic characteristics also place children at an increased risk for separation from siblings. for example, because of their developmental needs, younger children are often most attached to their siblings, yet are the least likely to be kept with their older siblings (shlonsky et al., 2003). gender, age, and ethnicity regularly limit the placement options for siblings (smith, 1998). sisters are more frequently kept together than brothers (tarrensweeney & hazell, 2005), even though some studies show that boys benefit more from the presence of their siblings (smith). mixed gender sibling groups are more frequently often apart than same gender siblings (shlonsky et al.). thus, children are often frequently and permanently deprived of an important relationship with someone of the opposite gender and all the sheehan journal of student social work, volume iv 1� learning and growth that such a relationship offers. they are also deprived of the roles they play for one another: chaperone, confidante, challenger, mentor, caretaker, guardian, and clown. wendy piccus (2005), an author who has worked and published literature on sibling foster care, entered foster care and lost her “sole purpose” in life, which was being a big sister; she described her separation from her sibling as “devastating” (p. 848). recommendations though more research is needed on the best practices for making sibling placement decisions (chapman, wall, & barth, 2004; shlonsky et al., 2003; smith, 1996; smith, 1998), there is evidence that points to some of the potential benefits of keeping siblings together. such benefits include less time in placement, fewer placements overall, and more stable behavior and emotions in the children who remain with siblings (groza et al., 2003; smith, 1998). children who were placed with a consistent number of siblings, though not necessarily the same siblings, during the length of their out of home care were better adjusted to their foster homes than children separated from siblings or placed inconsistently with siblings (leathers, 2005). foster children placed with siblings were also more likely to be adopted (leathers) and thus more likely to experience a long-term stable home environment. for children from unstable home environments, siblings may provide “a sense of safety and emotional continuity” (shlonsky et al., p. 29). these children, perhaps more than any others, need stability, which siblings can offer (herrick & piccus, 2005). the following changes would help foster care agencies meet the new york state standard for the best interests of siblings in foster care: 1) ensure that children entering care are assigned to the same agency and the same worker. as it now stands in practice, children in foster care may be served by different caseworkers, or even different agencies. this is especially likely when children enter care at different times. children entering care within one month of one another were found to be four times as likely to share a residence than if they entered care at separate times (shlonsky et al., 2003). the need for consistency in caseworker asssignment was furthered by the adoption and safe families act of 1997, which sped up the process of terminating parental rights in hopes of placing children the sibling relationship in foster care 20 journal of student social work, volume iv into permanent homes more quickly. as a result, however, siblings separated during removal from their homes have less time to be reunited (groza et al., 2003). foster care workers now have less time to find a suitable home for a sibling group, which poses unique challenges to the system. therefore, it is crucial that sibling relationships be considered from the very beginning of the placement process, otherwise it becomes unlikely that siblings may ever be reunited. 2) work to recruit foster families and reserve foster homes specifically for sibling placements. at this time, foster care agencies do not specifically recruit foster homes for sibling groups. often, those foster homes able to care for multiple children have already been filled by individual children and are unavailable when a sibling placement is needed. homes that could potentially accept sibling groups should be reserved for sibling groups, rather than filled with single children as they enter the system (leathers, 2005). also, as groza et al. (2003) note, the amount of physical space required per child could be reduced from the requirements currently in place for for single children, potentially freeing up more homes to accept sibling groups. even though most foster parents and caseworkers report that they want siblings to remain together and believe there is no added burden in keeping them together, caseworkers report that intact placement options are difficult to find (smith, 1996). in contrast to the caseworkers’ views, foster parents generally felt that sibling groups were no more difficult to care for than non-related children (smith). the foster mothers also felt that siblings integrated more easily into the foster family (smith). caseworkers believed the opposite: caseworkers felt that siblings had more trouble integrating into a new family (smith). there seems to be a disconnect between the views of the workers and foster parents. personal biases or preconceptions may be overriding policy and professional education is needed to address these discrepancies. 3) set up regular case reviews for siblings who are separated after initial placement with the goal of sibling reunification whenever possible and as quickly as possible. children in placement who have siblings should receive more frequent reviews of their placements (groza et al., 2003). whelan (2003) suggests that siblings should not always be kept together, especially if the presence of one endangers another or hinders that child’s development. he argues that older siblings who may have a parent-like sheehan journal of student social work, volume iv 21 role in the context of an abusive home may be freed from this burden of responsibility, and ulitimately benefit from an opportunity to take on a new, more appropriate role, if his siblings are placed elsewhere. sensitivity to the roles children have played in what was likely an unsupportive home is critical. however, a parentified role may be a healthy coping response to an abusive situation and may change as children are given the opportunity to redefine their roles and relationships with one another in the context of a more supportive environment. again, professional training would be helpful for caseworkers to be able to support foster parents as they attend to each child’s development. morton and browne (1998) and whelen support the drive to attune workers to these relationships. though siblings may not always get along, if they are separated due to normal sibling rivalries and coping responses, they may regret the loss of that relationship as adults. sibling relationships should be expected to be fluid and evolving. the regard one sibling has for another at any given point in time does not represent the breadth and depth of the relationship and should not determine the future of that relationship. regular and frequent reviews of placements should be mandatory so that if siblings are placed separately they may be reunited as soon as possible, whenever possible. 4) educate caseworkers on attachment theory, disenfranchised grief and ambiguous loss (boss, 1999), and the importance of sibling relationships. the influence of siblings upon development should be mandatory training for all caseworkers so that keeping siblings together becomes an informed priority, rather than an unlikely hope. caseworkers seem to need more training about attachment relationships (grigsby, 1994). in a sample of caseworkers and foster mothers, nearly half did not view a sibling relationship as very important in a child’s life (smith, 1996). furthermore, caseworkers, legal representatives, and politicians may often overlook the “enormity of the losses” (leathers, 2005, p. 817) already endured by children removed from their homes. for these children, as with children whose parent or sibling has died, the world loses its predictability (devitaraeburn, 2004). siblings have the unique ability to offer each other continuity and stability. siblings, perhaps more than parents or other adults, help us to create and understand ourselves. without them, that identity may be fractured or even lost (devita-raeburn), which graduates of the foster care system acknowledge as a common feeling among separated siblings (herrick & piccus, 2005). the sibling relationship in foster care 22 journal of student social work, volume iv 5) empower the children to name their family members, to emphasize key relationships, and to build on their strengths. very few studies cite the preferences or experiences of children in foster care, yet children know their family better than any caseworker. children are best equipped to guide workers towards maintaining close sibling relationships (leathers, 2005) or supporting existing roles within the family system (herrick & piccus, 2005). sibling relationships may serve as “permanent, unconditional relationships” (herrick & piccus, p. 851) that the children can no longer experience with their birth parents nor can they anticipate enjoying from anybody unrelated to them. siblings represent a lifetime relationship. 6) for those children who are separated from siblings, ensure and enforce their rights to regular visitation. children in separate placements are supposed to have regular visitation with each other. however, there is no guarantee of any sibling visits in different placements, and indeed very little support of regular visitation is built into the child welfare system. grigsby (1994) found that siblings placed separately into care lacked documentation of sibling visitations. researchers have found that less than half of these children see their sibling at least monthly, while nearly 80% expressed the desire for more contact with their absent siblings (chapman et al., 2004). only half of children in separate placements believed they would ever live with their siblings again (chapman et al.). also, once children are separated, even if visitation plans are made, the foster and adoptive families may relocate to different communities, geographically severing the sibling bond. 7) sibling supportive placement practices must be integrated into the foster care placement as a framework more than a goal. all forms should include, as a priority, sibling information including ages, educational needs, amount of time spent with the primary sibling, and other factors pointing to shared histories and emotional and practical interdependence. forms could also include the children’s placement desires. children in foster care are rarely given a voice, and, accordingly, emphasis should be placed on strengthening efforts to document children’s preferences as related to sibling placement. sheehan journal of student social work, volume iv 2� conclusion new york state’s commitment to sibling relationships has been solidified by the best interests standard to keep siblings together in foster care whenever possible. it is now time to put policy into practice. new systems must be developed to accurately track siblings in placement. sibling groups, even if placed separately, should all be guarded by the same caseworker who has been educated on sibling issues and supports the policy to reunite siblings as quickly as possible when it does not endanger one of the siblings to do so. foster families have already indicated their support of sibling relationships and their belief that siblings are no more difficult to care for than unrelated children. foster families, then, may be more receptive to accepting sibling groups than caseworkers imagine them to be. more research needs to be conducted on the best practices when making sibling placement decisions. future research should especially focus on the long-term effects of sibling separation from the point of view of the children themselves, particularly emotional well-being as measured by self-esteem, feelings of worth, and interpersonal skills. this information, along with the appropriate and supportive theoretical and practical frameworks, should be regularly disseminated to caseworkers in order that they may best serve the interests of the children they work to protect. references administration for children’s services. (2005). the children’s services update. retrieved december 1, 2005, from http://www.nyc.gov/html/ acs/html/home/home.shtml administration for children and families. (2004). child and family services review summary of key findings fiscal year 2003-2004. retrieved february 27, 2006, from www.acf.hhs.gov/programs/cb/ cwmonitoring/results/ keyfindings2003.htm boss, p. (1999). ambigious loss. cambridge, ma: harvard university press. chapman, m. v., wall, a., & barth, r. (2004). children’s voices: the perceptions of children in foster care. american journal of orthopsychiatry, 74(3), 293-304. devita-raeburn, e. (2004). the empty room: surviving the loss of a brother or sister at any age. new york: scribner. grigsby, r. k. (1994). maintaining attachment relationships among children the sibling relationship in foster care 2� journal of student social work, volume iv in foster care. families in society, 75(5), 269-276. groza, v., maschmeier, c., jamison, c., & piccola, t. (2003). siblings and out-of-home placement: best practices. families in society, 84(4), 480-490. hegar, r. (1993). assessing attachment, permanence, and kinship in choosing permanent homes. child welfare, 72(4), 367-378. hegar, r. (2005). sibling placement in foster care and adoption: an overview of international research. children and youth services review, 27(7), 717-739. herrick, m. a., & piccus, w. (2005). sibling connections: the importance of nurturing sibling bonds in the foster care system. children and youth services review, 27(7), 845-861. leathers, s. (2005). separation from siblings: associations with placement adaptation and outcomes among adolescents in long-term foster care. children and youth services review, 27(7), 793-819. morton, n., & browne, k. (1998). theory and observation of attachment and its relation to child maltreatment: a review. child abuse & neglect, 22(11), 1093–1104. shlonsky, a., webster, d., & needell, b. (2003). the ties that bind: a cross-sectional analysis of siblings in foster care. journal of social service research, 29(3), 27-52. smith, m. (1996). an exploratory survey of foster mother and caseworker attitudes about sibling placement. child welfare, 75(4), 357-375. smith, m. (1998). sibling placement in foster care: an exploration of associated concurrent preschool-aged child functioning. children and youth services review, 20(5), 389-412. tarren-sweeney, m., & hazell, p. (2005). the mental health and socialization of siblings in care. children and youth services review, 27(7), 821-843. whelan, d. (2003). using attachment theory when placing siblings in foster care. child and adolescent social work journal, 20(1), 21-36. katherine sheehan is a second year master’s student at cussw. she is currently an intern at st. vincent’s services families in transition program in brooklyn, ny. she holds a master’s degree in comparative literature from the university of north carolina at chapel hill, a dcf in french literature from the university of paris sorbonne, and a bachelor’s degree in french and english from birmingham-southern college. her email address is kms2123@ columbia.edu. sheehan journal of student social work, volume iv 2� 63 diagnostic disclosure social work practice with children perinatallyinfected with hiv: considerations regarding diagnostic disclosure the development of antiretroviral therapies (arts) has signifi cantly lengthened the lifespan and changed the life course of most individuals infected with hiv and aids in the united states. furthermore, art use during pregnancy has signifi cantly reduced the rate of mother-to-child (perinatal) hiv transmission. while perinatal infection rates among children in the united states have declined since the 1990s, art regimens became standard treatment protocol, there remains a population of children entering adolescence who were born hiv-positive. this paper discusses: 1) the importance of diagnostic disclosure of hiv and aids status to infected children, 2) stigma and the disclosure process with children, and 3) the role of clinical social workers in facilitating the disclosure process. he most common means of human immunodefi ciency virus (hiv) transmission to children in the united states is through mother-to-child vertical transmission during pregnancy (center for disease control [cdc], 2006a). perinatal transmission increased throughout the 1980s and peaked during the early-to mid-1990s, during which time an estimated 1,750 children were born perinatally-infected each year (cdc, 2004; lindegren, et al., 1999). since the beginning of the hiv and aids epidemic in the united states, about 57% of perinatally-infected children have died as a result of aids-related complications (cdc, 2004; 2006a). since the mid-1990s, the introduction of arts combined with hiv and aids testing among pregnant women has signifi cantly reduced the risk of mother-to-child hiv transmission (cdc, 2006a; lindegren, et al., 1999). by the year 2000, the number of perinatal hiv and aids infections had decreased to about 325 annually. currently, an estimated 9,419 perinatally-infected children are living in the united states (wiener & battles, 2006). still, disclosure of an hiv and aids diagnosis remains a challenging topic for parental caregivers. research indicates that 25 to 75% of school-aged children with hiv or aids do not know their status (blasini, et al., 2004; lester, et al., 2002; mellins, et al., 2002). the american academy of pediatrics recommends that all hiv-infected and aids-positive natasha k. nalls t 261809_columbia 01-72 sec1:63261809_columbia 01-72 sec1:63 4/5/07 2:12:34 pm4/5/07 2:12:34 pm 64 journal of student social work, vol. v school-aged children be disclosed to and educated regarding their diagnosis and health status (committee on pediatric aids, 1999). the majority of perinatallyinfected children living with hiv and aids are african american (60%) and latino (20%) (cdc, 2004; cdc, 2006a). stigma and hiv and aids diagnostic disclosure the use of arts has made perinatallyand adult-acquired hiv a disease comparable to cancer in terms of its clinical course as a chronic, long-term, sub-acute, yet life-threatening disease (mellins, et al., 2002; brown, laurie, pao, 2000). however, unlike cancer, hiv and aids has greater social stigma, perhaps related to the high hiv transmission rates and short-term life expectancy of aids-infected homosexual and substance abusing populations during the 1980s and 1990s (fife & wright, 2000). the stigma is highly related to the fact that the virus is often transmitted through sexual contact (valdiserri, 2002). though male-to-male sexual contact remains a risk factor, the risk of hiv transmission through heterosexual sex and drug use is greater still. moreover, research has shown that many misconceptions exist about the actual modes of hiv transmission (herek, capitanio, & widaman, 2002). several factors affect a caregiver’s decision to tell a child of his or her hiv or aids status. social stigma is a primary reason why parents are reluctant to disclose. a desire to protect the infected child from social ostracism combined with a sense of guilt related to mother-to-child transmission of the virus may plague the family system (committee on pediatric aids, 1999; blasini, et al., 2004). in addition, parents may be concerned that the child may then disclose to others, jeopardizing the social standing of all family members (nehring, 2000; lashley & malm, 2000). fife and wright (2000) noted that the social stigma associated with hiv and aids is related to internalized feelings of shame and social isolation. the current literature examining hiv and aids disclosure to children has posited contradictory research fi ndings about the impact of disclosure on a child’s health and mental health outcomes. some studies have shown that hiv and aids status disclosure to children generally results in positive outcomes for both children and their parental caregivers. parental caregivers have reported a sense of relief after disclosure, as well as lower levels of stress, compared to parental caregivers who have not disclosed (blasini, 2004; committee on pediatric aids, 1999). contrary to caregivers’ concerns related to social stigma, there are no indications that knowledge of hiv and aids diagnosis n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:64261809_columbia 01-72 sec1:64 4/5/07 2:12:35 pm4/5/07 2:12:35 pm 65 signifi cantly increases psychological distress or mental health problems among children (wiener & battles, 2006). a growing body of literature suggests that children who are disclosed to have higher self-esteem and are less depressed compared to their non-disclosed to counterparts (mellins, et al., 2002; committee on pediatric aids 1999). mellins, et al. (2002) suggested that the burden of an “unknown secret” may be psychologically taxing and create worrisome thoughts for a child. another study suggested that the occurrence of psychiatric disorders among perinatally-infected youth were comparable to the occurrence in non-infected youth, suggesting that perinatally-infected hiv youth were not at greater risk for mental health diffi culties (mellins, 2006). furthermore, disclosure seems to be an important factor in garnering social support around the diagnosis and the child’s care. the earlier children learn about their hiv status, the more people they disclose to by the time they reach adolescence (wiener & battles, 2006). having friends and relatives who know these children’s medical status is important for social support. children and adolescents living with hiv and aids who are not disclosed to exhibit more confusion about their illness and medication compliance (abadia-barrero & larusso, 2006). over time, these children may become cynical about their care and develop attitudes of shame and anger. other research, however, has highlighted the negative outcomes of disclosure. for example, disclosing hiv and aids status to friends and family may heighten caregiver and child stress levels and feelings of anger, particularly because disclosure to family and friends may be only in response to the child’s declining health (ledlie, 1999). these increased feelings of stress and anger, in turn, may decrease medication adherence (garvie, 2006). furthermore, some parental caregivers have reported that, following disclosure, their child experienced emotional distress due to concerns about his or her own long-term reproductive and family planning (mellins, 2002). contrary to other fi ndings regarding perinatally-infected children, gaughan, et al. (2004) reported a higher incidence of psychiatric hospitalizations among children and adolescents living with hiv and aids along with a signifi cantly higher occurrence of depression and behavioral disorders. still, despite the lack of consensus, battles and wiener (2002), in a review of the literature, noted that most researchers found that disclosure is positively related to social support, feelings of self-competence, and decreased behavioral problems among children. the diagnostic disclosure process diagnostic disclosure n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:65261809_columbia 01-72 sec1:65 4/5/07 2:12:35 pm4/5/07 2:12:35 pm 66 journal of student social work, vol. v as children perinatally-infected with hiv and aids age, disclosure of their hiv and aids status by caregivers, medical professionals, social workers, and psychologists becomes a sensitive yet important clinical issue that must be addressed. disclosure of hiv and aids status at an early age is important for several reasons. first, children perinatally-infected with hiv and aids are most likely to be urban, low-income, and african american or latino (cdc, 2004). studies have shown that this population is especially at risk for an early onset of sexual activity and drug use (cdc, 2004). as a result, this hiv and aids infected sub-population is at an increased risk of transmitting the virus via sexual intercourse and drug use (browning, leventhal, & brooks-gunn, 2004). in addition, research has suggested a signifi cant correlation between disclosure and positive health status as measured by viral load. children who know their health status are more likely to adhere to an art and have a lower viral load, demonstrating a better health status (blasini, et al., 2004). this is important because failure to adhere to an art regimen may result in treatment resistance, therefore compromising the child’s long-term health prognosis (matsui, 1997). in this way, disclosure is closely related to transmission prevention and the child’s health maintenance. ideally, disclosure should be conducted gradually throughout the child’s development and include the support of health and mental healthcare providers. disclosure should never occur as a “single revelation” (domek, 2006). parental, peer, and mental health staff support are all key to successful disclosure (blasini, et al., 2004). as with grieving around other chronic, potentially terminal illnesses, children and adolescents with hiv and aids will likely go through the following stages of grieving: anger, bargaining, depression, and ultimately, acceptance (blasini, et al., 2004; kindy-mcpherson, 2005). immediately following disclosure, children report feeling shocked, sad, angry, worried, and confused (mellins, et al., 2002). over time, children’s anxious feelings generally become more neutralized, and many have reported feeling hopeful about their prognosis. domek (2006) noted that it may take children some time to understand the nature of their diagnosis, necessitating an ongoing, open dialogue of what the disease is and what the diagnosis means. in addition, disclosure may provide a context to reveal other family secrets, such as other infected family members, the child’s biological parents, the child’s health prognosis, and that the child was perinatally-infected. though families may be in denial and refuse to disclose to their children, it is not uncommon for children to “accidentally” learn of their diagnosis by overhearing conversations or reading something related to their health status n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:66261809_columbia 01-72 sec1:66 4/5/07 2:12:36 pm4/5/07 2:12:36 pm 67 (e.g., medical charts, insurance paperwork, or school medical records). or, for example, a child may discern that he or she has a medical condition based on family members’ behaviors, a consistent medication regimen, and ongoing medical care (champ+, 2007; lester, et al., 2002). this type of accidental disclosure is dangerous and should be avoided because emotional isolation may develop as children independently attempt to make sense of what their diagnosis means and why it has been hidden from them (blasini, et al., 2004). despite these risks, social work clinicians should not force a parental caregiver to disclose to a child, and they should remain non-judgmental about the guardian’s decision around disclosure; clinician respect for each family’s right to self-determination is most important. the clinician’s fi rst and foremost role is to provide ongoing support to the family system, taking into consideration the family’s community and ongoing stressors (kindy-mcpherson, 2005; lester, et al., 2002). less expressive and less communicative families, who are also less likely to disclose to their children, may need additional support (lester, et al.). the disclosure process should take into consideration the child’s age, maturity, cognitive functioning levels, and ability to handle the diagnosis (committee on pediatric aids, 1999; lester, et al., 2002). while younger children should receive simple explanations about their medical condition, older children should be provided with full disclosure and be encouraged to actively participate in their own medical care (committee on pediatric aids, 1999). due to developmental differences, children and preadolescents understand that hiv and aids are serious illnesses, but they do not relate it to their future, as adolescents do (blasini et al., 2004). this likely refl ects adolescents’ emotional, social, and physical development, and their general interests in romantic relationships and considerations around family planning. implications for social work practice social workers may encounter perinatally-infected youth in a number of contexts, including hospitals, outpatient pediatric aids clinics, child welfare agencies, and schools. within these settings, where there are few interventions tailored to the needs of perinatally-infected children, social workers are in a unique position to provide mental health service support for this population’s ongoing and emerging mental health needs. social workers’ skill sets in the areas of engagement, assessment, advocacy, case management, and crisis intervention, combined with their conceptual grounding in ecosystems theory, make them especially qualifi ed to assist families facing enormous psychodiagnostic disclosure n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:67261809_columbia 01-72 sec1:67 4/5/07 2:12:36 pm4/5/07 2:12:36 pm 68 journal of student social work, vol. v social-environmental problems related to the disclosure process. a full understanding and consideration of the child’s particular family circumstance and health status is imperative. the child’s family represents a group directly affected by hiv and aids. at a social worker’s point of contact, the child may be living with an infected parent, a non-infected parent, within the foster care system, or with another family member, such as a grandmother or uncle. furthermore, the child may also have infected siblings and other family members, or be the only infected person within the entire family. in addition, some perinatally-infected children may be very healthy; others, however, may be chronically ill, very symptomatic, and present with signifi cant immunological deterioration (lester, et al., 2002). the mental health status and daily concerns of these two populations may be very different. psychodynamic, emotional peer support groups for hiv-infected adolescents can help reduce the risk of depression and increase medication adherence (funck-brentano, 2005). disclosure to preadolescents and adolescents should include a psycho-educational component and at least some discussion about self-care and responsibility related to future independent living (battles & wiener, 2002). clinical work with this population should include a thorough sexual education component and foster the development of communication skills related to negotiating safe-sex practices and disclosing hiv and aids status to sexual partners. furthermore, “one stop care” that offers counseling and social support, case management services, standard medical care, reproductive care and education, enables social service and medical providers to collaborate and offer responsive, comprehensive care along a continuum that addresses this population’s unique needs (levine, aaron, & foster, 2005). conclusion the onset of adolescence combined with the uncertainty of a chronic, life-threatening, and highly stigmatized illness undoubtedly creates a context for fear, anxiety, and feelings of isolation among perinatally-infected hiv and aids positive children and adolescents. disclosure, especially early on, may buffer these feelings, providing the child with an increased sense of hope, confi dence, and self-esteem. these children are likely to confront a host of other issues, including poverty, discrimination, mental health issues, violence, sexual abuse, limited access to health care, and lack of familial support. responsible, clinician-led support may serve as the basis for the development of self-agency, resiliency, self-advocacy, and self-actualization among these n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:68261809_columbia 01-72 sec1:68 4/5/07 2:12:37 pm4/5/07 2:12:37 pm 69 children (battles & wiener, 2000; brown, lourie, & maryland, 2000, domek, 2006; kindy-mcpherson, 2005). references abadia-barrero, c. & larusso, m. (2006). the disclosure model versus a developmental illness experience model for children and adolescents living with hiv/aids in sao paulo, brazil. aids patient care and stds, 20(1), 36-43. battles, haven b. & wiener, lori s. (2002). from adolescence through young adulthood: psychosocial adjustment associated with long-term survival of hiv. journal of adolescent health, 30(3), 161-168. blasini, i., chantry, c., cruz, c., ortiz, l., salabarria, i., & scalley, n., et al. (2004). disclosure model for pediatric patients living with hiv in puerto rico: design, implementation, and evaluation. journal of developmental & behavioral pediatrics, 25(3), 181-189. brown, l., lourie, k., & pao, m. (2000). children and adolescents living with hiv and aids: a review. the journal of child psychology and psychiatry and allied disciplines, 41(1), 81-96. browning, c., leventhal, t., & brooks-gunn. (2004). neighborhood context and racial differences in early adolescent sexual activity. demography, 41(4), 697-721. centers for disease control and prevention. (2006a, may). cdc hiv and aids fact sheet: mother-to-child (perinatal) hiv transmission and prevention. retrieved november 1, 2006, http://www.cdc.gov/hiv/ resources/factsheets/perinatl.htm centers for disease control and prevention. (2006b, april ). cdc hiv and aids fact sheet: a glance at the hiv and aids epidemic. retrieved november 1, 2006, http://www.cdc.gov/hiv/ resources/factsheets/at-a-glance.htm centers for disease control and prevention. (2004). youth risk behavior surveillance united states, 2003. morbidity and mortality weekly report, 53(ss-2), 1–29. centers for disease control and prevention. (2004). cases of hiv infection and aids in the united states, 2004. retrieved november 1, 2006, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/ default.htm centers for disease control and prevention. (2006, september). revised diagnostic disclosure n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:69261809_columbia 01-72 sec1:69 4/5/07 2:12:37 pm4/5/07 2:12:37 pm 70 journal of student social work, vol. v recommendations for hiv testing of adults, adolescents, and pregnant women in health-care settings. morbidity and mortality weekly report, 1-17. retrieved november 1, 2006, http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5514a1.htm champ+: supporting hiv-infected youth and families (january, 2007). [data from interviews with hiv-infected youth] mount sinai school of medicine. unpublished raw data. committee on pediatric aids. (1999). disclosure of illness status to children and adolescents with hiv infection. pediatrics, 103(1), 164-166 cooper, e., charurat, m, & mafenson, l., et al. (2002). combination antiretroviral strategies for the treatment of pregnant hiv-1 infected women and prevention of perinatal hiv-1 transmission. journal of acquired immune defi ciency syndrome, 29(5), 484-94. domek, g. (2006). social consequences of antiretroviral therapy: preparing for the unexpected futures of hiv-positive children. the lancet, 367(9519), 1367-1370. fife, b. & wright, e. (2000). the dimensionality of stigma: a comparison of its impact on the self of persons with hiv and aids and cancer. journal of health and social behavior, 41(1), 50-57. funck-brentano, dalban, c., veber, f., quartier, p., et. al (2005). evaluation of a peer support group therapy for hiv-infected adolescents. aids, 19(14), 1501-1508. garvie, p., cremeens, j., rai, s., an, qian, hadley, w., & west, r. (2006, april). disclosure of children’s perinatally-acquired hiv-1 diagnosis in relation to medication adherence, physical functioning, & parental psychological functioning: a prospective pilot study of process & outcome. paper presented at the biannual conference on children’s health psychology, gainesville, fl. gaughan, d., hughes, m. oleske, j., malee, k., gore, c., &nachman, s. (2004). psychiatric hospitalizations among children and youths with human immunodefi ciency virus infection. pediatrics, 113(6), 544-551. herek, g., capitanio, j., & widaman, k. (2002). hiv-related stigma and knowledge in the united states: prevalence and trends 1991-1999. american journal of public health, 92(3), 371-377. kindy-mcpherson, j. (2005). to tell or not to tell: bereaved undisclosed children and hiv and aids. relational child & youth care practice, 18(1), 75-79. ledlie, s. (1999). diagnosis disclosure by family caregivers to children who n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:70261809_columbia 01-72 sec1:70 4/5/07 2:12:37 pm4/5/07 2:12:37 pm 71 have perinatally acquired hiv disease: when the time comes. nursing research, 48(3), 141-149. lester, p., chesney, m., cooke, m., weiss, r., whalley, p., perez, b et al. (2002). when the time comes to talk about hiv: factors associated with diagnostic disclosure and emotional distress in hiv-infected children. journal of acquired immune defi ciency syndromes, 31(3), 309-317. levine, a., aaron, e., foster, j. (2005). pregnancy in perinatally hiv-infected adolescents. journal of adolescent health, 38(6), 765-768. lindegren, m., byers, r., thomas, p., davis, s., caldwell, b., et al. (1999). trends in perinatal transmission of hiv and aids in the united states. journal of the american medical association, 282(6), 531-538. matsui, d.m. (1997). drug compliance in pediatrics: clinical and research issues. pediatric clinics of north america, 44(1), 1-14. mellins, c.a., brackis-cott, e., dolezal, c., richards, a., & abrams, e. (2002). patterns of hiv status disclosure to perinatally infected hiv positive children and subsequent mental health outcomes. journal of child psychology and psychiatry, 7(1), 101-114. mellins, c.a., brackis-cott, e., dolezal, c., & abrams, e. (2006). psychiatric disorders in youth with perinatally acquired human immunodefi ciency virus infection. pediatric infectious disease journal, 25(5), 432-437. nehring, w., lashley, f., & malm, k. (2000). disclosing the diagnosis of pediatric hiv infection: mother’s views. journal of the society of pediatric nurses, 5(1), 5-14. thorne, c., newell, m., botet, f., bohlin, a., ferrazin, a., giaquinto, c., et al. (2002). older children and adolescents surviving with vertically acquired hiv infection. journal of acquired immune defi ciency syndromes, 29(4), 396-401. un aids. (2006). fact sheet: north america, western, and central europe. retrieved november 1, 2006, http://www.unaids.org/en/hiv_data/ 2006globalreport/press-kit.asp valdiserri, r. (2002). hiv/aids stigma: an impediment to public health. american journal of public health, 92(3), 341-342. wiener, l., & battles, h. (2006). untangling the web: a close look at diagnosis disclosure among hiv-infected adolescents. journal of adolescent health, (3), 307-309. diagnostic disclosure n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:71261809_columbia 01-72 sec1:71 4/5/07 2:12:38 pm4/5/07 2:12:38 pm 72 journal of student social work, vol. v natasha k. nalls is a second year master’s student at cussw within the advanced generalist practice and programming method in the health, mental health, and disabilities fi eld of practice. she currently interns at mount sinai school of medicine in the department of psychiatry, where she assists with research implementation and coordination. ms. nalls holds a bachelor’s degree in spanish and leadership studies from claremont mckenna college. her email address is nn2144@columbia.edu. n a t a s h a k . n a l l s 261809_columbia 01-72 sec1:72261809_columbia 01-72 sec1:72 4/5/07 2:12:38 pm4/5/07 2:12:38 pm journal2012   9        columbia social work review, volume iii  a license to abuse?  the need for national policy reform of kinship  care licensing procedures    amanda prater    the last 20 to 30 years have seen a significant rise in the use of  kinship care as a formal out­of­home placement option for  abused or neglected children in the government’s custody. this  shift has generated debate concerning the benefits and risks of  kinship care, and thus far, research findings are largely inconclu­ sive. notably, there has not been an accompanying formal and  holistic review and reformation of relevant child welfare policies.  one particularly critical legislative area that has been over­ looked by the existing literature is the process by which states  license kinship foster homes. due to the lack of federal leadership  in setting universal safety standards for kinship care licensing  procedures, states’ policies may fail to protect children adequate­ ly. an overview of current federal policy is presented, and the  state of indiana is used as a case study to provide a basis for un­ derstanding the significant gaps in states’ policies that necessi­ tate national policy reform. federal mandates are necessary to  ensure that all states provide a consistent and proper level of  safety for vulnerable children. finally, recommendations for ap­ propriate new policies are made.!     over the last two to three decades, kinship care has be­ come an increasingly popular placement option for children who  were removed from their homes by the child welfare system fol­ lowing a report of parental abuse or neglect (geen, 2004; u.s.  department of health and human services [us dhss], 2000). in  the child welfare field, there is a consensus that placing children  with kin reduces the trauma of being removed from their home  and possibly leads to improved outcomes across a spectrum of  measures compared with children placed in traditional foster  homes (gibbs & müller, 2000; rubin et al., 2008; wilson, 1996;  winokur, crawford, longobardi, & valentine, 2008; winokur,  holtan, & valentine, 2009). in response to these perceived bene­ prater  columbia social work review, volume ii        10  fits, the personal responsibility and work opportunity reconcili­ ation act (p.l. 104­193) of 1996 prioritized placement with kin  over placement with nonkin foster parents, which led states to  increase their usage of kinship care (allen, devooght, & geen,  2008).   the movement toward kinship care, however, is based on  research that is insufficient in scientific rigor, scope, and depth  (geen, 2004; winokur et al., 2009), and for this reason, consider­ able debate exists regarding the balance between the benefits and  detriments of kinship care (gibbs & müller, 2000; rubin et al.,  2008). children placed in kinship care experience higher levels of  poverty; live with aging and less physically and mentally healthy  caregivers; and are exposed to physical safety hazards, violence,  and drug and alcohol use at a higher rate than children in nonkin  placements (bartholet, 1999; ehrle, geen, & clark, 2001; geen,  2004; koh, 2010; pecora et al., 2009; rubin et al., 2008; u.s.  dhss, 2000). in one of the few longitudinal studies conducted on  the practice, kinship care was also shown to be associated with  higher levels of “unhappiness with life” and “the presence of pro­ longed anxiety” in adult women who lived in kinship care as chil­ dren (carpenter & clyman, 2004). despite a greater need for ser­ vices due to the above risks, kinship caregivers continue to re­ ceive fewer services than traditional foster parents (geen, 2004;  rubin et al., 2008).  these concerns notwithstanding, the rapidly increasing  number of children in need of placement without a corresponding  increase in nonkin caregivers, as well as the observed benefits of  kinship care, underscore the necessity to continue providing kin­ ship care as a viable option (geen, 2004; u.s. dhss, 2000). in  light of contradictory research findings, however, national and  state policies should incorporate unambiguous precautions on the  use of kinship foster homes. although the efficacy of kinship care  has been a primary focus of debate in the literature (geen, 2004;  gibbs & müller, 2000), the role of licensing procedures in con­ tributing to the safety of kinship foster homes has been largely  overlooked. there is currently no federal law that cogently man­ dates national safety guidelines for states to follow when licens­ ing kinship foster homes, which results in unequal levels of pro­ a license to abuse?  11        columbia social work review, volume ii  tection for vulnerable children across state lines. the practices  used by some states to approve kinship home licenses are danger­ ously lenient. indiana is one of the worst culprits, and is used here  as a case study in order to better understand the crucial need for  improvements in federal­ and state­level policies. the following  analysis provides innovative approaches to improve existing fed­ eral and state kinship care licensing policies, and calls upon feder­ al and state legislatures to implement necessary amendments to  current relevant law.    current status of federal licensing regulations    although federal law regarding kinship foster home licen­ sure encourages certain licensing policies by restricting the avail­ ability of funds and reimbursements depending upon states’ laws,  there is no national standard that dictates that kinship care licens­ ing requirements ensure minimal assurance of a child’s safety (42  u.s.c. 671; allen et al., 2008; geen, 2004). the standards that  states typically require for licensing traditional foster parents in­ clude the completion of a home study assessment by a trained so­ cial worker, positive references from nonrelatives, space require­ ments in the home, completion of several hours of training on  how to care for abused and neglected children, income require­ ments, and clearance of criminal history and child abuse back­ ground checks (allen et al., 2008). federal law in title iv­e of  the social security act stipulates that standards of licensure for  kinship foster parents must match the nonkin standards in order  for the state to receive federal reimbursements for foster care pay­ ments made to such a family (42 u.s.c. 671; allen et al., 2008;  child welfare information gateway, 2012; geen, 2004). thus,  the federal government encourages states to apply their nonkin  licensing standards equally to kinship caregivers by making such  a policy more fiscally beneficial than using a separate (often less  strict) process. yet the federal law falls grievously short of mak­ ing this a requirement that states must follow.  despite the government’s claim that the intended purpose  of this stipulation in title iv­e is to ensure the safety of a foster  placement (geen, 2004), logical inconsistencies indicate that fi­ prater  columbia social work review, volume ii        12  nancial motivations eclipsed safety considerations in this policy  choice (allen et al., 2008; geen, 2004). if the denial of federal  funds to nonlicensed kinship foster families were truly about safe­ ty concerns, then the policy would prohibit nonlicensed place­ ments under all circumstances. on the other hand, if nonlicensed  kinship placements were deemed safe, then there would be no  reason for the government to deny funds in any case. the afore­ mentioned situations are mutually exclusive: it does not make  sense that the withholding of funds is due to safety concerns and  at the same time the government allows placements in unsafe  homes. consequently, it holds that safety must not be the decid­ ing factor of whether or not to reimburse states (allen et al.,  2008). instead, it is probable that these title iv­e provisions are  financially motivated as a convenient avenue for the federal gov­ ernment to curtail national spending on foster care.  it is imperative that the federal government embrace a  leadership role in ensuring that children’s safety is unquestiona­ bly the paramount concern of the child welfare system. the cur­ rent ambiguity in both the language and intention of the federal  law sets a precedent that leaves far too much room for states to  enact policies that do not ensure the safety of children above any  other considerations, monetary or otherwise. to provide a con­ vincing rationale for national policy reform regarding kinship fos­ ter home licensing, the following section will analyze the specific  adverse effects of the current gap in federal law on one state’s  policies.    case study: indiana’s kinship care licensing policies      the state of indiana was chosen for this case study be­ cause, although the state has some policies in place that regulate  the approval of kinship placements, they are fragmented and only  include minimal provisions for ensuring the safety of children  placed into such homes. the state’s policies are some of the most  dangerous in the country in regard to licensing kinship foster  homes, and the indiana department of child services (dcs) has  a documented track record of egregious and fatal failures in pro­ tecting the children in its care (evans, 2012a; evans, 2012b; ev­ a license to abuse?  13        columbia social work review, volume ii  ans, 2012c). indiana presents an alarming warning of the potential  consequences that could occur in any state due to the lack federal  guidance in issues pertaining to child welfare. this analysis will  rely heavily on two sources: relevant legislation in the indiana  code, and the dcs child welfare policy manual. the policy  manual is based on the applicable laws in the indiana code and  outlines requisite procedures for state employees.   to begin, it is not clear in the dcs policy manual whether  licensing standards for potential kinship caregivers must mirror  the same process and standards as traditional foster parents, or if a  different process, which would not meet federal reimbursements  standards, pertains to potential kinship caregivers. the dcs poli­ cy manual does not include a section dedicated explicitly to li­ censing kinship caregivers, but rather there are fragmented poli­ cies included in various sections regarding licensure of traditional  foster homes. this haphazard approach could easily lead to im­ portant safeguards being overlooked by workers. it is quite possi­ ble that this disorganized method of kinship licensing could be  deliberate in order to allow indiana to claim that they are licens­ ing kin through the same process as nonkin, and thus maintain  eligibility for federal reimbursement.   secondly, whereas indiana code and dcs policies are in  harmony regarding the administration and evaluation of back­ ground checks for potential kinship foster parents, the guidelines  regarding license approval based on the results of those back­ ground checks are questionably lenient (ic 31­27­4­13; ic 31­34­ 4­2; indiana dcs). indiana law allows for the use of waivers to  place children with persons who have criminal or child abuse his­ tories, including felony charges such as battery, criminal confine­ ment, arson, and cases involving a weapon. federal policy cur­ rently mandates that preference for placement with relatives only  applies when “the relative caregiver meets all relevant state child  protection standards” (p.l. 104­193). in addition, waivers of li­ censing standards for kin are only to be used for matters that do  not affect the safety of children, but the federal government al­ lows the state to define what constitutes a “non­safety” standard  (42 u.s.c. 671; allen et al., 2008). the lack of clarity in these  federal policies regarding precisely what constitutes “matters af­ prater  columbia social work review, volume ii        14  fecting the safety of children” and “non­safety standards” has per­ mitted indiana to create policies that allow children to be placed  with a kinship caregiver even if s/he has a documented history of  criminal activity or child abuse.   although stipulations exist in the administration of crimi­ nal history waivers that appear to protect the safety of the child,  there is no system of checks and balances to ensure that dcs em­ ployees comply with all of those caveats. indeed, it is worth not­ ing that according to a manager of a highly esteemed indiana non­ profit foster care agency, indiana dcs workers frequently fail to  discuss the nature or context of criminal history charges with kin­ ship families before approving the placement (personal communi­ cation, november 3, 2011). although the aforementioned policies  allow greater flexibility in promoting family preservation and are  beneficial in certain situations, such as when a potential kinship  caregiver had a past charge of neglect involving an abusive do­ mestic relationship that is no longer an issue, these policies are  overly inclusive to a dangerous degree. in fact, it is possible that  they are in violation of some of the federal policies of the social  security act. title iv­e, section (a)(20)(a) of the social security  act prohibits the apportioning of federal money to any foster  family that was convicted of certain felony charges at any time,  including a crime against children or a crime involving violence,  including rape, sexual assault, or homicide. the legislation also  prohibits a felony conviction for physical assault, battery, or a  drug­related offense within five years of application for foster  care licensure (42 u.s.c. 671). this contradiction between the  state and federal law points to the need for closer federal over­ sight of state policies.   indiana’s lax and poorly enforced policies regarding crim­ inal and child abuse backgrounds endanger children through the  introduction of the possibility of continued abuse or neglect. ex­ isting literature raises critical concerns that while in kinship care,  children may be more likely to be abused than in traditional foster  homes, unsupervised contact with abusive or neglectful parents is  more common, and intergenerational violent behavioral patterns  may emerge more readily and with greater frequency (bartholet,  1999; dubowitz, feigelman, & zuravin, 1993; geen, 2004). the  a license to abuse?  15        columbia social work review, volume ii  following questions are also provoked by critical inconsistencies  in policies regarding waivers: (1) if charges such as domestic bat­ tery are non­negotiable restrictions and automatically disqualify a  relative from becoming a kinship foster parent due to their violent  nature, then what explains the failure to include all violent charg­ es as non­negotiable disqualifiers? (2) if the guiding philosophy  of a given state refuses to acknowledge the potential for batterer  rehabilitation, on what basis does it believe that a person can be  rehabilitated from being guilty of child abuse or from other charg­ es relevant to the care of a child, such as criminal confinement? if  the state lacks clear scientific evidence or a logical protocol re­ garding which crimes endanger a child, then it should always err  on the side of safety. if such evidence exists, then only past  charges with clear indications that no continuing threats exist  should be eligible for a waiver. indiana needs to make relevant  modifications to the indiana code and the dcs child welfare  policy manual to ensure that children are only placed with kin­ ship foster parents when the state can provide clear evidence that  those individuals are able to safely provide for that child’s needs.     recommendations    the purpose of licensing a foster home is to provide an  avenue for assessing and verifying potential caregivers’ abilities  to provide for children’s needs safely and adequately. therefore,  it is essential to consider the impact of national policies on the  integrity of the kinship licensing process in terms of ensuring that  a placement would be in the child’s best interest. although no  studies were identified that contrasted the safety, permanency,  developmental, or other outcomes of children in kinship care to  the type of licensing process that their state utilizes, stricter li­ censing policies are more likely to ensure the physical and emo­ tional safety of a child. legislation that mandates a full licensure  process for kinship care that mirrors standards for nonkin foster  homes would ensure the highest level of safety, assuming adequa­ cy in the state’s full licensing procedures.   the number of states that require kinship caregivers to  complete the same full licensure process as nonkin foster parents  prater  columbia social work review, volume ii        16  has steadily increased over recent years, indicating a preference  for this practice and perhaps demonstrating recognition that this  practice best protects the safety and well­being of children in the  foster care system (allen et al., 2008). in addition, the analysis  presented in this article is not the first sound argument in favor of  an overhaul of the federal policy regarding foster care. a report  by an office of the u.s. dhss found that current licensing and  funding policies are outdated and do not lead to quality services,  and that reimbursement claims do not correlate to service quality  or outcomes (2005). this report confirms that merely tying feder­ al funding to those kinship foster homes that met the same stand­ ards as traditional foster homes is not an effective method to pro­ mote safety.  the limited knowledge on the effects of kinship care war­ rants special caution and additional federal policies to set a na­ tional standard for licensing kinship foster homes. the following  framework for federal legislators creates a clear and separate set  of laws regarding all kinship care placements, regardless of  whether they receive funds from the federal government. these  federal laws, which states would be subject to and which would  take precedence over any state laws, should:   (a) clearly stipulate the standards that kinship caregiv­ ers must meet in order to be approved to care for a  child and outline the practices that workers must  follow in order to complete this process,   (b) require the application of state standards for tradi­ tional foster care licensing to kinship foster parents  and require that standards (c) to (h) are included in  this process, even if they are not required by the  state’s traditional foster care licensing process,  (c) explicitly state that under all circumstances, allow­ able waivers are to be on an individual basis and  only for standards which refer to the caregiver’s  age, income, and the space requirements of the  home,  (d) explicitly require national fingerprint­based crimi­ nal history background checks and child abuse/ neglect registry checks for all states that the appli­ a license to abuse?  17        columbia social work review, volume ii  cant has lived in since the age of 18,  (e) explicitly state that no potential kinship foster par­ ent may be approved if they are shown to have a  history of a criminal offense as listed in title iv­e,  section(a)(20)(a) of the social security act and  that waivers may not be used to circumvent this  standard,   (f)  explicitly state that no potential kinship foster par­ ent may be approved as a caregiver if they are  shown to have had a substantiated case of child  abuse or neglect, unless the charge was due to cir­ cumstances that were out of the person’s control  and/or are no longer occurring (e.g., domestic vio­ lence), and that waivers may not be used to cir­ cumvent this standard,   (g) demand that kinship foster homes undergo a thor­ ough home study and any other assessments  deemed necessary, which are to be completed by a  trained social worker,   (h) demand a check of the state’s own child abuse/ neglect registry prior to placing a child in a home  even under “emergency” circumstances, and pro­ hibit such a placement if a substantiated case is  found,   (i) institute a system of checks and balances to ensure  the proper, full, and ongoing implementation of the  new policies by requiring the naming and authori­ zation of a national office responsible for periodi­ cally verifying states’ adherence to the above poli­ cies and which would have authority to enact ap­ propriate penalties against the state if the standards  are not met.    the adoption of a portion of these proposals, particularly  (c) through (f), would considerably advance current policies in a  direction that ensures the child welfare system is not favoring fi­ nancial or other considerations to the great detriment of its stated  goal of promoting the safety of vulnerable children.    prater  columbia social work review, volume ii        18  conclusion      given its documented benefits and the need for caregivers,  there is reason to continue the use of kinship care. those benefits,  however, will only ensue when the safety of a kinship foster  home is carefully assessed before allowing the placement of a  child. indiana’s child welfare policies demonstrate one example  of a state’s failure to provide necessary precautions to verify the  safety of a kinship foster home. the federal government must  acknowledge and rectify the deleterious impact of states’ danger­ ous policies through national reform of kinship foster home li­ censing procedures. the information presented in this study un­ derscores the necessity of restructuring federal policy to explicitly  demand certain safety standards and provide proper leadership.    references    42 u.s.c. 671. title iv­e, section 471 of the social security act.  retrieved from http://www.ssa.gov/op_home/ssact/ title04/0471.htm.  allen, t., devooght, k., & geen, r. (2008). state kinship care  policies for children that come to the attention of child  welfare agencies: findings from the 2007 casey kinship  care policy survey. retrieved from http:// www.childtrends.org/files/child_trends­ 2009_02_24_fr_kinshipcare.pdf.  bartholet, e. (1999). nobody’s children: abuse and neglect,  foster drift, and the adoption alternative. boston: bea­ con.  carpenter, s., & clyman, r. (2004). the long­term emotional and  physical wellbeing of women who have lived in kinship  care. children and youth services review, 26(7), 673– 686.  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u.s. dhhs. (2005). federal foster care financing: how and why  the current funding structure fails to meet the needs of the  child welfare field. aspe issue brief.  winokur, m., crawford, g. a., longobardi, r. c., & valentine,  d. p. (2008). matched comparison of children in kinship  care and foster care on child welfare outcomes. families  in society: the journal of contemporary social services,  89(3), 338–346.  winokur, m., holtan, a., & valentine, d. (2009). kinship care  for the safety, permanency, and well­being of children re­ moved from the home for maltreatment. campbell sys­ tematic reviews, 1. the campbell collaboration.                            cswrfinal_4.1.13 columbia social work review, volume iv 80 the beauty ideal: the effects of european standards of beauty on black women susan l. bryant black women are particularly vulnerable to the effects of european standards of beauty, because these standards emphasize skin colors and hair types that exclude many black women, especially those of darker skin. using a social work lens, this article explores the black woman’s internalization of european beauty standards through family, peers, the media, and society, and the related outcomes of this internalization on self-perception, academic achievement, sexual behavior, employment, marital status, and mental health. a review of the research indicates that european standards of beauty can have damaging effects on the life trajectories of black women, especially those with dark skin, primarily in the form of internalized self-hatred. suggestions are made for social work practitioners to address the effects of these internalized european beauty standards among black women through programming and clinical practice. “what shall i tell my children who are black? of what it means to be a captive in this dark skin. what shall i tell my dear ones fruit of my womb, of how beautiful they are where everywhere they are faced with abhorrence of everything that is black...?”—margaret burroughs, 1968 kenneth and mamie clark published one of the earliest studies on the effects of skin color and self-perception among black children (clark & clark, 1947). this study, now referred to as the “doll test” (abc news, 2006) and made famous by the landmark case of brown v. board of education, illustrated how black children were negatively affected by european standards of beauty (russell, wilson, & hall, 1992; taylor, 1999). the european beauty standard is the notion that the more closely associated a person is with european features, the more attractive he or she is considered; these standards deem attributes that are most closely related to whiteness, such as lighter skin, straight hair, a 81 columbia social work review, volume iv the beauty ideal thin nose and lips, and light colored eyes, as beautiful (taylor, 1999). in 2005, 58 years after the initial study, kiri davis, a 16year old student, recreated the experiment in a video documentary. her findings suggest that the negative effects of these racialized standards of beauty are still pervasive today (abc news, 2006). the detrimental effect of these european beauty standards on black women is a societal issue that is often unaddressed on a multisystem level. black women today are subjected to incessant messages about european ideals of beauty through family, peers, partners, the media, and larger society. if young black women stand in contrast to what society dictates as attractive, they may find it difficult to grow to accept themselves. as a result, the internalization of racialized beauty standards can perpetuate into a lifelong, intergenerational culture of self-hatred (hunter, 1998). the research discussed in this article serves as a guide to recognize and identify how these standards of beauty can negatively affect the life course of black women, the context in which the impact is felt, and the implications for social work practice and policies. the “doll test” clark and clark (1947) conducted an experiment with 253 black children between the ages of three and seven at nursery and public schools in arkansas and massachusetts. the children were shown two identical dolls, one black and one white. approximately two-thirds of the children indicated that they liked the white doll better, in spite of their own skin color (clark & clark, 1947). when kiri davis recreated this experiment in 2005, her results showed that 16 of the 21 preschool-aged black children involved in the experiment still chose the white doll (abc news, 2006). when asked to show the doll that “looks bad” (abc news, 2006, para. 12), one subject—a black girl—chose the black doll, but when asked for the doll that looked like her, the girl first touched the white doll and then reluctantly chose the black doll (abc news, 2006). bryant columbia social work review, volume iv 82 between 1947 and 2005, the findings of the doll study did not change, suggesting that this internalization of self-hate among black children based on european beauty standards still exists and has not been adequately addressed. a closer look at the literature indicates that this self-hatred permeates throughout the life course, is passed through generations of black women, and is rooted in early childhood interactions with both the immediate environment and the social sphere (robinson-moore, 2008). family context: outcast by kin as a primary component of a child’s early and immediate environment, family is often the biggest influence on a child’s life. family helps shape a child’s ideals, including what is deemed acceptable or unacceptable in terms of beauty (bronfenbrenner, 1993; hutchinson, 2007). raskin, coard, and breland (2001) asked college students in the northeast, between the ages of 17 and 41, about the effect of skin color on their racial identity. the findings showed a significant relationship between one’s attitudes toward his or her own skin color and the skin color that was idealized by their family members. while lighter skin was positively related to higher levels of pride in racial identity, darker-skinned individuals reported lower self-esteem (raskin et al., 2001). school context: assimilation for success the educational system reinforces the messages surrounding skin color that are learned within the family and further encourages young black girls to internalize beauty standards that emphasize lighter skin. umberson and hughes (1987) found that people deemed attractive by society are given more professional and social opportunities from childhood through adulthood, thus giving lighter-skinned black women greater access to success than darker-skinned black women. if society rewards lighterskinned black women with more opportunities, dark-skinned black women may be set up for failure from childhood (robinson-moore, 2008). 83 columbia social work review, volume iv the beauty ideal socio-cultural standards of beauty and attractiveness play a significant role in academic achievement. holcomb-mccory and moore-thomas (2001) investigated the links between skin color and school engagement and found that black adolescent females whose hair and skin color were most unlike those of white females were often alienated from others at school and in social settings. this social isolation resulted in lower levels of academic achievement and higher high-school dropout rates among black adolescent females (robinson-moore, 2008). the lower levels of academic achievement among darker-skinned black girls can ultimately lead to reduced employment outcomes as adults, illustrating how skin color alone can shape the life trajectory of black girls and women (mcadoo, 1997). media context: shades of risk in addition to the beauty standards perpetuated by the family and education system, the media also play a significant role in furthering these standards. gordon (2008) notes that black children are particularly vulnerable to media portrayals due to their higher rates of media consumption. in a sample of 176 black girls ages 13 to 17, gordon (2008) examined associations between the amount of media that black girls’ consume— particularly media containing sexual images—and their focus on beauty and appearance. gordon (2008) found that black girls strongly identified with black music and television and that hair texture and skin tone were central in many of the girls’ descriptions of the images that they were shown. the study’s results suggest that exposure to and identification with portrayals of black women as sex objects contribute to the emphasis that black adolescent girls place on appearance in their own lives (gordon, 2008). townsend, thomas, neilands, and jackson (2010) found a positive relationship between stereotypical images of black women, racialized beauty standards of light versus dark skin, and sexual risk, such as early onset of sexual intercourse or unprotected sex (townsend et al., 2010). these studies suggest that black girls with darker skin may be more vulnerable than their lighter-skin peers to negative messages from the media about bryant columbia social work review, volume iv 84 their physical appearance and attractiveness, which can lead to long-term risky behaviors. employment context: hired by hue after a childhood of potential academic challenges and internalized negative self-perceptions derived from familial and media messages, a darker-skinned black woman reaching adulthood faces significant barriers to her employment prospects if she is deemed less attractive and inferior to a lighter-skinned black woman (robinson-moore, 2008). black women who do not meet the established standards of european beauty are more likely to be unemployed than those who have more of the preferred european physical characteristics (robinson-moore, 2008). aschenbrenner (1975) studied black families in chicago and found that poor women were more likely to have darker skin than women of higher economic status. similarly, umberson and hughes (1987) found that attractiveness bias “interacts with employment status” (p. 231), because attractive people are more likely to be hired and given further opportunities to obtain higher employment and education. thus, if lighter skin is considered to be most attractive, then darker-skinned black women may be more likely to be under-educated, under-employed, and poorer than lighterskinned black women (robinson-moore, 2008), which can have significant negative implications throughout the life course. spousal status: the color of matrimony in addition to employment, romantic relationships can be another major area of black women’s adult lives that are affected by european standards of beauty. social work theory dictates the importance of human beings forming intimate and loving relationships; failure in intimacy results in loneliness and isolation, which may be prevalent for black women of darker skin (hutchinson, 2007). ross (1997) explored the relationship between skin color and the dating preferences of black college students and found that males were more likely than females to prefer dating and marrying people with light skin. 85 columbia social work review, volume iv the beauty ideal similarly, raskin et al.’s (2001) study analyzed the effect of skin color on college students’ racial identity and dating preferences and concluded that lighter-skinned black women are considered a “prize” (p. 2271) among black men who recognize that there are economic and social advantages to having a lightskinned wife, such as greater social acceptance and subsequent employment outcomes (mcadoo, 1997). in general, men of any skin color with higher socioeconomic status are more likely to marry a light-skinned woman (hunter, 1998). darker-skinned black women, as a result, are the least likely of all black women to be married (robinson-moore, 2008) and thus the least likely to have the economic security of a two-income household, further exacerbating the previously addressed negative economic effects of their poor employment prospects. raskin et al. (2001) did not specifically address non-heterosexual couples, so further research would be required to address the skin color preferences of individuals of other sexual orientations. psychological outcomes: the ripple effect the negative effects that european beauty standards can have on employment and marital status can translate to the poor mental health of black women in adulthood. the social work lens aims to help people alleviate stress by understanding the impact that multiple oppressions can have on one’s life (hutchinson, 2007; nasw, 2012). the combination of lower academic achievement, fewer employment opportunities, and limited marital options, compounded by familial and media-perpetuated messages, can lead to both a negative self-perception of the darkerskinned black woman and difficulty coping with the outcomes she can expect for her life course. hall (1995) summarizes the longterm mental health issues that black women may encounter. because black women, especially dark-skinned black women, deviate furthest from european beauty standards, they are more likely to experience self-hate, distorted body image, depression, and eating disorders (hall, 1995). they are also likely to suffer feelings of inadequacy and report emotions of anger, pain, and confusion toward traits such as skin color and hair. many black women bryant columbia social work review, volume iv 86 carry this internalized shame and self-hatred of their appearance from adolescence into adulthood. ultimately, these internalized feelings can be significant risk factors for depression in black women (hall, 1995). keith, lincoln, taylor, and jackson (2010) evaluated the direct and indirect effects of skin tone and discrimination on depressive symptoms and suggested a link between discrimination and emotional well-being that is especially salient for black women. due to their physical attributes and associated socioeconomic factors, such as employment and income, black women are at a greater risk for emotional difficulties, as they may experience more stressful conditions depending on their skin tone. depressive symptoms related to internalized feelings about skin tone may ultimately depreciate feelings of self-worth over the life course of black women (keith et al., 2010). implications for social work practice a review of the research suggests that, based on the preferences demonstrated by their family, peers, potential partners, employers, and greater society, black women today may still feel pressured to choose the white doll. the individuals affected most are the dark-skinned black women who deviate furthest from european standards of beauty. society’s acceptance of european standards of beauty at the expense of those who do not meet them can have pervasive and devastating consequences for darkskinned black women throughout the life course. how can professionals in the social work field recognize and address the darkskinned black woman, who is grappling with repressed selfhatred? the research suggests that oppressive beauty ideals are ingrained into the institutional racism and sexism of american culture. adjusting policies at the national and state level are necessary to address this issue at a macro level, and social workers in administrative and policy-focused positions can play integral roles in this work. yet, because this issue is so entrenched in the communities of these black women, much of the work must be accomplished by social workers on the ground level through pro87 columbia social work review, volume iv the beauty ideal gramming and clinical practice. clinicians and program administrators who work with black women should be aware of the risk factors that these women face across their life course and should be educated on the available resources designed to serve this population. social workers are trained to recognize the forces within dominant culture and society that affect the thoughts, feelings, and behaviors of marginalized individuals and should use this knowledge through their work with this population (cooper, 1998). there are programs currently in place, such as the beautiful. project (the beautiful. project, 2012), black girls rock! inc. (black girls rock, inc., 2012), and sisterhood agenda (sisterhood agenda, 2012), that are geared towards the selfknowledge and self-development of black girls. black girls rock! inc. is a nonprofit youth empowerment organization established to promote the arts through mentorship and leadership development, and encourage a dialogue about the ways women of color are portrayed in the media (black girls rock!, inc., 2012). the beautiful. project uses photography and reflective workshops to give young black girls an opportunity to confront both positive and negative portrayals of black girls and women in the media and in their communities, and seeks to influence the way black girls see the world and the way that the world sees black girls (the beautiful. project, 2012). sisterhood agenda is a nonprofit that empowers women and girls through sisterhood, selfknowledge, self-development, and self-esteem (sisterhood agenda, 2012). there is a necessity for more programs such as these that recognize the unique needs of this population and focus on attending to these needs through dialogue and empowerment. on a direct practice level, social work clinicians working with young black female clients should create a therapeutic relationship that provides positive reinforcement and helps these young women to realize their beauty and to value their own selfworth by using a strengths-based empowerment approach (paniagua, 2005). empowerment is an important approach to therapy with clients from any racial background, but it is especially important in the case of black clients because of the long history of oppression experienced by members of this group. bryant columbia social work review, volume iv 88 in the assessment and treatment of black women, it is important for the clinician to discuss possible racial differences between the client and clinician, explore the client’s level of acculturation to the european beauty ideal, and to avoid offering generalized explanations for problems. incorporating family counseling may be useful in exploring the role the client's family plays in managing the issue (paniagua, 2005). it is important that the therapist avoid any suggestion (either stated or implied) that the client likely comes from a disorganized, unstable, and psychologically unhealthy family. this stereotype does not take into consideration the extent to which factors such as the involvement of the extended family, nontraditional roles of family members, strong religious orientation, or strong emphasis on the value of education, may be strengths of a black family. therapists should emphasize these strengths to encourage and support their client’s participation in therapy (paniagua, 2005). it may also be important to include religious institutions in this process, because for many black women, religious communities are an important part of the extended family. the involvement of religious communities may be particularly important in treating black women, because they tend to be more involved with religious and spiritual activities than black men and view these communities as a source of economic and emotional support (paniagua, 2005). empowering dark-skinned black women with these programs and interventions can help reinforce the notion that all black skin tones should be part of the established beauty standard. through addressing the young black women’s negative selfperception and how it affects an individual’s daily life, social workers may be able to decrease the risks that these young women face across the life course and promote positive life outcomes and self-development. conclusion clark and clark (1947) and kiri davis demonstrated that the internalization of racial beauty standards is a societal problem that begins in childhood and has a significant impact on the self89 columbia social work review, volume iv the beauty ideal perception and self-worth of black girls and women throughout the life course. not only are black women negatively categorized by society for both their gender and race, but they can also be subjugated within their own communities. this article aims to bring awareness to an issue that, if properly addressed, could positively affect the life trajectories of young black women. the self-hatred of black women based on european beauty standards is not commonly acknowledged in social work conversations or practice. black women need to be empowered so that they can protect themselves against the negative messages that they receive from their environment. social workers have a unique opportunity to bring voice to their clients, break the cycle of internalized self-hatred in the black female community, and help create a new definition of beauty. references abc news. (2006, october 11). what dolls can tell us about race in america. retrieved from http://abcnews.go.com/ gma/ story?id=2553348& page=1#.u jh36cxr7ta ashenbrenner, j. (1975). lifelines: black families in chicago. chicago, il: holt, rinehart and winston. black girls rock, inc. (2012). retrieved from http:// www.blackgirlsrockinc.com/ about-us/#.ukrrt4dfbx0 burroughs, m. (2009, july 10). what shall i tell my children who are black? retrieved from http:// www.sojournersplace.com/2009/07/what-shall-i-tell my-children-who-are.html clark, k., & clark, m. (1947). racial identification and prefer ence in negro children. in t. m. newcomb and e. l. hartley (eds.), readings in social psychology. new york, ny: henry holt. cooper, r. (1998). socio-cultural and within-school factors that affect the quality of implementation of school-wide pro grams. retrieved from center for research on the educa tion of students placed at risk. gordon, m. k. (2008). media contributions to african american girls’ focus on beauty and appearance: exploring the con bryant columbia social work review, volume iv 90 sequences of sexual objectification. psychology of wom en quarterly, 32, 245-256. hall, c. c. (1995). beauty is in the soul of the beholder: psycho logical implications of beauty and african american women. cultural diversity and mental health, 1(2), 125 137. holcomb-mccoy, c & moore-thomas, c. (2001). empowering african-american adolescent females. professional school counseling, 5(1), 19-27. hunter, m. l. (1998). colorstruck: skin color stratification in the lives of african american women. sociological inquiry, 68(4), 517-535. hutchison, e. d. (2007). dimensions of human behavior: the changing life course. in e. d. hutchinson (ed.), a life course perspective (3rd ed., pp. 1-38). thousand oaks, ca: sage publications. keith, v. m., lincoln, k. d., taylor, j. r., & jackson, j. s. (2010). discriminatory experiences and depressive symp toms among african american women: do skin tone and mastery matter? sex roles, 62(1-2), 48-59. mcadoo, h. p. (1997). upward mobility across generations in african american families. in h.p. mcadoo (ed.), black families (3rd ed.). thousand oaks, ca: sage publications. nasw. (2012). children and families. retrieved from http:// www.socialworkers.org/pressroom/features/issue/ children.asp paniagua, f. a. (2005). assessing and treating culturally diverse clients: a practical guide. (3rd ed.) thousand oaks, ca: sage publications. raskin, p., coard, s. i., & breland, a. m. (2001). perceptions of and preferences for skin color, black racial identity, and self-esteem among african americans. journal of applied social psychology, 2256-2274. robinson-moore, c. l. (2008). beauty standards reflect eurocentric paradigms-so what? skin color, identity, and black female beauty. journal of race & policy, 4(1), 66-85. ross, l. e. (1997). mate selection preferences among african american college students. journal of black studies, 27 the beauty ideal 91 columbia social work review, volume iv (4), 554-569. sisterhood agenda. (2012, july). about us. retrieved november 14, 2012, from sisterhood agenda web site: http:// sisterhoodagenda.com/about/ townsend, t. g., thomas, a. j., neilands, t. b., & jackson, t. r. (2010). i’m no jezebel; i am young, gifted, and black: identity, sexuality, and black girls. psychology of women quarterly, 34(3), 273-285. umberson, d & hughes, m. 1987. the impact of physical attractiveness on achievement and psychological well-being. social psychological quarterly, 50(3), 227-236 columbia social work review, volume v 21 global trade limitations to hiv medication access in developing countries yixuan wang international trade and patent laws pose monetary and logistical challenges to all countries affected by the hiv/aids epidemic in their abilities to access the most current and effective treatments. the development of international patent law applicable to medications has undergone significant changes since the 1990’s under the agreement on trade related aspects of intellectual property rights (trips) established by the world trade organization (wto). case studies of china, india and brazil’s implementation of pharmaceutical patent protection reveal the limitations of trips and its subsequently recognized flexibilities. although the goal of these flexibilities is to allow for greater access to medications, they fall short in reaching the universally accepted goal of a right to health. despite decreasing incidence, in 2012, 35.3 million people were living with hiv worldwide, and 2.3 million are newly infected each year (unaids, 2013). in order to alleviate the hiv/aids epidemic, the world health organization (who) has expanded coverage of hiv treatment. still, in 2012, only 9.7 million out of over 30 million people in lowand middle-income countries received antiretroviral therapy (unaids, 2013). meanwhile, in wealthier industrialized countries, even more advanced forms of antiretroviral medications are sold that are less toxic, are more effective, and require simpler regimens. challenges to expanding hiv treatment in low-income and developing countries include the inabilities of these countries to import inexpensive pharmaceuticals or manufacture antiretroviral medications domestically because of restrictions placed by the world trade organization (wto). global patent protections on pharmaceuticals increase costs and constrain developing countries’ attempts to access the most advanced forms of antiretroviral medications. the agreement on trade related aspects of intellectual property rights (trips) requires countries within the wto to adopt international intellectual property rules (iprs) which provide strict national protections for competing pharmaceutical companies internationally. specifically, trips obliges all wto member 22 columbia social work review, volume v global trade limitations to hiv medication countries to grant at least 20 years of patent protection for new medications, resulting in costly market prices for new medications (alikhan & mashelkar, 2004). as corporations in developed countries hold the majority of pharmaceutical patents, some advocates maintain that iprs generally reflect the economic interests of those developed countries. to improve access to hiv medications in least developed countries, in 2001, the wto developed the concept of trips flexibilities. initiating trips flexibilities to obtain lower cost medications has proven difficult at a practical level. the challenges and importance of trips policy, its established flexibilities and successes serve to underline inequity in healthcare as a human rights issue. with a focus on the conflict between patent rights and the right to health, this paper focuses on brazil, india, and china as examples of how trips flexibilities help provide adequate access to hiv medications. then, this paper will advocate that trips flexibilities should be unconditionally expanded to all developing countries experiencing an hiv/aids epidemic, not only to those at the lowest degree of development. social workers, particularly those involved in the formulation and evaluation of macro-level policy, are bound under the national association of social workers (nasw) code of ethics to advocate for just and equal treatment of all people, which includes access to healthcare and treatment. this article serves to inform social workers of the complexities involved in accessing hiv/aids treatment in order to improve their ability to advocate for universal access. trips framework the research and development (r&d) of a new hiv medication requires the investment of billions of dollars and intense intellectual labor over many years (smelyanskaya, 2013). in order for pharmaceutical manufacturers to recover r&d costs and provide protection for their products, companies patent their new medications. patent registration grants the manufacturer a certain period of time to exclusively sell their medication on the open market. entities seeking to produce or sell formulations must obtain permission from the patent holder. as a result, pharmaceutical manufacturers may set high prices for their products to maximize profits due to the de facto legalized monopoly that the patent registration effetively creates. established in 1994 during the uruguay round of the general agreement on tariffs and trade, trips requires countries within the columbia social work review, volume v 23 wang wto to establish domestic minimum protection standards for intellectual property products. in addition to iprs inherited from predecessor agreements, trips introduced patent protection of pharmaceuticals into the international trading system. wto members must internalize the iprs of trips into their domestic laws to gain national jurisdiction against international intellectual property rights infringements. developing countries not part of the wto can potentially sell, manufacture, or make use of patented hiv pharmaceuticals without permission of patent holders. however, “special and differential treatment” as a wto member, exemplified in technology transfer and investments from wealthy countries and preferential trading rules, attracts developing countries to join the wto. for example, while wto members trade amongst one another with relatively low tariffs on goods, non-wto countries who trade with wto members incur higher tariffs, potentially hindering domestic economic growth. historically, developing countries strived to become members of the wto and established or modified domestic patent laws to adopt trips iprs in preparation. once admitted, if the patent of a new hiv medication is filed and international valuations remain constant, prices would likely be unattainable for most national health programs in developing countries (intellectual property watch, 2013). under this framework, industrialized countries that export medications achieve legal grounds to initiate trade actions against piracy in developing countries. these restrictions, while offering intellectual protections, place remarkable burden on emerging international economies. while international patent laws may be necessary to drive innovation, royalties drastically drive up the price of new hiv medications and put low-income patients’ lives at risk. generally speaking, the average cost of hiv treatment is $14,000 $20,000 a year (vann, 2009), which is more than ten years’ income for people living in low-income countries (undesa, 2013). for instance, uganda has one of the highest hiv/aids adult prevalence rates around the world (central intelligence agency, 2014), but its gross national income per capita was only $479 a year in 2011 (world bank, 2014). as such, ugandans living with hiv are often unable to access the most effective hiv treatments. the history of flexibilities with the implementation of trips pharmaceutical iprs in the 24 columbia social work review, volume v global trade limitations to hiv medication 1990’s, the conflict between the right to health and intellectual property intensified. in 2010, companies within industrialized countries held more than 80% of the pharmaceutical patents (julian-arnold & gianna, 1993), while over 80% of people living with hiv were in developing countries (avert, 2011). increasingly, the clash between healthcare and economic development began to receive attention internationally, and on august 17, 2000, the united nations high commissioner for human rights approved a resolution on intellectual property and human rights. the resolution claimed that trips did not “adequately reflect the fundamental nature and indivisibility of all human rights, including…the right to health…[t]he apparent conflicts between the intellectual property rights regime embodied in the trips agreement…and international human rights law” (united nations high commissioner for human rights, 2000). on june 27, 2001, a un report further discussed the relationship between trips and human rights, encouraging governments to take legal and administrative measures to protect human rights under the trips framework (united nations committee on economic, social and cultural rights, 2001). the trips agreement was reinterpreted during the wto doha round (wto, 2001) in order to explicitly deliver an international consensus that the private interest of patent rights should not go against public interest and human rights during a public health crisis. the doha declaration clarified the scope of trips and detailed the application of its flexibilities. one of the most crucial flexibilities is compulsory licensing, which can be applied under a “national emergency or other circumstance of extreme urgency” such as “public health crises, including those relating to hiv/aids” (wto, 2001). it allows a national government to issue licenses to domestic pharmaceutical manufacturers to produce generic versions of patent medications without the permission of patent holders. in 2003, a permanent amendment was inserted in trips allowing wto members of least developed countries (ldcs) to import inexpensive generics made under compulsory licensing provisions (wto, 2003). therefore, even ldcs lacking production capacity could continue to access inexpensive medications. kenya, an ldc, currently has 1.6 million people living with hiv out of a population of about 40 million (unaids, 2014), but in 2003 only 5% of the people who needed antiretroviral treatment received it (who/unaids/unicef, 2007). following columbia social work review, volume v 25 wang the trips amendment, the government of kenya passed a bill to legalize the purchase of generics from other countries (avert, 2013). the impact was significant – in 2010, 540,000 people living in kenya could access antiretroviral drugs (nacc and nascop, 2012), more than 30% of the total population living with hiv. implementation of flexibilities while ldcs enjoy unconditional application of flexibilities and are granted a transition period to defer the implementation of trips on pharmaceuticals until january 2016, the transition period for other developing countries ended in january 2005. since then, many developing countries have been urged under trips guidelines to issue or protect patents for new hiv medications. china, india and brazil are three active wto member countries with high hiv prevalence rates. owing to their rapidly growing national economies, the international community expects these countries to take steps to combat their hiv epidemics while adhering to trips iprs. the divergence of these countries’ domestic social practices reveals how trips flexibilities fail to adequately provide access to medication for people living with hiv in many developing countries. china in 2000, china modified its patent law to comply with trips in preparation for joining the wto. the patent law was last amended in 2008 when china fully internalized trips flexibilities and exhaustively listed the grounds for initiating compulsory licensing. according to the law, china can grant compulsory licenses to domestic pharmaceutical manufacturers or import lower cost hiv generic medications from other countries to combat the hiv crisis. in spite of a well-developed legal basis, china has not yet issued any compulsory licenses for hiv medications in practice because the country has been categorized as having low hiv prevalence (ministry of health of the people’s republic of china, 2012) and thereby does not qualify for compulsory licensing according to international standards. however, china’s hiv epidemic is quite severe. china ranks 13th in the world in number of people living with hiv with more than half of this population living in poorer provinces (index mundi, 2014). 26 columbia social work review, volume v global trade limitations to hiv medication in order to provide treatment to its 780,000 people living with hiv (ungass, 2012), china began to provide free hiv medications to low-income communities in 2003 (yardley, 2003). however, as trips obliges all wto member countries to grant at least 20 years of patent protection for new medications (alikhan & mashelkar, 2004), the chinese government provided patients with an older generation of antiretroviral therapies. one study found that half of the patients who received these older forms of therapy did not benefit from the treatment after five years, most often due to regimen ineffectiveness or medication side effects (zhang et al., 2009). although the chinese government started to provide newer medications in 2009, as of 2011 only 18,703 adults and 216 children had received them (ungass, 2012). india india has the 85th greatest hiv incidence rate yet ranks third in the world in terms of prevalence, with 2.4 million people living with hiv (central intelligence agency, 2014). having established its own generic drug industry, india exports inexpensive hiv medications to other developing countries while also selling them domestically. in 1995, when india the joined wto and internalized trips iprs into its domestic patent laws, the indian government chose to continue to allow generic medication production by domestic companies. while hiv medications cost $14,000-$20,000 per year in industrialized countries, cipla, an indian drug manufacturer, offers the medications for as low as $80 per year (harris, 2008). as indian patent laws support robust generic medication manufacturing to the detriment of patent protections, an abundance of pharmaceutical patent disputes initiated by foreign pharmaceutical manufacturers have arisen in indian courts. as a result, the united states placed india on its trade blacklist (carter & siddiqui, 2013). internationally, trips iprs have challenged india’s efforts to promote universal access to hiv medications. utilizing international legalities and trade agreements, the governments of pharmaceutical exporting countries have filed complaints against india within the wto dispute settlement body. however, for a government providing universal healthcare and free hiv medication for 2.4 million people since 2004 (naco, 2013), india should retain its proactive position of applying trips flexibilities and challenging the tolerance of international patent holders. columbia social work review, volume v 27 wang brazil as a result of rapid economic growth, the international community has expected brazil to fight hiv independently while adhering to trips iprs. brazil provides free hiv medications for its 530,000 to 660,000 people living with hiv (unaids, 2012). the brazilian government has found it increasingly difficult to manage its budget for free hiv medications since 1997, when they became a wto member and internalized trips into intellectual property laws. to overcome challenges, in 2007, brazil issued its first compulsory license to bypass merck’s patent on efavirenz, a modern antiretroviral drug. this action would offer treatment to 75,000 people living with hiv and was celebrated by human rights activists, but regarded as a step backward by the u.s.-brazil business council (janeiro, 2007). the u.s.-brazil business council did not support compulsory licensing for brazil because the country is neither an ldc nor under conditions of “extreme urgency” with regard to the hiv epidemic. as there are no quantifiable definitions of “extreme urgency” or “public health crisis,” brazil used “extreme urgency” to justify its actions. former president luiz inacio lula da silva responded to censure from international trade partners by defending the action under the name of public health, saying, “between our trade and our health, we have chosen to look after our health” (janeiro, 2008). conclusion intellectual property rights and licensing laws stem from the ownership of ideas for profit–an appropriate concept in a generally capitalistic world. international organizations that monitor trade and offer individuals, companies, and countries protections for their intellectual and physical properties are essential in ensuring this system. pharmaceutical patent law offers a method to protect intellectual and market interests. trips flexibilities bridge international law and medical need, however, unregulated infringement would undermine incentives for new r&d projects. facing a public health crisis, many poor and developing economies are unable to offer their citizens available treatments and alleviate human suffering. these countries lack resources, making them vulnerable to trade systems driven purely by profit. the technicalities of policies and securing profits, however, have superseded universal access to treatment for hiv–one of the most devastating public health crises in 28 columbia social work review, volume v global trade limitations to hiv medication modern times. brazil’s use of trips flexibilities contrasts with china’s inaction and, what some consider, india’s patent infringements. the diversity of responses these countries have chosen demonstrates how technicalities and profit margins inhibit countries from ensuring the wellbeing of their citizens. each exemplifies challenges faced by developing countries to apply trips flexibilities under accepted wto guidelines. the strict, yet poorly defined, trips flexibilities make it difficult for many developing countries to initiate compulsory license mechanisms to address public health crises. the improbability of pharmaceutical companies foregoing their profitable patent rights on new hiv medications creates significant delays in access to inexpensive generics. historically in wto pharmaceutical disputes, wealthier countries, which have a disproportionate number of companies with pharmaceutical patents, resist trips flexibilities to appease companies and foster economic growth. strict trips iprs have become weapons to hinder access to hiv medicines in developing countries. if we choose to live in a world where human rights are valued above profit, the wto should work to encourage its member countries to protect human rights by expanding the application of trips flexibilities for hiv medications unconditionally. references alikhan, s., & mashelkar, r. a. (2004). intellectual property and competitive strategies in the 21st century. the netherlands: kluwer law international. attaran, a. & gillespie-white, l. (2001, october, 17). do patents for antiretroviral drugs constrain access to aids treatment in africa? the journal of the american medical association, 286(15), 1886-1892. avert. (2011). regional statistics for hiv and aids, end of 2011. retrieved from: http://www.avert.org/worldwide-hiv-aids-statistics.html avert. (2013). treatment access. retrieved from: http://www.avert.org/ treatment-access.htm avert. (2014). global epidemic: asia – hiv&aids in china. retrieved from: http://www.avert.org/hiv-aids-china.htm#footnote86_ http://www.avert.org/worldwide-hiv-aids-statistics.htm http://www.avert.org/treatment-access.htm http://www.avert.org/treatment-access.htm http://www.avert.org/hiv-aids-china.htm#footnote86_gfxc8fa columbia social work review, volume v 29 wang gfxc8fa carter, z., & siddiqui, s. (2013, may 1). india’s u.s. drug rulings earn trade blacklist spot from obama administration. huff post – politics. retrieved from: http://www.huffingtonpost.com/2013/05/01/india-us drugs-trade_n_3196458.html central intelligence agency. (2014). the world factbook: country comparison hiv/aids adult prevalence rate (based on 2009 estimates). retrieved from: https://www.cia.gov/library/publications/the-world factbook/rankorder/2155rank.html harris, g. (2008, october 31). the safety gap. new york times. retrieved from: http://www.nytimes.com/2008/11/02/ magazine/02fda-t.html?pagewanted=all index mundi. (2014). country comparison: hiv/aids: people living with hiv/aids top 100. retrieved from: http://www.indexmundi.com/g/r.aspx?v=35&t=100 intellectual property watch. (2013). fact sheet: extending the trips waiver for least developed countries. retrieved from: http://www.ip-watch.org/weblog/wp content/uploads/2013/02/ldc-extension-fact-sheet.pdf janeiro, r. d. (2008, july, 30). brazil’s success in aids fight depends on cheap drugs. afp. retrieved from: http://www.google.com/hostednews/afp/article/aleqm5i et0ihsjgohepjvbfkczg75i\ocrq janeiro, r. (2007, may 4). brazil to break merck aids drug patent. government wants lower price on anti-retroviral medication. nbcnews. retrieved from: http://www.nbcnews.com/id/18490388/ns/health-aids/t/ brazil-break-merck-aids-drug-patent julian-arnold, & gianna. (1993). international compulsory licensing: the rationales and the reality. idea: the journal of law and technology, 33(4), 349-400. ministry of health of the people’s republic of china. (2012). 2012 china aids response progress report. china: ministry of health naco. (2013). annual report 2012-13. india: ministry of health and family welfare. national bureau of statistics of china. (2012). national data: http://www.avert.org/hiv-aids-china.htm#footnote86_gfxc8fa http://www.huffingtonpost.com/2013/05/01/india-us-drugs-trade_n_3196458.html http://www.huffingtonpost.com/2013/05/01/india-us-drugs-trade_n_3196458.html https://www.cia.gov/library/publications/the-world-factbook/rankorder/2155rank.html https://www.cia.gov/library/publications/the-world-factbook/rankorder/2155rank.html http://www.nytimes.com/2008/11/02/magazine/02fda-t.html?pagewanted=all http://www.nytimes.com/2008/11/02/magazine/02fda-t.html?pagewanted=all http://www.indexmundi.com/g/r.aspx?v=35&t=100 http://www.ip-watch.org/weblog/wphttp://www.google.com/hostednews/afp/article/aleqm5iet0ihsjgohepjvbfkczg75i\ocrq http://www.google.com/hostednews/afp/article/aleqm5iet0ihsjgohepjvbfkczg75i\ocrq http://www.nbcnews.com/id/18490388/ns/health-aids/t/brazil-break-merck-aids-drug-patent http://www.nbcnews.com/id/18490388/ns/health-aids/t/brazil-break-merck-aids-drug-patent 30 columbia social work review, volume v global trade limitations to hiv medication population [data file]. retrieved from: http://data.stats.gov. cn/workspace/index?m=hgnd nacc, & nascop. (2012). the kenya aids epidemic update 2011. nairoby, kenya: office of the president national aids control council. sapa-afp. (2001, may 28). aids activists in kenya launch campaign for cheap drugs bill. south african press association. retrieved from: http://www.hst.org.za/news/aids-activists-kenya-launch campaign-cheap-drugs-bill smelyanskaya, m. (2013). funding scientific innovation: global investments in hiv treatment research and development in 2010 and 2011. treatment action group. unaids. (2010, june, 10). unaids welcomes the efforts of unitaid towards the creation of a patent pool entity. retrieved from: http://www.unaids.org/en/resources/ presscentre/ featurestories/2010/june/20100610unitaidpp/ unaids. (2012). hiv and aids estimates: brazil. retrieved from: http://www.unaids.org/en/regionscountries/countries/ brazil/. unaids. (2013). global report. unaids report on the global aids epidemic 2013. unaids. (2014). county webpage of kenya, 2012 data. retrieved from: http://www.unaids.org/en/regionscountries/countries/ kenya/ undesa. (2013, augest). the criteria for identifying least developed countries. retrieved from: http://www.un.org/en/development/ desa/policy/cdp/ldc/ldc_definitions.shtml ungass. (2012). china aids response progress report. retrieved from: http://www.unaids.org/en/dataanalysis/knowyourresponse/ countryprogressreports/2012countries/ united nations committee on economic, social and cultural rights. (2001, june 27, 42nd session). the impact of the agreement on trade-related aspects of intellectual property rights on human rights. retrieved from: http://www.unhchr.ch/huridocda/huridoca.nsf/0/5905 http://data.stats.gov.cn/workspace/index?m=hgnd http://data.stats.gov.cn/workspace/index?m=hgnd http://www.hst.org.za/news/aids-activists-kenya-launch-campaign-cheap-drugs-bill http://www.hst.org.za/news/aids-activists-kenya-launch-campaign-cheap-drugs-bill http://www.unaids.org/en/resources/presscentre/featurestories/2010/june/20100610unitaidpp/ http://www.unaids.org/en/resources/presscentre/featurestories/2010/june/20100610unitaidpp/ http://www.unaids.org/en/regionscountries/countries/brazil/ http://www.unaids.org/en/regionscountries/countries/brazil/ http://www.unaids.org/en/regionscountries/countries/kenya/ http://www.unaids.org/en/regionscountries/countries/kenya/ http://www.un.org/en/development/desa/policy/cdp/ldc/ldc_definitions.shtml http://www.un.org/en/development/desa/policy/cdp/ldc/ldc_definitions.shtml http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ http://www.unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/ http://www.unhchr.ch/huridocda/huridoca.nsf/0/590516104e92e87bc1256aa8004a8191/$file/g0114345.pdf columbia social work review, volume v 31 wang 16104e92e87bc1256aa8004a8191/$file/g0114345.pdf united nations high commissioner for human rights. (2000, august 17, 25th meeting). intellectual property rights and human rights. 2000/7. retrieved from: http://www.unhchr.ch/huridocda/huridoca.nsf/testframe/ c462b62cf8a07b13c12569700046704e?opendocument vann, m. (2009, may 13). can you afford your hiv treatment? everyday health. retrieved from: http://www.everydayhealth.com/hiv-aids/can-you-afford hiv-treatment.aspx wto. (2001). doha agenda. retrieved from: http://www.wto.org/english/tratop_e/dda_e/dda_e.htm wto. (2001, november 20). declaration on the trips agreement and public health. doha wto ministerial 2011: trips. retrieved from: http://www.wto.org/english/thewto_e/minist_e/min01_e/ mindecl_trips_e.html wto. (2002, june 28). council approves ldc decision with additional waiver. the wto 2002 press releases, press/301. retrieved from: http://www.wto.org/english/news_e/pres02_e/pr301_e.htm wto. (2003, august 30). decision removes final patent obstacle to cheap drug imports. the wto 2003 press release, press/350/ rev.1. retrieved from: http://www.wto.org/english/news_e/pres03_e/pr350_e.htm who/unaids/unicef. (2007). towards universal access: scaling up priority hiv/aids interventions in the health sector. retrieved from: http://www.who.int/hiv/pub/2010progressreport/report/en/ world bank. (2014). country data: uganda. retrieved from: http://data.worldbank.org/country/uganda yardley, j. (2003, november 8). china begins giving free hiv/aids drugs to the poor. new york times. retrieved from: http:// www.nytimes.com/2003/11/08/world/china-begins-giving free-hiv-aids-drugs-to-the-poor.html zakumumpa, h. (2012, may 4). kenya: court ruling on generic drugs sets precedent for the region. all africa. retrieved from: http://allafrica.com/stories/201205050203.html zhang, f., duo, z., ma, y., zhao, y., liu, z., bulterys, m., & http://www.unhchr.ch/huridocda/huridoca.nsf/0/590516104e92e87bc1256aa8004a8191/$file/g0114345.pdf http://www.unhchr.ch/huridocda/huridoca.nsf/testframe/c462b62cf8a07b13c12569700046704e?opendocument http://www.unhchr.ch/huridocda/huridoca.nsf/testframe/c462b62cf8a07b13c12569700046704e?opendocument http://www.everydayhealth.com/hiv-aids/can-you-afford-hiv-treatment.aspx http://www.everydayhealth.com/hiv-aids/can-you-afford-hiv-treatment.aspx http://www.wto.org/english/tratop_e/dda_e/dda_e.htm http://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm http://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm http://www.wto.org/english/news_e/pres02_e/pr301_e.htm http://www.wto.org/english/news_e/pres03_e/pr350_e.htm http://www.who.int/hiv/pub/2010progressreport/report/en/ http://data.worldbank.org/country/uganda http://www.nytimes.com/2003/11/08/world/china-begins-giving-free-hiv-aids-drugs-to-the-poor.html http://www.nytimes.com/2003/11/08/world/china-begins-giving-free-hiv-aids-drugs-to-the-poor.html http://www.nytimes.com/2003/11/08/world/china-begins-giving-free-hiv-aids-drugs-to-the-poor.html http://allafrica.com/stories/201205050203.html 32 columbia social work review, volume v global trade limitations to hiv medication chen, ry. (2009). five-year outcomes of the china national free antiretroviral treatment program. ann intern med., 18:151(4), 241-251. 64 columbia social work review, volume v columbia school of social work can better support development of effective writing skills editorial board the editorial board of the columbia social work review holds a firm conviction that social workers must possess advanced written communication skills to serve individuals and communities and advance the field as a whole. to pair this conviction with action, the board conducted a survey to explore student experiences with writing in graduate studies at columbia school of social work (cssw). the surveyed students agreed that effective writing skills are imperative for social work professionals, and they overwhelmingly wanted the school to do more to help them develop these skills. although students highly valued writing, their enthusiasm did not always translate into perceptions of adequate writing instruction, exposure to diverse writing assignments, or adequate institutional support. as editors of a student-run journal, we believe in the value of cogent writing to our field, and we feel compelled to share this student perspective as a contribution to a meaningful discussion on writing at cssw. this editorial uses student opinion from survey data to underscore the value of critical writing skills to the social work profession, and recommends ways that school supports can be enhanced to match student need. the goal of this editorial is to enrich the scholarly and professional nature of cssw. why write about writing? the idea for this editorial emerged from a series of conversations between editors of the review and members of the cssw community. at a review-sponsored event in the fall, students expressed a desire to challenge themselves through written assignments, and many placed a high value on writing in social work education and in the profession. recognizing this was part of a larger issue, the editorial board wanted to engage in formative research to determine the writing skills that students learn, apply, and expect to utilize in their careers. further, the board hoped to assess the extent to which students receive adequate instruction and support in developing their writing skills during their time at cssw. columbia social work review, volume v 65 editorial board last, we wanted to explore innovative changes to improve the student experience of writing at cssw. to do this, the editorial board of the review designed a survey about specific written assignments, the development of writing skills at cssw, the importance of writing in social work, the resources students have utilized, and the additional supports that might be helpful for students. although the majority of questions were closed-ended, there were two open-ended questions for students to provide qualitative comments and offer new suggestions for changes to the cssw experience. the board used google forms to administer the survey, a copy of which is available on the review’s website, http://cswr.columbia.edu. the writing center and the office of academic affairs sponsored the survey, and the office of student services approved the questionnaire. on behalf of the review, the writing center sent an e-mail message with the survey link to the 997 currently enrolled master of science students, and the board advertised the survey on social media. participation was voluntary, and respondents were not compensated. seventy (n=70) students completed the questionnaire, and the breakdown of students by program and method of practice is presented in table 1. demographic information (age, race, gender) was not gathered due to sensitivity concerns from cssw departments. of the 70 respondents, 10 reported that english was not their first language, 50 said they were native english speakers, and 10 did not respond to this question; 8 international students took part in the survey. these percentages of non-native speakers and international students (17 and 11 percent respectively) are roughly comparable with school-wide levels of 12-15 percent available on the cssw website (see http://socialwork.columbia.edu/about-cssw-0, 2014). what the survey tells us although all current m.s. students received a link to the survey, the voluntary nature of the survey creates a respondent bias—students who completed the survey were probably more likely to have an interest in the topic of writing or be different from the student body in some other way. therefore, statistical tests of significance were not conducted because the sample would not have satisfied all necessary assumptions. the following section discusses trends among responses. 66 columbia social work review, volume v developing writing skills at cssw ta bl e 1. n um be rs o f r es po nd en ts b y pr og ra m a nd m et ho d of p ra ct ic e pr og ra m a dv an ce d c lin ic al pr ac tic e (a c p) a dv an ce d g en er al is t p ra ct ic e an d pr og ra m m in g (a g pp ) po lic y pr ac tic e so ci al e nt er pr is e a dm in is tra tio n (s ea ) u nd ec id ed to ta ls 2ye ar p ro gr am 18 13 5 14 1 51 16 -m on th 2 — — — — 2 a dv an ce d st an di ng 2 3 2 1 — 8 d ua l d eg re e 3 1 1 1 1 7 ex te nd ed p ro gr am 1 — 1 — — 2 r ed uc ed r es id en cy — — — — — 0 to ta ls 26 17 9 16 2 70 columbia social work review, volume v 67 editorial board cssw’s student body believes that a diverse array of writing skills are necessary for professional social workers—the most convincing results from the survey. at least eight out of 10 respondents (82%) noted that it was “very important” to articulate a clear thesis and write persuasively, compile and analyze research, possess editing and proofreading skills, use professional language, use sensitive language, and write concisely and directly (table 2). the only skill that students did not find as important as the above issues was writing in apa style. despite the consensus on the importance of writing skills, fewer (62 percent or more) agreed that coursework and field instruction have helped them adequately develop all of these skills (table 3). although general, instructional, and written assignment satisfaction ratings were mixed, the survey results overwhelmingly suggest that students crave more feedback from instructors. although 70% of respondents reported feeling “satisfied or very satisfied” with cssw’s contribution to the development of their writing skills, 53% of respondents rated the instruction for written tasks unfavorably (“fair or poor”). this suggests that students are able to develop their writing skills to a satisfactory level, even while they may not be satisfied with writing instruction. fifty-seven percent (57%) of the responding students rated instructor feedback as “fair or poor,” suggesting that teachers can do more to help students grow from each assignment. indeed, in the open-ended responses, one student stated her appreciation of instructor feedback: “i enjoy constructive criticism so i can grow as a writer. i want to read my professor’s interpretation of my writing, areas of strength, and areas of growth. the more feedback, the better.” eighty-four percent (84%) of respondents said greater feedback on assignments would be “very helpful.” more research is needed to assess the extent to which students develop their skills through practice, peer interactions, or other supports, as opposed to faculty. it is also important to consider that although students enter our program with a certain writing ability from undergraduate studies and work experience, they often leave needing to write in a much different role and context. some student experiences differed across method of practice. only 50% of social entrepreneurship administration (sea) students felt they had developed the ability to write clearly and persuasively, that is, to the standards required in their intended career path, compared to 68% of all respondents. this may reflect a greater focus on written work and 68 columbia social work review, volume v developing writing skills at cssw ta bl e 2. p er ce iv ed im po rt an ce o f c er ta in w ri tin g sk ill s, ex pr es se d in p er ce nt ag es sk ill ve ry im po rta nt so m ew ha t im po rta nt a li ttl e im po rta nt n ot a t a ll im po rta nt d on ’t kn ow a bi lit y to a rti cu la te a c le ar th es is an d w rit e pe rs ua si ve ly 94 6 — — — a bi lit y to c om pi le a nd a na ly ze re se ar ch 82 16 1 — — ed iti ng o r p ro of re ad in g sk ill s 88 10 1 — — u si ng p ro fe ss io na l l an gu ag e 93 7 — — — u si ng se ns iti ve la ng ua ge 88 9 1 — 1 w rit in g co nc is el y an d di re ct ly 99 1 — — — w rit in g in a pa s ty le 37 30 19 4 — n ot e. t ex t o f t he q ue st io n: “ h ow im po rta nt o r u ni m po rta nt d o yo u be lie ve it is fo r g ra du at es o f c ss w to po ss es s t he fo llo w in g sk ill s? ” columbia social work review, volume v 69 editorial board ta bl e 3. e xt en t t o w hi ch c ou rs ew or k an d fi el d in st ru ct io n h as d ev el op ed c er ta in w ri tin g sk ill s, ex pr es se d in p er ce nt ag es sk ill st ro ng ly a gr ee a gr ee d is ag re e st ro ng ly d is ag re e d on ’t kn ow a bi lit y to a rti cu la te a c le ar th es is an d w rit e pe rs ua si ve ly 21 47 24 7 1 a bi lit y to c om pi le a nd a na ly ze re se ar ch 18 56 21 3 3 ed iti ng o r p ro of re ad in g sk ill s 16 46 24 10 4 u si ng p ro fe ss io na l l an gu ag e 21 58 13 5 1 u si ng se ns iti ve la ng ua ge 25 57 9 6 3 w rit in g co nc is el y an d di re ct ly 27 52 12 7 1 w rit in g in a pa s ty le 40 40 18 1 1 n ot e. t ex t o f t he q ue st io n: “ h ow m uc h do y ou a gr ee o r d is ag re e w ith th e fo llo w in g st at em en t: ‘c ss w ’s co ur se w or k an d fie ld in st ru ct io n ha ve h el pe d m e de ve lo p th e fo llo w in g sk ill s t o th e st an da rd s r eq ui re d in m y in te nd ed c ar ee r p at h. ’” 70 columbia social work review, volume v developing writing skills at cssw communication skills in typical sea careers; coursework in this method of practice should therefore address this unique challenge. advanced clinical practice (acp) students rated instruction for written assignments less favorably than respondents overall: 69% of acp students gave unfavorable ratings (“fair or poor”) to the instruction received for writing that they expect to be called on to do in the five years after graduating, compared to 53% overall. acp’s emphasis on practical, clinical skills may account for these lower scores on instruction, as discussion of these assignments likely occupies less class time. yet acp students think these writing skills, like composing letters, are equally important to learn and develop. thus, more attention might be paid to the role of writing in clinical practice. a further disconnect exists between what students currently complete as part of their graduate studies and what students expect to do after graduation (table 4). when asked about the frequency of completing certain writing tasks, respondents reported that they most commonly completed process recordings, academic papers, reflection papers, and progress notes/documentation. however, the writing tasks that people expect to execute after graduation include writing letters, progress notes/documentation, and program and proposal development pieces (see figures 1-3). although students’ expectations are opinionbased assessment of future career tasks, we believe that a better mix of practical writing skills needs to be taught in the curriculum to prepare students for the diverse written tasks of our profession. for example, 78% of respondents expect to write program proposal and development papers “sometimes or very often” after graduating, but only 38% of respondents work on these pieces with such frequency at cssw (see figure 4). moreover, 54% of acp students expect to write program and proposal development grants at least “sometimes” within five years of graduating, but 77% of these students currently write these kinds of papers “rarely or not at all.” in comparison, more than half of agpp, policy, and sea students write these papers “sometimes or very often.” furthermore, at least 31% of respondents reported that they were unable to assess the quality of instruction for how to write letters, program proposals, and opinion pieces. a more in-depth assessment should be done to see if students feel a strong need for more instruction around these tasks, and if these exercises would be beneficial for students. survey results highlighted the contribution of the writing center to the cssw academic community (table 5). of those who took columbia social work review, volume v 71 editorial board ta bl e 4. c om pa ra tiv e fr eq ue nc y of p re se nt a nd e xp ec te d as si gn m en t c om pl et io n an d in st ru ct io n q ua lit y a ss ig nm en t “c ur re nt ly c om pl et e” f re qu en cy “e xp ec t t o c om pl et e” f re qu en cy d efi ci t ( cu rr en t m in us e xp ec ta tio ns )a q ua lit y of in st ru ct io n a ca de m ic p ap er s 3. 54 2. 30 1. 25 2. 58 a dv oc ac y pa pe r 2. 64 2. 67 -0 .0 3 2. 63 c as e st ud y/ n ar ra tiv e 2. 59 2. 88 -0 .2 9 2. 35 le tte r 2. 12 3. 58 -1 .4 6 2. 11 o pi ni on p ie ce 2. 17 2. 73 -0 .5 6 2. 24 po lic y b rie f/a na ly si s 2. 18 2. 85 -0 .6 7 2. 56 pr oc es s r ec or di ng 3. 74 1. 92 1. 82 2. 38 pr og ra m a nd p ro po sa l d ev el op m en t 2. 06 3. 30 -1 .2 4 2. 36 pr og re ss n ot es /d oc um en ta tio n 3. 16 3. 44 -0 .2 8 2. 34 r efl ec tio n pa pe r 3. 22 1. 92 1. 30 2. 56 n ot e. t hi s t ab le c on ve rte d re sp on se s o f f re qu en cy (1 =n ev er , 2 =r ar el y, 3 =s om et im es , 4 =v er y o fte n) a nd q ua lit y ra tin gs (1 =p oo r, 2= fa ir, 3 =g oo d, 4 =e xc el le nt ) t o a 4po in t s co re . a n eg at iv e nu m be rs in di ca te th at st ud en ts c ur re nt ly w rit e th es e as si gn m en ts w ith le ss fr eq ue nc y th an th ey e xp ec t t o af te r g ra du at io n. p os iti ve n um be rs in di ca te th at st ud en ts c ur re nt ly w rit e th es e as si gn m en ts m or e at c ss w th an th ey ex pe ct to a fte r g ra du at io n. 72 columbia social work review, volume v developing writing skills at cssw figure 1. student responses to the following two questions: “since you enrolled at cssw, how often have you had to write academic papers for cssw coursework or your social work field placement?” and “in the five years immediately after completing your studies at cssw, how often would you expect to complete academic papers in your career?” figure 2. student responses to the following two questions: “since you enrolled at cssw, how often have you had to write letters for cssw coursework or your social work field placement?” and “in the five years immediately after completing your studies at cssw, how often would you expect to complete letters in your career?” 0 10 20 30 40 50 perceived current frequency expected future frequency n um be r o f r es po nd en ts figure 1. comparative frequency of present and expected assignment completion: academic papers very often sometimes rarely never don't know 0 10 20 30 40 50 perceived current frequency expected future frequency n um be r o f r es po nd en ts figure 2. comparative frequency of present and expected assignment completion: letters very often sometimes rarely never don't know columbia social work review, volume v 73 editorial board figure 3. student responses to the following two questions: “since you enrolled at cssw, how often have you had to write reflection papers for cssw coursework or your social work field placement?” and “in the five years immediately after completing your studies at cssw, how often would you expect to complete reflection papers in your career?” figure 4. student responses to the following two questions: “since you enrolled at cssw, how often have you had to write program proposal and development papers for cssw coursework or your social work field placement?” and “in the five years immediately after completing your studies at cssw, how often would you expect to complete program proposal and development papers in your career?” 0 10 20 30 40 perceived current frequency expected future frequency n um be r o f r es po nd en ts figure 3. comparative frequency of present and expected assignment completion: reflection papers very often sometimes rarely never don't know 0 5 10 15 20 25 30 35 perceived current frequency expected future frequency n um be r o f r es po nd en ts figure 4. comparative frequency of present and expected assignment completion: program proposals and development very often sometimes rarely never don't know 74 columbia social work review, volume v developing writing skills at cssw advantage of one-on-one appointments, two out of three students reported that the sessions were “very helpful,” and only four individuals said that the sessions were “not at all helpful” (table 6). many students praised the writing center for contributing to their professional development: one believed that the writing center helps people “grow as students,” and there were calls for extended hours and more staff. it is clear that cssw students have an invaluable resource at their disposal that provides an opportunity for students to become more confident social work writers and students. respondents made a strong call to increase writing support for students (table 7). ninety-four percent (94%) of students surveyed agreed with the statement, “cssw should do more to help students develop their written communication skills.” eight out of ten students surveyed thought that an optional course—an elective on writing in the social work profession—could help students improve their writing skills. a majority of respondents (61%) thought that devoting more class time to developing writing skills would be helpful. three out of four individuals surveyed said that completing different kinds of assignments as part of cssw coursework would help improve their writing ability. to this end, the editorial board of the review has begun to reach out to curriculum committees across methods of practice to promote written assignments that encourage students to produce thought-provoking content relevant to the profession. we support further efforts preparing students to be critical thinkers, writers, scholars, and practitioners among a new generation of social workers. recommendations the review is eager to work with students, faculty, and administrators to make improvements to cssw’s curriculum as it relates to written work. students showed strong support for an optional course on writing as part of graduate studies of social work (see table 7). a course could be offered to focus on students’ writing skills, enhance understanding of different documents that social workers produce, provide detailed feedback on written work, and access peer support. in developing the curriculum, surveys could gauge student interest and town hall events could encourage students to provide their input. the course might address different types of written tasks in the field, and columbia social work review, volume v 75 editorial board ta bl e 5. s tu de nt u se o f w ri tin g c en te r se rv ic e ve ry o fte n so m et im es r ar el y n ev er d on ’t k no w o ne -o non e ap po in tm en ts 14 13 15 26 1 w rit in g c en te r h an do ut s 14 21 17 17 — w rit in g c en te r e ve nt s 2 14 13 30 1 o th er w rit in g c en te r s er vi ce s 3 6 13 38 9 to ta ls 33 54 58 11 1 11 n ot e. t ex t o f t he q ue st io n: “ h ow o fte n ha ve y ou u se d th e fo llo w in g se rv ic es a t c ss w ’s w rit in g c en te r s in e yo u en ro lle d at c ss w ?” 76 columbia social work review, volume v developing writing skills at cssw ta bl e 6. s tu de nt r at in gs o f w ri tin g c en te r s er vi ce sa se rv ic e ve ry h el pf ul so m ew ha t he lp fu l a li ttl e he lp fu l n ot a t a ll he lp fu l d on ’t k no w o ne -o non e ap po in tm en ts 27 5 5 4 — w rit in g c en te r h an do ut s 20 16 7 1 2 w rit in g c en te r e ve nt s 5 9 6 — 5 o th er w rit in g c en te r s er vi ce s 7 — 4 — 7 to ta ls 59 30 22 5 14 n ot e. t ex t o f t he q ue st io n: “ if y ou h av e ev er u se d th e w rit in g c en te r s er vi ce s, ho w h el pf ul o r u nh el pf ul di d yo u fin d th e se rv ic es y ou u se d? ” a “ n ot a pp lic ab le ” (n /a ) r es po ns es a re e xc lu de d fr om th is ta bl e. columbia social work review, volume v 77 editorial board ta bl e 7. p er ce iv ed h el pf ul ne ss o f i nn ov at iv e o ffe ri ng s o r c ha ng es a t c ss w o ffe rin g/ c ha ng e ve ry he lp fu l so m ew ha t he lp fu l a li ttl e he lp fu l n ot a t a ll he lp fu l d on ’t k no w a re qu ire d co ur se o n w rit in g in th e so ci al w or k pr of es si on 16 21 15 10 5 a n op tio na l c ou rs e on w rit in g in th e so ci al w or k pr of es si on 38 17 5 5 2 m or e cl as s t im e de vo te d to d ev el op in g w rit in g sk ill s 27 14 16 8 2 d iff er en t a ss ig nm en ts th at b et te r h el p st ud en ts d ev el op w rit in g sk ill s 29 22 12 1 3 m or e fe ed ba ck o n as si gn m en ts fr om in st ru ct or s 56 9 2 0 0 n ot e. t ex t o f t he q ue st io n: “ h ow h el pf ul o r u nh el pf ul d o yo u be lie ve th e fo llo w in g po te nt ia l c ss w o ffe rin gs / ch an ge s m ig ht b e at h el pi ng st ud en ts d ev el op w rit te n co m m un ic at io n sk ill s? ” 78 columbia social work review, volume v developing writing skills at cssw provide short assignments, such as writing a concise policy memo or a plan for the design and implementation of a new program. the course could be tailored to students’ needs by allowing for choice among assignments. just as students learn direct practice skills through field placements, we can also learn writing through practical applications if we receive targeted support. a pilot course could be developed to gauge interest and effectiveness. students crave detailed feedback on their written work. given professors’ time constraints, students cannot expect every paper to be covered in red ink. but students deserve formal assessments of their writing, access to their professors, and class time devoted to analyzing written work. a common rubric template, adaptable across classes, could provide structured and streamlined feedback. instructors could assess discrete and defined aspects of student writing, such as clarity of expression and thesis, persuasive and concise delivery of material, research analysis, and use of apa style. the administration might provide resources to faculty to encourage them to discuss writing skills before and after assignments are due, and foster student comfort in attending office hours to examine written work in more detail. students want to complete diverse writing tasks in preparation for their careers. written assignments are physical, tangible products that demonstrate the same abilities that social workers possess and implement across practice methods: coherent statement of purpose, explanation and analysis of evidence-based interventions, and a coherent discussion of a topic’s importance. students have an ample portfolio of academic papers, and would likely benefit from a wider variety of assignments, yet many social work jobs expect candidates to implement a more diverse array of professional writing abilities. students could gain a great deal of writing experience from exposure to grantwriting, policy memos, psychosocial assessments, program proposals, opinion pieces, evaluation reports, and case studies. we need to incorporate an evaluation of writing into annual student evaluations if we are to seriously achieve a goal of improving the quality of students’ writing skills. course evaluations could have a separate section on writing to hold instructors accountable for addressing the topic. certain results across the school could be publicly available to better track, evaluate, and discuss progress around the development of writing skills. columbia social work review, volume v 79 editorial board conclusion the review’s annual publication is a testament to the capabilities of our student body. the five articles in this publication that precede this editorial—and 11 previous editions of the review—are concrete products from some of our finest students. in the process of writing this editorial, the board has utilized a diverse skill set taught through course and fieldwork at columbia university. we developed research questions, administered a survey and analyzed results, wrote and edited the text of the editorial, collaborated with community members, and devised original interventions to address a pressing concern in our community. the board wants to see more students engage in work like this. moving forward, we must ensure that discussions about writing take place throughout the graduate experience here at cssw. institutional supports must exist to mirror the value students place on writing in social work, so that all students may gain the opportunity to advance their skills, career, and service. cswrfinal_4.1.13 11 columbia social work review, volume iv crucial conversations: exploring intergenerational trauma in post-conflict guatemala eliza ramos guatemala is a country fractured by years of sociopolitical conflict and instability. in the summer of 2011, i secured grant funding to implement supportive counseling and educational services, in conjunction with a local nonprofit organization, to help local children better understand and process the profound effects of the country’s civil war, which ended in 1996. upon beginning this project, however, it became apparent that many of the children with whom i interacted had limited or no knowledge of the conflict. this article explores the pervasive and systematic avoidance of discussing widespread psychosocial trauma and the potential effects of this avoidance on parents, children, and the greater community. i compare these observations with existing social work and psychology research literature, drawing from the concept of intergenerational trauma, or the transference of trauma symptoms from parent to child. i then discuss whether the avoidance of trauma discussion with children can protect their psychological well-being and prevent the transference of trauma, or if such avoidance leads to increased risk of individual psychological impairment and cyclical community problems. based upon this analysis, the article finally discusses implications for social workers confronting psychosocial trauma in post-conflict settings. guatemala is a country fractured by years of sociopolitical conflict and economic instability. in huehuetenango, one of the country’s many small rural towns composed mostly of indigenous people, hundreds of bodies remain in mass graves as a haunting shadow of the massacres perpetrated during guatemala’s civil war that ended in 1996. in the summer of 2011, i secured funding from the davis projects for peace to implement an initiative to help guatemalan children better understand and process the profound effects of the country’s internal conflict. two colleagues and i facilitated a peace-centered curriculum for children ages 10 ramos columbia social work review, volume iv 12 to 16 about the conflict; the local nonprofit organization committees of victims concurrently supported children’s parents who had lost loved ones. it quickly became apparent that a significant barrier hampered effective implementation of our program: many of the children had limited or no knowledge of the conflict. almost all of the parents, it seemed, had not disclosed the full details of their tumultuous histories. observing interactions within the community, we noticed an absence of discussions about the conflict and its lingering effects. although based on anecdotal evidence as a foreigner, my observations led me to believe that many children did not seem to receive any information about the civil war from either families or school. this article reflects on my observations during the project and their potential implications. after providing a historical context and background of the initiative, the article then explores how the systematic absence of discussions of trauma can affect children, parents, and the greater community. the theme of intergenerational trauma, the transference of trauma symptoms from parent to child (kellerman, 2001), will also be addressed. this article strives to explore whether the avoidance of discussing trauma with children protects their psychological well-being, or if failing to address trauma leads to an increased risk of individual psychological impairment and cyclical community problems. i will argue that social workers in post-conflict settings can assist families and communities in addressing traumatic experiences to facilitate the healing of a repressed or violent past. background a history of inequality guatemala’s instability reflects a complex history of violent conquest and inequality. during the spanish conquest, many indigenous groups—mainly maya populations—were forced off their ancestors’ land as the colonizers forcefully seized huge portions of the country’s arable land. the spanish “exploited the indigenous labor force” for trade, setting into motion dimensions of crucial conversations 13 columbia social work review, volume iv ethnicity and oppression that still exist today (viscidi, 2004). the indigenous population still accounts for the majority of guatemala’s poorest citizens (freedom house, 2012). democratically elected leaders in the 1940s and 1950s attempted to implement land, labor, and economic reforms to help the nation’s poor (calderón, 2011). in 1952, the administration of jacobo arbenz enacted agrarian reform to expropriate idle land and distribute it to approximately 100,000 peasant families (writenet, 1995). under intense lobbying pressure from united fruit—a u.s.-based company and guatemala’s largest landowner (writenet, 1995)—and in an era of fear of communism, the u.s. government approved a coup d’état in june 1954 to overthrow arbenz, who was replaced by a military general (writenet, 1995; calderón, 2011). the subsequent reversal of agrarian reform left guatemala with greater inequality and the most skewed distribution of land in latin america (writenet, 1995), setting the stage for the guatemalan civil war. the guatemalan civil war the guatemalan civil war began in 1960 and erupted over economic and social discord as some unrepresented indigenous guatemalans joined guerilla groups to rebel against conservative and strict military governments. the inter-american human rights commission cited the era between 1970 and 1983 as “the worst for human rights violations in guatemala…at least 50,000 people died in the violence and hundreds of thousands more were internally displaced because of systematic repression by the military” (calderón, 2011). in 1982, guerrilla resistance groups, consisting of mainly poor and indigenous guatemalans, gained strength and support. the guatemalan government retaliated, launching a counterinsurgency campaign against the guatemalan national revolutionary unity (urng). the result was devastating: more than 200,000 people were killed during the conflict, with state forces responsible for 93% of those deaths, and 83% of the killed were indigenous (guatemala commission for historical clarification [ceh], 1999). as a result of this widespread violence, the united nations ramos columbia social work review, volume iv 14 and other international actors brokered peace agreements between the guatemalan government and guerilla groups, signed in december 1996. the guatemalan government has since passed legislation criminalizing ethnic discrimination and established institutions to protect the rights of indigenous peoples (freedom house, 2012). however, due to economic circumstances and “lack of resources and political will,” marginalization continues and legacies of the conflict remain (cultural survival, 2008, p. 1). huehuetenango, guatemala during the government’s counterinsurgency campaign, the bodies of hundreds slaughtered indigenous people of huehuetenango were hastily buried in mass graves, where many remain today. the horrific memories of the civil war and its human rights violations are still fresh in the minds of many survivors. according to indigenous mayan belief, a person must receive a proper and dignified burial in a community cemetery to allow his or her spirit to find peace (palazuelos, 2010). motivated to help rebuild their country, some refugees returned home and founded the nonprofit organization equipo técnico de educación en salud comunitaria (etesc, technical team for education in community health). etesc works to help victims of the conflict in huehuetenango bring closure to the traumatic events through locating mass graves, uncovering and identifying bodies, and helping families obtain death certificates and conduct dignified burials (palazuelos, 2010). although significant steps still remain in the effort to achieve closure for many, these processes provides oppressed communities with an opportunity to heal from the past. davis projects for peace grant implementation funding from davis projects for peace enabled my involvement with etesc. etesc planned to exhume 50 bodies in mass graves during the war and assist families with dignified burial processes and memorial ceremonies. concurrently, my partcrucial conversations 15 columbia social work review, volume iv ners and i worked within five schools in three rural villages, conducting educational and psychologically supportive workshops, to help the children critically understand and process their country’s recent past. groups of children ages 10 to 16 were led through historical storytelling, role plays, theatrical activities, and group discussions. i learned that many children had limited knowledge of the conflict. they appeared to only partially comprehend that the burial ceremonies were in honor of their relatives; the children did not seem aware of the grim historical context associated with the deaths. in perhaps an effort to protect their children from their horrific memories of the conflict, many parents had chosen not to discuss the past. i also observed that this silence permeated the community. within families, between adults, and among elder generations, it appeared to be mutually understood that the harrowing past should not be discussed. although parental avoidance seemed like a wellintentioned effort to shelter children from facing the traumatic past they had experienced, i feared this could cause unintended negative consequences for the children. such silence has been shown to potentially affect children’s mental health, identity formation, and ability to form trusting relationships with their parents if the truth is uncovered in piecemeal form or far into the future (coles, 2011). furthermore, some parents still seemed to struggle through their own healing processes. it appeared improbable that families could fully heal from their own trauma while keeping the past hidden. avoiding intergenerational trauma the effects of trauma trauma can be defined as sustained emotional distress following a disturbing experience (coles, 2011). a traumatic event may be sudden or unexpected, shocking, a threat to life or bodily integrity, and/or invoke the feeling of intense terror or helplessness (4th ed., text revision, american psychiatric association, 2000). the result is behavioral, cognitive, emotional, and/or ramos columbia social work review, volume iv 16 physical difficulties directly related to the traumatic experience (cohen et al., 2006). when a person experiences a traumatic event, he or she may develop post-traumatic stress disorder (ptsd), a set of behavioral and emotional reactions to an extreme stressor (appleyard & osofsky, 2003). ptsd can entail persistent re-experiencing of the traumatic event, avoidance of stimuli associated with trauma, and physiological hyperarousal, all causing significant impairment to social, emotional, and occupational functioning (apa, 2000). moreover, studies of children exposed to orchestrated violence and war exhibit moderate to high rates of ptsd. children have been shown to experience frequent headaches, disrupted sleep, altered memory performance, difficulties concentrating, trouble socializing, and loss of trust (kinzie et al., 1989; saigh, 1991; schauer et al., 2004). vicarious, or secondary, trauma is the transmission of the effects of trauma from the primary victim to a secondary person (coles, 2011). although the secondary person does not directly experience the traumatic event, subsequent interactions between the trauma victim and secondary person lead to the development of similar trauma symptoms in both persons. intergenerational trauma, also referred to as transgenerational or cross-generational trauma, refers to vicarious trauma from parent to child (coles, 2011). following circumstances of political violence, the psychosocial trauma experienced by one generation can often “pass” to the next generation (weingarten, 2004). children of holocaust survivors tend to absorb the psychological burden of their parents, thus causing the offspring to experience a form of trauma themselves (kellermann, 2001). trauma symptoms were transferred either through repeated narrative storytelling from parent to child, or through heightened stress levels and abusive tendencies of the parent as a result of trauma (kellerman, 2001). survivors of other conflicts, such as the vietnam war and the cambodian genocide of the 1970s, have also shown this kind of transference (lin et al., 2009). repeated narratives of traumatic events can perpetuate intergenerational trauma. when trauma affects an entire community, a culture of silence can arise when community members avoid discussing the crucial conversations 17 columbia social work review, volume iv trauma (lin et al., 2009). survivors of mass trauma often resist talking about their experiences, particularly with their children. parents frequently avoid discussing their own traumatic histories to prevent re-experiencing the trauma and protect their children from psychological harm (appleyard & osofsky, 2003). breaking the culture of silence in huehuetenango, war-related conversations between adults in the community appeared to be short-lived and tense. although negative effects of intergenerational trauma are welldocumented (gorden, 2011; yehuda et al., 2001), research also demonstrates that discussing trauma can be therapeutic. lin et al. (2009) studied cambodian-american refugee families and concluded that educating children about socio-cultural trauma had a positive effect on fostering intergenerational communication and healing through narrative sharing. similar results are cited in somalia, rwanda, uganda, and other sites of forced migration and war (schauer et al., 2004). although comparing examples requires an understanding of cultural and societal circumstances, examining one context can provide applicable lessons to others. discussion of trauma may better enable children to understand their family’s past. such dialogue helps youth integrate their family history into their overall identities and context in which they live, bringing meaning and healing into their lives (hammack, 2010). structured and developmentally appropriate discussion mitigates the risk of transmitting intergenerational trauma (axelrod, schnipper, & rau, 1980). sorsher and cohen (1997) identified parent communication style as a crucial determinant in a family’s ability to adapt in light of a catastrophic or traumatic event. measham and rousseau (2010) found a positive relationship between family disclosures of war trauma to children’s play, a sign of psychological well-being. a strengths-based approach enables parents to serve an integral role in mitigating intergenerational trauma. many of the parents in huehuetenango survived years of conflict and violence, creating tremendous potential for them to engender resilience and coping skills in their children. parents, as potential mediators between traumatic events ramos columbia social work review, volume iv 18 and children’s adjustment, deserve significant consideration in the healing process (gewirtz et al., 2008). the long-term and societal effects of silence along with interpersonal and psychological effects of avoiding these conversations, long-term and societal implications must be considered. younger generations can seize this opportunity to learn from the past, for lack of knowledge may perpetuate a cycle of conflict. even though educating children about conflicts may endanger their immediate well-being, the true risk may be not to educate future generations about the past. even now that the war has ended, discrimination and violence toward indigenous guatemalans persists (amnesty international, 2011). children and subsequent generations may unknowingly carry on this discrimination; opening up a dialogue about the conflict and its implications is vital in the movement towards reconciliation and sustained peace. a culture of openness could decrease the prevalence of discrimination as people learn to see the indigenous and elderly as strong and courageous survivors. the next generation could create measures to ensure prevention of future conflicts. discussing historical events enables survivors and families to therapeutically acknowledge the intergenerational effects that continue to be felt. societies “…can learn to change for the better in the future [as] the pain and shame of genocide becomes clearer for all to grasp” (lin et al. 2009, p. 197). by avoiding crucial conversations, a society may not be able to integrate trauma in a meaningful way and wounds may not be healed. the next generation—and the future leaders within its ranks— cannot learn from the past if these discussions do not take place. implications for social workers in post-conflict settings avoiding conversations about past trauma may also impede positive family and identity development. the key, then, to helping parents and children process the past, is understanding when and how to discuss the past constructively—in a way that mitigates potentially harmful effects both of the trauma itself and crucial conversations 19 columbia social work review, volume iv the discomfort surrounding disclosure. measham and rousseau (2010) argue that the timing and manner in which the trauma is disclosed are also linked to children’s well-being. there are ways to conduct crucial conversations in a manner that strengthens the parent–child relationship and the mental health of both parties; narrative building and psycho-education are among the proven methods (tedeschi & calhoun, 1995; weingarten, 2004). parents who struggle with mass trauma can grow in awareness of these healing methods and feel empowered to have sensitive discussions in a beneficial, nonharmful way. as social workers, we can aid families in fostering crucial conversations. first, the social work community must cultivate the skills to understand the intergenerational effects of mass trauma, where the transference of trauma can be mitigated, and specific interventions. social workers must also appreciate the mechanisms through which parents and children are exposed to the effects of political violence. we can play an integral role in helping clients understand the importance of mourning the pain and losses suffered by previous generations. individual, familial, and societal acknowledgement and integration of the past are steps towards a peaceful future (weingarten, 2004). the helpfulness of trauma disclosure as part of the healing process depends on culture and context (measham & rousseau, 2010), so social workers in cross-cultural contexts must first strive to listen to locals and appreciate their social location within the broader context. gray and allegritti (2003) argue that for cross-cultural social work to take place, the first step must be extensive dialogue between cultural groups on appropriate practices, recognizing that approaches to social work and to grieving differ across cultures. cross-cultural social work is predicated on two interrelated ideas: first, the interests of local practitioners and communities are integrated into all interventions and treatment plans, and second, local practitioners and clients should take the lead. in the case of the guatemalan civil war, cross-cultural social work would begin by a discussion on people’s experiences today and during the civil war. furthermore, increasing the capacity of local communities to be their own agents of change and healing can allow families to ramos columbia social work review, volume iv 20 rebuild in their own manner. the united nations permanent forum on indigenous issues (unpfii) cites a culturally sensitive approach as one “based on respect for and inclusion of their [indigenous peoples’] world-views, perspectives and experiences” (secretariat of the unpfii, 2008. p. 41). the unpfii recently called for full inclusion of indigenous populations in the designing, implementing, and monitoring of all programs that affect them (unfpii, 2005 via secretariat of the unpfii, 2008). some of their examples can serve as learning opportunities for others. niños, familias, y educación primero (nfep, children, families, and education first) in guatemala and peru has demonstrated success in creating workshops that enable local educadores to lead therapeutic sessions in their own communities (roberts, 2010). during my time in guatemala, i could not help but think of the irony of my presence as a u.s. citizen attempting to educate and rebuild a community that has been affected by the actions of my government. this realization was humbling. crosscultural social work practice goes beyond understanding the relevant literature—it is a personal and political endeavor. crucial conversations in post-conflict guatemala are just one example in which locally driven cross-cultural social work can be a supportive part of the healing process. references american psychiatric association. 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(2001). childhood trauma and risk for ptsd: relationship to intergenerational effects of trauma, parental ptsd, and cortisol excretion. development and psychopathology, 13, 733-753. cswrfinal_4.1.13 57 columbia social work review, volume iv suicide and soul wound: stress, coping, and culture in the american indian and alaska native youth context eleni malka zimiles suicide, the second leading cause of death for american indian and alaska native (ai) youth ages 15 to 24, raises a critical issue for social work research and practice. this paper argues that ai youth suicide is a contemporary manifestation of “soul wound” and expands the definition of soul wound to include present stressors and coping mechanisms for youth that are characterized by a legacy of colonization and cultural oppression. while ai youth come from diverse communities, this paper will demonstrate the importance of examining youth suicide as part of the overall ai experience in the united states. using an indigenist stress process model framework, it will subsequently examine four forms of stressors informed by the marginalization of the ai population: psychological strains of historical trauma, environmental stressors, quotidian stressors arising from socioeconomic factors, and adversity from personal and relational role conflicts. ai youth mediate these stressors through coping mechanisms around social support and collective mastery. this paper will conclude with a call to develop an anti-oppressive, culturally relevant social work practice that supports meaningful identity development and collective efficacy. on december 21, 2012, members of the pine ridge indian reservation gathered for a candlelight vigil outside the rushmore plaza civic center in rapid city, south dakota. bringing pause to the lakota nation invitational tournament of the same night, the vigil aimed to create awareness of and demand attention to the youth suicides of pine ridge. three years earlier, south dakota state senator theresa two bulls declared a state of emergency when the suicide rate of the area reached over 10 times the national average. one hundred and twenty years earlier, the massacre of wounded knee took place at pine ridge, where soldiers of the u.s. 7th cavalry regiment killed over 150 lakota sioux. from the pine ridge reservation in south dakota, zimiles columbia social work review, volume iv 58 to the mescalero apache reservation in new mexico, to the northern plains of alaska, american indian and alaska native (ai) youth navigate a complex web of history and reality. suicide, the second leading cause of death for ai youth ages 15 to 24, raises a critical issue for social work research and practice. the alarming constellation of ai youth suicide statistics complicates and problematizes current operational understandings of suicide in the u.s., highlighting the fundamental role of cultural marginalization in self-injurious behavior. suicide, defined by the centers for disease control and prevention (cdc; 2012) as a “death caused by self-directed injurious behavior,” is largely regarded by the mental health profession as a complication of a psychological disorder (oquendo, baca-garcia, mann, & giner, 2008, p. 165). this individualistic and pathological perspective ignores the socio-political and cultural dimensions of youth suicide. this paper argues that ai youth suicide is a contemporary manifestation of “soul wound” (walters & simoni, 2002, p. 520). native scholars (brayboy, 2005; evans-campbell, 2008; walters & simoni, 2002) describe soul wound as the accumulation of unresolved grief stemming from colonization. using pearlin and skaff’s (1996) stress model within an indigenist framework, this paper expands the definition of soul wound to include present stressors and coping mechanisms for youth that are characterized by a legacy of colonization and cultural oppression. understanding suicide as an expression of soul wound captures the complex relationship between the private and public spheres, allowing for an acknowledgement and opportunity to engage with the deep imprint left on a person and community by our historical narratives. although ai youth come from diverse and distinct communities, the paper will demonstrate the importance of examining youth suicide as part of the overall ai experience in the u.s. using an indigenist stress process model, the paper will subsequently examine four forms of stressors informed by the marginalization of the ai population: psychological strains of historical trauma, environmental stressors, quotidian stressors arising from socioeconomic disparities, and adversity resulting from personal and relational role conflicts. next, the paper will explore how ai suicide and soul wound 59 columbia social work review, volume iv youth mediate these stressors through coping mechanisms around social support and collective mastery—the ability of youth to understand their ability to confront hardships and marginalization. in conclusion, the paper will demand the development of an antioppressive, culturally relevant social work practice that supports meaningful identity development and collective efficacy. who are american indian and alaska native (ai) youth? the ai youth behind the statistics come from a heterogeneous population comprising distinct tribes across the u.s. in the 2010 census bureau results, 5.2 million people identified as american indian/alaska native (norris, vines, & hoeffel, 2012). there are currently 565 federally recognized tribal nations across the country, and another 200 recognized within individual states (kenyon & hanson, 2012). the majority of ai communities live on federaland state-recognized reservations and in low-income sections of metropolitan areas across the u.s. (freedenthal & stiffman, 2004). such diversity manifests in dynamic cultures experienced uniquely by individuals and groups of different geographic and historical landscapes. current ai youth suicide statistics comprise a birth cohort of the current adolescent and young adult generation ages 15 to 24 that spans the distinct tribal nations. census figures estimate that there are over 1.1 million ai people between the ages of 15 to 24, making up approximately 20% of the total ai population (dorgan, 2010). while the ai youth population is a small percentage of the overall population in the u.s., they are overrepresented in the welfare system. ai children constitute 1% of the u.s. child population; however, they make up 2% of children in foster care, and over 50% of the children in foster care in select states (lawler, laplante, giger, & norris, 2012). living in communities with chronically underfunded federal programs, ai youth live in households with an income less than half the national average and often without healthcare coverage. the disproportionate challenges experienced by the ai youth population due to conditions of poverty necessitate the attention of the social work profession. zimiles columbia social work review, volume iv 60 defining an indigenist stress-process model the conjunction of a stress-process model and a critical indigenist framework allows for an anti-oppressive, strengthsbased analysis of cultural identity and realities in relation to stressors and mediators experienced by young people. the stress process model, first introduced by pearlin, menaghan, liberman, and mullan (1981), contextualizes varying life strains in a movement between exposure, mediators, and outcomes. compared with an event produced from a single pathway, suicide sits within a more holistic and heuristic framework. differentiating between stressors and coping mechanisms, the model highlights the complex interactions between converging life dynamics. the danger of studying suicide as an outcome of stress exposure and response is the heightened possibility of oppressive, deficit-based analyses of cultural structures and human agency, particularly in application to ethnic minorities (stiffman, 2007; walters & simoni, 2002). as stressors are “traced to the very boundaries of societies, their structures and cultures” (pearlin et al., 1981, p. 338), they can quickly slip into analyses of pathologies or cultural essentializations, instead of being placed within distinct socio-political and historical contexts. walters and simoni (2002) suggest applying an indigenist perspective on stresscoping studies of populations to “acknowledg[e] the colonized or fourth world position of natives in the united states and advocat [e] for their empowerment and sovereignty” (p.520). this perspective recognizes that indigenous populations have been targeted by federal policies embedded in imperialism and “intimately linked around the problematic goal of assimilation” (brayboy, 2005, p. 429). the indigenist framework orients its analysis within tribal critical theory. evolving from critical race theory work, tribal critical theory places the connections between colonization and contemporary experiences of socioeconomic and political marginalization at the center of its analysis (brayboy, 2005; yosso, 2005). using a critical indigenist paradigm to re-frame the analysis of the stress-process model allows for a deeper analysis of the intimate relationship between suicide and soul wound. suicide and soul wound 61 columbia social work review, volume iv the stress universe stressors, according to pearlin and skaff (1996), are events, conditions, challenges, or experiences that adversely affect an individual or group’s interactions with their environment, their understanding of self in relation to community, and their strategies for everyday life. within the realities of ai youth, stressors are multi-layered and interconnected. the following analysis looks particularly at how indigenous cultural identity and experience characterize the “stress universe” (walls & whitbeck, 2011, p. 417)—the amalgamation of primary eventful, ambient, and quotidian stressors, as well as secondary “role strain” stressors (pearlin & skaff, 1996, p. 239). examining the various stressors within the stress universe facilitates an analysis of how cultural marginalization informs and produces multiple life strains. pearlin and skaff (1996) define eventful stressors as unscheduled life events that cause adversity in an individual’s life. at the core of culturally influenced eventful stressors for ai youth is historical trauma. historical trauma, as defined by braveheart (1999), is the “cumulative emotional and psychological wounding over the lifespan and across generations emanating from massive group experiences” (as cited in walls & whitbeck, 2011, p. 416). youth experience historical trauma as a chronologically nuanced example of pearlin and skaff’s (1996) “nonegocentric” (p. 240) eventful stressors. while past colonization of ai lands, subsequent tribal displacement, and punitive federal policies of cultural repression were not directly experienced by present day ai youth, the effect of such trauma from their ancestors, families, and communities remains strongly felt. a process that “extends through time” (pearlin & skaff, 1996, p. 239), stress spans across historical generations. inherited collective experiences and narratives derived from a deep legacy of colonization influence youth’s individual exposure and reactivity to stress (ong, burrow, & fuller-rowell, 2009). in a study conducted by walls and whitbeck (2012), ai youth reported daily thoughts of historical and cultural loss. the events of european-american imperialism created a status of disequilibrium, which led to an extended “period of readjustment during which the system strugzimiles columbia social work review, volume iv 62 gles to reestablish a homeostasis,” (pearlin, 1981, p. 339). such events left young people vulnerable to secondary stressors and stress proliferation, where the strains from multiple stressors accumulate to produce more drastic effects. historical trauma refers to primary psychological stressors related to legacies of colonization; however, ai youth also directly experience a host of environmental stressors defined by pearlin and skaff (1996) as chronic “ambient strains” (p. 241) arising from years of federal neglect and abuse. current figures cite 28% of ais living in poverty (u.s. census bureau, 2012). according to the american foundation for suicide prevention (2012), an estimated 33% of all ai individuals are without health insurance and are entirely reliant on indian health services (ihs), one of several chronically underfunded programs established as part of the federal government’s trust responsibility to protect ai treaty rights, lands, and resources (bureau of indian affairs, 2013). as members of the u.s.’s poorest population of color, ais are at a greater risk for psychological distress due to heightened exposure and reactivity to environmental stressors (ong, burrow, & fuller-rowell, 2009). ai communities have an overall lack of ready access to healthcare services, full-service grocery stores, resourced schools, recreational facilities, and other amenities (fleischhacker et al., 2012). these deficiencies in social infrastructure foster disheartening realities of soaring crime rates, high rates of substance abuse, extreme prevalence of obesity, and other stressors involving and/or affecting young people. social and economic disparities produce adversity in ai youth’s daily strategies and routines, labeled by pearlin and skaff (1996) as “quotidian stressors” (p. 241). depending on their particular locale, young people may confront challenges on a regular basis, such as getting to school, feeling safe at home and in their neighborhood, obtaining access to necessities such as food, and participating in enrichment and/or support services. socioeconomic disadvantages manifested in the local neighborhood affect the everyday levels of functioning and satisfaction of ai youth (silmere & stiffman, 2006). increased neighborhood instability and material deprivation contribute to depression (matheson et al., 2006). these hardships look different within each distinct suicide and soul wound 63 columbia social work review, volume iv community due to local manifestations of poverty. the disparities realized within daily life are the social determinants of youth’s stress exposure, reactivity, and their ultimate health outcomes. historical trauma and socioeconomic disparities intersect with adolescent development processes to produce “role strain stressors” (pearlin & skaff, 1996), which are defined as strains arising from the demands of one’s individual status and relationships. a fundamental element of adolescence is the formation of a self-identity and recognition of role expectations within varying environments (wexler, 2009). ai youth struggle with the process of self-actualization in the face of cultural loss and discrimination. multiple scholars have documented the struggle youth undergo as they encounter cross-cultural contradictions between the normative values of their tribal cultures and those of the dominant european american society (brayboy, 2005; johnson & tomren, 1999; kenyon & hanson, 2012; walters, 1999; wexler, 2009). public schools and wider communities outside of reservations expose young ais to systems of eurocentric knowledge that devalue general tenets of indigenous beliefs, such as the dominance of individualist over collective modes of thinking and the depreciation of holistic conceptions of health and well-being (kenyon & hanson, 2012). these experiences of cultural disconnection strain relationships between youth, older family members, and non-ai peers, ultimately nurturing internalized oppression and hindering positive notions of self-worth and support. between childhood and adulthood, eurocentric and native contexts, ai youth find themselves within a fragile and complicated web of expectations. role strain stressors arise from the biological and cultural liminal spaces that youth occupy. struggling to balance opposing systems of knowledge and visions of success, youth become vulnerable to a cultural anomie, a loss of a sense of personal identity and life purpose (johnson & tomren, 1999; walters, 1999). self-incoherence leading to relational conflicts establishes cultural identity as a burden and source of overall life dissatisfaction and disappointment (pearlin & skaff, 1996; wexler, 2009). zimiles columbia social work review, volume iv 64 healing soul wound: developing meaningful coping strategies individuals and communities operate numerous interdependent and multidimensional coping mechanisms to navigate the stress universe. the stress process model identifies coping as an individual’s cognitive ability to adapt to adversity (pearlin & skaff, 1996). social support and mastery are two crucial mediators for young ai individuals in moderating the experience of soul wound stressors. “shaped by the values the person holds as a consequence of social group membership” (pearlin & skaff, 1996, p. 242), coping repertoires are intimately intertwined with the social fabric of many collective-oriented ai communities (brayboy, 2005; wexler, 2009). successful mobilization of community resources and cultural capital is crucial to cultivate relationships and structures that encourage positive identity development and tribal unity. coping as a “management of meaning” (pearlin & skaff, 1996, p. 242) must rely on building a relevant and coherent cultural identity that reinforces agents of social support. scholarship around the development of ai youth identity documents how relationships with extended kin networks led youth to actively find ways to integrate ai identity into their lives, using indigenous values, traditions, and spirituality as positive sites for incorporation (lucero, 2010; strickland & cooper, 2011). youth narratives around cultural ceremonies and conversations with relatives facilitated the development of a meaningful identification with their tribal nation and the ai community at large. having a strong connection to cultural identity, particularly within a framework of one’s network, returns power to the individual and community at large. pearlin and skaff (1996) describe this “global sense of control” as “mastery” (p. 243), a crucial mediator for harmful stress exposure. while mastery refers to the individual youth’s ability to understand their competence in facing difficult situations and internalized oppression, it also holds a strong potential for the tribal community in building collective efficacy. in building strategies for suicide prevention, it is essential to capitalize on the collective orientation of ai commusuicide and soul wound 65 columbia social work review, volume iv nities. for many suicide prevention programs in the u.s., the emphasis is on individual power and a singular sense of future (gould & kramer, 2001). strengthening ai identity through collective meaning-making and management can communicate “an empowered and empowering image of indianness, and provid[e] native americans, particularly native youth, opportunities for action and participation in the larger indian cause [toward selfdetermination]” (wexler, 2009, p. 267). revitalization and resistance movements such as the keetowah society and the red power movement have provided tribes with a vehicle to combat cultural subjugation and to participate in linking historical and contemporary experiences of ai peoples (walters, simoni, & evans-campbell, 2002; wexler, 2009). community mastery cultivates a rich and nuanced cultural experience that utilizes multigenerational realities and manifestations of cultures, and supports an individual sense of purpose and life-satisfaction. conclusion today, ai communities are actively engaging in grassroots-based suicide prevention measures. it would behoove social workers to connect with this work and reflect on how suicide and soul wound affects praxis with youth. ultimately, this analysis calls for the development of anti-oppressive, culturally relevant programming that mobilizes the necessary resources to mediate stress exposure. these programs must mediate youth realities of historical trauma, social disparities, discrimination, and bicultural liminality through a cultivation of meaningful identity development and a celebration of individual and collective mastery. understanding suicide as a contemporary expression of soul wound relocates the phenomenon beyond an individual pathology and into a broader, more complex schema. with an eye on the individual in relation to systems, social work benefits from an engagement with the realities of soul wound, allowing for a richer practice able to traverse past, present, and future socio-political narratives. zimiles columbia social work review, volume iv 66 references brayboy, b. m. j. 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(2005). whose culture has capital? a critical race theory discussion of community cultural wealth. race, ethnicity and education, 8(1), 69-91. undoing the damage: working with lgbt clients in post-conversion therapy horner   columbia social work review, volume i        8   undoing the damage: working with lgbt   clients in post­conversion therapy    jessica horner    as a mecca of diversity, new york city is one of the epicenters for the lesbian,  gay, bisexual, and transgender lgbt community. as such, lgbt identified  clients present in new york’s counseling and mental health agencies with a  cross section of issues unique to the lgbt community. one of these issues is  the deleterious effects lgbt­individuals face after an experience with conver­ sion therapy. conversion therapy aims to alter a person’s sexual orientation  away from homosexuality and into heterosexuality or celibacy. clients seeking  counseling after an experience with conversion therapy present distinct prac­ tice challenges that require special consideration in treatment. these clients  may experience both sexual and spiritual identity crises, symptoms of depres­ sion and anxiety, hopelessness, sexual dysfunction, and symptoms of post­ traumatic stress. integrative solution therapies, grief work, community­based  interventions, and trauma work offer healing strategies for treating lgbt cli­ ents after conversion therapy.      one associates the practice of conversion therapy with a time when  homosexuality was a diagnosable mental illness. many contemporary clini­ cians readily classify such practices as unethical and therefore conclude that  they are rare in occurrence. furthermore, prevalence rates of conversion ther­ apy are unclear and vary geographically. individuals suffering from the ad­ verse effects of conversion therapy appear in diverse urban areas such as new  york city’s lesbian, gay, bisexual, and transgender (lgbt) affirmative agen­ cies, indicating that it is still a relevant concern for the lgbt community and  mental health practitioners serving these populations.     though we generally consider those who undergo conversion therapy  to be bisexual, gay men, or lesbians, transgender individuals have also experi­ enced conversion therapy since not all transpersons identify as heterosexual.  consequently, conversion therapy may affect anyone in the lgbt community.    as an historically underserved sexual minority population subjected  to homophobia and transphobia, lgbt clients present with symptoms of de­ pression, anxiety, and post­traumatic stress disorder. these symptoms are the  result of overt aggression, physical assault, living with limited civil liberties,  microaggressions, and the overall unaccepting social climate of an inherently  homophobic society. embedded in these societal oppressions is the practice of  conversion therapy in which a licensed clinician, priest, rabbi, or other spiritual  advisor works with the lgbt­identified client to “convert” the individual to a  heterosexual, or at least a celibate, lifestyle. in opposition to conversion thera­ pies, the national association of social workers committee on lesbian, gay,  and bisexual issues (nclgb) firmly asserts:    undoing the damage   9        columbia social work review, volume i  lesbians and gay men often are pressured to seek reparative  or conversion therapies, which cannot and will not change  sexual orientation…nclgb believes that such treatment  potentially can lead to severe emotional damage…no data  demonstrates that reparative or conversion therapies are ef­ fective, and in fact they may be harmful.   (nclgb, 2000, p. 1­2)      with this statement in mind, this paper explores evidence­based ap­ proaches that affirm and support both the sexual and spiritual identity of the  lgbt­identified client seeking mental health services after conversion ther­ apy. such approaches are referred to as “integrative solutions” (gonsiorek,  2004). the following case example highlights many of the traumatic experi­ ences unique to lgbt populations involved in conversion therapy.    consequences of conversion therapy       m.h. arrived disheveled and exhausted for counseling services during  walk­in hours at a lgbt community center in new york city. lgbt commu­ nity centers often serve as sanctuaries for lgbt individuals who have experi­ enced trauma by providing them with counseling and case management ser­ vices. m.h. arrived at the center hoping the agency could help him find some­ where to stay. his affect was flat, and he held his head in his hands as he ex­ plained that he was 21 years old and running away from home. his parents,  particularly his father, abused him for being gay. his mother and father called  him derogatory names and often hit him. in tears, m.h. disclosed that his par­ ents sent him to a christian conversion counselor who tried to “turn him  straight” and also verbally assaulted him. he wanted desperately to move away  from his parents but lacked the resources to live on his own. through his tears,  his face remained flat and unanimated as if he were resigned to giving up. he  confirmed this sentiment when he stated that he no longer cared whether he  lived or died. unfortunately, the conversion therapy movement profoundly  impacted m.h., and the issues he encountered are highly relevant to those  working in social services with lgbt populations.    some consider conversion therapy a phenomenon of the past, but  many lgbt clients who seek various types of counseling still encounter ideas  and therapies that attempt to convert an individual’s sexual orientation, espe­ cially in the context of religion. conversion therapy, also referred to as repara­ tive therapy, began with the idea that lgbt individuals are “sexually bro­ ken” (kort, 2008; haldeman, 2002b). despite the removal of homosexuality  from the diagnostic and statistical manual of mental disorders in 1973 by the  american psychological association, these therapies persisted, justified by  theological arguments that define homosexuality as a moral transgression. in  an attempt to rectify this perceived transgression, conversion therapists used  abusive aversion techniques with their clients, which included electric shocks  to the hands and genitals when exposed to homosexual material, encourage­ horner   columbia social work review, volume i        10   ment of heterosexual activity such as sex and dating, and the teaching of skills  to manage homosexual tendencies. clients who experienced such therapies  present unique practice challenges for mental health providers because conver­ sion techniques are frequently associated with religious conviction (kort,  2008; gonsiorek, 2004).  a client seeking services after conversion therapy may be in a state of  emotional and/or spiritual crisis. clients seeking counseling after an experience  with conversion therapy present with increased levels of depression, low self­ esteem, and suicidal ideation and intention (nicolosi, byrd, & potts, 2000).  they frequently feel intense shame and self­loathing from internalized homo­ phobia (carroll, 2010). furthermore, some consider the infliction of conver­ sion therapy upon an lgbt individual a type of hate crime and sexual minori­ ties endure devastating and long­lasting effects from hate crimes (rose & me­ chanic, 2002). other studies confirm chronic depression and low self­esteem in  post­conversion clients, as well as sexual dysfunction and significant relational  issues (haldeman, 2002b).   in addition to psychological consequences of conversion therapy, in­ dividuals experience a series of concrete losses. clients may feel that they have  “failed” at conversion therapy and, as a consequence, may be ostracized by  family, community, and work, all of which are significant and potentially inca­ pacitating losses (haldeman, 2002b). this sense of failure and loss can contrib­ ute to debilitating feelings of guilt (haldeman, 2002b). clients not only experi­ ence the identity trauma of intrinsically homophobic conversion therapy, but  also experience another level of psychological pain when they consider them­ selves failures for not having the ability to change their sexual orientation.  when conversion therapy fails to change one’s sexual orientation, it eliminates  any hope for change a client may have had prior to the conversion therapy.  consequently, clients enter post­conversion therapy attempting to manage the  aforementioned issues, and they may also endure dangerous levels of hopeless­ ness.    clients who seek counseling and mental health services after conver­ sion therapy survived psychological manipulation and possibly physical  trauma. they may have suffered some threat to and/or crisis of identity. the  identity component of the trauma adds another level of complication to clinical  work in mental health counseling, especially when the client cannot decouple  spiritual and sexual identity. historically, the controversy around conversion  therapy centered on the ideological debate of whether or not it should exist.  even some mental health practitioners who are not necessarily proponents of  conversion therapy argue that client self­determination ranks as a priority over  the ethical considerations of the treatment (carroll, 2010; haldeman, 2002a).  therefore, many practitioners who honor client choice above other ethical  standards believe individuals should have access to conversion therapy.    working in tandem with sexuality and spirituality creates precarious  clinical situations for the practitioner. researchers highlight the fact that the  saliency of spiritual identity and the need for a spiritual belief system often  exceed those of sexuality, and a practitioner who suggests “an abandonment of  undoing the damage   11        columbia social work review, volume i  their spiritual traditions in favor of a more gay­affirming doctrine” may also  inflict psychic damage on the client (haldeman, 2002a, p. 263). haldeman  (2002b) reiterates in another article that religious beliefs can define the self as  much as or more than sexual orientation. for some, positive associations with  religion, such as comfort, family connection, and routine, are lost with accep­ tance of sexual orientation, a loss that the practitioner must acknowledge and  respect. furthermore, acknowledgment of sexual orientation does not always  automatically earn acceptance into the lgbt community. some lgbt clients  complain that, “it is easier for some individuals to come out as lesbian or gay  men in their communities of faith than it is to come out as spiritually or relig­ iously oriented in the lgb community” (haldeman, 2002a, p. 262). the prac­ titioner must not assume that a client can easily “give up” a religious commu­ nity in exchange for the lgbt community.    implications for practice    integrative solution therapies propose that mental health clinicians  respect all the components of a client’s identity and assist the client in making  room for a variety of aspects of identity in their overall self­schema  (gonsiorek, 2004). the therapist does not seek to indoctrinate the client into  the lgbt­affirmative community, but rather intends to illuminate the ways in  which social forces coalesce to devalue, invalidate, and sometimes oppress  gender and sexually non­conforming individuals. frequently, significant loss  may be associated with these truths. for example, a client’s deeply embedded  schema that everything about her religion is true and good will be compro­ mised with the acknowledgement that this fundamentally “true and good”  community has also oppressed her in some way. therefore, grief work will be  necessary for such clients (haldeman, 2002b). after the client acknowledges  the pain of her losses, she may need to deal with internalized homophobia,  guilt, and shame. haldeman (2002b) advises:    neutralization of shame takes place by examining a self that  has been firmly embedded in a socio­cultural environment  that did not value the self for who it was, but that required it  to change (or hide) in order to be acceptable…this is not a  problem of the self, but of the social environment.   (p. 121)      creating an environment that simultaneously affirms and validates  both spiritual and sexual identity requires illustrating for the client a concept of  the self within a socio­cultural environment. collectively, some of the integra­ tive solution practice goals for working with clients after conversion therapy  include acknowledging and validating pain and loss, neutralizing shame, and  encouraging clients to live for themselves rather than the social institutions that  pressure them to conform to a certain standard (haldeman, 2002b).    the literature highlights other important practice considerations when  horner   columbia social work review, volume i        12   working with lgbt clients participating in post­conversion therapy. for ex­ ample, lgbt­identified individuals who attempt conversion therapy com­ monly believe that their homosexuality resulted from inadequate or inappropri­ ate bonding with one or both parents, that they are morally corrupt, or that ho­ mosexuality represents a failure in adequate psychological development  (carroll, 2010; kort, 2008; haldeman, 2002a; haldeman, 2002b). such clients  often need varying amounts of psychoeducation following conversion therapy.  the practitioner must address these beliefs without denigrating religious con­ viction or disparaging the client for her potential belief in such statements. fur­ thermore, practitioners must be absolutely comfortable with addressing and  discussing sex with their clients in order to ensure they have the most accurate  information with which to protect themselves. in particular, therapists need to  comfortably address the topic of sex because of the way in which trauma and  sexual orientation have impacted the client’s formation of identity.      in many ways, lgbt clients in post­conversion therapy suffer a dou­ ble assault to their identity formation. they entered, or were coerced into, con­ version therapy because their spiritual and/or self­concept clashed with their  sexual orientation. unfortunately, the trauma experienced in conversion ther­ apy further disturbs a client’s sense of self on a less conscious level. for exam­ ple, traumatic memory remains highly accessible to an individual and, conse­ quently, autobiographical knowledge organizes itself into a new, salient, cogni­ tive schema created by the trauma memory; it may be interpreted as a feature  of one’s personal identity (berntsen & rubin, 2007). furthermore, trauma cre­ ates highly accessible memories which, according to the availability heuristic,  cue the victim to overestimate the frequency of the traumatic events. not only  will a client organize any or all knowledge of self into the cognitive schema  created by the trauma of conversion therapy, she may expect to be hurt and  traumatized again when re­entering treatment after an experience with conver­ sion therapy. consequently, the client may shut down, be defensive, suicidal,  highly anxious, and/or experience symptoms of post­traumatic stress disorder.  knowing and expecting the cognitive effects of trauma equip the practitioner  for work with lgbt clients in post­conversion therapy.    the implications of these findings for work with individuals in post­ conversion therapy are extensive. the social worker and/or mental health prac­ titioner must consider trauma, spiritual and sexual identity, and any presenting  clinical pathology. distinguishing pathology from the negative effects of a  lifetime of internalized homophobia contributes to the complexity of treatment  considerations. however, a practitioner has the opportunity to do meaningful  and important work by simply providing a client with information incongruent  with their maladaptive schema, which commences the process of forming new,  healthier, and more adaptive schema (berntsen & rubin, 2007). therefore, a  significant component of practice with post­conversion clients involves provid­ ing them with schema­deviant material through a series of corrective emotional  experiences. unconditional positive regard, valuing all features of a client’s  identity, and resisting impulses both to coax her into openly embracing her  sexuality and to compel her to integrate into the lgbt community all provide  undoing the damage   13        columbia social work review, volume i  the client with some level of remedial emotional experience, thus increasing  the likelihood that she will remain in treatment and achieve some healing. in  order to achieve a safe environment, the clinician must recognize her own het­ erosexual and gender­normative privilege (if she does not identify as lgbt),  and acknowledge the grief that comes with losing heterosexual privilege in the  community after unsuccessful conversion therapy (kort, 2008). other ap­ proaches to trauma work, discussed below, are particularly relevant to work  with post­conversion therapy clients.    healing trauma    judith herman (1992) adopts a feminist perspective on trauma theory  and practice. herman describes many of the features characteristic of a trauma­ tized individual. one feature includes “re­living” the trauma in thoughts, ac­ tions, and dreams. this phenomenon is particularly relevant in working with  clients after conversion therapy. for example, many clients who have under­ gone conversion therapy report persistent sexual dysfunction. for clients who  received aversion stimuli, such as electric shocks, sexual intimacy brings back  the moment of conversion therapy trauma, and she may be unable to continue  any sexual activity. this repetitive intrusion produces debilitating effects.  when she coins the “dialectic of trauma” phenomenon, herman describes the  converse of intrusive re­living experiences in which the traumatized individual  vacillates between states of complete numbness and amnesia of the trauma, to  states of overwhelming sensitivity and re­living of the event. practitioners  working with individuals in post­conversion therapy should recognize this dia­ lectic vacillation and cultivate awareness of the danger and emotional distress  involved in both of these states. according to herman, the emotional/re­living  state could produce complete inhibition in the client, creating a variety of un­ safe situations ranging from self­harm, substance abuse, and unsafe sex.  numbness and complete lack of feeling may lead to extreme isolation and the  development of symptoms of depression, both pertinent concerns for individu­ als who identify as lgbt.  herman (1992) also discusses the way in which trauma affects faith  and sense of community, both critical factors involved in working with clients  in post­conversion therapy. she asserts that to repair the connection between  the traumatized person and the community, the community must concurrently  acknowledge the harm inflicted on the individual and take action in response to  the inflicted harm. herman states that “these two responses – recognition and  restitution – are necessary to rebuild the survivor’s sense of order and jus­ tice” (p. 70). this may present a particular challenge to clients in post­ conversion therapy. in many cases, the community that inflicted the harm on  the individual will neither publicly acknowledge the damage nor take responsi­ bility or action to make amends. in order to achieve recognition and restitution  for the traumatized client, the practitioner must investigate resources that help  satisfy these needs. for example, a client forced under threat of expulsion by  her religious community to engage in conversion therapy has the opportunity  horner   columbia social work review, volume i        14   to gain recognition from inclusion in a lgbt­affirmative religious setting.  unfortunately, such resources are difficult to access even in densely populated  urban areas because homosexuality is still highly stigmatized within and out­ side of the context of religion, but the practitioner should remain aware of po­ tential avenues for achieving recognition and restitution within a community.  the best opportunity for recovery from trauma is in interpersonal rela­ tionships, rather than in isolation (herman, 1992). in this way, the survivor  rebuilds and repairs the psychological functioning that was jeopardized by the  trauma. in discussing the significance of allowing a client to remember and  mourn losses, herman delivers wisdom particularly suited to those who have  survived conversion therapy:    [the survivor] often comes into conflict with important peo­ ple in her life. there is a rupture in  her sense of belonging  within a shared system of belief. thus she faces a double  task: not only must she rebuild her own “shattered assump­ tions” about meaning, order, and justice in the world but she  must also find a way to resolve her differences with those  whose beliefs she can no longer share.     (herman, 1992, p. 178)    a client seeking lgbt­affirmative treatment after an experience with conver­ sion therapy may confront overwhelming psychic tension in trying to “resolve  differences” between conflicting systems of belief. this poses particular chal­ lenges for the clinician who may gravitate to theological solutions for the client  either by trying to alter the client’s system of belief or by trying to find differ­ ent interpretations of those beliefs. instead, the clinician must assist the client  in deciding which beliefs to cherish and which doctrines to mourn. herman  (1992) describes multiple features of trauma, such as re­living and intrusion of  the event into daily life, and the importance of community in healing from the  trauma. the aforementioned treatment considerations pertain to affirmatively  supporting a lgbt client post­conversion therapy and providing critical tools  for working with any traumatized individual.    conclusion      though m.h. and i met only once, strong interpersonal factors  emerged during this meeting. m.h. maintained a defensive and guarded pos­ ture, sitting with his legs double­crossed and his arms tightly crossed around  his abdomen. he rarely made eye contact and covered his face so i could not  see his tears. he also repeatedly apologized for crying. such acute discomfort  was difficult to witness, and my primary goal during the intake session was to  provide constant reassurance, validation, and a sense of safety in the hopes of  creating a mini­corrective emotional experience that would be just enough to  bring him back for continued services. in an attempt to be as affirmative as  possible, i made the mistake of openly judging the community and family from  undoing the damage   15        columbia social work review, volume i  which he came, and i rushed to reassure him that he had a place in the lgbt  community. as discussed, the literature reveals the danger in using such a tac­ tic. in my concern for his well­being, i was extremely eager to whisk him away  from his abusive family and community into the lgbt community with which  he may not yet, or ever, identify. the outrage one feels for the devastating ef­ fects such overt hate and discrimination produce may be one of the most diffi­ cult emotions for clinicians working with clients post­conversion therapy. it  triggers an impulse to “rescue” or “save” the client which, ironically, are some  of the same verbs used by conversion therapists to justify their work. this is a  sobering realization.  future research must explore the ways in which social workers and  other mental health practitioners can empower individuals who seek treatment  after an experience with conversion therapy. greater attention to the subject  would help contradict the erroneous belief that conversion therapy no longer  exists since homosexuality was removed from the diagnostic and statistical  manual of mental disorders. clients who survived conversion therapy suffer a  myriad of psychological symptoms ranging from depression and anxiety to  ptsd and sexual dysfunction. they may be in spiritual and emotional crisis,  experiencing shame, low self­esteem, relational issues, and the loss of family  and/or community.  the biggest challenge for practitioners in treating the symptoms of  clients exposed to conversion therapy lies in the fact that clients need guidance  in resolving the tension between their religious conviction and their sexuality,  a very precarious task for the clinician. integrative solution therapies that at­ tempt to make room for all aspects of oneself (spiritual, sexual, and otherwise)  offer some hope for lgbt individuals seeking treatment after an experience  with conversion therapy. integrative therapies also strive to bring awareness to  the client of how environmental and social forces contribute to their pain and  experiences with homophobia, and they aim to acknowledge and validate pain  and loss, neutralize shame, and teach clients to live for themselves rather than  for institutions. trauma and grief work also assist in this process. as demon­ strated in the case of m.h., these issues are deeply ingrained and may even be  life threatening at times. despite some social progress, conversion therapy ex­ ists and practitioners must be prepared to adequately serve lgbt individuals;  they deserve the same non­judgmental, affirmative, and evidence­based thera­ pies as their heterosexual counterparts.    references    berntsen, d., & rubin, d. (2007). when a trauma becomes a key to identity:    enhanced integration of trauma memories predicts posttraumatic    stress disorder symptoms. applied cognitive psychology, 21, 417­   431.  carroll, l. (2010). counseling sexual and gender minorities. new jersey:    pearson education.    horner   columbia social work review, volume i        16   gonsiorek, j. (2004). reflections from the conversion therapy battlefield. the    counseling psychologist, 32 (5), 750­759.  haldeman, d. (2002). gay rights, patient rights: the implications of sexual    orientation conversion therapy. professional psychology: research    and practice, 33 (3), 260­264.  haldeman, d. (2002). therapeutic antidotes: helping gay and bisexual men    recover from conversion therapies. journal of gay and lesbian    pschotherapy, 5 (3), 117­130.  herman, j. (1992). trauma and recovery: the aftermath of violence from    domestic abuse to political terror. new york: basic books.  jenkins, d., & johnston, l. (2004). unethical treatment of gay and lesbian    people with conversion therapy. families in society, 85 (4), 557­561.  kort, j. (2008). gay affirmative therapy for the straight clinician: the essen­   tial guide. new york: w.w. norton & company.  national committee on gay, lesbian, and bisexual issues. (2000).    “reparative” and “conversion” therapies for lesbians and gay men.    washington, dc: national association of social workers.  nicolosi, j., byrd, a., & potts, r. (2000). retrospective self­reports of changes    in homosexual orientation: a consumer survey of conversion therapy    clients. psychological reports, 86, 1071­1088.  rose, s., & mechanic, m. (2002). psychological distress, crime features, and     help­seeking behaviors related to homophobic bias incidents. ameri­   can behavioral scientist, 46, 14­26.                                            journal2012 ! !"########$%&'()*+#,%-*+&#.%/0#123*245#6%&'(2#777! !"#$"%&''&"#()*&+,-+#./01#2*#30)+45#6&''&"# 0'&"7#2"*1)181)&"04)9-,#6/)4,+-"! ! ,8+499+#:+&+;*9<8+(! ! !"#$%&'"(#%%#$)*"+%(,&-./,"/(0!123(&-(#(4-5$).6.7&$#6(,&-./,"/( %)#%(#88"$%-(#($)&6,9-(#:&6&%5(%.(,"'"6.4(#44/.4/&#%"(-.$&#6(/"6#%",; 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/a(#%%#$*+",%(1&./01"0.(/a(&,a#,$bd(!"#$%&'(")(*"%/#'3,%2( &%-(*',%,1&'(./01+"'"204(k52e3>(_ogtod((! e"#,#*>(6d(ud>(:$*""0&,j#>(nd>(^/0&.>([d(;d>(u"77#0>(:d(:d>( :+b<">()d(vd>(m(v0#c#,&>(kd(2oii_3d(!"#$%&'"(#%%#$*+",%( 1&./01"0(&,(+#7%0"#%"1(%/117"0.d(*+,'-(7l#/9(&%-(m92'9134(! !"#$%&'"()%%#$*+",%(-&./01"0(2!)-3! !"#"$%&'(")*! +,#-).%"*/,0%"#*1,23*456%578*9,#-)5*:::********;<! ! ! !"8*=;;>===?! @5"&"(8*+?*a?8*/)b358*c?*d?8*e,'"8*/?*f?8*g*+"2#$,&8*h?*ij<<kl?* cmm"0()5&m*%&*%&$m%m-m%,&"#%n5o*"&o*0,))-&%mb*0(%#o25&*%&* 4,)"&%"?*#$%&'()*+*&,-.*/01(23ikl8*p<pk>p<j=?*! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 29 developmental disability americans with developmental and other disabilities are often excluded from society due to the assumption that they cannot or do not wish to work. this paper examines the possibilities for and benefits of creating jobs for persons with developmental disabilities through the lenses of policy, law, evidence-based practice and social work ethics. while different perspectives on this issue exist, it is important to reframe our assumptions about the employment of people who have developmental disabilities, taking our cues from these individuals, rather than personal, professional, or societal notions. these notions, if they frame people as unable to participate in our culture, can undermine the many achievements that those with disabilities have fought for in law and public perception. including people with developmental disabilities in the workplace is beneficial to these individuals and society in a variety of ways. this paper provides an overview of some excellent models of how to create space for people with developmental disabilities who wish to be employed in the workplace and outlines reasons why this type of economic inclusion is essential in order for these individuals to be included in american society. as specialists in understanding the gap between society and those who are typically rejected from it, social workers are well positioned to find creative solutions for this problem. ccording to the united states administration on developmental disabilities (add), developmental disabilities are “severe, life-long disabilities attributable to mental and/or physical impairments, manifested before age 22. developmental disabilities result in substantial limitations in three or more areas of major life activities: capacity for independent living, economic self-sufficiency, learning, mobility, receptive and expressive language, self-care, and self-direction” (add, 2004, p. 1). there are approximately 4.5 million individuals with developmental disabilities in the united states. national rates of developmental disabilities, including autism spectrum disorders, are thought to be rising. according to the centers for disease control and prevention (cdc), currently one in 150 children born will have autism as compared with one in every 222 in 2000 (cdc, 2007). people with developmental disabilities have an unemployment rate of 72 percent, in comparison with five percent of the population katie cox a developmental disability & employment: a social work priority 30 journal of student social work, vol. vi as a whole (united states census bureau, 2006; united states department of labor, 2008). as people of a nation that claims to allow citizens life, liberty and the pursuit of happiness, and as social workers who adhere to a code of ethics which espouses social justice, the dignity and worth of each person, and client self-determination, it is crucial that we work toward the inclusiveness of people who have developmental disabilities (national association of social workers [nasw], 1999). while pushing away that which may create cognitive dissonance and allow people who are not affected by developmental disabilities (dds) to live more comfortable lives in the short-term, the relegation of people with dds to special facilities excludes them from adequate and equal education, employment, transportation, recreation and other activities, harming us all (whitehead & hughey, 2004). the administration on developmental disabilities (add) recently released a report entitled, “the american dream belongs to everyone,” which describes the purposes and implications of the developmental disabilities assistance and bill of rights act of 2000 (p.l. 106-402) and highlights the importance of the societal inclusion of developmentally disabled (dd) individuals (add, 2004). details of this report, discussed later in this paper, demonstrate the steps that the united states government is taking to ensure the rights of people with dds. social workers might tend to agree that the “american dream” should belong to everyone; however, programs for and treatment of people with dds do not always reflect our code of ethics (nasw, 1999). developmental disability: history and legislation traditionally, people with disabilities have often been considered unable to contribute to society because they have been labeled “sick” or “dependent.” early public policies reflected this social construct of disability. public benefits program requirements have tended to disenfranchise and disempower recipients by requiring that they fall below certain functional benchmarks in order to receive services (whitehead & hughey, 2004). since the 1960s, the disability rights movement has helped individuals with disabilities re-label themselves as whole people and participants in society capable of making choices for themselves. this movement eventually led to government-funded sheltered workshops and vocational programs, set up to provide work experience for individuals with dds (kregal, wehman, & banks, 1989). in the 1980s, the use of sheltered workshops began to evoke wide criticism due to the degree in which they isolated people with dds from mainstream society. in the late 1980s, supported employment k a t ie c o x 31 began to replace sheltered workshops as the generally accepted method of skillbuilding and employment for people with dds (bond et al., 2001). this shift toward supported employment fits appropriately in a society where the centrality of work is undeniable (akabas & kurzman, 2004). the americans with disabilities act of 1990 (ada) was one important milestone in the effort to ensure that those with dds are able to participate in the workforce (pl 101-336). some see the ada as an attack on the welfare state and an attempt to push people off of welfare rolls. they cite the possibility that individuals with disabilities are still extremely limited by the courts’ stricter-than-intended interpretation as skepticism of ada law. judges sometimes decide that people with disabilities do not qualify for as many provisions as the law was originally intended to provide. further, those who challenge the law feel that the ada’s enforceable accommodation standards (e.g., making a large company install a ramp for wheelchair access) may create negative employer reactions because they are averse to making the necessary and required accommodations (bagenstos, 2004). while proponents of this view believe that improved social welfare services are a better answer to barriers than the ada, they fail to recognize that the dominance of these services alone was the very system disability activists fought to change. the reality that people who have dds may still be discriminated against despite ada legislation should not stop dd individuals and their guardians from working toward a society that recognizes dd individuals’ civil rights. tash (formerly the association for persons with severe handicaps), an international association of people with disabilities, their family members, and advocates, has outlined a variety of lobbying and educational efforts designed to include people with dds in the workplace, based on the belief that “no one with a disability should be forced to live, work, or learn in a segregated setting; that all individuals have the right to direct their own lives” (tash, 2008). the social security administration offers special provisions that ensure that people with disabilities can work and continue to receive social security disability insurance (ssdi). these provisions, called work incentives, include provisions for individuals to set aside money, resources, and expenses that are excluded from earned income calculations (fichthorn & scott-gilmore, 2005). the ada is focused on ensuring that those with disabilities are able to enjoy an equal opportunity to participate in society—including the culturally-valued realm of employment. the equal opportunities employment commission seeks to eliminate barriers to employment for individuals with dds by providing de-incentives in the form of fines to those employers who discriminate (equal k a t ie c o x developmental disability 32 journal of student social work, vol. vi employment opportunity commission, 2008). unfortunately, there is a growing body of evidence that people with developmental disabilities are discriminated against at higher levels than people with physical disabilities (gouvier, mayville, & sytsma-jordan, 2003). overall, the ada is an important progression within our society that furthers the cause of people who have dds and wish to work. importantly, the ada furthers this cause without reducing (or failing to advocate for) the much-needed benefits of those individuals who may not wish to or who are not able to work. this paper proposes that gainful employment is an excellent way to ensure that dd individuals are given the self-determination valued by society. while some individuals are treated for their developmental disabilities during childhood, others carry their developmental disabilities into adulthood. as their parents age, and less-than-adequate caretaking facilities remain the norm, these individuals’ life options are severely limited (pruncho, 2003). as the add (2004) report notes, “locating and/or maintaining reliable and stimulating employment is one of the most important steps individuals can take towards personal and financial independence” (p.3). not only does this employment benefit society, it also allows fellow citizens the personal choice to decide what degree of independence they wish to have. while the ada champions the right of dd individuals to work, which is significant for their inclusion in society, the provision of this right does not necessarily create the opportunity for work. the developmental disabilities assistance and bill of rights act of 2000 proposes that “individuals with developmental disabilities and their families participate in the design of and have access to needed community services, individualized supports, and other forms of assistance that promote self-determination, independence, productivity, and integration and inclusion in all facets of community…” (title 1 p.l. 106-402) (add, 2004, p.2). other important legislation that aids people with developmental disabilities include the americans with disabilities act of 1990 (p.l. 101-336), the social security act (p.l. 74-271), the rehabilitation act (p. l. 93-112), and the individuals with disabilities education act (idea) (p. l. 101-476), each of which addresses one or more of the forms of discrimination faced by individuals with disabilities (add, 2004). these policies put into place important supports for people with dds: the ada ensures appropriate workplace accommodations and outlines penalties for discriminatory practices; the social security act provides funds for living and medical care; the rehabilitation act attends to vocational and rehabilitation services; and the individuals with disabilities education act addresses the educational needs of children with disabilities from birth to age 21. another recent piece of legislation k a t ie c o x 33 that aims to benefit people with developmental disabilities is the new freedom initiative, launched by president george w. bush on february 1, 2001. the goal of this initiative is to promote full access to community life for people with dds through the collaboration of federal agencies in removing barriers to independent living (add, 2004). together, these pieces of legislation seek to empower individuals with disabilities to advocate for themselves, build social capital and increase support and choice within the service organizations that affect them and society as a whole. the administration on developmental disabilities is responsible for the implementation and administration of the developmental disabilities assistance and bill of rights act of 2000 (dd act). federal funding from the add allows for programs, including state councils on developmental disabilities (scdd), to pursue systems changes in service or support availability. further, the legislation makes it possible for protection and advocacy (p&a) systems to protect the legal and human rights of individuals with disabilities and for university centers for excellence in developmental disabilities (ucedds) to provide interdisciplinary pre-service preparation and disseminate research findings. projects of national significance (pns), also made possible by this legislation, address areas of emerging concern through discretionary funds (add, 2007). this funding, along with private donations and corporate and foundation grants, has allowed for the creation of a wide range of programs for individuals with dds. however, the number of people with dds that states serve through employment programs remains low as compared to beneficiaries of programs such as education and quality assurance that are also designated for people with dds (add, 2006). while the existing programs provide important services to people with developmental disabilities, the talk of empowerment in the legislation and human service literature is inconsistent with the fact that there are not more programs devoted to employment. employment can lead to empowerment through skill and creativity-building, earning wages, having control over one’s money and contributing to the economy and to the social work environment. despite the fact that 14 percent of people with disabilities who are seeking work are unemployed compared with five percent of the population as a whole, the provision of employment programs for people with disabilities is insufficient (cdc, 2007). while people with dds have benefited from the programs provided by the above mentioned legislation, recent research has shown that these have not been enough to ensure that individuals with dds are participating in the american workplace through integrated jobs (metzel, boeltzig, butterworth, sullivan-sulewski, & k a t ie c o x developmental disability 34 journal of student social work, vol. vi scott-gilmore, 2007). in other words, while legislation and non-employment programs are plentiful, real jobs are few. in order for individuals with developmental disabilities to truly be included in society and reap the benefits that work can offer, this paper proposes a shift toward integrated employment in federally-funded projects. while the reality is that some persons with developmental disabilities may need a great deal of assistance or even full-time care, the majority of dd individuals is able to perform some work. unfortunately, studies have shown that individuals with dds in program care settings exhibit a significant amount of “learned helplessness” in language use, adaptation and behavior. this raises concerns regarding health, physical safety and individual development, because individuals with dds learn to accept substandard living conditions and lower expectations regarding their potential (reynolds & miller, 1985; domingo, barrow, & amato, 1998; janssen, schuengel, & stolk, 2005). while caregivers and those who shape programs tend to see the developmentally disabled as having little ability to develop without a sheltered environment, studies have shown that even severely autistic individuals have personal preferences for certain tasks in the workplace (e.g. vacuuming vs. dusting) (lattimore, parsons, & reid, 2002). this ability illustrates that even those individuals typically considered lowest functioning can acquire skills to make choices, learn, and interact in a social or work setting. is it really these individuals’ disabilities that keep them from productive employment, or it is society’s view that they have no potential to contribute that isolates dd individuals and consigns them to lives of segregated stagnation outside the traditional bounds of our work-centered society? inclusive education and inclusive employment in recent years, following a national debate about educational inclusiveness, the movement for inclusive education for people with developmental and intellectual disabilities in our nation’s classrooms has experienced much success. this achievement is evidenced in the surge of opportunities for children with and without disabilities to be educated together, under the clause of idea legislation that requires free and appropriate education in the least restrictive environment (klierwer, 1998). klierwer (1998) explains: “segregated education separates people from their own culture. it denies them the right to participate in the complex and everchanging realities that constitute regular lives. segregation does not lead to community participation; it leads to the need for furk a t ie c o x 35 ther restrictive placements. on the other hand, inclusion is about full membership; and in that active participation, the form and shape of the community itself is changed as traditionally banished people alter the very appearance of who and what constitute valued and effective membership” (p. 318). the concept of inclusive education can also be extended to incorporate inclusive employment. it is important to continue to address the negative impacts of separation from culture and membership in society as people with developmental disabilities complete their educational programs. is it not cruel to educate people in an integrated manner only to send them out into a cultural reality where they find no place to belong due to the lack of employment options? laying the groundwork for inclusive employment may be difficult in a culture so permeated by capitalistic ideals. advocates and scholars have laid a solid foundation of research and program ideas in the past decade; yet proposing practical, creative and effective programs that serve both society and individuals remains a contemporary challenge for social workers. building toward employment: skills and preparation wehman (2006) has stressed that the developmentally disabled population is heterogeneous and that each group of people with specific developmental disabilities has unique strengths and barriers. this reality highlights the importance of understanding each type of developmental disability while taking care to focus on the person, not solely on the disability. to that end, wehmeyer, garner, yeager, and lawrence (2006) have identified a multi-stage, multi-component model to promote dd student involvement in transition planning and implementation. this model incorporates social interaction, community inclusion, outcome measurements, skill-building and family/caretaker involvement to help ensure the participation and perspectives of people with developmental disabilities. in stage one, high-quality supports enable students to establish shortand long-term goals based on their own preferences, abilities and interests. students were involved in “whose future is it anyway?”, a curriculum designed to increase dd students’ self-awareness and build problem-solving, decision-making, goal-setting and small group communication skills (wehmeyer & kelchner, 1995). the self-determined learning model of instruction allows students to become self-regulated problem-solvers and to self-direct transitional goal-setting, action planning and program implementation (wehmeyer, palmer, agran, mithaug, & martin, 2000). k a t ie c o x developmental disability 36 journal of student social work, vol. vi stage two involves convening a student-directed, person-centered planning meeting that incorporates stakeholders in the learning process to help students refine goals (such as, “i will make a budget based on my paycheck and learn to use my budget”) and provides support for the second phase of the self-determined learning model of instruction. in the final stage of the model, the student, along with supports identified in the second stage, implements the plan, monitors his or her own progress, and evaluates his or her own success, making revisions to the goal or the plan as desired (such as, “i will ask my vocational counselor for help if i cannot understand my paycheck”). this curriculum provides an excellent model of employment preparation for people with disabilities. with proper planning, this model can foster many of the skills needed in an integrated workplace, including group communication, goal-setting, action-planning, self-determination and self-awareness. in fact, after the intervention, students demonstrated significant increases in autonomy and independent living skills and lower levels of learned helplessness (wehmeyer et al., 2006). it is imperative that students learn these skills as they transition to the workplace because they are important for self-determination, which has been sought by dd individuals and is crucial for transitioning to supported employment. additionally, individuals with dd typically work with a vocational counselor, whose job it is to assist them in implementing their plans as well as in gaining and maintaining employment (palmer & wehmeyer, 1998; wehman, 2006). it is these vocational counselors who help students transition to employment in an inclusive setting. inclusive employment several researchers have outlined approaches to integrated employment programs that offer positive outcomes. by contrast, sheltered employment programs have drawn criticisms due to lack of staff knowledge about job and personal development, low expectations, and low integration with communities (rusch & hughes, 1989). rusch & hughes (1989) describe several positive models for job placement and transition: (a) the individual placement model, in which an individual is placed in a workplace with the continuing support of a vocational counselor; (b) the clustered placement model, in which a group of individuals works in close proximity within a workplace, often performing the same task; (c) the mobile crew model, in which a group of fewer than eight employees provide contract services (e.g., grounds work) in the community; and k a t ie c o x 37 (d) the entrepreneurial model, in which a group of fewer than eight emplopees provide a product or service (e.g., electronics assembly) to a manufacturing company. the group models (b, c, and d) are considered appropriate only for extremely low-functioning individuals because mean hourly wages and levels of integration, two important positive outcomes, are greater for workers who have been individually placed (kregel, wehman, & banks, 1989). wehman (2006) outlines job-searching steps for dd individuals and recommends job coaches that can further integration. researching the job market, working with the potential employee to identify and build a network of business contacts, presenting to the employer in a positive manner that showcases the potential employee while answering any questions or concerns, and educating the employer on relevant legislation are important steps toward obtaining employment. steps that will formalize and finalize employment include ensuring that job development activities are being implemented effectively and efficiently, conducting a meeting with the employer and employee in which expectations are presented and choices are given, ensuring that the employee and employer understand the terms of the contract, and (later) asking the employee if she or he would like to take the job. another important quality for job searchers to consider about potential places of employment for dd individuals is the degree to which workplace inclusion is possible. the number of opportunities for physical and social integration, whether all employees (including dd workers) participate in these opportunities, and whether the workers are satisfied with the job setting and the opportunities it offers should all be evaluated. particular value should be placed on whether the dd workers are comfortable with other employees, included in general workplace activities, and provided with opportunities to develop new skills and learn new tasks. each of these aspects of a work environment must be monitored during the follow-up process, in which a vocational counselor continues to work with and support the individual who has been placed for employment (wehman, 2003). the vocational counselor must indicate to the employer the need to return for intermittent job analysis appointments in which the counselor evaluates the fit between the employee’s skills and the job he or she is performing (wehman, 2006). “systematic and ongoing assessment of the job setting and the worker is critical if maximum integration is to be achieved and maintained” (wehman, 2003, p.139). this is the case because individuals with dds, more so than nondd individuals, can fall behind quickly if they are not receiving an appropriate degree of support in the workplace. the counselor should constantly be looking k a t ie c o x developmental disability 38 journal of student social work, vol. vi to explore the need for accommodation, information about the company and its services, opportunities for development and promotion, how technically and socially inclusive the work environment is, and how to proactively and creatively provide any other needed support. menchetti and garcia (2003) emphasize supportive training for employees, employers and service providers, collaborative problem solving, and continuous process improvement as crucial components of job stabilization. conflict resolution skills, positive interviewing and knowledge of the indicators of depression and anxiety to ensure an employee’s wellbeing throughout his or her employment would also be helpful in providing individuals with dds the support they may need to thrive in an inclusive employment setting. the cost-effectiveness of supported employment not only do many individuals with dds, their guardians, and scholars prefer the shift toward inclusive employment, it is also cost-effective for these individuals and for society (kregel, wehman, & banks, 1989; cimera, 1998). including dd individuals in the workplace can lead to increased understanding of the needs of and appropriate responses to a wide variety of consumers, and therefore increase company sales or productivity (mor barak, 2000). cimera (1998) provides an extensive literature review and economic analysis, which examines the cost-efficiency of supported employment for individuals with developmental disabilities. cost-benefit ratios were used to measure cost-efficiency from the perspective of the worker, the tax-payer and society. costs and benefits included supported employee operating costs, alternative program operating costs, gross wages, forgone wages, fringe benefits, taxes withheld, interest on taxes withheld, taxes refunded, reduced subsidies and targeted job-tax-credits. societal costs were supported employee operating costs, forgone wages, and targeted job tax credits. societal benefits were alternative program operating costs and gross wages. cimera (1998) concluded that, “supported employment programs are a good [cost-effective] investment for workers, taxpayers, and society in general. even more important, results showed that regardless of the severity and number of disabilities, supported employment is cost-effective for all individuals.” (p. 89). the above research provides several reasons why employment in a real work setting is a cost-effective option for everyone involved. k a t ie c o x 39 a social work opportunity with so much groundwork for supported employment laid by individuals with developmental disabilities, advocates, and scholars, there remains an excellent prospect for social workers to bind the policies with the curriculum already set forth and create opportunities for work for the developmentally disabled in our society. there remains a deep need for workers to provide the actual services necessary to take action on the resources provided. at the level of service provision, social workers can work collaboratively with people who have dds (and their guardians) to create linkages with prospective employers and individually tailor supportive services appropriate to their needs (parish & lutwick, 2005). social workers can work as liaisons between various parties in the employment process, advocating for those dd individuals who wish to be employed in the workplace and involved in the community (akabas & kurzman, 2004). by doing so, social workers are answering the call of the nasw policy to work with individuals with disabilities and their families to provide services that are respectful, appropriate and directed by individuals with disabilities (nasw, 2000). conclusion the above-mentioned curriculum and programs designed for inclusive employment outline an effective response that social workers can use to address the lack of viable employment opportunities for individuals with dds. the failure for real programmatic shift toward integrated employment despite the pro-autonomy language of current legislation, the general attitudes (conscious or unconscious) of caregivers and the american public as exhibited in the history of our treatment of dd people, as well as the learned helplessness and latent potential of these individuals, reveal a need for stronger emphasis on well-planned, selfdetermined employment options. these options must be provided with careful preparation and training, supportive transition and detailed follow-up. as experts in interpersonal relationships, navigating the space between social systems and people’s lives and the great degree of impact legislation has on individuals, social workers are well-positioned to confront the lack of inclusiveness for citizens with dds who desire to participate in our society through gainful employment. references administration on developmental disabilities. 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(2000). promoting causal agency: the self-determined learning model of instruction. exceptional children, 66, 439-453. wehmeyer, garner, yeager, & lawrence. (2006). infusing self-determination into 18-21 services for students with intellectual and developmental disabilities: a multi-stage, multiple component model. education and training in developmental disabilities, 41(1), 3-13. wehman, p. (2003). workplace inclusion: persons with disabilities and coworkers working together. journal of vocational rehabilitation, 18, 131–141. wehman, p. (2006). life beyond the classroom: transition strategies for young people with disabilities. baltimore: paul h. brooks publishing company whitehead, t. d. & hughey, j. b. (2004). exploring self-advocacy from a social power perspective. new york: nova science publishers, inc. katie cox is a second-year master’s student at cussw within the social enterprise administration method and workers in the workplace field of practice. she holds a bachelor’s degree in psychology with minors in english, sociology, and child development from california polytechnic state university, san luis obispo. she is currently an intern in the program planning and development department at palladia, inc. in east harlem. her e-mail address is kec2134@ columbia.edu. k a t ie c o x journal2011 ! "#!!!!!!!!$%&'()*+!,%-*+&!.%/0!123*245!6%&'(2!77! !"##$%%&"'()*++",-./(0$$,.1/(2&.$1(( 3,#41#$14.-*,5(678'*1-,9(3,.4,9-:'$(( 2%8$#.%(*&(!*#-4'(!"88*1.(;"1-,9(( .<$(0$-,.$914.-*,(=1*#$%%! ! 8/9'&+!:2&2;2!<*-=0%490*! ! 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the diathesisstress model kashonda l. davis abstract schizophrenia is classified as one of the most debilitating mental health disorders due to the chronicity of symptoms and the magnitude of impairments in multiple domains of the individual’s life (shetty & bose, 2014). research has consistently demonstrated that black americans, in comparison to other racial groups, have the highest prevalence rates of schizophrenia. with a paucity of empirical evidence ascertaining the etiology of schizophrenia, many scholars assert that elevated levels of stress play a critical role in the development of the disorder. this paper draws upon the diathesis-stress model to elucidate a relationship between significant levels of stress endured by black americans due to racism and their elevated rates of schizophrenia. the presented argument calls for further research on the impact of racism on black americans’ disproportionately high rates of schizophrenia diagnoses. introduction racism is the menace embedded into the fabric of american culture interlaced with the propensity of predation for-profit and subjugating groups of color to perpetuate privilege in another. historically, black americans have been the victims of its objective to denigrate, discriminate, and systemically disenfranchise the race as a whole, resulting in assaults to their bodies and the psyche (utsey & payne, 2000). in recent years, the invisible wounds of racism on the black american psyche have been studied to elucidate a relationship with health disparities in their community (clark, anderson, clark, & williams, 1999). of the many health conditions exacerbated by psychosocial stress and overrepresented among black americans, schizophrenia is identified to have especially significant implications on the person’s life (bresnahan et al., 2007). schizophrenia is defined as a complex multidimensional psychotic syndrome, marked by hallucinations, delusions, affective dysregulation, blunted affect, interpersonal functioning, and impaired cognition (van os, kenis, & rutten, 2010; wykes, moghaddam, & silverstein, 2013). black americans are diagnosed with schizophrenia three to five times more than their white counterparts and have the highest prevalence rates in the u.s (mueser & mcgurk, 2004; schwartz & blakenship, 2014). while schizophrenia contains a genetic component, its onset is heavily influenced by the presence of environmental factors. social defeat, a type columbia social work review, vol. 18 | 28 of social stress, has been specifically studied because of its influence on the etiology of schizophrenia, which has been consistently replicated in animal studies (moran et al., 2016). social defeat refers to the defeated feelings of subordination after experiencing an adverse social encounter (moran et al., 2016). social defeat may be triggered by a variety of racist processes that subjugate black americans to feelings of inferiority (williams & williamsmorris, 2000). perceptions of subjugation and discrimination among black americans have been linked to higher levels of psychological distress, life dissatisfaction, and acts as an underlying mechanism for psychosis (williams & williams-morris, 2000; van winkel, stefanis, & myingermeys, 2008). a 2015 kaiser family foundation survey highlighted the distress experienced from social defeat, with results detailing that a third of black americans have been denied opportunities in employment or housing based on racial discrimination (dijulio, norton, jackson, & brodie, 2015). more than half of black americans report some connection to the prison system that includes being incarcerated themselves or knowing someone who has, and 45% indicated that at some point in life fearing that their life was in danger due to their race (dijulio, norton, jackson, & brodie, 2015). in summary, black americans face disproportionately high levels of stress. a possible explanation is that racism causes black americans to experience social defeat and noxious psychological stress, which have been strongly linked to the onset of schizophrenia. this paper calls for future research to further examine this relationship between racism experienced by black americans and the higher rates of schizophrenia found in this community. the diathesis-stress model researchers suggest that all individuals have a level of vulnerability for mental disorders, but the degree of stress experienced by their environment plays a key role in their overall susceptibility (abela & hankin, 2005). the american psychological association has identified perceived discrimination as pivotal in contributing to chronic stress and health disparities amongst people of color (american psychological association, 2016). van os, kennis, and rutten (2010) suggest that holding a minority group position increases the risk of psychotic disorders. collectively, various sources demonstrate that the stresses of racism make black americans more vulnerable to several psychiatric and physiological conditions. the impact of this stress is best understood through the framework of the diathesis-stress model. the diathesis-stress model was initially developed to describe the etiology of schizophrenia when emerging evidence demonstrated that the disorder is a product of gene-environment interaction (mccutcheon, 2006). the diathesis-stress model posits that an individual with a predisposition to a specific disorder will be more likely to develop the disorder in the presence of adverse environmental stimuli inducing stress (linehan, 1993). the diathesis to schizophrenia is supported by genetic mapping, which yields 29 | columbia social work review, vol. 18 heritability estimates of 79-83% (green, girshkin, teroganova, & quidé (2004); hilker et al., 2018). however, heritability functions as a limited index in the etiology of schizophrenia unless it is viewed within the context of interaction with social effects (van os, kenis, & rutten, 2010). twin studies investigating the genetic influence of schizophrenia in patients with the disorder have found that genes account for no more than 50% of the etiology, which suggests that an individual’s environment is a critical factor (moran et al., 2016). perceived racism and experienced racism elicit deleterious stress the anticipation of discrimination has the potential to increase an individual’s vigilance for mistreatment, resulting in interracial mistrust, negative emotions, and depleted cognitive resources (sawyer, major, casad, townsend, & mendes,., 2012). persistent vigilance induced by mistrust prolongs evoked stress, causing deleterious effects on mental health (sawyer et al., 2012). the “stress in america: the impact of discrimination” survey conducted by the american psychological association (apa) shows that 76% of black americans report having experienced “everyday discrimination,” such as being treated with less respect or being viewed as less intelligent (american psychological association, 2016). the perception of being prejudged or devalued, or the anticipation of discrimination evokes emotional distress signaling the body’s stress response (sawyer et al., 2012). the apa survey demonstrated black and hispanic participants also experience stress based on the anticipation of discrimination. for example, these demographics often feel a necessity to make a concerted effort on their appearance in order to receive good service at public establishments (american psychological association, 2016) the conscious effort exerted to prepare for forms of discrimination, and an individual’s experience of perceived discrimination, is a cognitive appraisal of threat, harm, or danger (clark et al., 1999). a perceived threat initiates a stress response by the sympathetic nervous system, prompting it to mobilize the brain and body’s resources for safety (sawyer et al. 2012; clark et al., 1999). activation of the stress response the activation of the sympathetic nervous system is a response to sensory processing of stressful stimuli causing the hypothalamic-pituitaryadrenal (hpa) axis to secrete neurotransmitters, enzymes, and hormones in preparation for a threat (pruessner et al., 2016). anticipating the self as a target of discrimination or prejudice is a potential stressor that activates the hpa axis to exercise the release of hormones that prepare for defense against the threat (sawyer et al., 2012). this biological reaction is often automatic and unconscious to perceived threats in our environment and functions as a fundamental survival mechanism in preparation of defense (pruessner, cullen, aas, & walker, 2016) during instances of stress, individuals will columbia social work review, vol. 18 | 30 notice an elevated heart rate, muscle tension, and a sudden increase in energy due to cortisol being released into the bloodstream (american psychological association, 2019). however, after exposure to chronic stress, such as the stress black americans experience with racism, the fidelity of the sympathetic nervous system’s response to stress is suppressed (american psychological association, 2019; clark et al., 1999). when confronted with stress, the sympathetic nervous system releases glucocorticoids and cortisol (pruessner et al., 2016). the release of glucocorticoids and cortisol is salient in the performance of the sympathetic nervous system’s ability to prepare for threats and restoring homeostasis (pruessner et al., 2016) glucocorticoids (cortisol in humans) and adrenocorticotropic hormones (acth) are two of the hormones released during this process and have been highly researched in relation to the adverse effects they have on the brain’s structure and functioning (pruessner et al. 2016; gubba, netherton, & herbert, 2000). relative to schizophrenia, glucocorticoids have been found to modify neural functioning and elevate neurotransmitter systems activity, which is implicated in the pathophysiology of psychosis— a defining characteristic of the disorder (pruessner et al., 2016; stahl, 2013). additionally, cortisol levels are found to be increased in individuals with schizophrenia compared to control groups without the disorder (green et al., 2014). the continuous activation of the sympathetic nervous system and increased secreted hormones as a response to perceived and experienced racism is a sophisticated process that can induce the expression of a genetic vulnerability to schizophrenia (green et al., 2014; sawyer et al., 2012). while empirical research on the neurophysiology of schizophrenia is compelling, future research should be directed towards measuring the magnitude of stress related to racism on cortisol levels in individuals with a predisposition to schizophrenia. clinician bias in the diagnosis of schizophrenia to date, researchers have been unable to empirically verify explanations regarding black americans’ overrepresentation of schizophrenia (schwartz & blankenship, 2014). a compelling argument that dominates the literature base is clinician biases and lack of cultural competence (schwartz & blankenship, 2014). professional standards of care require clinicians to assign diagnoses based upon maladaptive patterns of clinically significant emotional, psychological, and cognitive disturbances that yield distress or disability (schwartz & blankenship, 2014). instead, research on racial influence in diagnostic evaluation supports that clinical measures used were developed with euro-american samples, which present a discrepancy when applying the measure to a different race that varies in clinical presentation (schwartz & blankenship, 2014). a review by neighbors et al. (1989) found misdiagnosis of disorders is often the result of a clinician’s lack of sensitivity to cultural variances that are portrayed in the patient’s psychopathology. in 31 | columbia social work review, vol. 18 schwartz, docherty, najolia, and cohen’s 2019 study of racial diagnostic biases, black american participants were diagnosed with schizophrenia at higher rates when assessed by white clinicians due to variances in linguistic style. the authors suggest that these variances influenced elevated schizophrenia diagnoses, which are aligned with prior research documenting notable phonological and linguistic styles in black american culture (schwartz et al., 2019; wyatt, 1995). schwartz et al. (2019) provide empirical evidence of how cultural differences and insensitivity influence misdiagnosis. differences in social norms and communication processes can lead to miscommunication, mistrust, attributional ambiguity, and heightened vigilance amongst minorities in the diagnostic process (olbert, nagendra, & buck, 2018). accordingly, eack, bahorik, newhill, neighbors, & davis (2012) found that mistrust and clinician-perceived dishonesty was the strongest predictor of schizophrenia diagnoses among black american participants, which increased the likelihood by one and half times of the sample group being diagnosed with schizophrenia. clinicians make the assumption that psychopathology is presented similarly and are unaware that the disorder can differ in a clinical presentation based upon race and culture (strakowski et al. 2003). additionally, schwartz and blankenship (2014) note that the assignment of psychiatric diagnosis is influenced by personal perceptions or stereotypes held by the clinician. however, without the clinician observing their obligation to test these forms of judgments, coupled with their lack of consideration for whether or not the individual is operating within their cultural norms, misdiagnoses are promoted (schwartz & blankenship, 2014). gara, minsky, silverstein, miskimen, & strakowski (2019) posit that schizophrenia is a diagnosis made by exclusion of criteria, and often major depressive disorder (mdd) is not ruled out. instead, clinicians under-diagnose mdd and bipolar disorder or subjectively overemphasize deviant behavior and associate it with schizophrenia (gara et al., 2019; schwartz & blankenship, 2014). misdiagnosis of schizophrenia among black americans was further investigated in a study by strakowski et al. (2003). the study uncovered a discrepancy in diagnoses among black american participants that were assessed in-person versus assessments conducted by a different clinician using a transcript that concealed the ethnicity of participants (strakowski et al., 2003). results from the study yielded inflation of schizophreniaspectrum diagnoses for black americans participants (strakowski et al., 2003). these studies’ findings support clinicians’ lack of uniformity in the diagnostic process and an overemphasis of certain symptomatology when assessing black americans. empirical evidence on biases exercised in psychiatric care such as strakowski et al. (2003), advances the notion of race playing a critical role in social and health disparities. columbia social work review, vol. 18 | 32 propelling resiliency with adaptive coping mechanisms the role of clinician deficits in cultural competence contributing to the diagnostic inflation of schizophrenia amongst black americans presents an alternative hypothesis to the diathesis-stress model. however, both explanations share the basis that racism is a salient factor in the disproportionate rates of schizophrenia diagnoses amongst black americans. for black americans, racism is an everyday, chronic experience that results in adverse consequences to the psychological and somatic well being of a person (utsey & payne, 2000). researchers emphasize the importance of mitigating the stress of racism with adaptive coping mechanisms (utsey & payne, 2000; pittman, 2011). historically, black americans have been forced to use passive forms of coping, such as avoidance, withdrawal, silence, or laughter (pittman, 2011). these coping styles have been shown to exacerbate stress, induce anger, decrease life satisfaction, and lower self-esteem. clinicians can influence the health outcomes of race-related stress by equipping individuals with a broader, more adaptive set of coping mechanisms. as specialists in mental health, clinicians can influence the health outcomes of race-related stress by equipping individuals with adaptive coping mechanisms. one example is the practice of mindfulness, defined as deliberate and nonjudgmental attentiveness to present-moment experiences (shallcross & spruill, 2018). mindfulness is antithetical to passive coping responses such as avoidance and withdrawal (shallcross & spruill, 2018). this process of awareness is a vital tool to incorporate into therapy when engaging clients’ relaxation response. (edenfield & saeed, 2012). mindfulness exercises help the individual to build an awareness of their psychophysiological response to racist events. (shallcross & spruill, 2018). as a result, black americans clients can better understand their experience of discrimination and how it impacts their sense of self-worth while simultaneously reducing their biological sensitivity to threats (shallcross &spruill, 2018). another possibility for clinicians is to employ the racial trauma recovery model proposed by comas-diaz (2015). the model details a fivestage process for combating race-related stress. the model provides safety in openly discussing the racist event, teaches self-regulation, reprocesses the event, fosters resilience through psychological decolonization, and promotes engaging in social action. social work clinicians represent the majority of mental health professionals, making them the best-positioned to intervene, diagnose, and encourage preventative forms of psychosocial intervention that can abate the prevalence of schizophrenia (gonzález &colarossi, 2014; lukens & devylder, 2014). clinical social workers must be aware of the etiology of schizophrenia and be prepared to provide relevant coping mechanisms in accordance with this understanding. 33 | columbia social work review, vol. 18 conclusion the present article proposes that black americans’ disproportionate rate of schizophrenia diagnoses may be best understood through the diathesisstress model. under this framework, racism causes psychosocial stress that increases the risk of developing adverse health outcomes, including schizophrenia. two hormones, glucocorticoids and adrenocorticotropic hormones, have been specifically identified for their association with both the stress of racism and the symptoms of schizophrenia. the article calls for researchers to further explore this causal pathway through empirical study. a series of adaptive coping mechanisms are also recommended for immediate use by social workers who wish to address the stress of racism among their clients. about the author kashonda l. davis earned an mph and mssw in advanced clinical practice from columbia university in 2017. her graduate education in clinical practice was fostered by a practicum at rikers island correctional facility where she learned the application of dialectical behavioral therapy (dbt) and developed a research interest in the causal relationship between stress and mental health outcomes. upon graduating from columbia university, kashonda was awarded a behavioral health fellowship with harvard vanguard medical associates in boston, ma where she further honed her skills in evidenced based therapeutic practices. today, kashonda practices dbt at kaiser permanente department of psychiatry and leads a research study for the center of behavioral health and integration research at stanford university. her clinical interests are vested in cultural adaptations of evidenced based care modalities that aid in ameliorating health disparities among minority populations. references american psychological association. 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(2013). schizophrenia : evolution and synthesis. cambridge, ma: mit press. a social exclusion perspective on social work in latin america andrea laura bacher this paper explores the relationship between social work and social exclusion within the context of poverty as capability deprivation. it suggests that a social exclusion perspective could be relevant and useful to social work theory and practice in latin america. the chile solidario program is used as an example of a social program that incorporates a social exclusion perspective and in which social workers play a vital role in promoting social inclusion. a context of exclusion in latin america1, 44% of the population live in poverty, 60% of children live below the poverty line, and nearly 20% of young people are unemployed (kliksberg, 2005; inter-american development bank [iadb], 2008). a major cause of poverty is inequality. while the richest 10% possess 48% of the regional income, the poorest 10% possess 1.6% (kliksberg, 2005; iadb, 2008; iadb, 2003). latin america has the most unequal income distribution in the world, and these inequalities are exacerbated by the exclusion of minority groups that are discriminated against on the basis of ethnicity, socioeconomic status, race, gender, physical disability, and geographic location. in spite of the variations across latin american countries, many actual problems of deprivation are widely shared across the region. latin america has great economic potential, and is ethnically, racially, and culturally diverse; a diversity that could be a major asset in the process of constructing an inclusive society. however, the entire region must overcome a long history of exclusion that has left societies unequal, divided, and blind to diversity’s riches. the 1980s and 1990s were periods of profound transformation in latin america. neoliberal reforms applied in most countries in the journal of student social work, volume vii 16 / a social exclustion perspective for social work in latin america region changed the existing “intervening” states into “minimal” states. active strategies to downsize the state caused accelerated privatization policies, elimination of public institutions, and reductions of personnel in the public sector2 (carlson & paine, 2002). one of the consequences of these policies was the deterioration of the notion of state as representative of collective action (o’donnell, 1993). these policies also had a huge impact on many economies in the region and worsened poverty and inequality. as stiglitz described it, “growth under liberalizations is just over half of what it was under the old pre-form regime…where growth has occurred, the benefits have accrued to those at the upper part of the income distribution...” (2003, p. 230). as a result of the policies implemented in the region during the 1980s and 1990s, the salaries, working conditions, and career prospects of social workers have deteriorated (o’donnell & tokman, 1998). the professional identity of social workers in latin america started as health workers (velez, 2003; alayon, 2005). the first school of social work, the school of social service, was established in santiago, chile in 1925 by the physician alejandro del rio. the second school of social work in the region was founded in argentina in the early 1930s. it was connected to the school of medicine at the university of buenos aires, and it followed the european idea of using “hygiene visitors” as auxiliaries for doctors. since then, the social work profession in latin america underwent various paradigm changes that weakened its identity. first it was influenced by a philanthropic and moralizing tone; then, it was focused on integrating social science epistemology, and after that, it went through a re-conceptualization process. the profession has been struggling to find a place for itself since 1925 (parada, 2007; velez, 2003; alayon, 2005; healy, 2001). presently, there is a need for social workers in latin america to renegotiate the profession’s position and its specific role through the use of new frameworks or perspectives that can inform both the theory and practice of social work. this paper suggests that a social exclusion perspective could be valuable in analyzing and influencing social work theory and practice in latin america. it explores the relationship between social exclusion placed in a broader context of the idea of poverty as capability deprivation3 and social work. the emphasis is on the relevance and usefulness of a social exclusion perspective for social work theory and practice. journal of student social work, volume vii 17 / bacher a social exclusion definition the present debate on social policy in latin america hinges on the issue of social inclusion and exclusion. according to the last iadb report on economic and social progress (2008), social exclusion is the most dangerous threat facing democracy in latin america. politicians and policy analysts mention the fight against social exclusion as the main objective of development and substantive democratization in the region (iadb, 2008). the term social exclusion was first coined in france in 1974 by rene lenoir to identify and refer to the “excluded”, including the “mentally and physically handicapped, suicidal people, aged invalids, abused children, substance abusers, delinquents, single parents, multi-problem households, marginal, asocial persons, and other social misfits.” since lenoir, there have been major advances in the literature on social exclusion, and the concept has acquired various definitions. this paper uses amartya sen’s definition of social exclusion, which considers social exclusion by placing it in a broader context of the idea of poverty as capability deprivation (2000). this definition is particularly suitable for latin america because there is general agreement that social exclusion contributes mainly to the analysis of poverty and marginality (faria, 1995; rodgers et al., 1995). faria (1995) argues that social exclusion’s usefulness stems from its potential as a way of integrating poverty, deprivation, and lack of access to goods or assets into a single framework. sen examines the term by placing it in the broader context of poverty understood as the lack of capability to live a minimally decent life. he defines social exclusion as “…constitutively a part of capability deprivation as well as instrumentally a cause of diverse capability failures” (sen, 2000). social work and social exclusion previous authors who have analyzed the relationship between social work and social exclusion have focused on the strong and natural intuitive appeal of the idea that a concern with social exclusion is embedded in the guiding principles of the social work profession (sheppard, 2006; smale, tuson, & statham, 2000). in a broad sense, social work’s mission is to increase opportunities for excluded populations. social work is arguably founded on notions of social exclusion and inclusion. in spite of its recent origin, the term social exclusion can journal of student social work, volume vii 18 / a social exclustion perspective for social work in latin america give expression to some of the major issues, which have been, and continue to be, of concern to social workers. but what is the specific aspect of social exclusion that is useful for social work? is social exclusion merely a relabeling of already known notions and concepts? social exclusion theory is adaptable, and it may be tempting to characterize every deprivation as a case of social exclusion. does the concept add anything that we would not know or recognize without a social exclusion perspective? what is the specific relevance or new insight provided by the idea of social exclusion for the social work profession? what aspects or characteristics of a social exclusion perspective may be considered relevant for social work? does it contribute to our understanding of the nature of poverty, or in identifying causes of poverty that may otherwise be neglected? described in this paper are the characteristics of the social exclusion approach which, placed in the context of poverty as capability deprivation, make it a valuable and useful concept for social work. one of the main characteristics of the social exclusion approach lies on its specific emphasis on the relational features in the deprivation of capability or lack of freedom to lead the life an individual values. following sen, the main attribute is that social exclusion literature provides a central role to relational connections. this feature is applicable for social workers in informing the theory and practice around relational connections and more fully understanding the person-in-environment transactions taking place at various systems levels that lead to capability deprivation. the relational aspect of social exclusion can also shed light on the multidimensionality of the experience of poverty. social exclusion is constitutively a part of capability deprivation. this is relevant in the sense that being excluded can sometimes be a deprivation, and it can be of intrinsic importance on its own. for example, not taking part in a community, not being able to relate to others, and not having social connections, can directly impoverish a person’s life (sen, 2000). these are losses on their own, independent of whatever further deprivation they may generate. social work has an important role in understanding social exclusion as constitutive of capability deprivation and in presenting possible ways in which it can be addressed. the profession recognizes the importance of the dignity and worth of all members of society and their equality as humans, as well as the right of every individual to participate in the community. being excluded from society can affect people’s well-being in several respects, including mental health and ability to feel empowered. journal of student social work, volume vii 19 / bacher 20 / a social exclustion perspective for social work in latin america journal of student social work, volume vii 19 / bacher working in the different fields of practice and with different methods of intervention, social work has the knowledge-base to recognize and address the intrinsic importance of social exclusion and its effects, as well as recognizing external factors leading to exclusion and working to change them. social exclusion is also an instrumental cause of capability failures (sen, 2000). exclusion from social relations results in other deprivations, which further limit opportunities. when a deprivation has instrumental causes, it is useful to use the perspective of social exclusion to analyze whether the causal process can be better understood by invoking the idea of exclusion. for example, to be excluded from the formal labor market, which is not intrinsically damaging, can effect the opportunity of having social protection, which may lead to insecurity, poor health, or income poverty. this example has particular relevance for latin america, where social protection is inconsistent, and where many informal-sector workers do not have health protection, which causes wide-spread feelings of insecurity (tokman, 2007). entry into the formal employment sector can open the door to social and economic citizenship, which in turn, is a prerequisite for belonging and being integrated in society. understanding the causal processes leading to capability deprivation is relevant for social work to analyze the dynamics and interplay of the different factors affecting the interaction of the individual and the environment, and it can also inform policy decisions to improve the conditions of excluded groups. a social exclusion perspective can enrich the practice and theory of social work at various levels. a vital interest in the issue of social exclusion for social workers must be focused on policy issues and on research which can lead to taking action. the challenge for social workers includes not only gaining a better understanding of the diverse phenomena of deprivation and poverty but also improving the conditions of clients; enhancing developmental, problem-solving, and coping capacities; contributing to the development and shape of social policy; and responding to the levels of social exclusion by introducing change and promoting social inclusion. strengthening social policies and programs: a role for social work? some governments in latin american countries are making important efforts to implement innovative programs to promote social inclusion and the integration of excluded peoples, and have placed journal of student social work, volume vii 20 / a social exclustion perspective for social work in latin america the issue of confronting social exclusion at the top of their priorities4. such programs include zero hunger in brazil, heads of households in argentina, national front against hunger in guatemala, and chile solidario in chile. now there is an unprecedented opportunity for latin american social workers to contribute to the design and implementation of social policies and programs aimed at fostering social inclusion. this does not mean, as parada (2007) states, that social work will be “…simply a discipline in charge of the operationalization of implementation of state policies” (p. 566), but rather, it is an opportunity for social workers to both engage in a process prioritizing social issues that can bring change and provide their knowledge in understanding social exclusion and working toward an inclusive society. chile solidario: an illustration established by the chilean government in 2002, chile solidario is a program of social protections for families in extreme poverty that combines aid and skills development in an integrated approach3(ministerio de planificación nacional y política económica [mideplan], 2002). the program acknowledges the distinction between the constitutive and instrumental aspects of social exclusion, which is evident in that its main objective is achieving social inclusion of poor families by integrating them into the public network of social services. the goal of this system was so that families would be integrated into their local surroundings and into existing social networks with an income above the line of extreme poverty (world bank, 2004). the current aid approach of the program is to offer cash benefits and cash subsidies for participating families, as well as personalized psychosocial support for two years through the puente program as an effort toward social inclusion. the program also takes into account the instrumental aspects of exclusion, by recognizing that exclusion from active citizenship can lead to other deprivations, further limiting opportunities for employment and access to education. for this, the program provides psychosocial support and participants also gain access to social promotion programs, including educational vouchers and labor benefits. chile solidario is innovative in understanding social protection as a central part of development and as an important instrument for freedom. social workers are presently playing a crucial role in this program (saracostti, 2008). using a social exclusion perspective, social workers are involved in direct practice, community intervention, and macro journal of student social work, volume vii 21 / bacher journal of student social work, volume vii policy practice. social workers go door to door and invite poor families to participate in the program. if the family chooses to participate, the social worker helps them to identify their health, education, employment, housing, income, family life, and identification needs. the household and the social worker create a strategy for how these needs will be met and how progress will be monitored. at the communityintervention level, social workers are involved in coordinating an action network that supports the work of each family. at the macro level, social workers are involved with the ministry of social planning in overseeing the program’s progress and its design. social workers and latin american policy makers can be encouraged by this example and consider the role of the social worker as strategic in understanding social exclusion while also relating this understanding to their knowledge and skills in promoting social inclusion. conclusion a social exclusion perspective is both relevant and useful for social work theory and practice. at present in latin america, there is a need to fill the important role of implementing active and efficient social policies and programs which can alleviate poverty and exclusion. latin american social workers could be involved in strengthening these actions by contributing and engaging in a process aimed at social renewal and the attainment of inclusive societies, states, and countries. social workers can play a vital role in latin america using a social exclusion perspective to understand the relational features in the experience of poverty, the intrinsic importance of exclusion, and the nature of social exclusion as an instrumental cause of capability failures. relating this understanding with their knowledge, social workers would improve the community work, research, and influence policy issues at the macro level. in this sense, social workers can make significant and valuable contributions to social change and build more inclusive, stable, safe, and accepting societies that respect diversity and equality of opportunity for all. notes 1 in this paper i define latin america to include the parts of the american continent where spanish or portuguese is the main national language (that is, mexico, central, and south america, including some countries in the caribbean). 2 the capability approach is a framework for evaluating and assessing social arrangements, standards of living, inequality, poverty, justice, quality of life, and well-being. according to nobel laureate amartya sen, poverty must be seen as “the deprivation of basic capabilities rather than merely as lowness of income.” the capabilities a person has according to sen are, “the substantive freedoms he or she journal of student social work, volume vii 22 / a social exclustion perspective for social work in latin america enjoys to lead the kind of life she or he has reason to value” (1999, p. 87). sen argues that a person’s freedom to live in the way one would like has intrinsic value and is therefore constitutive of the person’s being. the individuals’ capability of choosing and discriminating among possible livings is as valuable as the achieved functionings (“doings” and “beings”). 3 for more detailed information on the program, see palma, j. and urzua, r. 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(2003). reconfigurando el trabajo social: perspectivas y tendencias contemporáneas [reshaping social work: contemporary perspectives and tendencies]. buenos aires, argentina: editorial espacio. world bank. (2004). an introduction to chile solidario: el programa puente. international conference on local development. journal of student social work, volume vii 24 / a social exclustion perspective for social work in latin america journal2011 ! "#!!!!!!!!$%&'()*+!,%-*+&!.%/0!123*245!6%&'(2!77! !"#$!%&'"($)*((%+,-$.//+%,,&0'$$ 12/#$3"*4&0'$&0$("%$325&*6$$ 78,(&5%$924480&(#$ $ 8+/+9!8+:9*! ! "#$%&'()!&*(($+*(!(,%%-,./'.+!)0*!-1*(')2!*3'/*&'4!0$5*!'.6#,7 *.4*/!&$.2!'.!)0*!(-4'$#!8,()'4*!4-&&,.')2!)-!$/-3)!$!4-&1$)'5*! 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"&*%'4$.!f-,%.$#!-6!u(240'$)%25!pv]5!gj^ngejb!! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! $ $ 5 research suggests that latino children are at an elevated risk for a variety of mental health problems (flores, fuentes-affl ick, barbot, et al., 2002). latinos are often vulnerable to the deleterious effects of poverty, institutional racism, community violence and other types of psychosocial stressors, which have been linked to negative mental health outcomes (flisher, kramer, grosser, et al., 1997; saunders, resnick, hoberman, et al., 1994). furthermore, latino children are likely to face signifi cant barriers to accessing mental healthcare services, such as limited availability of spanish-speaking providers, diffi culty obtaining and navigating health insurance, and cultural obstacles, such as the belief that mental illness is a spiritual or religious matter. the current paper will: (1) explore specifi c risk factors for mental health disorders among latino children; (2) examine barriers to appropriate mental health treatment among latino children; (3) provide an overview of the types of intervention strategies currently used to address mental health problems among latino children; and (4) offer recommendations for the development of additional and/or improved methods for the prevention and treatment of mental health disorders among latino children. here are more than 11.6 million latino children living in the u.s., compromising the largest minority group of children in this country (flores, et al., 2002). despite the growing number of latino children, there is a dearth of empirical research on specifi c mental health problems experienced by this burgeoning population. lack of education regarding childhood mental illness and limited access to services are suspected to contribute to underreporting and, in turn, lack of treatment among latino children. for example, studies have demonstrated that white children are more than twice as likely to receive diagnosis and treatment of attention defi cit hyperactivity disorder (adhd) than african american and latino children (olfson, gameroff, marcus, et al., 2003; eiraldi, mazzuca, clarke, et al., 2006). in addition, despite problems with surveillance of latino childhood mental health problems, a study by canino, could, prupis, and shaffer (1986) indicated that latino children are at greater risk for depression, anxiety, school refusal, and diffi cult interpersonal relationships with other children than their black or white counterparts. ian holloway t latino children’s mental health: an analysis of risk factors, healthcare access, and intervention strategies latino children’s mental health 6 journal of student social work, vol. v ia n h o l l o w a y the disproportionate mental health disease burden among latino children is especially troubling given the negative health outcomes that result from childhood mental health disorders (flores, et al., 2002). childhood is a crucial period in the lifecycle, marked by rapid changes in cognitive and emotional development; mental health disorders can cause academic and social impairment, which have serious ramifi cations on the developmental trajectories of children later in life. for example, research has demonstrated that early-onset emotional and behavioral problems in children are related to negative consequences in adolescence, such as educational diffi culties (tuakli-williams & carillo, 1995), substance use (sterling, kohn, lu, & weisner, 2004), juvenile delinquency and school dropout (loeber, 1991; ramey, & ramey, 1998), and attempted suicide (cdc, 1999). risk factors for latino children’s mental health problems while it is clear that additional research must be conducted in order to determine base rates of mental illness among latino children, a signifi cant body of literature exists documenting risk factors that may lead to or exacerbate mental health disorders among latino youth. twenty-eight of latino families reside in poor families (nccp, 2005), and latino children are more likely to live in resource poor, urban neighborhoods than their white counterparts (kasarda, 1993; fass & cauthen, 2006). these children are often exposed to negative environmental stressors, such as overcrowding, neighborhood disorder, community violence, and trauma exposure, factors which have been linked to childhood psychopathology (wandersman & nation, 1998; vostanis, tschler, cumella, et al., 2001; mckay, lynn, & bannon, 2005). a study by xue, leventhal, brooks-gunn, et al.(2005) demonstrated that children in neighborhoods of low socioeconomic status have the highest levels of mental health problems when compared to children in medium and high socioeconomic status neighborhoods. low social control, lack of community cohesion, and compromised social capital networks have all been linked to negative mental health outcomes in children (o’brien, o’campo, & muntaner, 2003; xue, et al., 2005). two other crucial factors that may contribute to the development of childhood mental health disorders among latinos are acculturation and adjustment stress. recent data from the mexican american prevalence and services survey indicated a positive association between acculturation and risk for lifetime prevalence of diagnosable mental disorders, such as affective, 261809_columbia 01-72 sec1:6261809_columbia 01-72 sec1:6 4/5/07 2:12:12 pm4/5/07 2:12:12 pm 7 ia n h o l l o w a y anxiety, and substance use disorders (organista, manoleas, & herrera, 2001). latinos who emigrate to the u.s. often experience diffi culties maintaining their traditional cultural norms while attempting to integrate north american cultural practices and beliefs (sue & sue, 2003). while some latino children are able to navigate the acculturation process smoothly and establish a bicultural identity, which has been shown to be the most benefi cial resolution to acculturation confl icts for the individual (miranda & umhoefer, 1998), other latino children often fi nd themselves caught between expectations of their family and their school or peer groups (flores-gonzalez, 2002). these types of acculturation confl icts can cause signifi cant psychosocial adjustment stress, which may lead to the development of mental health problems. latino children’s access to mental health care despite the greater need for mental health services among latino populations, there is evidence that the majority of these children are not receiving necessary care. recent studies by kataoka, zhang, and wells (2002) and zimmerman (2005) revealed that latino children have especially high rates of unmet need in terms of mental health service delivery relative to other children. this diffi culty accessing mental health services can be attributed to three primary factors: (1) insuffi cient services, (2) health insurance barriers, and (3) cultural barriers. insuffi cient services the u.s. currently faces a dramatic shortage of mental health providers who are specifi cally trained in the provision of mental health services to children and adolescents (kim, 2003). a recent study by thomas and holzer (2006) indicated that youth living in poverty were least likely to have access to specialty child psychiatry services. these fi ndings are especially salient for latino families, 28% of which are living below the federal poverty line (nccp, 2005). a study conducted by lopez (2002) cited availability of services as one of the many barriers to accessing mental health care among latino families. in addition, many latino families lack information regarding mental health services and recognition of child mental health problems (teagle, 2002). thus, latino parents may not have the knowledge necessary to obtain appropriate mental health services for their children even when such services do exist. furthermore, some latino families may have diffi culty seeking mental health treatment due to immigration status. a study by granados and latino children’s mental health 261809_columbia 01-72 sec1:7261809_columbia 01-72 sec1:7 4/5/07 2:12:12 pm4/5/07 2:12:12 pm 8 journal of student social work, vol. v ia n h o l l o w a y colleagues (2001) demonstrated that latino children of immigrant parents were less likely to access routine healthcare than latino children of u.s. born parents. while more research must be conducted to determine specifi c reasons why children of immigrant parents seem to have more diffi culty accessing healthcare services, one possible explanation is that these parents may fear that they will be questioned about their immigration status when seeking care for their children. research conducted by canlas (1999), which examined mistrust of the health care system among latinos in east harlem, new york, found that fear of deportation was a major reason given for underutilization of medical services by latino participants. as such, undocumented latino parents may be afraid to inquire about mental health services for their children, for fear they may be questioned about their immigration status, harassed or deported. health insurance barriers other factors impacting latino children’s ability to access mental health services revolve around health insurance. approximately 26% of latino children are uninsured, compared with 10% of white children and 14% of african american children (flores & vega, 1998). while signifi cant improvements have been made in health insurance for minority children over the past 30 years, such as the expansion of medicaid eligibility and the introduction of the state children’s health insurance program (schip), insurance status continues to present a signifi cant barrier to latino families’ ability to access mental health services (alegría, canino, ríos, et al., 2002; busch & mccue horwitz, 2004). medicaid and private insurance benefi ts are often administered through managed care organizations.while this arrangement has conserved a considerable amount of government money, signifi cant questions arise regarding pre-certifi cation for mental health services, disenrollment, and quality of care provided to minority children with mental illness. in addition to ineffective diagnostic and referral systems, managed care’s confusing guidelines also complicate coordination efforts between mental health providers, families, and schools. children with mental health problems are often treated by many different systems and agencies, including schools, social services, and the juvenile justice system. lack of coordination and failed communication (many times resulting from language barriers) among teachers, social workers, and the courts often lead to inconsistent care for latino children. in some cases there may be an overlap in services, where children and families receive confusing messages from multiple sources. however, more commonly, due to large caseloads and reduced funding, children 261809_columbia 01-72 sec1:8261809_columbia 01-72 sec1:8 4/5/07 2:12:13 pm4/5/07 2:12:13 pm 9 ia n h o l l o w a y fall between the cracks as the various agencies try to pass off costs to other sectors. this is evidenced by the fact that 92% of children with serious emotional disturbances receive mental health services from two or more systems, and 19% from four or more (glied & cuellar, 2003). cultural barriers latino communities face signifi cant cultural obstacles to obtaining mental health care. research suggests that latino families often do not view mental illness as a medical problem; instead some latino families conceptualize mental illness as a spiritual or religious issue (maduro, 1983; sue & sue, 2003). as a result, latinos tend to underutilize mental health services while relying heavily on religious services for the resolution of emotional and interpersonal disturbances (organista, manoleas, & herrera, 2001). while churches and other religious organizations may be a useful source of psychosocial support for latino families, staff is seldom trained in the recognition of mental health disorders, which may lead to underreporting of mental health disorders and in many cases insuffi cient treatment of latino children with mental health disorders. insuffi cient research has been conducted on the impact of culture and language on the etiology of mental health disorders and the underutilization of mental health services among latino children (flores, et al., 2002). for example, few studies have examined the ways in which cultural constructs specifi c to latino populations may impact the way in which mental health is viewed and treated in latino communities. a shortage of bilingual and bicultural mental health providers further impedes access to effective mental health services for latino children (vega & lopez, 2001). as a result, if latino children are receiving mental health services, these services may be culturally irrelevant and ineffective, leading to premature discontinuation of treatment. some critics of the u.s. mental health system assert that the dearth of bicultural mental health professionals is representative of a form of aversive institutional racism that may make it diffi cult for latino families to participate in treatment altogether (whaley, 1998). latino children’s mental health service delivery micro-level interventions: individual & family the majority of intervention programs that address latino children’s mental health on the micro level have been carried out within family systems. latino children’s mental health 261809_columbia 01-72 sec1:9261809_columbia 01-72 sec1:9 4/5/07 2:12:13 pm4/5/07 2:12:13 pm 10 journal of student social work, vol. v ia n h o l l o w a y children’s ability to access health care services almost always relies on their parents’ willingness to seek out and/or accept these services (newacheck, hughes, hung, et al., 2000). unfortunately, latino parents may not realize that their children may be experiencing a serious mental health problem. for example, a recent study that sought to measure parental problem recognition and its impact on child mental health service use, determined that parental perceptions of their children’s mental illness played a key role in determining whether or not their children were able to receive services (teagle, 2002). education at the parental level is crucial to the identifi cation of serious mental health problems. a handful of empirically tested intervention programs specifi cally tailored for latino populations have helped to educate latino parents on normal childhood development and train parents to identify abnormal child behavior. for example, culturally adapted parent management training was designed by the oregon social learning center to educate parents on mental illness and help parents acquire general parenting skills in order to decrease externalizing behaviors in their adolescent children (martinez & eddy, 2005).this intervention proved successful in reducing a range of adolescent problem behaviors, including aggression and drug use. the strength of this program was its specifi city; all parent-adolescent dyads studied were spanish-speaking and parents were encouraged to express their own views of normal vs. abnormal child behavior based on previous experiences. mezzo-level interventions: school & community school-based interventions are perhaps the most widespread programs to address mental health problems among latino children. schools are a logical place for the identifi cation of child mental health problems because the vast majority of children attend school and can be closely monitored by teachers and ancillary mental health staff (hoagwood, burns, kiser, et al., 2001). one of the primary strengths of school-based programs is their ability to provide consistent support to children struggling with mental health problems. in 1999, ambruster and lichtman conducted a study to evaluate the effectiveness of 36 school-based mental health services in inner city new haven, connecticut. this study demonstrated that children enrolled in school-based mental health services showed comparable improvement in functioning on the children’s global assessment scale and the global assessment of functioning scale to children enrolled in clinic-based mental health care. this study also highlighted the crucial role that schools can play in mental health problem 261809_columbia 01-72 sec1:10261809_columbia 01-72 sec1:10 4/5/07 2:12:13 pm4/5/07 2:12:13 pm 11 ia n h o l l o w a y identifi cation and treatment because they are able to reach disadvantaged children who otherwise would not have access to mental health services. schoolbased mental health services can be highly affective at improving academic achievement in high-poverty urban areas (atkins, frazier, birman, et al., 2006) and are able to coordinate treatment planning with teachers and administrators, which allows for the development of educational plans that are informed by mental health treatment and vice-versa. community-based interventions that address mental health treatment are also widespread (hoagwood, et al., 2001). these interventions most often take place in community outpatient mental health centers or through integrated treatment coordinated through case management services at community-based organizations.while these settings are particularly effective in addressing mental health problems among children due to the presence of more skilled providers and psychiatrists who are able to prescribe medication, the weaknesses of community-based interventions lies in their inability to reach many latino children. as previously mentioned, structural barriers, such as availability of services and insurance restrictions inhibit latino children’s access to mental health services (flores, et al., 2002). furthermore, cultural barriers to treatment, such as lack of spanish-speaking and/or bicultural providers, even in communities where the majority of children come from latino backgrounds, often prevent latino families from utilizing community outpatient services (vega & lopez, 2001). macro-level interventions: structural transformation and policy development policies to improve insurance coverage for low-income children, such as medicaid expansion and the formulation of schip, are examples of structural level interventions that have helped to alleviate the mental health disease burden in latino children (shone, dick, crach, et al., 2003). another example of structural level change resulting in improved access to mental health services for latino children is the mental health parity act, which took effect in 1996. this act, which was an important step in acknowledging the importance of mental health and placing it on an equal plane with physical health, ensured that mental health care benefi t limits were comparable to all other benefi ts (sturm & mcculloch, 1998). this change was accompanied by the development of many new pharmaceuticals to treat mental health problems, and increased prescription benefi ts. as a result, insurance companies now cover mood stabilizers and psychotropic medications in the same way other medications latino children’s mental health 261809_columbia 01-72 sec1:11261809_columbia 01-72 sec1:11 4/5/07 2:12:14 pm4/5/07 2:12:14 pm 12 journal of student social work, vol. v ia n h o l l o w a y are covered, which has further equalized the mental and physical health sectors while reducing costs to patients. two other examples of macro-level interventions that have helped improve mental health among latino children are head start and early head start, two federal programs within the administration on children, youth and families in the department of health and human services.these programs offer comprehensive services aimed at improving the physical and emotional well-being of pre-school children in low-income families (acyf, 2007). head start programs have been effective in promoting mental health among participants by working closely with parents to identify mental health problems in the family system and work with children and parents to address these concerns (mann, 1997). while head start and the other structural level interventions mentioned above were not specifi cally aimed at improving the mental health of latino children, such far-reaching policy implementation has been crucial to the improvement of latino children’s mental health due to its ability to affect systemic change. recommendations micro-level interventions: individual & family mental health disorder identifi cation in children can be most effective if it occurs early (dhhs, 2000). future intervention programs aimed at latino families must target parents of younger children in order to help them recognize abnormal behaviors and seek appropriate care. in addition, all individual and family level interventions targeting latinos must be culturally tailored to the specifi c latino subgroup being targeted. there is a tendency in social work and public health research to group all latino populations under the umbrella terms “latino” or “hispanic,” without paying attention to specifi c differences between subgroups based on country of origin (flores, et al., 2002). this is problematic in that it fails to recognize the unique social and historical differences between latino subgroups, including acculturation and other factors which may speak directly to child development and mental illness. while emerging research in the fi eld of mental health has begun to examine latino subgroup differences, this is another area for the improvement of intervention strategies on the individual level. mental health problem intervention programs must be tested with specifi c latino subgroup populations in order to determine effi cacy and inform further specifi city. 261809_columbia 01-72 sec1:12261809_columbia 01-72 sec1:12 4/5/07 2:12:14 pm4/5/07 2:12:14 pm 13 ia n h o l l o w a y clinicians who work with latino youth must also make themselves aware of the unique social and cultural issues affecting this population and the ways in which these factors may impact clinical work on the individual level. as previously mentioned, latino youth are disproportionately affected by a number of psychosocial stressors, including the deleterious effects of poverty, institutional racism, and community violence. in preparing to work with latino children, social workers must make a thorough assessment of the context in which the client lives, as well as individual functioning. parental involvement is crucial to any intervention aimed at children (mckay, pennington, lynne, et al., 2001). recent research has demonstrated that family support and family cultural confl ict were strongly associated with selfrated mental health among latinos (mulvaney-day, alegria, & sribney, 2007). therefore, it is essential that social workers treating latino children engage parents and other family members in their efforts to help the child achieve greater psychosocial functioning. mezzo-level interventions: school & community in order to improve school and community-based services, a number of steps could be taken. first, schools and community-based clinics could begin funding and implementing social marketing campaigns to educate children, parents, and community members about mental health problems. social marketing campaigns can have small-to-moderate effects on health knowledge, beliefs, attitudes, and behaviors, which can be translated into signifi cant, positive public health outcomes (noar, 2006). community mental health intervention programs with a strong social marketing component have been used in australia with favorable results (wright, mcgorry, harris, et al., 2006); similar programs that specifi cally target latino children’s mental health in the u.s. may also be effective. through culturally tailored materials and targeted outreach efforts in english and spanish, schools and community-based clinics may educate latino families on the early detection of childhood mental health problems, inform parents of where to take their children for mental health screenings, and help to reduce the often confl icting information regarding etiology and treatment of mental illness in latino communities. service providers, especially teachers and pediatricians that work with latino families, may also be targeted on a community level. these professionals are often encumbered by limitations in implementing preventative services. for example, teachers are often assigned large class sizes and primary care latino children’s mental health 261809_columbia 01-72 sec1:13261809_columbia 01-72 sec1:13 4/5/07 2:12:14 pm4/5/07 2:12:14 pm 14 journal of student social work, vol. v ia n h o l l o w a y physicians are required to see more patients in less time. as a result, these professionals have less time to develop strong, ongoing relationships with families and are less likely to identify mental health problems (aap, 2000). while the american academy of pediatrics recommended increased funding for specialized training programs and job incentives for qualifi ed child mental health clinicians in 2000, the u.s. continues to lack suffi cient numbers of trained mental health workers to handle the specifi c mental health care needs of latino children. in order to address this problem, schooland community-based interventions may offer teachers and pediatricians extensive training on the recognition of mental health problems in children. by educating these providers about the importance of mental health screening, schooland community-based programs can expand the network of competent providers evaluating latino children for mental health problems. macro-level interventions: structural transformation and policy development despite the success of existing policy-level interventions, much more can be done to improve latino children’s mental health on a structural level. for example, one of the key problems with mental health service delivery to latino children is the severe shortage in culturally competent, bilingual service providers. without spanish-speaking mental health professionals who are able to understand and address the unique cultural considerations surrounding mental illness in latino communities in clients’ preferred language, latino children will continue to be underserved by the mental healthcare system. local, state, and federal governments must be involved in efforts to expand minority provider networks. this may be done through the implementation of scholarship programs for latinos interested in mental healthcare and/or tuition payback programs for providers who learn spanish, participate in cultural competency trainings and work in minority neighborhoods after graduation. these types of programs currently exist but they are often fi nanced by private foundations. city, state, and federal policymakers may expand such programs by drafting legislation that institutionalizes and funds tuition payback programs in order to improve latino children’s mental health in a more widespread manner. policymakers can also improve mental health services for latino children by implementing monitoring systems for mental health service provision and economic penalization for substandard service. “families need mechanisms to communicate their comments and experiences [regarding mental health services] to those who purchase health care plans” (aap, 2000, p. 862). in turn, healthcare purchasers must be responsible for providing adequate 261809_columbia 01-72 sec1:14261809_columbia 01-72 sec1:14 4/5/07 2:12:15 pm4/5/07 2:12:15 pm 15 ia n h o l l o w a y latino children’s mental health information to clients about the quality and availability of culturally relevant mental health services. many latino children receive mental health services through federal programs, such as medicaid and schip. by setting up feedback systems that allow parents to express dissatisfaction with the quality of care their children are receiving, policymakers will help clients have a voice in the type of care they are offered. opening channels for criticism, and backing up criticism with economic ramifi cations, will encourage mental health care providers to increase levels of service to meet clients’ needs. state and federal level policies can also help improve the detection and prevention of mental health problems among latino children by implementing mandatory mental health screening programs in public schools. one of the main reasons for disparity in the need for mental health services and service provision is missed opportunities for early intervention. while time, energy, and fi nancial resources have been devoted to programs promoting children’s physical health, little emphasis has been placed on mental health among children. u.s. children are required to have physical examinations in order to attend public school; however, psychological evaluations are usually reserved until social, behavioral, or cognitive problems are far advanced. government policies to implement mandatory screening for mental health problems in public schools will ensure the early detection of latino children’s mental health problems. however, in order for screening programs to be effective, they must be reinforced by comprehensive services to treat latino children’s mental health problems. conclusion latino children are at heightened risk for developing mental health problems due to a range of psychosocial factors, including poverty, community violence, acculturation, and adjustment stress (wandersman & nation, 1998; vostanis, tschler, cumella, et al., 2001; mckay, lynn, & bannon, 2006). at the same time, these children often face signifi cant barriers to receiving mental health services resulting from limited education regarding mental illness, scarcity of bilingual and bicultural service providers, and aversion to the mental health system due to cultural, spiritual, and religious factors. while some intervention programs have been implemented at the individual, community, and structural levels to address latino children’s mental health, much remains to be done in order to address this signifi cant public health concern. 261809_columbia 01-72 sec1:15261809_columbia 01-72 sec1:15 4/5/07 2:12:15 pm4/5/07 2:12:15 pm 16 journal of student social work, vol. v ia n h o l l o w a y improvement of education campaigns targeted at parents and primary healthcare providers, expansion of community-based programs to address the limited knowledge surrounding mental illness and the scarcity of appropriate service providers, and implementation of policies for early screening, detection, and treatment are just a few of the strategies that may be employed to reduce the negative outcomes resulting from mental health problems in latino children. in order for these changes to take place, mental health practitioners must view latino children’s mental health as a priority and engage in advocacy 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(2005). neighborhood residence and mental health problems of 5to 11-year-olds. archives of general psychiatry, 62, 554-563. zimmerman, f.j. (2005). social and economic determinants of disparities in professional help-seeking for child mental health problems: evidence from a national sample. health research and educational trust, 40(5), 1514-1533. ian holloway is a second year student in the dual-degree master’s program with the mailman school of public health, within the reproductive, adolescent and child health track in the heilbrunn department of population and family health and cussw, within the advanced clinical practice method, in the health, mental health and disabilities fi eld of practice. he is a graduate of the university of california, san diego with a bachelor’s degree in literatures of the world and a minor in law and society. ian is currently placed at the payne whitney clinic of new york presbyterian hospital. his e-mail address is iwh2101@columbia.edu. 261809_columbia 01-72 sec1:20261809_columbia 01-72 sec1:20 4/5/07 2:12:17 pm4/5/07 2:12:17 pm cswrfinal_4.1.13 69 columbia social work review, volume iv technology's role in the nonprofit sector: increasing organizational effectiveness and efficiency through technology innovations brianna boles increasing technology uptake in the nonprofit sector will allow nonprofit organizations and social workers to provide more effective services through improved work processes. the following paper will discuss how these processes (service delivery, fundraising, and outreach) are carried out in the nonprofit sector given the current technology landscape in nonprofits. i will provide background information about innovations such as cloud computing systems, social media, and mobile technologies that should be incorporated into the nonprofit sector in order to improve the quality of services and work processes. an overview of the barriers that nonprofits face, such as lack of knowledge, lack of resources, and demands by funders, will explain the challenges accompanying increased technology uptake. the final section provides a method to overcome obstacles, allowing the optimal integration of technology into the nonprofit sector. social workers prioritize the needs of others before their own, devoting time and resources to offer services that improve the lives of individuals, organizations, and communities. technology integration in the nonprofit sector provides an enhanced method for social workers to improve the quality of their services and make their jobs more effective. for example, customized mobile applications for nonprofits could offer social workers the opportunity to conduct fieldwork and to access agency information confidentially and safely off-site. database software also provides a method for social workers to collect and analyze data while reporting outcome requirements to funders. although nonprofit organizations incorporate technology functions into their day-to-day work, there still remains untapped potential. nonprofits have the ability to implement technology innovations progressively, in order to improve service delivery, fundraising methods, and outreach tactics. the following article will discuss the technology boles columbia social work review, volume iv 70 gap in nonprofit organizations, innovations that will allow nonprofits to optimize technology uptake, and an explanation of the barriers preventing the incorporation of technology into organizational operations. the final section demonstrates why collaboration and education initiatives are necessary to overcome challenges so that nonprofits and social workers can benefit from technology’s offerings. background nonprofits have the opportunity to benefit from emerging technologies such as cloud computing systems, social media, and mobile technology in order to increase the quantity of clients served and improve service quality. cloud computing, also known as “the cloud,” refers to applications, services, or software offered over the internet instead of requiring direct connection to a server (nten & idealware, 2012). nonprofits can use cloud technologies to improve internal communications among staff members (with e-mail and collaboration software) and to store information (with office software and data backup). cloud technologies reduce the cost of services and the time it takes to communicate information. social media is a unique cloud solution in that it improves external communications, such as stakeholder engagement, in nonprofit organizations. social media is an online platform communication tool that includes channels such as facebook, twitter, linkedin, instagram, and pinterest. the purpose of social media is to allow people to connect and interact with each other using the internet. because nonprofits connect people to services and provide resources to strengthen communities, social media is a method for nonprofits to convey their purpose and recruit stakeholders. stakeholders are individuals who have an interest or stake in the organization, and may include volunteers, donors, and service users. the pew research center internet & american life project found that in 2012 alone, 69% of adults across gender, race/ethnicity, and income groups in the u.s. used social networking sites (smith, 2012). as a result of steady growth, social media networks are increasingly important tools for nonprofits to technology’s role in the nonprofit sector 71 columbia social work review, volume iv raise awareness and conduct outreach. mobile technology refers to an array of cellular communication technology, such as smart phones (cellular phones with internet access), mobile applications or apps (software units available for download on smart phones with specific functions), and tablets (mobile computers that are typically operated by touch screen) (techopedia, 2012; techterms, 2011). nonprofit organizations can use the versatile functions of mobile technology to fundraise and generate interest in their missions and social causes. given that nearly half of cell phone users own smart phones, one in three american adults downloads apps to cell phones or tablets, and one in ten adults makes charitable contributions using text messaging, there is a large market of potential stakeholders available to nonprofits (smith, 2012). the offerings of mobile technology have the potential for nonprofits to provide services to clients, fundraise, and—in addition to social media—raise awareness and conduct outreach. in an increasingly digital age, nonprofits and social workers use technology on a daily basis, yet they do not optimally benefit from the technology innovations available. technology potential in the nonprofit sector technology innovations in the realm of mobile, data, and cloud-based solutions provide nonprofits with the opportunity to reduce the time and cost it takes to effectively deliver services, fundraise, and engage stakeholders. service delivery nearly all nonprofits use information technologies to provide services to clients (johns hopkins, 2010). current information technologies that most nonprofits use for program and service delivery include websites, e-mail systems, and databases (map & idealware, 2012). yet mobile technologies and software systems, which would allow social workers to improve communications with clients and access agency information off-site, are used by few nonprofits. only 35% of nonprofits use mobile techboles columbia social work review, volume iv 72 nologies such as smart phones, personal device assistants (pdas), and mobile applications to track clients, and only 40% of those users collect data while in the field with clients (map & idealware, 2012). even fewer nonprofits, less than 20%, use tracking software systems that would allow them to record outcome data for client and volunteer management (npower & sbc, 2009). although nonprofits integrate basic technologies into program areas to serve clients, the degree to which updated technologies are incorporated should be re-evaluated for improvement. a combination of data and mobile solutions would allow social workers to provide services more quickly and reach more users. to overcome the challenges that social workers face when traveling in the field, npower technology guide for nonprofit leaders (2011) suggests syncing portable devices to office databases. data could be accessed off-site through server software, which would save social workers time from having to go back to their sites and reduce translating paperwork and notes into agency-based computers. to meet funders’ requirements, which depend on results-driven service delivery to inform decision making, a secure database with outcome tracking software would allow nonprofits to measure inputs (the expected goal, preintervention) and outputs (the actual goal, post-intervention) (npower, 2011). as a result, nonprofits would have an easier time reporting client outcomes to funders. using data and information to inform programmatic and service delivery practices is essential to providing scalable services to clients. from a national sample of nonprofits, half of the nonprofits that did not define a plan for measuring the success of a program also failed to track data about outcomes of clients and stakeholders (nten & idealware, 2012). this demonstrates how the absence of a plan to measure program successes is a potential reason for nonprofits’ failure to adopt technologies. fundraising to drive fundraising efforts, most nonprofits rely on foundation proposals, special events, major gifts, direct responses via mail, board support, and online giving (afp, blackbaud, camptechnology’s role in the nonprofit sector 73 columbia social work review, volume iv bell rinker, convio, the center on philanthropy, giving usa, & nccs, 2012). the only type of fundraising to grow consistently is online giving, which increased between 51% and 88% each year between 2002 and 2011 (afp, et al., 2012). additionally, more nonprofits should target individual contributions, given that 75% of the funds nonprofits received in 2011 were from individual donors (rebecca gordon group, 2011). despite a growing market, limited numbers of nonprofits use facebook advertising for fundraising and individual giving purposes (nten, common knowledge, & blackbaud, 2012). data show that only 3% of nonprofits are fundraising, and receiving less than $10,000 in annual donations, on facebook (nten & m+r strategic service, 2012). although growing numbers of nonprofits tap into social media sites, they are not maximizing facebook’s fundraising functions. mobile technologies, specifically applications and text messaging functions, are a missed fundraising opportunity for nonprofit organizations. text-to-give campaigns have become increasingly popular channels for donors to contribute to causes. text-to-give campaigns require donors to text a keyword to a code in order to quickly make a $5 to $10 donation (idealware, 2012). because not all cell phone users prefer to use the text messaging feature of their cell phones, smart phone applications are another way for cell phone users to donate to causes. examples include the “ikettle” app from salvation army, which allows users to set up their own fundraising campaigns (idealware, 2012). when using apps to solicit donations, organizations are provided with immediate receipt of the donation, and users can donate any amount, instead of a limited donation of $5 to $10 dollars through text messaging (idealware, 2012). mobile capacities offer nonprofits an effective way to generate donations while engaging with stakeholders. outreach and engaging stakeholders most nonprofits use social media to generate awareness about their cause-driven work and its impact in the community. nonprofits appear to understand the usefulness of facebook to boles columbia social work review, volume iv 74 increase engagement and outreach to more constituents: 80% of nonprofits believed facebook provided stakeholders with more information and generated more awareness (idealware, 2011). although nonprofits actively use facebook to engage donors, fewer nonprofits use mobile phones for outreach and awareness (branded4 good, 2012; map & idealware survey, 2012). mobile functions that allow nonprofits to reach more consumers include the development of mobile websites and smart phone applications. prior to implementation, however, nonprofits should first assess whether mobile technology fits into their organizational objectives (idealware, 2012). if organizations find that their stakeholders regularly use cell phones and can be effectively engaged through that method, then nonprofits may benefit from integrating mobile technology into practice. a potential strategy for a nonprofit could be to develop a website that can be accessed on mobile devices and incorporate techniques such as highlighting key messages, keeping content organized and interactive, and using videos, larger pictures, and text with less content (branded4 good, 2012). in addition to providing better services to clients and increasing fundraising efforts, integrating mobile technology into operations will allow nonprofits to build a stronger community base and foster better interactions with donors. barriers to technology uptake although a large market of technology users exists, nonprofits do not experience the same high levels of technology uptake and integration. an abundant need for technology is present in the nonprofit sector as a way to develop efficient and effective operational functioning. to integrate technological innovations and improve service delivery, it is critical that organizations overcome their lack of funding and resources, as well as the barriers posed by funders. knowledge and expertise a survey of 10,500 nonprofits, charities, and ngos found technology’s role in the nonprofit sector 75 columbia social work review, volume iv that 60% claimed lack of knowledge is the single greatest barrier to new technological advancement adoption (techsoup global, 2012). another study found that education was needed to teach nonprofits how to bridge social impact missions with technology innovation, identify the causes and effects of tech investments that lead to intended social impact, and train staff in mobile strategies (gahran & perlstein, 2012). although nonprofits attempted to train employees, several impediments occurred, including resistance to change at all levels of staff, the absence of a training plan, and challenges to develop a training to meet an array of staff needs (nten & the nonprofit times, 2011). resources resource shortages also explain nonprofits’ inability to integrate advanced technologies into operations. to improve technology uptake, nonprofits must, in addition to seeking education, collaborate across sectors to better manage and acquire new resources. three causes of reduced resources include more competition from other nonprofits to provide services, increased requirements from funders to provide outcome and other data reporting, and increased regulatory mandates (npower, 2011). additionally, the top three resource shortages nonprofits faced were lack of funds, time, and it staff (johns hopkins, 2010). half of nonprofits reported a shortage of it staff (npower & sbc, 2009) and two-thirds of respondents in a different survey reported no inhouse it staff (johns hopkins, 2010). technology spending is also reportedly a small proportion of nonprofits’ annual budgets, averaging less than 4.2% (johns hopkins, 2010). techsoup global and techsoup.org’s (2012) survey supported this claim: respondents reported cost as the second greatest barrier to cloud computing technology adoption. in particular, key challenges for nonprofits to develop and sustain innovations are the lack of much-needed resources such as growing capital and the tendency of foundations to encourage innovations but not sustain support for them. boles columbia social work review, volume iv 76 funders funders are challenged in similar ways as nonprofits, because they must remain informed of the fast-paced technology landscape and become educated on the potential impacts of technology in nonprofits (gahran & perlstein, 2012). as a result, many funders have limited expertise and knowledge of the role of technology in serving clients and improving operations. after interviewing 41 funders and 13 nonprofit technology service providers, gahran and perlstein (2012) found that funders do not know about the benefits of technology trends, and therefore do not develop technology-funding plans. additionally, funders are faced with competing funding priorities and lack of clarity about how organizations will use technology for social impact outcomes (gahran & perlstein, 2012). although funders struggle to understand the technology landscape of nonprofits, agencies must also comply with complicated funder requirements that quantify the impact of services (nten & idealware, 2012). nonprofits faced roadblocks when they attempted to demonstrate assets to funders, including proving positive impacts on communities served by a program and tracking funding sources and program allocations for various funders and regulators (npower & sbc, 2009). nonprofits struggle with data collection, analysis, and strategy in order to achieve funders’ measurement standards, because the process is time-consuming, expensive, skill-based, and difficult (nten & idealware, 2012). overall, nonprofits face significant challenges, such as lack of education and resources coupled with limited funder awareness, in the face of technology innovation implementation. in response to a complex technology landscape that prevents organizations from optimizing technology’s offerings, collaboration across sectors provides a solution. bridging the gap to improve the quality and quantity of service delivery to disadvantaged populations, nonprofit organizations should integrate technological advancements into current practice. to address the barriers previously mentioned, and to strengthen the role technology’s role in the nonprofit sector 77 columbia social work review, volume iv of technology in the nonprofit sector, fegs health and human services system, one of the largest nonprofits in the u.s. serving over 100,000 new yorkers annually, proposed a new initiative. center4, a method to increase technology uptake, will provide a collaborative space for nonprofits, technologists, social entrepreneurs, and funders to address technology needs in the nonprofit sector. center4 will engage nonprofits to raise concerns about the barriers faced in the field, so that technologists, social entrepreneurs, and funders will collaborate with nonprofits to develop innovative and efficient solutions. the generation of new ideas will help nonprofits incorporate innovative technologies into the social service sector (a. keefe, personal communication, december 6, 2012). center4 will accomplish its objectives with two education tracks, programs, and events. the first education track will target nonprofit executives to identify technology issues in the nonprofit sector and assist them to select and apply technology solutions to solve problems. the second track will be for it professionals to address technology issues faced by nonprofits, learn about new and emerging technologies, and share problem-solving experiences in the nonprofit sector. center4 will host programs to accomplish these goals, with informational sessions, problem solving sessions, and nonprofit specialization sessions for each track. the expected outcome of providing education is to increase nonprofits’ technology uptake and increase expertise and understanding of it solutions for challenges. center4 will also host community events, such as hackathons or competitions, for technologists to target needs voiced by nonprofits. during hackathons, technologists will form teams and match their interests and qualifications to nonprofits’ needs. teams will have a time frame to produce a corresponding technological solution, including a mobile application or software. center4’s role will be to convene these various sectors so that nonprofits can understand the breadth of technology’s capabilities and implement solutions into operations. center4’s function as a bridge, connecting nonprofits and technology, will enable nonprofits to provide better services that target the social issues they seek to ameliorate (a. keefe, personal communication, december 6, 2012). boles columbia social work review, volume iv 78 for example, to address the social problem of homelessness, center4 could develop a mobile application for social workers and service providers to become aware of empty spaces in shelters, transitional housing, and permanent housing locations. social workers would be able to respond to openings and to ensure that homeless individuals are directed to open spaces. this same concept of match availability of services to clients in need could be tailored to domestic violence shelters, to match open beds to women and children in need. the goal of applying technology developments to social issues such as homelessness and domestic violence is to increase the number of individuals connected to services. in this way, technology functions to strengthen the capacities of nonprofits. conclusion nonprofit organizations must leverage technology to improve how clients receive services and how social workers deliver them. technology integration provides a method for nonprofits to achieve better service delivery, fundraising, outreach, and communication outcomes. social workers benefit from technology uptake in the nonprofit sector with reductions in the time it takes to complete services and the cost of conducting them. by becoming educated on technology’s potential to reach more clients, advocating for the creation of joint innovations such as center4, and initiating collaboration with donors and the private sector, barriers can be overcome and social impact can be strengthened. overall, the advocacy and social justice efforts of social workers can contribute to the expansion of technology in the nonprofit sector. references afp, blackbaud, campbell rinker, convio, the center on philanthropy, giving usa, & nccs. (2012). nonprofit fundraising study: covering charitable receipts at u.s. nonprofit organizations in 2011. retrieved from http:// www.urban.org/publications/1001601.html/ branded4 good. (2012). how mobile-ready are the largest nontechnology’s role in the nonprofit sector 79 columbia social work review, volume iv profits in the us? retrieved from http:// branded4good.com/blog/mobile-ready-nonprofits/ gahran, a & perlstein, j. (2012). funding mobile strategies for social impact. san francisco, ca: author. idealware. (2012). what every nonprofit should know about mo bile report. retrieved from http://idealware.org/reports/ mobile-global-development/ johns hopkins. (2010). the nonprofit technology gap – myth or reality? (communiqué no. 20). baltimore, md: author. map & idealware. (2012). unleashing innovation: using every day technology to improve nonprofit services. st. paul, mn: author. npower & sbc. (2009). community technology survey. brook lyn, ny: author npower. (2011). technology guide for nonprofit leaders: a mis sion support tool for community development. brooklyn, ny: author. nten, common knowledge, & blackbaud. (2012). nonprofit social network benchmark report (4th ed.). portland, or: author. nten & idealware. (2012). the state of nonprofit data report. portland, or: author. nten & m+r strategic service. (2012). enonprofit benchmarks study. retrieved from http://www.ebenchmarksstudy.com/ nten & the nonprofit times. (2011). nonprofit technology staffing and investments survey report. portland, or: au thors. rebecca gordon group. (2011). nonprofits’ impact on the econo my. retrieved from http://rebeccagordongroup.org/site/ nonprofits-impact-on-the-economyinfographic/ smith, a. (2012). cell internet use 2012: pew research center’s internet & american life project. retrieved from http:// pewinternet.org/reports/2012/cellinternet-use 2012.aspx/ techopedia. (2012). mobile application (mobile app). retrieved from http://www.techopedia.com/definition/2953/mobile application-mobile-app/ techsoup global. (2012). 2012 cloud computing survey. san francisco, ca: author. techterms. (2011). tablet. retrieved from http:/ www.techterms.com/definition/tablet/ 18 journal of student social work, vol. vi more than twenty-five percent of the us american indian* population lives at or below the poverty line; unemployment is nearly ten percent higher than that of the general population (u.s. census, 2006). on or near reservations, the numbers are much higher. american indian youth commit suicide at a rate three times that of the general population, (indian health services [ihs], 2001) while american indians as a group have a higher mortality rate due to alcoholism than any other group in the us (gray & nye, 2001). the following will examine both the mental health and socioeconomic condition of this community in order to understand the ways in which the experience of poverty and the high rates of poor mental health might relate. there are a number of challenges facing the american indian community; this paper will explore poverty as only one of the potential factors adding to the mental distress exhibited in the population. poverty is defined from both an absolute and social exclusion perspective. the suggested influences on mental health include economic stress, sociohistorical trauma, and isolation from institutional resource. overty can be explained as an absolute and in terms of social exclusion. absolute poverty refers to a fixed measurement of paucity. in the united states this measurement is defined by the poverty line. all individuals who earn an income less than or equal to the federally mandated poverty line are considered to be living in absolute poverty. poverty defined in terms of social exclusion refers to a lack of institutional resources. this formulation has less to do with one’s financial standing, and more to do with the non-monetary variables that affect a person’s life. silver and miller (2003) champion the use of the concept of social exclusion as a way to encourage a multidimensional understanding of the experience of poverty. according to the european union (2004), social exclusion refers to the process by which individuals are systematically marginalized, resulting in consistent disadvantage in terms of educational resources, houslarkin sealy p poverty and mental health in the american indian community *because the term american indian is used by the national congress of american indians, the nation’s largest inter-tribal organization, it will be used throughout this paper to refer to native americans or first nations people living in the united states. 19 poverty and mental health ing conditions, employment opportunities, formal justice, political participation and freedom of cultural expression. silver and miller expand this definition to include the degree to which discrimination or racism affect economic and social opportunities. exclusionary poverty should not be confused with a lack of interpersonal or cultural assets, but instead understood as inopportunity for equal resource acquisition at the institutional level. while closely related, absolute and exclusionary poverty offer different insights into the ways in which individuals experience being poor. poverty in the american indian community the experience of the us-based american indian population† offers a rich context within which to examine the association between mental health and poverty. american indians live in some of the most economically depressed conditions in the country and experience significant rates of mental illness. (beals, piasecki, nelson, jones, keane, dauphinias, red shirt, sack & spero, 1997; andersen & brownson, 2000, harris, edlund, & larson, 2005). it is therefore important to examine the factors and influences that have gone into shaping these conditions within the community. one factor greatly affecting the american indian population is poverty. in absolute terms and according to the 2000 u.s. census, nearly twenty-six percent of american indians nationwide live below the poverty line; among the fifteen major tribes, this statistic ranges from almost forty to no lower than fifteen percent. for american indians living on or near reservations, the unemployment rate is at forty-nine percent, with thirty-four percent of those working still living below the poverty line (bia, 2003). these numbers show improvement from only a decade earlier and yet they still signal serious economic trouble within the community. in their exploration of the impacts of the socio-historical experience of american indians, kawamoto (2001) and beals et al. (1997) highlight the exclusionary element of poverty within the community. the multiple historical traumas endured by the community, coupled with cultural and geographical marginalization from the mainstream, have left many resource gaps. impacts of cultural assault enacted through a number of assimilation-focused u.s. policy choices can be clearly seen. the 1881 policy prohibiting the practice of american indian ceremonies, the dawes act of 1887 which took from the american indian population nearly 93 million acres of tribal land, the infamous indian boarding schools, and the termination and relocations acts of the 1950s are only a few such policies. these violent interruptions to tribal life have left much l a r k in s e a ly 20 journal of student social work, vol. vi of the american indian community with limited resources. efforts to maintain tribal communities have consistently been challenged, as has access to full participation in the majority culture. the effects of poverty, in the form of economic deprivation and social exclusion, as influenced by racist us policy and marginalization, are felt on a day-to-day basis. while reservations in many ways ensure cultural growth and sustainability – and for those tribes that escaped removal, a connection to tribal homelands – the economic and social conditions on reservation are such that residents often go without basic amenities. currently, slightly more than half of the american indian population lives off the reservation, but the reservation environment is still important to explore for a number of reasons. not only have reservations played an important part in the recent history of the community, but the majority of the people living on reservations are younger than those living outside of tribal lands (u.s. census, 2002). this means that for the most part, the newest generation of american indians is being brought up in an environment with extremely low employment rates, poor housing quality and a host of other indicators of poverty. in addition, lobo (1998) asserts that most american indians living in urban settings still have a strong sense of “back home” in regards to tribal lands. she notes that return visits to reservations and rural territories for family and cultural events are common. there has been a consistent history of migration between urban sites and reservations within the population (snipp, 1997). finally, conditions on the reservation also offer an interesting perspective with regard to the relationship between mental illness and poverty. the fact that a great portion of the american indian population operates in a different economic sector from the rest of the country, and as such is removed from direct socioeconomic competition with national peers, challenges the commonly held belief that individuals with mentally illness slowly drift towards poverty as a result of their inability to successfully compete for societal resources. reservations offer the opportunity to observe the relationship between mental health and poverty outside of the influence of direct competition. mental health issues in the american indian community compromised mental health is an area of great concern within the american indian community. specifically suicide, alcoholism, and post-traumatic stress disorder (ptsd) all exist at levels higher than that of the general population. the importance of examining poor mental health and its causes within the american indian community is made abundantly clear when looking at mortall a r k in s e a ly 21 ity statistics. suicide is the second leading cause of death for american indians between the ages of fifteen and twenty-four and occurs at a rate twice that of the national average (ihs, 2001). for american indian youth between the ages of fifteen and nineteen, this statistic rises to three times that of the national average (lemaster, beals, novins & spero, 2004). deaths related to alcoholism are higher for american indians than for any other racial group in the us, at four times the national average. moreover the loss of productive years of life due to alcohol abuse is nearly five times the national average (cameron, 1999). lemaster et al. note that while the occurrence of ptsd in a random selection of american indian participants from one community was nearly twenty-two percent, findings for other american-based populations typically range from one to nine percent. gray and nye (2001) note that this percentage is equivalent to that seen in survivors of traumatic events such as mass shootings, major burns, and combat. ptsd is often found in tandem with depression, substance abuse, anxiety, and violence, which makes its exaggerated presence in portions of the american indian community a source for real alarm. in a study comparing the mental health status of women of differing ethnic backgrounds in the united states, andersen and brownson (2000) showed that american indian women exhibited the highest rates of depression of any other group. because of the extreme nature of the mental distress present within this community, it is critical to try and understand the factors driving it. examining the relationship between the deterioration of mental health and the consistent experience of poverty may offer some insight and thus lead to better strategies for addressing the problem. poverty’s impact on mental health within the united states, the relationship between mental health and poverty is often explained through a causal lens: poor mental health acts on the individual to increase his or her potential for poverty-level existence. the practical and imposed hurdles to social and economic functioning encountered on a day-to-day basis by people with mentally illness may compromise their ability to stay afloat in american society. individuals suffering from mental illness either find themselves drifting to the bottom of the socioeconomic pool or barely able to keep their heads above water. while there is definite value in recognizing this directional link between mental health and socioeconomic standing, it is also important to examine the relationship through an inverse lens. in order to truly grasp the nature of mental illness as well as the effects of poverty, it is imperative to explore the ways in poverty and mental health l a r k in s e a ly 22 journal of student social work, vol. vi which poverty may also intensify the potential for poor mental health. link and phelan (1995) suggest that the more commonly held belief about the interplay between mental health and poverty is reflective of a western vision of the world, wherein a kind of sanctity is assigned to the responsibility and agency of the individual. what can sometimes be problematic about this perspective is that it does not allow for human vulnerability to external influence. by giving weight to the alternative analysis, a departure from the dominant perspective is possible and a more nuanced understanding of the potential for successful interventions in mental health and poverty work can be attained. there are a number of identifiable points of intersection between the effects poverty and mental health within the american indian community that seem to confirm link and phelan’s (1995) proposed explanation of the relationship between these variables. these authors state that an individual’s health must be understood from within their socioeconomic context because it is only from within that context that all of the risks factors an individual encounters can be clearly seen. link and phelan urge the health community to use this contextualization to begin to identify the circumstances of poverty that may act as “fundamental causes” of poor health. kawamoto (2001) locates these “fundamental causes” in american indian history. alcoholism, other forms of substance abuse, suicide and ptsd can all be linked to a historically-born exclusionary poverty. he references the communal memory of the indian boarding schools which did not allow children to speak their native language, practice their own religion, or connect with their families on a regular basis; the 1954 termination act which saw 109 tribes formally dissolved and 109 communities scattered; and the 1956 relocation act which encouraged the dissolution of a portion of the remaining nations into large american urban centers. kawamoto argues that each of these key periods or moments in american indian history, instrumental in inflicting the exclusionary elements of poverty, have served to create a sense of hopelessness and loss of control in the psyche of the community. duran, duran, brave heart, & yellow horse (1998) also contend that beyond the immediate economic stresses encountered within the population, the traumatic history of genocide, displacement, and cultural assault has resulted in what they term a “soul-wound” within the american indian community. szlemko, wood, and jumper thurman (2006) suggest that the pervasiveness of alcoholism may be in part an attempt to medicate the sense of loss and alienation produced by this communal shock. the pain that has resulted from these historical experiences, which were very much a part of growing exclusionary poverty, has tipped the scales of health in l a r k in s e a ly 23 the american indian community. johnson and tomren (1999) also look at the roots of alcoholism and suicidal behavior through lens of the poverty with special attention paid not only to the historical events that have played a part in shaping the health of the community, but also to current experiences. johnson and tomren contend that most schools do not cater to american indian children’s sense of cultural functioning nor do they address any language needs. american pop culture also moors american indian identity in the past, often stripping the community of any contemporary agency, and racism and cultural marginalization keep many american indians alienated from an ever-present mainstream. johnson and tomren suggest a potential connection between these larger experiences of disaffection and the feelings of anomie, helplessness and hopelessness that often accompany suicide. whitbeck, mcmorris, hoyt, stubben, and lafromboise (2002) contend that as a result of the pervasive economic deprivation and social stress encountered by many american indian communities, some individuals experience high levels of consistent depression, which in turn increases their potential for suicidal ideation and substance abuse. they specify that continued financial strain as well as feelings of unrelenting social assault, in the form of experienced or perceived discrimination or racism creates significant social stress. this in turn compromises the individual’s capacity for free, unfettered development, increasing their risk for developing mal-adaptive behaviors. gray and nye (2001) write specifically about the prevalence of ptsd in the community and also connect it to the larger context that surrounds many american indian lives. they assert that the trauma that comes with constantly living under economic and social stressors can eventually take its mental toll. robin, chester, rasmussen, jaranson, and goldman (1997) suggest that the american indian community’s disproportionately high exposure to traumatic events accounts for the unusually high rates of non-combat related ptsd. according to their study, which was conducted in a southwest american indian community, the traumatic events most often cited by individuals suffering from ptsd included motor vehicle accidents and the death or severe injury of a loved one. these are events often linked to alcohol abuse and suicide, the high rates of which have been shown to be the result of or at least greatly exacerbated by the poverty experienced in the community. brave heart (1998) expands this analysis even further, suggesting that american indians as a community are suffering from historical trauma response (htr) as a result of hundreds of years of traumatic events. all of these authors maintain that the damaging effects of the poverty and mental health l a r k in s e a ly 24 journal of student social work, vol. vi acute poverty experienced by the american indian population, both in absolute and exclusionary terms, has had an undeniable effect on the mental health of the community. changing poverty; changing mental health costello, compton, keeler, and angold (2003) present a relevant study in which they track the mental health of a group of children from varied socioeconomic backgrounds. about one quarter of the study participants are american indian children from one reservation, while the rest are white children from the surrounding area. in the middle of the eight-year study, a casino opened on the reservation and each american indian family began to receive a benefit from the casino profits in addition to their annual income. each year the benefits went up, and by the end of the study each family was receiving an additional six thousand dollars per year—almost half of what a family of four living at the poverty line would have made at the time of the study. while the american indian children who qualified as persistently poor had scored much worse on their mental health evaluation in the first years of the study, four years after the opening of the casino almost all of the behavioral problems that the american indian children had been exhibiting improved to the point that they were on par with the non-poor white children in the group. it seems that relieving poverty in absolute terms was having a measurable impact on the health of the community. unlike the behavioral problems, many of the emotional problems that had occurred with more frequency among the poor american indian children still remained. costello et al. suggest that this may be because emotional dysfunction takes more time to rectify itself with intervention than do behavioral problems. another analysis is that while the relief of absolute poverty can bring about some definite improvement in the mental health of the community, it is not a panacea. kawamoto (2001), szlemko et al. (2006), johnson et al. (1999), whitbeck et al. (2002), gray and nye (2001), robin et al. (1997) and brave heart (1998) all suggest that the long-term effects of exclusionary poverty are very real and cannot be eased so quickly. the grand traverse band of ottawa and chippewa indians have attempted to address this long-term damage by using gaming profits to create a comprehensive health department, complete with counseling and psychological services (cornell, kalt, krepps & taylor, 1998). they are only one in a great number of tribes that have taken similar action (taylor & kalt, 2005; grant, spilde & taylor, 2004; cornell et al., 1998). grant et al. (2004) suggest that using l a r k in s e a ly 25 increased revenue in tribal communities in this way not only increases personal funds, but elevates the quality of life. with the means to attend to problems, both through direct services and by building on strengths with the creation of culture and language preservation programs, heritage centers, and community building initiatives, the american indian community can continue to heal and strengthen on a holistic level. real change in the health of an individual can be found by assuaging economic hardship, but improving poverty must also involve attention to in one’s lived experience. conclusion the american indian population is just one example of a community that is currently experiencing great stress due to poverty. the challenges that poverty creates are felt on a day-to-day basis, and are only amplified when the person in poverty is not a member of the majority race or culture. by understanding mental health not only as a determinant of poverty, but also as an outcome, we can begin to develop productive treatment models. gray and nye (2001) argue that if it seems preposterous for a mental health practitioner to treat a young woman suffering from ptsd without addressing a past experience of incest, then it should seem preposterous to treat the mental health of the american indian community without addressing the experience of poverty. bringing to bear the ill effects of the larger context of poverty on the mental health of an individual has great implications for the future well being of the american indian community, as well as for the wider populations of poor. if we can engage in treatments that take into account the observable strain that results from the experience of poverty, both in absolute and exclusionary terms, honest and productive health care can begin to happen. references andersen, e. & brownson, r. (2000). disability and health status: ethnic differences among women in the united states. journal of epidemiology and community health, 54(3), 200-206. beals, j., piasecki, j., nelson, s., jones, m., keane, e., dauphinais, p., red shirt, r., sack, w., & manson, s.m. (1997). psychiatric disorder among american indian adolescents: prevalence in north plains youth. journal of the american academy of child & adolescent psychiatry, 36(9), 12521259. poverty and mental health l a r k in s e a ly 26 journal of student social work, vol. vi beals, j., novins, d.k., whitesell, n.r., spicer, p., mitchell, c.m., & manson, (2005). prevalence of mental disorders and utilization of mental health services in two american indian reservation populations: mental health disparities in a national context. american journal of psychiatry, 162(9), 1723-1732. brave heart, m.y.h. (1998). the return to the sacred path: healing the historical trauma response among the lakota. smith college studies in social work, 68(3), 287-305. cameron, l.a. (1999). understanding alcohol abuse in american indian/ alaskan native youth. pediatric nursing, 25(3), 297-300. cornell, s., kalt, j., krepps, m., & taylor, j. (1998). american indian gaming policy and its socio-economic effects, a report to the national gambling impact study commission, economic resource group incorporated. costello, compton, keeler, & angold. (2003). relationships between poverty and psychopathology: a natural experiment. journal of the american medical association, 290(15), 2023-2029. council of the european union. (2004). joint report by the commission and the council on social inclusion. council (employment, social policy, health and consumer affairs). duran, e., duran, b., brave heart, m.y.h., & yellow horse-davis, s. (1998). healing the american indian soul wound. in yael danieli (ed.), international handbook of multigenerational legacies of trauma (pg. 341-254). new york: plenum. grant ii, k., spilde, k., & taylor, j.b. (2004). social and economic consequences of indian gaming in oklahoma. american indian culture and research journal, 28(2), 97-129. gray, n., nye, p.s. (2001). american indian and alaskan native substance abuse: co-morbidity and cultural issues. american indian and alaskan native mental health, 10(2), 67-85. harris,k., edlund, m., & larson, s. (2005). racial and ethnic differences in the mental health problems and use of mental health care. med care, 43(8), 775-784. johnson, t., tomren, h. (1999). helplessness, hopelessness, and despair: identify¬ing the precursors to indian youth suicide. american indian culture and research and journal, 23(3), 287-301. kawamoto, w.t. (2001). community mental health and family issues in l a r k in s e a ly 27 sociohistori¬cal context. the american behavioral scientist, 44(9), 14821491. lemaster, p., beals, j., novins, d.k., & spero, m.m. (2004). the prevalence of suicidal behaviors among northern plains american indians. suicide & life – threatening behavior, 34(2), 242-255. link, b., phelan, j. (1995). social conditions as fundamental causes of disease. journal of health and social behavior, extra issue, 80-94. lobo, s. (1998). is urban a person or a place? characteristics of urban indian country. american indian culture and research journal, 23(2), 89-102. robin, r.w., chester, b., rasmussen, j., jaranson., j., & goldman, d. (1997). prevalence and characteristics of trauma and posttraumatic stress disorder in a southwest¬ern american indian community. american journal of psychiatry, 154, 1582-1588. silver, h., miller, s.m. (2003). social exclusion: the european approach to social disadvantage. indicators, 2(2), 1-16. snipp, m.c. (1997). the size and distribution of the american indian population: fertility, mortality, migration, and residence. population research and policy review, 16(1-2), 61-93. szlemko, w.j., wood, j.w., jumper, t. (2006). native americans and alcohol: past, present, and future. the journal of general psychology, 133(4), 435-451. taylor, j.b., kalt, j.p. (2005). cabazon, the indian gaming regulatory act, and the socioeconomic consequences of american indian governmental gaming: a ten-year review. harvard university, malcolm wiener center for social policy. u.s. department of commerce, census bureau. (2006). we the people: american indians and alaskan natives in the united states. census 2000 special reports. retrieved on march 1, 2008 from: http://www.census. gov/population/www/socdemo/race/censr-28.pdf u.s. department of health and human services, indian health services. (2001). trends in indian health 2000-2001. retrieved on february 17, 2008 from: http://www.ihs.gov/nonmedicalprograms/ihs_stats/trends00. asp u.s. department of the interior, bureau of indian affairs. (2007). indian enti¬ties recognized and eligible to receive services from the united states bureau of indian affairs; notice. federal register, 72(55). retrieved february 17, 2008 from: http://www.loc.gov/catdir/cpso/biaind.pdf poverty and mental health l a r k in s e a ly 28 journal of student social work, vol. vi u.s. department of the interior, bureau of indian affairs. (2003). indian population and labor force report. retrieved on march 1, 2008 from: http:// www.doi.gov/bia/laborforce/2003laborforcereportfinalall.pdf whitbeck, l.b., mcmorris, b.j., hoyt, d.r., stubben, j.d., & lafromboise, t. (2002). perceived discrimination, traditional practices, and depressive symptoms among american indians in the upper midwest. journal of health and social behavior, 43(4),400-418. larkin sealy is a first year master’s student at cussw. she is planning to continue her studies at the school of social work within the advanced generalist practice and programming method. her concentration will be in family, youth and children’s services. larkin’s current field placement is at the antonia pantoja preparatory academy in the bronx. she holds a bachelor’s degree in sociology from vassar college. her email address is las2208@ columbia.edu. l a r k in s e a ly journal2011 ! "#!!!!!!!!$%&'()*+!,%-*+&!.%/0!123*245!6%&'(2!77! ! 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>*9a&+-2>!-+(a9!4*b:!2992=b*+&!&*e2&*=2!/29%'/-295!b:2*/!+aa/%+-:! 9b*&&!/+*929!a/%3%-+b*32!j'29b*%=9f!!j%/!2?+(a&25!4:+b!a/2-+'b*%=9! +/2!*(a&2(2=b2>!b%!-%=b/%&!b:2!*=-/2+9*=c!='()2/9!%e!/+a2!+=>! -/*(2!3*-b*(9l!! .:*&2!*b!*9!a%99*)&2!b%!-%(a&2b2&;!/2a+*/!>+(+c2>!+=>!>2d 9b/%;2>!*=e/+9b/'-b'/2!%32/!b:2!=2+/!e'b'/25!*b!*9!*(a2/+b*32!b%!+>d >/299!b:2!a9;-:%9%-*+&!*(a+-b!%=!p+*b*+=9!+9!42&&f!!7b!*9!%'/!(*9d 9*%=5!+9!9%-*+&!4%/0!9b'>2=b9!+=>!+9!e'b'/2!9%-*+&!4%/0!a/%e299*%=d +&95!b%!a/%(%b2!+4+/2=299!%e!b:2!9*b'+b*%=!*=!p+*b*f!!.2!('9b! :*c:&*c:b!b:2!*(a%/b+=-2!%e!2+/&;!/2-%32/;!+-b*%=5!b:2!9b+)*&*@+b*%=! %e!b:2!9*b'+b*%=5!+=>!b:2!a/232=b*%=!%e!e'/b:2/!>2b2/*%/+b*%=f! ! z*9+9b2/9!4*&&!:+aa2=f!!<%!&2992=!b:2*/!*(a+-b9!*=!b:2!e'd b'/25!3'&=2/+)&2!-%(('=*b*29!=22>!b%!9b/2=cb:2=!b:2*/!/29*&*2=-;! +9!42&&!+9!c+*=!+4+/2=299!%e!a%b2=b*+&!/*90!e+-b%/9!b:+b!-%'&>!*(d a2>2!b:2*/!j'+&*b;!%e!&*e2!*=!b:2!232=b!%e!+!>*9+9b2/f!!z+(+c2>! :%'9*=c!+=>!*=e/+9b/'-b'/2!=22>!b%!)2!/2)'*&b!+=>!(+>2!(%/2!/2d 9*9b+=b!b%!2=3*/%=(2=b+&!b:/2+b9f!!z*9+9b2/9!+/2!*=-%(2d=2'b/+&!+=>! 7=b2/=+b*%=+&!,%-*+&!.%/0!+=>!z*9+9b2/!129a%=92! n#!!!!!!!!$%&'()*+!,%-*+&!.%/0!123*245!6%&'(2!77! -%&%/!)&*=>5!;2b!b:2*/!*(a+-b9!+/2!=%b!k$'bb2/5!lmmtof!!1292+/-:!%=! b:2!lmmn!7=>*+=!i-2+=!b9'=+(*5!b:2!lmmt!p'//*-+=2!q+b/*=+!*=!b:2! s=*b2>!,b+b295!+=>!b:2!lmum!2+/b:j'+02!*=!p+*b*!>2(%=9b/+b295! %=-2!+c+*=5!b:+b!*(a%32/*9:2>!-%(('=*b*29!9'ee2/!c/2+b&;!e/%(! -+b+9b/%a:29!b:+b!/29'&b!e/%(!=+b'/+&!>*9+9b2/95!+9!b:*9!a%a'&+b*%=! %eb2=!&*329!+=>!4%/09!*=!:*c:&;!3'&=2/+)&2!&%-+b*%=9f! ! 7$-$%$(+$,! ! 899%-*+b2>!]/299f!klmmt5!8a/*&!umof!lmmn!>2+>&*29b!j'+02!;2+/!e*32! -2=b'/*29f!12b/*232>!e/%(!:bbahgg444f(9=)-f(9=f-%(g *>g[\nh##tg! <:2!a+b2;2!12&*2e!8&&*+=-2f!klmuuof!12b/*232>!e/%(!:bbahgg 444f)+b2;/2&*2ef%/cg4%/0ga/%g2-b9gb:2d)+b2;9g! $2=b/+&!7=b2&&*c2=-2!8c2=-;f!klmuuof%<"#%52./)%8-1':22>f!12d b/*232>!e/%(!:bba9hgg444f-*+fc%3g&*)/+/;ga')&*-+b*%=9g! b:2d4%/&>de+-b)%%0gc2%9g:+f:b(&m! $'bb2/5!,f!^f!klmmtof!<:2!c2%c/+a:;!%e!9%-*+&!3'&=2/+)*&*b;h!1+-25! -&+995!+=>!-+b+9b/%a:2f!12b/*232>!e/%(!:bbahgg4+9*9f%'f2>'g >%-9g$'bb2nlmmtfa>e! r/%2=5!if!8f5!`!]%&*30+5!8f!ff!klmmhof!p'//*-+=2!q+b/*=+!23+-'d 229h!4:%!b:2;!+/25!4:2/2!b:2;!+/25!+=>!:%4!b:2;!+/2!e+/d *=cf!a2$'"/*%b-:2.%c#7+#55!ded5!"lotuf! p+*b*+=!-:*&>/2=!*=!z%(*=*-+=!12a')&*-5!b:2!e*c:b!e%/!+=!*>2=b*b;f! klmmh5!j2)/'+/;!uof!f$'.#1(/'(.-&5%f)(1-.#&%)-.%g62.9 '($+)-)#&f!12b/*232>!e/%(!:bbahgg444f2=b/2-'&b'/+9f%/cg =%b*-*+9g=249gp+b*+=n-:*&>/2=n*=nz%(*=*-+=n12a')&*-! nb:2ne*c:bne%/n+=n*>2=b*b;!! p+(*&b%=5!af!ff5!,'bb%=5!]f!zf5!_+b:2495!<f5!_+/b*=5!if!8f5!`! 62=b'/+5!,f!if!klmm\of!<:2!2ee2-b!%e!p'//*-+=2!q+b/*=+h! a*/b:9!*=!b:2!sf,f!c'&e!-%+9b!/2c*%=5!)2e%/2!+=>!+eb2/!b:2! 9b%/(f!h-'+2$-/%i+'-/%j'-'+&'+1&%c#62.'&5!klklo5!uo"lf! p%&&*e*2&>5!_f5!p24+c25!$f5!r'=+4+/>2=+5!$f!wf5!q%>*b'4+00'5! ]f5!`!.22/+/+b:=2c25!qf!klmmhof!,;(ab%(9!+=>!-%a*=c!*=! ,/*!^+=0+!lmolu!(%=b:9!+eb2/!b:2!lmmn!b9'=+(*f!<"#%m.+'9 +&"%n2(.$-/%28%o&*1"+-'.*5!dpq5!"\onnf! _*&&95!_f!8f5!f>(%=9%=5!zf5!`!]+/05!$f!^f!klmm#of!</+'(+!+=>! 9b/299!/29a%=92!+(%=c!p'//*-+=2!q+b/*=+!23+-'229f! <+')(+=!+=>!.2*9@! $%&'()*+!,%-*+&!.%/0!123*245!6%&'(2!77!!!!!!!!nh! r4#.+1-$%n2(.$-/%28%o(:/+1%s#-/'"5!ptk,uo5!uu[oul"f! _%//*992;5!,f!klmum5!i+='+/;!llof!sf,f!$%+9b!r'+/>!*=!p+*b*h!j*/9b! 129a%=>2/9!o*=!e%/!b:2!&%=c!:+'&f!<?af;!12b/*232>!e/%(! :bbahgg444fb*(2f-%(gb*(2g9a2-*+&9ga+-0+c29g+/b*-&2g! m5lhhmn5u\t""#\nu\t"n\nnu\t[m"n5mmf:b(&! w+g+/*+=5!^f!_f5!r%2=g*+=5!8f!qf5!]2&-%3*b@5!zf5!_+=>2&5!jf5!`! w+g+/*+=5!af!klmmuof!<:2!2ee2-b!%e!/2&%-+b*%=!+eb2/!+!=+b'/+&! >*9+9b2/f!n2(.$-/%28%<.-(4-'+1%j'.#&&5!duk"o5!tuuotl[f! i&92=5!,f!af5!_+b'9@290*5!.f5!]+>(+5!<f!6f5!`!.*-0/2(2/+b=25! pf!_f!klmmtof!12)'*&>*=c!+eb2/!b:2!<9'=+(*h!r2bb*=c!*b! /*c:bf!ram?gv%r%n2(.$-/%28%'"#%s(4-$%f$7+.2$4#$'5!eu kho5![uuo[unf! ]%/b2/5!_f5!`!p+9&+(5!wf!klmmtof!]/2>*9a&+-2(2=b!+=>!a%9b>*9d a&+-2(2=b!e+-b%/9!+99%-*+b2>!4*b:!(2=b+&!:2+&b:!%e!/2e'd c229!+=>!*=b2/=+&&;!>*9a&+-2>!a2/9%=9h!8!(2b+d+=+&;9*9f! n2(.$-/%28%'"#%r4#.+1-$%a#)+1-/%r&&21+-'+2$5!qpukto5! [mlo[ulf! ! ,+99*5!if!klmum5!8a/*&!u\of!r,,!a/%e299%/e9!9b'>;!b%'/!c*329!9b'd >2=b9!%=d9*b2!>*9+9b2/d+*>!2?a2/*2=-2f!12b/*232>!e/%(! :bbahgg444fe%/>:+(f2>'g-+(a'9n/29%'/-29g2=249/%%(! g*=9*>2e%/>:+(!g+a/*&nu\nlmumg*=ne%-'9ne+-'&b;n+=>g c99na/%e299%/9n9b'>;n#tumnf+9a! ,*&%325!zf5!`!b4*5!8f!af!klmmtof!</+=9&+b*=c!-%(a+99*%=!*=b%! a9;-:%9%-*+&!+*>!+eb2/!b:2!b9'=+(*f!<"#%b-$1#'5!ewk5!l[\o l#uf! sw7$fj!klmum+5!j2)/'+/;!ulo!,*b'+b*%=!sa>+b25!sw7$fj! _%=b:&;!,*b'+b*%=!12a%/bh$:*&>/2=!*=!p+*b*!i=2!_%=b:! 8eb2/f! ! ! ! ! ! sw7$fj!klmum)5!_+/-:!umo!s=*b2>!e%/!$:*&>/2=5!sw7$fj!f(2/d c2=-;!129a%=92!sa>+b2h!sw7$fj!*=!p+*b*h!ludlh!j2)/'d +/;!lmumf! 6+=1%%;2=5!_f5!`!^2+=*=c5!if!klmmtof!8eb2/!b:2!b9'=+(*!d!j+-*=c! b:2!a')&*-!:2+&b:!-:+&&2=c29f!<"#%h#5%f$,/-$)%n2(.$-/%28% a#)+1+$#5!ekq5!n"ton"hf! ! ! ! ! journal2012   21        columbia social work review, volume iii  cash transfers in emergencies    jennifer lee      “famines occur because they are not prevented: they are allowed  to happen.”  – stephen devereux, economist     “transferring cash directly takes the power away from the hu­ manitarian community and puts it into the hands of the benefi­ ciaries, a notion that people still remain uncomfortable with.”  – sarah bailey, overseas development institute    "i had no choice; i could not even afford a piece of meat or one  tomato. now with the cash i feel like a free woman. sometimes i  even buy shoes for my children, when i have saved enough… i  can now decide what is important for my family."   – jawahir hassan ali, somali mother    the famine that began in the horn of africa during the summer of  2011 is the worst that the region has seen in over 60 years. with  13.3 million people in need of assistance and the lives of 750,000  in jeopardy, there is an urgent need for a quick and effective re­ sponse. a growing body of evidence suggests that cash transfers  are the most appropriate means of providing assistance in food  emergencies. this paper examines the use of cash transfers in  food emergencies by providing a brief overview of food security  and famines, reviewing literature on the use of cash transfers,  and providing an example of cash transfer intervention imple­ mented in somalia between 2003 and 2004. with evidence of the  effectiveness of cash transfers in specific contexts, the question  remains why these interventions are not more readily used. this  paper argues that the reluctance to use cash transfers is rooted in  paternalism, and calls upon donors and organizations to re­ examine themselves and their organizations in an effort to not  only restore dignity to those in need, but to save lives.    lee    columbia social work review, volume iii       22    currently, the horn of africa—the peninsula in east afri­ ca that is composed of eritrea, djibouti, ethiopia, somalia, and  parts of kenya—is experiencing the worst drought in over 60  years (rosenberg, 2011). somalia is in a particular state of emer­ gency, as famine has been declared in six of its regions due to a  “perfect storm” of high food prices, crop failure, and armed con­ flict (u.s. fund for unicef, 2011; world concern, 2011). an  estimated 13.3 million people are in need of humanitarian assis­ tance, and 750,000 lives are in jeopardy (world concern, 2011).   traditionally, in­kind donations—such as food, seeds,  tools, and shelter—are provided to aid in these emergencies, (ali,  toure, & kiewied, 2005; harvey & bailey, 2011; rosenberg,  2011). beneficiaries are seldom given money to buy necessities  themselves and ostensibly with good reason: if people are starv­ ing, they need food. monetary assistance can reinforce corruption,  increase conflict and instability, endanger women, cause inflation  and weaken local markets, and be spent by beneficiaries on alco­ hol, drugs, and other anti­social activities (ali et al., 2005).   there is, however, a growing body of evidence suggesting  that cash transfers are a more effective means of providing assis­ tance, and at the very least a necessary complement to direct food  aid (harvey & bailey, 2011; la brooy, 2009; rosenberg, 2011).  this paper will examine the use of cash transfers in food emer­ gencies by: (1) providing a brief overview of food security and  famines, (2) reviewing literature on the use of cash transfers, (3)  describing the emergency cash relief program implemented in  somalia between 2003 and 2004, and (4) questioning why cash  transfers are not more commonly used in appropriate contexts.     food security, food crises, and famines        the 1996 rome declaration on world food security de­ fines food security as, “…when all people, at all times, have  physical and economic access to sufficient, safe and nutritious  food to meet their dietary needs, and food preferences for an ac­ tive and healthy life” (food and agriculture organization of the  united nations, 2011; jönsson & åkerman, 2009). food is secure  when it is available, affordable, accessible, and utilized (global  cash transfers in emergencies  23        columbia social work review, volume iii  education, 2011; jönsson & åkerman, 2009). insecurity in food  supply and subsequent food crises are caused by myriad factors,  for example, poverty, scarcity of water, unfavorable environmen­ tal conditions, natural and man­made disasters, conflict, barriers  to trade, population growth, gender inequity, and poor health  (global education, 2011).   while all famines are food crises, not all food crises are  famines. technically, three conditions have to be met for a food  crisis to be declared a famine: (1) at least 20% of the population  must consume fewer than 2,100 calories a day, (2) acute malnutri­ tion must be prevalent in more than 30% of children, and (3) the  death rate must exceed two deaths (or four child deaths) per  10,000 people per day (world food programme [wfp], 2011).  according to devereux (2000), food crises prior to the 1900s  were caused by natural disasters that triggered food shortages,  then developing into famines because of political, economic, and/ or technical inabilities to intervene. by the 1970s, however, fam­ ines essentially became preventable. new technology, improved  infrastructure, and coordinated international humanitarian re­ sponse to food crises were sufficient enough to avert famines.  crop failure no longer causes death to millions of people in al­ most every region around the world—every region except for sub ­saharan africa.   understanding the horn of africa’s phenomenon in the  realm of food security requires a rethinking of contemporary fam­ ines. with technological changes and globalization, characteris­ tics of famines are less straightforward than they once were. in  his groundbreaking work poverty and famines, sen (1981) ex­ plains that most food shortages are a result of restricted purchas­ ing power and limited access to food (i.e., failure in demand) ra­ ther than a lack of food supply (bailey, savage, & o’callaghan,  2008; devereaux, 2007; peppiatt, mitchell, & holzmann, 2001).  walker (1989) adds a social component to sen’s perspective, de­ fining famine as “a socio­economic process which causes the ac­ celerated destitution of the most vulnerable, marginal, and least  powerful groups in the community, to a point where they can no  longer, as a group, maintain a sustainable livelihood” (p. 143).  devereaux (2007) stresses the centrality of politics to the contem­ lee    columbia social work review, volume iii       24  porary famine, underscoring a famine’s dependence on and vul­ nerability to institutional administrations and their political strate­ gies. other current theorists emphasize the multi­dimensionality  of famines, pointing to a combination of natural, social, political,  and economic causes (ali et al., 2005; devereux, 2007). the re­ cent famine in somalia embodies these complexities: a two­year  drought in the context of political instability, longstanding con­ flict, chronic poverty, and limited infrastructure (oxfam america,  2011).    using cash transfers to address food emergencies        complex problems often require time to develop appropri­ ate solutions. since august 2011, somalia has lost 29,000 chil­ dren, and 6 out of 10,000 individuals are dying daily. time is a  luxury that somalia cannot afford (sheikh nor, & straziuso,  2011). direct cash transfers are expedient and have been found to  be effective in ameliorating food emergencies (ali et al., 2005).  development and implementation of long­term, sustainable solu­ tions is necessary, but cash transfers, when appropriate, can be  prompt and effective interventions.   a cash transfer is a relief response that entails distributing  free cash to targeted beneficiaries (la brooy, 2009). cash­based  responses to emergencies have existed since the 19th century in  colonial india; however, recent cash transfer programs have been  rooted in sen’s investigation into the extent to which an individu­ al’s purchasing power can affect the flow of goods (bailey et al.,  2008; peppiatt et al., 2000).  sen’s exposure to the economics of famines began at an  early age. as a young boy, sen witnessed individuals starve to  death in the 1943 bengal famine not due to a lack of food, but  due to a lack of access to food; floods destroyed livelihoods, leav­ ing little income or other entitlements to purchase available food  (pressman, 2000). later in his life, sen examined african and  south asian famines of the 1970s and found parallels with the  bengal famine of his childhood—those with purchasing power  hoarded food, while those without were left to starve (devereaux,  2007).   cash transfers in emergencies  25        columbia social work review, volume iii  as a result of sen’s findings, there has been a shift from  traditional food distribution to a more appropriate economic re­ sponse: direct cash transfers increase the market demand—and  consequently, price as well—for food, thereby enticing food sup­ pliers to enter or re­enter the market (peppiatt et al., 2001). be­ cause markets tend to recover quickly from disasters, conflicts,  and other emergencies, providing those in need with cash can  give them the means to purchase food (as well as other goods and  services they require the most) through local markets (bailey et  al., 2008). while there are various types of cash transfer programs  specific to emergencies, such as unconditional cash transfers,  conditional cash transfers, vouchers, and cash for work, the focus  for this analysis is on unconditional cash transfers through which  individuals are given money directly without any subsequent re­ quirements (harvey & bailey, 2011).     benefits and risks of cash transfers    there is a growing recognition of cash transfers programs  as effective tools for addressing food emergencies (bailey et al.,  2008). the suitability of cash transfers depends on the context of  the specific emergency. public donors are increasingly recogniz­ ing that, in certain contexts, cash transfers are more effective than  in­kind assistance, particularly in environments characterized by  minimal administrative challenges and certainty of adequate mar­ ket response to demand for food (bailey et al., 2008; peppiatt et  al., 2001; wfp, 2011). traditional in­kind interventions require  overhead for food packaging and transportation. a recent analysis  of wfp operations in food emergencies found that replacing cur­ rent in­kind interventions with cash transfer programs could result  in a significant reduction in costs (egeland, harmer, & stoddard,  2011; wfp, 2011). in regions where infrastructure is available,  there is evidence of even greater benefits, such as monitoring of  financial activity, risk mitigation, and potential partnerships with  the private sector. mobile technology and smart cards have creat­ ed innovative opportunities to transfer cash to beneficiaries in  more efficient and effective ways (wfp, 2011).   in their most recently published guidebook , the united  lee    columbia social work review, volume iii       26  nations office for the coordination of humanitarian affairs  (2011) identifies cash transfer as an innovative practice with  demonstrated effectiveness in the most challenging security con­ ditions. one of the most significant benefits, in contrast to food  distribution, is efficiency, which in this case means quicker, tar­ geted response at a lower cost (bailey et al., 2008; peppiatt et al.,  2001). not only is the distribution of food more logistically com­ plex and time consuming, but the average overhead cost of han­ dling, transporting, storing, and distributing food can range any­ where from 30% to 50% of the total aid provided (peppiatt et al.,  2001). another benefit of cash transfer systems is the potential to  stimulate local market activity and restore market equilibrium.  distributing cash gives greater flexibility to beneficiaries, as the  funds can be used not only for food, but for other means as well,  such as investing and livelihood development. cash transfer pro­ grams also restore dignity to beneficiaries by giving them the  power to determine what their own needs are and to address them  in a way that responds to their context (bailey et al., 2008; peppi­ att et al., 2001).   these benefits must be weighed against risks associated  with the use of cash transfer programs in food emergencies  (bailey et al., 2008; peppiatt et al.,, 2001). one of the greatest  deterrents from using cash transfers more readily is the fear that  the cash will be used for unintended, anti­social purposes, namely  things other than food (peppiatt et al., 2001). another concern is  that men tend to control money and other resources in many soci­ eties, so cash transfers could increase gender disparity and threats  to women. safety of staff and beneficiaries is yet another concern,  as individuals and programs themselves could be targets for. cash  transfers could also cause inflation in local markets, and a subse­ quent devaluation of funds that would further disadvantage bene­ ficiaries and those who do not receive aid (bailey et al., 2008;  peppiatt et al., 2001). while these risks should be considered,  most could apply to any program involving resource transfers— even in­kind food donations (bailey et al., 2008).  despite the relative cost effectiveness of cash transfers,  the decision to use this intervention is highly dependent on the  context of the particular emergency, and the context should deter­ cash transfers in emergencies  27        columbia social work review, volume iii  mine program objectives (bailey et al., 2008; egeland et al.,  2011; harvey & bailey, 2011; ; jönsson & åkerman, 2009; pep­ piatt et al., 2001; román, 2010; wfp, 2011). many humanitarian  aid organizations have developed useful decision trees to deter­ mine whether a cash transfer program will be effective (bailey et  al., 2008; harvey & bailey, 2011). in addition, rigorous assess­ ments of market conditions should be conducted before using  cash transfer programs (bailey et al., 2008). even when a cash  transfer program is deemed most suitable and is implemented, the  process is iterative and therefore must be reviewed periodically to  ensure quality and appropriateness (wfp, 2011).     case study: the emergency cash relief program in somalia    the best determinant of whether cash transfer programs  are effective is observation. ali et al. (2005) found that in 2003  and 2004, somalia, very much like today, was in the midst of a  complex emergency. the sool plateau in northeastern somalia, in  particular, was experiencing a food emergency due to drought,  internal conflict, and ongoing political instability. most inhabit­ ants of the sool plateau function in clans to support and protect  one another, and are nomadic and pastoralist, migrating in cycles  according to rainfall patterns to ensure the survival of their live­ stock. they are highly dependent on a credit system that allows  them to access capital during economically slow periods, and to  repay their debts when they are able. in 2003, after seven consec­ utive rain failures, decimation of livestock, and subsequent over­ dependence on the credit system, the local economy was in near  failure. in addition, territorial conflict between various self­ declared states in the region made international humanitarian as­ sistance difficult. the united nations office for the coordination  of humanitarian affairs (ocha) determined that 12,000 house­ holds were at risk of starvation (ali et al., 2005).  upon completion of an interagency assessment in 10 vil­ lages within the sool plateau, ocha determined that the most  viable and effective response would be a direct cash transfer pro­ gram due to the availability of food in local markets, the weak­ ened credit system, and the presence of established and credible  lee    columbia social work review, volume iii       28  money­transfer companies (ali et al., 2005). in response, horn  relief and the norwegian people’s aid (npa), two organizations  that had maintained a consistent presence in northeastern somalia  for over 10 years, implemented the emergency cash relief pro­ gram (ecrp), which provided the most vulnerable households in  the sool plateau with temporary, one­time payments of us$50  over a six­week period. while the transfer of cash was simple, the  project required effective program design, which included deter­ mining the size of the grant needed, securing funding, mobilizing  the community, training inhabitants of the sool plateau, involving  local staff and elders to create buy­in among the community, and  registering the households (a.k.a., beneficiaries).   according to ali et al. (2005), the results of ecrp were  overwhelmingly positive. in terms of cost­effectiveness, for every  us$100 of funding, only us$17 went to overhead costs, as com­ pared with us$25­$35 overhead costs for other interventions. in­ take of food among beneficiaries increased by at least one meal a  day, and dependence on social support among beneficiaries fell  by 90%. no increased volatility between men and women was  observed, although some community members expressed resent­ ment toward the emphasis on gender equity and the role of wom­ en in the program. the cash grants were not used to buy weapons  or drugs, and the subsequent increase in drug use was caused not  by the beneficiaries themselves, but by urban traders who used  monies paid to them by beneficiaries (repayments for debts) to  purchase drugs. the credit system and local economy were re­ vived according to plan. beneficiaries expressed appreciation and  a feeling of restoration of dignity with this opportunity to priori­ tize their own needs.   it should be noted, however, that there were various limi­ tations to ecrp including: (1) accounting for fluctuations in the  exchange rate, which resulted in a devaluation in local currency;  (2) antagonization of the somaliland government; and (3) de­ crease of effectiveness due to a lag in follow­up interventions (ali  et al., 2005).  in addition to the successes achieved through ecrp in  somalia, programs in various other countries and contexts have  shown promising results. in august 2008, food security in geor­ cash transfers in emergencies  29        columbia social work review, volume iii  gia was at risk due to conflict with russia (jönsson & åkerman,  2009). a direct cash transfer program implemented in georgia  has resulted in improved access to and utilization of food re­ sources. the zimbabwe emergency cash transfer (zect) pilot  program implemented between 2009 and 2010 concluded that  70% of cash assistance was used for food items, and that less than  0.5% was used on less favorable items such as tobacco and alco­ hol, refuting beliefs that funds would be used inappropriately  (román, 2010). this cash transfer program also improved rela­ tionships within households, despite initial concerns that cash  transfers to women would encourage domestic violence (román,  2010). in bangladesh, malawi, and sri lanka, cash transfer pro­ grams implemented by wfp have improved dietary diversity  (wfp, 2011). mobile phone technology has been effective in  kenya and the philippines in delivering cash transfers to benefi­ ciaries, and in burkina faso, cash transfer programs have protect­ ed food security even in the midst of a failing economy (wfp,  2011).     conclusion    the question remains: if direct cash transfers have been  effective in addressing food emergencies in specific contexts,  why are they not used more readily? specifically, if cash transfers  were effective in somalia nearly 10 years ago, why is there a con­ tinued reluctance to use cash transfers in food emergencies? ali et  al. note that “the use of cash seems to be fundamentally inhibited  by an a priori reluctance to even consider it as an option,” and  argue that the hesitance is rooted in paternalism and fear (2005, p.  15). this attitude is reminiscent of the historically anti­poor ideol­ ogy toward welfare that questions the character of those in need,  and suspects or even assumes that their poverty is a result of poor  behavior (alston & dean, 1972). donors and aid agencies, who  seek to work toward the empowerment of individuals and com­ munities in need, should be encouraged to assess the sources of  their unwillingness to provide cash transfers.   apart from cash transfer programs being more cost­ effective and rapid in providing support, they have the unique ad­ lee    columbia social work review, volume iii       30  vantage of giving power back to those who are most vulnerable  and marginalized. in an article in the new york times, jon c.  brause of the agency for international development says, “the  thinking has always been that the u.s. government needs to have  as many tools in its tool box as possible to meet emergency food  needs of people in crisis” (rosenberg, 2011). cash transfers  should be viewed as one of these many “tools” and used appropri­ ately given the context and conditions of emergencies.     references    ali, d., toure, f., & kiewied, t. (2005). cash relief in a contest­ ed area: lessons from somalia. humanitarian practice  network, number 50. retrieved from http:// www.odihpn.org/documents/networkpaper050.pdf.  alston, j. p., & dean, k. i. (1972). socioeconomic factors associ­ ated with attitudes toward welfare recipients and the caus­ es of poverty. social service review, 46(1), 13–23.   bailey, s., savage, k., & o’callaghan, s. (2008). cash transfers  in emergencies: a synthesis of world vision’s experience  and learning. humanitarian policy group. retrieved from  http://www.odi.org.uk/resources/docs/4813.pdf.  devereux, s. (2000). famine in the twentieth century. institute of  development studies. retrieved from http:// www.ieham.org/html/docs/famine%20in%20the% 20twentieth%20century%20devereaux.pdf.  egeland, j., harmer, a., & stoddard, a. (2011). to stay and de­ 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world food programme. (2011, july 27). understanding the dec­ laration of famine in somalia. retrieved from http:// usa.wfp.org/blog/understanding­declaration­famine­ somalia.  u.s. fund for unicef. (2011). east africa emergency. re­ trieved from http://www.unicefusa.org/work/emergencies/ horn­of­africa/.                  2020_cswr_journal.indd 1 | columbia social work review, vol. 18 the implications of disproportionate individualized education plan classifications in new york city schools amanda cordell cswr prize winner abstract overand under-representation of students of color within disability classifications is a nationwide phenomenon that has a major impact on students’ ability to thrive in school and is especially prevalent in new york city department of education schools. the present paper uses a dis/crit framework to analyze this phenomenon, revealing that disproportionality of disability classification is a symptom of underlying racism and ableism in the education system. despite the relatively recent addition of policy to address both racial and disability discrimination in schools, students continue to experience inequitable educational opportunity both because of their race and their ability. introduction there are widely-documented disparities in how special education services are provided in new york city (the research alliance for new york city schools, 2019). these disparities can be seen in an overand under-representation of the way students are labeled, or “classified” on their individualized education plan (iep), and are arguably a symptom of white supremacist and ableist values embedded in an education system that structurally oppresses both race and disability across all social systems (connor, ferri, & annamma, 2016). this paper seeks to show that the legacy of white supremacist values embedded in the us education system continues to use race and ability to disadvantage students of color, specifically students of color who are identified as needing special education services, by using discrit as a grounding theory. discrit is a theory that combines critical race theory and disability studies to examine the ways in which race and ability are intertwined in widespread issues across education (connor, ferri, & annamma, 2016). the first part (“background”) gives an overview of how the special education system functions, specifically in new york city (nyc). nyc’s school system provides a compelling example of the way structural inequities inherent in the education system are disproportionately impacting students of color, students with disabilities, and students of color who are being labeled as having disabilities. the lessons learned from nyc’s experience are especially valuable because nyc is the largest school district in the country and also has the highest percentage of students identified as needing columbia social work review, vol. 18 | 2 special education services (mirakhur et al., 2018) part two provides a theoretical framework for how federal and nyc department of education (doe) policies affect both students of color and students with disabilities (swds). notable federal and nyc-specific policies created to afford educational rights for swds as well as educational rights for students regardless of race or ethnicity are examined chronologically, as well as some of their shortcomings. part three will discuss the need for structural reform and propose ways of initiating broad structural reform. part one: background the iep is essentially a legal contract between the school, the school district, and the students’ legal guardian(s). it outlines the educational needs of the student and what accommodations and services will be provided to the student to meet those needs (stanberry, n.d.). students must be evaluated to receive services, regardless of whether their challenges in school are behavioral or academic, then they are classified and often placed into special classrooms and sometimes different buildings, removing them both from the shared physical spaces with their peers and from the statistics of how the full student body is achieving. federal law dictates that ieps should be classified in different categories that, in theory, should help educators and schools provide appropriate support. there are thirteen different federal classifications that can be named on the student’s iep; some examples include “autism,” “specific learning disability,” or “emotional disturbance” (individuals with disabilities education act, 2004). in new york city, the overall rate of classification for “emotional disturbance” (ed) for white, asian, and latinx students is 2-5%, while the rate of classification for emotional disturbance for black students is 11% (the research alliance for new york city schools, 2019). this data demonstrates that there is a gross overrepresentation of black students classified with emotional disturbance, in comparison to their peers in other racial groups. moreover, students with ed classifications also have the highest rates of discipline, suspension, absenteeism in comparison to other types of iep classifications (the research alliance for new york city schools, 2019). for these students, it is conceivable, and arguably even likely, that externalizing behavior in schools is more likely to be met with disciplinary responses instead of evaluation for an underlying learning difference. asian and latinx students in nyc doe schools are more likely to be labeled with a “speech and language impairment.” more than 35 percent of asian and latino students with ieps are classified as having speech or language impairments, compared with 26 and 29 percent, respectively, for black and white students (the research alliance for new york city schools, 2019). these data likely demonstrate that students who are in the process of learning english are being mislabeled as having a speech and language impairment instead of being provided with the appropriate instruction for 3 | columbia social work review, vol. 18 language learners (the research alliance for new york city schools, 2019). while these disparities are a well-documented phenomenon nationwide (national education association, 2007), nyc’s public school system is an especially relevant case study for the implications of inequity in iep classifications. as the largest school district in the country (mirakhur et al., 2018), there are over one million students in nyc’s public school system, and about 20% of those students have an iep (the research alliance for new york city schools, 2019). this percentage of the population being identified as needing special education services is also disproportionately high in comparison to the other three largest school districts in the country: los angeles, chicago, and houston. in those cities, the numbers of students identified as needing special education services is 12%, 14%, and 7% respectively (mirakhur et al., 2018) in other words, there are more students identified as needing special education services in new york city than there are in la, chicago, and houston combined, by a margin approaching 100,000 (mirakhur et al., 2018). part two: applying a dis/crit theory lens approaching the issue of disproportionality of iep classifications through a dis/crit framework, it is apparent that the correlation between iep classification and race in new york city schools is not incidental. marginalized identities of non-white students with disabilities are negtively compounded in the education system, and the function of that structural oppression is to maintain the privileges inherent in a white supremacist and ableist structure. an integral component of discrit theory is acknowledging the ways in which both race and ability have been socially constructed to create a norm that propagates white supremacy in the infrastructure of the united states’ social systems. the political and social systems were initially designed only to accommodate property-owning or rich, white men (carlin, 2002). therefore, large social infrastructure was never intended to serve or accommodate participants who are not white. dividing students into different iep classifications divides the student population and reduces the visibility of the larger issue that roughly 20% of the nyc doe student population is being segregated from general education. looking at the overall issue illuminates that the special education system labels are being utilized to segregate students, particularly students of color, who are recognized as needing academic support (the research alliance for new york city schools, 2019). when critically examining the disproportionate use of iep classifications for students of color in schools, the question is raised of which metrics are being used to evaluate students for iep classification and who created those metrics. black students exhibiting the same externalizing behavior that their white peers present in schools are more likely to be met with an evaluation for emotional disturbance classification instead of columbia social work review, vol. 18 | 4 evaluating for an underlying learning difference (colker, 2013). as these students are more likely to be perceived as having a mental health concern versus a learning disability, this could lead to an overrepresentation of ed classifications and an underrepresentation of learning disability classifications. moreover, students with ed classifications are more likely to be assigned to specialized classrooms and schools, instead of being educated in inclusive settings with their general education peers (the research alliance for new york city schools, 2019). disproportionately classifying black students with ed classifications ultimately segregates them into isolated education settings. some would say iep classifications enable students to receive supportive services, but others may argue iep classifications operate to map a student’s trajectory of lesser academic achievement. part three: policy analysis disproportionately referring students of color for special education services, and misidentifying or mislabeling their needs within the special education system, is having a major impact on those students’ ability to thrive in school. broadly, students identified as needing special education in nyc doe schools are far less likely to graduate high school than their general education peers, even after receiving services that should have improved their ability to succeed academically (advocates for children of new york 2019). more specifically, new york university’s research alliance for new york city schools (2019) found that students in nyc doe schools with an ed iep classification are likelier to be segregated into separate classrooms and schools than their general education peers, likelier to be suspended or meet harsh disciplinary outcomes than other iep classifications, and likelier to be chronically absent from school. as stated above, in nyc doe schools, black students are twice as likely as other students to be classified with ed (the research alliance for new york city schools, 2019), and so black students are also experiencing the brunt of these negative impacts. however, the us education system, as with all us social and political systems, was never intended to serve populations of students of color or students with disabilities. it wasn’t until relatively recently that policy has been enacted in an attempt to amend the education system and to afford educational rights and opportunity specifically for students of color and students with disabilities. as will be discussed below, the policies that were created essentially acted as a bandage and could not address the deeper structural flaws necessary to truly envision a more equitable system. an analogy would be changing a motorcycle into a four-person vehicle. the motorcycle was designed just for one person, and in order to change the basic design, additional pieces like a series of sidecars could be welded onto the sides. those who are relegated to sitting in the sidecars will always be in a less safe and less comfortable position and will not be able to speak loud enough for the driver of the motorcycle to hear their needs and requests 5 | columbia social work review, vol. 18 while the motorcycle is on the road. arguably, the policy reforms address symptoms of a structural issue rather than provide large structural change are inadequate to meet the needs of the people most affected. most think of brown v. board of education in 1954 as the first example of the courts addressing race in schools. however, state courts considered racial inequity in schools even earlier. the court in mendez v. westminster (mendez v. westminster school dist., 1946) was the first to hold that separate-but-equal public institutions are inherently unconstitutional because of the 14th amendment (mendez v. westminster school dist., 1946). while mendez v. westminster was ultimately overturned on appeal (on grounds not pertaining to the 14th amendment), the lower court’s decision was influential because it recognized the principle of equal educational opportunity for all students regardless of lineage (united states courts, n.d.). the first statement on racial desegregation in schools by a federal court was in brown v. board of education (1954). this supreme court decision was a join of five different cases from five different states or u.s. territories that were being argued on the same grounds, namely that separate but equal education is unconstitutional. despite this supreme court decision, desegregating schools was never successfully enforced (legal defense and educational fund, n.d.). in fact, more recent supreme court decisions such as milliken v. bradley (1974), which removed the burden from states to redistrict in the interest of desegregation (nadworny& turner, 2019), have further impeded efforts to desegregate. schools now are more “more racially isolated” at any point in the past forty years (legal defense and educational fund, n.d.). the elementary and secondary education act (esea), the first federal legislation specifically focused on creating educational rights for students, was passed by president johnson in 1965 (brewer & picus, 2014). the esea is notable because it outlined affirmative rights for students, as opposed to prohibitions on schools. the legislation originally had six sections, which detailed how the funding would be distributed amongst different programs and students, with the largest allocation for low-income families (brewer & picus, 2014). since then, the esea has been amended and reauthorized many times. however, while this act was intended to regulate public schools on a national level, some of the reauthorizations have been publicly criticized as having profoundly negative effects on the school system. for example, the no child left behind reauthorization under the bush administration is largely blamed for dramatically increasing the amount of standardized testing in schools (klein, 2015), which is an assessment system that is widely recognized as racially biased (rosales, 2018). while certain opportunities were afforded to swds in the esea in 1965, the individuals with disabilities education act (idea), passed in 1975, is the federal law that most shapes the way swds experience u.s. public schools. most notably, the idea introduced the terms “free and appropriate public education” and “least restrictive environment” columbia social work review, vol. 18 | 6 (individuals with disabilities education act, n.d.). these two terms have been interpreted in different ways over the past forty years, and the law does not provide clear guidelines for implementation (zirkel, 2013). since the idea’s inception, swds have argued in courts all over the country about the correct construction of the word “appropriate” when it comes to the allocation of services by schools that are intended to support swds to have access to the same level of education as their peers. the term “least restrictive environment” is vague and ambiguous, and can be interpreted by schools to segregate swds, whether different classrooms in the same school or in different schools altogether. in new york, the range of environments a student can be placed in to receive services is called the special education continuum (advocates for children of new york, 2016). the concept of educating special education and general education students together in the same classroom did not become common practice in new york city until the early 2000s, and still has many flaws in its implementation (stiefel et al., 2017, p.6). this type of setting is called an “inclusive setting” and is one of the least restrictive settings available for students on the special education continuum of services (advocates for children of new york, 2016). the type of iep classifications listed on a student’s iep is highly correlated to what type of setting the student is placed in. in nyc schools, students classified with emotional disturbance and intellectual disability are less likely to be referred for inclusive settings, and because black students are likelier to have these iep classifications, this means that these students are less likely to be educated in classrooms with their general education peers (the research alliance for new york city schools, 2019). analyzing this outcome of increased segregation for black students through a historical and systematic lens of oppression that the dis/ crit framework suggests provides an argument that the inherent biases in the system continue to exclude black students from partaking inequitable educational opportunity as their non-black and non-disabled peers (connor, ferri, & annamma, 2016). most recently, in new york city, to address the shortcomings of these federal laws in nyc schools, the nyc department of education created a three-year strategic plan called “a shared plan to success.” this plan had four main goals: “(1) provide swds with greater exposure to the general education curriculum, (2) provide swds with greater exposure to gen students, (3) build school capacity to support swds, and (4) improve the academic performance of swds (nycdoe, 2012 as quoted by stiefel et al., 2017, p. 6).” these goals were guided by the principle that swds should access the same services and spend time in classrooms with their general education peers to the greatest extent possible (stiefel et al., 2017, p. 6). providing greater access for swds to general education settings and peers is beneficial because not only does the idea mandate that students are educated in the least restrictive environment, but research shows that integration of students with disabilities is advantageous to both students 7 | columbia social work review, vol. 18 with disabilities and general education students (the research alliance for new york city schools, 2019). in many ways, these four outcomes are reminiscent of the arguments that students, families, and lawyers argued about racial inequality in mendez vs. westminster and brown vs. board of education. “separate but equal” education for swds is unacceptable. there are two other federal laws that afford students additional rights in schools and that are overseen by the office of civil rights. these are the rehabilitation act of 1973 and the americans with disabilities act of 1990 title ii rights for idea-eligible swds (individuals with disabilities education act, n.d.). instead of affording specific rights to students with disabilities, these two acts are used to prevent discrimination against students because of their rights to additional services as swds (individuals with disabilities education act, n.d.). despite being entitled to “free and appropriate public education” in the “least restrictive environment,” segregating swds from general education students inherently changes the quality of education those students are receiving. while the mechanisms for segregation of students because of race and disability have been obscured by purportedly helpful iep classifications and special education law, the historical legacy of racism and ableism still functions in the american education system. arguably, “separate but equal” education for swds may be unlawful in the same manner that segregating students because of race has been found to be unlawful. the current education system structurally oppresses both race and disability; the oppression at the intersection of those identities is compounded. the function of that structural oppression is to maintain the privileges inherent in a white supremacist structure. part four: opportunities for reform as with most social issues in the us, disparities in iep classifications are hidden in a complex web of bureaucratic systems that obscure the larger reality of how policy is impacting large groups of students. in the u.s., “special education law is a conservative, individualistic approach that requires each of us to put forward enormous energy to help one child at a time in a resource-starved context” (colker, 2013). while individual advocacy for students and families remains key, the only way of addressing the disproportionately negative impact of the special education system on students of color is reconfiguring the policies and practices that shape the system. policy reform that promotes the creation of safe and affordable housing, healthcare, and employment that pays a living wage equitably across race and ability lines, will lift up our education system and everyone who participates in it (colker, 2013). additionally, funding structures on federal, state, and city levels need to be adjusted to allocate more funds to under-resourced districts and schools; and decoupled from punitive standardized testing measures. in envisioning and creating this policy change, the voices and columbia social work review, vol. 18 | 8 perspectives that were initially excluded in the creation of social systems need to be centered. centering the voices of those who are most impacted by policy is taking a liberatory approach to school desegregation (love, 2013). it is crucial for the families, students, and teachers who are most affected by education policy to be integrally involved at every step of the decisionmaking process. integrating student, family, and teacher voices is the only way to truly envision the changes necessary to create an equitable education system. specific to the integration of students with disabilities, the nyc doe should eliminate the requirement of iep classifications as they segregate populations further and categorize students in unnecessary ways. iep classification labels are abstract and unspecific, and do not give guidance about what types of support students who have them should receive. just as race is socially constructed as a way to use language which organizes people into groups for the purpose of affording some rights and privileges to some and denying them others (spearit, 2012), so are the labels assigned to students regarding their needs in a classroom. also important, as not talking about race or appearing to be “colorblind” isn’t an answer to addressing issues of race in the us (spearit, 2012), neither is ignoring disability and that some students need additional educational services and support in school to access the same educational opportunities as their peers. moreover, as a society, the temptation to replace using iep classifications with medical diagnoses as a catch-all replacement for iep classifications needs to be avoided. instead, this paper is a call to recognize the ways that both race and disability are socially constructed, and use direct and specific language about which interventions and services students need in the classroom and school building to remove barriers students experience in accessing education opportunity because of developmental delays, cognitive processing differences, and socioemotional challenges. conclusion if students continue to be separated from their peers and the burden of providing support is placed on individual families, teachers, and school administrators, the problematic systems that perpetuate a structural disparity in iep classifications will remain. further, the more students are referred to by their iep classifications, the less the trends of racial and disability segregation are visible. iep classifications are not necessarily correlated to physical or mental disability diagnosis and have no bearing over what services students receive. instead, iep classifications serve the purpose of labeling students and segregating them from their peers. they should be removed from ieps. in implementing the structural change necessary to reform the education system, it is critical to center the voices of the stakeholders in the system that are most impacted and least likely to be heard: students, families, and teachers, especially black, latinx, and low-income students, 9 | columbia social work review, vol. 18 families, and teachers. integrating student, family, and teacher voices is the only way to truly envision the changes necessary to create an equitable education system. as a current high school student who is also part of the teens take charge student-led group wrote, “this stigma surrounding special education or needing extra help needs to stop. because the more we focus on our weakness, the less we see our strengths, and the more we’re left behind” (mejia, 2018). about the author amanda cordell is originally from northern california and holds a ba from humbolt state university. over the past 10 years, she has worked in education in the san francisco bay area and new york city. amanda is currently enrolled in the dual degree program at columbia school of social work and bank street college of education. references advocates for children of 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(2010). elementary and secondary education act. in t. c. hunt, j. c. carper, & t. j. lasley (eds.), encyclopedia of educational reform and dissent (pp. 338-340). thousand oak, ca: sage. https://doi. org/10.4135/9781412957403.n149 zirkel, p. (2013). is it time for elevating the standard of fape under the idea? council for exceptional children, 79(4), 497-508. advisory board speaking truth to power: interrogating the invention of the social worker and the client the development of a professional social work identity involves being socialized into the history, mission, values, and ethics of the profession--learning what social workers can say and do. this socialization also corresponds with a silence about the limits and philosophical extremities of the profession--what social workers do not, perhaps cannot, say. drawing from social theorist michel foucault’s analysis of subjectivity, power, knowledge, and discourse, this article aims to articulate the limits of the social work profession. by examining the historical and contemporary invention of the “social worker” and the “client,” i challenge social workers to consider the work that must be conducted upon themselves. f or nearly 100 years, public debate has been circulating regarding the identity of contemporary social work. the nature of this debate is reflected in arguments concerning social work’s values, the relevancy of its knowledge base, and its professional status (bitensky, 1978; bar-on, 1994; eaton, 1958; flexner, 1915; gibleman, 1999; haynes & white, 1999; risler, lowe, & nackerud, 2003). at the heart of this debate lay questions concerning epistemological, theoretical, and methodological challenges and opportunities for social work in the 21st century. what is social work? is it a quasi-profession? has professionalization privileged technique over social justice? michel foucault (1984a) provides a strong starting point for examining these questions: “my point is not that everything is bad, but that everything is dangerous, which is not exactly the same thing as bad, if everything is dangerous, then we always have something to do” (p. 343). we always have tracee worley journal of student social work, volume vii 8 / speaking truth to power something to do. this is a positive position: not all social work knowledge and practices are bad, but they all can be problematized in an effort to expose their limitations and highlight their possibilities. from this position, social workers can grasp the nature of the debate by focusing on the dangerous potential of knowledge and practices rather than starting with the assumption that they are inherently good or bad. moving beyond these moral categories, foucault advises us to conduct a “critical ontology of ourselves” in which we analyze and reflect upon what we are in order to recognize the dangers of our conduct (foucault, 1987). in problematizing the origins of social work and the shaping of the social work professional identity, i argue that critical examination of knowledge production, subjectivity, difference, and power allow us to help “determine which is the main danger” (foucault, 1984a, p. 343) in the creation of ourselves as professionals who help others in the name of social justice. by conducting a critical ontology of social workers, i will illuminate how particular “expert” and “client” identities, social relationships, and practices are made possible while others are excluded. it is in this space of social work discourse that potential “dangers” can be located: as social work produces knowledge, it necessarily blocks other ways of knowing and being. it is not my intention to provide a blueprint for alternative knowledge and practices; rather, by fostering a “limit attitude,” (foucault, 1984b) i contemplate the historical and contemporary limits that have been placed upon social workers and interrogate them in an effort to establish the possibility of moving beyond them. shaping of the social worker subject position before interrogating how contemporary social work professional identities are constructed, let us first consider the historical origin of the social worker. in the early 20th century, economic depressions, the emancipation of slaves, and the explosion of immigrants from southern and eastern europe to urban areas such as new york city, prompted an awareness of the need for social programs to assist millions of the poor and needy (glicken, 2006). social work as a profession began to take shape in the early 1880s with the formation of charity organization societies and settlement houses. their objectives, to “repress mendicancy” and inculcate values such as “politeness, cleanliness, and independence” were met through a system whereby “friendly visitors” and settlement house workers (most of them middle and upjournal of student social work, volume vii journal of student social work, volume vii 9 / worley per class white women) investigated applicants for charity and provided support in immigrant communities (specht & courtney, 1995). parton and o’byrne (2006) observe that the growth and legitimization of social work was closely allied with modernist aims to develop rational forms of social organization, which reflected broader utopian goals for creating ideal cities with ideal citizens. the central focus of the modernist project was the classification of the population based on the scientific claims of the different “experts” of the new human sciences--particularly medicine, psychiatry, psychology, criminology, and social work. these “experts” theorized about the nature of human beings, their perfectibility, the reasons for their behavior and the order in which populations could be classified. in this sense, human qualities were conceptualized as measurable and “could be changed, improved, and rehabilitated” (parton & o’bryne, 2006, p. 39). it is in the modernist tradition that a new scientific education was introduced into universities in the united states. operating under the assumption that scientific inquiry could be used to improve the human condition, professional schools of medicine, psychiatry, and law were established across the country. by adopting a scientific approach similar to the social sciences, social work found its home in the academy beginning with the first school of social work, the new york school of philanthropy in 1904, later known as the new york school of social work in 1917, and finally becoming the columbia school of social work in 1963 (feldman & kamerman, 2001). a necessary element in reconstructing the invention of the social worker is the concept of discourse. foucault (1980) defined discourses as “historically variable ways of specifying knowledge and truth--what is possible to speak at a given moment” (p. 93). following foucault, margolin (1997) conducted a discourse analysis of early 20th century social work case records to demonstrate how social workers created and sustained themselves as well as others, primarily through the language of helping. by examining this language, we can observe how as the classification of populations into “allegedly universal moral categories” such as the “mentally ill,” “the criminal,” “the delinquent,” “the drunkard,” “the wayward woman,” and the “orphan” (wagner, 1997) warranted the intervention of social workers. margolin pays particular attention to this classification process, suggesting that it reflected the power interests of the middle-class: “social work stabilizes middle-class power by creating an observable, discussable, [and] write-about-able poor” (p. 5). by inventing such categories, or what foucault (1969) calls “subjournal of student social work, volume vii 10 / speaking truth to power ject positions,” social workers became judges of normality. through their techniques of home visits, observations, and note-taking, a new figure arose that became the object of intervention, something to be reformed. foucault (1977) maintains that: “we are in the society of the teacher-judge, the doctor-judge, the educator-judge, the socialworker judge. it is on them that the universal reign of the normative is based” (p. 304). most salient in foucault’s analysis of the invention of subject positions is his notion of “power/knowledge relations,” in which he understood that it is impossible to think of knowledge outside of its connection to power. we know someone to be “delinquent” or “mentally ill” not because of traits that are inherent to those individuals, but, rather through the power of experts to conduct scientific research, distinguishing the deviant from the normal and the ill from the healthy. this process, in which the modern state confers power upon credentialed “experts,” allows for the creation of others as objects of knowledge. who is defined as “expert” and who is defined as “other” is the result of a particular configuration of power/knowledge relations. as social work evolved from the voluntarism of friendly visitors and settlement house workers into a full-fledged profession with a distinctive value base, body of knowledge, and method for training, several authors argue that it has matured from its preoccupation with the morality of the poor to having a keener appreciation of the limits of science and its ability to respond to complex societal problems (feit, 2003; gibelman & schervish, 1997; levy simon, 1994; reisch & andrews, 2002). the last 20 years have witnessed considerable scholarly and practice activity focused on empowerment, the strengths-based perspective, cultural competence, evidence-based practice, and person-in-environment considerations. the emergence of this knowledge base, transmitted systematically through formal education in schools of social work, gives shape and meaning to our self-fashioning as experts, both individually and as a professional collective. how are our subject positions shaped today? has the way we imagine ourselves as “experts” changed from the modernist goals of moralizing the poor and deviant? the code of ethics: how social workers imagine themselves and who they serve since the 20th century, codes of ethics have been central aspects of professions (banks, 2006). banks suggests that codes of ethics establish guidelines for professional behavior, contribute to the professional status of an occupation, establish and maintain professional journal of student social work, volume vii journal of student social work, volume vii 11 / worley 12 / speaking truth to power identity, explain the moral stance of a profession, and protect clients from harmful activities (banks, 2006, p.44). given the importance of the national association of social workers (nasw) code of ethics in guiding professional behavior, it is a key document for analyzing how contemporary subject positions of both social worker and client are formed. the code includes four major sections. the first section, the preamble, summarizes social work’s mission and core values and sets forth several key themes to practice, including service, social justice, dignity and worth of the person, the importance of human relationships, integrity, and competence (nasw, 1996). as the preamble lays out the framework for the rest of the code of ethics, it is a good starting point to conduct a discourse analysis to investigate how social worker and client subject positions are constituted: the concept of discourse is central to analyzing the subjectivities that are expressed within the nasw code of ethics. by paying particular attention to the representation of worker and client subject positions in the code, it becomes apparent that these positions are constituted through dualistic categories such as: privileged/oppressed, journal of student social work, volume vii journal of student social work, volume vii 11 / worley 12 / speaking truth to power the primary mission of the social work profession is to enhance human well being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. a historic and defining feature of social work is the profession’s focus on individual well being in a social context and the well being of society. fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living. social workers promote social justice and social change with and on behalf of clients. “clients” is used inclusively to refer to individuals, families, groups, organizations, and communities. social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice. these activities may be in the form of direct practice, community organizing, supervision, consultation administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation. social workers seek to enhance the capacity of people to address their own needs. social workers also seek to promote the responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems (nasw, 1996). financially stable/impoverished, unlimited technical knowledge/limited individual capacity, strong/vulnerable, powerful/powerless, and worker/client (one who does not ‘work’ on society, but on whom society and the social worker works). within these dualisms, social workers are always fixed to the positions on the left and clients on the right. furthermore, this mode of representation fails to acknowledge the complex individual and collective histories that exist within each category. to illustrate how these categories constrain the articulation of the whole self, consider the complexities inherent in my own formation as a social worker. according to the code of ethics, i fit the description of someone in need of the help of a social worker. i grew up as what could be categorized as “disadvantaged:” an african-american youth living in a low-income, single parent family. growing up in the economically blighted community of west oakland, california during the early 1980s, my family was intimately affected by the high rate of poverty, crime, and the crack epidemic. terms such as “crisis,” “at-risk,” and “marginalized” could be used to describe the conditions i faced, yet, within the logic of the code of ethics, in becoming a social worker, i must disengage with this experience, as the oppositional subject positions do not allow for being both the social worker and the oppressed. some may argue that rather than disengage with the experience of oppression, i could use this common experience to enhance my connection to the communities in which i work. such sentiment constitutes a further danger, as it masks the power i wield as a social worker over my clients. hence, in the social work context, my experiences beyond the practice setting are dislocated at worst or used to manipulate my power at best. the disempowering effects of the oppositional constitution of social worker and client identities is particularly problematic, given the profession’s stated commitment to social justice. although the code is intended to position social workers to challenge social injustice, the oppositional constitution of worker and client leaves little room for dialogue among equals, insofar as it assumes that social workers and clients do not exist in equal social worlds and that clients are dependent on the work that will be conducted upon them to become empowered. within these categories, there is neither reciprocal interaction nor a space where the social worker is on equal status with the client. in naming clients as objects of intervention, help can never flow both ways, and if it does, it is neither acknowledged nor codified within the code of ethics. the danger in this assumption is that, rather than enable a politics of social justice, oppositional categories foster journal of student social work, volume vii journal of student social work, volume vii 13 / worley a politics of domination, as “privileged” professionals make claims on behalf of “oppressed” groups. the placement of the social worker subject position as the helper, the powerful, and the invulnerable, fundamentally contradicts the pursuit of social justice; by beginning our work in a space of inequality, we effectively foreclose the possibility of moving toward equality. conclusion: speaking truth to power conducting a critical ontology of social worker and client subject positions is not about what is good or bad more than it is about an awareness of the limits of the social work profession. the aim of such a task is to unmask the forms of knowledge by which we construct ourselves as “experts” and by which our “clients” are objectified; the interventions that operate upon them; the judgments, decisions, and forms of authority to which they are subject; and the types of relationships to which they are drawn into, with us as social workers. by engaging in this critical ontology, my purpose is to articulate that the consequences of our expertise cannot be acknowledged while our professional identities are being formed. foucault (1977) argues that for any discipline to exist and have a piece of knowledge, there have to be certain things that go unsaid: “there is not one but many silences, and they are an integral part of the strategies that underlie and permeate discourses” (p. 27). i argue that in order to be aware of the main danger, it is critical to speak truth to these silences. social workers must not only acknowledge that the historical invention of the social worker and client are tied to certain moral imperatives, but that the present invention is also rooted in oppositional identities that are fixed in a relationship, which is fundamentally hierarchical, oppressive, and unequal. speaking truth to the power of the social worker identity requires that we do a kind of ethical work on ourselves by “shaking up habits, ways of acting and thinking, of dispelling commonplace beliefs, [and] of taking a new measure of rules” (foucault, 1991, p. 11-12). such ethical work pushes us beyond the limits of the nasw code of ethics and allows us to confront those things that cannot be said. the stakes are high: if we chose to work at the center of our subject positions as experts we run the risk of becoming uncritical and placing ourselves in a struggle against our clients and their realities, even if we believe that struggle is toward equality. however, working at the limits of ourselves stipulates that we work at the frontiers of what a social worker is, working from a place of vulnerability. it is through working at limits journal of student social work, volume vii journal of student social work, volume vii 14 / speaking truth to power that i have come to realize that in order to transgress oppositional categories, it is necessary to suspend a preoccupation for the care of the other (i.e., vulnerable, oppressed, powerless individuals) and focus on the care of the self. references banks, s. (2006). ethics and values in social work. london: macmillian. bar-on, a.a. (1994). the elusive boundaries of social work. journal of sociology and social welfare, 21, 53-67. bitensky, r. (1978). social work: a non-existent profession in search of itself. new university quarterly, 33, 65-73. columbia university school of social work. (2007). seminar in professional identity syllabus. retrieved february 13, 2009 from https://courseworks.columbia.edu eaton, j. w. (1958). science, “art,” and uncertainty in social work. social work, 3, 3-10. feit, m. (2003). toward a definition of social work practice: reframing the dichotomy. research on social work practice, 13, 357-365. feldman, r.a. & kamerman, s.b. (2001). the columbia university school of social work: a centennial celebration. new york: columbia university press. flexner, a. (1915). is social work a profession? in proceedings of the national conference on charities and corrections, (pp. 576-590). chicago: hildeman. foucault, m. (1969). the archaeology of knowledge. london: tavistock. foucault, m. (1976). the history of sexuality: volume 1. harmondsworth: penguin books. foucault, m. (1977). discipline and punish. london: tavistock. foucault, m. (1980). power/knowledge: selected interviews and other writings 19721977. new york: pantheon books. foucault, m. (1984a). on the genealogy of ethics: an overview of work in progress. in k. baynes, j. bohman &t. mccarthy (eds.), after philosophy: end or transformation (pp. 100-117). cambridge: mit press. foucault, m. (1984b). what is enlightenment? in p. rabinow (ed.), the foucault reader (p. 32-50). new york: pantheon books. foucault, m. (1987). questions of method: an interview with michel foucault. in p. rabinow ed.), the foucault reader (p. 32-50). new york: pantheon books. foucault, m. (1991). remarks on marx: conversations with duccio trombadori. new york: semiotext(e). gibelman, m. (1999). the search for identity: defining social work-past, present, future. social work, 44, 298-310. gibelman, m., & schervish, p. (1997). who we are: a second look. washington, dc: nasw press. glicken, m.d. (2006). social work in the 21st century: an introduction to social problems, social welfare organizations, and the profession of social work. thousand oaks: sage publications. haynes, d.t., & white, b.w. (1999). will the “real” social work please stand up? a call to stand for professional unity. social work, 44, 385-391. levy-simon, b. (1994). the empowerment tradition in american social work. new york: columbia university press. margolin, l. (1997). under the cover of kindness: the invention of social work. charlottesville: university press of virginia. national association of social workers. (1996). nasw code of ethics. washington, dc: author. parton, n., & o’byrne, p. (2000). constructive social work: towards a new practice. new york: st. martin’s press. reisch, m., & andrews, j. (2002). the road not taken a history of radical social work in the united states new york: brunner-routledge. risler, e., lowe, l.a., & nackerud, l. (2003). defining social work: does the working definition work today? research on social work practice, 13, 299-309. journal of student social work, volume vii 15 / speaking truth to power 2020_cswr_journal.indd 37 | columbia social work review, vol. 18 addressing communication barriers among deaf populations who use american sign language in hearing-centric social work settings yunhe bai and david “dt” bruno abstract the primary mission of social workers is to provide services to meet the needs of vulnerable populations, including people who are deaf and use american sign language (asl). it is imperative for social workers to conduct culturally and linguistically competent practices to address deaf clients’ unique requirements. however, due to a shortage of competent social workers specializing in the deaf population, deaf people are likely to interact with hearing social workers who have insufficient knowledge of asl, deaf culture, and proper accommodations for deaf people. this paper explores core issues that impact deaf people’s access to social work services and urges that hearing social workers become familiar with the policies that protect the rights of clients with disabilities. critical recommendations are offered to enhance access for deaf clients using asl to more comprehensive social work services. note: throughout this document, “deaf” will be used in an all-inclusive manner to refer to the population with hearing loss, regardless of their languages or community affiliations, including those who identify as d/deaf, hard-hearing, and late-deafened. when discussing deaf culture and the deaf community, a capitalized “deaf” will be used. introduction the united states census bureau estimates that there are nearly 11 million people who are deaf in the united states (mitchell, 2006). while it is difficult to determine the exact number of deaf people who use american sign language (asl), as many national surveys do not investigate the use of asl, it is estimated that five percent of the deaf population in the united states are asl users, approximately 500,000 people (mitchell et al., 2006). a significant portion of the deaf population who use asl identify asl as their primary or preferred language (hoang, lahousse, nakaji & sadler, 2010). since the deaf population is relatively small in the united states, many social workers may not regularly interact with deaf people. throughout history, deaf individuals have faced many challenges in using sign language due to hearing people’s exclusionary practices (greenwald & van cleve, 2015). in the 19th century, the second international congress on the education of the deaf, commonly known as the milan conference of 1880, stripped deaf children of their access to columbia social work review, vol. 18 | 38 sign language (monaghan, 2016). as a result of declaring that oral education was better than sign language education, many deaf children experienced language deprivation. language deprivation occurs when deaf children lack linguistic stimuli necessary for appropriate language acquisition during the first five years of life, known as the critical period. language deprivation has been a significant and prevalent issue among the deaf population, as it has been associated with negative outcomes in cognitive and learning development processes (ryan & johnson, 2019). given the hearing-centric environment across the united states, deaf individuals encounter a variety of obstacles due to inaccessibility and ineffective communication (steinberg et al., 1998). since deaf people tend to rely on their sense of sight and touch, including those who use asl, hearing social workers need to consider the importance of asl in how it enhances equitable access to communication and professional services for deaf people (ulloa, 2014). just like hearing individuals, deaf individuals are referred to social work services for a variety of reasons including, but not limited to, healthcare, mental health, vocational services, and education (glickman, 2013). due to the limited number of social workers who are able to provide culturally and linguistically competent services, deaf individuals are often left at a disadvantage with barriers to communication (sheridan et al., 2010). in working with deaf clients, both cultural and linguistic competencies are important to foster effective and appropriate interactions. these competencies include having empathy towards those who are deaf and a familiarity with the intricacies of asl. currently, many deaf clients are overlooked by social work services that are exclusively catered towards the hearing community. hearing social workers generally lack training opportunities to learn about deaf culture and the deaf community and are often unfamiliar with the legal requirements for accommodating deaf clients (harmer, 1999; meador & zazove, 2005). asl interpreting services have emerged as the most preferred communication approach among deaf people who use asl or have limited literacy in english. apart from asl interpreters, video remote interpreting and video relay services have been proposed as new technologies that enable deaf people to communicate with hearing people remotely. however, research on these technologies is still limited. this article presents current policies that address communication barriers between deaf clients and hearing social workers, as well as proper accommodations for deaf clients in hearing-centric settings, including the relatively recent technologies of video remote interpreting and video relay services. the information provided may bring the social work profession closer towards the goal of providing comprehensive and appropriate services to the deaf community, consistent with ethical guidelines. social work ethics and practice standards the national association of social workers (nasw) code of ethics declares that social workers are bound, legally and ethically, not to 39 | columbia social work review, vol. 18 discriminate against clients on the basis of mental and physical disability (national association of social workers, 2008). standard 9 in the nasw standards and indicators for cultural competence in social work practice states that, “social workers shall provide and advocate for effective communication with clients of all cultural groups, including people of limited english proficiency or low literacy skills, people who are blind or have low vision, people who are deaf or hard of hearing, and people with disabilities.” (bonner et al., 2015) standard 9 further specifies that both social workers and organizations are required to evaluate each client’s preferred language and provide suitable assistance to ensure effective communication (bonner et al., 2015). in other words, social workers must be able to communicate respectfully and effectively with clients from diverse cultural and linguistic backgrounds. this depth of communication requires proficiency in the client’s preferred language as well as proper knowledge of the client’s cultural values and identities (simmons et al., 2008). when working with deaf clients, social workers would address this need by providing various accommodations, including professional sign language interpreters. professional sign language interpreters should be treated as members of the social work service team and familiarize themselves with the types of settings and services that are being provided, such as legal services, mental health services, and child welfare services (national association of social workers, 2007). americans with disabilities act requirements social workers are required by the americans with disabilities act (ada) (1990) to provide deaf people with equal access to various forms of services, along with necessary considerations on local and state laws that may have stronger regulations (morgan & polowy, 2009). the ada prohibits discrimination against people with disabilities, including deaf people. it requires covered entities from both public and private sectors, including social work services, to provide reasonable accommodations for people with disabilities to have equitable opportunities to participate in and enjoy the benefits of their programs and services (americans with disabilities act, 1990b). in 2008, the united states congress amended the ada by updating the definition of “disability,” thereby broadening the scope of who would be protected and increasing the number of people protected under the law (georgetown university law library, 2020). according to title iii of the ada for public accommodations and commercial facilities, it is the responsibility of both public and private entities to provide necessary auxiliary aids and services to ensure effective communication with people with disabilities (americans with disabilities act, 1990a). entities are only exempt from providing accommodations if columbia social work review, vol. 18 | 40 they can prove that it would impose an undue burden on the operation of their business. nonetheless, exempt entities are still strongly encouraged to make every effort to provide proper accommodations for deaf people. these accommodations include, but are not limited to, qualified interpreters, written materials, telecommunication devices, videotext displays, open and closed captioning, and other methods of making aurally delivered materials available to deaf people. it is important to note that denying deaf clients these accommodations and, in some instances, requiring deaf people to pay for accommodations, is an unlawful form of discrimination (americans with disabilities act, 1990a).1 research on the effectiveness of the ada is limited, as employers are not required to monitor and report their ada compliance efforts. however, the accommodations that the ada advocates support have been proven to benefit deaf individuals who seek support for their communication (united states department of justice, 1994). accommodations for improved communication with deaf clients recurring findings indicate that many deaf people experience limited access to social work services due to communication barriers (steinberg et al., 1998; mueller, 2006). those communication barriers, which are the result of inadequate knowledge of asl and deaf culture among hearing social workers, leave deaf people vulnerable to isolation, poor service delivery, and place an unnecessary burden on their lives (cabral et al., 2013; fellinger et al., 2012). in order to determine which communication approaches are most appropriate for deaf clients, social workers must evaluate the preferences of the clients and identify the needed services. stewart (1986) does this by identifying “...strengths and limitations of the disabled individuals as well as the strengths and limitations of the disabled person’s environment and to assist the individual to realize his or her potentials through an enhancement of the environment or ecological circumstances” (p. 11). when deaf clients disclose their preferred accommodations, social workers need to familiarize themselves with these accommodations and incorporate them into their practices. this section discusses recommendations on accommodations for deaf people, including asl interpreters, video remote interpreting, and video relay services. all are discussed in relation to the communication barriers faced regularly by deaf clients. american sign language interpreters american sign language interpreters make communication possible between deaf people who use asl and people who hear by interpreting both asl and spoken english (olson & swabey, 2016). asl has its own grammatical rules, sentence structure, and cultural implications, thereby making interpretation between asl and spoken english a complex process that requires a high degree of cognitive, linguistic, and technical skill. 1 the terms “auxiliary aids and services” and “accommodations” are used interchangeably in this paper to represent the available services for deaf people as required by the ada 41 | columbia social work review, vol. 18 long sentences of spoken english can be interpreted into equivalent signs conveying the meaning of an english sentence (professional standards committee, 2007). interpreters enhance real-time communication by providing both simultaneous and consecutive interpretations. simultaneous interpretation is one-way communication where asl is interpreted at the same time as spoken english is delivered. consecutive interpretation is a one-on-one conversation where asl is interpreted after a hearing person speaks and pauses, which affords deaf people more time to comprehend the interpreted message (janzen, 2005). asl interpreters should have adequate knowledge of deaf culture and possess sign language certifications such as the national interpretation certificate (nic) from the registry interpreters for the deaf (rid) (landa & clark, 2019). due to different linguistic and sociocultural contexts among the deaf population because of racial and regionalized signs, including black american sign language and other variations, deaf individuals vary in their experience acquiring proficiency in asl and have their own preferred communication style (national institute on deafness and other communication disorders, 2019). for example, deaf people in the northeastern region of the u.s. tend to use one-handed variants of signs, whereas deaf people in the southern and western regions favor more traditional two-handed variations (lucas & bailey, 2011). while some social work professionals are familiar with arranging asl interpreters, there are too many social workers who have not made regular contact with deaf people (o’hearn, 2006). when it comes to working with deaf clients, social workers without adequate asl skills and experience with deaf clients commonly utilize improper communication approaches that lead to potential misunderstandings and misconceptions of information conveyed between the parties, such as lip-reading, speaking, and written communication (hommes, borash, hartwig & degracia, 2018). deaf clients have a better chance of receiving comprehensive services when social workers are able to take a role in accommodating the preferences of the clients and understand the logistics of working with asl interpreters. it would likewise be beneficial if asl interpreters have experience with social workers and are familiar with social work terminologies. when deaf clients request asl interpreters, social workers should book asl interpreters through interpreting agencies or contracts with asl interpreters. when asl interpreters are provided, the following suggestions should be made to ensure effective communication between deaf clients and social workers. the social worker should speak directly to the client and maintain eye contact with the client instead of the asl interpreter. the social worker should pay attention to the client’s facial expression, body language, and behaviors, while the asl interpreter is interpreting for the client. the social worker should also be close to the asl interpreter and face towards the client together and should not begin speaking until either the deaf client finishes signing or the interpreter columbia social work review, vol. 18 | 42 finishes interpreting (chapple, 2019). there are some circumstances where deaf clients may not understand interpreters using asl driven by english-based word order because the interpreters acquired asl as a second language after english. likewise, there may be times where asl interpreters may not understand the signing of deaf clients because of limited exposure to different signing styles among the deaf population. when deaf clients and asl interpreters struggle to understand each other, deaf interpreters may facilitate a more effective conversation among all parties (metzger et al., 2014). deaf interpreters are native or near-native users of asl and have profound knowledge of deaf culture (guardino, 2018). although deaf interpreting services are not relatively new, it did not obtain professional status until the 1980s. therefore, deaf clients and hearing social workers are often unaware of the option to request a deaf interpreter (boudreault, 2016). deaf interpreters are used to assisting deaf people who use home signs or non-standard signs, who experienced a delay in language acquisition, or who use ethnic or regionalized signs (professional standards committee, 2007). when a hearing person speaks, a hearing asl-english interpreter interprets the message to a deaf interpreter. the deaf interpreter is responsible for interpreting the message to a deaf client in asl, along with more visual gestures. once the deaf client comprehends and responds, the deaf interpreter interprets the deaf client’s signed message back to the asl interpreter, and the asl interpreter interprets the message in spoken english back to the hearing person. when a deaf client requests a deaf interpreter, social workers must arrange a deaf interpreter and an asl interpreter as a team, understanding that the interpreting process requires a slight delay in the delivery of messages. asl and deaf interpreting are the most common and favorable choice of accommodation because, while asl interpreters assist deaf clients to receive information from hearing social workers, deaf interpreters bring additional value in supporting deaf clients with limited literacy to comprehend the context. video remote interpreting video remote interpreting (vri) is a video conferencing technology that brings asl and spoken english interpreting services to deaf and hearing people when a local or nearby interpreter is unavailable (steinberg et al., 2006). due to rapid development in technology, vri has emerged as a popular tool for hearing people to communicate with deaf people using asl (kashar, 2009) ). vri is used through a desktop or monitor with a camera live-streaming an asl interpreter from a remote site who assists the communication between deaf and hearing individuals who are in the same room (alley, 2012). the deaf person and the asl interpreter communicate in asl through the camera while the conversation between the interpreter and the hearing person is aurally delivered. vri may be mounted on an 43 | columbia social work review, vol. 18 adjustable rolling stand for convenient relocation, oftentimes in medical settings (kushalnagar et al., 2019). for instance, when vri is brought to where a deaf client is present, a social worker connects to a remote asl interpreter on the tablet who will appear on the screen, and the video of the deaf client is also shown on the screen. vri is identified by many hearing people as an effective solution towards deaf clients’ access to communication and professional services for a variety of reasons (power & power, 2010). vri is not only cost-effective but more flexible when it comes to scheduling compared to the use of in-person interpreters, which generally require booking several weeks in advance and entail travel time (masland et al., 2010). vri also has a wider geographical reach, which is beneficial for deaf clients who live in regional or rural areas. vri providers also employ a larger pool of interpreters who have expertise in specialized settings related to social work, including hospitals and schools (stratus video, 2018a). vri is useful not only because it is more convenient to book a remote interpreter, but it also reduces the need for proximity and waiting for an in-person interpreter to arrive (lightfoot, 2006). for example, vri can quickly assist deaf clients with communication needs in emergency situations, even as a temporary solution while waiting for an in-person interpreter to arrive at the site if requested (stratus video, 2018b). nevertheless, vri is unable to produce the same quality of in-person interpreters in many situations (kashar, 2009; garrett & maryland, 2012). since vri equipment usually depends on a wireless connection, poor network connection and limited bandwidth can affect the effectiveness of interpreting service and the quality of video screens such as blurriness, freezing, and disconnection (kushalnagar et al., 2019). when the deaf client and the interpreter struggle to see each other clearly through the video screen, the accuracy and completeness of conveyed messages can be negatively impacted. consequently, deaf clients are denied access to full information and experience lower satisfaction with vri. compared to in-person interpreters, vri services have significant limitations for all parties in terms of mobility and visibility (kashar, 2009). while the vri interpreter attends remotely on the video screen, they neither have a broader view of their surroundings or are able to wholly focus on the signing and body language of deaf clients and social workers. it may also be difficult for vri interpreters to filter the environment and background noises while listening to the social worker who speaks. as for in-person interpreters, they are able to independently move and easily focus on the deaf client and the social worker. (kushalnagar et al., 2019). moreover, vri might not be fully accessible to deaf clients who have visual, cognitive, psychiatric, and linguistic difficulties (national association of the deaf, 2018). a clear and uninterrupted video screen with a qualified interpreter through vri is required to foster communication between deaf clients and social workers. the national association of the deaf (2018) suggests that hearing people provide qualified in-person asl interpreters and consider columbia social work review, vol. 18 | 44 the use of vri as an alternative option when an in-person interpreter is not available. there are several recommendations for utilizing requested vri services to enhance communication access for deaf clients. social workers need to ensure that the internet connection is in good condition when connecting to a vri interpreter. in addition, a video screen for vri should be at least 16 inches, which enables deaf clients to see interpreters more easily. social workers should adjust the position of the camera, allowing an interpreter to have a broader view of surroundings outside the potentially limited angle in order to ensure the accuracy of information being interpreted. a 360-degree camera is ideal as it improves the visuality of the signing of deaf clients and the entire setting where they are presented. video relay services video relay services (vrs) is a telecommunication service that allows a deaf person who uses asl and a hearing person who uses spoken english to communicate by phone. vrs makes a real-time interpretation possible by using a videophone application with a vrs phone number designated by telecommunication companies (steinberg et al., 2006; sorenson communications, llc, 2017). popular companies that offer vrs for the deaf population in the united states include sorenson, convo, and zvrs/purple (bravin, 2016). to use vrs, deaf individuals need to either have a vrs application installed on their electronic device, obtain particular vrs products, or both, which enable them to connect to an asl interpreter through a video relay call (video relay service, n.d.). once the deaf individual is connected to the asl interpreter by using a hearing person’s telephone number, the interpreter will then place a call to the hearing person. the hearing individual will receive a phone call and speak to the interpreter over the phone. as the hearing person talks, the interpreter interprets the message in asl over the video screen on the vrs application to the deaf person and vice versa. a hearing person can make a direct call to a deaf person without needing vrs equipment simply by calling a deaf person’s vrs phone number. upon calling the vrs phone number, the call will be automatically routed to an asl interpreter, who then places a video call to the deaf person (caserta, 2008). while telecommunication is rather straightforward, vrs requires a high-speed internet connection and a clear video phone screen on the deaf individual’s end, to avoid blurriness, freezing, and disconnections. deaf clients may decide to use vrs when they do not plan to come to the office. in addition to texts, emails, and online written communication, hearing social workers have the option to contact deaf clients through vrs to follow up on treatment results or additional information. deaf clients with limited literacy in english may find vrs more convenient compared to written communication, which hinders their ability to communicate in asl. vrs is funded and managed by the federal communications commission (fcc); this comes with several eligibility requirements for deaf consumers 45 | columbia social work review, vol. 18 addressing communication barriers with deaf clients using vrs. for example, vrs is limited to calls between deaf and hearing people in different locations, as it is a violation of the federal law to use vrs for calls between individuals in the same room (sorenson relay, 2020). for deaf clients who need deaf interpreters to interpret their signs, social workers cannot consider vrs as it does not offer deaf interpreting services. social workers are encouraged to keep both text and vrs numbers of deaf clients when future contact through text or call is needed. the aforementioned types of interpreting services allow interpretation of messages between spoken and visual languages to promote accessible interactions. they each address the cultural and linguistic communication needs of deaf clients who use asl, especially those who have limited literacy in written english. hearing social workers are encouraged to consult with their deaf clients regarding their preferred procedures and processes of the requested interpreting services. hearing social workers who are familiar with accommodations can build up a trusting relationship with deaf clients, though it would be ideal if they are able to sign or understand basic asl from their deaf clients, especially including the common terms related to their work settings. recommendations social workers with asl skills and knowledge of deaf culture are essential to offer more comprehensive service to deaf clients. social workers with this particular expertise should educate hearing practitioners about working with deaf clients, especially asl interpreters and other accommodations that are necessary to provide equal communication access. those without this expertise are strongly encouraged to participate in continuing education and training programs to advance their cultural competence on deaf clients. social workers should work with deaf and asl interpreting practitioners, institutions, and organizations to implement training and workshops to improve their knowledge of accommodations to work with deaf clients. moreover, those who are well versed in working with the deaf population should demonstrate their leadership by raising awareness about the ada and nasw policies, the cultural and social experience of being deaf, and accommodations available for working with deaf people. for example, through leadership, social workers may encourage hearing providers who work with deaf clients to be familiar with policies for people with disabilities and identify key components of project design and service delivery that meet the various needs and preferences of deaf clients. lastly, in order to produce more social work students who are capable of working with deaf clients in their future careers, schools of social work and other allied professions should incorporate deaf culture and disability policies into their educational curriculums and accreditations. columbia social work review, vol. 18 | 46 conclusion as the deaf community is considered a vulnerable and underrepresented population due to continuous communication barriers, they generally require the accommodations to facilitate their communication. hearing social workers who are not familiar with ada-required accommodations could fail to work with deaf clients. often, hearing social workers tend to consider a deaf client as someone living with a pathological condition rather than a cultural characteristic, and as a result, deaf clients may lose confidence in social work services. knowing that there are not enough culturally and linguistically competent social workers, deaf people may feel uncertain, oppressed, and undervalued when seeking further social work services in the future (jeffrey & austen, 2005; steinberg et al., 2006). therefore, it is important for hearing social workers to incorporate the recommendations discussed in this paper into their practices with deaf clients, which would ultimately lead to a more positive and beneficial impact on the overall wellbeing of deaf clients under the care of hearing social workers. about the authors david “dt” bruno was born to a deaf and signing family and grew up navigating the hearing-centric world, which forever shaped his experience as a disabled person. in 2018, dt graduated from gallaudet university with a bachelor’s degree in social work with minors in family studies and public health. dt previously presented at nasw-nys statewide conference in 2018, discussing best practices for deaf/hard of hearing people in social work settings. at columbia school of social work, dt is on the advanced clinical practice track and is specializing in health/mental health and disabilities. dt’s field placement is at partners deaf services, where dt offers behavioral health services for deaf and hard of hearing individuals in pennsylvania yunhe bai grew up navigating the roles of deaf person and person of color. through this experience, he has been exposed to various forms of oppression against the deaf population, mostly related to access to communication and opportunities for participation in public services. yunhe graduated from gallaudet university in 2019 with a bachelor’s degree in business administration. yunhe’s degree was awarded with university honors, and he was the undergraduate speaker at commencement. at columbia school of social work, yunhe is on the social enterprise administration track. yunhe’s field placement is with the new york center for law and justice. 47 | columbia social work review, vol. 18 references alley, e. 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(n.d.). http://www.dws.state. ut.us/usor/vr/employer/videorelay.pdf columbia social work review, vol. xix | 139 138 | columbia social work review, vol. xix transgender populations are disproportionately impacted by eating disorders and disordered eating behaviors; however, transgender clients lack access to affirming and culturally responsive mental health care and are frequently undiagnosed. in addition, conventional treatment models for eating disorders do not attend to the unique causes and manifestations of eating disorders among transgender people, which include: minority stress and gender trauma; gender dysphoria and lack of access to safe, gender-affirming treatment; safety concerns and the need for passing; cissexism and resulting disempowerment; and pervasive, harmful beauty standards coupled with hyper-scrutiny of trans bodies. this project includes a summary and analysis of the existing literature and data regarding the causes of and current treatment recommendations for eating disorders within transgender populations. it also suggests a socialwork-led shift within eating disorder treatment to center the sociopolitical forces which so often lead to such diagnoses. keywords: transgender, eating disorder, culturally responsive treatment, minority stress, gender trauma, access to care, cissexism, anti-oppressive approach unique causes and manifestations of eating disorders within transgender populations sula malina they,them columbia social work review, vol. xix | 141 140 | columbia social work review, vol. xix eating disorders within transgender populations unique causes and manifestations of eating disorders within transgender populations despite limited representation of transgender bodies in both popular media and a lack of attention in clinical training to transgender concerns, research over the past several decades has indicated a high prevalence of eating disorders (eds) and disordered eating behaviors among transgender populations. research on health outcomes among transgender people and research on eating disorders are each underfunded (feldman et al., 2016; murray et al., 2017); few studies have been published on the intersection of the two that are generalizable at a population level. those which do exist have focused nearly exclusively on transgender youth. a 2015 study of 289,024 students from 233 u.s. universities revealed that 15.8% of trans respondents had been diagnosed with an eating disorder, compared to 1.85% of cisgender, heterosexual women, and 0.55% of cisgender, heterosexual men (diemer et al., 2015). the study also collected data on reported disordered eating behaviors among participants within the past month: 13.5% of trans respondents reported using diet pills within the past month, compared with 4.29% of cisgender, heterosexual women. futhermore, 15.1% of trans respondents reported self-induced vomiting or laxative use within the past month, compared to 3.71% of cisgender, heterosexual women (diemer et al., 2015). in collecting symptom-specific data, diemer et al. identified behaviors in individuals who may not have received a formal diagnosis at the time of data collection due to either their nature or duration. other specified feeding and eating disorder (osfed) is generally considered more common among transgender people than the more widely recognized diagnoses of anorexia nervosa and bulimia nervosa, due to the unique manifestations of disordered eating motivations and behaviors among trans populations. a 2015 study of gender identity, sexual orientation, and self-reported ed diagnoses among college students (n=289,024) found that trans respondents (n=479) were more likely to report disordered eating behaviors generally, and particularly those consistent with a diagnosis of osfed (diemer et al., 2005). other researchers have importantly identified that mortality rates for eating disorders not otherwise specified (the dsm-iv diagnosis later renamed osfed in the dsm 5) are comparable to those for bulimia nervosa (arcelus, 2011); thus osfed is no less dangerous than the well-known diagnoses. though exact rates vary across research studies, the general trend of higher rates of eds among trans respondents are consistent. a 2016 study of 218 children and adolescents with gender dysphoria revealed that 13.3% had “eating difficulties” (holt et al., 2016), and a 2012 study of 97 youth with “gender identity disorder” (a dsm-iv diagnosis which later became “gender dysphoria” in the dsm 5) demonstrated a 7% rate of eds among its sample (spack et al., 2012). dangerously little research has been published on the experiences of transgender people of color (poc) navigating eating disorders. indeed, only 30.42% of respondents (including only 4.5% black and 5.96% latinx) to the 2015 study (diemer et al., 2015) and 11.3% of respondents to the 2016 study (holt et al., 2016) were poc. of the former, only 4.5% of respondents were black and 5.96% were latinx; the remainder of the 30.42% were comprised of asian american pacific islander (aapi), multiracial, native american, and “unknown” respondents (diemer et al., 2015). spack et al. (2012) did not include data around participant race and ethnicity, likely indicating a lack of attention to inclusive participant recruitment, and a fairly racially homogenous sample by extension. in spite of this, high rates of eating disorders among bipoc populations suggest that rates among trans people of color may be even higher (neda, 2018). these statistics are cause for alarm, not only because of their contrast to data on cisgender youth, but because of the considerable dangers associated with eating disorders. eds have “the highest rates of related medical complications, hospitalizations, and mortality of all psychiatric disorders” (duffy et al., 2016, p. 136). this paper seeks to explore the extent to which eating disorders among transgender populations are influenced by sociopolitical forces. social workers, who are trained to use an anti-oppressive, “social model” of mental health, are uniquely positioned to advocate and provide affirming interventions sula malina columbia social work review, vol. xix | 143 142 | columbia social work review, vol. xix eating disorders within transgender populations for transgender clients. clinicians must consider five major contributing factors to eating disorders among transgender populations: 1) minority stress and gender trauma, 2) gender dysphoria and lack of access to safe, gender-affirming treatment, 3) safety concerns and the need for passing, 4) cissexism and resulting disempowerment, and 5) pervasive, harmful beauty standards coupled with hyper-scrutiny of trans bodies. major contributing factors discrimination-based stress and gender trauma minority stress was first introduced in 2003 to describe the result of repeated exposure to microaggressions and other forms of stigma and discrimation among lesbian, gay, and bisexual (lgb) individuals. epidemiologist ilan h. meyer found that high levels of stress were associated with negative mental health outcomes (meyer, 2003). the concept has since been expanded to other marginalized populations, including black and indigenous people of color (bipoc), transgender communities, and disabled people, among others. experts recognize that the experience of transgender embodiment within a cissexist society precipitates gender trauma and stress (kosciewicz et al., 2020). moreover, for transgender poc this trauma is compounded by the violence of racism (harrington, et al., 2006). researchers have identified a relationship between stress, trauma, and maladaptive coping strategies such as disordered eating (witcomb et al., 2015, p. 292); high rates of such behaviors and disorders among a population so vulnerable to stress and trauma are, unfortunately, unsurprising. despite limited research, there is significant evidence to suggest that the risk of disordered eating among trans people of color is heightened due to the compounding nature of marginalized identities and oppression. legal scholar kimberlé crenshaw introduced the concept of intersectionality in 1991, noting the unique experience of those living at the intersection of multiple marginalized identities, and, consequently, subjugated by multiple systems of oppression. as crenshaw writes, “the intersectional experience is greater than the sum of racism and sexism” (crenshaw, 1991, p. 58). thus, navigating an eating disorder becomes more complex for a transgender person of color than for a white or cisgender person. gender dysphoria and lack of access to safe, gender-affirming treatment some transgender people experience gender dysphoria: a state of distress caused by the misalignment between their own gender identity and that which is associated with their sex assigned at birth. while the dsm 5 and the world professional association of transgender health (wpath) standards of care recommend gender-affirming medical intervention such as hormone therapy and surgeries as treatment for gender dysphoria, lack of access to affirming care as well as limited effects of interventions may lead trans individuals to physically “transition” through disordered eating behaviors. for many transgender people, disordered eating can be seen as a method of “either suppressing or accentuating gender by changing the shapes of their bodies” (kosciewicz et al., 2020, p. 73). for those assigned female at birth, this may mean weight loss to reduce hips, breasts, or buttocks, while those assigned male at birth may gain weight to de-emphasize shoulder breadth, among other characteristics (kosciewicz et al., 2020). transmasculine individuals (those assigned female at birth who are transgender and who identify with masculinity to a greater extent than femininity) may restrict their diet to induce amenorrhea, or the cessation of menses (testa et al., 2017). as chang et al. (2018) acknowledges, these behaviors, while dangerous, “may feel more accessible or actionable’’ than physical transition by medical means (p. 116). barriers to accessing gender-affirming care may fuel the desire to participate in harmful disordered eating behaviors. financial limitations may include lack of health insurance coverage, high out-of-pocket cost of care, and limited free time in which to seek care. geographic restrictions may also create challenges to accessing a gender-affirming provider in close proximity. finally, lack of support in familial/peer relationships and potential safety risks in altering one’s presentation and medical barriers, such as pre-existing conditions that might interfere sula malina columbia social work review, vol. xix | 145 144 | columbia social work review, vol. xix eating disorders within transgender populations with physical transition or require a particular medical specialist, restrict many transgender people from accessing affirming care. physical transformations by way of disordered eating behaviors may be heightened among transgender poc who experience significantly more limited access to gender-affirming medical care, beyond that of their white counterparts (howard et al., 2019). an analysis of the impacts of such barriers is explored in greater depth in the “critique of current treatment model” portion of this project. safety concerns and the need for passing the concept of passing was initially devised in reference to lightskinned black americans who navigated anti-black racism in the country by presenting themselves as white; historians trace this strategy back to the early years of slavery in the united states (hobbs, 2014). passing has since been adopted by transgender communities to refer to the phenomenon by which transgender people are seen by others as cisgender people of their affirmed gender identity. passing has been rejected by many transgender activists, as to some, the term suggests something inherently “correct” or “successful” about appearing cisgender. additionally, passing is not achievable for many people, depending on limitations of hormonal and surgical transition as well as gender identity (one might consider what it means to “pass” as nonbinary). it should be noted that passing is not a goal for all transgender people, just as it has certainly not been a goal for all black people. many individuals, whether marginalized by transgender identity, race, or both, equate passing to a loss of personal identity and of community/familial ties (hobbs, 2014). although gender dysphoria is understood by behavioral health providers primarily as a mental health concern, passing as one’s gender identity has significant societal implications related not only to acceptance, but also to safety. those “visible” as transgender are particularly susceptible to transphobic discrimination, including social othering, microaggressions, and verbal and physical harrassment and violence. transgender individuals are socialized to remain hyperaware of their appearance to onlookers as a matter of survival, and many recognize that “biological sex characteristics related to weight and shape . . . may reduce how often they are perceived and treated as the gender they experience themselves to be” (testa et al., 2017, p. 928). however, passing may precipitate greater safety risks for trans individuals. as activists and theorists alike note, passing as cisgender may be perceived as “deception” by cisgender people (billard, 2019, p. 463). all too often, “deceived” cisgender people respond to the disclosure of another’s transgender status with rage and sometimes fatal violence. passing as cisgender may be of even greater concern to black and brown transgender women, who face an epidemic of violence. in 2020 alone, at least 44 transgender and gender nonconforming people, almost exclusively black and/or latinx and transfeminine, were victims of fatal transphobic violence nationally (hrc, 2020). since 2015, the human rights campaign has recorded a total of 158 deaths (hrc, 2020; hrc, 2019; hrc, 2018; hrc & tpocc, 2017; hrc & tpocc, 2016; hrc & tpocc, 2015). this devastating pattern underscores the complexity of the drive to “pass” (or not) for transfeminine people of color in particular. the role of passing in driving disordered eating behaviors is complex. one 2018 study of transgender adults (n=452) found a slightly elevated rate of disordered eating among non-binary respondents who had been assigned female at birth, compared to trans men, trans women, and non-binary people assigned male at birth (diemer et al., 2018). while researchers could not identify a clear cause for the difference, they noted the impact of visible gender-nonconformity (in other words, “lack of passing”) often expressed by non-binary trans people and the possibility that some may turn to disordered eating behaviors as a response to the resulting minority stress in a highly binary and conformist society (diemer et al., 2018). in this sense, eds may be employed by trans people either as a strategy to control the body’s shape and “pass” as a cisgender man or woman, or result from a manifestation of stress and anxiety experienced by those who navigate the world as “unpassable” by virtue of their non-binary gender expression. for some, both factors may be at play. sula malina columbia social work review, vol. xix | 147 146 | columbia social work review, vol. xix eating disorders within transgender populations cissexism and related disempowerment in response to both pervasive cissexism and gender dysphoria, trans people may turn to disordered eating behaviors as a means of reclaiming a sense of power. as chang et al. (2018) acknowledge, such behaviors may serve to “provide a sense of control or influence over one’s body size or shape” (p. 116). the distress caused by a misalignment between internal identity and the gendered meanings attached to bodies in western cultures should not be underestimated; indeed, disordered eating may “facilitat[e] a level of omnipotent control in the midst of overwhelming and unbearable somatic feelings, and distress because of one’s inability to resolve the conflict between the reality of their gender experience and their heavily defended-against attachment that the body spells as gender’s reality” (kosciewicz et al., 2020, p. 68). thus, the sense of control some may achieve through disordered eating behaviors may extend beyond those behaviors’ visible impact on the shape or size of the body. hyper-scrutiny of trans bodies and pervasive beauty standards transgender and cisgender people alike risk profound influence by narrow societal beauty standards, though this may be compounded for transgender people who are socialized into a gender role different from their affirmed gender and who may internalize multiple, even contradictory body expectations. as witcomb et al. (2015) argue, “trans males may internalize the same ideals that natal females do with regard to the ideal aspects of being female, despite desiring to be male” (p. 291). the drive for thinness may be compounded by trans identity, given a perceived correlation between weight loss and the “suppress[ion of] features of the birth assigned gender and [accentuation of] the features of the identified gender” (witcomb et al., 2015, p. 292). hypervisibility and hyper-scrutiny of trans bodies perpetuates ideals that are even more extreme than those imposed upon cisgender people, “because they are expected to ‘prove’ themselves as being ‘man enough,’ ‘woman enough,’ or ‘trans enough’” (chang et al., 2018, p. 116). these dangerous beauty expectations are based in whiteness, and the fatphobic standards that underlie them, with roots in anti-black racism. sociologist sabrina strings unravels the history of fatphobia in her text fearing the fat body. though the current dominant culture in the united states and europe justifies societal discrimination against fat bodies by deeming them necessarily “unhealthy,” this was not the case historically. indeed, fatness historically came to be associated with “savagery” and “racial inferiority” amidst european colonization of africa (strings, 2019, p. 4). the impact this history has had on black americans more recently is nuanced. a 2014 series of focus groups comprised of black women students (n=31) at a large university explored various body image concerns and values among participants. while all participants reported being in some way affected by beauty standards based in whiteness, many also reported that they saw “curviness” as “optimal” for black women, and considered thinness to be “for white people” (awad et al., 2016, p. 550). regardless of its manifestation, there is widespread awareness of body image standards. these standards understandably impact transgender people’s relationships with and expectations around their body, shape, and size. pressures around conforming to beauty standards are compounded significantly for trans poc (johnson, 2019). critique of current treatment model the development of gender-affirming, culturally responsive interventions for eating disorders among transgender populations is of paramount importance; however, clients seeking healing face numerous obstacles stemming from a dearth of competent providers, comprehensive research, and safe(r) community spaces. accessing inclusive transgender community for many trans people, and especially trans youth, community may seem altogether nonexistent. as davis et al. (2018) point out, “the absence of trans-peers and a trans-social network can reinforce the maladaptive behavior that many trans-youth utilize to erase or reconstruct their identities” (p. 56). even when community is available, the persistent stigma around eating disorders often silences communities sula malina columbia social work review, vol. xix | 149 148 | columbia social work review, vol. xix eating disorders within transgender populations from healing through necessary conversation. this lack of openness may be explained by the reality that even in their own communities, vocal trans people risk not only “emotional vulnerability,” but also “reveal[ing] the fragility of their gender presentation” (kosciewicz et al., 2020, p. 85). as in many marginalized communities, the value of “pride” in oneself and one’s body in the face of systemic violence may backfire when other members feel unable to acknowledge and unpack their internalized oppression. limiting narratives & underdiagnosis transgender people are unrepresented in the singular, dominant “eating disorder narrative,” which narrowly defines those with eating disorders as thin, white, straight, cisgender women. consequently, disordered eating behaviors in trans people may go unrecognized--or even vehemently denied--altogether. kosciewicz et al. (2020) quote one interviewee who explains: “i’ve been told for so many years that i don’t have an eating disorder, there’s nothing wrong with me, i’m being dramatic” (p. 83). research indicates that clients of color, particularly black clients, are significantly less likely to be diagnosed with an eating disorder when displaying the same eating and exercise behaviors and thought patterns as their white counterparts and non-black counterparts of color (neda, 2018). underdiagnosis may also be attributed to an over-attribution of symptoms to gender dysphoria because “the conversation about bodies may be so focused on gender that important information is missed” (chang et al., 2018, p. 115). certainly the relationship between gender dysphoria and weight dysphoria or body dysmorphia is a nuanced one. reconciling contraindicated interventions this complex comorbidity of gender dysphoria and body dysmorphia must be explored further. on the surface, the most common treatment approaches to each are in fact contraindicated. chang et al. (2018) articulates the dangerous potential contradiction clearly: a common message in society as well as in eating disorder treatment and recovery communities is ‘just accept yourself as you are.’ although this may be an ideal or goal to strive toward regarding body size and weight acceptance, this message can be misapplied in a distorted and harmful way to trans people. it can suggest that trans people should just learn to accept and live in accordance with the gender identity associated with their sex assigned at birth. (p. 117) this failure to affirm and validate gender identity in eating disorder treatment drives potential patients away from seeking care in the first place. duffy et al. (2016) report on a study of transgender people with a history of eating disorder treatment, sharing that of the 84 participants, “some even expressed wishing they had never gone to treatment at all, despite acknowledging that it was likely life saving” (p. 144). gendercompetent care and empathy are critical if providers hope to “heal” their patients from what patients may experience as bringing about affirming physical change and a sense of control. kosciewicz et al. (2020) emphasize that there is “psychic and physical pain involved in relinquishing the ed as the primary means for self-regulation” (p. 69). medical transition & gatekeeping further, acknowledgement and diagnosis of an eating disorder for a trans patient may prevent access to gender-affirming medical treatments that could alleviate the need for “self-transitioning” behavior. because trans individuals require clearance from a behavioral health provider to access surgeries, the existence of any mental health diagnoses may halt the process--and, while wpath standards of care do currently clarify that “mental health conditions may be present” (if “reasonably well managed”), “health-care providers may believe that a client should resolve eating-disordered behavior before they are appropriate for undergoing gcmis” (testa et al., 2017, p. 928). such pitfalls would likely be ameliorated by adequate training of medical professionals. at the moment, few training programs offer information that is specific to transgender populations (duffy et al., 2016). given this lack of education, sula malina columbia social work review, vol. xix | 151 150 | columbia social work review, vol. xix eating disorders within transgender populations experiences of eating disorders specific to transgender populations are easily ignored. popular treatment models for eating disorders often target behavioral changes with insufficient attention to their underlying causes, and can thus be harmful for the transgender populations they may seek to serve. in part, limited research on the subject of transgender patients and eating disorders is to blame. without an understanding of how access to physical transition can impact mental health outcomes and level of body satisfaction for transgender people, clinicians risk conflating client body dissatisfaction rooted in gender dysphoria with a negative selfimage that centers around size and/or weight. nutritionists, dieticians, and doctors are limited in their ability to apply nutritional needs to transgender clients, due to a lack of guidelines on the calculation of such needs or ideal body weights for clients who are on hormones (kosciewicz et al., 2020). inaccessibility of care despite recent advancements in the clinical treatment of eating disorders among transgender populations, effective, gender-affirming interventions remain largely inaccessible to the most marginalized trans individuals. transgender people, and particularly transgender poc, are disproportionately impacted by poverty and homelessness, and thus face significant financial barriers in access to care (national lgbt health education center, 2018). despite recent policy advocacy, many insurance plans still exclude gender-affirming medical treatments from coverage (national lgbt health education center, 2018). even for those with access, limitations remain as to what changes existing treatments can facilitate. although testosterone therapy facilitates body fat redistribution, it brings with it a wide variety of other physical changes with which an individual may not identify (such as facial/body hair or a deeper voice). though witcomb et al. (2015) identify that “the body parts that were most reported to cause the most dissatisfaction were those associated with body shape” (p. 291), these may be the very adjustments most difficult to attain through current medical interventions, as they may be “relating to skeletal changes at puberty” that are irreversible (witcomb et al., 2015, p. 288). further limitations of medical intervention are demonstrated by the psychological and emotional effects of pubertal suppression on transgender pre-teens, as such intervention can leave them “looking younger than their peers,” causing distress (national lgbt health education center, 2018, p.3). while such medical advancements may fall beyond the purview of a social worker, clinicians must be informed on what their transgender clients may experience as deterrents to accessing medical interventions. promising practices for those working with a younger population in a clinical setting, early intervention is critical. the national lgbt health education center recommends that treatment for eating disorders begin prior to adolescence when possible, in order to prevent long term health consequences (national lgbt health education center, 2018). for those working with transgender clients of any age who experience disordered eating, existing literature suggests a few promising practices: unsettling “diagnosis”; querying “acceptance”; holding space for mourning; and utilizing modalities and frameworks which acknowledge the impact of discrimination-based stress, trauma, and attachment disruption on clients. given the potential contraindication of healing approaches to eating disorders and gender dysphoria, chang et al. (2018) recommend that practitioners not designate some patients’ concerns as either diagnosis, “but rather as both or an interaction of the two,” employing “the dialectic of acceptance and change that is integral to mindfulness-based approaches such as act and dbt” (p. 117). koscieweicz et al. (2020) open a critique of the very notion of mental health diagnosis. as they point out: we can challenge the normative treatment model of asking clients to learn to love their bodies by dismissing body dissatisfaction as a purely cognitive distortion. for all of our clients (especially trans and gnc people of color) the body exists within a social, political, and historical context that has been a place of both power and violence. ( p. 79) sula malina columbia social work review, vol. xix | 153 152 | columbia social work review, vol. xix eating disorders within transgender populations by rejecting the “medical model” of mental health in favor of a “social model,” practitioners can identify the sociopolitical forces culpable for both gender dysphoria and disordered eating. acknowledgement of this reality requires that clinicians guide clients through the simultaneous processes of mourning and behavioral shift. as kosciewicz et al. (2020) write, “this tolerance for the uncertainty, the unknowability of the outcome of mourning, is crucial to the treatment of clients who are reliant on disordered eating behaviors to defend against the body/psyche disjuncture” (p. 69). utilization of the minority stress framework is one component of anti-oppressive practice, which emphasizes the very real implications of socially constructed (but historically enacted) gender identity and cissexism. limitations existing research on eating disorders among transgender populations is significantly lacking, and that which does exist centers almost entirely on the experiences and diagnoses of white transgender youth. in order to begin to understand the impact of interlocking systems of oppression on transgender people of color, disabled transgender people, and those with other compounding marginalized identities, researchers must dedicate energy to the intentional recruitment of diverse respondents. additionally, current research largely omits experiences of transgender adults, greatly limiting opportunities for eating disorder professionals to develop best practices when working with those beyond adolescence. though many sociopolitical factors driving eds are consistent across age groups, transgender adults may be rendered further vulnerable to disordered eating behaviors if these are driven by gender dysphoria and medical transition has already been “completed.” indeed, much is left to learn regarding the treatment of gender dysphoria for those who have seemingly reached the “limits” of what physical transition (hormonal and surgical) can provide. conclusion this review of existing literature reveals that people who are transgender are disproportionately impacted by disordered eating due to forces that extend far beyond the “purely psychological” (koscieweicz et al., 2020). social workers, who embrace an anti-oppressive, “social model” of mental health, are uniquely positioned to advocate for and provide affirming, evidence-based interventions (koscieweicz et al., 2020). such interventions reject negative body image related to gender dysphoria as “purely cognitive distortions” and ground treatment in the validation of transgender clients’ lived experience with forces of oppression (koscieweicz et al., 2020). in this sense, social workers have the opportunity not only to address the unique needs of individual clients, but also to carry forward the work of activists past and present committed to dismantling cissexism, racism, sexism, and other forces of oppression in society at large. references arcelus, j., mitchell, a. j., wales, j., & nielsen, s. 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(2018). people of color and eating disorders. https://www.nationaleatingdisorders.org/people-color-and-eating-disorders national lgbt health education center (2018, february). addressing eating disorders, body dissatisfaction, and obesity among sexual and gender minority youth. the fenway institute. https://www.lgbthealtheducation.org/wp-content/ uploads/2018/04/eatingdisordersbodyimagebrief.pdf sula malina columbia social work review, vol. xix | 157 156 | columbia social work review, vol. xix eating disorders within transgender populations neda. (2018). people of color and eating disorders. https://www. nationaleatingdisorders.org/people-color-and-eating-disorders spack, n. p., edwards-leeper, l., feldman, h. a., leibowitz, s., mandel, f., diamond, d. a., & vance, s. r. (2012). children and adolescents with gender identity disorder referred to a pediatric medical center. pediatrics, 129(3), 418-425. doi: 10.1542/ peds.2011-0907 strings, s. (2019). fearing the black body: the racial origins of fat phobia. nyu press. witcomb, g. l., bouman, w. p., brewin, n., richards, c., fernandez-aranda, f. & arcelus, j. (2015). body image dissatisfaction and eating-related psychopathology in trans individuals: a matched control study. european eating disorders review, 23(4), 287-293. sula malina sula malina (they/them) is a masters of science in social work candidate at columbia school of social work in advanced clinical practice, concentrating in health, mental health, and disabilities. sula holds a bachelor of arts in gender & sexuality studies from bryn mawr college. they work as a social work intern at the gender & sexuality therapy center in new york city. originally from cambridge, massachusetts, sula lives in manhattan. journal2011 ! 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n+3&%'5!<=!n=5!_!:+-e?5!<=!,=!osxxap=!$%'&d!?2&9b;2g&2-f!*;!%&d2/! +d'&f?!)2!+!g2/*+f/*-!?c;d/%(2k!c/4-&2#+/$+)0"+=<"-*(2&+ h"-*2)-*(.+!/(*")57+eoowp5!jirjj"s=+ 12c2?b]/f*^5!$=!m=!osxxrp=!c*%g2;2?!?c;d/%(2f!\e2!?2&9b;2g&2-f! 2&d2/&c=!p/<9-"0"&.*3"+80"-2955+i?osp5!rr@jrsr=! ,2//+;%5!8=!n=5!:+f%//25!8=!<5!v+f^5!<5!_!<%;f+;2?5!8=!osxx"p!:*92! /23*24!fe2/+hc!'?*;g!+'f%)*%g/+he*-+&!/2f/*23+&!h/+-f*-2! 9%/!%&d2/!+d'&f!4*fe!d2h/2??*32!?c(hf%(+f%&%gc=!>.5(0/#% /'5+2&,++='*&'5+dfosp5!s@sjs@@=! ! ! ! ! ! ! ! ! ! ! ! ! # # provoking discomfort: a theoretical analysis of racism at columbia university school of social work 5 triggered by differing responses of columbia university school of social work students to a recent hate crime at neighboring teachers college, this paper explores evidence that parts of the student body may, through lacking awareness of its own prejudiced tendencies, be acting out subtle racism and perpetuating the very ethnic divides that fuel racist aggression. the paper argues that fear and an underrepresentation of minority students impede the real dialogue necessary to overcome such aversive racism but contends that the introspective and emotionally honest debate which has followed in the wake of the hate crime offers a window of opportunity for change. steps need to be taken to build the self-reflection witnessed in ensuing forums into the school curriculum and ensure that all graduating students are similarly provoked to the necessary understanding of our individual role in sustaining or combating prejudice and segregation. only in this manner can we hope to overcome racism as a whole and become the social work practitioners we aspire to be – capable of resolving the conflicts and tensions within us, as well as around us. he recent hate crime at columbia university teachers college, in which a noose was found outside the door of a black professor (o’connor, 2007), sparked an outpouring of responses from the university community to what most considered a deplorable act of racism. at the columbia university school of social work (cussw), a series of forums was arranged in the ensuing days to allow for students and teachers to come together and discuss the event and how it impacted them. as a participant in one of these meetings, i was simultaneously delighted and surprised at the content and form of the dialogue. roughly half of the participants in the forum were “non-white,” a large overrepresentation compared to the number in the school as a whole. i took this to mean that the people present at the forum were those most affected by or interested in the issues of prejudice and racism. while it was quickly evident that everybody present deplored the incident, two diverging responses manifested among participants in the dialogue. on the one hand, a group of people felt strongly that a public response was needed to andreas ring t provoking discomfort: a theoretical analysis of racism at columbia university school of social work provoking discomfort 6 journal of student social work, vol. vi a n d r e a s r in g outwardly express to the community our school’s condemnation of the racist act. this group’s response apparently echoed similar sentiments evident in other parts of the university, as students in the following days received a number of emails in which administrative university leaders expressed their denunciation of the hate crime. although students at the forum planned to go further than writing an additional email – they planned for a rally – their response was similarly focused on publicly distancing themselves from the racist act. the second, and in my view more interesting, response from forum participants argued against focusing on this particular incident and seemed to consider the rally somewhat of an overreaction. this group, consisting largely of people of color, argued that the noose incident was neither surprising nor new, and that such incidents happen all the time. they argued that instead of focusing on one overt act of racism, which everybody agrees to condemn anyway, we should address the many slighter acts of racism that go undetected every single day, even here at our own school. some participants of this group suggested a more introspective approach to addressing racism, which focused on training students in racism awareness. different models of awareness training were suggested, ranging from voluntary workshops for those most interested to mandatory training for all first-year students. interestingly, it was the “public condemnation” model of the first group that seemed to win the most popular support. having argued in favor of the introspective approach of the second group, i considered whether the lack of support for this approach reflects eagerness to point out the faults of others, and hesitance to look at our own. from previous exposure to anti-racist teaching, and from readings in my professional identity class, i realize that the diverging views of the two groups are not new. laymen and scholars alike have suggested for some time that racism is much more than the overt and hateful acts of skinheads, ku klux klan members, or angered youth. it is tempting to focus on the violent and aggressive acts such as noose-hangings, since the majority of us can agree that they are wrong and the blame is so conveniently located outside ourselves. many anti-racist authors ask us to look in our own hearts, however, to see how our inner biases and understandings of the world help to perpetuate a racist thinking and agenda. i believe we must turn to such authors in order to critically evaluate the first group’s view of racism as something located outside cussw, something that we must distance ourselves from through public displays of condemnation. these authors remind us that framing racism in this manner – as blatant and overt acts 7 a n d r e a s r in g of aggression – and defining ourselves in opposition hereto as “anti-racists,” represents an overly simplistic understanding of the nature of racist influence on society. distancing ourselves in this manner not only disregards the importance of addressing the many minor acts of racism that go unchecked every day, but also undermines the possibility of overcoming racism as a whole by failing to address our own inner biases and prejudicial actions, thus ignoring our role as system-actors in maintaining the status quo. they posit that racism must be understood more generally – as any individual act, intentional or not, and as any institutional policy or practice which has the effect of excluding or disadvantaging a particular ethnic group. it is when we accept this broader understanding of racism that it becomes clear how we ourselves, through our actions or words, may be inadvertently perpetuating perceptions and stereotypes that sustain racist, societal practices. the argument is aptly illustrated by the work of constantine (2007), the african american, female professor at teachers college targeted by the noose incident, who in her responses to the event has addressed what she calls the microaggressions that perpetuate a racial divide. based on her studies of cross-cultural counseling, she defines microaggressions as the “subtle and commonplace exchanges that somehow convey insulting or demeaning messages to people of color” (constantine, 2007, p. 2). as everyday examples of microaggressions against african americans, she mentions being ignored by salesclerks in favor of white customers, and being mistaken for service personnel in stores. professor constantine prompts us to remember that when we fall into the role of micro aggressors, we are often blissfully unaware of the oppressive impact of our actions. such aggressions are often the unintended, clumsy, but hurtful actions of people who do not consider themselves to be racist; actions characterized by “whites’ harboring of unconscious or preconscious negative racial feelings and beliefs towards people of color, despite the fact that they may perceive themselves as egalitarian, fair, and nonracist”(constantine, 2007, p. 2). constantine defines this less obvious but no less harmful form of racism as aversive racism. exploring the diverging views of the two forum groups through the lens of constantine’s research, i have to wonder whether it is a lack of awareness of our propensity to engage in microaggressions that lends the greatest support to the outward-oriented and condemning response of the first group. everybody can agree that hanging a noose on someone’s door is deplorable, but not everyone agrees with the second group’s contention that we must also examine ourselves for microaggressions, in order to combat racism as a whole – probably because the very nature of microaggressions implies that we are unaware of their presprovoking discomfort 8 journal of student social work, vol. vi a n d r e a s r in g ence in our actions. constantine’s framework reminds us that, because we tend to be blind to our own prejudices, we often end up addressing the overt racism of others and leaving our own more subtle racism unexplored. microaggressions may hardly register in the mind of a perpetrator – examples from daily life at cussw could include the unconscious tendency to overlook a particular ethnic group when choosing a partner for a class assignment, or the instinctive assumption that a student of color must be attending school on a scholarship. small as such insults may seem in comparison to noose-hangings, constantine cautions us not to ignore the accumulated impact of repeated and sustained prejudiced aggressions over a lifetime on the self-worth of a targeted individual. without a devoted effort to scrutinizing ourselves, our tendencies to engage in microaggressions can be hard to self-correct. ironically, our inability to address our own prejudice may be perpetuating the very racial divide that fuels the larger aggressions we leap to condemn, by implicitly sustaining the “them” and “us” mentality at the root of ethnically-based violence. building on such a framework of racist understanding, favaro (2004) has written a provocative reflection paper on the presence of aversive racism at the school of social work. she suggests, based on her own experiences as a student there that cussw is infused with its own share of subtle, racist thinking. building her argument on examples of prejudiced thinking at multiple levels in the school, favaro argues that both students and faculty alike display tendencies of aversive racism. among the student body, she points out the exaggerated fears of her fellow, white classmates when walking through minority neighborhoods as an example of a skewed perception of people of color. in the classroom, she puts forth an instructor’s avoidance of meaningful discussion about racism when class content is challenged by students as “racist propaganda” to exemplify how instructors are unaware of and susceptible to subtle racism themselves. at a collective or administrative level, favaro points to the lack of anti-racism workshops, classes, and field placements as evidence for the tacit acceptance of the status quo by the school, and challenges administrators to look to other schools of social work that have been more progressive in including anti-racism education in the curriculum. while i am left with little doubt that favaro has a firm antiracist mindset which may influence her perception and interpretation of events, the data that she presents us with is at least worth exploring. moreover, favaro’s observations are similar to those that i have made during my time at cussw. most visibly, consider why there is a black caucus, a latino caucus, and an asian caucus at the school – but no white caucus. most students would probably respond that we do not need a white caucus, but wherein then lies 9 a n d r e a s r in g the need for a black, latino, and an asian caucus? it can be argued that their purposes are to serve the ethnic communities, in principal leaving them open to students of all colors, and yet they tend to be predominantly made up of students of one particular ethnicity. in a society continually struggling with racism, such self-segregation must inevitably prompt us to question the extent to which we are successful in bridging our ethnic divides. do some black, latino, and asian students at our school feel the need to consolidate in ethnic groups above and beyond their desire to serve a particular ethnic community and, if so, why? does their consolidation result from a desire to immerse themselves in their culture and learn from and be inspired by other like-minded individuals – or is consolidation a result of external pressure, such as microaggression from the surrounding community? tatum’s insightful analysis, aptly entitled “why are all the black kids sitting together in the cafeteria?”, reminds us that the self-segregation of minority students commonly observed in school settings is a product of students defining themselves first and foremost in terms of their race or ethnic background. further, tatum suggests from years of clinical experience with bridging racial divides that ethnic consolidation may be the outcome of an oppositional response born from consistent exposure to perceptions of stereotyping and racist behavior, an oppositional stance which “both protects one’s identity from the psychological assault of racism and keeps the dominant group at a distance” (tatum, 1997, p. 60). tatum’s analysis urges us to bear in mind that the selfsegregation observable at the school may also be a response to perceived racism or lack of understanding and congruence with the residual community. it is my impression, from the conversations i have had to date, that tatum’s analysis may well be applicable to cussw. if so, what does this tell us about our supposed social work ability to be all-inclusive? are we successfully role modeling the non-judgmental and non-aggressive behavior we purpose to inspire in our clients – or does our own interaction reflect the very same patterns of fear, prejudice, and microaggression that characterizes society around us? more than the evident racial and ethnic segregation among students in the school, i remain dumbfounded that nobody seems to talk about it. debates on racism at the school seem to be impeded by a combination of high-sensitivity and raw emotion on the minority side, and a combination of insensitivity and a fear of stepping on toes on the white side – as a recent example from class illustrates. in a class discussion of racial identity, an african american friend of mine was asked by a white classmate why african american people were allowed to use the “n word” when white people were not. my friend’s response, presumably fueled by a perception of provocative intent and insensitivity on the provoking discomfort 10 journal of student social work, vol. vi a n d r e a s r in g part of the classmate, was a clever and not too friendly retort, which effectively closed the conversation. sadly, such non-conducive exchanges are not unusual at the school, and often fail to provide the more profound dialogue on racism which may mutually enrich both parties. even moderated class discussions tend to run awry, as favaro’s example and my own experiences testament to. all too often, discussions that touch upon race and racism are avoided in the classroom setting by instructors and students alike, rather than openly explored. sue’s (2006) model of racial and cultural identity development provides a theoretical underpinning that may explain self-segregation and students’ problems discussing it. based on his work with cross-cultural counseling, sue developed his model of racial and cultural identity development to describe how people of color and whites come to terms with their own inner racism or exposure to discrimination. briefly, people tend to go through five stages in dealing with their inner racism before they transgress on to a state of introspection and comprehensive awareness. the first stage is one of denial; white people refuse to acknowledge their active role in racism and explain it away for example with reference to “natural” tendencies for some races to be more hard-working, while minority groups deny that they are subjects of racism and subordinate themselves to the believed superiority of the dominant culture by taking on its values and perceptions, thus giving rise to derogatory terms such as “oreo” – black on the outside, white on the inside. this is the stage in which microaggressions are most prevalent as both whites and minority groups deny or denigrate the stereotyping and hurtful impact of prejudiced words and behavior. stage two begins when an event or a person challenges the individual’s belief system and prompts them to begin questioning their racial understanding and perceptions of racial groups. both whites and minorities are confronted with identity confusion at this stage, as they begin to see their active role in, or subjection to, racism. people who laugh along at the stereotyping jokes made by others, for example, start to see how their passive acceptance of racist behavior can be as harmful as active participation. in the third stage, the turning point, those who do not digress from confusion back into denial are now presented with feelings of anger and guilt as they come to an increasingly fuller understanding of their past participation in culturally sanctioned racism. for both minorities and whites, this anger tends to manifest itself as a fierce and sometimes generalizing rejection of white, “racist” society, coupled with a desire to be immersed in or learn more of minority culture. minorities tend to experience this as an almost global anti-white distrust or dislike, which often leads to a strong consolidation in ethnically based groups. whites on the other hand experience this as self-anger and 11 a n d r e a s r in g guilt and tend to seek out minority cultures with which to identify – efforts which are often rejected as paternalistic or over identifying by minority cultures. the subsequent stage four involves a more introspective role, in which minority and white individuals develop a more balanced appreciation for the strengths of all cultures alongside a maturing awareness of racism and oppressive social structures. finally, stage five comes to a state of integrative awareness, which involves acceptance of one-self as a cultural being and a deep commitment to eradicating oppression of all forms. using sue’s model as a framework for analyzing racism at cussw, several of the above discussed observations seem to indicate that we have quite a way to go yet as we seek to increase our racial and cultural self-awareness as a school. the split of the student caucuses along ethnic lines indicates the consolidation of minorities, which is characteristic of stage three in sue’s model. the lack of open discussion on racism due to a combination of high-sensitivity and insensitivity points to a student body generally caught somewhere between the anger and dismissal of stage three and the denial and microaggression of stage one, respectively. finally, the minor support for an inward-looking response to the noose-incident hints that only a small body of students are actively focused on an introspective approach representative of those in stage four or five of sue’s model. using this cursory analysis of student interaction at the school, the majority of students seem to be located in the early phases of racial identity development, somewhere between stages one and three, struggling with the accompanying sentiments of denial, confusion, and anger. while these struggles are a natural part of any student’s racial identity development, is it not surprising that favaro (2004) experienced that racism is neither acknowledged nor dealt with appropriately at the school. a cocktail of such strong emotions hardly produces the most conducive environment for debate. admittedly, this analysis is based on cursory and potentially biased evidence obtained by favaro (2004) and myself. supposing that the analysis accurately captures the current state of affairs at cussw, what can we do to change this? favaro challenges us to be proactively searching for the growth and selfawareness necessary to move beyond our aversive racism, and calls for debates and workshops on anti-racism to sensitize people to the impact of prejudice at the school. referring to the instructor who neglected to explore a student-initiated discussion on racism, favaro brings to our attention a critical barrier, however: “i sense that many students yearn to discuss context and impact, but without a catalyst or encouraging environment, conversations dealing honestly and frankly with race are not permitted to exist” (favaro, 2004, p. 57). her sentiments provoking discomfort 12 journal of student social work, vol. vi a n d r e a s r in g closely mirror my own as well as those i have heard expressed from several other students. on some topics, open and honest discussion seems to be more the exception than the rule, as exemplified by my last professional identity class, in which our discussion of the then-recent noose-hanging incident sparked a debate somewhat beyond the usual level of intensity. here, i recall students expressing pleasure at what they felt was an unusually honest and emotional expression of opinions, moving beyond what was often experienced as a superficial and politically correct dialogue. “politically correct” is a term i often hear used to describe the in-class conversations that take place at cussw – and most instructors do not seem eager to push us further. why are discussions on race and prejudice so hard to have? based on decades of work with overcoming racism, tatum (1997) offers consolation that we are not unique in our struggle with bringing these sensitive topics to the table. tatum identifies what she calls the “paralysis of fear” when it comes to speaking out on racial issues; a fear which affects all parties involved. minority students still in the early stages of exploring their racial identity may be genuinely afraid of rejection if they release the anger that has been held back. some white students may be unable to empathize with the pent-up anger that can emerge from minority students, and may react defensively or evasively to the sometimes sweeping criticism of racist, white society, leading to either explosive discussion or no discussion at all. other white students may empathize, but be hesitant to engage in debate with minority students for fear of stepping on toes by inadvertently asking inappropriate questions. feeling naïve in their questioning and ill-prepared to debate such a sensitive topic compared to minority students, who have often been exposed to these topics from an earlier age, white students may seek to steer around such debates altogether, despite a possibly genuine interest in bridging racial divides. instructors and administrators, no less human, may feel obligated to protect students from discussions they fear can spiral out of control and damage relationships beyond repair, or they may feel ill-equipped to moderate such challenging dialogues and tend to avoid them altogether. tatum’s response is unmistakable, however. to combat racism, we need to overcome our fear of openly addressing the issue: “in order for there to be meaningful dialogue, fear, whether of anger or isolation, must eventually give way to risk and trust” (tatum, 1997, p. 200). she adds from her work with one woman: ‘yes, there is fear,’ one white woman writes, ‘the fear of speaking is overwhelming. i do not feel, for me, that it is fear of rejection from people of my race, but anger and disdain from people of 13 a n d r e a s r in g color. the ones who i am fighting for.” in my response to this woman’s comment, i explain that she needs to fight for herself, not for people of color. after all, she has been damaged by the cycle of racism, too, though perhaps this is less obvious. if she speaks because she needs to speak, perhaps then it would be less important whether the people of color are appreciative of her comments. she seems to understand my comment, but the fear remains (tatum, 1997, p. 194). tatum’s experience in bridging racial divides is central to understanding the importance of the crossroad we stand at now. i believe that it is the open dialogue she asks for that we must increasingly strive to sustain at our school in order to come to a deeper understanding of race, racism, and oppression. all of the authors discussed above implore us to recall that aversive racism by its very nature is elusive, and that the danger lies in our tendency to overlook or deny our own prejudiced thinking. favaro (2004) and tatum (1997) univocally call for the instigation of real and open-hearted discussions at the school as the single, direct measure to overcoming racism and prejudice, while simultaneously pointing to the danger that fear will restrain the emergence of any real dialogue. the noosehanging incident, however – unpleasant as it was – may have provided us with the very catalyst necessary for students to move past their apprehension and fear to engage in an honest debate on these difficult issues. although the subsequent forums showed us that we differ in our perceptions of the nature and cures of racism, they also allowed the participants the opportunity to wholeheartedly share these views and to grow in self-understanding from observing and reflecting upon their differences. it is critical that we continue our progression along this path. if the forums inspired by the noose incident become a temporary high in our ability to talk openly about sensitive issues which then dies out, we will have failed to take advantage of an opportunity granted us to inspire our collective, personal growth and to address one of the fundamental and difficult challenges our school faces. we have to ensure that this event becomes the catalyst favaro asked for, which inspires students to take self-awareness training, especially pertaining to their own stereotypical treatment of those who are different from themselves, to a new and sustainable level. columbia already has a reputation for being a predominantly white university and we cannot, as a school of social work sending our students to work with mostly minority clients, afford to be seen as racially unaware or insensitive. it is the impression of favaro, myself, and other students i provoking discomfort 14 journal of student social work, vol. vi a n d r e a s r in g have spoken with that racism is not dead at cussw – it is alive, although subtle, and students sense this. the problem is unlikely to go away by itself. we have to create forums in which white students are allowed to say the wrong thing, minority students are allowed to vent the anger that may emerge, and both sides may learn to forgive each other and move on, strengthened in a renewed and deepened understanding of each others needs and basic humanity. cussw faculty should understand the key role they can play here in submitting students to open and honest classroom discussions on racism, helping us to challenge our own prejudiced ways of thinking and bridging the divides. because it is unawareness that fuels microaggression and aversive racism, faculty must recognize that students may need to be pushed to the level of confusion and discomfort necessary to induce growth. importantly, this demands of instructors that they are not afraid to deal with the denial, confusion, and anger that may emerge, and that they place faith in students’ ability to reflect, reconcile, and grow through the process. by staging in-class discussions on the issues of race and racism which students have trouble exploring, and playing devil’s advocate if need be, faculty can uniquely contribute to identify unrecognized prejudices and provoke the discomfort necessary to bring about a change of perception. the challenging dialogues initiative to increase instructors’ comfort in managing student discussions is an important step towards furthering in-class dialogues, which may be bearing fruit. i have witnessed some faculty members successfully conduct staged classroom debates on racism that were widely commended by attending students, and i sense other faculty members attempting the same. despite the positive responses from students, however, such methods are inconsistently applied across classrooms, and many faculty members still seem uncomfortable moderating debates on racism. administration could take a stand on tackling these difficult issues by organizing an anti-racism conference at the school of social work. a full-day event on anti-racism would unmistakably alert students and faculty to the significance of the topic and build a powerful foundation of interest, discussion, and inspiration from which to proceed. in light of the recent hate crimes at columbia, a conference would also send a valuable and resolute signal to the outside community that cussw is committed to taking a lead role on anti-racism and cultural competence. anti-racist pioneers, including any of the authors quoted in this article, could be invited to speak to students and faculty from cussw and affiliated schools such as teacher’s college on their perception of aversive racism and its cures. ethnically-based student caucuses and coalitions should be encouraged to involve themselves by arranging events and raising awareness. in the days 15 a n d r e a s r in g provoking discomfort following the conference, anti-racism educators such as the people’s institute for survival and beyond could arrange workshops for those students and faculty members passionate about anti-racism, specifically designed to challenge them to grow to a more complex understanding of their own prejudicial biases. sincere considerations should also be given to expanding the self-awareness training day from one day to three or four whole days, spread out on multiple workshops throughout the program. the current training day is a start towards instilling reflections on power, privilege, and racial identity in students but it cannot stand alone, particularly in light of the emphasis that the school places on self-awareness and cultural competence. while other initiatives such as community days and forums arranged throughout the year provide additional opportunities for reflection, these do not allow for the rigorous and incremental self-development that a repeated program of mandatory workshops would. community days and forums are largely voluntary and will tend to attract the students who are already attuned to the topic, leaving those “unattuned” without consistent training. to live up to our ambitions on self-awareness, we need a mandatory program of repeated workshops which may build upon the seeds that were sown in the beginning of the year. the problem we face is designing a curriculum to encompass a body of students in widely different stages of racial identity development, but work is currently in progress on how to solve this problem and improve the training for next year. importantly, administration should take charge of conducting a comprehensive survey of the student body’s experience with racism and prejudice. the arguments put forth in this paper are based on cursory and circumstantial evidence, yet coupled with favaro’s (2004) paper, a pattern emerges. surprisingly, very little hard data exists and no consistent surveys have been undertaken to document the extent to which students echo the sentiments presented here. a truly informed debate on the issue – and any real acknowledgement or disproval that subtle racism exists at cussw – would require a more complete understanding of the experiences of the student body, in particular students of color. we have the practitioners and know-how at the school to undertake such a study, so it should not be for lack of expertise that the data is not provided. the risk that embarrassing figures may emerge can only be reason to hasten the process, so any existing issues may be addressed sooner rather than later. care should be taken not to relegate responsibility for reform initiatives to student groups like the black and latino caucuses. as argued by the authors cited in this paper, racism is not a minority problem to be solved by minority champions but a communal problem, sustained by and affecting all parties and 16 journal of student social work, vol. vi a n d r e a s r in g resolved by all parties working together. student groups such as community organizing against racism (coar) and cross-caucus initiatives like coalition for action and awareness on race and ethnicity (caare) that have emerged (and reemerged) in response to the noose-hanging incident are an important step towards a self-reflective and multi-ethnic student response to addressing school racism which deserve our attention and support – and yet without substantial like-minded effort from other parts of the school, these groups are hard pressed to create any lasting change. student-led initiatives are inexorably prone to decline when the initial excitement wears off and interest shifts in favor of another topic, leaving often only a small core group to lift the burden. the responsibility for addressing racism at cussw is too great to leave to the fleeting support that a student initiative can muster. in the end, what we need is a joint student, faculty, and administration-led reform initiative – charged with inventing and implementing the tools necessary to address racism at the school, and instituting anti-racism training as a core part of the social work curriculum. faculty and administration need to bring further support to the burgeoning anti-racist movement, recognizing that they too may need training in order to deal with their own biases and microaggressions. we, as students, need to take individual responsibility for our role in acting out or perpetuating aversive racism and be willing to leave our comfort-zone and talk about race and racism. we need to deal with our discomfort on this issue, because if we leave the school and have not learned to address our own, inner prejudices, and then who are we to pretend that we can help other people live their lives? if we graduate without learning to honestly and fearlessly address the unspoken, ethnic tensions among our own student body, how can we hope to resolve the conflicts and heal the wounds of the communities around us? only by engaging in the painstaking self-scrutiny and difficult dialogues can we hope to overcome these challenges and become the social work practitioners we aspire to be – capable of resolving the conflicts and tensions within us, as well as around us. references constantine, m. g. (2007). racial microaggressions against african american clients in cross-racial counseling relationships, journal of counseling psychology 54(1), 1-16. favaro, j. (2004). reflections of racial consciousness in social work, journal of student social work 2, 53-61. o’connor, a. (2007, october 10). hate-crime investigation at columbia. new 17 a n d r e a s r in g york times [online]. retrieved february 9, 2008, from: http://www. nytimes.com. sue, d. w. (2006). multicultural social work practice. hoboken, nj: john wiley & sons. tatum, b. d. (1997). “why are all the black kids sitting together in the cafeteria?” and other conversations about race. new york: basic books. andreas ring is a first year master’s student at cussw within the policy practice method, in the international social welfare and services to immigrants and refugees field of practice. he is currently interning in a middle school in the south bronx doing individual and group counseling. he holds a master’s degree in economics from new york university and another from university of copenhagen, denmark. his e-mail address is ar2549@columbia.edu. provoking discomfort journal of student social work, volume vii 33 / pesso fencing fears: the united states border fence and the responsibility of social workers jen scott the october 2006 secure fence act permitted the construction of over 700 miles of double reinforced fence along the united states-mexico border. while perhaps not the one intended, the fence is having an impact: the death of migrants attempting to cross the border has increased and the construct of “illegality” is being reified, heightening the insecurity of individuals who live in the u.s. with illegal or undocumented status. in addition, the fence can be understood as a statement of exclusion that leads to the further erosion of societal unity among the people who live within the u.s. borders. this paper contextualizes the political discourse that presumes that the construction of a wall is a viable solution to national concerns about migration and security in the history of cross-border migration and legislation. in so doing it analyzes the fence by delineating its effects on undocumented migrants and the power imbalances already evident within the larger u.s. society. finally, it concludes by asking social workers to act in accordance with their obligation to promote social justice. in october 2006 the united states congress passed legislation that symbolically defines its current policy with regard to the country’s southern neighbor. the secure fence act permitted the construction of over 700 miles of double reinforced fence along the u.s.-mexico border (secure fence act, 2006). this policy was not a deviation from the norm: some form of border policing has been in place since the creation of the border patrol in 1904. the official “birth” of the modern fence can be traced to 1990, when the u.s. border patrol began constructing a barrier known as the “primary fence” on the california border (nuñez-neto & garcia, 2007). the first 14 miles of journal of student social work, volume vii 34 / fencing fears fence, completed in 1993, served as the “model” for the current fence project (nuñez-neto & garcia, 2007). the latest construction strategy, the southwest border fence project, is part of the u.s. department of homeland security’s secure border initiative that committed to completing 670 miles of fencing by december 2008 (dhsb, 2008). spanning the borders of texas, new mexico, arizona, and california, much of the planned fence construction has been completed. further plans include building through a number of major towns and across american indian nations, restricting rights previously protected by both the u.s. and mexican governments (seper, 2008). policies regarding fence construction and other forms of increased border enforcement have resulted in excessive spending and negative consequences for the people on either side of its boundaries. under the secure border initiative, the department of homeland security spent an estimated 625 million usd on 215 miles of fencing (government accountability office 2002, a). studies estimate that there have been between two and three thousand deaths along the u.s.-mexico border since 1995 (rubio-goldsmith et. al. 2006, 2007; gao, 2006). reports show that deaths along the border have doubled since 1995 (gao, 2006) and in 2005 a record 472 deaths were reported (nuñezneto, 2008). deaths along the border are predominantly due to conditions resulting from increased environmental exposure, including hypothermia and heat stroke, as migrants have been “funneled” into harsher terrain due to stricter u.s. immigration policies (rubio-goldsmith et al., 2006, 2007; gao, 2006; cornelius, 2001). while a complete historical analysis of u.s. immigration policy is beyond the scope of this paper, it is necessary to contextualize the problematic political discourse that presumes that the construction of a wall will resolve the complexities of migration and nationalism. this paper examines the fence from historical and legislative perspectives, analyzes its effects on undocumented migrants, offers a connection between the construction of the fence and power imbalances evident within the larger u.s. society, and asks social workers to act in accodance with their obligation to promote social justice. united states mexico border: history and migration the region of the us-mexico border has a complex territorial history. originally owned by several native american nations, after over 300 years of wars and purchases involving the u.s., spain, and mexico, the border was firmly established at its current location in 1853. journal of student social work, volume vii 35 / scott journal of student social work, volume vii initially, the u.s.-mexico border was poorly demarcated, sporadically policed, and easily traversed by migrant workers (massey, 2002). as it has become more “solid,” a complex interplay of socioeconomic and political forces on both sides of the border has come to shape who is and is not allowed to move across it freely. over time, the border has essentially come to represent the dividing line between the demand and supply sides of an international labor market. until immigration policy dramatically shifted in 1986, immigration from mexico to the u.s. reflected (or at least did not overtly prohibit) a pattern of circular migration. a variety of push and pull factors, linked to the economies of both states, influenced waves of migration during this period. mexican workers migrated, legally or otherwise, to the u.s. for temporary work and then returned home (massey, 2002). migrants would fill u.s. labor needs for a period of time, but did not settle permanently in great numbers (massey, 2002). laborers experienced cycles of both active recruitment from employers and active deportation from the u.s. government on several different occasions. various legal mechanisms, including guest worker programs, have facilitated this circular migration. the most well known, the bracero program, began in 1942 and provided temporary visas to agricultural workers. highly contested due to reports of civil rights violations by u.s. employers, this program was repealed in 1964. while the passage of the immigration and nationality act in 1965 provided few legal mechanisms for temporary work, circular migration continued unabated (massey, 2002). the passage of the 1986 immigration reform and control act (irca) disrupted the characteristic pattern of temporary migration. the law discouraged immigrant outflow by promulgating policies of increased border security, fences, and actual or promised pathways to legal status (massey, 2002). by coupling amnesty policies with increased impediments to entry, the irca essentially made it more beneficial for undocumented immigrants to stay in the u.s., since reentry became more costly (in terms of money, time, and/or security). additionally, a precedent that continued residence could potentially result in the granting of amnesty and legal resident status was set. possibly for these reasons, many migrants who would have returned home for temporary vacations began to take up permanent residence in the u.s. after 1986, substantial growth in the undocumented population began to be seen (passel, 2005). there were also other factors that led to an increase in undocumented immigration in the 1980s, including the collapse of the mexican journal of student social work, volume vii 36 / fencing fears peso and the passage of the north american free trade agreement (nafta) (massey, 2002). a significant challenge presented by nafta is its failure to loosen restrictions on the movement of labor despite relaxing the movement of capital and goods across the border (massey, 2002). little has been done to address the facts that the economic and social conditions of the u.s. and mexico are still widely disparate, and that no viable system that permits sufficient or unrestricted movement of labor across the border has been implemented. thus, in response to the persistent high demand for labor by the u.s., and mexico’s willingness to supply, undocumented migration has continued. recent increases in barriers to entry, including the border fence, have only resulted in fewer immigrant departures. as of 2006, there are approximately 11.1 million undocumented people estimated to be residing in the u.s., a number that appears to be steadily growing (passell, 2006). border fence “justification” supporters of the border fence justify its construction with two main claims. first, that it is necessary in order to curb the flow of undocumented immigrants, and second, that it will prevent terrorism. the actual impact of the border fence, however, is more accurately seen in the increased death rate of migrants attempting to cross the border; reinforcement of the construct of “illegality”; and heightened insecurity of the large population of families and individuals who live in the u.s. with undocumented status. while reports from the border patrol and the department of homeland security (dhs) often claim that their border enforcement efforts have been somewhat successful in curbing the flow of undocumented migration, the number of undocumented immigrants entering the u.s. has increased (ackleson, 2005). whereas in the 1980s, approximately 130,000 undocumented persons arrived per year, in the period from 2000-2004, the number of yearly new arrivals was estimated to have increased to around 700,000 (passel, 2005). similarly, the trends in apprehensions of undocumented migrants found crossing the u.s.-mexico border--the measure dhs uses to estimate undocumented migration--do not necessarily connect construction of the fence to decreased migration. despite ongoing border fence construction, the number of apprehensions has generally increased steadily, only showing signifijournal of student social work, volume vii 37 / scott journal of student social work, volume vii cant drops during three periods: from 1996 to 1997, 2000 to 2003, and recently, in 2006 (dhsois, 2006, 2008). these periods of decreased apprehensions coincide with other events: the initial passing of the new immigration law in 1996, the attacks of september 11th and subsequent economic downturn, and the burst of the housing bubble and subsequent global financial crisis. given that undocumented migration began to increase steadily in-between these two downturns despite the continued construction of the fence, it would be short-sighted to conclude that the fence caused them. proponents of the border fence assert that it is a necessary precaution in the war on terror. supporters might argue that this is demonstrated by the fact that there have been no terrorist attacks on the u.s. since september 11, 2001. yet in order for a claim that construction of the fence is necessary for the prevention of terrorism to hold, a connection must be made between the fence and the absence of terrorism. however, no such connection exists. construction of the modern fence began in 1994, well before the terrorist attacks in 2001. additionally, the majority of hijackers involved on september 11 held doctored passports and visas, and none entered the u.s. by crossing the southern border illegally (national commission on terrorist attacks on the united states, 2004). finally, if the illegal entry of terrorists via land borders was a legitimate concern, there would be similar anxiety and advocacy for fence construction on the northern border with canada. instead, the northern border project consists of minimal surveillance initiatives and no significant fence construction (dhs, 2008). immigration legislation comprehensive immigration reform that both provides for the large undocumented population currently residing in the u.s. and creates a legal means by which future u.s. labor demands can be met is desperately needed. recent legislation, however, has predominantly focused on increased enforcement of border and labor laws and deterrence strategies, including the border fence. two legislative proposals that were recently passed, the real id act of 2005 (h.r. 1268) and the secure border fence act of 2006 (h.r. 6061), focus on “securing” the southern border as the means of controlling illegal migration. the real id act grants the department of homeland security (dhs) the power to waive certain laws that interfere with the construction of physical barriers at the border, and waives the governjournal of student social work, volume vii 38 / fencing fears ment from compliance with previous regulations imposed to protect environmental and indigenous rights. the secure border fence act, essentially an extension of many of the components of the real id act, authorized construction of 700 miles of double reinforced fence, security cameras, lights, and other measures to be used in order to protect and defend the southern border (h.r. 6061). several policies aimed at addressing undocumented immigration have since been proposed in congress, though none of them garnered sufficient support to become law. comprehensive immigration reform bills have been proposed both in the senate (as s. 1033, s. 2611, and s. 1348) and in the house of representatives (as the border protection, anti-terrorism, and illegal immigration control act of 2005, the secure america through verification and enforcement [save] act of 2005 and 2007, and the strive act of 2007). despite their inclusion of some provisions for undocumented individuals and temporary work visa programs, they all propose considerable increases in funding for secure border initiatives, in other words, for increased fencing along the southern border. impact of the border fence the gravest consequences of the fence are felt by those attempting to cross the border. construction of the border fence has funneled migrants into dangerous terrain, resulting in a dramatic increase in deaths along the border due to environmental exposure (rubio-goldsmith et al., 2006; nuñez-neto & garcia, 2007; ackleson, 2005; cornelius, 2001; government accountability office [gao], 2006). a 2006 u.s. government accountability office report indicated that the annual number of deaths of undocumented migrants along the border has doubled since 1995 (gao, 2006). the same report estimates that there were over 2,000 deaths between 1998 and 2004, and a 29% increase in the number of deaths in this period (gao table page 42, 2006). the construction of the border fence also impacts the undocumented population by reinforcing the social construct of “illegal” status. being illegal is not an inherent personal quality; it is a status resulting from a combination of immigration laws and economic opportunities. though some assert that those with “illegal” status are by nature more criminal because they arrived in the u.s. without authorization, undocumented people currently living in the u.s. have journal of student social work, volume vii 39 / scott not been found more likely to commit crime than the documented citizen population (rumbaut et al., 2006). evidence indicates that the undocumented population contributes substantially to the u.s. economy despite the fact that they are granted limited access to its resources. it is estimated that undocumented immigrants pay 80,000 usd more in taxes per capita than the amount needed to cover the costs related to their use of government benefits (smith & edmonston, 1997). these tax payments come from a combination of sales and property taxes, and “voluntary” income tax payments through income taxpayer identification numbers (itns) (instead of social security numbers), which require immigrants’ employers to make mandatory deductions from their pay (smith & edmonston, 1997). additionally, workers who use false social security numbers, largely undocumented immigrants, are estimated to contribute 7 billion usd to social security and 1.5 billion usd to medicare (national council on la raza, 2008). despite their significant economic contributions, undocumented immigrants face significant difficulties in the u.s. they are denied access to the majority of benefits that are afforded to documented residents and citizens. undocumented immigrants are ineligible for the majority of government benefits--public school education and emergency medicaid being the sole exceptions (prowra, 1996). though they may have the capacity and training, as a result of their status, undocumented immigrants are often prohibited from obtaining high skills jobs and thereby precluded from obtaining higher economic status. a final impact of the fence is that in reinforcing the construct of illegality, it furthers the reality that life as an undocumented immigrant in the u.s. means living in a state of perpetual awareness, if not fear, of detection and deportation. this is due to the reality of the u.s. immigration and deportation system as it now operates. in 2007 roughly 29,786 immigrants were detained by the u.s. immigration and customs enforcement (ice) daily (ice, 2007). a call to action for social workers social workers, as professionals bound by a code of ethics, are obliged to take action on problems created by the fence. specifically, the core social work values of social justice and respect for the dignity and worth of every person drive this obligation. the value of social justice requires that “social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of journal of student social work, volume vii 40 / fencing fears people” (nasw, 1996). respecting the dignity and worth of the person means that social workers are obligated to “promote clients’ socially responsible self-determination” (nasw, 1996). these values provoke questions with regard to the fence. does the border fence serve to promote social change and break down barriers that create vulnerable and oppressed groups, or does it reinforce further oppression and the vulnerability of a certain group of individuals? likewise, does the border fence respect an individual’s right to determine what is right and necessary to best promote his or her survival and that of his or her family? the code of ethics highlights that “social workers should engage in social and political action that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully” (nasw, 1996). as the border fence does not grant all people equal access to resources, then, as the code of ethics asserts, social workers should be expected to address this through social or political action. for those living closer to the fence, it is possible to become involved in efforts to directly prevent more deaths along the border. many agencies and faith-based organizations on both sides of the border currently offer relief to border crossers. policy advocacy provides another avenue for engagement, as immigration and unnecessary death on u.s. soil are national issues that all representatives can be pressed to notice. if nothing else, on a personal level, education of friends and neighbors with regard to the border fence can help create national awareness about the issues that the fence generates. social workers cannot “sit on the fence.” they must instead consider their ethical obligations in addressing the immensely complex reality of undocumented migration from mexico to the u.s. references ackleson, j. 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(2006). the“funnel effect” recovered bodies of unauthorized migrants processed by the pima county office of the medical and examiner, 1990-2005. binational migration institute: mexican american studies & research center at the university of arizona. rumbaut, r. g., gonzales r.g., komaie, golnaz, and morgan c.v. (2006). debunking the myth of immigrant criminality: imprisonment among first-and secondgeneration young men. migration information source. washington, dc: migration policy institute. secure fence act (2006). h.r. 6061, public law 109-367. seper, j. (2008). southwest tribe calls for end of border fence construction. the washington times. friday, july 11, 2008. retrieved from: http://www. washingtontimes.com/ news/2008/jul/11/southwest-tribe-calls-for-end-of border-fence-cons/ smith, j. p. & edmonston, b. 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' cswr spring 2022 columbia social work review, vol. xix | 131 cyborg liberation: donna haraway's cyborg feminism as an emancipatory model of identity nicholas d. tolliver 132 | columbia social work review, vol. xix cyborg feminism and social constructions abstract donna haraway’s concept of the cyborg is a radical archetype for emancipatory self-construction that models conscious reshaping of socially imposed identities. the cyborg represents the plasticity of our socially constructed identities: our ability to transcend the limits of prefabricated identities and overwrite oppressive, socially imposed roles. understanding social construction through this lens gives social workers and clients the conceptual tools to deconstruct rigid identities—particularly those of gender identity—imposed by society. these identities are the subject of active political contestation; they are the product of economic, social, and cultural relations and institutions. the concept of the cyborg provides an emancipatory model that kluh[\yhspalz�huk�klz[hipspalz�ypnpk�lzzlu[phspz[�ipuhyplz�huk�puz[lhk� yljvnupalz�[ol�joptlypj�t\s[pwspjp[`�vm�[ol�pukp]pk\hs� keywords: cyborg, social construction, identity, gender, feminism columbia social work review, vol. xix | 133 nicholas d. tolliver i u�[opz�whwly��0�[\yu�[v�+vuuh�/hyh^h`»z�(�*`ivyn�4hupmlz[v��� ���� as an emancipatory model for rethinking the social constructions of gender and identity. haraway’s concept of the cyborg model as a kind of disassembled and reassembled, postmodern collective and wlyzvuhs�zlsm�jhu�olsw�zvjphs�^vyrlyz�yljvujlw[\hspal�nlukly�pklu[p[`� and wider notions of the self in our era of hyper-reality.1 the cyborg model can facilitate exploration of gender identity and deconstruction of socially imposed2�uv[pvuz�vm�zlsm��;opz�myhtl^vyr�jyp[px\lz�[ol� mainstream, hegemonic3 assumption that gender is binary, static, and essential, and instead highlights gender’s dynamic existence throughout cultures and histories (morgenroth & ryan, 2020). identities are not merely collective fantasies; they are ideological products of hegemonic and counter-hegemonic social, political, cultural, and economic institutions and discourses. we must become cyborgs with respect to our collectively constructed identities and begin the process of modifying them to better serve us, embracing notions of the self that are inclusive and liberating. the social construction of gender .lukly�pz�h�ål_pisl��z\wlyz[y\j[\yhs�pklu[p[`�[oh[�pz�[ol�wyvk\j[�vm� cultural and socio-economic relations (storm & flores, 2019). in the social construction of both gender and race, dominant groups forcibly use visible physical features, such as skin color and primary or secondary sex characteristics, to create socio-economic and political hierarchies that mediate the relations of economic production and access to consumption (federici, 2009; fields & fields, 2009). 1 hyper-reality: when a simulation becomes as real or more real than the reality it is simulating; coined by jean baudrillard. 2 an example of hyper-reality is social media. refer to: j. morris (2020). simulacra in the age of social media: baudrillard as the prophet of fake news. journal of communication inquiry���������� ¶�����o[[wz!��kvp�vyn����������� ��� �� ������mvy�m\y[oly�pumvyth[pvu� on how social media can blur the division between our real and virtually simulated selves. 3 hegemonic: ruling or dominant in a political or social context. 134 | columbia social work review, vol. xix >p[opu�[olzl�iv\ukhyplz��[ol�l_wsvp[h[pvu�vm�[ovzl�pklu[pälk�hz�^vtlu� has played a central role in the process of capitalist wealth creation. according to silvia federici, women have been the producers and reproducers of the most essential capitalist commodity: labor-power. federici (2009) stated that “women's unpaid labor in the home has been the pillar upon which the exploitation of the waged workers, wage slavery, has been built, and [is] the secret of its productivity” (p. 7). the strict gender binary, established by heteropatriarchal capitalism,� is not simply a fabrication; it is an ideological apparatus whose function is to create a clear material division between the oppressor and oppressed. those deemed women by society were transformed into zljvuk�jshzz�jp[paluz�k\ypun�,\yvwl»z�svun�[yhuzp[pvu�myvt�ml\khspzt5 to capitalism. throughout this transition, women were economically disenfranchised, and their work was largely restricted to unpaid domestic and reproductive labor, making them dependent on men for their survival (federici, 2009, pp. 28, 73-75). cisgender, heterosexual tlu�vm�hss�jshzzlz�ilulä[lk�myvt�[ol�l_whuzpvu�vm�[ol�wh[yphyjohs� domination of women and violently policed perceived deviations from the social-sexual hierarchy. same-gender relationships and non-binary nlukly�l_wylzzpvu�[oylh[lulk�[olpy�h\[ovyp[`�i`�vɉlypun�hs[lyuh[p]l�^h`z� vm�sp]pun�[oh[�ylk\jlk�nlukly�pulx\hsp[`�huk�kpzy\w[lk�[ol�z[ypj[s`�kyh^u� lines created to reinforce asymmetries of power and wealth, further pujlu[p]papun�ol[lyvzl_\hs�tlu�z�tvuvwvs`�vm�kvtpuh[pvu� a materialist deconstruction of the ideological binary of gender members of the lgbtqi+ community, especially transgender and nonbinary people, threaten the heteropatriarchal order because they ��*hwp[hspzt!�zvjphs��wvsp[pjhs��huk�ljvuvtpj�z`z[lt�jylh[lk�huk�jvu[yvsslk�i`�^lhs[o`� z[yhpno[�tlu�^ov�ilulä[�myvt�iv[o�[ol�l_wsvp[h[pvu�vm�^vyrlyz�huk�[ol�vwwylzzpvu�vm� women and sexual minorities. 5 feudalism: a political-economic system in which the vast majority of land is owned by a small group of aristocratic elites and worked by a large class of economically self-sufäjplu[�zlymz��^ov�hyl�[plk�[v�[ol�shuk�huk�wh`�h�wvy[pvu�vm�[ol�wyvä[�myvt�[olpy�ljvuvtpj� surplus to the elite in return for protection in the form of rent (nicholson, 2018). cyborg feminism and social constructions columbia social work review, vol. xix | 135 transgress, blur, and ultimately destroy the clear-cut, historically jvuz[y\j[lk�nlukly�yvslz�\zlk�[v�thpu[hpu�vwwylzzpvu�huk�pulx\hsp[ �̀� ;opz�ohz�slk�[v�[ol�opz[vypjhs�thynpuhspah[pvu��wlyzlj\[pvu��huk�zpslujpun� of these groups by heteropatriarchal capitalist societies (storm & flores, 2019). those who are materially and ideologically invested in patriarchal supremacy use violence, discrimination, exile, ex-communication, shame, stigma, and cultural-historical erasure as tools of oppression [v�thpu[hpu�[ol�z`z[lt�vm�pulx\hsp[`�myvt�^opjo�[ol`�ilulä[��-lklypjp�� 2009). the gender nonconforming person threatens the dualistic categories established by the patriarchal socio-economic conditions of industrial capitalism. during the modern era, nations in the imperial core saw a shift from an economy fueled by industrial production to one driven by technological consumerism, resulting in the emergence of new social forces that have greatly aided the cause of lgbtqi+ liberation. the entrance of women into the u.s. workforce post-world war ii and the shift to h�zly]pjl��ruv^slknl��[ljouvsvn �̀�huk�äuhujl�ljvuvt`�hs[lylk�[ol� material conditions upon which the heteropatriarchal nuclear family was lz[hispzolk��*ohml[a� �/hnhu��� ����4h[lyphs�pujlu[p]lz�[v�thpu[hpu� the strict binary-gendered divisions of labor gradually diminished as the economy shifted from the manual labor of industrial and agricultural production to the immaterial labor of the neoliberal6 economy that arose after world war ii. the heteronormative gender norms of the 20th-century imperialist, capitalist system are becoming irrelevant in the world of virtual hyperrealities (turkle, 1997; kendall, 1998). while heteropatriarchal ideology remains an oppressive and exploitative force, emancipatory spaces have emerged, allowing new modes of resistance and means to live outside the dominant ideological structures. new avenues have emerged for wlvwsl�[v�hj[\hspal�[olpy�å\pk��]pzpvuhy`�pklu[p[plz�pu�ylzpz[hujl�[v�[ol� binary mode existent in heteropatriarchal ideologies and institutions. 6 neoliberalism: an economic system in which a society’s needs are met by capitalist thyrl[z�huk�wyp]h[ls`�v^ulk�äytz"�p[�ltwohzpalz�[ol�wyp]h[pah[pvu�vm�z[h[l�puz[p[\[pvuz��[ol� klyln\sh[pvu�vm�jhwp[hspz[�thyrl[z��[ol�nsvihspah[pvu�vm�wyvk\j[pvu��huk�nv]lyutlu[�h\z[lypty (harvey, 2005). nicholas d. tolliver 136 | columbia social work review, vol. xix ;ol�pu[lyul[�ohz�pujylhzlk�[ol�]pzpipsp[ �̀�pu[lyjvuulj[pvu��huk�vynhupapun� capacities of the lgbtqi+ community. a new cyber body politic has ltlynlk��h�yopavth[pj�jvsslj[p]l�[oh[�pz�kljvuz[y\j[pun�[ol�pklvsvn`�vm� binary gender and forging new relationships with gender identity and å\pkp[`�pu�j`ilyzwhjl�� cyborgs and social constructions the cyborg is a metaphor for an emancipatory model that deconstructs socially imposed identities. relating to oneself in a cyborg-like manner entails an epistemological shift away from previously dictated identity and towards a non-dualistic, boundless, chimeric identity in which once-rigid borders are permeable and the self becomes a bricolage. >opsl�wyl]pv\z�\uklyz[hukpunz�vm�pklu[p[`�ylx\pylk�z[h[pj�yvslz��h�j`ivyn� pz�hu�l]ly�\umvskpun�k`uhtpj�ilpun�[oh[�jvu[hpuz�johunl��ål_pipsp[ �̀� contingency, and multiplicity. cyborgs exist not just outside of the binary of man and woman, but also beyond that of human and machine. in a cyborg manifesto��� �����+vuuh�/hyh^h`�wyvwvzlk�[ol�j`ivyn� hz�h�jvsslj[p]l�hyjol[`wl�[oh[�jhu�z`tivspal�[ol�jvuz[y\j[pvu�vm�v\y� pu[lyzlj[pvuhs�pklu[p[plz�pu�wvz[tvklyu�zvjpl[ �̀�/hyh^h`�kläulz�[ol� cyborg as “a cybernetic organism, a hybrid of machine and organism, h�jylh[\yl�vm�zvjphs�ylhsp[`�hz�^lss�hz�h�jylh[\yl�vm�äj[pvu�¹�hkkpun�[oh[� “social reality is lived social relations, our most important political jvuz[y\j[pvu��h�^vysk�johunpun�äj[pvu¹��/hyh^h �̀�� ����w������;ol� cyborg is a subject without an original identity, unity, or natural essence; p[�[yhuzjlukz�l_pz[pun�ipuhy`�jh[lnvyplz��.yhoht��� ���/hyh^h`��� ���� stated that “the cyborg has no origin story in the western sense… an origin story in the 'western,' humanist sense depends on the myth of vypnpuhs�\up[`¯;ol�j`ivyn�^v\sk�uv[�yljvnupal�[ol�.hyklu�vm�,klu"7 it is not made of mud and cannot dream of returning to dust” (p. 2). *`ivynz�yljvnupal�huk�ltiyhjl�[ol�hy[päjphsp[`�vm�pklu[p[`�huk�hz�h� result are able to reconstruct and manipulate it, creating selves that exist 7 the garden of eden was the birthplace of humanity in the abrahamic faiths (judaism, christianity, and islam), a utopian place where god created man from dust (genesis 2:7). in the bible we come from dust, and we will return to dust (ecclesiastes 3:20). cyborg feminism and social constructions columbia social work review, vol. xix | 137 v\[zpkl�vm�[ol�vwwylzzp]l�zvjphs�z[y\j[\ylz�[oh[�zllr�[v�kläul�huk�sptp[� them. cyborgs invalidate existing systems of oppression by displaying [ol�å\pkp[ �̀�t\[hipsp[ �̀�huk�t\s[pwspjp[`�vm�pklu[p[ �̀�;oyv\no�yljvnupapun� [ol�hy[päjphsp[`�vm�nlukly�pklu[p[ �̀�^l�oh]l�iljvtl�¸l_jy\jph[puns`� conscious of what it means to have a historically constituted body” �/hyh^h �̀�� ����w������-vy�/hyh^h �̀�h�zopm[�vm�wlyzwlj[p]l�[v^hykz�h� cyborg-like understanding of identity development “might better enable us to contest for meanings, as well as for other forms of power and wslhz\yl�pu�[ljouvsvnpjhss`�tlkph[lk�zvjpl[plz¹��/hyh^h �̀�� ����w������ 6ul�vm�[ol�ptwvy[hu[�mhjl[z�vm�j`ivyn�sprl�pklu[p[plz�pz�[oh[�[ol�zlsm�jhu� be constructed through engagement with technology, media, and the hyper-reality of virtual space. *`ivyn�wvsp[pjz�hyl�vynhupalk�hyv\uk�hɉup[plz�hz�vwwvzlk�[v�ypnpk� identities, giving the individual far greater agency in the development of the self and new ways of connecting politically with others. as haraway �� ����^yp[lz! 0[�ohz�iljvtl�kpɉj\s[�[v�uhtl�vul�z�mltpupzt�i`�h�zpunsl� adjective— or even to insist in every circumstance upon the noun. consciousness of exclusion through naming is acute. identities seem contradictory, partial, and strategic. with the hard-won recognition of their social and historical constitution, gender, race, and class cannot provide the basis for belief in 'essential' unity… gender, race, or class consciousness is an achievement forced on us by the terrible historical experience of the contradictory social realities of patriarchy, colonialism, and capitalism. (pp. 5-6) /hyh^h`»z�hɉup[`�wvsp[pjz�pz�z\wlypvy�[v�pklu[p[`�wvsp[pjz�iljh\zl�p[�m\ss`� embraces the multiplicity, partiality, and intersectionality of human identities, whereas identity politics capitulates to the prefabricated, socially imposed identities given to us by systems of oppression and pulx\hsp[ �̀� cyborgs and the social reconstruction of identities the cyborg archetype proposed by haraway is an excellent lens through which social workers can explore identity development with nicholas d. tolliver 138 | columbia social work review, vol. xix clients in our postmodern, technologically mediated world. haraway's framework encourages clients to become active agents in the social construction of their own identities. technology has given us the jhwhjp[`�[v�kl[lyyp[vyphspal�v\y�vwwylzzp]l��zvjphss`�ptwvzlk�pklu[p[plz� and reconstitute them toward emancipatory and inclusive ends. the internet has expanded our ability to connect with others outside of our local communities and their particular political, economic, and social hierarchies, increasing our capacity to learn new information that can change our perceptions and understanding of ourselves and the world around us. today, many privately nonbinary or transgender people are h�jv\wsl�vm�jspjrz�h^h`�myvt�jvu[lu[�[oh[�jhu�pumvyt�huk�hɉyt�[olpy� sense of self. in our postmodern world, we have an opportunity to help our clients contest oppressive social constructions and reconstruct their identities in both the virtual and physical realms. conclusion donna haraway’s concept of the cyborg can help social workers by giving them a theoretical understanding of how socially imposed pklu[p[`�pz�h�[vvs�vm�z\iq\nh[pvu�^opsl�hszv�jlsliyh[pun�[ol�å\pkp[`�huk� opportunity inherent beyond those walls. the cyborg is a revolutionary archetype that avows the contradictions at the core of the subject. it can help social workers relate to the alienating contradictions of socially constructed identities such as gender and race while simultaneously championing the political agency of the subject and the liberating potential inherent to the self-directed construction of identity. the cyborg is a postmodern cyber übermensch8 that goes beyond social roles imposed by patriarchy and racism, and embodies the will to zlsm�jylh[l�huk�zlsm�kläul��*`ivynz�hyl�lunhnlk�pu�[ol�wvsp[pjhs�z[y\nnsl� of self-determination and self-emancipation. it is integral that social ^vyrlyz�yljvnupal�[oh[�zvjphs�jvuz[y\j[pvuz�hyl�uv[�pss\zpvuz�vy�mhu[hzplz� but instead are active sites of political contestation. the cyborg myth can encourage us to better help our clients understand and navigate ��)l`vuk�4hu!�h�jvujlw[�pu�[ol�wopsvzvwo`�vm�-yplkypjo�5pl[azjol�^opjo�[olvypalz�h�z\iject that creates and lives by their own values outside the repression of reactionary social ]hs\lz��5pl[azjol�������� cyborg feminism and social constructions columbia social work review, vol. xix | 139 jvuåpj[�wyvk\jlk�i`�zvjphss`�jvuz[y\j[lk�nlukly�pklu[p[plz�huk�uvytz� produced by our heteropatriarchal, capitalist society. references *ohml[a��1��:��� �/hnhu��1���� ����;ol�.lukly�kp]pzpvu�vm�shivy�huk�mhtps`�johunl� in industrial societies: a theoretical accounting. journal of comparative family studies, 27(2), 187–219. https://doi.org/10.3138/jcfs.27.2.187 +h]pz��4���������6j[vily������can inequality be blamed on the agricultural revolution? world economic forum. retrieved march 17, 2022. https://www.weforum. vyn�hnlukh���������ov^�[ol�hnypj\s[\yhs�yl]vs\[pvu�thkl�\z�pulx\hs� delanty, g. 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(1985). a cyborg manifesto: science, technology, and socialist-feminism in the late twentieth century. socialist review. harvey, d. (2005). a brief history of neoliberalism��6_mvyk�<up]lyzp[`�7ylzz��o[[wz!��kvp� org/10.1093/oso/9780199283262.001.0001 kellner, d., & zalta, e. n. (2005). jean baudrillard (the metaphysics research lab, department of philosophy). in stanford encyclopedia of philosophy. metaphysics research lab, stanford university. retrieved march 30, 2022. https://plato.stanford. edu/entries/baudrillard/ nicholas d. tolliver 140 | columbia social work review, vol. xix kendall, l. 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(2020). simulacra in the age of social media: baudrillard as the prophet of fake news. journal of communication inquiry����������� ¶�����o[[wz!��kvp� vyn����������� ��� �� ������ 5pjovszvu��6����������the oxford dictionary of late antiquity.�6_mvyk�<up]lyzp[`�7ylzz�� https://doi.org/10.1093/acref/9780198662778.001.0001 5pl[azjol��-����������also sprach zarathustra: ein buch für alle und keinen. ernst :jotlp[auly�� public broadcasting service. (2015, august 11). a map of gender-diverse cultures. pbs. 9l[ypl]lk�4hyjo����������o[[wz!��^^ �̂wiz�vyn�puklwluklu[sluz�jvu[lu[�[^v�zwpyp[zf map-html/ ruyle, e. e. (2007). on the origin of patriarchy and class rule (aka civilization)��6uspul� reproduction by california state university long beach of the author’s 1980 article. 9l[ypl]lk�4hyjo�����������o[[wz!��ovtl�jz\si�lk\�ely\`sl�w\ispzolk�(2(���*0=�o[t� :[vyt��=��� �-svylz��,������ ��(wyps������the gender accelerationist manifesto. the anarchist library. https://theanarchistlibrary.org/library/vikky-storm-the-genderaccelerationist-manifesto#toc1 ;yhu��=����������7yp]h[papun�[ol�zljvuk�nlukly!�;ol�vypnpuz�vm�wyp]h[l�wyvwly[`�huk�p[z� relation to female sexual enslavement in the capitalist economy. anthós, 8(1). https:// doi.org/10.15760/anthos.2017.61 turkle, s. (1997). life beyond the screen: identity in the age of the internet. touchstone. cyborg feminism and social constructions columbia social work review, vol. xix | 141 wiggins, t. b. d. (2020). the pervert on your couch: psychoanalysis and trans/sexual health. in j. c. niemira (ed.), sex, sexuality, and trans identities: clinical guidance for psychotherapists and counselors (pp. 155–181). jessica kingsley publishers. nicholas d. tolliver 2020_cswr_journal.indd 51 | columbia social work review, vol. 18 when hope grows weary: treating hopelessness in older adults daniella spencer-laitt & amanda weiss editors-in-chief, columbia social work review abstract hopelessness is associated with suicidal ideation and completion, poor physical health, and poor quality of life, and is an important and littlediscussed dimension of the experience of older adults. however, hopelessness is not an inevitable part of the aging process. the present paper analyzes the construct of hopelessness specifically in the context of the aging population, discusses measuring and treating hopelessness, and makes recommendations, based on existing models of care, for how targeted services can be created to address this problem. introduction “this whole town does look like whatever hope becomes after it begins to weary a little, then weary a little more. ” -robinson, gilead the septuagenarian pastor, john ames, at the center of marilynne robinson’s gilead (2004) reflects on a long life soon to be cut too short. like the fictional town of gilead, he embodies a gentle and genteel despairing. ames concludes his narration by saying “hope deferred is still hope…i think sometimes of going into the ground here as a last wild gesture of love i too will smolder away the time until the great and general incandescence” (robinson, 2004, p. 247). the aging process poses many threats to the mental and physical health and psychosocial functioning of those aging. and hopelessness, as we will discuss in detail, is one of the most insidious. in the face of transition to any new phase of life, physiological, pathological and psychological changes arise. for the aging population, disconnection from social and professional roles can occur and lead to, or be precipitated by, the experience of negative emotions—such as, hopelessness. this paper will consider the role of hopelessness in the experience of older adults, often concurrent with general feelings of depression or low mood, because of the pivotal role hopelessness plays in poor psychosocial functioning and the need for new, targeted interventions to address its prevalence in older adults.1 many scholars have observed that study of the psychosocial challenges of older adults—from mental health issues to abuse—is about fifteen years 1 a substantial literature already documents the feelings of hopelessness and helplessness among caregivers of older adults (see for example, rzeszut, 2011; lin, 2018; jorgensen, 1992; duxbury, higgins, & smart, 2011). but in this paper, we are interested in the other half of the care dyad–the cared for. columbia social work review, vol. 18 | 52 behind the study of parallel challenges in children and adults (settersen, 2005; bardach & rowles, 2012; pedrick-cornell & geddes, 1982; beach et al., 2016; barber, 2008). the study of interventions for hopelessness in seniors seems to be similarly limited in scope and rigor. geriatrics and gerontology suffer a tendency to get bogged down in the weeds of semantic issues of what exactly constitutes old: we especially see this in industrialized countries where the mortality rate seems to be ever-increasing, as well as in life stages for which there seem to be no neat demarcations (the antithesis of which is the end of puberty and medical transition into adulthood). even when scholars concur on what defines old, a tension exists between the idea that on the one hand, older adults have unique medical and psychological needs in which practitioners need to be well-versed, and that on the other hand, older adults may benefit from the same attention paid to nominally younger adults with similar challenges. there is even a significant scholarly debate over what objectives interventions intending to serve older adults should have. some favor the notion of “healthy aging,” others prefer “productive aging” or “dynamic aging” (martinson & berridge, 2015). in our opinion, the terminology is neither here nor there—because no definition of the best possible aging experience should include the cognitive and emotional experience of hopelessness. this paper aims to transcend some of the conceptual and semantic challenges surrounding aging by 1) rejecting the false dichotomy of respect for unique aging processes and respect for the essential humanity of the older adult and 2) focusing on extant case studies and potential new approaches for intervention. ultimately, age (relative, absolute, chronological, medical, or other) should only be relevant to the treatment of hopelessness insofar as it can usefully inform our understanding of why hopelessness arises, the consequences of hopelessness, and clinical treatment. just as the popular and academic imagination have slowly come to understand memory loss as an abnormality in the aging process, we hope that practitioners and researchers will come to understand hopelessness as treatable rather than intractable. this paper will be divided into four parts. the first part will analyze the cognitive construct of hopelessness. the second will address the implications of hopelessness, including suicidal ideation, depression, vulnerability to abuse, and higher rates of physical illness. the third will address existing instruments and methods for measuring hopelessness. and finally, the fourth part will present case studies for how hopelessness can be addressed in the settings in which older adults most commonly come into contact with psychosocial services. in short, we argue that hopelessness is not incorporated as a key target in the treatment of older adults—but it should be—and that existing programs to promote older adult well-being could and should incorporate reducing hopelessness as an outcome. 53 | columbia social work review, vol. 18 part one: what is hopelessness? hope and hopelessness can be slippery concepts (hernandez & overholser, 2020). scholars have generally shied away from questions of whether “hope and hopelessness are polar opposites or separate constructs, so that conclusions of low hopelessness cannot be readily generalized to high hope” (hernandez & overholser, 2020, pp. 28-29). cognitive theory defines hopelessness as having negative expectancies towards the future (beck et al., 1974). along with suicidal ideation, hopelessness is positioned as a product of distortions in thinking including but not exclusive to catastrophizing, dichotomous thinking, and/or overgeneralization (uncapher et al., 1998). in depression, these distortions form part of a cognitive triad of negative thoughts of the self, the world, and the future (uncapher et al, 1998). hopelessness fits into this triad as a “determinant and a component of the depressive condition” (beck, steer, kovacs & garrison, 1985). that is, hopelessness is a construct that may be an antecedent to depression, and can be either acute (in response to a situation or event) or chronic (uncapher et al., 1998). when hopelessness is chronic, it can exist as a cognitive schema that directs how a person navigates the world and interprets information. a hopelessness schema may be activated by life stress, reflect a conclusion that one’s situation cannot be changed, and/or lead to suicidal ideation (wenzel & beck, 2008). those with a hopelessness schema or acute hopelessness may perceive no end to their suffering. therefore, hopelessness is both theoretically and empirically associated with suicidal ideation even in the absence of depression or other psychiatric illness, with death seen as a solution to the absence of hope about existence or an end to intolerable distress (uncapher et al., 1998; wenzel & beck, 2008). in older adults at the end of their life, the cognitive theory of hopelessness should supplement an understanding of transient and situation-related hopelessness (that is, state, as opposed to trait hopelessness). according to sullivan (2003), some people facing the end of their life suffer a transient hopelessness which is better characterized as a type of complicated grief. this characterization has important implications for the treatment of this hopelessness, which may be more supportive or focus on the restoration of meaning and creation of connections to family, friends, religion and community if there is no underlying depressive etiology. that said, hopelessness at the end of life is relatively well-studied. the literature on this topic may yet inform studies of treating and addressing hopelessness in seniors. though we should acknowledge that aging or being old is not the same as dying or being close to death, key similarities would appear to exist between treating hopelessness at end-of-life, including the role of acceptance rather than denial of circumstances (cf. hernandez & overholser, 2020; sullivan, 2003). notwithstanding his focus on end-oflife care, sullivan (2003) presents a broadly applicable conceptualization of hopelessness. he writes: columbia social work review, vol. 18 | 54 “in medicine, hope is often reduced to the issue of prognosis or chance for survival. in psychiatry, hopelessness is often reduced to a symptom of major depression. yet hope and hopelessness at the end of life are not simply medical or psychiatric problems. they encompass nearly all that human culture and spirituality have to offer.” (sullivan, 2003, p. 393) hopelessness, especially for the aging population, encompasses more than a situational response or a component of major depressive disorder (mdd). part two: the effects of hopelessness in a general clinical population of adults, hopelessness has proved to be a better predictor of suicidal intention than the severity of depression (beck et al., 1993). hopelessness is also a useful construct in evaluating the risk of suicide completion. in a longitudinal study of adult patients hospitalized with suicidal ideation, hopelessness was the only metric that significantly differentiated suicide completers from suicide non-completers (beck et al., 1985). completed suicide is also associated with hopelessness in adult outpatients (beck et al., 1990). these findings support the view, derived from cognitive theory, that hopelessness is not a proxy for mere depressed mood in adult populations (uncapher et al., 1998). numerous studies have also demonstrated the relationship between hopelessness and suicidal ideation in older adults. dennis et al. (2005) found that life events are not singularly precipitating factors for suicidal actions in older adults: rather hopelessness discriminates between those who commit self harm and those who do not. dennis et. al’s study also highlights the fact that the self harm group was more likely to have a poor social network, be lonely, and lack supportive services. while no analysis was undertaken to examine the direct correlation between hopelessness and poor social network, loneliness, or lack of supportive services, a connection between these variables may exist, exacerbating the psychosocial stressors for hopeless older adults. neufeld and o’rourke’s (2009) study of 117 older adults found that hopelessness was the strongest predictor of suicidal ideation of the variables studied at 83%. meanwhile, szanto et al. (1997) found that in a sample of older adults coping with grief, a typical experience of later life, participants who endorsed active or passive suicidal ideation were also more likely to endorse hopelessness. we should also note that the factors that buffer against hopelessness in adults operate differently in older adult populations. reasons for living are expectancies that might reduce risk of suicide; these include coping beliefs, responsibility to family, and moral objectives (britton, duberstein & conner, 2008). britton, duberstein and conner (2008) found while ordinarily, individuals with more reasons for living have lower levels of hopelessness, in older adults, responsibility to family may increase the association between hopelessness and suicidal ideation due to perceived burdensomeness. this reveals the need for thorough psychosocial assessment of hopeless, depressed, or potentially suicidal patients since clinicians cannot assume that reasons for living are protective. however, there are other factors unique to older adults that may be protective and contribute to the reduction 55 | columbia social work review, vol. 18 of hopelessness and depression severity scores, including but not exclusive to frequent practice of prayer and meditation (but not church attendance) (cruz et al., 2009). findings correlating suicidal ideation and hopelessness in older adults are notable given middle-aged and older adults are at higher risk of suicide than younger adults, and likelier to complete suicide when attempting it (piscopo, 2017). table 1 shows suicide completion rates per 100,000— highest among middle-aged and older adults. table 1. suicide rates completion per 100,000, by age group, in 2018 (data from suicide prevention resource center [sprc], 2020) age in years suicides per 100,000 65+ 17.5 45 64 20 25 44 17 15 24 14.5 table 2, meanwhile, shows dimensions of suicidal behavior separate from the completion of suicide. the trend here would seem to be reversed— suicidal thoughts and suicide attempts are less common among middle-aged and older adults. one possible interpretation of these data is that correlates of suicide are likelier to be lethal among middle-aged and older adults. table 2. suicide rates completion per 100,000, by age group, in 2018 (data from suicide prevention resource center [sprc], 2020) age in years suicidal thoughts in the past year, annual averages per 100,000, 2009-2014 suicide attempts in the past year, annual averages per 100,000, 2009-2014 65+ 1.6 0.2 60 64 2.5 0.2 55 59 3.5 0.4 50 54 3.6 0.3 45 49 4.2 0.5 40 44 3.8 0.5 columbia social work review, vol. 18 | 56 35 39 3.9 0.5 30 34 3.9 0.5 26 29 4.6 0.5 18 25 6.9 1.2 it is worth noting, here, that the data fail to elucidate the variability of risk within age ranges post-65—and significant variability would seem to exist.2 a recent study suggested that the risk of suicide and the methods of suicide vary considerably between the age groupings of 65-74, 75-84, and 85+ (koo, kolves, & de leo, 2017). among adults 65 and older, suicide completion rates were retrospectively observed to progressively increase with age—but men, who have higher suicide rates than women on average in the western world, drove that trend (koo, kolves, & de leo, 2017). while many correlates with suicide, such as psychiatric disorder, male gender, being white, widowhood, lower socioeconomic status, social isolation, and stressful life events certainly exist in the older adult population (lynch, cheavens, morse, & rosenthal, 2004), hopelessness is a characteristic that is amenable to change. that said, arguably, questions of hopelessness in older adults have focused too heavily on the dichotomy between life and death, and specifically on suicidal ideation. this positions the purpose of life as survival, and may mean that a person facing the end of their life has little reason for hope since they cannot survive. as sullivan (2003) notes, there are other bases for hope aside from survival, such as hope for salvation, dignity, or comfort. in addition, while hopelessness predicts suicidal ideation in the absence of depression, hopelessness is also a better indicator of depression in older adults than depressed mood (joiner et al., 2007). as hopelessness increases in severity, dysthymia and major depressive disorder (mdd) are more likely and hopelessness is associated with high rates of double depression (dysthymia plus mdd) in older adults (joiner et al., 2007). there is evidence that hopelessness mediates the relationship between quality of life and emotional distress in older adults (scogin et al., 2016). morthland et al. (2016) hypothesized that in a sample of rural adults, hopelessness results in poor motivation and hinders participation in both relationships and activities of daily life. 2 the population of american older adults is large and diverse. in 2016, 49.2 million americans were 65 or over (roberts, ogunwole, blakeslee, & rabe, 2018). of those, 28.7 million fell between the ages of 65 and 74 (inclusive), 14.2 million fell between the ages of 75 and 84 (inclusive), and 6.3 million were 85 years or older (roberts, ogunwole, blakeslee, & rabe, 2018). various researchers have pointed to the importance of, at minimum, differentiating between the younger old (sometimes listed as 75 to 84) from the oldest old (sometimes listed as 85 and older—see for example, von humboldt & leal (2015). 57 | columbia social work review, vol. 18 the literature has further established that hopelessness can be symptomatic of underlying problems. the fields of law, medicine, and social work all treat hopelessness as a symptom or possible indicator of elder abuse and neglect (bergeron, 2006; imbody & vansburger, 2011; katz, 1979-1980; nerenberg, 2013).3 and, emerging evidence suggests that hopelessness is positively correlated with severity of medical disease and mortality, particularly in terms of cardiovascular disease (dunn et al., 2014; sullivan, 2003). higher levels of hopelessness have been associated with higher levels of pain (yildirim et al., 2009) and lower functional status (vanservellen et al., 1996). all of this demonstrates the need to screen for hopelessness in order to avoid negative impacts on quality of life and physical health. at this point in the discussion, we would also like to note that the findings on hopelessness in older adults are not well studied for ethnic or cultural variations. in a study of the association between depressive symptoms and hopelessness in older adults, assari & lankarani (2016) compared white and black populations of older adults, with race operating as the moderator. the study revealed that the association between depressive symptoms and hopelessness is weaker in black older adults than in white older adults (assari & lankarani, 2016). the authors explain this finding by hypothesizing that despite higher rates of poverty, more severe depression, and less access to healthcare, black older adults are likely to have higher levels of religious observance and social support, buffering against hopelessness and boosting resilience (assari & lankarani, 2016). importantly, the authors did not measure the moderating effect of religious observance across racial groups, despite religious observance being a proven buffer against hopelessness in older populations. therefore, it is impossible to generalize about the relative rates of hopelessness in different racial or ethnic groups based on the available data. part three: measuring hopelessness there are several instruments utilized for the measurement of hopelessness in older adults, most notably the beck hopelessness scale (beck, weissman, lester & trexler, 1974) and the geriatric hopelessness scale (fry, 1984). despite practice guidelines urging the use of assessment measures that are either developed for, or modified for use with older adults (american psychological association, 2014), the beck hopelessness scale (bhs), developed for use with adult psychiatric patients, is the most commonly used measurement in studies of late-life hopelessness (neufeld, o’rourke, & donnelly, 2009). the bhs is a 20-item true/false scale based on affective, motivational and cognitive dimensions. while the bhs is used widely, few studies have measured its measurement invariance (and consequent utility for intergroup comparison) in large community representative samples (kliem, et al., 2018). 3 hopelessness can also be the result of elder abuse. see podnieks, 2006. columbia social work review, vol. 18 | 58 hence, the bhs may not capture the dimensions of hopelessness specific to older adults since it was not designed for use with this population. kliem et al. (2018) conducted the only investigation of the psychometric properties of the bhs in a large representative western community sample, and concluded that its psychometric properties were mostly sound, with a need for further research in variance between ethnic and cultural groups. they did not, however, report findings on the utility of the bhs according to age-based classifications.the bhs was only recently validated for use with a sample of older spanish adults in a study by satorres et al., (2018). it also demonstrated strong psychometric properties for use with older adults in studies conducted by fraser, burnell & salter (2014), duberstein et al. (2001) and szanto et al. (1998), respectively. conversely, psychometric research has generally indicated acceptable internal consistency and construct validity for the geriatric hopelessness scale (heisel & flett, 2005), yet the instrument has low predictive validity for suicidal ideation or behavior (trenteseau et al., 1989).4 notably, the ghs performed poorly in a sample of community residing adults, although these findings did not specifically focus on the construct validity of hopelessness (hayslip et al., 1991). heisel & flett (2005) partially supported hayslip et al. (1991)’s findings that the ghs is better suited to institutionalized seniors as it does not distinguish well between mental health patients and non-mental health patients. however, the ghs performed well in reliability and construct validity (heisel & flett, 2005). further important questions remain surrounding the utility of standard measures of hopelessness such as the bhs and ghs specifically in the very elderly population, who may be cognitively impaired (neufeld, o’rourke, & donnelly, 2009). perhaps even more importantly, older adults are less likely to self-report emotional distress, with those who see physicians more likely to focus on somatic symptoms unless specifically asked about factors such as suicide ideation (neufeld & o’rourke, 2009). this demonstrates the need for direct and specific questioning about hopelessness in this population by social workers and other service providers who come into contact with older adults, in addition to the use of psychometric instruments. part four: models for hopelessness treatment? often, wrongly, hopelessness is seen as inevitable, natural, or untreatable in older adults (uncapher et al., 1998; kjølseth, ekeberg, & steihaug, 2010). however, many modalities have shown promise, including goal-focused group psychotherapy (see for example, klausner et al., 2000); life review therapy (serrano et al.,, latorre, gatz, & montanes, 2004); problem-solving therapy (choi, marti, & conwell, 2016); and various cognitive and behavioral approaches (brown et al.,, brown, bhar, & beck, 2008; lynch morse, 4 note that an association between ghs scores and suicidal ideation in older men receiving health care was reported by uncapher et al. (1998) 59 | columbia social work review, vol. 18 mendelson, & robins, 2003). hernandez and overholser (2020), meanwhile, single out a few therapies as relatively ineffective for the treatment of hopelessness, including dignity therapy, physical exercise, and educational programming. even so, “[c]ontrolled trials with hope/hopelessness as a primary objective are needed to more clearly demonstrate effectiveness” (hernandez & overholser, 2020, p. 1). much research on interventions relevant to hopelessness has treated hopelessness as a secondary objective of the research and has been performed without a control group (hernandez & overholser, 2020). the research targeting reduction of hopelessness as a primary outcome is limited enough that we must turn to treatment programs targeting other problems of older adulthood as possible models of care. we have already discussed end-of-life care as a model for aging care in part one (see again sullivan, 2003) and we suggest that a key similarity between end-of-life care and aging care is setting. notwithstanding cultural shifts and advocacy around minimizing the amount of time that end-of-life patients and aging clients spend in medical institutions, these two populations spend a great deal of time in hospitals. likelier than not, this is where older adults may be most linked to mental health professionals as well as other health care (emergency department visits are the only time that many seniors leave their homes—see rosen et al., 2016). this holds especially true for low-income or otherwise marginalized seniors without other forms of access to healthcare (bazargan, bazargan, & baker, 1998; fan et al., 2011; counsell et al., 2007; o’mahony et al., 2008). hospitals are therefore a crucial site for prevention and intervention. hospital-based elder abuse prevention units, although technically specific in scope, offer a useful model for prevention, intervention, and provision of services for seniors in medical settings, and, we argue, should be extended to include reduction of hopelessness as an intervention target. new york city has long been a leader in developing social services for older adults (netherland, finkelstein, & gardner, 2011; morken, 2012; see also for example, vogel, ransom, wai, & luisi, 2007)5 and weill-cornell medical center’s vulnerable elder protection team (vept) is one of the jewels in the crown. following the interdisciplinary team model of care (already wellestablished in hospice settings and in the treatment of severe refractory depression—see oliver & peck, 2006; unützer & park, 2012), vept includes doctors and social workers, and collaborates with attorneys and other professionals (rosen et al., 2018). vept works similarly to many hospital child protection teams; elders coming through the emergency department (ed) with any signs of abuse (identified by other hospital professionals trained in identifying such signs) are immediately referred to vept for 5 the nyc department for the aging is the largest of its type in the country (“organization profile,” n.d.), and brooklyn district attorney’s office has a unique-in-the-nation elder abuse prosecution unit (hynes, 2010). columbia social work review, vol. 18 | 60 wrap-around services and referrals (rosen et al., 2018). the group meets regularly for case conferences, with a rotating cast of professionals involved in a given patient’s care (rosen et al., 2018). hospital-based senior health units can operate with similar principles of quick screening and referral and wrap-around care, and incorporate new services targeting hopelessness. vept is a useful model for senior care targeting hopelessness for three additional reasons. first, hopelessness, like elder abuse, is typically comorbid with other conditions and challenges and treating comorbid mental health conditions concurrently can offer a better chance of success than targeting one condition in isolation (e.g. stambaugh et al., 2007; pringle et al., 2002; furman & jackson, 2002). second, the model may actually be easier to implement for hopelessness than it is for abuse. as noted beforehand, hopelessness is relatively simple to test through a short question inventory or direct questioning, and may not entail the same level of extreme stigma associated with elder abuse (abused older adults are uniquely reluctant to report abuse—see dyer, connolly, & mcfeeley, 2003; lachs et al., 1998; mosqueda & dong, 2011). by the same token, hopelessness may be less intimidating for professionals to report or identify as well, because professionals who notice signs of abuse may hesitate to report because of fear of involvement with the legal system (rosen et al., 2019)—a concern that should not be present with hopelessness. third, vept is a crucial model for treating older adults who are marginalized and underserved for reasons other than their age—a lacuna in treatment programs and a limitation of many other treatment programs.6 vept serves an elderly population that is multiply disadvantaged. not only are ed-dependent patients likelier to be lower-income in general, the new york presbyterian hospital (nyph) system serves an especially large group of socioeconomically marginalized new yorkers. nyph has the third most medicaid discharges of any hospital in new york state (new york– presbyterian hospital [nyph], 2016). sixty percent of nyph inpatients are on public insurance (medicaid or medicare) (nyph, 2016). in this way, vept succeeds in offering services to a normally underserved population. outside of the hospital, a “public health” approach may be worthwhile in the prevention and treatment of elder hopelessness. analogously to the implementation of interdisciplinary teams in hospitals, the centers for disease control and prevention has been funding programs that weave together health advocacy led by physicians and mental health initiatives led by psychologists, including in geriatric mental health care (aldrich & benson, 2013). the cdc-appointed community preventive services task force has in the past recommended homeor clinic-based “depression care management” (dcm) for depression in seniors (community preventive 6 literature in psychology and social work has documented a lack of services for multiply marginalized older adults (for elder abuse issues specifically, see walsh et al., 2011; for other issues of intersectionality in aging, see finkenauer, sherratt, marlow, & brodey, 2012; espinoza, 2011;brotman et al., 2015; choi & kimbell, 2008; goins et al., 2006). 61 | columbia social work review, vol. 18 services task force [cpstf], 2014 [2008]). in dcm, an elderly patient receives services, psychoeducation, and treatment (often, cbt) from a “care manager”—typically, a nurse practitioner or social worker—supervised by a psychiatrist (aldrich & benson, 2013; cpstf, 2013 [2008]). programs following this model have been studied through the baylor university school of medicine and the university of washington (aldrich & benson, 2013). both sets of programs proved effective in reducing mdd, at least in the short term (casado et al., 2008; quijano et al., 2007; unützer et al., 2002; unützer et al., 2008). the challenge that such community-based programs face is stigma and recruitment (kobau et al., 2010; snowden, steinman, & frederick, 2008). we would speculate that integrating a dcm program with a hospital team consultation and referral model akin to vept would address the stigma and recruitment issue while providing another venue for continued follow-up (which is sometimes absent in hospital-based interventions) with a patient experiencing hopelessness. conclusion supposedly, the root of any solution lies in recognizing the problem. we suggest that this holds for older adult hopelessness and its sequelae (most concerningly, suicide). as scholars, we hope that the research community continues to study new treatment modalities specifically for the impact on elder hopelessness. too few treatment trials performed with older adults consider hopelessness as a primary outcome measure and only a few more studies include it as a secondary measure (again see hernandez & overholser, 2020). when clinicians recognize hopelessness as a needless correlate of the aging process, they can redress it as such. this, along with public funding and policy interventions, will lay the groundwork for a successful response to hopelessness in an aging world. older adults are likely to be in a uniquely marginalized position, carrying with them some of the challenges that they had when younger and taking on the new struggles of growing old. issues of concern to them deserve greater scholarly and clinical attention. in some sense, treating this single, albeit crucial aspect of their mental well-being is the least that (the broadly defined) we can do. to steal a phrase from twentieth-century german psychologist erich fromm, “rational despair” coexists alongside hopelessness (fromm, 1973, p. 436). in tackling hopelessness in older adults, we should ask: how fair is it to tell a patient with circumstances that might rationally cause him/her/them to lose hope, that he/she/they must simply feel, think, behave, or “construct reality” differently (nevid, 2007)? (criticisms such as these are far from new—see, for example, kant, 2015; gilbert, 2009.) but once again, we can attempt to address a seeming paradox by suggesting that doing something to address suffering, beats doing nothing—and that psychological treatment is surely one part of an integrated interventional agenda. columbia social work review, vol. 18 | 62 despite all of the limitations discussed herein—whether conceptual, clinical, or research-related—enough is known about effective therapies for practitioners to begin attempting to treat. and more existing programs on older adult wellbeing (such as the vept and baylor/washington dcm case studies noted hitherto) could incorporate reduction of hopelessness as a goal or outcome. aging is inevitable. aging hopelessly is not. about the authors daniella spencer-laitt is a second year advanced clinical practice student specializing in health/mental–health and disabilities and the co-editor-in-chief of the columbia social work review. she cofounded wh seniorlink to alleviate social isolation among older adults. she holds a ba in political science and an llb with honors from the university of western australia, and previously worked as an attorney. daniella’s research interests lie in the psychosocial experiences of grief and aging. amanda weiss is a second-year advanced policy practice student specializing in the study of american politics, quantitative methods, and violence; a research fellow at safelab; and co-editor-in-chief of the columbia social work review. she co-founded wh seniorlink to alleviate social isolation among older adults. amanda holds a ba magna cum laude from columbia college of columbia university, and she is starting a phd at yale university in fall 2020. references aldrich, n., & benson, w. 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examines how social justice has been separated from social service provision  by the system that has come to be known as the nonprofit industrial complex.       people working for social justice1 in the united states today are lim­ ited by the dysfunctional funding system that sustains most nonprofits. a sig­ nificant number of people who believe in and work for social justice are em­ ployed in the nonprofit sector: an industry that requires organizations to com­ pete for government and foundation funding. known as the nonprofit indus­ trial complex (npic), this system forces nonprofits to professionalize, wherein  they must focus on maintaining their funding sources rather than fulfilling their  mission.   when organizations participate in the npic and perpetuate this cycle  of sacrificing mission for funding, they disenfranchise their constituents. such  organizations become more concerned with remaining in business, and goals  rooted in social justice become of secondary importance. though lesser  known, alternatives to this system do exist, whereby social justice need not be  sacrificed for funding. it is important to examine these alternatives and to use  them to evaluate the current nonprofit funding system.       funding versus social justice    the latter part of the 20th century saw the american government de­ volving as it transferred its traditional responsibilities and processes for service  provision to other levels of government, private companies, and nonprofit or­ ganizations (kettl, 2000). the government no longer was the primary provider  of social services in america. at the same time, community groups increased  their capacity in the service provision domain. however, in order to receive  funds from the government or private foundations to provide these services,  these groups today are required to legally incorporate as nonprofits.   when funders have agendas that are inconsistent with the mission of  the organizations that they support, organizations then risk becoming pre­ disposed to mission drift. mission drift is a term used to describe instances  where an organization moves away from its mission, which in turn leads to a  loss of the original reasons for their organizational establishment (moore,  columbia social work review, volume i       18  samimi  2000). the concept of mission drift questions whether the organization main­ tains its original values and goals, exposing it to a potential compromise of its  contribution to the community it serves.   mission drift has the potential to result in tensions between staff and  others involved in the organization, wasted resources, and loss of revenue  (moore, 2000; dees & anderson, 2003). the possibility of mission drift di­ rectly challenges nonprofits to find a balance between seeking social justice  and seeking funding. understanding how nonprofits developed in america is  important in illustrating the establishment of the npic, and subsequently real­ izing how the npic resulted in the divergence of service provision and social  justice.    nonprofit organizations and social justice:   a brief history    in the united states today, social service delivery is commonly asso­ ciated with nonprofit organizations; a relationship that originated during the  country’s colonial period. in making the nonprofit sector in the united states:  a reader, david c. hammack (2000) outlines how religious groups during  colonial times espoused a doctrine that “required assistance to be offered to  those in need” (p. 19). the colonists implemented the british poor laws,  which established a distinction between those who were unable to work due to  their age or physical health and those who were able­bodied but unemployed.  those who were deemed unable to work were assisted with cash or other forms  of assistance from the colonial government. those deemed able to work were  sent to workhouses (axinn & stern, 2008). this concept of a “deserving poor”  informed the development of service provision.   the puritans established harvard college as a place to educate minis­ ters in 1643. in doing so, the religious group issued what was probably the first  american fundraising appeal of its kind (hammack, 2000). as the foundation  of the social service industry began to establish its roots in religion against the  backdrop of colonialism, the link to funding was also established. however,  the idea of social justice, with a focus on the poor, was the target of service  provision. colonial notions of social justice were explicitly pursued by, and  related to, the needs of the white settlers in america.   with the american revolution came the constitutional separation of  church and state. the newly established american nation state increased rights  for white male citizens, as well as property rights for organizations (hammack,  2002). these factors, along with a rise in egalitarianism, resulted in increased  civic participation of citizens. with this growing social equality came the phe­ nomenon of nonprofit schools, libraries, orphanages, and clinics in seeking out  private sponsorship (hammack, 2002; mccarthy, 2003).   until 1800, no organization existed that fit today’s concept of a non­ profit. over the next 100 years, most nonprofit work occurred within religious  contexts as religious groups and churches played a central role in american  community life. by 1900, schools and religious institutions were the largest  19        columbia social work review, volume i    funding america’s nonprofits  nonprofit employers. however, even with the addition of individuals employed  by private colleges, orphanages, old age homes, publishing houses, museums,  and other nonprofit organizations, the total was still estimated at less than 1%  of the labor force (hammack, 2002).     throughout the 19th century there was no federal system for recogniz­ ing nonprofits, and it was at the discretion of local authorities to allow groups  legal status. states had the permission of, and were often encouraged by, the  federal government to reject requests from groups seeking nonprofit status.  minority groups that sought to change the existing power structure and estab­ lish social justice for their communities were often denied permission to form  nonprofits by the government in an effort to maintain religious, racial, and gen­ der norms. the established missions of many groups that did manage to  achieve nonprofit status were likewise limited by the political stronghold on  accepted forms of social leadership (smith, 1997). catholics, for example,  were prevented from obtaining charters in many states due to a perception that  upon their formal establishment, these organizations would be subsequently  controlled by the pope (carey, 1987).     stifled by the governance of the strict system that limited access to  financial support that might be available to contemporary nonprofits, early  american nonprofits were only able to increase their income when local au­ thorities allowed resources to be accessed. states were able to undermine ac­ cess to resources by denying requests for charters, which also denied minori­ ties the ability to challenge the status quo. thus, as service providers continued  to define themselves as a group, social justice advocacy efforts were limited  because certain populations were excluded from access to resources through  nonprofit fundraising. from 1900 until the 1960’s, nonprofit employment grew  to about 3.7 percent of the labor force, which was in part due to the establish­ ment of nonprofit nonsectarian universities and medical centers, which were  not affiliated with religious institutions (hammack, 2002).     further growth of the nonprofit industry was limited during the first  half of the 20th century for several reasons.  the formation of new deal pro­ grams, which were designed to employ citizens directly by the government  through government agencies, did not provide funding for private welfare  agencies (brown & mckeown, 1997). the new deal dramatically expanded  the government’s role in the provision of services, including the establishment  of unemployment compensation and aid to families with dependent children;  two programs that still exist today (axinn & stern, 2008).    in addition to limiting the funding of existing organizations, many  people were not allowed to establish nonprofits due to prejudice and restrictive  traditions, for instance, existing religious discrimination in the north and segre­ gation in the south. additionally, some americans faced political and financial  constraints; for example, women were not able to gain control of these types of  funding resources despite having gained the right to vote (anderson, 1988;  gamble, 1995; mccarthy, 1990; scott, 1992).     the devolution of the federal government has resulted in the govern­ ment’s reliance on for­profits and nonprofits to provide a variety of goods and  columbia social work review, volume i       20  samimi  services, including welfare services (kettl, 2000). the transition of social wel­ fare provision from the public sector to the private has led the government to  develop and utilize a complicated system that consists of contracting inter­ governmental funding through grants and loans, other funding regulations, and  a series of mandated bureaucratic administrative methods (mosher, 1980). to­ day, most domestic programs and agencies to which congress allocates spe­ cific budgets, are managed through an indirect relationship between the federal  government, for­profits, and nonprofits (kettl, 1993).     the imposition of the npic   on the pursuit of social justice      while there is no single definition of a nonprofit organization, a  framework for understanding american nonprofits throughout history is evi­ dent by an agency’s possession of six organizational characteristics: nonprofits  are formal organizations, they are private entities, they do not distribute profits,  they are self­governing, they are voluntary, and they provide a public benefit  (hammack, 2002). nonprofits are fundamentally different from corporations in  two major ways; their funds are donated, not “earned,” and they are assumed to  meet a need that serves the public good (internal revenue service, 2008). non­ profits also operate under a mission statement, which serves to formally estab­ lish the goals and functions of an organization by defining what it does, whom  it serves, how they do it, and where it does its work (meshanko, 1996).   in 2005, there were over one million nonprofits in the united states,  and as of 2010 nonprofits are the seventh largest economy in the world  (cohen, 2005; national council of nonprofits, 2010). nonprofits today in­ clude organizations that represent diverse causes and groups. private hospitals,  theater spaces, environmental organizations, human rights groups, advocacy  groups, think tanks, and professional associations are all examples of nonprof­ its. for nonprofits to receive donated funds they must register as 501(c)(3) or­ ganizations (internal revenue service, 2009). recognition as a 501(c)(3) al­ lows nonprofits to access grant money from foundations, corporations, and the  government without paying income tax.   when government funding is not enough for programs to respond to  community needs and provide services, nonprofits often rely on foundations  for funding their activities. however, foundations are complicit in the develop­ ment of the npic and nonprofits’ divergence from social justice. today there  are over 75,000 foundations in the united states, who provided an estimated  total of over 45.6 billion dollars in 2008 alone (foundation center, 2009).   while foundation funding could represent an alternative to govern­ ment funding so that social justice aims could be achieved without limitations,  grants from foundations also come with an unfavorable set of requirements that  must be met. particular grant requirements may fit with the mission and work  of the organization; however, an organization may feel compelled to modify its  programs, and sometimes even its mission statement, in order to fit into the  requirements of the grant application.  21        columbia social work review, volume i    funding america’s nonprofits  paul kivel, a social justice educator, activist, and writer, examines the  consequences of the nonprofit system through the lens of his work with domes­ tic violence and abuse survivors in his essay “social service or social  change” (2000). kivel writes about how funding bodies have power over com­ munity leaders, stating that “the ruling class co­opts leaders from our commu­ nities by providing them with jobs in non­profits and government agencies,  consequently realigning their interests with maintaining the system” (p. 21).  kivel’s depiction is of a society that prevents community leaders from con­ fronting the root causes of social inequities while struggling to provide services  to those who are exploited and oppressed by institutions. he asks, “do our  efforts to provide human services maintain or even strengthen social inequal­ ity?” (p. 2).   while service delivery alone holds merit, an unfortunate consequence  of this system and its funding structure is its failure to recognize social justice  (kivel, 2000). kivel writes “when temporary shelter becomes a substitute for  permanent housing, emergency food a substitute for a decent job… we have  shifted our attention from the redistribution of wealth to the temporary provi­ sion of social services to keep people alive” (p. 12). unfortunately, this is the  typical evaluation of nonprofits as band­aid services that are unable to exact  real change focused on justice for all.   kivel describes his idea of a “buffer zone” created by the rich to  “prevent people at the bottom [of the economic ladder] from organizing to  maintain the power, the control, and, most important, the wealth they have  accumulated” (p. 13). the buffer zone provides three functions: to avoid chaos  by “taking care” of people at the bottom [of the economic ladder]; to keep hope  alive among the poor; and to control those who want to make change. the  buffer zone and its functions are a result of an over­reliance of nonprofits on  government and foundations as funding sources.   kivel’s buffer zone is a depiction of the npic. this system is built on  a series of relationships between the state, owning classes, foundations, non­ profit organizations, social service organizations, and social justice organiza­ tions.2 unlike nonprofits, grassroots movements like those described below do  not rely on traditional funding sources, and thus do not operate within the  npic framework. as a result, these grassroots movements become best  equipped to more seamlessly promote social justice, as well as to address the  structural causes at the root of social service provision.     alternatives to the npic    in the article “on our own terms...10 years of radical community  building with sista ii sista” four representatives of sista ii sista, an organiza­ tion that works with young women in new york, discuss the implications of  avoiding foundation funding and what that meant for their ten­year existence  (burrowes, cousins, rojas, & ude, 2007). sista ii sista facilitated a group  process that led to the decision to do away with paid staff and only engage in  grassroots fundraising techniques. sista ii sista concluded from their discus­ columbia social work review, volume i       22  samimi  sions that there are ways for social justice to be realized through nonprofit  work. “we are not saying that all foundations are bad….we are also not of the  belief that 501(c)(3)'s are bad….we are trying to figure out different ways to  live our values and model our vision” (p. 39). when groups challenge the  npic, the question shifts the focus from whether or not it is possible to realize  social justice within the current system to an examination of how the system  can be adjusted so that it might work for everyone.   the grassroots institute for fundraising training (gift) is one re­ source for people seeking to reconcile working within nonprofits and believing  in social justice. gift seeks to “promote the connection between fundraising,  social justice and movement­building” (grassroots institute for fundraising  training, 2010). gift trains people working for social justice how to sustain  their organizations in a way that they depend on the financial support of their  community, not outside funders or government grants. they encourage organi­ zations to build a large donor base that will invest not only financially in an  organization but that the organization will be held accountable in providing  services that the community needs. organizations like gift offer practical  solutions for moving away from and toward a systematic shift in the way social  justice organizations are funded.    conclusion    people working for social justice today bear the burden of carrying on  past social movements while working within the npic, a system that necessi­ tates taking on managerial structures that force services and fundraising apart.  nonprofits in the us are rooted in origins of colonization and oppression. so­ cial justice focused community­based initiatives would be possible if funding  sources did not compromise their mission. broad, public dialogue regarding  the nonprofit structure and the 501(c)(3) in particular, is lacking, and the priori­ ties of philanthropy need to be questioned. without prioritization of social jus­ tice, new leaders will be forced to take on the contradictions and dilemmas  regarding how funding restricts organizational activities, how nonprofit gov­ ernance relates to the working class people at the heart of the organization, and  how hiring and promotion policies can result in individualistic competition  (tang, 2007).   the npic’s separation of social justice and social service provisions  has silenced the people most directly affected by issues of injustice, and it  privileges educated employees and board members of nonprofits. constituents  should be more than just the recipients of service delivery “products.”  they  should invest in the sustainability of the organization, not leaving funders to  determine the organizational agenda. when nonprofits internalize the locus of  control, they are less likely to participate in mission drift and are more account­ able to their constituents. diversified funding allows an organization to retain  the autonomy necessary to maintain the control of the organization within the  community, ensuring that avenues to work towards social justice remain open.    23        columbia social work review, volume i    funding america’s nonprofits  notes    1  in this paper, the term social justice refers to a concept that is concerned  with ensuring equal rights and opportunities for all people. both nonprofit or­ ganizations and efforts extended by individuals and groups in pursuit of social  justice will be examined and referenced.    2  this definition is paraphrased from the website of incite! women of color  against violence. the full definition can be found at http://www.incite­ national.org/index.php?s=100    references    anderson, j. (1988). the education of blacks in the south: 1860­1935. chapel   hill, nc: university of north carolina press.   axinn, j., & stern, m. (2008). social welfare: a history of the american re­   sponse to  need. boston, ma: allyn & bacon.   brown, d.m., & mckeown, e. (1997). the poor belong to us: catholic    charities and american welfare. cambridge, ma: harvard university    press.   burrowes, n., cousins, m., rojas, p., & ude. i. (2007). on our own terms...10    years of radical community building with sista ii sista. in incite!    women of color against violence (eds.), the revolution will not be    funded: beyond the non­profit industrial complex (pp. 227­234).    cambridge, ma: south end press.  carey, p. w. (1987). people, priests, and prelates: ecclesiastical democracy    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statement, programs, history. retrieved from     http://www.grassrootsfundraising.org/index.php?topic=aboutus  hammack, d. c. (2000). making the nonprofit sector in the united states: a     reader. bloomington, in: indiana university press.  columbia social work review, volume i       24  samimi  hammack, d. c. (2002). nonprofit organizations in american history:     research opportunities and sources. american behavioral scientist,    45 (11), 1638­1674.   idealist. (2009). nonprofit faq: board basics. retrieved on march 12, 2010,     from http://www.idealist.org/if/i/en/faq/526­245/3­1  internal revenue service. (2009). applying for 501(c)(3) tax­exempt status,     tax­exempt and government entities, exempt organizations.     (internal revenue service, publication no. 4220, [rev. 8­200]).    washington dc: u.s. department of the treasury. retrieved from     http://www.irs.gov/pub/irs­pdf/p4220.pdf  internal revenue service. (2008). tax­exempt status for your organization.     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mccarthy, k.d. (1990). lady bountiful revisited: women, philanthropy, and     power. new brunswick, nj: rutgers university press.   meshanko, r. (1996). what should our mission statement say? idealist. non­    profit faq. retrieved march 3, 2010, from http://www.idealist.org/if/   idealist/en/faq/questionviewer/default?section=03&item=21  moore, m. h. (2000). managing for value: organizational strategy in for­ profit,   nonprofit, and governmental organizations. nonprofit and voluntary    sector quarterly, 29 (1), 183–204.  mosher, f. c. (1980). the changing responsibilities and tactics of the federal  government. public administration review, 40 (9), 541­548.  national council of nonprofits. (2010). myths about nonprofits. washington    dc: national council of nonprofits. retrieved on march 13, 2010,    from http://www.councilofnonprofits.org/telling­our­story/myths­   about­nonprofits  scott, a.f. (1992). natural allies: women’s associations in american history.     urbana & chicago, il: university of illinois press.       25        columbia social work review, volume i    funding america’s nonprofits  tang, e. (2007). non­profits and the autonomous grassroots. in incite!     women of color against violence  (eds.), the revolution will not be    funded: beyond the non­profit industrial complex (pp. 215­257).    cambridge, ma: south end press.                                                            utilizing exercise and nutrition in the treatment of chronic disease: community-based models columbia social work review, volume i        26  kim  utilizing exercise and nutrition in the treatment of  chronic disease: community­based models     jake t. kim    the prevalence of chronic diseases in america has increased substantially  within the last few decades, increasing the cost of healthcare by billions of  dollars. in addition, these diseases have a higher incidence rate for low­ income populations who may have greater difficulty accessing adequate re­ sources or appropriate treatments. there has been a growing body of litera­ ture supporting the use of community­based exercise and nutrition interven­ tions. community­based interventions emphasize social supports and personal  empowerment for behavioral change. given the chronic and growing nature of  these diseases, this paper will examine community­based exercises and the  surrounding elements which facilitate and hinder behavioral change.       chronic diseases1 are the most common, expensive, and preventable  healthcare challenges in the united states today (centers for disease control  and prevention, 2009). globally, low­income populations2 have higher rates of  chronic illness than the general population, resulting from common lifestyle  trends and a lack of resource availability. the prescriptive nature of traditional  interventions for prevention and management of chronic disease fails to sup­ port sustainable behavioral change. the failure of current health interventions  is compounded by economic and societal emphases on consumption, which  sabotage individuals’ efforts and opportunities to improve their health through  exercise and diet. alternatives, including empowerment­based community in­ tervention models, have been found to facilitate behavioral change among  members of low­income populations (hinkle, 2008).   social workers are equipped with knowledge and skills that prepare  them to play a pivotal role in facilitating behavioral change among members of  low­income communities. since the beginning of the profession, social work­ ers have worked with disadvantaged groups to empower individuals and mobi­ lize communities. attention to cultural nuances and the unique needs of di­ verse communities have been at the forefront of the profession. community­ based interventions for diet and exercise are ideal areas for social workers to  mobilize communities to increase support and self­efficacy in people’s behav­ ior change for better health.       the cost of chronic disease in america    current concerns regarding the need for prudent and effective health­ care interventions underscore the importance of addressing long­term and pre­ ventable illness. the prevalence of chronic disease continues to increase and  the cost of care is predicted to rise substantially due to the expensive interven­ tions and treatments necessary for addressing chronic illness. recent estimates  27        columbia social work review, volume i    chronic disease: community­based models    by the henry j. kaiser family foundation (2009) indicate that general health­ care costs surpassed 2.2 trillion dollars in 2007. traditional interventions for  chronic illness, such as surgery or medication, can be risky, have high costs,  and most importantly, fail to address the behavioral issues that maintain or  contribute to disease. the adequate management of chronic illness requires  behavioral modifications to break long­standing lifestyle patterns that can sus­ tain an individual’s decline in health. for long­term behavioral change to be  effective, individuals suffering from chronic disease must understand how life­ style choices and behavior impact their health. furthermore, the aid of commu­ nity support mechanisms has been studied as an effective strategy for long­ term behavioral change (arkowitz et al., 2007). without alternatives to tradi­ tional treatment models, chronic disease will continue to escalate healthcare  costs and americans, especially those in low­income communities, will con­ tinue to struggle with their health.    self­efficacy and empowerment      scientific studies support self­efficacy and empowerment­based models  in bettering health outcomes through improved diet and exercise. involvement  in exercise can empower an individual, “...through the self­efficacy mecha­ nism,” state ozer and bandura (1990). empirical evidence demonstrates how  equipping people with knowledge, skills, and resilient self­beliefs can alter  their lives and they can begin to believe that they have control over their lives.  alsop et al. (2006) state that the empowerment model “...hypothesizes that  interventions to improve agency and enhance opportunity structures can in­ crease a person’s capacity to make effective choices [and] this in turn can bring  about other development outcomes” (p. 1). ozer and bandura utilized a mas­ tery model for physical training and found that there were increases in self­ efficacy in community­based exploratory studies with women and adolescents  (ozer & bandura, 1990; guthrie, 1995; zivin et al., 2001).   one study conducted by folta et al. (2009) found that a greater sense  of self­efficacy in overweight and obese older women lowered cardiovascular  risk through participation in a community­based program. in a comparable  study concerning incidences of heart health in individuals, luszczynska and  sutton (2006) found that those with a history of one or more heart attacks had a  greater likelihood of adherence to an exercise program and reported higher  levels of self­efficacy. in their study, wellman et al. (2007) found that 620  participants showed significant physical and psychological improvements from  their community­based exercise and nutritional program. munro et al. (2004)  observed that the implementation of a community­based exercise program was  more cost­effective than medical interventions regardless of the lower exercise  participation rates, highlighting the effective nature of the nutritional compo­ nent of such health interventions.         columbia social work review, volume i        28  kim  financial benefits of self­efficacy and the community­based model    evidence from several studies show that community­based exercise  and nutritional programs can predict substantial cost­savings. ackermann et al.  (2003) found that a group of individuals participating in a community­based  exercise intervention experienced fewer hospitalizations compared to those  who received standard medical treatment. in the study, those who exercised  more than once per week had a total annual healthcare cost of 1,057 dollars per  person less than the control group (ackermann et al., 2003). in another exam­ ple, roux et al. (2008) evaluated and compared community­based exercise  interventions for chronic disease and found that they were cost­effective based  on a variety of statistical simulations. clearly, community­based exercise and  diet interventions show promising results, yet people in low­income communi­ ties face many barriers in accessing these interventions.     the role of institutions    traditionally, centralized institutions such as hospitals served as a  primary resource for addressing health concerns, providing a range of acute to  chronic care. the centralization of specialized knowledge and expertise in hos­ pitals, at times, can remove patients from their home communities. in hospital  settings, it is common for doctors to recommend exercise and a healthy diet as  supplemental aids for chronic disease management. however, comprehensive  exercise and nutritional change require an incorporation of the behavioral pat­ terns and motivations of the client. the particular needs of the client must ulti­ mately be acknowledged by both the prescriber of a program and the receiver  of care, which go beyond the primary general suggestion of a medical profes­ sional, and calls for secondary supports to fulfill the recommendation  (arkowitz et al., 2007).   in america, restaurants also play a key institutional role in hindering  the success of diet and nutrition interventions. representing a link between  nutrition and a community, restaurants facilitate consumption. according to  glanz et al. (2007), survey responses from the executives of several national  dine­in chain restaurants indicate that the high costs of carrying healthier ingre­ dients with a short shelf­life and lower demand make it less profitable to offer  healthy alternatives. the result of the cost efficiency of more sustainable, but  less healthy ingredients, is the availability of an abundance of processed and  preserved foods through these widely accessible chain restaurants to a mass  market. drewnowski (2004) states that energy­dense foods, usually made with  sugar substitutes and laden with fat, are profitable for companies not only due  to their lower production costs, but also because they have become a necessity  to those who cannot afford to pay for healthier, more expensive alternatives.  some consequences of these economically­driven behaviors are evidenced in  the high rates of obesity and type ii diabetes in the united states among low­ income populations (drewnowski, 2004).     29        columbia social work review, volume i    chronic disease: community­based models    the role and benefits of exercise    according to the centers for disease control and prevention (2009), ex­ ercise reduces the risk for cardiovascular disease, type ii diabetes, and various  cancers; strengthens bones and muscles; protects the body from potential  physical injuries such as falls; and, it improves individuals’ moods and psycho­ logical state (linenger, chesson, & nice, 1991). furthermore, increased mus­ cle density – a result of exercise – improves metabolic rates, physical function,  and guards against muscle wasting (baker et al., 2001). exercise also lowers  depressive symptoms for those suffering from chronic disease such as diabetes  (golden et al., 2008). exercise has also proven to produce a reduction in delin­ quent behaviors among adolescents (zivin et al., 2001), relieve trauma in those  suffering psycho­sexual abuse, and have positive results in women with eating  disorders and substance abuse problems (guthrie, 1995).   further, exercise has resulted in better balance, coordination, and a gen­ eral sense of well­being in older adults (kutner et al., 1997). continued exer­ cise fosters positive physiological and psychological benefits (paluska &  schwenk, 2000). in addition to the benefits of general physical activity, tradi­ tional and holistic approaches to exercise such as yoga and martial arts increase  an individual's sense of self­mastery, decrease anger, and generate a sense of  inner­peace (binder, 2007). despite the evidence demonstrating the benefits of  exercise, many people living in low­income communities are unable to access  these benefits.     existing community­based models    there is a growing body of literature supporting the use of community ­based exercise and nutritional interventions; however, the widespread applica­ bility of these programs requires further study. randomized clinical trials link  the effectiveness of community­based interventions with fewer hospitaliza­ tions, shorter inpatient stays, and decreased healthcare costs (ackermann et al.,  2003). community­based exercise and nutritional interventions have also  shown improvements in physical and psychological functioning after a debili­ tating illness (harrington et al., 2010).    a community­based exercise and nutritional model facilitates access  to the physiological and psychological benefits of exercise to individuals that  may be excluded by socioeconomic factors. a program in rural oregon is an  example of the success of a community­based exercise and nutritional program  for a low­income population (berkes, 2009). this program lacked the special­ ized equipment or dedicated space found in most commercial gyms or the spe­ cialists found in hospitals, but through the use of a supportive and cohesive  community, the participants developed a healthier lifestyle. similar results  were found in a rural montana community­based exercise program with the  use of a women's fitness boxing class (ritter, 2009). these programs took  place in the community and used the social supports of the participants to en­ courage and create a sense of empowerment. as per the empowerment model  columbia social work review, volume i        30  kim  (alsop et al., 2006), these two interventions assumed that the strength for posi­ tive development came from a collective effort by the members of the commu­ nity channeling strength toward a productive outcome. although these pro­ grams have shown significant promise in the rural setting with low­income  populations, more research needs to be conducted to understand the applicabil­ ity in urban settings.   there has been a growing number of successful community­based exer­ cise and nutritional programs targeting chronic disease. roux et al. (2008)  compared seven different community­based exercise programs and found that  they were all cost effective and exhibited positive results. some of these pro­ grams placed greater emphasis on social support and community­wide cam­ paigns while others utilized the community but strengthened skills through  individualized attention (reger et al., 2002; young et al., 1996; kriska et al.,  1986; lombard et al., 1995). additional programs focused on outreach and  education (knowler et al., 2002) and another program encouraged an active  lifestyle within the community (linenger et al., 1991). the success of these  programs can be attributed to the specificity and applicability to the target  populations.     cultural competency     effectively utilizing exercise as a tool for supporting individual health  and well­being should be viewed as akin to the process of learning a language,  rather than a focus on the end­goal outcome. learning a language requires con­ sistent and patient practice and a supportive community that nurtures practice  and development. fluency in exercise skills is not immediate, and it cannot be  purchased. in addition, as with language, learning and understanding exercise  requires comprehension and understanding throughout the process. as such,  individual needs and cultural understanding along with existing community  factors as well as supports must be taken into consideration when developing  community­based exercise interventions.  studies have indicated that african americans living in urban environ­ ments are less likely to exercise when compared to a group of white americans  living in urban environments, indicating that differences in cultural back­ ground are relevant to the feasibility of community­based exercise models  (lavizzo­mourey et al., 2001). the findings of the aforementioned study may  be the result of the ineffective selection of exercise interventions for the tar­ geted community. in addition, the study revealed that older african americans  were less likely to engage in exercises using weights and preferred to workout  in groups (lavizzo­mourey et al.). the implications of such findings substanti­ ate the call for culturally competent programming, and reinforce the applicabil­ ity of a community­based model given the evident preference for group exer­ cise. the study also provides implications for the role of social workers with  regard to their common professional capacity for supporting cultural sensitivity  in program implementation (nasw, 1999). regardless of the source of the  service provision, the development of community­based models should include  31        columbia social work review, volume i    chronic disease: community­based models    the consideration of community cultural factors, as well as foundational knowl­ edge of individual and community norms and preferences, in order to ensure  the successful implementation of a program.    conclusion    a shared focus on personal empowerment through the use of community  resources is an effective alternative to traditional medical interventions in the  successful management of chronic disease across communities. these pro­ grams have a proven efficacy in rural, low­income communities and have like­ wise shown great promise for low­income populations in urban settings. the  high cost of chronic disease reinforces the utility and feasibility of community­ based interventions and supports the plea for their wider application in national  efforts to reduce health risks and increase healthy lifestyle options for people  living in poverty. social workers play a pivotal role in community­based inter­ ventions, as community organizing is a key component of the national asso­ ciation of social workers’ code of ethics. social workers can provide support  through interventions that mobilize community resources, develop effective  programs, and evaluate and disseminate the programs’ results. a collective  effort toward mobilizing communities to apply exercise and nutrition models  to their health­management schemes would greatly benefit the country and  reduce health risks for current and future generations.    notes    1  in this paper, the term chronic diseases will be used to represent type ii   diabetes, obesity, and cardiovascular diseases.    2     the term low­income populations will be used in this paper to refer to  people living below the official poverty line, as designated by the u.s. census  bureau (2009).    references    ackermann, r.t., cheadle, a., sandhu, n., madsen, l., wagner, e.h., & lo­ gerfo, j.p. (2003). community exercise program use and changes in  healthcare costs for older adults. american journal of preventative  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psychosocial models of mental illness, and reintroducing protective social welfare programs. finally, the paper urges social workers to educate themselves about the harms of bd overdiagnosis as well as to recognize their own role in medicalizing their clients’ distress. the overdiagnosis of bipolar disorder within marginalized communities: a call to action paul doyen he, him the overdiagnosis of bipolar disorder within marginalized communities the overdiagnosis of bipolar disorder within marginalized communities: a call to action researchers have been sounding the alarm about the overdiagnosis of bipolar disorder (bd) for more than a decade (ghouse et al., 2013). for example, in 2008, goldberg et al. found that only 33% of a cohort diagnosed with bd actually met clinical conditions, and in 2010, ruggero et al. discovered that 60% of patients studied had been misdiagnosed as having bd. a meta-analysis by mitchell (2012) reported rampant overdiagnosis of bd driven by flawed screening tools and studies inflating the prevalence of bd. one year later, another literature review found bd misdiagnoses reaching rates of 67% (ghouse et al., 2013). the scope of the problem is vast, with some researchers pressing for even greater rates of diagnosis and setting bd prevalence as high as 27% (mitchell, 2012). while anyone can be subject to misdiagnosis, those who suffer from other mental health conditions, such as major depressive disorder (mdd) and substance use disorder (sud), are especially at risk (mitchell, 2012). bd diagnoses are also disproportionately applied to people with limited social support, low socioeconomic status, and a history of traumatic experiences (fusar-poli et al., 2017). given that bd is thought to be a lifelong affliction, the consequences of overdiagnosis extend far into each individual’s future. some of the most serious consequences of misdiagnosing bd are pharmacological. lithium, a prescription mood stabilizer medication and first-line treatment for bd, has been shown to increase risks of hypothyroidism and chronic kidney disease (littrell, 2012; livingstone & rampes, 2006; presne et al., 2003). a 2012 systematic review discovered renal, cardio-vascular, and neurotoxicity in older adults using lithium (sun, hermann & shulman, 2017). huxley & baldessarini (2007) report that lithium’s neurotoxic effects can lead to greater impairment and disability among those diagnosed with bd, such as memory loss and decreased executive functioning. severe risks associated with antipsychotics, another common treatment for bd, include cardiovascular disease, osteoporosis, and significant reductions in brain columbia social work review, vol. xix | 83 82 | columbia social work review, vol. xix tissue over time (voineskos et al., 2020; littrell, 2012; dorph-petersen et al., 2005). another harmful consequence of bd overdiagnosis is the risk of exposure to social and internalized stigma, which can lead to social exclusion, occupational failure, and reduced functioning (hawke et al., 2013). researchers suggest that the stigma imparted by bd diagnosis, similar to that of schizophrenia, may reflect the condition’s longevity and genetic roots (hawke et al., 2013). unfortunately, the harms of bd stigma appear to be highest for those most at risk of misdiagnosis: those who lack support systems and carry stigma brought on by other diagnoses (fusar-poli et al., 2017). perhaps the most insidious result of inflating bd diagnoses, and the one which may be of most concern to social workers, is the masking of oppressive social conditions. like all disorders involving psychosis, bd and its symptoms have been linked to childhood abuse, perceived stress, and poor physical health, all of which disproportionately affect poor communities and communities of color (fusar-poli et al., 2017). environmental stressors including poverty, crime, and racial discrimination are correlated with depressive symptoms, psychosis, and the dysregulation of the limbic system; research suggests that they may also be erroneously attributed to bd (cogan et al., 2020; gómez, 2015; jackson et al., 2010). as a result, there are serious concerns that the rise in bd diagnoses, with their biological underpinnings, is concealing increasing social and environmental distress among marginalized americans. policy response according to critics, the biggest drivers of bd overdiagnosis are its diagnostic criteria and estimates of prevalence, both of which have shifted dramatically over the past three decades (ghouse et al., 2013; mitchell, 2012; littrell, 2012; burrows, 2010). in 1994, the dsm iv introduced bipolar ii by expanding mania, the central feature of bipolar i disorder, into the less severe category of hypomania, despite mania’s paul doyenthe overdiagnosis of bipolar disorder within marginalized communities high concordance and limited evidence for its expansion (yutzy et al., 2013; singerman et al., 1981). following the introduction of bipolar ii, a small group of researchers developed the idea of “subthreshold” or “subclinical” bd, which further expanded criteria and prevalence estimates (mitchell, 2012). between 1994 and 2007, bd diagnoses doubled in adults and multiplied by 40 in children, while estimates of bd’s prevalence rose from 1.6% to 24.2% of the population (burrows, 2010; national institute of mental health, 2007). critics regard the dsm iv’s changes to bd’s nosology as arbitrary and unsupported by evidence (yutzy et al., 2013; mitchell, 2012). they reject that surges in bd diagnoses capture an increasing incidence of the disorder, which, given bd’s biogenetic roots, should remain stable over time (almeida et al., 2020). instead, these researchers argue that bd’s expanded diagnostic criteria and inflated prevalence estimates have led to an epidemic of overdiagnosis (ghouse et al., 2013; mitchell, 2012). despite these criticisms and growing evidence of overdiagnosis, researchers and policymakers have done little to address the problem. in 2013, the newly released dsm 5 rebuffed warnings of overdiagnosis by expanding subsyndromal criteria for bd, a change that may significantly increase the risk of depressive patients being misdiagnosed with bd (carta & angst, 2016; cerimele et al., 2014). other issues related to bd’s overdiagnosis, such as diagnostic overlap with schizophrenia, schizoaffective and borderline personality disorders, comorbidity with anxiety and unipolar depression, and reliance on overly sensitive screening instruments were not addressed within the dsm 5, even though they were well-documented at the time of its publication (cosgrove & suppes, 2013; mitchell, 2012; vieta & philips, 2007). of the factors contributing to bd overdiagnosis, one of the most serious is the dsm 5’s failure to clarify the relationship between bd and post-traumatic stress disorder (ptsd). the co-incidence of ptsd in bd patients has been cited at 35%; the two disorders share multiple symptoms and affect similar regions of the brain (carmassi et al., 2020; mccormack & thompson, 2017; rakofsky et al., 2011). despite columbia social work review, vol. xix | 85 84 | columbia social work review, vol. xix calls from some researchers, the need to screen and control for trauma disorders in potential bd patients has been ignored, leaving marginalized communities, who experience disproportionate rates of trauma and decreased access to trauma-informed care, at risk of misdiagnosis (etaine et al., 2008). evidence suggests that misdiagnoses of bd leave trauma survivors less likely to receive appropriate care, with bd patients on medicaid being offered less therapy and more unsupervised drug treatments than other patients (busch et al., 2007; fontanella et al., 2015). underlying assumptions diagnostic psychology has been slow to recognize the problem of bd overdiagnosis in part due to its underlying assumptions about individuals with bd. one such assumption is that bd and its symptoms are biogenetic in origin. this claim is supported by family studies of bipolar i, but has not been substantiated for the diagnostic labels critics believe are driving overdiagnosis: bipolar ii and subclinical bd (or “bipolar not otherwise specified”) (almeida et al., 2020; mitchell, 2012). in fact, inconclusive findings have led some researchers to question whether bipolar i and bipolar ii are genetically related conditions (littrell, 2012). despite this lack of evidence and a wealth of literature identifying bd symptoms with over 51 unique environmental stressors, diagnostic psychology continues to regard bipolar ii and sub-clinical bd as biogenetic disorders (bortolato et al., 2017). another assumption obscuring bd overdiagnosis is that people diagnosed with bd have little hope of recovery. once again, evidence of poor prognosis is significant for bipolar i but is less clear for bipolar ii and subclinical bd, both of which have garnered less research (almeida et al., 2020). one historically important variable in determining bd’s prognosis is unemployment, which involves social factors as much as it reflects individual impairment. for instance, data showing that around 57-65% of bd patients were unemployed in 2007 compared to only 15% in the 1970s is difficult to explain without recourse to other factors, such as deindustrialization and declining job security (huxley & baldessarini, 2007). indeed, opponents of overdiagnosis argue that social distress due to rising work insecurity has been systematically mislabeled as mental illness over the past four decades, disguising the problem and worsening outcomes (buffel et al., 2017; wong, 2016). a third assumption about those diagnosed with bd is that their condition is universal and “colorblind.” in light of this assumption, some researchers have taken the low prevalence of bd among black americans as a sign of underdiagnosis, dismissing findings that the prevalence of mood disorders is consistently lower in black communities than in white communities (alvarez et al., 2018; boyd et al., 2011; breslau et al., 2008; neighbors et al., 2003; woodward et al., 2011). calls for increased screening among black americans carry a notable threat of overdiagnosis, given that actual prevalence appears to be low, and the depressive and trauma-related symptoms associated with anti-black oppression are frequently mislabelled as mental illness (jarvis, 2007; stevenson et al., 1997). meanwhile, the dsm’s colorblind approach to mental health treatment, which has failed to account for how psychological diagnoses impact racial groups differently, means that the risks of bd overdiagnosis within communities of color have not been monitored by mental health policymakers (green et al., 2012). while these assumptions have all likely contributed to the failure to address bd overdiagnosis, diagnostic psychology’s neglect of social and environmental problems is rooted in its assumption that mental illness represents discrete, biologically based diseases, a claim unsupported by evidence despite over 40 years of influence (jacob et al., 2014; timimi, 2014). critics of the “bio-medicalization” of mental health, stemming from the publication of the dsm iii in 1980, complain that it has led to “tunnel vision” about mental illness, even as evidence has increasingly characterized mental illness not as distinct clusters of biogenetic symptoms, but as transdiagnostic distress linked to trauma, deprivation, and social inequality (pilgrim, 2014; rimke, 2016; timimi, 2014). one explanation for the persistence of the biomedical model of mental illness, despite a lack of evidence to support it, is its shared assumptions with neoliberalism, which holds that individuals are paul doyenthe overdiagnosis of bipolar disorder within marginalized communities columbia social work review, vol. xix | 87 86 | columbia social work review, vol. xix responsible for their own health, have equal agency, and resolve their needs and problems through the consumption of private goods (rimke, 2016). detractors argue that neoliberal assumptions about mental distress have pathologized poor and minority groups, who have limited agency to address their problems, and have helped medicalize social welfare, with government support becoming increasingly contingent on diagnoses of physical and mental disability (wong, 2016). from this perspective, the medicalization of social welfare and the overdiagnosis of mental illness are mutually reinforcing, expressing the same neoliberal logic of privatization and growth that has dominated u.s. policy since the 1980s (rimke, 2016). overdiagnosis and welfare reform while few, if any, peer-reviewed studies have explored the relationship between social welfare reform and the overdiagnosis of bd, evidence suggests that the two are closely related. following the 1996 personal responsibility and work opportunity act’s (prwora) dismantling of traditional welfare, bd diagnoses skyrocketed, along with enrollment in supplemental security income (ssi), which rose fourfold between 1996 and 1998 (burrows, 2010; jans et al., 2004). as impoverished americans flocked to ssi as a source of financial stability and medicaid access, mood disorders became the largest and fastestgrowing drivers of enrollment, with a 100% increase in children applying to ssi and medicaid under bd diagnoses between 2001 to 2010 (national academies of science, engineering & medicine et al., 2015; drake et al., 2013). findings of rampant bd overdiagnosis among ssi recipients indicate that these surges in ssi enrollment reflect welfare-related needs rather than shifts in bd’s true prevalence (ghouse et al., 2013). multiple studies have connected rising bd diagnoses to gaps in post-welfare services. for example, a 2006 study found that impoverished americans were pursuing bd diagnoses in order to receive substance-related treatment, which the prwora purged from coverage in 1996 (stein et al., 2006). meanwhile, multinational studies on the medicalization of unemployment suggest that increasing rates of joblessness among ssi recipients with bd diagnoses reflect unmet needs for stable employment, with many frustrated ssi enrollees expressing a desire to work (buffel et al., 2017; frank, 2013; holmqvist, 2009). as with most neoliberal policies, the prwora’s transfer of poverty services from welfare to disability programs has benefitted private interests, including pharmaceutical companies and a growing industry of mental health professionals, all of which reap profits from psychiatric overdiagnosis, expanded categories of mental illness, and reallocations of government spending (mitchell, 2012; rimke, 2016). vulnerable americans, including those applying for disability under misapplied bd diagnoses, suffer the greatest losses as unmet needs for employment, housing support, healthcare access, neighborhood investment, and antidiscrimination policies are met with irrelevant and often harmful mental health interventions (shepherd & wilson, 2018; rimke, 2016; mills, 2015; hansen et al., 2014). advocacy organizations according to prominent psychiatrist and dsm 5 critic allen j. frances, american mental health advocacy groups have consistently failed to push back against the overdiagnosis of psychiatric disorders (frances, 2010). instead, advocacy groups such as the american psychological association (apa), the national alliance of mental illness (nami), and the national association of social workers (nasw) have issued demands for heightened mental health screenings within marginalized communities, calls which have drawn frequent support from the pharmaceutical lobby (american psychiatric association, 2015; davis & williams, 2020; frances, 2010). these campaigns, which express the influence and assumptions of america’s powerful mental health industry, reflect that there are currently few, if any, advocacy groups addressing the problem of bd overdiagnosis within the u.s. the majority of organizations recognizing overdiagnosis now operate in other countries. paul doyenthe overdiagnosis of bipolar disorder within marginalized communities columbia social work review, vol. xix | 89 88 | columbia social work review, vol. xix one of the most influential of these organizations is mental health europe (mhe), a pan-european, non-governmental organization (ngo), which has pushed for a demedicalized, psychosocial approach to mental health policy over the past decade. in 2012, mhe set up a task force to investigate the development of the dsm 5, releasing a statement that denounced its biomedical assumptions, expanded diagnoses, and promotion of “unnecessary and harmful” drug treatments (mental health europe, 2014; mental health europe, 2013). in a follow-up report, mhe called on the european union and world health organization to ignore expanded dsm diagnoses unsupported by evidence, to offer diagnostic alternatives, and to cease promoting psychiatric medications as a first line response to distress (mental health europe, 2015). mhe’s criticisms of the dsm 5 have been influential across europe, with the superior health council of belgium declaring in 2019 that the dsm would no longer be at the nation’s “center of [mental health]care planning” (simons, 2019). in addition to curtailing the influence of the dsm 5, mhe has targeted several other drivers of psychiatric overdiagnosis. since 2013, mhe has called for legislation to expose the financial ties between mental health policymakers, professional organizations, and pharmaceutical companies (l’ecluse, 2019). mhe has also launched an investigation into the influence of chronic unemployment on rising “psychosocial disability,” a term mhe uses in place of mental illness (mental health europe, 2016). mhe’s proposal of work programs for those labeled mentally ill was approved by the council of the european union in 2016, suggesting that europe is moving away from the medicalization of unemployment, as well as from biogenetic models of mental illness in which disability is considered incurable (finn, 2017; mental health europe, 2016). meanwhile, the ascendency of mhe’s psychosocial approach to mental health was powerfully expressed in a 2017 report from the united nation general assembly, which declared that the “neurological paradigm [of mental illness] causes more harm than good,” and called for a shift “from focusing on chemical imbalances to focusing on power imbalances and inequalities” (kinderman, 2020). a call to action: policy and practice to address bd overdiagnosis within the u.s., policymakers must first study the hundreds of thousands of americans receiving ssi benefits under bd diagnoses, a growing population at high risk of childhood trauma, poverty, and homelessness (cerimele et al., 2014; etain et al., 2008; huxley & baldessarini, 2007). new and focused research is needed to determine if these are in fact “risk factors” for bd, as is usually assumed, or if they are generating transdiagnostic symptoms which are driving overdiagnosis. there is also an urgent need for studies exploring the socioeconomic deprivation behind bd diagnoses, and the extent to which underemployment and poor access to healthcare are motivating americans to seek ssi enrollment (ghouse et al., 2013; wong, 2016). finally, researchers need to examine the impact of bd diagnoses within communities of color and the intersections of racial stigma with those brought on by dsm diagnoses and disability status (hawke et al., 2013). as researchers develop a clearer image of bd overdiagnosis, the mental health community can begin taking steps to address it. one strategy is to demand that researchers stop using inflated figures to characterize bd and instead adhere to conventional, evidence-based estimates of bd’s prevalence, which have ranged from 1% to 2% of the population (mitchell, 2012). another step is to discourage or eliminate the use of screening tools like the mood disorder questionnaire (mdq) and return to clinical interviews as the “gold standard” in bd diagnosis (ghouse et al., 2013). the most direct path to reducing overdiagnosis is to revise expanded criteria for bd by removing the “bipolar not otherwise specified” category from the dsm 5, and by toughening criteria surrounding hypomanic episodes, the key symptom in bipolar ii (mitchell, 2012). some researchers, citing findings that bipolar ii has no clear genetic profile and is not phenotypically distinctive from unipolar paul doyenthe overdiagnosis of bipolar disorder within marginalized communities columbia social work review, vol. xix | 91 90 | columbia social work review, vol. xix depression, have explored eliminating the bipolar ii diagnosis altogether, which would lead to substantially fewer diagnoses of bd (gitlin & malhi, 2020; parker & fletcher, 2009). others insist that addressing the roots of bd overdiagnosis will require more dramatic changes to the dsm. bd’s high comorbidity, expanding criteria and subtypes, and failure to control for environmental distress point to a broader crisis in post-dsm iii psychiatry, which has failed to successfully classify mental illness into distinct conditions, find biogenetic markers for core diagnoses, or curtail its own expansion (ghaemi, 2014; timimi, 2014). thus, stemming the flow of overdiagnosis may require the diagnostic system established with the dsm iii, which has consistently prized reliability over external validity, to be abandoned (dutta et al., 2007; pilgrim, 2014; vieta & philips, 2007). in its place, researchers propose the dsm be reorganized into a dimensional system with less arbitrary divisions between symptoms and fewer pathologizing diagnoses (dutta et al., 2007; vieta & philips, 2007). others demand that the dsm adopt a “traumagenic” model of mental illness that is based on shared experiences of adversity and encourages environmental over drug-focused interventions (pilgrim, 2014). mhe’s campaign for financial transparency and protective social policies provides a potential blueprint for curbing psychiatric overdiagnosis within the u.s. legislation preventing researchers with drug industry ties from serving on dsm panels could reduce pressures to further widen diagnostic criteria, while housing and employment programs for those at risk of being labelled mentally ill would likely lead to fewer diagnoses and less biogenetic pessimism about mental illness (elinson et al., 2007; huxley & baldessarini, 2007). by following belgium’s lead and decentering the dsm within its healthcare system, the u.s. could begin to explore diagnostic models that are more sensitive to the social, economic and racial determinants of mental health. finally, retiring the stigmatizing term “mental illness,” which locates the roots of mental distress within dysfunctional individuals, may help cleanse u.s. mental healthcare of neoliberal assumptions that are driving overdiagnosis and the privatization of poverty (mills, 2015; rimke, 2016; shepherd & wilson, 2018). social workers will need to think critically about how to respond to the problem of bd overdiagnosis, both as clinicians and as advocates for change. as clinicians, social workers need to familiarize themselves with the harms that bd diagnoses can impose on clients, such as heightened stigma, adverse drug effects, and enrollment in disability programs that can further reduce functioning (hawke et al., 2013; huxley & baldessarini, 2007; littrell, 2012). similarly, social workers should be aware of the pressures they face to apply dsm diagnoses, including organizational needs for efficiency, growth, and specialization, directives which often benefit social workers and their status as health professionals (rimke, 2016). finally, clinical social workers need to look beyond biological theories and identify the environmental factors driving clients to seek bd diagnoses, such as childhood trauma, housing instability, underemployment, and a lack of welfare related services. they must bear in mind that a bd diagnosis is a mark of lifelong biogenetic dysfunction, one that may render clients less likely to receive the help that they need. as advocates, social workers must challenge calls to reduce mental health disparities through indiscriminate screening and warn policymakers about the differential impact of bd overdiagnosis within minority communities. they must resist the increasing bio-medicalization of mental health and be prepared to defy a system of diagnostic psychology which many researchers say has lost its claim to scientific validity (dutta et al., 2007; ghaemi, 2014; jacob et al., 2014; pilgrim, 2014; timimi, 2014). finally, social workers will need to join researchers in psychiatry and psychology to develop new systems of diagnoses that link mental distress to environmental risk factors and harmful public policies (rimke, 2016). social workers will need to decide for themselves whether a public conception of mental health is possible within the u.s.’s privatized healthcare system, and within an unregulated market economy that prioritizes innovation and profits over social protections. paul doyenthe overdiagnosis of bipolar disorder within marginalized communities columbia social work review, vol. xix | 93 92 | columbia social work review, vol. xix whatever they decide, social workers can no longer afford to ignore the overdiagnosis of bd, which has mischaracterized distress, bolstered stigmas, and placed the burden of change on those who are often least able to effect it. conclusion bd overdiagnosis is a growing problem within the u.s., especially among marginalized americans seeking social support through ssi enrollment. consequences of misdiagnosis include heightened stigma, adverse drug effects, and the concealment of environmental distress within poor communities and communities of color. a new frontline in the medicalization of poverty, the overdiagnosis of bd has been poorly monitored by mental health organizations, which have launched uncritical campaigns for increased mental health screening amidst widespread reports of invalid diagnoses (american psychiatric association, 2015). bd overdiagnosis is perpetuated by clinical assumptions that bd is undertreated, prone to subclinical presentations and underrecognized in communities of color, claims which have failed to amass significant evidence (littrell, 2012; mitchell, 2012). assumptions about bd’s poor prognosis and biogenetic origins are rooted in the unsubstantiated claim that mental illness involves discrete biologically based conditions, and from neoliberal assumptions about the sources of and solutions to mental distress, which have helped to medicalize and dismantle social welfare programs over the past four decades (timimi, 2014; wong, 2016). policymakers are encouraged to follow mental health europe’s example by passing financial transparency laws, decentering 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(2016). geographies of medicalized welfare: spatial analysis of supplemental security income in the u.s., 2000–2010. social science & medicine, 160, 9–19. yutzy, s. h., woofter, c. r., abbott, c. c., melhem, i. m., & parish, b. s. (2012). the increasing frequency of mania and bipolar disorder. the journal of nervous and mental disease, 200(5), 380–387. zimmerman, m., ruggero, c. j., chelminski, i., & young, d. (2008). is bipolar disorder overdiagnosed? the journal of clinical psychiatry, 69(6), 935–940. paul doyenthe overdiagnosis of bipolar disorder within marginalized communities paul doyen is a masters of science in social work candidate at columbia school of social work in advanced clinical practice concentrating in health, mental health and disabilities. he graduated from tulane in 2019 with a bachelor of science in psychology. paul is currently an intern at the psychoanalytic psychotherapy study center in manhattan, where he is practicing psychodynamic therapy with clients throughout new york. designer vaginas 57 designer vaginas designer vaginas the goal of creating the idealized female form is neither new nor novel. women have been altering their bodies for centuries. however, the focus recently has come onto the vagina the most culturally value-laden of anatomical parts. this paper seeks to explore how historical representations and contemporary perceptions of the vagina have shaped attitudes towards female genitalia, and why society has perpetuated the objectified, idealized female image and imposed that falsification on the vagina. additionally the author explores the practice of female genital cosmetic surgery (fgcs), potential impetus behind the increase in elective vagina surgeries, and the implications of fgcs for both the individual and broader society. further the author hopes to examine implications for social work practice working in a society blanketed with the pernicious cultural message that in order for a woman to be accepted and feel adequate, she must attain the “perfect” physical form. or centuries, women have altered their bodies to achieve a perceived physical ideal. in the developed western world, pervasive cultural constructions of “perfection” have motivated women to dye their hair, adorn themselves with permanent makeup, adopt emotionally and physically destructive diets, and at the most extreme, undergo cosmetic surgery (davis, 1995). popular culture and the media perpetuate this belief that women can and should literally construct themselves into the enigmatic, heterosexual female ideal (braun & kitzinger, 2001). thus, it was only a matter of time before women’s focus shifted to the vagina, and thus birthed an additional form of modification: female genital cosmetic surgery (fgcs). throughout this paper, the author will examine the history and current status of the vagina in public discourse. additionally, this author endeavors to explore the current phenomenon of elective fgcs and the role that the media and societal attitudes play in the practice of fgcs. while important, female genital cutting or surgery for transsexual and intersexed people will not be discussed within this paper as such topics are beyond the scope of this paper. the vagina has become increasingly prolific in contemporary art, which katherine (katie) querna f 58 journal of student social work, vol. vi is represented through popular culture. from judy chicago’s ‘the dinner party’ to annie sprinkle’s ‘speculum parties of in the 1980s, artists’ representations of the vagina have become increasingly more mainstream. these feminist artists paved the way for the most well-known representations of vagina in art such as eve ensler’s the vagina monologues (braun & wilkinson, 2001). additionally, the proliferation of pornography has furthered the dialogue around female genitalia (braun, 2005; 2001; davis, 2002; nagel, 1996; scheeres, 2006). this larger, vagina awareness in the media helps normalize anatomy and is a positive shift towards bringing the vagina into public discourse. these contemporary representations have developed after the years of derogatory discourse regarding female anatomy. the vagina has traditionally been thought of as gross and shameful, often as something to be hidden (braun, 2005; braun & wilkinson, 2001; davis, 2002). these attitudes manifested in secrecy around female genitalia, as something not to be discussed. when the vagina was made public, it was ridiculed or presented as disgusting (braun & wilkinson, 2001; braun, 2005; davis, 2002). historically, women’s bodies have been a site of struggle for power and control (brownmiller, 1994). as brownmiller (1994) commented “the female body often reduced to isolated parts, has been mankind’s most popular subject for adoration and myth, and also for judgment, ridicule, esthetic alteration, and violent abuse” (p. 58). while research about female bodies and the media’s representation of women is widespread, literature discussing the vagina as a topic is scant. despite this lack of attention, there exists a wealth of pejorative and paradoxical socio-cultural representations of the vagina. the vagina in history symbolic constructions of the vagina were originally created by a heterosexist, male-dominant culture which sought to perpetuate the subordinate status of women by creating the idea that women’s bodies are dangerous and uncontrollable, and thus, the vagina is something to be feared (davis, 2002). this construction of female bodies as a source of disgust, fear and danger (ussher, 1989) is manifested in the mythological idea of the dangerous vagina (beit-hallahmi, 1985; otero, 1996). for example, the vagina dentata –a vagina equipped with teeth is a common mythological motif around the world (beit-hallamhmi, 1985). lederer (1968) uses this imagery in the fairytale sleeping beauty, metaphorically comparing the impenetrable wall of deadly thorns to the vagina. in new zealand, maori legend describes the goddess of death, “in the place where men enter her she has sharp teeth of obsidian and greenstone” (alpers, 1964, p. 111). k a t h e r in e q u e r n a 59 designer vaginas perhaps the genteel status women aimed to occupy later in western history is in response to the early derogatory perceptions of women and their voracious desires as symbolized through their vaginas (braun and kitzinger, 2001). notions of female lust were transformed into the myth of feminine modesty. during the late eighteenth century, any derivation from that modesty was seen as amoral and promiscuous; the antithesis of what a woman was supposed to or would want to be. as to not be perceived as threatening, women were obliged to emanate demureness and docility, the goal of which was to convey self-control. self-containment was highly valued. this was the antithesis of the “sexually insatiable female” dogma of the past. during the same era, a large labia came to be associated with deviance, because they implied, albeit incorrectly, promiscuity (braun & wilkinson, 2001; pliskin, 1995). the vagina quickly morphed into a public health concern. a woman who was unable to control her sexual desires (just by virtue of feeling sexual desires), would pose a threat to the population as though her perceived promiscuity were contagious, and a disease in and of itself. women who lacked etiquette were perceived as sexual. women with “overly” long labia, as determined by the dominant culture were were dangerous to the public (1995). the vagina as dangerous arose symbolically arose as the uncontrollable female. in more practical or pseudo scientific terms, the vagina was the melting pot for diseases. such concepts were infused into contemporary periods as well. erik erikson (1968) suggested: “dreams, myths, and cults attest to the fact that the vagina has and retains (for both sexes) connotations of a devouring mouth” (braun & wilkinson, 2001, p. 24). american servicemen in vietnam recount hearing stories of sex workers with razors, sharp glass, or even grenades in their vaginas (gulzow & mitchell, 1980). thriller genre films frequently use vagina detanta imagery “for the purpose of portraying female sexuality as a monstrous threat to the male” (braun & wilkinson, 2001, p. 24, galvin, 1994, p. 9). the male psyche played a critical role in perpetuating the myth that the vagina is dangerous and erratic; a metaphorical part of the woman to be controlled. the vagina is seen as a hole of uncertainty –mysterious, fleshy, devouring the male penis (galvin, 1994). additionally, the vagina physically is not physically seen as easily as the penis, nor has it been represented as often in media and social dialogue around genetalia. thus the vagina (that we aren’t as familiar with) is unpredictable (braun & wilkinson, 2001; braun, 2005). the vagina in public these attitudes subsequently infiltrate popular psyche and seep into media k a t h e r in e q u e r n a 60 journal of student social work, vol. vi outlets, perpetuating cultural beliefs about the vagina. according to braun and wilkinson (2001), the vagina’s degraded status plays out in several ways: the vagina as (a) inferior to the penis; (b) as absence of a penis; (c) a passive receptacle for the penis; (d) sexually inadequate; (e) disgusting; (f) vulnerable and abused, and; (g) dangerous. the consistent invalidation of the vagina leads women to see their own anatomy as undesirable; as parts that need to be transformed to be accepted. women are inundated with derogatory cultural attitudes surrounding vaginas, which are portrayed as dirty, unhygienic, and even dangerous (braun & wilkinson, 2001). the media perpetuates this stigmatization of female anatomy by asserting that women need to clean and hide their vaginas to maintain some level of decorum. douches, scented panty liners, and a cadre of various “feminine hygiene” products created to sophisticate the vagina are marketed to women, increasing the stigma that vaginas are shameful things meant to be hidden and perfumed (kane, 1997; braun & wilkinson, 2001; davis, 2002). the vagina consistently has been portrayed as problematic. popular teen and women’s magazines are rampant with questions from readers about how to improve the look, smell, tone, even taste of their vaginas (kane, 1997). “a significant amount of women would gladly swap their real vaginas for something less troublesome-an unexploded warhead in their back garden, say…” (ellen, 1999). movies, television, and music, all perpetuate these imbedded attitudes by recycling tired jokes about the “foulness” of the vagina. such carriers of pop culture allude to the danger the vagina poses to society if it is not controlled (legman, 1975; braun & wilkinson, 2001; davis, 2002). the message is clear: women must conform to what the male authority of popular culture dictates as acceptable, so that men can feel some amount of control over women and their sexuality (braun, 2005). media representations of female sexuality as “insatiable” or “voracious” are arguably born from this fear of the female; that men’s penises could get devoured by the “uncontrollable beast” that is the vagina (pliskin, 1995). from a feminist perspective, women have internalized society’s misogynistic attitudes about women and their “sub-par” anatomy, and some have consequently elected to undergo female genital cosmetic surgery (fgcs). further, television shows glorify cosmetic surgery, creating the impression that “everyone is doing it.” the expectation becomes that one must improve their own appearance in order to fit in. fgcs is one of the newest in a lineage of surgical and cultural arsenals meant to popularize the idea that female bodies are inherently flawed. the ink a t h e r in e q u e r n a 61 designer vaginas creasingly normalized status of commercial pornography coupled with vaginally focused art and prints material, albeit positive cultural changes, may have led to an increase in fgcs (braun, 2005; davis, 2002; nagel, 1996; scheeres, 2006). women, who often look to magazines for representations of the traditional feminine ideal are increasingly shifting their focus to pornography and consequently to their own genitals. davis (2002) quotes a well-known cosmetic surgeon in saying “…they look at playboy, the ideal woman per se, for the body and the shape and so on. you don’t see women in there with excessively long labia minora” (p.7). women who internalize this notion of the vagina coupled with their attitudes around their own anatomy are susceptible to fgcs. plastic surgeons perpetuate the practice by emphasizing the notion of the “perfect, tight” vagina. a purveyor of fgcs, dr. gary alter proclaims “take out your hand mirror and check out those labia, after all, you just might not measure up” (braun and kitzinger, 2001, p.272). media reports covering the work of many modern practitioners state that vaginal tightening (vaginoplasty) increases the sexual pleasure for women. this has yet to be explored empirically; however it is often cited as the impetus for women undergoing surgery. curiously, this procedure seems like it would increase male pleasure more markedly than women’s. history of vaginal surgery fgcs began in the 1840’s with j. marion sims, a physician who performed a series of experimental surgeries for vesico-vaginal fistula on southern slaves. these fistulas were often a result of childbirth and presented as necrotized vaginal tissue between the bladder and the vagina, which allowed for the involuntary discharge of urine into the vaginal vault (littrell, 1995). although the procedure was intended for white women post-childbirth, a black woman’s subordinate status, manifested as an inability to refuse treatment. coupled with her higher birth rate, black women were increasingly vulnerable to this experimental surgery (adams, 1997). additionally, since enslaved women were often undernourished, the incidence of childbirth complications increased, and sims was endowed with a higher patient yield to experiment upon. although sims’ work provided a cure for visico-vaginal fistulas, it set the tone for further scrutiny of natural female anatomy and the creation of procedures for illusory maladies. such was the case for nineteenth century british physician baker brown who was called into question for performing non-consentual clitorectomies on women with reported pronounced sexual desire (1997). clitorectomies entail k a t h e r in e q u e r n a 62 journal of student social work, vol. vi surgical removal of all of the clitoris and sometimes the labia as well (littrell, 1995). current vernacular describes the procedure that brown performed on women as female genital mutilation or forced circumcision. brown’s apparent goal was to “cure” women of their want for clitoral stimulation, however, his procedure led to further pathologizing of female sexual desire. contemporary fgcs in this day and age, bodily perfection, a tight, unadulterated vagina-is cultural currency (davis, 1995; davis, 2002). many women who have undergone genital cosmetic surgery cite feelings of aesthetic dissatisfaction with the appearance of their vaginas, consistently noting that their labia are too loose or that their labia minora protrude beyond their labia majora (braun & kitzinger, 2001). it seems that women are proceeding under the assumption that there is a “normal vagina” that does not look like their own. society created the image of a “normal” vagina and ascribed a pejorative status to a “loose vagina” which purportedly signals sexual promiscuity (2001). it behooves the male-dominant, western culture to perpetuate this idea, as a large penis is conversely valued; thus if a man feels that the size of his genitalia is inadequate, he can turn his problem of a small penis into her problem of a loose vagina (braun & wilkinson, 2001; braun, 2005). the phenomena of contemporary fgcs began with controversial gynecologist dr. james burt, who stated in his 1975 book surgery of love that he had been performing “love surgery” on women without their consent for years (adams, 1997). this surgery involved realigning the vagina and removing the skin covering the clitoris, with the intent, burt asserted, of enhancing female sexual pleasure. burt was motivated by a self-held idea that women’s vaginas are “structurally inadequate for intercourse” (p.61), and thus should be altered. this claim was turned on its head when, in 1989, burt had his license revoked after several former patients filed suit for malpractice claiming that they were sexually crippled and suffered chronic debilitating pain, urinary tract infections, and incontinence (adams, 1997). both brown and burt operated on women under the guise of benevolence; however, they were guided by traditional, male-centric, heterosexual values and believed that women suffer from an inherent sexual pathology that necessitates intervention (adams, 1997). according to several theorists, medicine created numerous procedures intended to help construct the coveted “ideal” vagina: a youthful, tight, rounded vulva, with labia majora enclosing the labia minora and clitoris (braun, 2005; k a t h e r in e q u e r n a 63 designer vaginas braun & wilkinson, 2001; braun & kitzinger, 2001; davis, 2002). the scope of modern fgcs includes vaginoplasty (tightening of the vaginal muscles), labiaplasty/labioplasty (labia minora reductions), labia majora “augmentations,” (tissue removal, fat injections), liposuction (mons pubis, labia majora), vaginal tightening (fat injections, g-spot “amplification” collagen injected into the “g-spot” which swells it), -and hymen reconstruction (intended to restore the appearance of virginity). given the nature of these specific reconstructive surgeries, it would appear that women are after pubertal genitalia. although specific quantitative data regarding fgcs currently does not exist, a collection of qualitative interviews of 24 western surgeons suggests that increasing numbers of women are electing to undergo fgcs for a variety of motivations and costs, both emotional and material (braun, 2005). many patients who opt for fgcs previously have undergone cosmetic surgery (gagne & mcgaughey, 2002; braun & wilkinson, 2001; haiken, 1997: davis, 2002; scheeres, 2006). given the problematic historical representations of the vagina by the medical community, the media, and society at large, it seems natural that women would feel the need to alter their genitals. implications for practitioners regardless of the plethora of procedures conducted upon the vagina, or reasons given for their necessity, only in very rare cases do fgcs procedures serve any other purpose than to perpetuate the derogatory ideology that women’s vaginas are imperfect; their bodies are not good enough and they are not good enough follow (braun, 2005; braun & wilkinson, 2001; davis, 2002). however, there is hope to end this oppressive attitude. literature on fgcs is becoming increasingly prevalent in popular media. cosmopolitan, harpers bazaar, and marie claire, as well as salon online ran stories on the subject. these pieces all discussed labiaplasty, a relatively recent plastic surgery procedure that involves trimming away labial tissue and sometimes injecting fat from another part of the body into labia that have been deemed excessively droopy (davis, 2002). these articles also included remarks from skeptical colleagues and from polled readers who feel that their labia are satisfactory; encouraging reports that show resilience to the pernicious myth of perfection. judy chicago, annie sprinkle, and well-known writer eve ensler not only included the vagina in their work, but made it the focus. as well, the normalization of pornography has furthered modern discourse on human anatomy thus serving to de-stigmatize and de-mystify the “gross, dangerous” vagina (braun, k a t h e r in e q u e r n a 64 journal of student social work, vol. vi 2002; braun & wilkinson, 2001; davis, 2002; nagel, 1996; scheeres, 2006). because fgcs is manifested on/in the body, it is imperative that practitioners explore the potentially deleterious health consequences resulting from any one of the fgcs procedures. women report loss of sensation (ironically “increased pleasure for women” is a common reason cited for the decision to undergo the surgery), chronic pain, and frequent urinary tract infections (navarro, 2004; scheeres, 2006). there also exists evidence of increased incidents of vaginismus, a condition in which the vaginal muscles constrict, restricting access to the penis, thus compromising any sexual activity (scheres, 2006). the irony here is that some women who choose fgcs in order to create the “ideal vagina” or “increase their sexual pleasure” ended up with an inability to have sex at all (davis, 1995). along with a $10,000 price tag, fgcs may be an exorbitantly high price to pay for the “perfect” vagina. concurrently, the idea of women’s bodies as shameful, private things could affect women’s help-seeking behavior and willingness to discuss certain symptoms with practitioners, or even examine their own genitals and recognize causes for concern. normalizing real (as opposed to idealized) vaginas is beneficial to women as it may allow them to feel freer to discuss concerns with practitioners as well as serve to generally cultivate greater body acceptance. clinicians would be well served to investigate how these cultural attitudes manifest for women with whom they practice. female subordination and the drive for bodily perfection can manifest into destructive behaviors such as disordered eating, overzealous exercising, capriciously use of plastic surgery, and other body punishing rituals all in pursuit of a perceived physical ideal (blessing, 2005; delinsky, 2005). research suggests that women who undergo cosmetic surgery have a higher propensity for disordered eating patters, body dissatisfaction, and general attitudes of their bodies as defective (blessing, 2005; delinsky, 2005). future social work research should examine individual outcomes for those who choose to undergo surgery, as well as the impact of increased cosmetic surgery on societal ideals (delinsky, 2005). this gives rise to the question, is it the perceived ideals that are driving the increase in fgcs, or is it, the other way around? could the phenomena of more women opting to construct their perfect vagina constructing the perceived ideal? further, women could be proceeding under false assumptions; the reality could be that in our heterosexually driven culture, men do not lust after one perfect female form, but are happy with any number of differing aesthetics regarding a woman’s anatomy. the danger of fgcs is when dysmorphic thinking moves fluidly into ack a t h e r in e q u e r n a 65 designer vaginas tion; and the body becomes a site for alteration rather than reflection. blessing (2005) suggests: “… heartbreaking consequences can emerge when thinking is supplanted by action and when fantasies are responded to as if they were real” (p. ) future research should explore women’s reported motivations for undergoing fgcs. findings could inform best practice models targeted at mitigating the self-esteem issues that can be the impetus for women compelled to alter their appearance. gillespie (1996) discusses the implications for cosmetic surgery on the macro societal level. she states that cosmetic surgery “encourages women to experience their bodies as pathology and reinforces unrealistic ideals…this may lead to disharmony and dissatisfaction, and make body preoccupation normal feminine behavior” (p.83). if that cultural truism perpetuates it could exacerbate self-destructive behaviors, which are all topical issues for social workers. additionally, it must be said that body dissatisfaction is not limited to females. normalizing the creation of the perfect form could lead to increases in erratic and overzealous rituals aimed at body modification in males as well (striegel-moore, silberstein, & rodin, 1986). issues typically associated with males and cosmetic surgery are too broad for the scope of this paper, however, it is safe to say that creating a unilateral ideal for any population is harmful to the individual and for the broader society. the tenacity of negative representations suggests that society has an obligation to think critically about how the vagina is discussed in schools, media, and coming generations. cultural representations affect women’s health. sexual and psychological well-being can only be improved by a shift in ideology. breaking the taboos of shame and secrecy by talking seriously about the vagina and by challenging derogatory representations is imperative in this restorative process of healing the female psyche and steering attitudes towards what should be ideal: the vagina as a healthy, functional, beautiful part of female anatomy. references adams, a. 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(1995) littrell, h. (ed.). 2nd edition, baltimore: williams and wilkins. [is this an edited book with or without authors? i’m not sure, but please check out how the owl purdue website has this citation] striegel-moore, r. silberstein, l., & rodin, j. (1986). toward an understanding of risk factors for bulimia. american psychologist, 41(3), 246-263. ussher, j. (1989). the psychology of the female body. london: routledge. katherine (katie) querna is a second year master’s student in the advanced generalist practice and programming method. she holds a ba in elementary education with a minor in spanish from linfield college. she is currently an intern at the social intervention group working on international, public health and trauma studies research. her email is kaq2102@columbia.edu. k a t h e r in e q u e r n a columbia social work review, vol. xix | 63 62 | columbia social work review, vol. xix post-reconstruction black codes implemented throughout the south stunted the economic mobility of black workers and replicated the free labor system of slavery (nittle, 2021). while these laws were abandoned or outlawed over time (nittle, 2021; pbs, 2017), the use of contemporary preemption in southern states acts as a de facto continuation of black codes by barring legislation, often from progressive cities and municipalities, that seeks to strengthen rights and protections for black workers throughout the region. in order to properly understand the unique racial, political, and economic entanglement between twentyfirst century preemption and the oppression of black workers, one must first explore the origins of preemption and the history of black worker oppression in the south. this examination provides the backdrop for modern attempts to suppress black workers in states like alabama and tennessee. a closer look at the deep political divisions between southern legislatures and urban municipalities in their states offer arguments, though unfounded and insufficient, in favor of preemption, and outline the challenges worker advocates face when addressing the problem. despite its challenges, it is critical for organizers to continue fighting preemption using creative strategies and to reaffirm the rights and advancement of black workers. keywords: preemption, south, dillon’s rule, home rule, black codes, workers, oppression still fighting: the relationship between contemporary preemption in the south and the continued struggle for black worker rights resha t. swanson she/her columbia social work review, vol. xix | 65 64 | columbia social work review, vol. xix still fighting still fighting: the relationship between contemporary preemption in the south and the continued struggle for black worker rights in the south1, where the shadows of slavery loom long and heavy, the word preemption strikes fear into the hearts of local legislators and worker rights advocates. preemption is the “use of state law to nullify a municipal ordinance or authority” (dupuis et al., 2018, p. 3). predominantly white state legislatures use preemption to strike down ordinances passed by progressive cities, including legislation that raises the minimum wage, mandates paid leave, or advocates for fair workweeks. through it all, workers from these liberal, urban areas with highly concentrated black populations––often led by black and latinx city councils––suffer the economic consequences (blair et al., 2020). in short, preemption is more than a tool used by state legislatures to block progressive legislation. it is a racially charged mechanism that has been employed for centuries to perpetuate white supremacy and suppress the rights of black workers in the south. this paper explores the historical origins of state preemption, its connection to black worker suppression, and preemption’s manifestation in the twenty-first century south. while this paper focuses on the south, it does not mean to express that preemption does not thrive in northern states or that its effects are felt only by southern black workers. to the contrary, preemption oppresses all working class individuals wherever utilized. “state interference with local decision-making occurs in every region of the country” (blair et al., 2020, p. 3), but preemption in the 1 the deep south (also known as the lower south) refers to the states of alabama, georgia, louisiana, mississippi, and south carolina, whose economies were historically dependent on the production of cotton and slave labor (beck & tolnay, 1990). the upper south, composed of tennessee, kentucky, and missouri, relied less heavily on slave labor and traditionally grew wheat and grain-based crops (jordan, 1967). scholarly articles vary in their inclusion of arkansas and texas as deep or upper south states, but agree that they culturally and economically fall within one or both categories (beck & tolnay, 1990; jordan, 1967). for the purpose of this article, the author uses the term south (and other variations of the word) to refer to states of the upper and lower/deep south areas, and, texas, arkansas, north carolina, and florida (which share similar economic and cultural histories). south is distinctly shaped by conservative legislatures battling urban, progressive municipalities and cities, typically heavily populated by black and latinx individuals, for legislative power, making southern preemption uniquely racially divisive (blair et al., 2020). this paper explores racism’s deep-seated role in shaping worker-related preemption policies in the southern region (blair et al., 2020). in order to clearly understand contemporary preemption in the south, we must first study its roots in the united states and its context in the region. the framework for preemption two primary factors worked in tandem to set the stage for contemporary preemption–: (1) the supreme court conferring preemption powers to states and (2) the restricted economic mobility of black workers post-reconstruction. dillon’s rule and home rule the united states constitution’s “supremacy clause” clearly defines the hierarchy of authority between federal and state legislation, declaring federal law “the supreme law of the land” (u.s. constitution. art. vi, cl. 2.1.1.3). in other words, federal laws overrule state laws in situations where state legislation expressly and impliedly contradicts federal law (congressional research services, 2019). however, the constitution makes no mention of powers granted to municipalities2 and cities and their priority in lieu of less or more restrictive state legislation that does not already contradict federal policy. this left the matter in the hands of various courts. named after former iowa supreme court justice john dillon, dillon’s rule “derived from the two court decisions issued by judge john f. dillon of iowa in 1868” (national league of cities, 2016, para. 4). in the first decision, city of clinton v. cedar rapids and missouri river 2 in this article, the term municipality refers to counties, wards, and similar governing bodies that function as “political subdivisions of the state” (phillips, 2017, pp. 2230-2231). resha t. swanson columbia social work review, vol. xix | 67 66 | columbia social work review, vol. xix railroad company (1868), “the plaintiff, the city of clinton, sought to enjoin the defendant, railroad company (“cedar rapids”), from building railroad tracks across the city’s streets without the city’s consent” (hansford, 2020, para. 3). eventually, “the court held that the city could not prevent cedar rapids from building over the streets of the city because the iowa legislature granted cedar rapids the right to do so” (hansford, 2020, para. 3). regarding the decision, judge dillon wrote: the true view is this: municipal corporations owe their origin to, and derive their powers and rights wholly from, the legislature. it breathes into them the breath of life, without which they cannot exist...unless there is some constitutional limitation on the right, the legislature might, by a single act, if we can suppose it capable of so great a folly and so great a wrong, sweep from existence all of the municipal corporations in the state, and the corporation could not prevent it. we know of no limitation on this right so far as the corporations themselves are concerned. they are, so to phrase it, the mere tenants at will of the legislature. (city of clinton v. cedar rapids and missouri river railroad company, 24 iowa 455, 475, 1868) the second key decision, merriam v. moody’s executors (1868), challenged a city’s ability to “sell and convey real estate for the nonpayment of special taxes” levied in the city’s charter (merriam v. moody’s executors, 25 iowa 163, 170). dillon wrote: in determining the question now made, it must be taken for settled law, that a municipal corporation possesses and can exercise the following powers and no others: first, those granted in express words; second, those necessarily implied or necessarily incident to the powers expressly granted ; third, those absolutely essential to the declared objects and purposes of the corporation—not simply convenient, but indispensable; fourth, any fair doubt as to the existence of a power is resolved by the courts against the corporation—against the existence of the power. (merriam v. moody’s executors, 25 iowa 163, 170, 1868) justice dillon would expound on what came to be known as “dillon’s rule” in five editions of his legal treatise dillon on the law of municipal corporations (hansford, 2020). the united states supreme court adopted justice dillon’s analysis in a 1907 decision in hunter v. pittsburgh, where the court declared, “municipal corporations are political subdivisions of the state, created by it and at all times wholly under its legislative control” (hunter v. city of pittsburgh, 207 u.s. 161, 52 l. ed. 151, 28 s. ct. 40, 1907). the most crippling part of dillon’s rule is the provision that any powers not expressly given to localities have not been conferred, which severely limits municipalities’ ability to pass legislation that the state legislature may see as politically unfavorable (national league of cities, 2016). the national league of cities (2016) notes, “no local action could be undertaken without permission from the state legislature, which only met for short, biennial sessions…[and] generally requires that local officials spend a considerable amount of time lobbying the state legislature” (para. 6). concerned about the restrictive nature of dillon’s rule, judge thomas cooley held that local governments did possess some power to pass legislation within the bounds of state laws and constitutions (people ex rel. le roy v. hurlbut, 24 mich. 44, 1871). while home rule helped municipalities regain limited power in the early 1900s by “conferring some powers to local governments,” its “power is limited to specific fields, and subject to constant judicial interpretation,” and was, moreover, defined and applied differently by each state (national league of cities, 2016, paras. 7-8). the application of dillon’s rule and home rule is sporadic. dillon’s rule can be applied to municipalities, cities, or towns with a certain population or chartered before a certain year (or a combination of the two), which is the case in eight states (russell & bostrom, 2016). for example, alabama applies dillon’s rule to counties but home rule to other municipalities like towns and cities (hansford, 2020). some states provide for home rule through constitutional changes, while others do it through legislative statutes, and states may limit home rule to cities, municipalities, or a combination of the two (russell & bostrom, 2016). still fighting resha t. swanson columbia social work review, vol. xix | 69 68 | columbia social work review, vol. xix the uneven application of dillon’s rule and home rule sets the stage for battles over legislative power within states. a history of black worker suppression another key component to understanding contemporary worker rights preemption is the south’s torrid history of black worker suppression. the civil war, followed by reconstruction, upheaved the lives of southern aristocrats and governing entities. general sherman’s march to the sea left thousands of southerners with damaged or no property, burned cities and fields, and deep-seated resentment (pbs, 2021). in addition to economic loss and extensive property damage, many ruling southern whites also lost their labor source–– enslaved black people––in the years following the civil war (pbs, 2021). reconstruction forced former slave owners to live amongst (at least to some extent) their former “subjects” who, thanks to the newly passed fourteenth and fifteenth amendments, were now endowed (theoretically, at least) with the same inalienable rights, and competed for coveted economic and natural resources (united states senate, 2021). intensified by the tight stranglehold of reconstructionist northerners, emancipation threw southern governments into chaos. when president hayes reversed reconstruction in 1877 and withdrew troops, southern, white lawmakers jumped at the opportunity to “disenfranchise black voters and dismantle the reforms that had been instituted after the civil war…and restore the racial hierarchy of the pre civil war political order” (blair et al., 2020, p. 5). black codes or black laws were passed, primarily in southern states, that successfully “limited the rights of black people and exploited them as a labor source” (nittle, 2021, para. 1). these laws created a free labor system that mimicked slavery and served as early examples of southern legislatures using their power to prevent black people from gaining economic mobility. black codes included state legislation like the following: in addition to criminalizing joblessness for african americans, the codes required black people to sign annual labor contracts that ensured they received the lowest pay possible for their work. the codes contained anti-enticement measures to prevent prospective employers from paying black workers higher wages than their current employers paid them. failing to sign a labor contract could result in the offender being arrested, sentenced to unpaid labor or fined (nittle, 2021, para. 7). debt peonage also forced black individuals into free labor. the meager wages paid to black individuals post-reconstruction required many, especially those in the agricultural industry, to take out loans from creditors and sharecroppers (pbs, 2017). additionally, black people in the south were targeted and surveilled, often culminating in arrests for minor crimes like loitering and leading to exorbitant court fines and fees. (nittle, 2021; pbs, 2017). because they lacked economic means, black people often were mandated or opted to pay back debts via exploitative free labor (pbs, 2017). moreover, black workers endured vast abuses. paul worthman’s (1969) early survey of black workers and their relationship to unions noted the appalling conditions of early mines in birmingham, alabama, and the animus of white workers against their black peers. he wrote, “racial prejudice among birmingham workers sometimes broke out into open conflict as white working men attempted to eliminate the economic competition from black workers by barring them from certain trades” (worthman, 1969, p. 381). black workers faced not only verbal and physical conflict, but also financial manipulation and abuse from employers. worthman (1969) described the conditions at the ore mines of red mountain: “ore was dug by subcontractors who hired laborers at 65 cents per day...whether or not they lived at the camps, at least 50 cent per month was deducted for each man’s wages for rent” (p. 397). dillon’s rule, early black codes, and the economic suppression of black workers set the stage for volatile legislative conflicts over worker rights across the south. still fighting resha t. swanson columbia social work review, vol. xix | 71 70 | columbia social work review, vol. xix twenty-first century preemption seen through the historical lens of post-reconstruction, contemporary preemption can be seen as a perhaps more successful continuation of early black codes’ efforts to limit the mobility of black workers in the south––successful in the sense of using dillon’s rule and home rule as forces for maintaining a white supremacy that was codified into state law. it is an essential tool for majority white, conservative legislatures hoping to block municipal ordinances that would strengthen the rights of black workers. the economic policy institute’s “map of the campaign to suppress worker rights in the states” (2019) indicates that southern states have some of the most restrictive preemption laws. in these states--alabama, arkansas, florida, georgia, louisiana, mississippi, north carolina, south carolina, and tennessee--state legislatures have stifled local attempts to strengthen worker rights by preempting legislation that altered the minimum wage, established project labor agreements, paid leave, and fair scheduling, instituted prevailing wages, or regulated the gig economy. unsurprisingly, black people account for 15% to 27% of these states’ populations, significantly higher than the national black population of 13.4% (u.s. census bureau, 2019). nashville and birmingham serve as two contemporary examples of preemption in southern cities and illustrate how its modern-day invocation stifles attempts to expand black worker rights. nashville, tennessee & local hire laws (2015) in 2015, nashville voters passed a local hire ordinance titled nashville metro chamber amendment three, which aimed to create job opportunities for city residents. amendment three proposed that for “municipally funded construction projects that cost $100,000 or more, 40% of construction work hours must go to nashville residents, with 25% of those work hours going to low-income nashville residents” (blair et al., 2020, p. 12). in nashville, 14.5% of construction workers were black and 46.2% were latinx, and 45% of all construction workers living in nashville were born outside the united states (blair et al., 2020). at that time, 82.6% of tennessee state legislators were white (blair et al., 2020). a few weeks later, tennessee’s majority republican senate struck down amendment three. according to woodman (2016), “contractors’ associations have opposed local-hiring policies across the country as being anti-competitive, discriminatory to nonresidents, and ultimately a jobkiller” (para. 12). state senator jack johnson, the republican who spearheaded the bill, and attorney general herbert slatery argued that the local-hire agreement violated the state’s standing contractors licensing act of 1994 (ebert, 2016). when challenged on whether or not his bill was “overturning the will of the voters of nashville,” senator johnson answered, “in fact we are” (ebert, 2016, para. 6). progressive nashville worker-organizing groups recognized this as an attempt by the state to stymie liberal work practices and to suppress black and latinx workers in progressive municipalities (woodman, 2016). jason freeman, the co-chair of the nashville organized for action and hope’s economic equity and jobs taskforce, responded by saying, “we’re trying to get a handle on how to address systemic poverty but the best tools that are available are, one by one, being taken away from us” (woodman, 2016, para. 16). birmingham, alabama & minimum wage (2016) racism obstructed birmingham’s attempt to pass a minimum wage ordinance in 2016. the city of birmingham is a majority-minority city, with 70.5% of residents identifying as black compared to the state’s overall black population of 26.8% (u.s. census bureau, 2019). in 2016, birmingham city council was also majority black, so it came as no surprise that many saw the city council’s vote to raise birmingham’s minimum wage to $10.10 per hour as a significant victory for black workers. within two days, the 75% white alabama state legislature passed a bill barring “cities and counties from raising the minimum wage or requiring employers to provide leave or other benefits” (blair et al., 2020; roth, 2016, para. 2). the bill applied retroactively, nullifying birmingham’s attempt to rectify economic disparities. there is no state minimum wage in alabama, so the passage of the bill forced birmingham to adhere to the federal minimum wage of $7.25 per hour. this legislation not only preempted future attempts to raise the minimum still fighting resha t. swanson columbia social work review, vol. xix | 73 72 | columbia social work review, vol. xix wage, but it blocked any future efforts by municipalities to strengthen worker rights policies beyond what was enforced by the state. alabama’s preemption powers derive from the state’s adherence to dillon’s rule. in this case, the alabama constitution did not explicitly give municipalities the authority to set minimum wages, so the legislature determined the power to raise the wage was not reasonably implied, and quickly overruled the ordinance. sixty-five thousand low-wage workers, 28,000 of whom identified as black, were blocked from receiving higher wages (blair et al., 2020). arguments in favor of preemption: conservative states versus liberal cities despite its controversial use, many legislators favor preemption. the liberal metropolitan areas in southern states are the exceptions, not the norm, in what are otherwise deep red, conservative territories. the liberal politics of urban areas are often met with enormous opposition by republican constituents, lobbyists, and legislators, which makes statewide coalition building extremely difficult (adler, 2016). for example, a number of southern states enforce “right to work” laws, giving oppressed workers little incentive to organize and risk losing their jobs (shermer, 2018). some states see preemption as a tool for protecting rural areas from the threat of liberal cities. ebert’s (2017) article references texas lt. governor dan patrick, who remarked: where do we have all our problems in america? not at the state level, run by republicans, but in our cities that are mostly controlled by democrat mayors and democrat city councilmen and women. that’s where you see liberal policies. that’s where you see high taxes. that’s where you see street crime. (para. 17) others view preemption as a recourse for stopping “left-wing special interest groups” from implementing liberal policies that do not reflect the will of the majority of the state (ebert, 2017). less partisan arguments for preemption claim local autonomy will lead to confusing laws and statutes that will undermine the authority of state governments (dupuis et al., 2018). conservative lawmakers routinely frame progressive worker rights strategies as liberal overreach, but it is abundantly clear that preemption policies passed by legislatures do not hold the best interest of workers at heart nor acknowledge the legislations’ disparate racial affect. (k.w., 2017; graham, 2017). the cases of birmingham and nashville make it clear that preemption is not only a way to limit the power of more diverse cities in the south; more seriously, it codifies the oppression of black workers and limits their access to quality jobs. workers fight back: strategies to circumvent preemption despite numerous obstacles, advocates and policymakers have made some headway against preemption and found intersectional, contemporary strategies for a contemporary problem. cohen (2017) pairs traditional worker advocacy with creative techniques to create solutions that challenge contemporary preemption––for example, lobbying, using municipal administrative powers, and legally challenging legislatures. cohen (2017) argues that the first and perhaps the most obvious way to challenge legislatures is by lobbying and forming diverse coalitions among cities with the aim of strengthening the power of local municipalities, amending legislation, and asking legislatures to end preemption permanently. for example, “a coalition of grassroots groups in louisiana have been lobbying state leaders for at least the past five years to lift families out of poverty through an across-the-board wage increase” (partnership for working families, 2019, p. 8). of course, this strategy seldom yields results in states with “strong red/blue divide or anti-urban animus” like the south (cohen, 2017, para. 6). cities may also take legal action to halt preemption (cohen, 2017). avenues for legal recourse include “claiming that a preemption bill discriminates against a protected class, impinges on a fundamental right, or is motivated by animus” (bean & strano, 2019, p. 21). after still fighting resha t. swanson columbia social work review, vol. xix | 75 74 | columbia social work review, vol. xix the alabama legislature preempted birmingham’s minimum wage ordinance, several fast food workers and local organizations joined a class action lawsuit. the plaintiffs argued that the state’s bill “perpetuates alabama’s de jure policy of white supremacy, in particular its suppression of local black majorities through imposition of white control by state government” (koplowitz, 2019, para. 4). unfortunately, the eleventh circuit court of appeals dismissed the case on an improper filing technicality without considering the merits of the argument (koplowitz, 2019). cohen (2017) notes that smaller cities and municipalities with fewer resources may consider joining forces with other organizations, cities, and nonprofits when pursuing financially hefty cases against the state. finally, cohen (2017) asserts that in the absence of legislative power, cities must utilize other powers, such as setting a city policy, creating a new program, or using the so-called power of the purse. although administration actions (much like executive orders) can be repealed and are subject to changing administrations and partisanship, southern cities like atlanta and houston have used administrative means to success in circumventing preemption (cohen, 2017). atlanta, for example, increased the city employees’ minimum wage to $15 an hour over two years by allocating more money to employees’ salaries in the city budget, which avoided the state’s restrictions on raising municipal wages (cohen, 2017). to circumvent their republican legislature’s hard-line stance on marijuana legalization, houston city officials and the county district attorney used their enforcement powers to severely limit the arrest and prosecution of individuals with small amounts of marijuana, “leading to a de facto decriminalization of marijuana” (cohen, 2017, para. 9; dart, 2017). in the difficult racial and political context of southern preemption, this solution may appear most appealing and yield the most success. conclusion from reconstruction to the new millennium, southern lawmakers have used preemption to oppress black workers. dillon’s rule and postreconstruction black codes laid a firm foundation for contemporary black worker suppression through preemption. under the guise of exercising state power over “out-of-control” municipalities, twenty-first century conservative lawmakers continue to strike down any attempt to strengthen worker protections made by more progressive (and often more black) municipalities (blair et al., 2020). the alabama state legislature prevented the passage of birmingham’s ordinance that raised the minimum wage. in nashville, residents watched as their amendment to implement local-hire was reversed just a few weeks after its passage. although deeply-entrenched white supremacy makes the prospect of any immediate progress seem bleak, worker advocates, legal experts, and nonprofit organizations continue to make headway against preemption. victories in cities like atlanta and houston demonstrate the power of lobbying, administrative action, and legal advocacy, and provide a framework for organizers and community members to continue advancing the rights of black workers. the racial, political, economic, and community implications and effects of preemption provide the perfect landscape for social work practice. though social work is not traditionally linked to the fight for workers’ rights, modern-day preemption provides micro-, mezzoand macro-level advocacy opportunities for practitioners--opportunities that demand comprehensive organizing, advocacy, and legislative solutions. before his murder, dr. martin luther king jr. famously supported memphis sanitation workers striking for better treatment and wages (craig, 2018). the day before he was assassinated, king delivered a passionate speech on the topic to the bishop charles mason temple in memphis. he said: but then the good samaritan came by, and he reversed the question: “if i do not stop to help this man, what will happen to him?” that’s the question before you tonight. (yes) not, “if i stop to help the sanitation workers, what will happen to my job?” not, “if i stop to help the sanitation workers, what will happen to all of the hours that i usually spend in my office every day and every week as a pastor?” (yes) the still fighting resha t. swanson columbia social work review, vol. xix | 77 76 | columbia social work review, vol. xix question is not, “if i stop to help this man in need, what will happen to me?” the question is, “if i do not stop to help the sanitation workers, what will happen to them?” that’s the question. (king, 1968, para. 30) as we continue the centuries-old struggle for black liberation and rights, we must recognize that no worker is truly free until black workers are free. freedom starts with challenging preemption in the south. references adler, b. 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(2017, february 2). progressive cities vs. conservative states. the atlantic. https://www.theatlantic.com/magazine/archive/2017/03/red-state-bluecity/513857/ hansford, t. (2020). dillon’s rule and home rule: the history behind the two prevailing views on the powers of local government and what that looks like in alabama. american journal of trial advocacy, 44(1). https://cumberlandtrialjournal. com/2020/08/11/dillons-rule-and-home-rule-the-history-behind-the-two-prevailingviews-on-the-powers-of-local-government-and-what-that-looks-like-in-alabama/#_ edn37 hunter v. city of pittsburgh, (united states supreme court november 18, 1907). https://cite.case.law/us/207/161/ k.w. (2017, october 9). how conservative states and liberal cities vie for control. the economist. https://www.economist.com/the-economist-explains/2017/10/09/howconservative-states-and-liberal-cities-vie-for-control king jr., m. l. (1968, april 3). i’ve been to the mountaintop [in-person]. https:// kinginstitute.stanford.edu/king-papers/documents/ive-been-mountaintop-addressdelivered-bishop-charles-mason-temple koplowitz, h. (2019, december 14). federal appeals court upholds dismissal of birmingham minimum wage suit. al.com; alabama media group. https://www. al.com/news/birmingham/2019/12/federal-appeals-court-upholds-dismissal ofbirmingham-minimum-wage-suit.html merriam v. moody’s executors (iowa supreme court june 25, 2868). https://cite.case. law/iowa/25/163/ national league of cities. (2016, december 13). cities 101 — delegation of power. national league of cities. https://www.nlc.org/resource/cities-101-delegation-ofpower/ nittle, n. k. (2021, january 28). how the black codes limited african american progress after the civil war history. www.history.com. https://www.history. com/news/black-codes-reconstruction-slavery still fighting resha t. swanson columbia social work review, vol. xix | 79 78 | columbia social work review, vol. xix partnership for working families. (2019, may). for all of us, by all of us: challenging state interference to advance gender and racial justice. partnership for working families. https://www.forworkingfamilies.org/sites/default/files/publications/ pwf%20gender%20 preemption_0.pdf people ex rel. le roy v. hurlbut (michigan supreme court november 29, 1871). https:// cite.case.law/mich/24/44/ pbs. (2017). slavery v. peonage. pbs. https://www.pbs.org/tpt/slavery-by-anothername/themes/peonage/ pbs. (2021). rebuilding the south after the war | american experience | pbs. www. pbs.org. https://www.pbs.org/wgbh/americanexperience/features/reconstructionrebuilding-south-after-war/ phillips, l. e. (2017). impeding innovation: state preemption of progressive local regulations. columbia law review, 117(8). https://doi.org/ roth, z. (2016, february 26). birmingham raises minimum wage and alabama takes it away. nbc news. https://www.nbcnews.com/news/nbcblk/birmingham-raisesminimum-wage alabama-takes-it-away-n526806 russell, j. d., & bostrom, a. (2016). federalism, dillon rule and home rule. in acce.us. american city county exchange. https://www.alec.org/app/ uploads/2016/01/2016-acce-white-paper-dillon-house-rule-final.pdf shermer, e. t. (2018, april 24). the right to work really means the right to work for less. the washington post. https://www.washingtonpost.com/news/made-by-history/ wp/2018/04/24/the-right-to-work-really-means-the-right-to-work-for-less/ u.s. census bureau. (2019). u.s. census bureau quickfacts: multiple states. www. census.gov. https://www.census.gov/quickfacts/fact/table/tn,ar,ga,fl,al,ms/ pst045219? united states senate. (2019, february 5). u.s. senate: landmark legislation: thirteenth, fourteenth, & fifteenth amendments. senate.gov. https://www.senate.gov/ artandhistory/history/common/generic/civilwaramendments.htm u.s. constitution. art. vi, cl. 2. woodman, s. (2016, april 4). nashville voted to give poor people, locals new construction jobs. but the state gop blocked it. in these times. https:// inthesetimes.com/article/republican-prohibition-on-nashville-municipal-local-hires worthman, p. b. (1969). black workers and labor unions in birmingham, alabama, 1897–1904. labor history, 10(3), 375–407. taylor & francis online. https://doi. org/10.1080/00236566908584085 still fighting resha t. swanson resha swanson graduated from the university of alabama in 2018 with a bachelor of social work and a bachelor of arts in spanish. this spring, she will graduate from columbia school of social work with a master of science in social work in advanced policy practice concentrating in contemporary social issues. resha currently lives in birmingham, alabama, where she works as a policy coordinator at a low-wage worker center. 43 how long must they be alone? how long must they be alone?: the experience of unaccompanied minors and implications for social work practice unaccompanied minors often face severe trauma during their preflight lives as well as during the course of their migration. these traumatic experiences can have negative psychosocial impacts on the minors, and hostile reception policies in destination countries exacerbate their hardships. though social work services are traditionally undervalued in the areas of asylum and resettlement, the discipline has much to offer in terms of practice, programming, and policy. the complexity of circumstances in which children become unaccompanied, as well as the diverse needs of the children themselves, mean that no single country, discipline, or agency can solve the problem individually. complementary skills should be coordinated and international mandates must be established in a concerted effort to respond to this issue. there is a need for more research to determine the psychosocial issues of unaccompanied minors and identify best practices for social workers in destination countries to provide direct services and advocacy for this population. naccompanied minors are strong, resourceful, and resilient. however, these qualities are often challenged by circumstances beyond their control, such as violent conflict, oppression, persecution, trafficking, and severe deprivation. unaccompanied minors are separated from their parents and family members as a result of multiple deaths and chaotic circumstances during flight. at times they are pushed away for their own safety and well-being. their experiences during flight can often be as harrowing as what they experienced in their preflight lives. following these traumatic experiences, unaccompanied minors arrive to host countries and are often treated with hostility and encounter harsh, punitive policies. as such, these children are deprived of universal human rights as well as rights specific to children that were agreed upon in the united nations convention on the rights of the child (uncrc). the increase in the phenomenon of unaccompanied minors is fueled by globalization. james midgley (1997) describes globalization as “a process of global integration in which diverse peoples, economies, cultures and political processes are increasingly subjected to international influences” (p. xi). the efellen olsen u 44 journal of student social work, vol. vi fects of global interdependence are given wide recognition in economic and environmental spheres; however, global interdependence is not as well understood as a force impacting social work practice (healy, 2001). with the increase in globalization and greater access to international transportation and communication, forced migration continues to cause individuals to leave the turmoil of their home countries and seek refuge in foreign lands. many of those displaced are children, defined as human beings below the age of eighteen years (united nations, 1989). unaccompanied minors who reach western nations generally arrive alone, or sometimes in sibling groups, from various distant parts of the world (kohli, 2007). amongst them are children who are trafficked and others who are trying to flee from the collapse of civil order and extreme poverty in their nations of origin. unaccompanied minors are often separated from their parents due to emergency and conflict. they experience numerous atrocities and human rights violations in their home countries and then experience further distress during their flight. when children seeking asylum attempt to resettle in a foreign country, they seek a stable life of balance and peace (kohli, 2007). this is a complex process, and children often need someone to guide them through difficult circumstances. unaccompanied children need social workers to provide them with care and protection that will help them with resettlement in new territories and assist them in their efforts to reach their full potential. while social workers are traditionally undervalued in the arena of asylum and resettlement services, their professional background provides significant knowledge and skills to help the unaccompanied minor population. definition of unaccompanied minors according to the definition of the united nations high commission for refugees (unhcr, 1994), unaccompanied minors are those separated from both parents and are not being cared for by an adult who, by law or custom, is responsible to do so. unaccompanied asylum seeking children are young people below 18 years old who have applied for asylum and who have gained temporary admission to the host country while their claim is considered. these definitions are frequently conflated. for the purposes of this paper, the term ‘unaccompanied minors’ will be used primarily, and the term ‘unaccompanied asylum seeking children’ will be used specifically when referring to youth who have arrived in a destination country and are requesting asylum status. the experiences of unaccompanied minors e l l e n o l s e n 45 the displacement of children across borders has occurred for several decades, sometimes to countries located at great distance from their homelands. the phenomenon of displaced children increased dramatically during the social upheaval associated with world war ii and has continued to persist during subsequent violent conflicts. international migration patterns demonstrate that wars in particular generate great numbers of displaced children. the majority of these children move to neighboring countries (kohli, 2007), and many minors are displaced within their own countries. although this paper focuses on unaccompanied minors who seek asylum in western countries, the backgrounds of minors who seek asylum in western countries and those who are displaced internally or to neighboring developing countries are similar. unaccompanied minors are exposed to myriad risks. they arrive in the asylum country alone for various reasons. perhaps their parents were killed or separated from them during flight or their families sent them away to avoid military recruitment and seek a better life (seugling, 2004). the primary reasons unaccompanied minors leave their countries of origin include experiencing or witnessing violence, rape or other sexual violence, forced military recruitment, war, persecution, political instability, and trafficking (thomas, nafees, & bhugra, 2004). exposure to these atrocities and subsequent ordeals can create significant developmental problems for children. while some youth have shown their resilience (geltman et al., 2005), there is a lack of longitudinal research regarding the outcome of former unaccompanied minors during adulthood. case study of an unaccompanied minor the experiences of fauziya kassindja, an unaccompanied minor, are documented in the novel do they hear you when you cry? (kassindja & bashir, 1998). fauziya’s idyllic childhood in togo, west africa ended with the death of her father. forced into an arranged marriage to an older man when she was 17 years old, fauziya was informed that she must undergo the tribal ritual of female genital mutilation (fgm). instead of adhering to the cultural practice that had killed and maimed many other young females, fauziya fled togo in fear only hours before the ritual was scheduled to take place. through the financial support of some of her female family members, fauziya escaped to germany for a brief period before traveling to the united states to seek asylum. upon her arrival to newark international airport in new jersey, fauziya informed the immigration officers that she traveled with a false passport and was how long must they be alone? e l l e n o l s e n 46 journal of student social work, vol. vi seeking political asylum (kassindja & bashir, 1998). the officers immediately interrogated fauziya about her story and expressed their disbelief. they instructed fauziya to remove her clothes while she was searched, then she was handcuffed and transported to esmor detention facility in elizabeth, new jersey. fauziya was treated like a criminal and suffered insults and indignities throughout the 16-month stay in detention centers and jail. the frequent ordeal of strip searches and the inability to cover her nudity was a violation of her beliefs as a muslim. she suffered loneliness, depression, injustice, humiliation, and deterioration of her mental state through a system that is often hostile and unsympathetic to those who are fleeing adversity and seeking asylum. during much of her time in detention, fauziya was still a minor, but she was locked in facilities with adult women, some of whom were incarcerated for committing crimes. after a long and tumultuous 16 months, fauziya attained asylum status (kassindja & bashir, 1998). fauziya’s cousin who was living in the united states hired an attorney to represent fauziya in her asylum hearing. with the support of a team of lawyers, fauziya received political asylum, and her case served as the precedent to recognize fgm and other such gender based violence acts as qualifying criteria for female asylum. while fauziya’s story is one of many, it speaks to the mechanical process through which most unaccompanied minors seeking asylum endure. the range of experiences to which unaccompanied minors are exposed is wide and varied. those who are not as fortunate as fauziya often lack adequate legal representation and support systems. unaccompanied minors frequently undergo expedited removal, returning them to the dangerous situations from which they came without receiving an opportunity to speak with anyone in the asylum country aside from immigration officers. psychosocial impact of the estimated 18 million refugees around the world, approximately half are children (sourander, 1998). minors without parents are especially disadvantaged because they must endure traumatic events without the support of parental protection and guidance. goodman (2004) points out that parents often serve as buffers to mediate the effects of negative experiences in a child’s life, and the presence of family and community support are seen as requisite for the successful coping of children who have been traumatized by war or violence. goodman also states that several reports have indicated a high incidence of behavioral problems, depression, somatization, and suicide attempts among unaccompanied asylum seeking children. while research demonstrates the psychosocial e l l e n o l s e n 47 needs of the unaccompanied minor population, such an evaluation has not been made standard protocol by all governments regarding the reception of minors. sourander (1998) performed a study that examined the traumatic events and behavior symptoms of 46 unaccompanied minors who were awaiting placement in an asylum center in finland. he evaluated the children through their completion of the child behavior checklist (cbcl) and found that they had experienced multiple losses, separations, persecution and threats. his study evidenced that younger age was associated with increased psychiatric symptoms, as younger children are more vulnerable to emotional distress and have less established coping strategies than older youth. the most common symptoms of the population were related to post-traumatic stress disorder (ptsd), depression, and anxiety. when interviewed, most of the children reported somatic complaints and uncertainty about their future, and some expressed suicidal thoughts. exposure to multiple stressors greatly decreases a child’s ability to cope successfully. despite evidence of the occurrence of severe symptoms, all minors do not receive psychosocial services given the absence of a formalized evaluation component in some circumstances. unaccompanied minors have the capacity to recover and adjust to life after arrival in a western country (kohli, 2007). promoting the psychosocial wellbeing of unaccompanied minors involves finding ways to regenerate a lost sense of belonging and volition in their own lives (kohli & mather, 2003). detaining the unaccompanied minors in jail-like settings where they are removed from the community abolishes any sense of agency in their own lives. detention without access to mental health services further exacerbates psychosocial difficulties. hostile reception policies after facing traumatic life events, most unaccompanied minors arrive in their destination countries suffering from tremendous stress as they strive to survive. they subsequently encounter immigration officials at ports of entry who often treat them with hostility (reijneveld, de boer, bean, & korfker, 2005). western nations have become increasingly punitive with their treatment of unaccompanied asylum seeking children (cemlyn & briskman, 2003). upon arrival in the united states or other destination countries, many of these young people are detained. they frequently remain in detention throughout the long process of waiting for hearings. it is not uncommon for the period of detention to extend beyond a year. studies show that unaccompanied asylum seeking children who are placed in restrictive settings report more emotional problems than minors who how long must they be alone? e l l e n o l s e n 48 journal of student social work, vol. vi are placed in settings where they are allowed greater autonomy (reijneveld, de boer, bean, & korfker, 2005). those children who are suffering from symptoms of ptsd, particularly those who have been victims of torture, and other mental health issues need access to psychological services (sourander, 1998). placed in detention facilities, these minors are often confined in secure environments for administrative purposes and live alongside others who are incarcerated for committing crimes. in addition, many are stigmatized and face serious discrimination in the new host country (christie, 2003). currently there is no international protocol mandating how governments should serve the unaccompanied minor population aside from vague guidelines developed by the unhcr. western countries develop their own policies for dealing with these minors, and the policies often vary by locality within a country (mitchell, 2003). though governments claim to apply the principle of the child’s best interest concerning treatment of unaccompanied minors, engebrigtsen (2003) points out that most decisions are made in the interest of the country. degruijter and rijkschroeff (2005) describe an effective program for unaccompanied minors in the netherlands called ‘choices and opportunities’ which encourages community integration. this program focuses on the strengths and capacities of the youth rather than on their problems, and aims to involve unaccompanied minors with recreation and service activities in their community in order to develop the support networks they lack. however, the method of encouraging community participation among unaccompanied minors is rare, and the majority experience social isolation in foreign countries. most western countries have legal proceedings that are administrative and adversarial, bringing children with limited skills in the local language to hearings against trained trial lawyers (nugent, 2005). the majority of children are unrepresented in removal hearings due to a dearth of pro bono or governmentappointed attorneys. unlike citizens, unaccompanied asylum seeking children are not automatically appointed attorneys to represent them at their hearings (nugent, 2005). these children rarely have anyone to speak on their behalf, and are treated as detainees first and children second. the systems dealing with unaccompanied minors tend to be punitive rather than protective, and therefore fail to address the needs of this population. hostile reception policies are detrimental to the well-being of unaccompanied minors. in recent years the united states has made some efforts to improve the treatment of unaccompanied minors. section 462 of h.r. 5710, the homeland security act of 2002 transferred responsibility for the care of unaccompanied foreign-born children from the immigration and naturalization service (ins) e l l e n o l s e n 49 within the department of justice to the office of refugee resettlement (orr) within the department of health and human services (national conference of state legislatures, 2005). this transfer removed the fundamental conflict of interest when the ins served as both jailer and caretaker of unaccompanied minors. while this transfer of responsibility is a positive step in providing effective care for unaccompanied minors, many more steps need to be taken to ensure more compassionate treatment for this population. according to the national conference of state legislatures (2005), each year over 80,000 unaccompanied minors seek entry into the united states, but only a fraction of those children remain in the country. most are deported back to their country of origin, typically within 72 hours. in 2004, 6,200 unaccompanied minors entered into federal custody in the united states through the orr, and this number is expected to increase in future years. more efforts should be undertaken within and across destination and sending countries to create policies that promote the well-being of these children. human rights framework the notion of human rights is one of the most powerful in contemporary social discourse. human rights are particularly important in the context of social workers and others in human services professions (ife, 2001). rayner (2004) asserts that every society should have policies in accordance with human rights. she states that detention is intended to be a punishment for convicted criminals and not an administrative method of handling a class of people. rayner also discusses the reality that few nations have thoroughly implemented the uncrc (united nations, 1989). the united states and somalia are the only two member nations that have not yet ratified this treaty. the convention spells out the basic human rights of children: the right to survival; to develop to the fullest; to have protection from harmful influences, abuse and exploitation; and to participate fully in family, cultural and social life. the four core principles of the convention are: non-discrimination; devotion to the best interests of the child; the right to life, survival, and development; and respect for the views of the child. policies pertaining to unaccompanied minors should uphold these principles as children are among the most vulnerable victims of human rights violations, and unaccompanied minors are particularly at risk for abuses. article 22 of the convention (united nations, 1989) asserts that special protection shall be granted to a refugee child or to a child seeking refugee status. this special protection is absent in the policies of western asylum countries. how long must they be alone? e l l e n o l s e n 50 journal of student social work, vol. vi maloney (2002) describes efforts made at the transatlantic workshop on unaccompanied/separated children, convened by georgetown university’s institute for the study of international migration, which focused on identification of the nature of migration and creation of appropriate policies and international frameworks to protect these children. conferences such as this one should be replicated and expanded. the increasing numbers of unaccompanied minors and the research indicating the detrimental effects of hostile reception policies support the need for an international protocol of established procedures and practices to support the needs of unaccompanied minors. all countries have a responsibility to develop and enforce national and international policies that are based on a human rights framework and respect the universal rights of each individual and child. social work with unaccompanied minors under the national association of social workers code of ethics (nasw, 1996), social workers have an ethical responsibility to their clients that includes recognizing and understanding culture and its effect on human behaviors and societies. social workers should be prepared to understand the reality of social diversity and the nature of oppression and persecution. through understanding the connection between the ethics of the social work profession and the human rights framework, social workers can apply human rights to the profession through ethical principles (reichert, 2003). the internationally recognized and accepted perspective of human rights is able to supply more power to the application of social work ethics. further research must be undertaken to determine the most effective interventions and placements for unaccompanied minors. there is a particular need for longitudinal studies that follow groups of unaccompanied minors through adulthood to observe how different environments influence their internal and external functioning. each study that has been completed to examine the treatment of unaccompanied minors supports less restrictive settings, and host countries must heed these findings. the body of research should include studies of various placements, such as foster care, group homes, and return to country of origin. in addition, attention should be given to cultural phenomena that could aid or impede resilience in these youth (geltman et al., 2005). social workers have important roles to play in ameliorating the treatment of unaccompanied minors and thereby improving their mental health. social e l l e n o l s e n 51 work education should provide training on effective strategies for working with unaccompanied minors and in recognizing issues relevant to their development (cemlyn & briskman, 2003). social workers are increasingly placed in positions where they work directly with the unaccompanied minor population, particularly in group home settings and establishing foster care or other residential placements for the minors. social work professionals should be prepared for this responsibility and demonstrate their effectiveness in assisting unaccompanied minors in order to be given more opportunities to work with this population. social workers have the opportunity to guide the minors through the process of seeking asylum and resettling in a foreign land, and are more adept at meeting the needs of these minors than the immigration officials who historically have been responsible for this population. unaccompanied minors are often hesitant to talk to mental health practitioners about their experiences. this reluctance to disclose personal information may arise out of an association of social workers with other authority figures whom they fear (kohli, 2006). they remain silent due to a lack of trust developed through persecution as well as a resistance to discuss experiences filled with pain and guilt (kohli, 2006). such obstacles to communication can be overcome by a social worker making efforts to establish a warm, empathetic relationship with the minor (sourander, 1998). according to kohli (2006), an unaccompanied minor’s choice to remain silent can be viewed as part of healing and managing hurt, and as such, the process is both burdensome and protective for the child. when unaccompanied minors talk, they often do so reluctantly and tell ‘thin stories’ that are constructed as an acceptable entry mechanism in compliance with international conventions related to the status of asylum. through building a therapeutic relationship, the young people feel safer to tell more detailed stories. unaccompanied minors have experienced multiple losses, and their most common symptoms are related to ptsd, depression and anxiety (sourander, 1998). exposure to multiple traumatic stressors greatly decreases a child’s ability to cope effectively. social work services for unaccompanied children should be child-centered and culturally sensitive. younger children are particularly at risk and in need of psychosocial services. lustig et al. (2004) assert that unaccompanied minors’ reactions to stressors may be mediated by the presence of coping strategies, belief systems and social relations. they determined that more research needs to be undertaken relating to interventions with the unaccompanied minor population, specifically taking into account effectiveness and cultural relevance. how long must they be alone? e l l e n o l s e n 52 journal of student social work, vol. vi social workers are accustomed to complexity in providing services to meet the needs of clients. due to their concentration on a variety of service levels, social workers are in a position to move closer to a multi-dimensional understanding of the complicated needs of unaccompanied minors. however, social work skills are often undervalued in the context of providing resettlement services and other services to youth and adult asylum seekers (kohli, 2007). social work practitioners are able to show a depth of understanding about the reasons children flee their homes and seek asylum. they can also strategize about how policies can be organized to maximize the chances of positive outcomes for unaccompanied minors. social workers must advocate for unaccompanied minors on the macro level in addition to providing interventions for their specific individual needs. only by providing a voice for the rights of unaccompanied minors can they be prevented from slipping through the cracks of an unjust system. conclusion globalization has created new relationships within and between countries. interactions are increasingly determined by mobility rather than inhibited by national borders. the advent of globalization has literally changed the way in which the international community operates. while globalization has helped to facilitate the exchange of information and thereby advanced many societies, it has also exacerbated the plight of the world’s most vulnerable. social workers increasingly should be prepared to work with individuals and groups who have diverse identities. the complex needs of unaccompanied minors that arise from the circumstances of their mobility require social workers to expand their range of tasks and services (christie, 2003). since national policies treat asylum seeking children less favorably than native children, social workers also need to support unaccompanied minors on the macro level. cemlyn and briskman (2003) maintain that too often social workers focus on managing the current system instead of challenging it. the complexity of circumstances in which children become unaccompanied, as well as the diverse needs of the children themselves, mean that no single country, discipline, or agency can solve the problem individually. efforts to assist the population of unaccompanied minors must be coordinated among those in different countries, disciplines and agencies to provide them with an opportunity to overcome the atrocities of their past and to develop brighter futures. a u t h o r e l l e n o l s e n 53 how long must they be alone? international organizations, governments, agencies and service providers should adhere to the following recommendations in order to improve the wellbeing of unaccompanied minors: • establish and enforce internationally accepted policies for aiding unaccompanied minors that are in accordance with the perspective of human rights and the rights of the child as per the uncrc. • unaccompanied minors should be provided with care in a safe residential setting that includes access to health, mental health, educational and legal services. • countries should appoint legal counsel as well as guardians ad litem for unaccompanied asylum seeking children. age determinations should be undertaken more carefully in order to avoid the frequent errors when minors are mistaken as adults and wrongfully detained. • countries need to learn from each other about how to manage issues of prevention, protection and durable solutions. international attention must be given to using best practices to assist unaccompanied minors. • social work education should emphasize the impacts of globalization and the ethical responsibility for cultural competency. • social workers should view the phenomenon of forced migration and its consequences, such as the prevalence of unaccompanied minors, on micro, mezzo and macro levels. • social workers should align themselves with non-governmental organizations and other child protection organizations to advocate for the development of progressive policies in relation to asylum seeking children. • social workers should gain more holistic knowledge of policies and systems and embrace a global analysis in order to help unaccompanied minors through a human rights perspective. • social workers should also build alliances with other activist groups so that they can work together to create change on the macro level as well as improve lives for individual unaccompanied minors. • continued longitudinal research should be undertaken to determine best practices in providing services to unaccompanied minors that will most improve their life trajectories as well as improving policies to decrease the phenomenon of their migration. e l l e n o l s e n 54 journal of student social work, vol. vi references ayotte, w. 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(2003). the social services response to unaccompanied children in england. child and family social work, 8, 179-189. national association of social workers (1996). code of ethics. washington, d.c.: nasw press. national conference of state legislatures (2005). unaccompanied immigrant and refugee minors. retrieved february 2, 2008, from http://www.ncsl.org/programs/immig/unaccompaniedminorsfactsheet.htm nugent, c. (2005). protecting unaccompanied immigrant and refugee children in the united states. human rights, 32(1), 9-22. rayner, m. (2004). resilience, refugees and the rights of children an immorality play. psychiatry, psychology, and law, 11(2), 350-358. reichert, e. (2003). social work and human rights: a foundation for policy and practice. new york: columbia university press. reijneveld, s.a., de boer, j.b., bean, t., & korfker, d.g. (2005). unaccompanied adolescents seeking asylum: poorer mental health under a restrictive reception.the journal of nervous and mental disease, 193(11), 759-761. seugling, c.j. (2004). toward a comprehensive response to the transnational migration of unaccompanied minors in the united states. vanderbilt journal of transnational law, 37. retrieved october 24, 2006, from http:// www.immigrantchildren.org/articles. sourander, a. (1998). behavior problems and traumatic events of unaccompanied refugee minors. child abuse and neglect, 22(7), 719-727. thomas, s., nafees, b., & bhugra, d. (2004). ‘i was running away from death’ the pre-flight experiences of unaccompanied asylum seeking children in the uk. child: care, health and development, 30(2), 113-122. united nations (1989). the convention on the rights of the child. retrieved september 20, 2007 from the world wide web: http://www.unicef.org/ crc/. e l l e n o l s e n 56 journal of student social work, vol. vi united nations high commission for refugees (1994). refugee children: guidelines for protection and care. geneva: unhcr. ellen olsen is a second year master’s student at cussw within the advanced generalist practice and programming method, in the international social welfare and services to immigrants and refugees field of practice. she hold’s a bachelor’s degree in english and sociology from the university of virginia. she is currently an intern at the international rescue committee in new york refugee resettlement office’s youth department. her e-mail address is efp2107@columbia.edu. e l l e n o l s e n international social work is gaining recognition as a distinct field of study and practice, and in this process, its meaning continues to be delineated. in this paper, i describe a series of experiences during a summer field practicum coordinating the final phase of a year-long qualitative research study on sexual and gender-based violence (sgbv) in lira, northern uganda. while not a conclusive statement on the nature of all international social work, this paper presents personal experiences to illustrate how the psychosocial skills, practices, and theory of the social work profession can lend themselves well to the emotional and managerial demands of international work in a postconflict, developing country context. in the summer of 2008, following my first year of graduate social work studies, i was hired to coordinate the third and final phase of a yearlong qualitative research study in lira, northern uganda. undertaken collaboratively between an american university and a prominent international nongovernmental organization (ingo), the study aimed to explore adolescent girls’ experiences of sexual and gender-based violence (sgbv) and to assess relevant support structures in the context of conflict and displacement. since the early 1980s, civil conflict ravaged northern uganda, killing thousands and leaving more than 1.8 million people displaced (integrated regional information networks [irin], 2007; internal displacement monitoring centre [idmc], 2008). rape and forced marriage were systematically and widely perpetrated as war tactics, and domestic violence increased due in part to the destruction of many traditional family and community support mechanisms (annan, blattman, carlson, & mazurana, 2008; olara, 2004; patrick, 2005). despite recent improvements in security that have enabled international social work in practice: a case study from northern uganda lauren pesso journal of student social work, volume vii 25 / pesso many of those who were displaced to begin returning to their home villages, multiple forms of sgbv remain commonplace (idmc, 2008; irin, 2007). my task in lira was to supervise four ugandan research staff in conducting and recording the final round of interviews with study participants.1 all interviewees were adolescent girls who had been displaced by the region’s civil conflict, and half were known survivors of sgbv. i came to the position with previous work experience in uganda, a background in international public health, and a recently completed social work field placement in domestic violence. while i hoped the summer job would allow me to draw on my earlier professional work while providing hands-on management experience, the opportunity also unexpectedly helped clarify what “international social work” could mean for me in practice. in this paper, i present examples from my experiences in lira to illustrate how the psychosocial skills, practices, and theory of social work can lend themselves well to the emotional and managerial demands of international work in a postconflict, developing country context. looking at my role primarily as one of “helper” in facilitating the completion of a study, i organize this discussion according to the three key phases of the helping process – beginning, middle or work, and ending phases – described in direct social work practice literature (birnbaum & cicchetti, 2005; hepworth et al., 2006). the beginning phase: exploration, engagement, and planning what is international social work? as i entered graduate school, i was particularly interested in exploring the integration of social work into the international development and humanitarian fields. while much has been written on the subject, the definition of “international social work” continues to be debated. the international federation of social workers (2000) suggests that the social work profession “promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being.” within this broad understanding of the profession, definitions of international social work range from a set of specific skills and knowledge, to intercultural exchanges between social workers, to a more general global awareness within the profession (healy, 2001; midgley, 2001). activities can include engaging with international populations domestically, conducting international development work, creating exchanges through international professional journals and meetings, and adapting interventions cross-culturally (healy, 2001; midgley, 2001). journal of student social work, volume vii 26 / international social work in practice cox and pawar (2006) build on these definitions by emphasizing the importance of promoting social work education and practice around the world to establish an integrated international profession that can respond appropriately and effectively to ongoing global challenges. caragata and sanchez (2002) suggest that international social work remains largely in the domain of academia, noting that few of the posts within international development agencies are filled by social workers. however, many of the needs identified in the guidelines on mental health and psychosocial support in emergency settings,2 for instance, point to the strengths of the social work profession, including provision of basic psychosocial services, security measures, and specialized mental healthcare when necessary (inter-agency standing committee [iasc], 2007). in the sections that follow, i draw on my experiences working with a research team – albeit distinct from strict development or humanitarian work – to contribute to the broader discussion of the meaning and relevance of international social work. being where the staff are i arrived in lira enthusiastic to meet the research staff and begin our work together. we had only six weeks, and since the staff had all worked on earlier phases of the study, i expected that we could start quickly. due to funding cuts, however, the ingo had recently laid off three of the four team members. resources were secured to hire them back as consultants, but only through the duration of the study. at our first meeting, staff were reluctant to engage in discussions about anything but their grievances. they objected to how their terminations were handled, demanded higher salaries, and revealed little interest in introducing me to their earlier work. in social work, the maxim “being where the client is” implies that a social worker must be attuned to a client’s concerns, expectations, life situation, cultural background, and psychological state, and adjust interventions accordingly (goldstein, 2001). in some cases, this means addressing immediate matters before more substantive work can occur. still jet-lagged and having spent weeks preparing for our early meetings, i was admittedly frustrated by how my work with the research team was beginning. recognizing that to push forward with my own agenda would be both unwise and unsuccessful, though, i tried to “be where the staff were.” we spent much of our first day together processing what had gone wrong in the past. given the opportunity to talk openly, some staff eventually began to share deeper issues that were fueling their resentment. journal of student social work, volume vii 27 / pesso some of the staff admitted that they felt they had not been offered sufficient input into or ownership over earlier research phases, pointing to the fact that previous interview transcripts were locked in a room they had no access to. others felt that concerns they had raised to previous staff in my position had not been sufficiently addressed. taking the time to be where the staff were initially helped me better understand their concerns and expectations, and allowed us to begin to address some of the issues that we had control over. collaboratively, we established guidelines for how we would work together (including how data would be stored and shared among us); developed contracts specifying expected roles, tasks, and salaries; and agreed to air work-related concerns when they arose. though time consuming and seemingly slow moving, being where the staff were during our early meetings helped us address underlying concerns, set a precedent for tackling future problems, and helped us arrive at a place where we could move forward with our principal work. the work phase: implementation and goal attainment self-care and staff well-being the methodology used in our study involved traveling long distances – often by a combination of car, bicycle, and foot – to conduct extensive interviews with adolescent girls affected by conflict and sgbv, most of whom had recently left internally displaced person camps to resettle in remote villages. interviewees were also facing a number of other difficulties: most were not in school because their families could or would not pay their school fees, many were having difficulty feeding their own young children because of a recent drought, and some faced ongoing domestic abuse. a smaller number of the participants were suffering from serious psychological distress or medical conditions, including hiv. though safety in northern uganda had significantly improved by the summer of 2008, rumors of re-insurgency were not uncommon. at times the researchers and i were left feeling powerless against these considerable systemic obstacles. to prevent burnout and the vicarious trauma that can result from exposure to such difficult circumstances, social work promotes the importance of maintaining staff wellness through a combination of self-care and organizational responsiveness (clemans, 2004; pross, 2006). given the challenging context and content of our study, the research staff and i established a plan to regularly check safety updates, set a norm that no one would travel to a place where they journal of student social work, volume vii 28 / international social work in practice felt unsafe, and agreed to the importance of establishing a work/ life balance. in my own experience working at an agency serving domestic violence survivors, i had also found group debriefings valuable for reflecting on the emotional nature of the work (clemans, 2004). some of the research staff also suggested such debriefs, so we agreed to meet periodically as a group to express and share our experiences (united nations high commission on refugees [unhcr], 2001). doing so was helpful, enabling us to discuss the importance of establishing boundaries with interviewees despite our natural desire to assist them beyond our means, and to reflect on what we could do. together we developed a list of interviewees with acute needs, should discrete funding become available to assist them; identified referral sources including free or low-cost hiv services, village-based social workers, and a regional hospital with a psychiatrist on staff; and we brainstormed ideas for more sustainable programs that could address the needs of study participants. supportive supervision social work also places importance on individual supportive supervision, in which a supervisor is concerned with decreasing jobrelated stress, and enhancing skills, knowledge, and positive attitudes toward work (coleman, 2003). such supervision, offered in a culturally appropriate manner, might have been useful for the research staff whose jobs required intimate conversations with sgbv survivors, and who had themselves lived through the region’s conflict. given the complexities of managing a team from a different culture, working for the first time in a post-conflict setting, and hearing daily stories of significant trauma, i certainly would have benefited from supportive supervision as well. unfortunately, such support was not available within the context of our study or in the ingo partner office more broadly. promoting critical reflection as i reviewed interview transcripts from earlier research phases, i noticed that the researchers often seemed to stifle or overtly direct interviewees’ responses. researchers tended to rely on close-ended questions, leading interviewees to stop when they might have had more to say. they also stacked questions, making it difficult for interviewees to know which to respond to first and they frequently revealed their own personal feelings about an issue, potentially hindering injournal of student social work, volume vii 29 / pesso terviewees from sharing their own experiences and perspectives. process recordings, which require students to reflect critically with a trained supervisor on interactions with clients, are an important aspect of social work training (neuman & friedman, 1997). i found that adapting the process recording tool was also helpful in working with research staff to improve data collection. the researchers and i reviewed their earlier interview transcripts together, exploring why they might have asked a question in a particular way, what the implications might be for interviewees’ replies, and how they could support more free-flowing interviewee responses. in some cases, i learned that cultural norms dictated the interviewing style that a researcher had chosen. in others, by dissecting and analyzing their communication through this adaptation of a simple social work learning tool, the research staff seemed to become more aware of their own roles in shaping interviewee responses. eventually, this practice helped improve the data that we collected and, more importantly, created a space for interviewees to more freely share their stories. the ending phase: termination given the emotional content of their discussions and the fact that our research involved intense contact and disclosure over an extended period of time, many of the researcher/interviewee relationships had become quite close (bordeau, 2000). one interviewee had named her daughter after a research staff member, others had invited researchers to their wedding ceremonies. the research staff similarly shared that they had become attached to the interviewees and felt guilty about leaving them once the study ended. bordeau (2000) suggests that the sensitive nature of some qualitative research can contribute to many of the same dynamics of a therapeutic relationship. in direct social work practice, termination refers to the process of formally ending a social worker/client relationship. ideally, this process recognizes that separation involves mixed feelings for both social workers and clients, and helps prepare clients for a future in which the gains from the social work relationship will be maintained (hepworth et al., 2006). while not required as part of the study, facilitating appropriate and meaningful termination between researchers and interviewees seemed important given that we were conducting the final phase of a year-long study, during which close relationships had developed. early on, the research team and i began to discuss how interviewjournal of student social work, volume vii 30 / international social work in practice ees and the staff themselves might feel about and react to the study ending. as a result of these discussions, we added space at the end of our interview guide for researchers to share what they had gained from the year-long process, as well as explicit questions to allow interviewees to discuss their feelings about ending. some interviewees chose not to use this time, but others shared many feelings, including sadness, disappointment, contentment, or hope for the future. to address some of these feelings and draw on a strengths perspective, which asserts that the strengths and resources of people in their environments rather than their problems or deficits should be the focus of the helping process, we also devoted time to helping interviewees identify strengths and supports that they could call upon after the study was over (chapin, 1995). combined, these efforts helped us actively prepare for and make more meaningful the study’s inevitable ending. recommendations though neither a statement on what all international social work is or should be, nor a complete description of my work in lira, i have sought to provide just a few examples of how social work tools and frameworks influenced my efforts to facilitate group cohesion, problem-solving, and the completion of research in an international context. in hindsight, i might have applied lessons from social work even further; facilitating, for instance, more explicit group discussions about how individual, cultural, and social power dynamics affected my relationship – as a white supervisor from an american university – with the ugandan research staff, as well the relationships of interviewees – mostly poor with limited formal education – with the university-educated researchers (sakamoto & pitner, 2005). more than any academic exploration of international social work could, reflecting on both what i did and what i might have done differently in lira has helped me clarify the potential that social work has to contribute to both the managerial and technical aspects of work in an international context. to further move international social work from an academic debate to a more recognized and relevant field of practice, a combination of action, promotion, and education is needed (cox & power, 2006). when appropriate, traditional social work interventions, tools, and methods of supervision can be thoughtfully adapted to new professional and cultural contexts. social work journal of student social work, volume vii 31 / pesso ers currently in the humanitarian and development fields should do more to articulate and promote the advantages that our professional training brings to bear. social work schools and professional associations must offer more international field practica to help students and journal of student social work, volume vii recent graduates learn to apply the skills gained from courses and domestic fieldwork. though neither academic study nor short-term practicum opportunities alone can ensure culturally sensitive, high quality, and locally appropriate international efforts, such opportunities have the potential to considerably benefit students, the social work profession, and the international community more broadly. notes 1 throughout this paper, “study participants” and “interviewees” are used interchangeably. 2 the iasc issued these draft guidelines in 2007 with the stated goal of enabling humanitarian actors to “plan, establish and coordinate a set of minimum multi-sectoral responses to protect and improve people’s mental health and psychosocial wellbeing in the midst of an emergency” (iasc, 2007, p. v). references annan, j., blattman, c., carlson, k., & mazurana, d. (2008). the state of female youth in northern uganda: findings from the survey of war-affected youth. phase ii. survey of war-affected youth (sway). retrieved february 7, 2009 from the world wide web: https://wikis.uit.tufts.edu/confluence/display/fic/the+state+of + female+ youth+in+northern+uganda--findings+from+the+survey+of+war+ affected+youth. birnbaum, m. l., & cicchetti, a. (2005). a model for working with the group life cycle in each group session across the life span of the group. groupwork, 15(3): 18-37. bordeau, b. (2000). dual relationships in qualitative research. the qualitative report, 4(3&4). retrieved february 7, 2009 from the world wide web: http://www.nova. edu/ ssss/qr/qr4-3/bourdeau.html. caragata, l., & sanchez, m. (2002). globalization and global need: new imperatives for expanding international social work education in north america. international social work, 45, 217-238. chapin, r. k. (1995). social policy development: the strengths perspective. social work, 40, 506-514. clemans, s. e. (2004) understanding vicarious traumatization – strategies for social workers. social work today, 4(2): 13. retrieved february 7, 2009 from the world wide web: http://www.socialworktoday.com/archive/swt_0204p13.htm. coleman, m. (2003). supervision and the clinical social worker. clinical social work, 3, 1-4. cox, d. & pawar, m. (2006). international social work: issues, strategies and programs. thousand oaks, ca: sage publications. goldstein, e.g. (2001). object relations theory and self psychology in social work practice. new york : the free press. healy, l. m. (2001). international social work. oxford university press: oxford, uk. hepworth, d. h., et al. (2006). direct social work practice. belmont, ca: thompson books/cole. integrated regional information networks (irin). (2007). uganda: sexual abuse survivors in north denied justice – amnesty. retrieved november 30, 2007, from the world wide web: http://www.irinnews.org/report. aspx?reportid=75620. journal of student social work, volume vii 32 / international social work in practice inter-agency standing committee (iasc) (2007). iasc guidelines on mental health and psychosocial support in emergency settings. geneva: iasc. internal displacement monitoring centre (idmc). (2008, november 3). uganda: focus shifts to securing durable solutions for idps. retrieved february 6, 2009 from world wide web: http://www.internal-displacement.org/8025708f004ce90b/ (httpcountries)/04678346a648c087802570a7004b9719?opendocument&cou nt=10000. international federation of social workers (ifsw). (2000). definition of social work. retrieved december 22, 2008 from the world wide web: http://www.ifsw.org/ en/p38000208.html midgley, j. (2001). issues in international social work: resolving critical debates in the profession. journal of social work, 1, 21-35. neuman, k. m., & friedman, b. d. (1997). process recordings: fine-tuning an old instrument. journal of social work education, 33, 237-243. olara, s. (2004, november 10). rape: the hidden weapon against women in war-torn northern uganda. the monitor. retrieved february 12, 2009, from the world wide web: http://www.unhcr.org/cgibin/texis/vtx/protect/opendoc.htm ?tbl=protection&id=434a7de02. patrick, e. (2005). surrounded: women and girls in northern uganda. migration policy institute. http://www.migrationinformation.org/feature/display.cfm?id=310. web site accessed 12 february 2009. pross, c. (2006). burnout, vicarious traumatization and its prevention. torture, 16, 1-9. sakamoto, i., & pitner, r. o. (2005). use of critical consciousness in anti-oppressive social work practice: disentangling power dynamics at personal and structural levels. british journal of social work, 35, 435-452. staff welfare unit, career and staff support service: unhcr hq(2001). managing the stress of humanitarian emergencies. geneva: united nations high commission on refugees (unhcr). journal of student social work, volume vii 33 / pesso a case for evidence-based practice 45        columbia social work review, volume i    evidence­based practice  a case for evidence­based practice    tara batista    evidence­based practice (ebp) has enjoyed increasing popularity in the field  of social work. however, not everyone is enthusiastic about this movement.  this paper defines ebp, attempts to clarify common misconceptions about  ebp, and organizes and analyzes some of the criticisms of ebp so that the  field of social work can move onto a more productive debate about its legiti­ mate strengths and limitations.     evidence­based practice (ebp) has increased in prevalence in the  field of social work and enjoys a strong body of supporters. however, not eve­ ryone is enthusiastic about this shift. indeed, one need not look hard to find  resistance to this movement from the field and even from schools of social  work that teach ebp. some practitioners contest that their authority, expertise,  and reflective judgment should not be replaced by a mechanistic evidence­ based decision­making process and are skeptical about the practicality of such  a research­based approach. other social workers and researchers feel that ebp  is too narrow to encompass the dynamic nature of complex social problems.  still others worry that ebp may inadvertently restrict the development of novel  interventions. this paper attempts to clarify common misconceptions about  ebp and to organize and analyze some of the criticisms of ebp so that the  field of social work can move to a more productive debate about its legitimate  strengths and limitations.     what is evidence­based practice?    ebp is “the conscientious, judicious and explicit use of the current  best evidence in making decisions about the care of individuals” (gibbs &  gambrill, 2003, p. 453). ebp is conscientious in the sense that it should be  ethical, effective, and honest. it is judicious because the decision to incorporate  a piece of evidence into practice should be considered and prudent. using the  current best evidence means that practice and policy decisions are based on  evidence that utilizes the most rigorous methodology possible and is subject to  updating. ebp should also be explicit in its transparency. this means practitio­ ners and policy makers are expected to share the evidence with their clients or  constituents and consider client feedback in the decision­making process. cli­ ents also feed into the decision­making process through qualitative research on  client views and experiences, and satisfaction surveys. through this collabora­ tive process, practitioners incorporate clients’ values as a key part of their deci­ sion­making. therefore, ebp must be a comprehensive approach that inte­ grates client values and preferences with practitioner knowledge, expertise, and  judgment. there are a variety of diagrams like the one below that illustrate the  inclusive ebp model.   columbia social work review, volume i       46  batista  figure 1    source: gibbs, 2003, p. 14.   the definition and model above describe using the “best external evi­ dence.” determining what constitutes the best evidence depends on the type of  question. for questions concerning effectiveness, ebp advocates refer to a  hierarchy of evidence where the best external evidence sits at the peak as dem­ onstrated below in figure 2. this hierarchy places systematic reviews of ran­ domized controlled trials (rcts) and meta­analysis at the top, and personal  testimony and expert opinion at the bottom with many other methods of  evaluation in between such as: cohort studies, case­control studies, and case  reports. if there are no systematic reviews or rcts conducted on a specific  research topic, the evidence­based practitioner moves down the hierarchy until  an appropriate study design can be found.                47        columbia social work review, volume i    evidence­based practice  figure 2    source: university of north carolina chapel hill, 2008.        as a holistic approach, ebp adheres to a hierarchy of the best, cur­ rent, and available evidence while incorporating client and practitioner values,  yet it should be emphasized that ebp is a process that actually includes several  steps. these steps consist of: (1) converting information needs into answerable  questions; (2) searching for the best evidence to answer the questions; (3)  critically appraising the evidence for validity and usefulness; 4) applying the  results of this appraisal to policy/practice decisions; and 5) evaluating the out­ comes (gibbs & gambrill, 2002). as both a process and an approach, an ex­ ample of ebp can be found in gibbs and gambrill’s text which follows a so­ cial worker through the five steps described above (2002).     a social worker at a nursing home learned that the facility might be  shut down in 60 days by state inspectors. all 135 residents would have to  move. (step 1: answerable questions) the social worker wondered: “what is  the effect of relocation on mortality rates in elderly residents of a nursing  home?” and “if relocation is necessary, what is the most effective way to relo­ cate elderly residents?” (p. 455). (step 2: evidence search) she conducted an  online literature search using seven different relevant databases. (step 3: evi­ dence appraisal) after reviewing abstracts to indentify well­designed studies,  she found a review summarizing 11 studies that addressed both of her research  questions. two of these studies were single­group pre­posttest studies, two  were posttest only, seven were pre­test/posttest with a control group, and one  was a rct. the general results of her research indicated that “inter­ institutional relocations are stressful but usually not life­threatening” (p. 456)  and much of the stress can be reduced by consulting with nursing home resi­ dents in preparation for a move. the studies described different preparation  systematic reviews and meta analysis of rcts  columbia social work review, volume i       48  batista  techniques such as taking residents and families on tours of the new facility  and asking them for input on the color and location of their rooms. (step 4:  apply results) the social worker presented her findings at a staff meeting  which better prepared the staff in the event of relocation. (step 5: evaluate)  fortunately, the residents did not have to relocate; however mortality rates and  other undesirable outcomes could have been measured after a move to see if  the preparation was effective.   this example incorporates the definition, steps, and comprehensive  approach of ebp. the story effectively demonstrates how ebp can and should  work. although seemingly straightforward and reasonable, ebp has actually  proven to be quite controversial. common criticisms in the literature concern­ ing ebp can be allocated to four main categories: limitations of ebp based on  misconceptions, inapplicability critiques, practicality arguments, and philoso­ phical critiques. this list is not exhaustive, as delineating every single criticism  of ebp is beyond the scope of this paper.     limitations based on misconceptions of   evidence­based practice     many criticisms are based on misinterpretations of ebp. two main  criticisms that fall under the umbrella of misconception critiques are: ebp is  too narrow and too simplistic in its approach. critics believe it is too nar­ row because it relies heavily on rcts and that it is too simplistic because it  imposes universal “cookbook” solutions that dictate intervention application  without sufficient regard to individual and situational factors.         a narrow approach    ebp is often described as over­emphasizing the “gold standard” of  rcts. a few of the many examples of criticisms regarding rcts are demon­ strated in the following statements: “the orthodoxy of experimental manipula­ tion and rcts is dangerous when applied unthinkingly to health promotion,”  or, “randomized comparisons can yield biased assessments of true effects of  interventions,” and “randomized designs have, like all designs, important limi­ tations” (as cited in chalmers, 2003, p. 8).   it is true that “ebp favors methods that critically appraise claims so  that we do not misinform ourselves and our clients” (gibbs & gambrill, 2002,  p. 464). ebp uses rcts because they are the optimal evaluative design for  measuring intervention effects. with questions about whether an intervention  produces the desired outcome, “non­experimental approaches …routinely lead  to false positive conclusions about efficacy” (sackett et al., 1996, para. 8).  rcts, and especially systematic reviews of several randomized trials, are con­ sidered the “gold standard” because they rely on an experimental design and  are therefore more likely to inform than mislead (sackett et al.). rcts accom­ plish this in two ways: 1) through randomly allocating participants to com­ parison groups to abolish selection bias and 2) through the use of a control  49        columbia social work review, volume i    evidence­based practice  group so that we know it is the intervention that is causing the change instead  of external lurking variables. systematic reviews are also at the top of the hier­ archy because they are “typically more rigorous,” “exhaustive in the search”  strategy, “transparent” and “less grandiose in claims of effective­ ness” (gambrill, 2003, p. 13­14). in short, depending on the research question,  certain kinds of evidence are more accurate, useful, and reliable than others.     although rcts are ideal when applied to questions concerning cau­ sality and effectiveness, ebp recognizes the limitations, biases, and applicabil­ ity of each research approach, including rcts. this understanding is illus­ trated in ebp textbooks, articles, and instructional manuals. the curriculum  describing ebp clearly states that it is not restricted to rcts. it involves iden­ tifying the best external evidence in order to answer important clinical ques­ tions (sackett et al., 1996). different research designs are applicable to answer  different types of questions. for example, “to find out the accuracy of a diag­ nostic test, we would use cross­sectional studies of patients who might have  the relevant disorder, not a randomised trial” (sackett et al., para. 8).       often, rcts cannot and need not be used at all; nor does ebp require  it. for example, researchers would not use a rct to test the effectiveness of  parachutes even though proof of their effectiveness is based largely on anecdo­ tal evidence and observational data. in fact, pell and smith conducted a sys­ tematic review titled “parachute use to prevent death and major trauma re­ lated to gravitational challenge” (2003) and were shockingly unable to iden­ tify any rcts. there are also instances where researchers cannot use randomi­ zation. this is especially true in the arena of program evaluation where govern­ ment and nonprofit agencies do not allow randomization for ethical or political  purposes, or researchers are contracted to evaluate existing programs that have  not employed randomization. in fact, the vast majority of the social work evi­ dence base consists of quasi­experimental or observational research.     the confusion among critics about the role of rcts in evidence­ based social intervention lies in the failure to distinguish the purpose of using  one research design over another (chalmers, 2003). the key question to ask is:  “can researchers manipulate the factors?” for example, to understand the ef­ fects of divorce on child development, a researcher would not use a rct be­ cause it is a contextual question and the researcher cannot manipulate the vari­ ables (i.e. the researcher cannot make one half of the children’s parents di­ vorce). after conducting primary cross­sectional research or reading studies of  child development, the researcher might be able to form a theory. the theory  can then lead to intervention ideas. these intervention ideas can be tested in  three stages. the first stage is a pilot or feasibility study. if feasible, the inter­ vention can then be investigated using a rct in a tightly controlled efficacy  study, then later in a “real world” effectiveness study (carroll & onken, 2007).  furthermore, the rct can be combined with qualitative methods and mediator  and moderator analyses to elucidate the processes and mechanisms that explain  why, how, and for whom the intervention works. in other words, there is actu­ ally no need to pick one design over another. in fact, mixed­method ap­ proaches are becoming increasingly popular in evidence­based social interven­ columbia social work review, volume i       50  batista  tion research.     in short, ebp incorporates an array of different kinds of evaluation  methods based on the best available evidence that can answer the specific type  of question asked to solve a particular problem. it is too simple to focus on the  flaws of rcts or any particular evaluation method. ebp does not  “unthinkingly” apply experimental methods to promote any intervention. it is  understood that biases and limitations are an inevitable part of any methodol­ ogy; however, ebp attempts to choose an appropriate method that reduces bias  as much as possible.       a simplistic approach    there is a common fear that ebp will replace practitioner expertise  by dictating solutions to professionals that ignore their values and preferences  and those of their clients. this is based on the misunderstanding that ebp takes  a “cookbook” approach or uses a one­size­fits­all model. this recipe for poten­ tial disaster does not consider the actual definition of ebp and the steps and  diagram described earlier. practitioner’s expertise decides whether research  evidence applies to the individual client at all, and if so, how it should be im­ plemented into practice while keeping the client’s voice in mind. those who  employ ebp argue that external evidence can inform, but not replace, individ­ ual clinical expertise (sackett et al., 1996). as the earlier diagram illustrates,  ebp is intended to be a comprehensive and empowering strategy that inte­ grates the best, current, available evidence with practitioner expertise and cli­ ent preferences.     the “cookbook” misconception suggests that ebp poses one certain  solution for each individual problem. as newman, moseley, tierney, and ellis  (2005) explain, “contrary to popular belief, evidence­based practice is not  about searching for a ‘right answer’ because there rarely is only one right an­ swer” (p. 5), in social work and social policy. additionally, ebp actually  makes no statement on the individual level. systematic reviews and rcts as­ sess the probability of an outcome occurring on an aggregate level. in other  words, ebp “cannot deliver certainties, just increase probabilities” (newman,  moseley, tierney, & ellis, 2005, p. 5).     an approach inapplicable to social interventions    there is a belief that the problems social work and social policy ad­ dress are too complex and dynamic to apply the formulaic process of ebp  (plath, 2006) and that while ebp might work for medical interventions, it will  not work for social interventions. however, evidence­based social interven­ tions are not new. in fact, social work has a long history of using scientific  research evidence to guide practice, dating back to the turn of the twentieth  century (gibbs, 2002). in the 1930s social scientists in the united states were  trained in experimental methods, and evaluations of social interventions were  carried out by independent investigators. between the early 1960s and late  51        columbia social work review, volume i    evidence­based practice  1980s, rcts emerged as the ideal method for assessing a wide range of public  policy interventions (oakley, 1998). one of many examples of ebp in action  is a recent systematic review that evaluated the effectiveness of sexual absti­ nence­only hiv prevention programs in high­income countries. the review  found that these programs had no effect on the hiv rate (underhill, montgom­ ery, & operario, 2007). in response to the evidence, the us congress reas­ sessed funding for these programs. another example of the successful imple­ mentation of ebp is when professionals delivering an education and training  program for high school dropouts agreed to a rct to assess its effects, in spite  of their concern that it might fail to find any beneficial effects of their work.  the results of the trial were positive and led to a 15­site expansion serving  hundreds of disadvantaged youth (chalmers, 2003).    these examples demonstrate that rigorous scientific methods and ap­ propriate design choices can be used to successfully evaluate social interven­ tions. critics who claim that ebp is not applicable to social interventions be­ cause we “cannot quantify the human experience” (chalmers, 2003) are right:  the human experience may not be quantifiable, but the effectiveness of spe­ cific interventions is.     an impractical approach for real world practitioners    there are many practical reasons practitioners do not incorporate ebp  into their daily routine. these include lack of resources, time, training, and  evidence. practitioners are often busy with overwhelming caseloads, managing  several job titles. they may feel that they have more pressing tasks to accom­ plish than to become researchers on the side (newman, moseley, tierney, &  ellis, 2005). although this argument is legitimate, social work practitioners are  professionally obligated to use evidence to inform their practice if they seek to  adhere to a code of ethics.    incorporating evidence into practice is not just ethical, but practically  speaking, ebp actually saves time and money. ebp can help practitioners to  identify the most effective interventions. systematic reviews summarize rcts  so practitioners do not have to search, find, and read each one and then try to  evaluate their collective effectiveness. additionally, developments in informa­ tion technology have greatly accelerated the process by which information can  be searched, identified, obtained, and updated. practitioners no longer have to  spend hours attempting sophisticated searches because “the average length of  time to conduct an electronic search [is] between 5.5 minutes ­7 minutes 6 sec­ onds” (gibbs, 2003, p. 18). furthermore, a simple search of google scholar  can provide useful results. as previously demonstrated in the example of the  social worker in the nursing home, incorporating ebp into decision­making  does not necessarily entail a lengthy research process.     even when practitioners have time to search, they may feel they lack  the skills to navigate the vast amount of available information. to exacerbate  this problem, schools of social work in the united kingdom and united states  have not dedicated adequate attention to instruct students how to search for and  columbia social work review, volume i       52  batista  locate pertinent research from online databases (newman, moseley, tierney, &  ellis, 2005). although this is a legitimate problem, it is far from insurmount­ able. simple searches of the most important and relevant databases are achiev­ able by any practitioner with access to a computer and the internet (newman et  al.). additionally, practitioners can refer to several user­friendly guides on how  to search and can also seek assistance from reference librarians for sophisti­ cated searches.     where practitioners have the time and skill to conduct searches, there  may not be enough evidence to establish which interventions work. in the case  when there is no evidence for an intervention, or the evidence is scarce, practi­ tioners should report their findings, use their best judgment, and be open to  alternatives (newman et al.).     philosophical criticisms    perhaps the most legitimate criticism of ebp is philosophical in na­ ture. organizational theory professor jim mandiberg warns, "evidence­based  practice is anti­innovation! it is a bunch of like­minded funders who already  agree with ebp reading each other’s proposals deciding only to fund the hand­ ful of evidence­based practices that they agree with" (personal communication,  january, 21, 2010). khun's theory of the structure of scientific revolutions sug­ gests that real innovation comes from the periphery – that is, from those mem­ bers who do not follow the established paradigm (1962). ebp must then seek  to incorporate and evaluate social interventions and ideas from alternative  sources in addition to peer­reviewed academic journals. to a certain extent, the  growing popularity of the evaluation of existing social programs can help in  this area. if a client and/or practitioner implements a new intervention, then the  success or failure of that intervention should be documented and absorbed into  the evidence base so that others can learn from it. furthermore, the recent sup­ port of the stage model of intervention development (the aforementioned proc­ ess where researchers design and test inchoate interventions in feasibility, effi­ cacy, and effectiveness study stages) is spawning innovation from within aca­ demia. we must be cautious not to focus exclusively on current evidence­based  practices and, as a consequence, ignore more ground­breaking interventions  from non­conformist social work pioneers.       conclusion    ebp is criticized for a variety of reasons. these critiques are mainly  based on misconceptions and the impracticality of ebp. however, ebp is a  comprehensive approach incorporating research evidence together with clients  and practitioners’ values. it utilizes the best, current, and available evidence  relevant to the research question asked. there is a clear hierarchy of evidence  with regard to questions of effectiveness. if little or no evidence is available,  practitioners should report the state of the evidence and use their best judg­ ment. ebp gives us a mode of comparison for competing interventions and a  53        columbia social work review, volume i    evidence­based practice  set of tools to make informed decisions. it is a constantly evolving journey, not  a stance. ebp researchers must be careful not to overlook innovative ap­ proaches, but rather incorporate them into the process as best identified by cli­ ents and practitioners. better methods of evaluation and interventions will re­ place previous best practices. ebp is not perfect, but when used correctly, it  has tremendous potential to provide clients with information, options, and pro­ grams that work.        references    carroll, k.m., & onken, l.s. (2007). behavior therapies for drug abuse. the    journal of  lifelong learning in psychiatry, 5 (2), 240­248.   chalmers, i. (2003). trying to do more good than harm in policy and practice:    the role of rigorous, transparent, up­to­date evaluations. annals of the    american academy of political and social sciences, 589, 22­40.   gambrill, e. (2003). evidence­based practice: sea change or emperor’s new   clothes? journal of  social work education, 39, 3­23.   gibbs, l., & gambrill, e. (2002). evidence­based practice: counterarguments     to objections. research on social work practice, 12, 452­476.  gibbs, l. (2003). evidence­based practice for the helping professions: a     practical guide. pacific grove, ca: thomson/brooks cole.   kuhn, t.s. (1962). the structure of scientific revolutions. chicago: university    of chicago press.   newman, t., moseley, a., tierney, s., & ellis, a. (2005). evidence­based    social work: a guide for the perplexed. lyme regis: russell house    publishing.   oakley, a. (1998). experimentation and social interventions: a forgotten but     important history. british medical journal, 317, 1239­1242.   pell, j., & smith, g. (2003). parachute use to prevent death and major trauma    related to gravitational challenge: systematic review of randomized    controlled trials. british medical journal, 327, 1459­1461.   plath, d. (2006). evidence­based practice: current issues and future directions.    australian social work, 59 (1), 56­ 72.   sackett, d.l., rosenberg, m.c., muir gray, j.a., haynes, b.r., & richardson,    s.w. (1996). evidence based practice: what it is and what it isn’t.    british medical journal, 312, 71­72.   underhill, k., montgomery p., & operario, d. (2007). sexual abstinence only    programmes to prevent hiv infection in high income countries:     systematic review. british medical journal.     doi: 10.1136bmj.39245.446586.be   university of north carolina chapel hill. (2008). [graphic representation of    the hierarchy of evidence pyramid]. hierarchy of evidence from the    prescribing for better outcomes project. retrieved from     http://prescribingforbetteroutcomes.org/?q=resources/ evaluating    2020_cswr_journal.indd columbia social work review, vol. 18 | 12 religious observance as a tool for domestic violence in custody disputes between haredi jewish co-parents karen a. kadish abstract domestic violence victims in haredi jewish communities face serious obstacles to leaving their abusers and escaping domestic violence. leaving their abusers often entails divorce and fierce custody disputes. for many haredi women who have experienced domestic violence, leaving their abusers also involves leaving their religious sect or even religious observance in general. this paper will explore the dynamics that contribute to these concerns for haredi jewish domestic violence survivors and address how courts deciding child custody can inadvertently perpetuate domestic violence. this paper will then recommend changing the courts’ analysis in child custody cases to a “friendly religious co-parent” model in order to better protect victims of domestic violence. introduction domestic violence victims in haredi1 jewish communities face serious obstacles to leaving their abusers. by the time a domestic violence survivor leaves her abuser in these communities, they are likely to be married to their abuser with children in common (pew research center, 2015). the victim may also face significant community pressures to stay with her2 abuser (schneerson & chabad.org, 2001a; schneerson & chabad.org, 2001b) and within her specific sect of religious practice (ruz & pritchard, 2016). for many of these women, leaving their abusers involves leaving their particular religious sect and, in certain cases, they choose to leave their religious observance in general (ausch, 2018). theoretical models relating to domestic violence emphasize that domestic violence is not an individual phenomenon, but derives from “structural relationships of inequality between women and men. . . . it cuts across both the public and the private spheres” (united nations, 2006). this paper will explore the cultural dynamics that make it difficult for haredi jewish individuals to leave an abusive relationship when the victim shares children with the abuser, as well as address how new york state courts deciding child custody can consider religion in a way that does not create additional risks of religious domestic violence. 1 “haredi” signifies “devout” in hebrew and is used to signify a particular group of traditional orthodox jews (shafran, 2020). it is preferred to the more common, pejorative term “ultraorthodox” (shafran, 2020). 2 this article will use female pronouns as a default to refer to haredi jewish victims of domestic violence, because the overwhelming majority are female. 13 | columbia social work review, vol. 18 this paper does not address cases in which child abuse or neglect exist concurrently with domestic violence within a family. rather, it focuses on custody disputes conducted outside of the realm of child protective services, as part of a divorce or other civil legal action. specifically, the paper will explore how religious law can be used by abusers to marginalize and control haredi or formerly haredi female victims of domestic violence in the context of a custody dispute. part one of this paper will discuss the background of religious control as a mechanism of domestic violence and how religious control manifests in the haredi jewish community. this type of control will be called “religious domestic violence” in this paper. part two of this paper will address the ways in which custody orders given by new york state courts aimed at maintaining religious stability for children create additional difficulties for victims attempting to leave an abusive relationship in which religion figures prominently. part three of this paper will recommend changing the best-interest analysis that courts currently employ when considering a child’s religion. this shift will assist in protecting women against religious domestic violence. part one: religious communities and domestic violence religious control can function as a mechanism for domestic violence. religious domestic violence occurs in many different faiths (fortune, abugideire, & dratch, 2010; bent-goodly & fowler, 2006; foss & warnke, 2003; ghafournia, 2017; nason-clark, 2004). most references noted in this paper refer to the “big three” monotheistic faiths of judaism, christianity, and islam, and of course this paper focuses on a particular group within judaism. irrespective of religious group, women in observant religious communities often face idiosyncratic abuse and barriers to leaving their abusers (fortune, abugideire, & dratch, 2010; bent-goodly & fowler, 2006; foss & warnke, 2003; ghafournia, 2017; nason-clark, 2004). however, religiosity and participation in a religious community also serve as a protective factor for many women (fortune, abugideire, & dratch, 2010). while religiosity, in general, is inversely correlated with domestic violence, religious fundamentalism and patriarchal religious power models are risk factors for domestic violence in religious communities (warren, 2015). control based on religion has been incorporated into one version of the power and control wheel that is frequently used to conceptualize the power dynamics that exist within an abusive relationship. specific mechanisms of domestic violence that have been identified as common to abusers and victims who belong to observant members of all three abrahamic faiths. these mechanisms include a) using religious teachings to control sexuality and reproduction; b) using members of the religious community as tools for coercing or intimidating the victim; and c) using religious teachings to assert gender-based authority over a victim (rapoport, 1991; bent-goodly & fowler, 2006). columbia social work review, vol. 18 | 14 the expressions of religious domestic violence in the haredi jewish communities are idiosyncratic because these communities are small, cohesive, and organized around religion. (friedman, 1991; berman, 2000; freund & band-winterstein, 2013). haredi jewish practice is vulnerable to manipulation by abusers because the vast majority of the haredi community feels itself to be bound to jewish law (“halacha”) and to the rabbinic authorities who are the decisors in the jewish legal system (pew research center, 2015). while religious principles are used in religious domestic violence in a variety of different faiths, their expression in haredi judaism has not been extensively explored. halacha governs almost every aspect of a religious jew’s life (aiken, 2015). it is often through the use and misuse of halacha that abusers in haredi communities exert religious control over their victims (cares & cusick, 2012). in haredi communities, there is also a strong societal pressure to adhere to the strictures and traditions of the community (auerbach, n.d.; schapiro, n.d.). these strictures can be additional loci where abusers take control from their victims because traditions tend to pass down along the male familial line. while many parts of halacha and jewish tradition could be used for abusive behavior, three aspects of halacha are particularly susceptible to being used as mechanisms of control by abusers: the laws of modesty, the laws of sexual conduct, and the strong value placed on marital harmony (shalom bayit). 3 the laws of modesty can be used as a mechanism of domestic violence because they dictate the social interactions of women and men in orthodox jewish communities. the laws of modesty are primarily thought of as a dress code of sorts for jewish people. community standards vary, but in haredi communities, married women typically are expected to wear clothes that cover their collarbones, their arms past their elbows, and their legs to mid-shin. in addition, they almost always cover their hair with a wig and often a scarf or hat on top of a wig(nir, 2016). these laws can be used as tools for domestic violence because abusers can control victims’ social relationships and access by threatening to expose the victim to embarrassment in the community as a whole. consider, for example, a husband who refuses to give his wife money to repair or replace a damaged wig. the woman cannot go out in public in her community without wearing 3 note that interpretations and implementations of halacha and tradition vary widely between communities and between individuals. the discussion of halacha in this paper is not intended to give a representation of how halacha functions in any one community, but rather to identify the manipulations or extreme interpretations of halacha that exist and can be used by abusers. it is particularly not intended as a critique of religious obligations that women freely take upon themselves as part of a haredi community. the use of the religious law to exert control are, to the author’s knowledge, atypical even within haredi communities, where religious practice (although strongly reinforced by community norms and expectations) is an individual responsibility and is not subject to coercion by either a person’s spouse or their community. see taubes (2008) (discussing the limited circumstances in which an individual is permitted to rebuke another, and emphasizing that religious practice is incumbent on the person—not their friends or family—and that rebuke is only appropriate when done kindly and when the listener is open to changing their behavior). 15 | columbia social work review, vol. 18 a wig, so she is forced to choose between wearing a damaged wig and facing public embarrassment or staying home. haredi interpretations of modesty laws additionally operate as a barrier to women accessing resources in the greater community because women are discouraged or prohibited from speaking to men who are unrelated to them (zeveloff, 2011). even if victims decide to ask a male community figure for help, it is likely that there will be no way for the woman to approach him or that he will refuse to speak to her because doing so could be considered immodest. abusers can use these laws to cut women off from figures of power within the community, especially because the legal decisors are all men. questions to these decisors—and their responses—are expected to be conveyed through women’s husbands or fathers, which allows abusers to manipulate or invent rabbis’ decrees to control their wives’ behavior. sexual relationships within jewish marriages are also governed by halacha, providing another avenue for abusers to control women’s behavior. while a full discussion of these laws is beyond the scope of this paper, halacha addresses the times when spouses may be intimate with each other and the transition between times when spouses can be intimate and times when they cannot be intimate (zimmerman, 2001; guterman, 2008). these laws can lead to religious domestic violence in two major ways: a) abusers may pressure their victims to have sex when they are religiously prohibited from doing so and b) abusers can misconstrue halacha to try to coerce their victim into believing that they are religiously required to have sex with their spouse when, in reality, no such obligation exists (cares & cusick, 2012). this is sexual assault, and also forces the woman to abandon her own religious practice and to face the shame and fear of having violated a serious religious law (abusive husband, 2009). finally, much religious domestic violence in haredi communities is done under the guise of telling the woman she must create shalom bayit—peace in the home. shalom bayit is considered of central importance to jewish marriages (maimonides, n.d.). shalom bayit is cited as the justification not only for spouses taking special care for each other, but also as a priority of household economic choices and, at its best, the conduit for the divine presence (see talmud bavli, koren, shabbat 23b; talmud bavli, koren, sotah 17:a in steinsaltz, n.d.). the laws of shalom bayit apply to both men and women (maimonides, n.d.). however, they are very susceptible to manipulation by abusers to control their victims and force them to acquiesce to the abuser’s demands. abusers can tell their victims that they may not contradict them or must contribute more labor to the household (even as the abuser refuses to do so) in order to maintain shalom bayit. furthermore, rabbinic authorities—either due to bias or ignorance—may tell victims of domestic violence to exert more effort to maintain shalom bayit in their home instead of helping them to leave abusive relationships (schneerson & chabad.org, 2001b). by framing domestic violence in the terms of shalom bayit, abusers columbia social work review, vol. 18 | 16 can place the blame for abuse on a victim’s shoulders. arguably, shalom bayit can be utilized as a religious framework for telling the victim that she would not be abused “if only she created shalom bayit”—i.e., fulfilled any and all demands of the abuser. couples going to a rabbinic authority or other community resources with marriage troubles often are counseled to stay together for the sake of shalom bayit, and to simply “try harder” to achieve this illusory peaceful home (schneerson & chabad.org, 2001b). jewish law can be misused not only in the perpetration of domestic violence but also as a barrier to women’s leaving abusive relationships. the prohibition against “mesirah”—turning a jewish person over to nonjewish authorities (teshuvot harosh 17:1), especially given concerns about widespread antisemitism and anti-haredi sentiment—is a significant obstacle to victims of domestic violence accessing help from outside of their community. in insular haredi communities, this prohibition is interpreted very broadly, which results in almost all legal matters being handled within the community (aviv, 2014). for victims of domestic violence, this prohibition means that a victim can face community censure for going to the secular police or courts for help. haredi women may not pursue an order of protection in a secular court, because doing so will be considered a betrayal of the community. husbands also have the ability to refuse a religious divorce (a get) to their wives. the refusal to grant a get is domestic violence because it functions as a way for abusers to prevent their wives from leaving them or the community. by halacha, women are unable to remarry in a jewish ceremony unless they obtain a jewish divorce. part two: religious disagreements and domestic violence in custody disputes custody orders aimed at maintaining religious stability for children create additional difficulties for victims attempting to leave an abusive relationship in which religion is a major factor. custody disputes may lead to further or more severe religious domestic violence because an abuser can exert control over a co-parent’s religious practice either individually or by channeling the resources of the community, and isolate a co-parent who is not following religious law scrupulously, all under the guise of enforcing a court order about the best interests of the child. custody disputes for haredi couples can be complicated by the social and religious implications of childrearing within their communities. this is partially due to demographic realities—haredi couples do not live together or have children before marriage (negiah and relations for unmarried couples, 2017). these couples tend to get married earlier (pew research center, 2015), and typically begin to have children soon after marriage. child custody disputes are also more common—and more intense—because of the social connotations of leaving the haredi community or changing religious practice (cohen, 2017). thus, custody disputes are not only about the individual parents’ own relationships with the children 17 | columbia social work review, vol. 18 but also implicate the greater community’s hopes for the children and their religious and social education (fenton & rickman, 2016; santo, 2013). courts strive to maintain a “religious status quo” for the child and “will consider religion in a custody dispute when a child has developed actual religious ties to a specific religion and those needs can be served better by one parent than the other.” (gribeluk v. gribeluk, 2014; ervin r. v. phina r., 2000). this approach is grounded in the broader perspective that a child’s best interests are served by maintaining stability in the child’s life (gribeluk v. gribeluk, 2014). courts’ concern for the religious status quo of the child can be determinative in child-custody cases of haredi couples, because the custodial parent has the right to determine the child’s religious upbringing (de beer v. de beer, 1990; stevenot v. stevenot, 1987). if one parent is now practicing the religion in a different way—or not at all—courts may decide that the child should stay with the parent whose religious practice has not changed in order to maintain the status quo. in a recent case, etty ausch, a formerly haredi mother of seven, was severely limited in her visitation of her older children and prohibited from seeing her younger children because she is no longer religious (ewing & grady, 2017). despite ms. ausch’s allegations of her ex-husband’s significant sexual abuse against her, the court denied her custody of her children and severely limited her visitation (ewing & grady, 2017). courts routinely place religious requirements on haredi co-parents in order to maintain religious stability for haredi children. they commonly require parents to keep kosher and observe the sabbath when their children are with them (weisberger v. weisberger, 2018; m.c. v. r.c., 2008). these requirements are extremely ambiguous given the diversity of opinions within jewish law regarding what is or is not “kosher” and what constitutes a violation of the sabbath. because of first amendment concerns, the enforcement of such orders tends to rely on discerning the credibility of the parents’ assertions about their religious practice and the parents’ complaints about the religious practices of their co-parent rather than an investigation into normative religious practice in the community.4 nonetheless, courts continue to use these markers because they are very obvious elements of religious jewish practice and because they directly address the lifestyle of the child. most recently, courts have begun to require parents to adhere to children’s “school rules”—the (often-unwritten) comprehensive requirements for parents who send their children to haredi jewish private schools5 (weisberger v. weisberger). arguably, this requirement is especially 4 constitutional concerns about the separation of church and state prevent a court from issuing a legal decision about which parent is “right” regarding a question of religious law. because of the constitutional concerns, courts are often opaque about their application of religious rules to custody and visitation cases. while there may be a constitutional issue with requiring non-custodial parents to acquiesce to the custodial parent’s religious standards, a constitutional analysis is beyond the scope of this paper. for a discussion of the constitutional angle, see generally barshay (1997); volokh (2006). 5 these rules are difficult to obtain because haredi schools rarely have a religious presence, columbia social work review, vol. 18 | 18 vulnerable to manipulation by abusers because courts cannot easily verify what the school’s rules are. there are three ways in which custody determinations that adhere to the religious status quo inquiry in a best-interests analysis create additional risks of religious domestic violence or may increase the severity of such violence. first, focusing on maintaining the child’s religious status quo by mandating certain religious practices or comportment by the victim gives the abuser a tool to continue domestic violence by policing the victim’s adherence to court orders. because a victim’s visitation with her children or her custody of her children may be contingent on her maintaining the religious status quo, abusers can come to court and allege that the victim’s religious practices have changed and ask for custody or visitation to be modified. while the use of the legal system to perpetuate domestic violence is possible in every custody dispute, it is especially problematic in the haredi context because court orders regarding jewish religious practice generally involve practices that are beyond the court’s own understanding.6 evidence regarding religious practice is hard to provide to a court and even hard to apply because of constitutional concerns that limit the ways in which courts can rule on the validity of a litigant’s religious practice. therefore, if the abuser claims that the victim has violated the court order, the court is unable to easily identify whether there has or has not been a violation and may end up supporting an abuser’s frivolous or manipulative claim. even if the victim is ultimately able to defend against the abuser’s claim, the abuser has still been given a legally-sanctioned way to monitor the victim’s religious practice and subject her to traumatic and intrusive legal proceedings. these concerns are even greater when a court has ordered both parents to maintain the “school rules” of their children. most children who grow up in a haredi community attend a private jewish school that adheres to the tenets of their sect of judaism (pew research center, 2015). haredi schools rarely have an online presence, and the school rules are often unwritten or the rules are unwritten, and the school operates in yiddish. however, rules of the school bnos menachem were circulated in the jewish community in 2017 after the school issued a letter instructing mothers of students at their school that new school rules for mothers of students included “1) nail polish should be conservative/soft colors; 2) no denim; 3) [wig] length should not exceed the shoulder blades; 4) no tight fitting or provocative clothing; 5) no leggings; 6) elbows, feet, neckline completely covered; 7) skirts mid-calf ” and asking the mothers to sign a statement that they would “do [their] utmost to fulfill them” (gurary, 2017). 6 consider, for example, the following scenario: an abuser comes in and claims that the victim is feeding the children “non-kosher” food. the victim explains that the food has kosher certification and that it is, indeed, kosher. the abuser responds that he does not think the certification is valid and that when they were living together, the family never would have considered such food kosher. both parties have witnesses who can testify to the fact that the food is/is not kosher. in such a scenario—or the thousands of possible analogs that could come up in religious practice—it will be incredibly difficult for the court to know whose claim is correct. the court cannot know which kosher certifications are acceptable to the family or the community, and how much the victim’s conduct does or does not deviate from the agreed-upon religious practice of “keeping kosher.” 19 | columbia social work review, vol. 18 even unspoken. by linking child custody or visitation to school rules, the court creates an opportunity for the abuser to use the children’s schools as a tool of domestic violence. for instance, an abuser can begin to highlight examples of school-rules violations that might not get policed by the school itself. furthermore, because the school rules generally apply to parents, whether their children are with them or not, the school-rules requirement invites the abuser to monitor the victim’s conduct even when the children are not in her custody. chava weisberger was denied custody of her children due to her failure to adhere to a religious conduct custody agreement until the lower court’s ruling was overturned on appeal in january 2018 (weisberger v. weisberger, 2018). even to the extent that ms. weisberger donned religious apparel and abided by the abuser’s religious dictates while she was with their children, her irreligiosity was used by the abuser to justify intensive monitoring of her behavior and limiting her contact with her children, for instance asking that the victim’s visitation be supervised by a haredi relative. accordingly, abusers can engage in manipulative applications of the laws of modesty, the sabbath, or kashrut in order to continue to control the victim even when the victim is not with her children. a second problem with using community norms or school rules as a conduct-requirement for victims is that courts provide opportunities for abusers to channel the resources of the community into controlling the decisions of the victim about religious observance. in many haredi communities, there is a very deep fear of people leaving the sect, and the community will mobilize in order to convince wavering members to remain in the sect (brodesser-akner, 2017; halime, 2015). therefore, the abuser can exert control over the victim by co-opting these communal efforts and using the community as a tool for controlling the decisions of the victim. finally, requiring victims to maintain the religious status quo or to follow school rules in custody or visitation orders may unintentionally isolate victims from resources outside of the religious community. many haredi communities and schools have a requirement that families refrain from having smartphones and refrain from using computers or the internet if they are not required to do so for their jobs (grynbaum, 2012; fenton, 2016). therefore, by requiring a victim to maintain the religious status quo or to follow the school rules of her children’s schools, a court may unintentionally lend state-enforcement to community policies that cut the victim off from the nonreligious world at a time when such contact might be especially necessary part three: how courts can avoid perpetuating religious domestic violence in custody disputes given the impact of the current best-interest analysis that courts employ when considering a child’s religion, a change is required to protect against religious domestic violence. the best-interests analysis in custody columbia social work review, vol. 18 | 20 disputes is a child-focused analysis (peskind, 2004). whereas earlier courts focused on a parent’s right to raise their child or on traditional assumptions of which gender parent is better for children at different stages of the child’s life, courts have moved to a case-by-case and child-by-child approach to determining custody (peskind, 2004). in cases involving domestic violence, multiple legislatures have articulated that courts must consider domestic violence when determining child custody, and that it is a weighty factor in the best-interests analysis.7 in the context of religious domestic violence, courts should consider the ways in which custody orders that address religion in order to maintain the child’s religious status quo can intensify or perpetuate domestic violence between religious co-parents. courts should replace the “status quo” model with a “friendly religious co-parent” model, in which courts consider which parent is more likely to support the child’s own religious choices and to foster a relationship with the other parent’s religion. that is, one way to prevent abusers from using custody disputes as a locus of domestic violence is to change the model that courts use to determine the best interests of the child in custody disputes between religious co-parents. due to the dangers inherent to the present model for considering religion, it is vital that courts create a model that does not give abusers tools to continue religious domestic violence. one potential solution is for courts to consider religion in the way that they currently consider each parent’s ability to foster the child’s relationship with the other parent. this paper proposes this model and calls it the “friendly co-parent” model. under a friendly co-parent model, the court would look into whether each parent is willing to allow the other co-parent to have access to the children, whether the parent speaks badly of the other parent, or if either parent is trying to turn the child away from the co-parent. all of these metrics tend to bias a court against a domestic violence survivor who is acting out of a rational fear of her abuser. however, while the friendly co-parent model can burden domestic violence victims by forcing them to protect their children’s relationship with a person who has abused them, using the friendly co-parent model to guide decisions about the child and parents’ religious observance does not face 7 see, e.g. ariz. rev. stat. ann. §25-404.03 (2015) (“the court shall consider evidence of domestic violence as being contrary to the best interests of the child. the court shall consider the safety and well-being of the child and of the victim of the act of domestic violence to be of primary importance. the court shall consider a perpetrator’s history of causing or threatening to cause physical harm to another person.”); n.d. cent. code §14-09-06.2 (“in determining parental rights and responsibilities, the court shall consider evidence of domestic violence. if the court finds credible evidence that domestic violence has occurred, and there exists one incident of domestic violence which resulted in serious bodily injury or involved the use of a dangerous weapon or there exists a pattern of domestic violence within a reasonable time proximate to the proceeding, this combination creates a rebuttable presumption that a parent who has perpetrated domestic violence may not be awarded residential responsibility for the child.”); n.y. dom. rel. §240 (“where… allegations [of domestic violence] are proven by a preponderance of the evidence, the court must consider the effect of such domestic violence upon the best interests of the child”). 21 | columbia social work review, vol. 18 the pitfalls of the religious status quo model, which are discussed above in part two. to apply a friendly religious co-parent model, a court should consider whether a parent is speaking disparagingly about the other parent’s religious practice, whether the parent is supporting the child’s own religious development and beliefs, and which parent is open to fostering the child’s relationship with the other parent’s religious beliefs. while this still is burdensome for a parent who is faced with supporting their child’s relationship with a religion that is not (or is no longer) their own practice, it does not force victims to support their abuser directly, but rather to support the child’s own religious beliefs and the child’s relationship with the co-parent’s religion. this mitigates the problem of religious policing by the abusive co-parent because the inquiry is framed in terms of the parent supporting the child’s needs, rather than the co-parent’s desires regarding the victim’s own religious conduct. for example, a mother who feeds her child kosher food and supports the child’s observance of the sabbath, cannot be penalized for choosing not to adhere to a haredi dress code, simply because her new mode of dress changes the child’s religious status quo. adopting a model that is focused more on the parent’s ability to support the child’s religious development and exposure to each parent’s religion minimizes the risk of court-enforced religious domestic violence in several ways. first, it limits the abuser’s ability to use the court to monitor the victim’s religious behavior and to threaten the victim if she does not comply with his religious standards. this model does not dictate parents’ own religious conduct. as a result, the abuser cannot use a court order to dictate the victim’s religious observance or to control her lack of observance. second, it allows parents to consider their children’s own religious choices and desires. therefore, while a custody order may require that victims accommodate their children’s own desire to keep kosher or to observe the sabbath, the driving force of religious requirements in the parents’ life are the child’s own religious needs and opportunities, not the abuser’s mandates for the children. this model is most relevant for children who are old enough to verbalize their religious desires and does not fully address the problem of religious upbringing for infants or toddlers. however, this model is more consistent with the children’s rights-focus of modern family law (fortin, 2003) and also further distances the victim from her abuser’s attempts to control her religious life. the religious conduct required of the victim is only the conduct that is necessary to support the child’s opportunity to participate in the coparent’s religious practices—the victim would no longer be bound to follow the abuser’s religion in full, even where the religious observances do not impact the child’s own practice of the religion.8 while communal pressures 8 consider, for example, a mother who no longer wishes to adhere to the modesty laws of their ultraorthodox sect. the mother’s dress has no bearing on the child’s own religious practice. however, under the current model, courts could require mothers to maintain their columbia social work review, vol. 18 | 22 can still be brought to bear on a mother who chooses to leave the religious sect, victims will be protected from having formal court orders that require the mother’s own religious conduct. this added level of separation is a small change but creates a crucial difference. for a mother who has a court order requiring her own religious conduct, her clothing and other choices can be a direct violation of the custody order, and per se puts her custody or visitation rights at risk. for a mother whose conduct is the subject of social pressure but is not violative of a court order, the court can act as a protective factor for the mother and protect her custody rights in the face of religious pressure regarding the mother’s conduct that goes against community norms but does not have a significant impact on her child’s ability to practice religion. third, a model that requires the parents to support the child’s exposure to the other parent’s religious practice will protect against abusers that try to cut off a victim’s access to her children because of her lack of religiosity. abusers who denigrate their victims for a lack of religiosity or for changing their religious practices will no longer be rewarded (as he is under the status quo arrangement) and instead will rightfully be seen as alienating the children from the victim’s religious practice. finally, adopting this approach to religious differences in custody disputes is consistent with the child’s best interest. it would be impossible for a secular court to determine what religious practice is best for the child. therefore, the court should look at which parent best provides for the religious development of the child, which includes the child being able to make their own religious choices (dwyer, 1994; kilkelly, 2009). while stability is important, the need for stability in religion is outweighed by the need for the child to have stable relationships with his or her parent—no matter whether the parent and child’s religious paths diverge. therefore, by factoring in which parent is best able to encourage the child’s religious growth and accept the child’s involvement with the co-parent’s religious practice, courts will be closer to finding the best interest of a child whose parents have different religious practices. conclusion haredi victims of domestic violence are vulnerable to continued domestic violence during custody disputes with an abusive spouse. despite the grave risks facing such victims, courts consider co-parents’ religious practices in a way that is vulnerable to exacerbating the dynamics of religious domestic violence. courts routinely tie child custody or visitation to specific types of religious practice and to community norms or children’s school rules. in doing so, the court creates a tool for abusers to use to ultraorthodox dress code in order to maintain stability for the child or because the court has ordered parents to follow school rules. under a friendly religious co-parent model, the court would need to consider whether the mother’s dress is relevant to the child’s own religious practice and to consider that the abuser’s attempts to coerce the victim into dressing a certain way is anathema to the abuser supporting the children’s relationship with the mother’s own religious practice. 23 | columbia social work review, vol. 18 continue religious domestic violence—with court enforcement. to mitigate the religious domestic violence faced by haredi domestic violence survivors in custody disputes, courts should consider religion not as a question of specific practices, but as a question of choice and development. courts should find that it is in the best interest of a child to be placed with a parent who is open to accommodating the child’s own religious choices and to the child developing a relationship with the co-parent’s religion or lack thereof. by changing their consideration of religion in this way, courts can protect against custody orders being used to perpetuate religious domestic violence and cease to reward abusive religious behavior against haredi or formerly haredi victims of domestic violence. about the author karen kadish is a student at columbia law school and columbia school of social work. at columbia law school, karen has served as an editor of the columbia law review and a member of the adolescent representation clinic. karen’s work is primarily in public defense, with a focus on preventing the separation of families by the foster system. before coming to columbia, karen co-founded a program that provides access to community resources to low-income middle schools in san jose, california. karen is from palo alto, california, and holds a b.a. in international studies and french literature from johns hopkins university. references abusive husband. 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(2001). a lifetime companion to the laws of jewish family life. new york; jerusalem: urim publications. journal2012   33        columbia social work review, volume iii  dual punishment:   incarcerated mothers and their children  !  julie smyth  ! children with incarcerated parents are among the most at­risk  populations in the united states. the recent trend toward mass  incarceration in the united states, especially of women, has  harmful implications for children because often their primary  caregiver becomes incarcerated. research indicates that children  with incarcerated mothers are at heightened risk for attachment  disturbance, leading to depression, anxiety, and other trauma­ related stress. such children are often subject to frequent chang­ ing of caregivers within the foster care system, which exacerbates  these problems. child welfare legislation is becoming more sensi­ tive to the needs of children of incarcerated parents, but less reli­ ance on prisons and more alternatives to incarceration are need­ ed in order to mitigate the harmful impact of maternal incarcera­ tion on children. this review will focus on the following: (1) a  history of the mass incarceration of women; (2) emotional, psy­ chological, and social risk factors for the children of incarcerated  women; (3) the intended and unintended repercussions of child  welfare legislation; and (4) a case study of an alternative to in­ carceration program.  !   there are currently 2.3 million people incarcerated in the  united states, a number that has more than doubled since the  1980s (bureau of justice statistics, 2011; glaze, 2011). the trend  toward mass incarceration inflicts irreparable damage on families  and communities (richie, 2002). of the innumerable problems  associated with mass incarceration, one of the most serious, and  often ignored, repercussions is the lifelong harm inflicted upon a  child with an incarcerated mother.     children of incarcerated parents are often referred to as  “hidden victims,” because they bear the heavy burden of a crime  they did not commit (miller, 2006). as a result of increasing!jail  and prison populations, at least 2.4 million children in the u.s.     smyth  columbia social work review, volume iii        34  have one or both parents in a correctional facility (boudin &  zeller­berkman, 2010). nearly 75% of women in correctional   facilities were the primary, and sometimes sole, caretakers of  their children prior to their arrest, which often led to their chil­ dren’s entrance into the foster care system (margolies & kraft­ stolar, 2006). these children are put at risk for lifelong attach­ ment difficulties, which may lead to the externalization of nega­ tive behaviors (bowlby, 1980; bowlby, ainsworth, boston, &  rosenbluth, 1956; shalfer & poehlmann, 2010). the following is  an overview of the rise in female incarceration over the past three  decades. a discussion of the traumatic implications of maternal  incarceration on children will further explain the saliency of this  trend. additionally, changes in child welfare legislation will be  reviewed and a case example of an alternative to incarceration  program will be presented.      a brief history of mass incarceration        the number of incarcerated women in the u.s. more than  doubled during the 1990s, and the number of incarcerated women  with children increased by 87% during that time (chesney­lind,  2002; travis & waul, 2003). this major increase occurred along­ side new york’s rockefeller drug laws, which were the bedrock  that established the criminalization of drug addiction. the rocke­ feller drug laws were enacted in 1973, initiating mandatory sen­ tences for the possession and/or sales of illicit drugs. under the  rockefeller laws, a person convicted of the possession of 4 ounc­ es or the sale of 2 ounces of narcotics receives a mandatory sen­ tence of 15 years­to­life in prison (gray, 2009; schlosser, 1998).  despite the repeal of the rockefeller drug laws’ mandatory sen­ tences in april 2009, these laws still serve as the catalyst for mass  incarceration by criminalizing addiction rather than treating it as a  public health concern (chesney­lind, 2002; schlosser, 1998).    black and hispanic communities are disproportionately  affected by mass incarceration; staggeringly, 36 out of 1,000  black women and 15 out of 1,000 hispanic women will be incar­ cerated at some point in their lifetime, whereas only 5 out of  1,000 white women ever serve time in a correctional facility  dual punishment  35        columbia social work review, volume iii  (richie, 2002). this puts black and hispanic children at a height­ ened risk for extended separation from their mothers (richie,  2002).  incarcerating women by the masses        shortly before the turn of the 21st century, the number of  incarcerated women in!the u.s. soared from 12,000 to over  90,000 in less than 20 years (chesney­lind, 2002). in response to  the rapid increase of women sentenced for criminal charges, the  number of female­only correctional facilities in the u.s. grew  from!34 before 1980, to over 104 facilities by the mid­1990s  (chesney­lind, 2002). rising rates of incarceration appear to im­ ply that women are committing significantly more crimes today  than they were 30 years ago. however, between 1990 and 1999,  the total number of arrests of adult women, which could be inter­ preted as a measure of women’s criminal activity, increased by  only 14.5%, while the number of women in prison increased by  105.8%. (chesney­lind, 2002). less than half of all incarcerated  women have been convicted of a violent offense, indicating that  many of these incarcerated women were serving time under man­ datory sentences for drug­related crimes (chesney­lind, 2002).  the recent rise in the incarceration of women creates unprece­ dented instability within families and communities by inflicting  punishment rather than promoting justice (chesney­lind, 2002;  richie, 2002).     traumatic impact on children of incarcerated mothers      the escalation in maternal incarceration over the past  three decades poses significant risk for incarcerated women’s  children, who arguably suffer more long­term effects of the incar­ ceration than their mothers do (myrna, 2006). as previously not­ ed, 75% of women were the primary caregiver of at least one  child before their incarceration (margolies & kraft­stolar, 2006).  there are numerous mitigating and facilitating factors that influ­ ence the degree of the traumatic effect on children, such as a  child’s age at the time of maternal incarceration. however, it is  clear that mass incarceration places the children of incarcerated  smyth  columbia social work review, volume iii        36  parents, especially children with incarcerated mothers, as one of  the largest at­risk populations in the u.s. (mumola, 2000).     attachment theory provides a deeper understanding of the  profound impact that caregiver separation has on both the imme­ diate and lifetime behavior of infants and young children, includ­ ing children’s ability to develop future healthy relationships  (bowlby, 1980; bowlby et al., 1956; shlafer & poehlmann,  2010). bowlby et al. (1956) explain that young children who are  deprived of maternal care and affection not only experience tem­ porary trauma, but also may suffer long­term effects. externalized  negative behavior, which results from insecure caregiver attach­ ment, can negatively affect peer relationships, lower self­esteem,  and even hinder children’s ability to exhibit empathy toward oth­ ers (bretherton & munholland, 2008; shlafer & poehlmann,  2010).   there are many organizations that support children with  incarcerated parents. in discussing the impact of incarcerated  mothers on their children,!tanya krupat, the program director of  the new york initiative for children of incarcerated parents at  the osborne association, posits that the prevailing societal as­ sumption that incarcerated mothers are a negative influence on  their children is inconsistent with, and unreflective of, an incar­ cerated woman’s actual role in the lives of her children, which  may have been very positive. as such, most criminal charges and  sentences do not accurately account for a woman’s role as a  mother, and are not indicative of how well a mother parents  (personal communication, november 29, 2011; hairston, 2003).   !krupat acknowledges that the traumatic loss experienced  by children separated from a parent due to incarceration is  marked with feelings of social stigma and shame that surround  the parent’s incarceration, distinguishing it from other forms of  parental loss (personal communication, november 29, 2011). the  internalization of this stigma and shame heightens children’s risk  of insecure attachment, which increases the possibility of long­ term negative outcomes (shlafer & poehlmann, 2010). the social  stigma and shame associated with parental incarceration can have  a profound impact on a child’s sense of self and can ultimately  cause lasting emotional hardship (shlafer & poehlmann, 2010),  dual punishment  37        columbia social work review, volume iii  such as “elevated levels of anxiety, fear, loneliness, anger, and  depression” (margolies & kraft­stolar, 2006, p. 9).     children whose primary caregiver becomes incarcerated  are also at an increased risk of antisocial and delinquent behavior  as a result of the sudden change in caregiver and overall home  environment (graham, harris, & carpenter, 2010). kampfner  (1995) conducted an assessment of children with incarcerated  parents to examine the impact of the separation on a child’s acute  stress reactions. approximately 75% of the children with an in­ carcerated parent were identified to have trauma­related stress  (kampfner, 1995; miller, 2006). similarly, krupat observed that  the removal of, or change in, the primary caregiver makes chil­ dren—particularly infants and young children—vulnerable to in­ secure attachment and ultimately the inability to attach if no sta­ ble caretaker steps into the role of consistent and responsive pri­ mary caregiver (personal communication, november 29, 2011).    foster care: a safe haven?  ! ! foster care is not inevitable for children with incarcerated  mothers, but it is often the only viable option. approximately  68% of incarcerated mothers in state prison have children who are  cared for by grandparents or other relatives (glaze & maruschak,  2010). some of these children have plans to return to their moth­ er’s care after her release (miller, 2006). this can be the most  reasonable and least disruptive option for children.!kinship foster  care is an arrangement in which a child’s relative assumes the role  as caregiver as a foster parent when a child is placed in custody of  the state. kinship foster care can be a positive alternative to living  with one’s mother, but not every child has a family member will­ ing or able to take on this responsibility. a relative with a crimi­ nal history or past involvement with the child welfare system is  likely to not be approved as a kinship foster caregiver. if a kinship  foster care placement is not secured, then a child must be placed  in a nonfamilial foster care arrangement. eleven percent of incar­ cerated mothers in state prison have children in a foster care home  or agency, compared to only 2.9% of incarcerated men who re­ port a their child’s caretaker as a foster care home or agency  smyth  columbia social work review, volume iii        38  (glaze & maruschak, 2010). incarcerated mothers with children  in the foster care system face numerous barriers to exercising  their parental rights from the correctional facility and often strug­ gle to maintain strong ties with their children (bedell & boudin,  1993).    subjection to numerous foster care placements is common  yet problematic for children with an incarcerated parent, placing  children at greater risk for the aforementioned externalized nega­ tive behaviors (shlafer & poehlmann, 2010). attachment theory  research demonstrates the detrimental psychological outcomes of  movement from one caregiver to another within the foster care  system, which is the unfortunate reality for many children whose  primary caregiver becomes incarcerated (shlafer & poehlmann,  2010).    problems & progress: child welfare legislation  ! ! while child welfare laws may be well­intentioned, many  are not framed in a way that protects children with incarcerated  mothers (christian, 2009). unfortunately, and ironically, while  these laws aim to protect children, there are often unintended neg­ ative consequences. the adoption and safe families act of 1997  (asfa) is an example of one such law. asfa is one of the most  problematic pieces of federal legislation facing families with an  incarcerated parent. in an effort to secure a permanent residence  for children to prevent multiple foster care placements, asfa  allows for parental rights to be terminated if a child resides in fos­ ter care for 15 of the most recent 22 months (christian, 2009;  margolies & kraft­stolar, 2006; miller, 2006). asfa proves to  be problematic for incarcerated parents because a typical sentence  for an incarcerated parent is between 80 and 100 months, mean­ ing that asfa could lawfully terminate parental rights during a  parent’s incarceration even if the parent is completely capable of  caring for her/ his child after release (christian, 2009). margolies  and kraft­stolar (2006) provide a striking example of asfa’s  impact on families: “it is entirely plausible that a mother sen­ tenced to three years as a first time felony drug offender for sell­ ing $10 worth of drugs will face the real and disturbing prospect  dual punishment  39        columbia social work review, volume iii  of permanently losing all rights to her children” (p.17). children  have been deeply affected by the unforgiving combination of  strict sentencing and asfa regulations on the termination of pa­ rental rights.    through committed efforts by service providers and child  advocates, several states have passed amendments to asfa in  order to protect the parental rights of incarcerated parents. in june  2010, new york state passed an amendment to asfa providing  foster care agencies discretion to delay parental rights termination  on a case­by­case basis if a child’s primary caregiver is incarcer­ ated (the correctional association of new york, 2010). under  this amendment, foster care caseworkers are not mandated to file  a termination of parental rights petition in the family court if  they can demonstrate that the continuation of the parent­child re­ lationship is in the best interest of the child (christian, 2009).     colorado and california have passed asfa amendments  similar to new york’s, and a handful of other states have drafted  their own caveats in order to protect children of incarcerated par­ ents. however, some states, such as north carolina and pennsyl­ vania, have not passed any legislation regarding the rights of in­ carcerated parents, leaving many children still vulnerable to their  mother legally losing custody during her incarceration on the  grounds of “permanent neglect” (christian, 2009, p.10). amend­ ing asfa at the federal level would alleviate the need for state­ by­state amendments; either way, amending asfa is a necessary  step toward maintaining family ties during maternal incarceration.  however, more alternatives are needed to keep children out of the  foster care system altogether, as demonstrated by their heightened  risk of delinquent behavior, insecure attachment, anti­social be­ haviors, anxiety, depression, and other trauma­related stress re­ sulting from caregiver separation and, specifically, foster care  placement (bedell & boudin, 1993; graham et al., 2010;  kampfer, 1995; margolies & kraft­stolar, 2006; miller, 2006;  shlafer & poehlmann, 2010).      keeping families together: exploring alternatives to   incarceration  smyth  columbia social work review, volume iii        40  !  a basic understanding of the risk factors associated with  maternal incarceration demands the development and implemen­ tation of more alternatives to incarceration (atis). the need for  atis still far exceeds the options currently available. atis create  an effective way to combat the detrimental impact of maternal  incarceration on children, while remaining accountable to the  court system, and treating the root causes of criminal activity,  such as drug addiction (chesney­lind, 2002).     ati case study: drew house    a small pilot project of the office of the brooklyn district  attorney was designed for the specific purpose of not sending  mothers to jail or prison so that they can stay with their children.  the women and their children who participate in this project live  in their own apartment at drew house in brownsville, new york.  women in the program fulfill their court mandates, are supervised  by treatment alternatives for safe communities, and live in a  private apartment with their children. without this program, their  children would have been placed in foster care upon their moth­ er’s incarceration. women qualify for the program at drew house  if they are homeless, have custody of dependent children, suffer  from mental illness or substance abuse, are not currently taking  illicit drugs, and have been charged with a felony. the program  supplies a safe and therapeutic environment for women and their  children, while providing financial security, housing stability and  most importantly, avoiding the traumatic impact of maternal sepa­ ration on children.     a house manager lives on site to oversee the program,  while family therapists and employment specialists regularly  work with participating families. this program is a more inten­ sive treatment model, however it is cost­effective; to house a  mother and two children for a year, it costs $34,000, compared  with $129,000 for both incarceration and foster care. (robbins,  2011). successful completion of this ati program takes approxi­ mately 18 months and subsequently dismisses the felony offense,  keeps the family together, and avoids the damaging and irreversi­ dual punishment  41        columbia social work review, volume iii  ble affects of removing mothers from their children (drew house,  n.d.).     conclusion      !as demonstrated in this analysis, a severely detrimental  consequence of female incarceration is the removal of mothers  from their children. mandated sentencing for drug­related crimes  over the past 30 years, in conjunction with problematic child wel­ fare legislation, creates a two­fold dilemma for women. they are  not only incarcerated, but potentially face termination of their pa­ rental rights. the current functioning of the child welfare and  criminal justice systems places children at risk of severed rela­ tionships and considerable negative outcomes. research demon­ strates that caretaker instability increases children’s risk of expe­ riencing the traumatic effects of insecure attachment, such as de­ pression, anxiety, suicidal ideation, other trauma­related stress,  and the externalization of negative behaviors.     ati programs that keep families together, such as drew  house, treat the complex issues of mental illness and substance  abuse, while also protecting children from the traumatic impact of  maternal separation. if the u.s. reduces its reliance on prisons and  begins offering more community­based programs, both women  and their children will have greater protection from the damaging  impact of incarceration. a movement toward more ati program­ ming has begun, but it is still far from resolving the widespread  problem of maternal incarceration. children do not deserve to  suffer for a crime they did not commit, and by keeping families  together, children will be protected from the lasting detrimental  impact of separation from their mothers through incarceration.    author’s note      i wrote this paper in response to my experiences working  with incarcerated mothers with the osborne association on  rikers island. “the osborne association offers opportunities for  individuals who have been in conflict with the law to transform  their lives through innovative, effective, and replicable programs  smyth  columbia social work review, volume iii        42  that serve the community by reducing crime and its human and  economic costs... [offering] opportunities for reform and rehabili­ tation through public education, advocacy, and alternatives to in­ carceration that respect the dignity of people and honor their ca­ pacity to change” (the osborne association, 2010). prior to be­ ginning the field placement, i was naive to the pervasive issues  facing women in the criminal justice system. throughout the fall  of 2011, i co­facilitated a parenting class for incarcerated mothers  with the osborne association and coordinated a visiting day for  the women’s children and families. these experiences broadened  my understanding about the hardships of parental incarceration  and ultimately increased my desire to advocate for!women and  families adversely affected by the criminal justice system.     references  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resist, regulate, reimagine, and reinforce: how social workers can advocate for digital inclusion sarah e. dillard 66 | columbia social work review, vol. xix resist, regulate, reimagine, and reinforce abstract (snvyp[otz�oh]l�iljvtl�tvyl�jvtwsl_��jylh[pun�hy[päjphs�pu[lsspnlujl� (ai) with the hope it will match human decision making. they are now being used behind-the-scenes in areas such as healthcare, housing and employment, and criminal justice. these computer formulas were jylh[lk�i`�h�wyp]pslnlk�zl[�vm�pukp]pk\hsz�^ov�vm[lu�wypvyp[palk�wyvä[� and growth over privacy and protection. this has led to gross injustices [oh[�oh]l�wyl]lu[lk�thynpuhspalk�jvtt\up[plz�myvt�yljlp]pun�jhyl�� äukpun�qviz��vy�nhpupun�myllkvt��:vjphs�^vyrlyz�t\z[�il�hisl�[v�kpnp[hss`� advocate for their clients. resisting these technologies, regulating them through legislation, reimagining the role one can play, and reinforcing what is already experienced in day-to-day interactions with ai are all ways social workers can be involved in creating a world that is digitally inclusive. columbia social work review, vol. xix | 67 sarah e. dillard s vjphs�^vyrlyz�hyl�hk]vjh[lz�mvy�thynpuhspalk�wlvwsl�� clinicians, case workers, policy makers, and others all interact with populations that are considered “protected” vy�¸zluzp[p]l¹�pu�[ol�älsk�vm�hy[päjphs�pu[lsspnlujl��(0���;olzl� groups include, but are not limited to, women, immigrants, people of jvsvy��76*���3.);80��wlvwsl��[ovzl�^p[o�kpzhipsp[plz��huk�[ovzl�myvt� low socioeconomic status (ses). as ai becomes more integrated into our everyday lives, algorithms are puå\lujpun�h�]hypl[`�vm�kljpzpvuz�wyl]pv\zs`�ohukslk�i`�sp]l�o\thuz!� criminal risk assessment, health insurance costs, home loan eligibility, and employee resume review are just a few examples. what can a social worker do when their client has been labeled highypzr�mvy�yl�vɉluzl�klzwp[l�uv[�oh]pun�h�opz[vy`�vm�]pvslujl&�>oh[�jhu�h� zvjphs�^vyrly�kv�^olu�[olpy�jsplu[»z�ovtl�jhyl�ilulä[z�oh]l�illu�j\[� pu�ohsm&�>oh[�jhu�h�zvjphs�^vyrly�kv�pm�[olpy�jsplu[�ohz�opno�\[psp[`�yh[lz� iljh\zl�[olpy�jylkp[�zjvyl�mhj[vylk�pu�[olpy�zvjphs�tlkph�hj[p]p[`& ;opz�whwly�^pss�jv]ly�[ol�opz[vy`�vm�hy[päjphs�pu[lsspnlujl��h�why[phs� overview of its current implementation and sources of bias, and four ways social workers can advocate for digital inclusion: through resistance, regulation, reimagination, and reinforcement. as technology is changing rapidly, the examples that follow may already have changed in the time that has passed between the writing of this hy[pjsl�huk�p[z�w\ispjh[pvu��;ol�jvtt\up[`�vynhupah[pvuz�huk�tv]ltlu[z� highlighted can therefore be explored for the most recent updates. history of artificial intelligence an algorithm is a set of rules or calculations—like a recipe— [oh[�t\z[�il�mvssv^lk�pu�vykly�[v�zvs]l�h�wyvislt��6_mvyk�(k]hujlk� learner’s dictionary, n.d.). in use for centuries, they were originally developed to aid in the construction of buildings, agriculture, and commerce in order to to streamline processes and create a uniform 68 | columbia social work review, vol. xix method for getting results (ausiello, 2013). it was not until the mid-1950s [oh[�hy[päjphs�pu[lsspnlujl�iljhtl�wvzzpisl��h�[ljouvsvn`�klzpnulk�[v� ylålj[�[ol�wyvislt�zvs]pun�jhwhipsp[plz�vm�o\thuz��(u`voh���������<zpun� algorithms as the structure and data as the substance, technologists started to use ai as a substitute for human analysis and interpretation. 6ujl�jvtw\[lyz�pujylhzlk�pu�z[vyhnl�huk�wyvjlzzpun�wv^ly��(0�^hz� hisl�[v�åv\ypzo��4vyl�kh[h�jv\sk�il�z[vylk�vu�jvtw\[lyz�huk�pu� turn used to train machine learning (ml) algorithms (anyoha, 2017). computers became more adept at problem solving and interpreting language. as they became cheaper, more institutions became involved in research and development. today, we are seeing ai and big data—a term used to describe the vast amount of online information that companies are able to garner on an individual—come together (bean, 2017). digital footprints consisting of all the data a person has following them online are thus being used for (0�thjopul�slhyupun�pu�[ol�älskz�vm�ihurpun��olhs[ojhyl��jyptpuhs�q\z[pjl�� employment, and national security (anyoha, 2017; benjamin, 2019). areas of impact technologists wrongfully assumed that a computer would eliminate bias by being based in formulas and mathematical calculations. ;olzl�jhsj\sh[pvuz�^lyl�ptwsltlu[lk�[v�ptwyv]l�huk�vw[ptpal�o\thu� decision-making, especially in areas such as criminal justice, in which judges were making subjective decisions (eckhouse et al., 2019). /v^l]ly��[ol�opz[vypj�kpzjyptpuh[pvu�vm�thynpuhspalk�nyv\wz�pz�vus`� reproduced and reinforced by these systems in what experts are calling “the new jim code” or “coded bias” (benjamin, 2019; buolamwini l[�hs����������6ul�rl`�l_htwsl�vm�[opz�pz�hu�hsnvyp[ot�ilpun�\zlk�[v� kl[lytpul�h�wlyzvu»z�ypzr�vm�ylvɉlukpun�hm[ly�hyylz[��+l]lsvwlyz�ilspl]lk� that by not including race as a data point, the machine would not wyvk\jl�yhjphss`�iphzlk�ylz\s[z��;ol`�kpk��ov^l]ly��pujs\kl�wlvwsl»z�apw� codes. geographic data—such as the area someone lives in—is often a proxy for race due to residential segregation and redlining (eckhouse et al., 2019). by not being familiar with this history, technologists created a resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 69 system that reinforced existing biases. accountability must be taken by companies instead of operating under the guise of expertise. the following sections outline three areas where algorithms have nylh[s`�ohytlk�thynpuhspalk�jvtt\up[plz�huk�wlywl[\h[lk�z`z[ltpj� oppression. housing and employment credit score and homeownership algorithms have been used to determine credit score since the 1980s (trainor, 2015). before that, lenders would keep their own records of who they believed was “trustworthy” enough to receive a loan, often barring thynpuhspalk�jvtt\up[plz�z\jo�hz�)shjr��3h[pu_��huk�1l^pzo�pklu[pm`pun� wlvwsl�myvt�why[pjpwh[pun��;vkh �̀�jylkp[�zjvylz�hɉlj[�thu`�mhjl[z�vm� everyday life, including loan eligibility, home ownership, utility rates, and social standing. ;ol�shynlz[�jylkp[�zjvyl�jvtwhuplz·,_wlyphu��,x\pmh_��huk� transunion—use data such as bill payment history, employment information, and current debt to determine one’s score. they also factor in child support payment history, arrest and incarceration history record, and app usage. the companies have not released information on what metrics are used to determine the weight of each category (hao, 2020). with the rise of big data, smaller credit score companies are beginning to use data outside the typical sources used by larger companies. this includes social media information (likes, friends, locations, and posts), the amount of time you spend on their website, and what percent of income is spent on rent given geographic location (hurley et al., �������(u`�jylkp[�ylwvy[pun�hnluj`��*9(��jhu�ylx\lz[�kh[h�myvt�zvjphs� media or data scraping companies (entities one can hire/pay to collect vast amounts of information from people online) in order to build their reports. despite the fair credit reporting act of 1970 outlining what kh[h�jhu�il�\zlk��mlklyhs�slnpzsh[pvu�ohz�uv[�jh\no[�\w�^p[o�ov^�x\pjrs`� technology is changing and becoming more integrated in our everyday lives. social media likes, for example, are not mentioned as an accepted or prohibited datum anywhere in the bill. sarah e. dillard 70 | columbia social work review, vol. xix there is a large racial discrepancy between those with good vs. bad credit (singletary, 2020). this directly correlates with the biased history of credit scoring and systemic oppression that is inherent in the rating. if uv�vul�pz�^psspun�[v�wyv]pkl�h�svhu��i\pskpun�jylkp[�iljvtlz�zpnupäjhu[s`� tvyl�kpɉj\s[��9lkspupun�vm�)shjr�huk�3h[pu_�ulpnoivyovvkz�thkl�p[� ptwvzzpisl�mvy�mhtpsplz�[v�x\hspm`�mvy�tvy[nhnlz�i`�zhuj[pvupun�[olzl� areas as “risky” for lending (lerner, 2020). at the same time, these mhtpsplz�wh`�hu�h]lyhnl�vm�����tvyl�pu�[h_lz�jvtwhylk�[v�^op[l� mhtpsplz�sp]pun�pu�ovtlz�vm�lx\p]hslu[�]hs\l�� 0u�[ol�<:��vus`�������vm�)shjr�ov\zlovskz�v^u�[olpy�ovtl�jvtwhylk� [v�������vm�^op[l�ov\zlovskz��pu�why[�k\l�[v�yhjpz[�ylkspupun��*htwpzp�� 2021). since credit score focuses on ownership through mortgages, the majority of black americans do not have this assurance to add into the algorithm. if rental payments, however, were taken into consideration, a nylh[ly�z^h[o�vm�thynpuhspalk�pukp]pk\hsz�^v\sk�il�hisl�[v�i\psk�il[[ly� credit. ;ol�shjr�vm�ovtlv^ulyzopw�pu�thynpuhspalk�jvtt\up[plz�pz�wlywl[\h[lk� by ai in other ways. without any privacy regulations or civil rights laws pu�wshjl�[v�yln\sh[l�[ol�\zl�vm�lslj[yvupj�kh[h��sluklyz�hyl�hisl�[v�äs[ly� candidates using racial proxy data, resulting in digital discrimination and continued historic exclusion. for example, black and latinx individuals are charged more for home loans, amounting to an 11 to ����hkkp[pvuhs�wyvä[�mvy�sluklyz��*v\u[z���������;opz�hkkz�\w�[v������ $500 million annually from black and latinx individuals. despite foggo et al. reporting that lending discrimination being on a “steady decline,” the authors did not indicate how that was measured (2020). most importantly, any lending discrimination directly impacts the potential to buy a home, one of the main ways a family can build generational wealth �+l4h[[lv���������6^upun�h�ovtl�tlhuz�vul�jhu�yläuhujl�vy�zlss�h[�h� opnoly�wypjl�[ohu�[ol�ovtl�^hz�w\yjohzlk�mvy��ylz\s[pun�pu�h�wyvä[�[oh[� can be passed down to children or other dependents. achievements such as the fair housing act of 1968—which disallowed kpzjyptpuh[pvu�pu�[ol�i\`pun��ylu[pun��vy�äuhujpun�vm�h�ovtl·hyl�\uhisl� to protect those they were meant to. algorithms are often protected hz�[yhkl�zljyl[z�i`�[ljouvsvn`�jvtwhuplz��>p[o�uv�^h`�[v�huhs`al� resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 71 vy�ylzlhyjo�[ol�mvyt\shz�ilpun�\zlk��p[�pz�kpɉj\s[�[v�i\psk�h�jhzl�[oh[� proves someone’s civil rights were violated. hiring ai is also being used by companies to accelerate the hiring process. (snvyp[otz�jhu�nv�[oyv\no�[ov\zhukz�vm�hwwspjh[pvuz�x\pjrs`·jovvzpun� [ol�jhukpkh[lz�^ov�ilz[�ä[�^oh[�pz�jvklk�pu[v�[ol�z`z[lt�hz�pklhs� �/lps^lps����� ���6ul�vm�[ol�thpu�ilulä[z�pz�[oh[�tvyl�wlvwsl�jhu�il� considered for a position than, for example, when an individual in the hr department had to manually review resumes. however, ai is also being used for facial recognition to deduce applicants’ personalities based on their expressions and appearance (castelvecchi, 2020). 6m[lu[ptlz��[olzl�wov[vz�hyl�vi[hpulk�[oyv\no�x\pjr�vuspul�zlhyjolz� of a candidate’s social media platforms, such as linkedin or facebook. the practice of discerning personality traits from face recognition algorithms has been proven generally inaccurate but some companies are still deploying this technology (wells, 2020). in addition, facial recognition technology is shown to be less accurate on dark skinned faces and women/femmes’ faces (buolamwini et al., �������;opz�ylz\s[z�pu�pukp]pk\hsz�myvt�[olzl�opz[vypjhss`�thynpuhspalk�� intersecting communities often registering as “non-human” to these computer systems. this will be discussed more in a later section. gender bias in hiring algorithms was most notably reported in 2018 ^olu�(thavu�ohk�[v�nl[�ypk�vm�[olpy�z`z[lt�^opjo�wluhspalk�jhukpkh[lz� who had “women’s” in their application—that is, attended a women’s college or were in a women’s group (vincent, 2018). according to sources at the company, this was because the algorithm was trained on l_pz[pun�ltwsv`tlu[�pumvyth[pvu��<zpun�[ol�kh[h�[oh[�tvz[�vm�(thavu»z� employees are men, the algorithm decided that applications with the word “woman” or “women” should be rejected, reinforcing the preexisting gender bias at the company. by learning from data based on l_pz[pun�pulx\p[plz��[ol�thjopul�puolyp[lk�h�iphz�huk�[o\z�wlywl[\h[lk� this unconscious preference in silicon valley. sarah e. dillard 72 | columbia social work review, vol. xix healthcare insurance costs lifestyle data—the food you eat or how much you watch tv—is now readily available as industries collect information they hope to use to keep you as a customer. in addition, many insurance companies are also using this data to determine a patient’s risk of incurring high medical costs (allen, 2019). concerns are mounting over whether or uv[�[opz�kh[h�pz�ptwhj[pun�[ol�jvz[�h�wlyzvu�pz�x\v[lk�mvy�[olpy�tvu[os`� health insurance rate. in addition, the accuracy of the predictions is pu�x\lz[pvu��hz�[ol`�ylålj[�kpzjyptpuh[vy`�hzz\tw[pvuz�hiv\[�jly[hpu� groups of people. the health insurance portability and accountability act (hipaa) only covers medical information that was collected through a “covered entity,” which limits the bill's protective capabilities for health and mental health facilities. in recent years, health insurance companies such as aetna and unitedhealth have been collecting (either independently or through contracts) personal or lifestyle data such as social media activity, hours spent watching tv, education status, place of residence, and net worth (allen, 2019). by raising health insurance costs based on certain social demographics, lzwljphss`�z[h[pj�mhj[vyz�z\jo�hz�whylu[z»�lk\jh[pvu�sl]ls��thynpuhspalk� communities become stuck in a cycle of poor health and poverty as the assessment is based on metrics they cannot change. in addition, by \zpun�kh[h�wvpu[z�[oh[�kpzwyvwvy[pvuh[ls`�ptwhj[�76*��z\jo�hz�hyylz[� records, health insurance companies perpetuate racist oppression. thus, the algorithmic results are inherently biased. at-home care hours the use of algorithms to make healthcare decisions is becoming more widespread as industries try to streamline processes in order to cut time and cost while also eliminating human bias. in arkansas, a software was implemented to determine how many hours of at-home-care medicaid wh[plu[z�ullklk��3ljoly���������6ɉjphsz�zh`�[oh[�ilmvyl�[opz�z`z[lt�� their assessments were done by individuals who would make decisions that favored some and were arbitrary with others. resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 73 after the algorithm, which was developed by a group of health researchers at interai, was implemented, many people had their hours j\[·iv[o�wh[plu[z�yljlp]pun�zly]pjlz�huk�z[hɉ�wyv]pkpun�h[�ovtl� assistance (lecher, 2018). legal aid of arkansas started receiving calls myvt�pukp]pk\hsz�^p[o�jvtwshpu[z��zvtl�vm�^ovt�^lyl�ovzwp[hspalk�k\l� to lack of care. when the president of interai was interviewed about transparency in the algorithm’s metrics, he argued that one should trust that “a bunch of smart people determined this is the smart way to do it” (lecher, 2018). however, during court proceedings it was revealed that the wrong calculation was being used for at least one case. this kind of error could have been caught if someone had overseen the deployment and checked all results. potential illnesses a risk-assessment tool used by large health systems in the united states was shown to give sick black patients the same score it was np]pun�[v�olhs[oply�^op[l�wlvwsl��6ilytl`ly�l[�hs������ ���9lzlhyjo� zov^lk�[oh[�ä_pun�[opz�kpzwhyp[`�^v\sk�oh]l�jh\zlk�hu�pujylhzl�pu� )shjr�wh[plu[z�^ov�ylx\pylk�l_[yh�jhyl�myvt�������[v��������;opz� algorithm did not use race as one of its data points; it did, however, use insurance claims data over a certain year (information such as age and sex, insurance type, diagnosis, medications, and detailed costs). in the end, it predicted accurately what people would spend on healthcare the following year; it did not predict who was more in need of improved care due to adverse health conditions. proxies for race are often unknowingly used in developing algorithms, which then produce biased results. ruha benjamin refers to this as ¸jvklk�pulx\hsp[`¹�huk�[ol�lu[pyl�z`z[lt�hz�¸;ol�5l^�1pt�*vkl¹� (benjamin, 2019). without proper knowledge of systemic racism, the individuals working for companies such as interai continue to wlywl[\h[l�[ol�vwwylzzpvu�vm�thynpuhspalk�nyv\wz�^opsl�np]pun�tvyl� power to the privileged. the notion that healthcare should be provided to an individual based on the amount of money they are able to spend m\y[olyz�j\yylu[�yhjphs�kpzwhyp[plz�pu�spml�l_wlj[huj`�huk�ilulä[z�[ovzl� with greater capital. sarah e. dillard 74 | columbia social work review, vol. xix criminal justice risk assessment in the 1980s, lawmakers across the united states passed legislation for harsh, mandatory minimum sentencing in order to eliminate human bias in decision making (forman, 2017). this meant an individual had to spend a certain amount of time in prison based on the crime they committed. with the crack-cocaine epidemic ravaging black jvtt\up[plz��z\iz[hujl�\zl�^hz�m\y[oly�jyptpuhspalk��;vkh �̀�[ol�wypzvu� industrial complex (pic) in the u.s. has in part expanded because of this legislation as the number of people incarcerated rose from hundreds of thousands to millions over the following decades (the sentencing project, 2021). the need for improved criminal risk assessment therefore became present and private companies started creating algorithms in order to more accurately predict the probability of a defendant ylvɉlukpun�� 6ul�vm�[olzl�[vvsz��[ol�*vyylj[pvuhs�6ɉlukly�4huhnltlu[�7yväspun�mvy� (s[lyuh[p]l�:vs\[pvuz��*647(:���wyvk\jlz�[oyll�jh[lnvyplz�vm�ypzr·sv �̂� medium, or high—and has been shown to reproduce racial disparities in its results (angwin, 2016). black people are twice as likely as white wlvwsl�[v�il�shilslk�h�opnoly�ypzr�i\[�uv[�ylvɉluk��6]lyhss��[ol�zvm[^hyl� ^hz�zov^u�[v�il�hjj\yh[l�����vm�[ol�[ptl� the biased results are not the only problem. the labels produced by [ol�*647(:�hsnvyp[ot�kv�uv[�jvyylsh[l�^p[o�h�z[h[pz[pjhs�johujl�vm� ylvɉlukpun"�[ol`�hyl�nlulyhspah[pvuz�vy�lzzlu[phss`�yhukvts`�hzzpnulk� u\tilyz��(u`vul�jhu�pu[lywyl[�[ol�yh[pun�kpɉlylu[s`"�h�opno�zjvyl�vy� opno�johujl�vm�ylvɉlukpun�kvlz�uv[�jvyylsh[l�[v�h�u\tily�vm�kh`z�� months, etc. in addition, these results are shown to judges without any explanation of the data that went into them or the formula used. in 2016, one defendant challenged a wisconsin court’s ruling and the label produced by the risk-assessment. the judge decided that because the algorithm was not deterministic in the ruling, there was no ^h`�[v�wyv]l�p[�ohk�z\jo�h�nyh]l�puå\lujl�vu�[ol�kljpzpvu��,jrov\zl� l[�hs������ ���/v^l]ly��[ol�jv\y[�mhpslk�[v�yljvnupal�[oh[�[opz�kljpzpvu� goes against the purpose of using an algorithm—eliminating human resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 75 bias—by adding the judge’s input on top of the low, medium, or high result, and by not using the algorithm in a deterministic way, its objectivity (assuming they were objective, which they are not) is not being employed. at the end of the day, a judge—a human with bias— pz�thrpun�[ol�kljpzpvu�huk�[oh[�kljpzpvu�pz�uv^�ilpun�puå\lujlk�i`� inaccurate algorithms. in the wisconsin case, the judge declared that since the defendant was able to see the results of the algorithm, there was nothing else that needed to be revealed (eckhouse et al., 2019). however, the data, metrics, and formulation all impact the algorithm’s output and can all be sources of bias (miron, 2020). as stated previously, using static pumvyth[pvu��apw�jvkl�h[�ipy[o��shz[�uhtl��whz[�jyptpuhs�opz[vy`��ohz�illu� shown to correlate with the social factors of sensitive groups more so than dynamic information (current substance use, peer rejection, hostile behavior). facial recognition )pvtl[ypj�pklu[päjh[pvuz��äunlywypu[z��]vpjl��huk�pypz�zjhuz��oh]l� been used by the criminal justice system for decades (najibi, 2020). in addition, tsa’s advanced imaging technology present at airport joljrwvpu[z�ylx\pylz�hnlu[z�[v�zlslj[�vul�vm�[^v�i\[[vuz�^olu�wlvwsl� enter the machine: man or woman. this means anyone who does not ä[�^p[opu�[opz�vwwylzzp]l�nlukly�ipuhy`�nl[z�w\sslk�hzpkl�huk�zlhyjolk� �*vz[huah�*ovjr���������� 6\[�vm�hss�[ol�hiv]l�ipvtl[ypj�l_htwslz��mhjphs�yljvnup[pvu�[ljouvsvn`� is being deployed across the widest variety of industries, including law enforcement, employers, manufacturers, and government housing authorities (klosowski, 2020). in 2018, the gender shades study found [oh[�[oyll�kpɉlylu[�jvttlyjphs�hsnvyp[otz�^lyl�nyh]ls`�puhjj\yh[l�h[� pklu[pm`pun�khyrly�zrpuulk�^vtlu��^p[o�lyyvy�yh[lz�hz�opno�hz������� �)\vsht^pup�l[�hs����������*vtwhylk�[v�h������lyyvy�yh[l�mvy�spno[ly� skinned males, the disparity is astonishing. however, the impact of this bias is more frightening. in a test conducted i`�[ol�(*3<�vm�(thavu»z�mhjphs�yljvnup[pvu�[vvs��^opjo�^hz�h]hpshisl�mvy� hu`vul�[v�\zl��[ol�[vvs�pujvyylj[s`�pklu[pälk����tltilyz�vm�*vunylzz� sarah e. dillard 76 | columbia social work review, vol. xix hz�jyptpuhsz��:uv �̂��������)shjr�*vunylzz�tltilyz�thkl�\w����� vm�[ovzl�th[jolz�klzwp[l�vus`�thrpun�\w�����vm�[ol�/v\zl��;olzl� results reinforce the historic over-policing of the black community and jyptpuhspah[pvu�vm�pukp]pk\hsz�ihzlk�vu�[olpy�zrpu�[vul� /h]pun�tvyl�hjj\yh[l�mhjphs�yljvnup[pvu�[ljouvsvn`�^v\sk�uv[�ä_� the problem of over-policing; in fact, it might exacerbate it. during zsh]ly`�pu�[ol�<:��¸shu[lyu�sh^z¹�^lyl�luhj[lk�pu�5l^�@vyr�ylx\pypun� enslaved people to carry a light by their faces in order to remain visible (najibi, 2020). this same tracking of black individuals could thus be done by high resolution cameras disproportionately located in certain neighborhoods which capture images and use them for databases. digital inclusion: what can social workers do? even as technology expands and overtakes many human jobs, social workers are here to stay. according to a 2015 study done by npr, mental health workers are the least likely profession to be automated by h�thjopul��)\p���������;opz�tlhuz�[oh[�mvy�hz�svun�hz�(0�hɉlj[z�v\y�sp]lz�� there will be social workers ready and able to advocate. according to the nasw code of ethics, social workers must challenge social injustice and address social problems (nasw, 2021). with technology companies often unknowingly perpetuating systemic vwwylzzpvu�vm�thynpuhspalk�nyv\wz�[oyv\no�v]ly�wvspjpun��puhklx\h[l� healthcare, or discrimination, social workers have the responsibility to advocate for those targeted by these practices. the following outlines current models addressing algorithmic harm and ways social workers can be involved in mitigating the gap of algorithmic knowledge, digital pulx\hsp[ �̀�huk�jvklk�iphz� resist ;olyl�hyl�thu`�vynhupah[pvuz�^vyrpun�[v�ihu�[ol�\zl�vm�mhjphs� yljvnup[pvu�zvm[^hyl�i`�wvspjl��6aly�l[�hs����������;ol�^lizp[l� ihumhjphsyljvnup[pvu�jvt�pz�z\wwvy[lk�i`�kvaluz�vm�nyv\wz�huk�[ol`� provide an interactive map marking places where facial recognition is used (ban facial recognition, n.d.). this not only includes law resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 77 lumvyjltlu[�hnlujplz��i\[�(thavu�9pun�kl]pjlz�hz�^lss�� it is nearly impossible today to avoid an online footprint. however, resisting the use of ai in one’s everyday life is one of the main forms of not only advocacy but protection. social workers can both inform their clients and resist these technologies in their own lives. guidelines to follow include limiting the amount of information shared online, refusing [v�vw[�pu�[v�tvup[vypun�zly]pjlz��huk�[\yupun�vɉ�zthy[wovul�mlh[\ylz� [oh[�nyv\w�wov[vz�ihzlk�vu�pklu[pälk�mhjlz��2svzv^zrp��������� 6m[lu[ptlz�^olu�zpnupun�\w�mvy�hu�vuspul�hjjv\u[��^lizp[lz�^pss�hzr� for personal identifying information (pii) such as full name, birthdate, and address. unless absolutely needed, providing these sensitive facts about oneself can result in unwanted tracking and associations. analytics such as cookies are another way websites use online history [v�äs[ly�hkz�huk�zlhyjo�ylz\s[z��;ol`�zh]l�jly[hpu�[`wlz�vm�kh[h�pu�vykly� to track what individuals are clicking on, looking at, and engaging with. the social isolation this causes limits online content and can be khunlyv\z�mvy�jsplu[z�^ov�äuk�[oltzls]lz�svjrlk�pu[v�tpzpumvyth[pvu�� meanwhile, under the guise of social connection, facial recognition zvm[^hyl·zwljpäjhss`�pu�p7ovulz·hssv^z�\zlyz�[v�[hn�[olpy�myplukz�� however, this data is being shared beyond one’s personal device. the zl[[pun�t\z[�il�[\yulk�vɉ�thu\hss �̀� resistance can come in many forms. creative ways of avoiding the [ljouvsvn`�hyl�wyl]hslu[�lzwljphss`�pu�[ol�whz[�ä]l�`lhyz��tvz[�uv[his`� the umbrella movement in hong kong, in which protestors used open umbrellas to shield their faces from government surveillance cameras (bbc, 2019). regulate currently, there are no federal laws in the us regulating ai. governing bodies lack the expertise and knowledge to properly create legislation that protects privacy, limits surveillance, and bans discrimination �7haahulzl���������;olzl�[ljouvsvnplz��hz�v\[spulk�hiv]l��ylålj[�[ol� structural biases that have been present in society for centuries, and [o\z�jvu[pu\l�[v�ohyt�thynpuhspalk�jvtt\up[plz��7yp]hj`�slnpzsh[pvu� sarah e. dillard 78 | columbia social work review, vol. xix from the 1960s-80s are now out of date. data protection only covers government and medical databases while anti-discrimination in housing and employment does not extend to a computer formula (bock, �������;olzl�wvspjplz�ullk�[v�il�ylmylzolk�[v�ylålj[�[ol�]hz[�nyv^pun� implementation of ai. technology companies monitor their systems in-house and rarely wyv]pkl�[ol�l_hj[�kl[hpsz�vm�[olpy�hsnvyp[otz�mvy�x\hsp[`�joljrz�i`�v\[zpkl� researchers. they claim their system is protected by being a trade secret: intellectual property that cannot be released because it is integral [v�[ol�äuhujphs�^lss�ilpun�vm�[ol�jvtwhu`�huk�jv\sk�w\[�[olt�v\[�vm� i\zpulzz�pm�jvwplk��<up[lk�:[h[lz�7h[lu[�huk�;yhklthyr�6ɉjl��u�k���� however, this claim prevents diverse and informed research entities from tp[pnh[pun�iphzlk�v\[w\[z�vy�ylz\s[z�^opjo�ylålj[�opz[vypj�kpzjyptpuh[pvu�� +\l�[v�h�mlhy�vm�svzpun�wyvä[z�pm�[ol�jvtwhu`»z�ylw\[h[pvu�pz�ohytlk�� many data-driven industries hide behind this trade secret policy, which intentionally obscures them from public review. social workers in policy can educate themselves on the uses of ai in a älsk�[ol`�hyl�l_wly[z�pu��olhs[ojhyl��jyptpuhs�q\z[pjl��vy�huv[oly��;ol`� can write briefs on biased algorithms and the need for federal regulation as members of safelab at columbia university did (anguiano et al., 2021). cities such as san francisco and boston have passed their own legislation disallowing facial recognition technology, ahead of federal changes (associated press, 2021). petitioning lawmakers to focus on ai and its potential for harm is another way social workers can get involved in advocating for digital inclusion. as stated before, with biometric systems such as facial recognition spreading surveillance, it is likely that a more accurate algorithm will be used to continue the over-policing of black individuals. social workers, who are educated in the historic and systemic harms kvul�[v�thynpuhspalk�jvtt\up[plz��jhu�pumvyt�[ovzl�^p[o�wvsp[pjhs�wv^ly� the ways in which ai perpetuates this oppression. >p[ov\[�yln\sh[pvu��[ljouvsvn`�jvtwhuplz�^pss�il�\usprls`�[v�zjy\[pupal� their systems to the same degree as outside researchers. limiting the uses of a product, whether by disallowing hate groups from posting on a resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 79 wsh[mvyt�vy�i`�lukpun�kh[h�why[ulyzopwz�^p[o�v[oly�äytz��tlhuz�sptp[pun� i\zpulzz�huk�[olylmvyl�wyvä[��;olyl�ullkz�[v�il�h�tvul[hy`�pujlu[p]l� in the form of a tax (ideally on data storage) that encourages these companies to delete digital footprints. reimagine there are many other roles that social workers can take in advocating for digital inclusion. technology companies are now creating jobs pu�älskz�z\jo�hz�ylzlhyjo�l[opjz�huk�jvtt\up[`�ylsh[pvuz�huk�hyl� attempting to diversify their hiring practices through apprenticeships for people with unconventional backgrounds. with an extensive \uklyz[hukpun�vm�z`z[ltpj�iphz��zvjphs�^vyrlyz�hyl�^lss�lx\pwwlk�[v�il� a part of these discussions. ,[opjhs�kl]lsvwtlu[�huk�klwsv`tlu[�vm�(0�pz�vul�ltlynpun�älsk�zvjphs� workers must be a part of. knowledge of criminal justice and healthcare is integral in decisions concerning what data should be used, whether that data is a proxy for race, and if the data results in biased outputs [oh[�ohyt�thynpuhspalk�jvtt\up[plz��(wws`pun�[opz�q\kntlu[�huk� empathy will be a growing necessity as automation continues to expand (johnson, 2021). in research, teams improving machine learning algorithms need annotators from a wide range of backgrounds in order to capture the nuances of human expression (johnson, 2021). by including stakeholders with varying sources of knowledge, discussions open up and opinions are provided which could not have been captured by people who mostly think the same. time and diligence are also needed, something tech companies try to cut by paying annotators by the social media post. working with a group means a consensus must be reached, rather than allowing one person to determine the meaning behind a post (patton et al., 2020). (z�[ljouvsvn`�jvtwhuplz�zllr�[v�kp]lyzpm`�[olpy�z[hɉ�pu�vykly�[v�ptwyv]l� the systems they create, social workers can be consultants for unbiased hiring practices. firms such as race forward are employing people to svvr�h[�z[y\j[\yhs�vwwylzzpvu�huk�äuk�^h`z�[v�lsptpuh[l�p[�pu�kpɉlylu[� sarah e. dillard 80 | columbia social work review, vol. xix hylhz��9hjl�-vy^hyk��u�k����)pn�jvuz\s[pun�äytz�hyl�hszv�[hrpun�vu� projects to create more inclusive employment searches and outreach, huk�zvjphss`�ylzwvuzpisl�[ljouvsvn`�pz�hu�ltlynpun�älsk�vm�ylzlhyjo��� reinforce (snvyp[otpj�ruv^slknl�nhwz�hyl�huv[oly�mvyt�vm�kpnp[hs�pulx\hsp[`� ptwhj[pun�thynpuhspalk�jvtt\up[plz��*v[[ly�l[�hs����������<uklyz[hukpun� how personal data is used, where one may encounter bias due to ai, and ways to protect oneself are all crucial for agency in the digital world. socioeconomic status is viewed as the main determinant for algorithmic knowledge (cotter et al., 2020). in the us, class often relates to one’s race, as a disproportionate number of black and latinx individuals sp]l�ilsv^�[ol�wv]ly[`�spul��*ylhtly���������/v^l]ly������vm�)shjr� people in the us use social media (pew, 2021). this means a vast majority of black users—given the disproportionate number of black individuals who experience intersecting poverty—likely are not aware of the underlying algorithms, data scraping, or implications of their online presence in their physical lives. 9lpumvyjpun�ihzl�ruv^slknl�vm�[ljouvsvn`·zwljpäjhss`�(0�huk�ov^� it is used—is another way social workers can support digital inclusion lɉvy[z��;ol�(snvyp[otpj�1\z[pjl�3lhn\l��mvy�l_htwsl��[vvr�h�jylh[p]l� approach by creating a workshop called “drag vs. ai” (ajl, 2020). participants learn about facial recognition software and then learn from drag performers how to do their makeup in order to escape the thjopul»z�¸jvklk�nhal�¹�0[�lukz�^p[o�h�äuhs�y\u^h`�zov^�huk�hkkp[pvuhs� information on how to resist, not only individually but as part of an v]lyzpno[�vynhupah[pvu�� conclusion it is necessary for social workers to become advocates for digital inclusion. technology is only progressing and becoming a greater part vm�v\y�l]ly`kh`�sp]lz��*\yylu[s �̀�[ol�(0�z`z[ltz�ilpun�kl]lsvwlk�ylålj[� [ol�opz[vypj�kpzjyptpuh[pvu�vm�thynpuhspalk�pukp]pk\hsz�ihzlk�vu�zluzp[p]l� characteristics such as race, class, and gender. well-versed in systemic resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 81 oppression—its roots, causes, and manifestations—social workers t\z[�il�pu]vs]lk�pu�kpzthu[spun�[opz�sh[lz[�p[lyh[pvu!�jvklk�pulx\hsp[`� (benjamin, 2019). through resistance, regulation, reimagination, and reinforcement social workers in any position are able to advocate for those being harmed by an algorithm. references algorithmic justice league. 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(2020, may 22). a.i. can now correctly predict something we think about privately. inverse. https://www.inverse.com/innovation/ai-photo-judgment resist, regulate, reimagine, and reinforce columbia social work review, vol. xix | 85 sarah e. dillard columbia social work review, vol. xix | 101 100 | columbia social work review, vol. xix 1 in every 25 children in the united states currently has a parent incarcerated in jail or prison. black and latinx children make up the majority of this population, as their parents are overrepresented in local jails and state and federal prisons. parental incarceration affects a child’s behavior, emotional and mental health, social interaction, and financial stability. daughters of incarcerated parents are particularly affected. this research investigates testimonios (testimonies), a narrative form of counter-storytelling, as a tool to address the traumatic effect of parental incarceration on female children of color. testimonios give a person agency and allow them to share their unique and nuanced experiences in detail. in-depth interviews demonstrated that testimonios can be an effective healing tool for women who have been impacted by parental incarceration and can improve social service organizations directed towards families affected by incarceration. testimonios provided space in which daughters of incarcerated parents were able to express their emotions and make sense of their experiences. the interviews also revealed shared themes in the experiences of multiple interviewees. the testimonios of systemimpacted daughters of color on healing from parental incarceration angie belen monreal she, her columbia social work review, vol. xix | 103 102 | columbia social work review, vol. xix the testimonios angie belen monreal the testimonios of system-impacted daughters of color on healing from parental incarceration background despite having 5% of the world’s population, the united states currently holds over 25% of the world’s incarcerated population, with 2.3 million people currently in jail or prison (american civil liberties union [aclu], 2020). data shows that 52-63% of individuals who are incarcerated have children, with the number of mothers rapidly increasing in recent years (thomson et al., 2018). nationwide, one in every 25 children currently has a parent incarcerated in jail or prison, and an estimated five to eight million children have experienced parental incarceration in their lifetime (haskin & turney, 2018). parental incarceration affects entire families, but children experience higher instances of trauma and adversity as a result of parental incarceration (arditti & savla, 2015). children who have experienced the incarceration of a parent, family member, or community member are often referred to as being “system-impacted” (cerda-jara et al., 2019, p. 2). in this paper, “system-impacted” specifically refers to a child’s experience of parental incarceration. this research focuses on female system-impacted children, referred to as daughters, because previous literature has demonstrated that daughters experience higher instances of antisocial behavior, anger, impulsivity, low self-esteem, and delinquency than sons as a result of parental incarceration (burgess-proctor et al., 2016). this research also focuses on system-impacted daughters of color because black and latinx parents are disproportionately represented in state and federal prison populations. for example, black people make up 13% of the u.s. population, but 40% of the incarcerated population (sawyer & wagner, 2020). these numbers are a reflection of the disproportionate incarceration rates for the black and latinx populations (western & pettit, 2010). current literature has found that parental incarceration has both shortand long-term negative effects on children (miller, 2006). in the short term, system-impacted children experience traumatic separation, loneliness, unstable childcare arrangements, and the effects of reduced family income (murray et al, 2012). in the long term, systemimpacted children are at higher risk of experiencing intergenerational incarceration, antisocial behavior, stigmatization, poor educational performance, and stress (murrey, 2015), as well as general anger and additional mental health problems (wakefield, 2007). existing research, largely based on quantitative analyses, fails to capture the voices of system-impacted children and the nuances of their unique experiences with parental incarceration. academics have too often lumped all system-impacted children together when researching their experiences. for example, burgess-proctor et al. (2016) studied the effects of parental incarceration on both daughters and sons, but failed to analyze the impact of race and ethnicity on the lived experiences of both genders. it is important that an intersectional lens is applied to fully capture experiences of children with incarcerated parents. testimonios are intended to capture the intersectional and nuanced experiences of system-impacted children with regard to gender, race, ethnicity, socioeconomic status, and so forth. research questions this paper focuses on the traumatic effects of parental incarceration on daughters of color and demonstrates how testimonios, a form of counter-storytelling, can be used as an effective healing tool. conversations around parental incarceration are limited due to immense stigma and shame. family members often tell children that their incarcerated parent is on vacation, rather than in jail or prison; however, children discover their parent’s incarceration through other social means, such as friends (burgess-proctor et al., 2016). when children are told about the incarceration, they often proceed to conceal their parent’s incarceration from friends and others (burgess-proctor et al., 2016) due to the stigmatization that will follow them into adulthood (sykes & pettit, 2014). to counter the stigma and shame around parental incarceration, columbia social work review, vol. xix | 105 104 | columbia social work review, vol. xix the testimonios this research shed light on the following research questions: 1. how have daughters of color with incarcerated parents expressed themselves through storytelling? 2. can counter-storytelling be used as an effective healing tool for daughters who have experienced parental incarceration? counter-storytelling is a framework used to elevate the voices of populations who are often forgotten and long silenced, making it an ideal method for addressing the needs of system-impacted daughters of color (yosso, 2013). counter-storytelling occurs when a person tells their life story or shares a particular experience, either informally in a conversation with another person or formally as a culturally responsive tool in a therapeutic setting. it has been found to be an effective tool for healing after trauma. for example, native americans who experienced forced boarding school reported emotional release and healing when sharing their stories through counter-storytelling (charbonneau-dahlen et al., 2016). counter-storytelling promotes resiliency by showcasing how a person has adapted and built skills in order to overcome the systemic barriers and oppression they have faced (hess, 2019). for instance, in response to an environment where there was an absence of nurturing roles in boarding schools, native american fifth and sixth graders developed survival skills by becoming caregivers themselves for younger children. most important, counter-storytelling shifts and challenges the white supremicist paradigm by illuminating patterns of racialized inequality through recounting experiences of individualized and shared racism (yosso, 2013). in this paper, critical race theory (crt) will be used in conjunction with counter-storytelling to elevate the voices of marginalized, underserved, and silenced system-impacted daughters of color. crt is a theoretical framework used in the social sciences that examines the relationship between society and race, law, and power (crenshaw et al., 1995). using this framework will provide an in-depth look at how race and power impact populations who experience parental incarceration. crt and counter-storytelling have been used in a variety of situations to help individuals heal from trauma and have been shown to acknowledge the resilience and survival skills of marginalized populations (solorzano & yosso, 2001). crt is important for this research because most children who experience parental incarceration are people of color, creating an increase in future class and racial inequality through the negative consequences of mass incarceration on children (wildeman & western, 2010). testimonios are used strategically to give agency to daughters of color. agency gives people the power to negotiate their needs and identify what they feel in spaces of inequality (cushing & lewis, 2009). this form of storytelling has been used in feminist research methodologies as a form of resistance, a tool for resilience building, and a source of hope in the midst of challenging systemic oppression (huber & cueva, 2012). testimonios decolonize storytelling by giving a person agency to highlight power and oppression, and can be viewed as a genre within counter-storytelling (medina, 2018.). methodology previous research on the experiences of system-impacted children has reduced their experiences to statistics using quantitative methods. as such, through the practice of counter-storytelling with a crt lens, this research provides a more in-depth representation of the experiences of system-impacted daughters of color. the qualitative data comes from in-depth interviews with two women who had incarcerated parents and one employee from homeboy industries’ legal services department who had worked with the interviewees for over a year. homeboy industries, based in los angeles, ca, is a nonprofit organization that assists former gang members, previously incarcerated individuals, and their families to become positive contributing members of society through providing access to job placements, tattoo removals, therapy, and legal services (leap et al., 2011). the organization is considered a good fit for this research because of their work with system-impacted families. the women interviewed were from los angeles, ca, mexicanamerican, in their late twenties, and both experienced the incarceration angie belen monreal columbia social work review, vol. xix | 107 106 | columbia social work review, vol. xix the testimonios of their fathers when they were adolescents. respondents were asked 18 questions during the interview about how they navigated their parent’s incarceration, communicated with others, and what resources they deem necessary for healing. the interview questions include: “looking back, how would you say being system-impacted affected your trajectory?”; “as of today, do you share your narrative of being system-impacted with others?”; “how do you feel when you talk about your mother’s/ father’s incarceration?”; and ”what services do you feel are necessary for daughters to heal from parental incarceration?” the employee interviewed was asked different questions, such as, “in your role, do you experience listening to the children’s narratives/stories about their experience with parental incarceration?” these questions were constructed ahead of the interview and were open-ended to promote discussion. additional probing questions were asked during each interview when a respondent disclosed new information. for example, when an interviewee disclosed the impact her father’s incarceration had on her career choice, she was asked to elaborate. interviews were conducted in the homeboy industries legal office and recorded using a phone device and deleted soon after the interview was transcribed by the researcher. all respondents were given consent forms and informed about the study’s objective beforehand. ethical measures were taken throughout the duration of the research project and pseudonyms are assigned to each respondent to maintain confidentiality. before the interviews, the researcher built rapport with each interviewee through legal assistance and everyday interactions at homeboy industries. furthermore, columbia university institutional review board (irb) approved this research. the data from the semi-structured interviews were thematically transcribed and analyzed. google drive, google docs, and microsoft excel were used for coding and tracking emerging themes. after the data collection, thematic analysis was used to identify themes and patterns in responses. results the objectives of using testimonios are to showcase the point of view of the person being interviewed, identify what they deem important from their experiences, and make an urgent call to action based on the themes and patterns that emerge from their intentional sharing (reyes & rodirguez, 2012). themes that arose across the interviews conducted in this study included a strong sense of healing from sharing testimonios, increased willingness to share, education as an escape, financial instability, and negative feelings towards individuals who did not share their struggle. in general, daughters of incarcerated parents found that telling stories of their lived experiences was a form of empowerment. interview results strong sense of healing the homeboy industries’ staff person who was interviewed reported observing a strong sense of healing from the women who shared their testimonios. maria and gabriela, who shared their testimonios, agreed and reported that sharing their narratives about their parent’s incarceration with others was healing and therapeutic. a staff member who works in homeboy industries’ legal services department focusing on family reunification, expungement, and other court services, stated: [they share] all the little details that are important to them and half the time they end up crying. it is more like a therapy session. i only end up using half of...the stuff they have already told me. half of it is not important to the case...but it is important for me to understand where they are coming from, so i can sort of better craft those declarations for a judge that is going to read. yeah, a lot of times them doing their legal work ends up sort of being therapeutic sessions because they get to talk to someone who is not going to judge them, who is actually doing something to help them. the themes in the interview reveal that storytelling and full disclosure about the traumatic experience of having a parent incarcerated can be therapeutic because the speaker is given a chance to share their own angie belen monreal columbia social work review, vol. xix | 109 108 | columbia social work review, vol. xix the testimonios experiences and emotions regarding what occurred during this vulnerable part of their lives. the legal services staff stated that when women who are impacted by the criminal justice system are given the opportunity to speak about their experiences, they find it to be therapeutic and healing, especially because they are met with no judgement. for storytelling to work as an effective strategy, the speaker must have an attentive and encouraging listener (rosenthal, 2003). therefore, the professional staff at homeboy industries fulfilled this role by creating a judgment-free environment for her participants. avoidance by professional staff avoidance has been observed in research on parental incarceration (mcginley & jones, 2018), as well as in this research. the employee interviewed discussed the prevalence of avoidance, or the staff member’s reticence to speak of the client’s parental incarceration unless they first broached the topic. when asked if she discusses with the children their experiences and feelings about having an incarcerated parent, the staff member responded, “me no. because the kids i usually see are five or under so they do not really understand what’s going on. they will think their parents were on vacation or somewhere doing a work thing.” the professional staff usually avoids mentioning the incarceration of the children’s parents, allowing the children to think that their parents are away on business or vacation. this is a relatively common experience for children as their parents, teachers, and service providers shield the child from the truth of what is really happening with their parents (burgessproctor et al., 2016). this is often due to the parent’s shame and guilt of being incarcerated and not wanting to inflict it on their children or not knowing how to address the topic in a way that is understandable for children. however, it is important for these children to grow up and begin to ask questions about their parents. counter-storytelling can prove beneficial for this population as it speaks directly to these issues and gives voice to them, instead of perpetuating avoidance and secrecy. education within all three interviews, education was identified as a form of healing by both staff and the daughters. when asked what is necessary for system-impacted daughters to heal, maria stated, “i would say education. something they can be in control of [like] college degrees.” she explained that by giving girls who are dealing with their parent’s incarceration something they can control, like education, they begin to feel liberated. she recalled, “i would just be at the library, reading books, or learning stuff at school. it would take me to another place, a place where you don’t need money.” long-term financial instability financial instability was another common theme. both participants shared how their parent’s incarceration led to a loss of family income and an increase in financial stress. it is important to acknowledge that in addition to the economic insecurity that exists while a parent is in prison, financial instability continues beyond release. the negative consequences of having a parent incarcerated do not disappear once they return home. gabriela, who experienced her father’s incarceration in middle and high school, reflected on her dad’s experience after release: “he did not have a job for five years after that. so my mom was struggling for a long time. i feel like my dad’s financial instability affected my mom and our household. so i could not go to college right after high school.” gabriela’s father’s unemployment and inability to contribute to the family’s income affected her educational trajectory by limiting her ability to seek higher education. both maria and gabriela mentioned struggling with food insecurity and paying bills, as well as needing additional assistance while their parents were incarcerated and in the years following. privilege another theme that emerged was anger that the daughters had towards others whom they identified as having “privilege,” or those who they saw as not having any “real” problems. through time, however, the angie belen monreal columbia social work review, vol. xix | 111 110 | columbia social work review, vol. xix the testimonios anger transformed into a motivation to excel. maria expressed, “at first, it made me a bit bitter because i would see people who do not have any real problems in life… but i grew out of that.” she later explained that her bitterness about her parent’s incarceration turned into motivation and increased her personal resilience. the concept of resilience appeared in both of the interviews, when maria and gabriela discussed how they came to understand and accept their parent’s incarceration and use their adversity as motivation. previous research has shown that children who experience separation and poverty due to a parent’s incarceration experience lasting negative effects. however, through the use of external resources and strength-based factors, children can showcase resiliency (miller, 2007). resilience and healing may arise from the practice of storytelling. benefits of testimonios by sharing their narratives, maria and gabriela were able to open up about what they felt when having to deal with their incarcerated parents. although there were only two interviews with system-impacted daughters and one staff interview conducted, the data supported the predicted hypotheses. testimonios are therapeutic for children of incarcerated parents, allow for a nuanced understanding of their experiences, and provide insight for service providers about the specific needs of the people they serve. limitations one of the limitations of this research was limited time. data collection was limited to less than ten weeks. there was not enough time to recruit a larger sample size of participants and it was difficult to create a strong bond with the participants in such a short period of time. another limitation was the structure and sensibility of the interview. the interview was recorded on a device, creating an environment where interviewees felt reluctant about the amount of information they shared and skepticism about their privacy. a further limitation is that this research was conducted independently without team support. future directions this research highlighted the positive impacts of daughters of color sharing their testimonios. because testimonio sharing was shown to be a source of empowerment, this research demonstrates a need for more safe spaces where daughters of color can feel comfortable sharing their testimonios, and in doing so, address their needs and emotions. safe spaces can include a support group or an after-school program where youth with similar experiences of parental incarceration can get to know each other and feel less alone. these spaces can also provide an outlet for system-impacted children to understand their emotions and process the complexity of their anger. social services organizations and social work practitioners should strive to create educational programs and support groups for system-impacted children of color. through the themes revealed in the interviews, this research points towards the specific needs of system-impacted daughters of color, including financial and educational resources. without financial support of incarcerated parents, system-impacted children should have rental assistance, food pantries, and educational school supplies available. it is essential to create educational programs that serve this population, as those who experienced parental incarceration have demonstrated that they could be a potential escape. given the findings of this research, future research with a larger sample size that includes women from other marginalized populations, in particular black women, is needed to argue the effectiveness of storytelling in healing from parental incarceration. acknowledgements i gratefully acknowledge the study participants for their willingness to share their experiences, as well as homeboy industries for making this research possible. additionally, i want to acknowledge my family for their support, especially el gerarchos punk and lula munoz. i also want to thank nayeli monreal, gerardo monreal, citlali monreal from anaheim, and humberto. this research was supported by grants from the university of california, los angeles advanced academic placement angie belen monreal columbia social work review, vol. xix | 113 112 | columbia social work review, vol. xix the testimonios program’s community development and social justice (cdsj), and the mentorship and guidance of ms. noemi rivera-olmedo and dr. alice ho. references american civil liberties union. 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(2013). critical race counterstories along the chicana/chicano educational pipeline. routledge. angie belen monreal angie belen monreal (she/her) is an incoming ph.d. student in the sociology department at the university of california, irvine. she will be graduating this year with a master of science in social work from columbia university. angie received her b.a. in sociology from the university of california, los angeles and her a.a. in sociology from fullerton community college. she has done hands on and research work on parental incarceration, reentry, and immigration. angie is a proud first generation college student and was born and raised in anaheim, ca. columbia social work review, vol. xix | 3 2 | columbia social work review, vol. xix approximately 15% of couples in the united states (u.s.) suffer from infertility. existing infertility treatments and alternate paths to parenthood, such as adoption, are available but financially inaccessible and require self-payment. although organizations such as the american medical association (ama) and world health organization (who) classify infertility as a disease, the u.s. has not federally mandated insurance coverage for infertility. currently, only 15 states require insurance companies to offer some type of fertility benefit and these requirements vary across states. this paper discusses the need to federally mandate insurance coverage for infertility in the u.s. infertility not only causes devastating outcomes for individual families, but affects nearly all demographics across the world. however, national legislation on infertility coverage continues to fail the many couples who suffer from this condition. the paper concludes with implications for social work practice and recommends ways social workers can support this policy movement. social workers have an ethical duty not only to address clients’ mental and emotional needs, but also to be at the frontlines of policy and to advocate for federal insurance coverage for clients who desperately want to realize their dream of conceiving a child. keywords: fertility, infertility, insurance coverage, insurance, in vitro fertilization (ivf) healthcare policy: federally mandated insurance coverage for infertility treatment tanesha goldwire tutt cswr paper prize recipient she/her columbia social work review, vol. xix | 5 4 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt of research that exists on other populations that may be dealing with infertility. as a person of fertility privilege and disenfranchisement, i can identify with those in both categories. the experiences of being dismissed, unheard, and unrecognized fueled my passion to write this article, in hopes that it would generate awareness of infertility, its effects, and the need to advocate for changes in laws and policies that marginalize those who are suffering with the disease. healthcare policy: federally mandated insurance coverage for infertility treatment in 2020, ucla health reported that approximately 15% of couples will struggle with infertility (ucla health, 2020). according to medlineplus (n.d.), infertility is the inability to become pregnant after 12 months of trying to conceive and includes miscarriages and stillbirths. despite the who and the ama classifying infertility as a disease, there is no federally mandated insurance coverage for infertility treatment (insogna & ginsburg, 2018; strauss, 2018). for many couples around the world, having a baby is a critical step to building a family. for both the person trying to conceive and their partner, a diagnosis of infertility can lead to many challenges such as anger, depression, sexual dysfunction, divorce, and social isolation (deka & sarma, 2010). given the prevalence of infertility, its underrecognized status as a disease that warrants coverage, and the high costs people pay to exercise their right to conceive a child, federally mandated insurance policies are a vital but missing component of our nation’s healthcare landscape. the social problem in the u.s., at least one in eight couples will experience infertility (resolve, 2019). among married couples, about 7% of women and 16% of men, ranging in age from 15-44, are classified as infertile (centers for disease control [cdc], 2016; chandra et al,, 2013). infertility is typically viewed as a female condition, but in approximately 40% to 50% of infertility cases, the male is the factor leading to infertility positionality statement i write from the positionality of an individual who has had personal experience with infertility. as a cisgender woman, i know what it is to face the reality that conceiving a child is a privilege, and that not everyone will know the joy of pregnancy through heterosexual intercouse. i know what it is to grieve over the unmet expectation of bearing a child. the mental, emotional, physical, and financial strain my husband and i experienced seemed unreal, unfair, and unfathomable. the level of bias, discrimination, and sometimes ignorance we encountered while trying to navigate our infertility was unbelievable. i also write from a positionality of privilege as a cisgender woman in a heterosexual relationship. our diagnosis forced me, my husband, and those in our circle to confront our own ignorance. we were guilty of “meddling” in others’ fertility, failing to consider that a person or couple may not have had a choice in either delaying or forgoing starting a family. we also had to confront our own bias, as we were conditioned to believe that only women could suffer from infertility. feeding into gender binary viewpoints, i dismissed the idea that lgbgtqia+ couples and individuals also face the pain and demoralization that infertility can cause. finally, i write from the positionality of a minority. while i speak as a person of privilege in terms of my sexual and gender identity as a heterosexual cisgender woman, i am a black woman married to a black man. i understand what it is to be stigmatized and marginalized when trying to access infertility treatment and financial support. i witnessed firsthand the privilege that exists for white women, white men, and white couples who are afforded opportunities and access to fertility treatments that are not available to those of other races and ethnicities. i realized that social constructs narrowly define who can be impacted by infertility, who is deserving of support, and who should have access to various types of treatments, coverage, and care. this article reflects a gender binary point of view and focuses on those who are cisgender, and in that way it is indicative of the lack columbia social work review, vol. xix | 7 6 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt received assisted reproductive medical support, while only 7% of minority heterosexual women and white sexual minority women received support. furthermore, only 1% of women who identified as both racial and sexual minorities were found to have received such support. men were not included in the study, speaking to the gap in the literature on infertility in men. feinberg and colleagues (2005) found that when african americans had access to healthcare through partial insurance, there was a 400% increase in their utilization of arts. yet even with access, minority patients had poorer health outcomes than white patients, including higher spontaneous abortions, lower clinical pregnancy rates, and lower live births (insogna & ginsbury, 2019). thus, even with lower successful outcome rates, minorities clearly benefit from having insurance to cover infertility treatments. barriers to accessing treatment in addition to its widespread impact and disproportionate effects on marginalized groups, infertility warrants insurance coverage. however, inconsistent nationwide coverage policies have created major cost burdens for individuals. in 1948, the united nations universal declaration of human rights stated that every person has a right to start a family, and in 2015, the american society of reproductive medicine (asrm) ethics committee stated that “reproduction is a fundamental interest and human right” (2015). however, u.s. legislation has failed to recognize that infertility is a disease that denies people the basic human right of conceiving a child. additionally, while the who and ama classify infertility as a disease, many insurance companies in the u.s. do not cover infertility and erroneously view infertility treatment as experimental medicine (strauss, 2018). this label neglects the substantial body of research highlighting that procedures to address infertility, such as egg freezing, are no longer experimental and arts, such as ivf, have increased in success with as many as 8 million babies being born through ivf in 2018 (dunne & roberts, 2016; strauss, 2018). without federal assistance, individual states bear the responsibility to determine how to regulate infertility coverage (american society (kumar & singh, 2015). infertility can be treated with medication, surgery, intrauterine insemination (iui), or assisted reproductive technologies (arts) such as in vitro fertilization (ivf). these fertility treatments involve extracting eggs and embryos from a female and either combining them with sperm in a laboratory and reinserting into the body, or donating them to another woman (cdc, 2019). each treatment comes with its own costs, risks, and rates of success. disproportionate impacts on marginalized populations the medical definition of infertility is the “inability of couples to conceive after at least 1 year of having sex without using birth control methods” (u.s. national library of medicine, 2019, para 1). this definition limits those capaable of experiencing infertility to heterosexual couples that have intercourse. it assumes that only men and women try to have children, and also focuses on women’s bodies instead of men’s. however, men and same sex-couples need support with infertility, too. the current definition of infertility fails to address the inclusiveness needed to ensure all populations can receive equal and adequate access to support and care for infertility and leaves room for interpretation of who does and does not deserve access to care. much of the research, advocacy, and support for infertility focuses on white, heterosexual women (shreffler et al., 2017). although african american, chinese, and latine couples have higher rates of infertility than white couples, they are less likely to seek treatment (inhorn & patrizio, 2018; insogna & ginsbury, 2019). according to a study published in health psychology, “heterosexual white women are twice as likely as racial or sexual minority women to obtain medical help to get pregnant” (blanchfield & patterson, 2015, p. 575). the study further explains that a cause for this lack of pursuing treatment a lack of health insurance. moreover, as of 2018, blacks are still 1.5 times as likely as whites to be uninsured (ariga et al., 2020). blanchfield and patterson (2015) found that in studies conducted in 2002 and again from 2006 to 2010, 13% of white heterosexual women columbia social work review, vol. xix | 9 8 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt of reproductive medicine [asrm] ethics committee, 2015, para 5; national conference of state legislature [ncsl], 2019; universal declaration of human rights, 1948). currently, 19 states have infertility coverage laws that require insurance companies to either cover or offer infertility treatments as part of the policy (resolve, 2020; ncsl, 2019) (see table 1). of those 19 states, 13 have comprehensive coverage for costs associated with ivf, and 10 have fertility preservation laws (resolve, 2020) (see table 1). however, coverage may not exist for other art treatments and associated medications (insogna & ginsburg, 2018). four states (georgia, michigan, minnesota, and new mexico) offer one medicaid plan to diagnose infertility, but do not mandate any level of coverage for infertility treatment (weigel et al., 2020.) of the states listed in table 1, massachusetts, new hampshire, and new york offer this same benefit, but new york is the only state that requires medicaid coverage to treat infertility (weigel et al., 2020). thus, most individuals with government insurance (state or federal) have no coverage for infertility treatments and are given no choice but to personally cover all fees associated with any arts (resolve, 2018). white, mcquillan, and greil (2006) found that many physicians may hold biases about who should and should not receive infertility treatment. without federally mandated infertility coverage, states and providers can personally define infertility and determine who receives treatment (asrm ethics committee, 2015). giving physicians power to determine who receives treatments creates an indirect and subtle--but deeply harmful--form of ethnic cleansing. consequently, the medical field risks prioritizing communities with privilege in the provision of access. this system enables racism, ableism, transphobia, and many other forms of oppression to influence decisions of who can conceive. the subjective selection of those receiving infertility treatment promotes privilege and creates a system in which those from specific racial, ethnic, gender, and socioeconomic communities are denied access to insurance coverage and medical procedures that are critical to being able to have a baby. table 1. states with infertility insurance benefits states states with infertility insurance laws states with ivf insurance laws states with fertility preservation laws arkansas x x california x x colorado x x x connecticut x x x delaware x x x hawaii x x illinois x x x louisiana x maryland x x x massachusetts x x montana x new hampshire x x x new jersey x x x new york x x x ohio x rhode island x x x texas x utah x x west virginia x from “infertility coverage by state,” by resolve, 2020 (https://resolve.org/what-are-my-options/insurance-coverage/infertility-coverage-state/) columbia social work review, vol. xix | 11 10 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt intercourse without success in forming an embryo (including single men, single women, and lgbtqia+ couples) (asrm ethics committee, 2015; weigel et al., 2020). for benefits, such as fertility preservation, an individual would have to have suffered from an iatrogenic condition--that is, infertility that resulted directly or indirectly from a healthcare provider performing a medical procedure (i.e. surgery) or treating a medical condition (i.e. use of radiation) (campo-engelstein, 2010). while it would seem that this would apply to transgender individuals receiving mendical care, gender-affirming medical and surgical treatments are not consider iatrogenic conditions (weigel et al., 2020). additionally, some insurance companies exclude coverage for all men, both single and married, as women are traditionally viewed as the main factor in infertility (dupree, 2016). a case for federally mandated insurance federally mandated insurance is essential to ensuring that infertility is recognized and treated as a disease. this mandate would open the door for social workers to advocate for marginalized groups, such as lgbtq+ couples and men, ensuring that insurance policies do not exclude certain groups on the basis of society’s definition of who can or cannot experience infertility. two previously introduced pieces of legislation would require all insurance companies to mandate coverage for infertility treatments: the family building act (2009, 2007, 2003, 2005) and the medicare infertility coverage act (2005, 2003). the family building act of 2009 stipulated that all healthcare plans should offer infertility treatment benefits (family building act, 2009; holtzman, 2013). the medicare infertility coverage act of 2005 was an amendment to medicare aimed at covering infertility treatments for those entitled to the benefit because of a disability (holtzman, 2013; us government publishing office, 2005). two other major pieces of legislation, the patient protection act and the affordable care act, expanded health care, but neither addressed the issue of coverage for infertility treatments. the idea of infertility as a disability was introduced in 1998 with bragdon v. abbott, during which without consistent coverage, the costs of treatment far exceed what many couples can afford. in 2018, the average cost for infertility treatments, such as ivf, was $12,000, but some couples paid over $22,000 for one ivf cycle, depending on the types of medication needed to prepare for the treatment (leonhardt, 2019; strauss, 2018). in engaging in ivf, 71% of women who completed an ivf cycle were not covered by insurance (leonhardt, 2019). many couples spend the money fully aware that an unsuccessful fertilization could mean a loss of $12,000 and potential cost an additional $12,000 to try again. according to a 2017 article by robert kiltzman, the cost of a successful delivery from ivf in california was $112,799, and the cost of other paths to parenthood, such as adoption, can cost around $30,000 minimum. these are out-of-pocket funds that the average person likely does not have. the cost to treat infertility, coupled with a lack of insurance coverage for this disease, leaves many couples either struggling to fund treatment or giving up on having a baby altogether. the social policy response although there are states that do require some type of infertility insurance coverage, the federal employee retirement income security act exempts companies who engage in self-insurance (i.e., the companies pay medical claims themselves) from having to comply with state mandates (resolve, 2018). this means that even in the states that do have some form of a mandate, people may still struggle to have their infertility treatments covered. some companies and providers use the medical definition of infertility to justify their inadequate infertility policies. in her interview with physicians and top executives from both united healthcare and aetna, fairyington (2015) highlighted that policies do not provide a pregnancy benefit but a benefit to those who meet the medical, evidence-based definition of infertility. it is the biased interpretation of how infertility should be defined that disenfranchises many groups. some state policies deny fertility support to parties that cannot necessarily meet the guidelines for infertility because they may not have engaged in 12 months of heterosexual columbia social work review, vol. xix | 13 12 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt implications for social work practice as social workers, supporting couples with infertility can be challenging given the lack of federally mandated insurance coverage for infertility treatment. with the distress that a diagnosis of infertility may cause, social workers may face the difficult task of helping clients find viable options for conceiving a child or accepting the reality that parenthood may not be possible. in 2007, the national association of perinatal social workers introduced standards for social work provision in infertility treatment centers to assist social workers helping clients navigate the mental, emotional, physical, and financial demands of infertility. supporting couples experiencing infertility can be challenging given the dearth of policies that legitimize infertility as a disease, as well as the groups of people infertility can impact. in 1987, obstetrician-gynecologist (obgyn) social worker sima k. needleman recognized that social workers would play an integral role in supporting clients dealing with infertility. in her article, needleman (1987) describes the psychosocial impact of infertility.including the trauma that could result from learning of infertility and the emotions often associated with trying to decide how or even if to move forward with pursuing alternate paths to parenthood. while the therapeutic responsibility of the social worker is vital to improving the mental and emotional well-being of the client, “infertility is not only a medical and emotional dilemma; in many ways it is also a social problem” (needleman, 1987, p.136). social workers must think beyond therapy to being advocates for clients facing infertility. given the lack of recognition around infertility as a disease, one of the key ingredients in advocating for policy change surrounding infertility is redefining infertility for lawmakers and insurance companies. for example, social workers may spread awareness of how psychologically damaging the experience of infertility can be. a study of 200 couples undergoing fertility treatments found that approximately 50% of women and 15% of men stated that infertility was the most devastating experience of their lives (freeman et al., 1985). the supreme court ruled that reproduction was “a major life activity” that should be protected under the americans with disabilities act (hawkins, 2007, p. 209). however, the ruling only ensured employers could not discriminate against an individual based on infertility and did not expand the mandate to cover infertility in company insurance plans. consequently, insurance companies could still promote ableism by denying coverage to those physically unable to conceive through heterosexual intercourse. while the patient protection and affordable care acts expanded health care, these laws did not address the issue of coverage for infertility treatments (norris, 2020). unfortunately, both the family building act and the medicare infertility coverage act never made it to congress for a vote. opponents of federally mandated infertility treatment coverage have argued that covering infertility treatments would come at a high cost. yet, data from massachusetts, connecticut, and rhode island indicate that state-mandated infertility coverage does not significantly raise premiums. in the 30 years these states have been mandating infertility coverage, the cost is less than 1% of total premium costs (emd serono 2019; wigel et al., 2020). another argument is the social cost of infertility treatments. those able to conceive through intercourse are reluctant to bear the costs of treatment for those who experience infertility (hawkins, 2007). however, the very nature of health insurance demands that individual clients pay for treatments that they themselves may never receive. though an individual client may never struggle with infertility, or for that matter, heart disease or cancer, insurance companies have always collected payments from these clients to ensure a large pool of resources. the barrier to federally mandated coverage encourages a system where groups are marginalized and systematically robbed of the right to become parents. however, until legislation is in place, many couples struggling with infertility must apply for grants and loans or use personal funds to assist themselves in becoming parents. columbia social work review, vol. xix | 15 14 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt current definitions used to identify who qualifies for fertility treatments and infertility coverage. social work practitioners are critical to helping those with infertility overcome mental and emotional trauma. as such, they can be catalysts for changing narratives about infertility by highlighting systems of privilege at work in denying some the right to parenthood. social workers are often voices for the voiceless and should be the leading advocates for federal laws and policies that promote equality and equity in infertility insurance coverage. everyone deserves the chance to build a family. references blanchfield, b. v., & patterson, c. j. (2015). racial and sexual minority women’s receipt of medical assistance to become pregnant. health psychology, 34(6), 571. campo-engelstein, l. (2010). for the sake of consistency and fairness: why insurance companies should cover fertility preservation treatment for iatrogenic infertility. cancer treatment and research, 156, 381–388. https://doi.org/10.1007/978-1-44196518-9_29 centers for disease control. (2019). what is assisted reproductive technology? https://www.cdc.gov/art/whatis.html centers for disease control. (2016). infertility. https://www.cdc.gov/nchs/fastats/ infertility.htm chandra, a., copen, c. e., & stephen, e. h. (2013). infertility and impaired fecundity in the united states, 1982-2010: data from the national survey of family growth. national health statistics report, 14(67) 1-18. https://www.ncbi.nlm.nih.gov/ pubmed/24988820 deka, k. p., & sarma, s. (2010). psychological aspects of infertility. british journal of medical practitioner, 3(3), 336. https://www.bjmp.org/content/psychological-aspectsinfertility dunne, c. & roberts, j. (2016). social egg freezing: a viable option for fertility preservation. british columbia medical journal, 58(10), 573-577. https://bcmj.org/ articles/social-egg-freezing-viable-option-fertility-preservation dupree, j. m. (2016). insurance coverage for male infertility care in the united states. asian journal of andrology, 18(3), 339-341. https://doi.org/10.4103/1008682x.177838 emd serono. (2019). employers and evidence-based infertility benefits: a guide to making informed decisions. http://familybuilding.resolve.org/site/docserver/ employers-and-evidence-based-infertility-benefits.pdf ?docid=10584 social workers can advocate for policies that motivate or even incentivize insurance companies to recognize infertility as a disease and to provide coverage for infertility treatment, which can give a sense of hope to those who might see no other path to parenthood. federally mandated insurance coverage would allow those individuals to undergo treatment for infertility without having to worry about significant out-ofpocket expenses. policies offering incentives for companies that provide support for alternatives, such as adoption, may increase the number of organizations that will provide funding, so individuals can realize their dreams of becoming parents. demonstrating how becoming a parent helps improve the emotional and mental well-being of a client may be critical in changing the minds of lawmakers at all levels. conclusion misconceptions about conception abound: that conceiving a child is an easy process, that only heterosexual couples can conceive, that problems with fertility originate with women, and that all child-free couples are child-free by choice. in contrast, few are aware that numerous individuals wake up every morning questioning their existence because they are unable to conceive a child naturally, a dream so central to their sense of personhood and identity. in addition, few healthcare providers and lawmakers realize the discriminatory effects of one-dimensional definitions of fertility and reproduction. if society understood the circumstances beyond peoples’ control that lead to infertility, then we could collectively embrace the reality that infertility is a disease and those suffering from it need the same level of care and support as those suffering from other diseases. society must recognize that regardless of race, class, sexual orientation, or gender, any person may one day find that they are infertile. this public awareness is the first step to establishing universal laws and policies that federally mandate coverage for infertility treatments and accelerating conversations that aim toward deconstructing a system that alienates certain groups from receiving the treatment and care necessary to start a family. this deconstruction includes reimagining the columbia social work review, vol. xix | 17 16 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt leonhardt, m. (2019, august 13). women are traveling far and wide for affordable ivf— here’s why it’s so expensive. cnbc. https://www.cnbc.com/2019/08/13/womenare-traveling-far-and-wide-for-affordable-ivf.html livingston, g. (2018, july 17). a third of u.s. adults say they have used fertility treatments or know someone who has. pew research center. https://www.pewresearch.org/ fact-tank/2018/07/17/a-third-of-u-s-adults-say-they-have-used-fertility-treatmentsor-know-someone-who-has/ medline plus. (2019). infertility. https://medlineplus.gov/ency/article/001191.htm medline plus. (n.d.). infertility. https://medlineplus.gov/infertility.html national conference of state legislatures. (2019). state laws related to insurance coverage for infertility treatment. http://www.ncsl.org/research/health/insurancecoverage-for-infertility-laws.aspx needleman, s. k. (1987). infertility and in vitro fertilization: the social worker’s role. health and social work, 12(2), 135-142. resolve. (2020). infertility coverage by state. https://resolve.org/what-are-myoptions/insurance-coverage/infertility-coverage-state/ resolve. (2019). fast facts. https://resolve.org/infertility-101/what-is-infertility/fastfacts/ resolve. (2018). health insurance 101. https://resolve.org/what-are-my-options/ insurance-coverage/health-insurance-101/ shreffler, k.m., greil, a.l., & mcquillan, j. (2017). responding to infertility: lesson from a growing body of research and suggested guidelines for practice. family relationships, 66(4), 644-656. doi: 10.1111/fare.12281 strauss, e. (2018). 40 years later, why is ivf still not covered by insurance? economics, ignorance, and sexism. https://www.cnn.com/2018/07/25/health/ivf-insuranceparenting-strauss/index.html the national association of perinatal social workers. (2007). standards for social work services in infertility treatment centers offering assisted reproductive technologies and the use of donor gametes [pdf]. https://www.napsw.org/assets/docs/infertilitystandards.pdf ucla health. (2020). infertility. http://obgyn.ucla.edu/infertility universal declaration of human rights. (1948). https://www.ohchr.org/en/udhr/ documents/udhr_translations/eng.pdf u.s. government publishing office. (2005). h.r.2758 (ih)medicare infertility coverage act of 2005. https://www.govinfo.gov/app/details/bills-109hr2758ih ethics committee of the american society for reproductive medicine. (2015). disparities in access to effective treatment for infertility in the united states: an ethics committee opinion. fertility & sterility, 104(5), 1104-1110. https://www.fertstert.org/ article/s0015-0282(15)01650-7/fulltext family building act of 2009, s. 1258, 111th cong. (2009). https://www.congress.gov/ bill/111th-congress/senate-bill/1258/text fairyington, s. (2015). should same-sex couples receive fertility benefits? the new york times. https://well.blogs.nytimes.com/2015/11/02/should-same-sex-couplesreceive-fertility-benefits/ feinberg, e. v., larsen, f. w., catherino, w. h., zhang, j., & armstrong, a.y. (2005). comparison of assisted reproductive technology utilization and outcomes between caucasian and african american patients in an equal-access-to-care-setting. fertility and sterility, 85(4), 888-894. https://doi.org/10.1016/j.fertnstert.2005.10.028 freeman, e. w., boxer, a. s., rickels, k., tureck, r., & mastroianni jr, l. (1985). psychological evaluation and support in a program of in vitro fertilization and embryo transfer. fertility and sterility, 43(1), 48-53. gleicher, n. (2018). expected advances in human fertility treatments and their likely translational consequences. journal of translational medicine, 16(1), 149. https:// doi.org/10.1186/s12967-018-1525-4 hawkins, j. l. (2007). separating fact from fiction: mandated insurance coverage of infertility treatments. washington university journal of law and policy, 23, 203-228. https://openscholarship.wustl.edu/cgi/viewcontent.cgi?article=1337&context=law_ journal_law_policy holztman, j. (2013). infertility: a plague gone unnoticed. stanford journal of public health. https://web.stanford.edu/group/sjph/cgi-bin/sjphsite/infertility-a-plaguegone-unnoticed/ inhorn, m. c., & partizio, p. (2018). is lower quality clinical care ethically justifiable for patients residing in areas with infrastructure deficits? ama journal of ethics, 20(3), 228-237. https://doi.org/10.1001/journalofethics.2018.20.3.ecas1-1803 insogna, i. g., & ginsburg, e. s. (2018). infertility, inequality, and how lack of insurance coverage compromises reproductive autonomy. ama journal of ethics, 20(12), e1152-1159. https://doi.org/10.1001/amajethics.2018.1152 kiltzman, r. (2017). how much is a child worth? providers’ and patients’ views and responses concerning ethical and policy challenges in paying for art. plos one, 12(2), e0171939. https://doi.org/10.1371/journal.pone.0171939 kumar, n., & singh, a. k. (2015). trends of male factor infertility, an important cause of infertility: a review of the literature. journal of human reproductive science, 8(4), 191-196. https://doi.org/10.4103/0974-1208.170370 columbia social work review, vol. xix | 19 18 | columbia social work review, vol. xix mandated insurance coverage for infertility treatment tanesha goldwire tutt weigel, g., ranji, u, long, m., and salganicoff, a. (2020). coverage and use of fertility services in the u.s.. https://www.kff.org/womens-health-policy/issue-brief/coverageand-use-of-fertility-services-in-the-u-s/ white, l., mcquillan, j., & greil, a.l. (2006). explaining disparities in treatment seeking: the case of infertility. fertility and sterility, 85(4), 853–857. tanesha goldwire tutt (she/her) graduated in 2020 with a masters of science in social work from columbia school of social work concentrating in advanced clinical social work practice. tanesha holds a bachelor of science in both english and communication, as well as a masters of science in communications from florida state university. she also holds a doctorate in health education from a.t. still university. she currently works on the federal level as a public health advisor in atlanta, ga. finalized digital files.pdf columbia social work review, vol. xxii | 95 94 | columbia social work review, vol. xxii inspiration for article i have lived in the bushwick community for five years, and during this time, i have witnessed several changes. the chance to regain some of the power within an ever-changing process has inspired me to write this paper. i use the photovoice methodology to integrate images into the narrative and highlight the intersections and real consequences of redevelopment and policing in my neighborhood. the paper was written within a year, and the challenges posed by the changes within the city, such as budget cuts and fluctuations in the number of police, were constant. i hope that readers can understand the impact of gentrification and the significance of community through this piece. during my twenties, i worked as an educator and gained valuable insights that prepared me for a career in social work. after two empowering years in columbia's msw program with a significant emphasis on community-focused, evidence-based interventions, i am thrilled to begin my studies toward my ph.d. in social policy and practice at the university of pennsylvania this fall. ayana colvin columbia social work review, vol. xxii | 97 96 | columbia social work review, vol. xxii redevelopment and police presence in bushwick ayana colvin abstract the relationship between redevelopment and police presence is demonstrated in many neighborhoods by the influx of new residents from suburban or rural areas and shifts in police response. as property values increase, police may prioritize order maintenance policing, also known as "broken windows" policing (beck, 2020, p.247). this is disproportionately felt by black and brown residents who often suffer the consequences of rising costs, displacement, increased surveillance, and police presence. this paper explores the relationship between urban redevelopment and policing in one of the most popular neighborhoods in the borough of brooklyn–bushwick. as a social work researcher of color, i want to share the narratives that often go overlooked. i felt secure and empowered to conduct research and report my findings as a community member who is seeking to support and collaborate with my community. photovoice allows me to do just this by highlighting the daily realities in my neighborhood. however, having more voices from long-term community members is imperative and will be essential in further exploration of this topic. keywords: gentrification, redevelopment, policing, police presence, bushwick, brooklyn, new york city, photovoice, etc. part i: research question background after years of protests against police brutality and what critics called a racial reckoning in the summer of 2020 (payne, 2021), the urgency to center racial justice, community, and police relations has shifted in the past four years. before taking office, current new york city mayor eric adams campaigned heavily on a tough-on-crime platform that emphasized prosecuting low-level offenses and reducing gun violence by pledging to spend up to $5 billion on the new york city police department (nypd) (goldenberg & anuta, 2022). new york city has recently announced budget cuts that will affect the funding of important community services. while the nypd will not face any budget cuts in 2024, new yorkers will have to adjust to significant reductions in services such as library services, school summer programs, and universal pre-kindergarten (cramer, 2024). the nypd has increased its presence in all five boroughs, especially in areas with black and brown populations (morales & nickeas, 2022). according to the nypd's end-of-year citywide crime statistics, the overall decline in crime can be attributed to their policing strategies, including deploying more officers in the neighborhoods deemed most needed (2024). one of the neighborhoods where i have felt an increase in police presence is bushwick. as per the nyc planning (2018) publication, bushwick's growing population was about 121,000. i have been residing in bushwick since the summer of 2019; however, the current heavy police presence in the area under the adams administration has changed the way many of us, including myself as a black woman, navigate our neighborhood. columbia social work review, vol. xxii | 99 98 | columbia social work review, vol. xxii influence of redevelopment bushwick has a diverse history. it was originally a dutch settlement in the 17th century; later, through an influx of european immigrants around the turn of the 20th century, it became known for its small family homes and factories (valli, 2015). the neighborhood significantly contributed to the brewery industry but never fully recovered after the prohibition era (saraniero, 2022). the great migration resulted in the influx of black people from southern states, mexicans, and puerto ricans moving to northern cities, including bushwick. this caused many white workingclass families to leave the neighborhood (valli, 2015). despite becoming desolate to some, the neighborhood remained a significant residence for black and brown families and small business owners. during the early 2000s, the bushwick initiative was introduced to enhance the quality of life and promote economic growth within the neighborhood (city of new york, 2006). these initiatives encouraged several new businesses, and redevelopments were established. as of 2019, the white population has more than doubled, while that of latinos has shrunk from 70% to 54% (murphy, 2019). this research aims to find an answer to the question; to what extent does community policing influence redevelopment? most scholarship on redevelopment explores the process of gentrification as a response to public investments in fostering environmental sustainability. gentrification reinforces the dominant methods of creating physical space while neglecting the disempowered ones. in areas undergoing gentrification, gentrifiers and developers exercise their power to shape the environment while economically and socially vulnerable groups have limited access to space production capabilities (stabrowski, 2014). studies concern the growth of new residents in urban areas from more suburban or rural areas, arguing the link between redevelopment and police presence in low-income neighborhoods intensifies during these periods (beck, 2020). these changes make lower-income neighborhoods more desirable for inhabitants who previously lived outside of urban areas (harris et al., 2020). the research shows that criminalization disproportionately affects black and brown communities, often leading to the displacement of communities of color due to systemic inequalities (beck, 2020; fayyad, 2017; harris et al., 2020). social dynamics and expectations undergo a shift when higher-income residents move into low-income neighborhoods, which can lead to long-term residents being targeted by the criminal justice system for minor offenses deemed "quality of life" crimes (fayyad, 2017, para.7). part ii: methods this study was conducted independently through photovoice, a qualitative research method. the research was conducted in my neighborhood, which gave me a better understanding of the photos selected. i am familiar with the areas where the police are usually present and have witnessed people recycle cans at local stores. i have personally visited the locations that represent the tension and unity within the community. photovoice captures images that portray a research topic's realities. this methodology was chosen because it emphasizes visual aspects over written words, uses photography for knowledge development, and is a powerful tool for critiquing law enforcement in a safe and accessible way (evans-agnew & rosemberg, 2016). it is a strategy for advocacy and can assist in raising awareness of community needs and showcasing the structural barriers imposed on achieving those needs. over three days in march of 2023, i photographed everyday life and its intersections with signs of redevelopment and police presence in the neighborhood of bushwick in brooklyn, new york. the photographs were analyzed in conjunction with scholarly research. as a woman of color living in the neighborhood, the images i captured showcase the impact of redevelopment and policing in my community. more than seven photos were taken, but the ones included in this study highlight the topic of policing and redevelopment. there was a significant police presence on the three days the photos were taken. to grasp a better understanding of the information obtained from the captured images, i searched for supporting materials, academic articles, redevelopment and police presence in bushwick ayana colvin columbia social work review, vol. xxii | 101 100 | columbia social work review, vol. xxii and research studies using relevant keywords like "redevelopment and policing," "gentrification and policing," "displacement," and "bushwick." although the images in this paper were taken individually, photovoice can also be done collaboratively with colleagues and members of communities. this allows more people to participate in research meaningfully and can lead to advancements in areas that may have remained hidden from the direct experience of readers. by incorporating participant voices, themes that reflect a wider range of perspectives can be developed (evans-agnew et al., 2016). photography is a quick process that allows images to be captured for research purposes. this approach also ensures safety when the research subject is unpredictable. as a black woman who moved from low-income to the fringes of the middle class as an adult, i have always been cautious of law enforcement, recognizing the implications of their presence and the challenges of navigating it. this caution has only increased as my research aims to hold our current legal systems accountable by documenting what is truly happening and focusing on individuals and communities that may be overlooked. this is especially important during times of redevelopment and increased policing, when communities may be subject to displacement and over-surveillance without any say in the matter. through photovoice, i can support my community without risking getting too close to or aggravating law enforcement. part iii: narrative of photos during the mornings of march 1-4, 2023, i walked around the bushwick neighborhood to explore the impact of policing and redevelopment in the area. i planned to capture photos showcasing police tactics such as patrolling the neighborhood streets and subways. additionally, i aimed to document examples of redevelopment and how it has affected the historically black and brown communities. i walked between subway stops on the l train line from dekalb ave. to jefferson st. and captured numerous examples of policing, redevelopment, and community impact. the following best represents my findings. policing in the community three images were selected to depict the current police presence in the bushwick community. figure 1, taken on the morning of march 1, 2023, shows two officers standing beside their squad car. graffiti, a common sight in the neighborhood, can be seen in the background. apart from a delivery man, no one else is on the street. it is common for men to spend time socializing by listening to music, smoking weed, and drinking, especially during warmer weather. although their group may have evolved, they have always been present. since figure 1 was taken close to where i live, i better understand what their presence means. on this day, there was no sign of these men or anyone else on the street corner, raising the question of where they had gone. studies have shown that as more white and middle-class people move into a neighborhood, the level of policing tends to increase (harris et al., 2020). in a recent article by brenden beck (2020), the impact of police presence on low-level arrests in gentrifying neighborhoods is explored. beck highlights the correlation between rising housing costs and increased police spending, particularly in terms of order maintenance policing, which concerns maintaining social order and the monitoring of minor offenses. figure 2 regards the police presence in the community, which was captured near subway stations within walking distance. i have noticed that most people use the train stations during weekday mornings to commute to work or school. i spotted two police cars parked near the entrances, which may result from the current city administration's efforts redevelopment and police presence in bushwick ayana colvin figure 1. cops on corner. columbia social work review, vol. xxii | 103 102 | columbia social work review, vol. xxii to crack down on lower-level crimes such as fare evasion. being a woman of color with my own experiences of law enforcement, i maintained a safe distance while capturing these photos. it was unclear whether the officers were in the car or inside the station. being able to document such an apparent police presence during commute hours is concerning given that their presence results in the absence of others or induces stress if one cannot pay the current $2.90 fare for a subway ride. figure 3 depicts the police presence in a bushwick community that is prominent and appears to focus more on minor offenses, which will have a disproportionate impact on the lives of the black and brown residents. redevelopment in the community the community is connected to manhattan via four different subway lines, making it an ideal location for development. by the time the 2007 recession hit, redevelopment was underway and continued as the vulnerable conditions that followed the recession allowed many developers to take advantage of the situation (parés et al., 2017). the change in the community continues rapidly, and more local businesses are closing their doors due to rising costs, further accelerating the transformation of the community. while walking home, i came across figure 4, an infrastructure with development for sale sign, nestled between the jefferson st. and dekalb ave. l train stops. seeing signs of redevelopment in my neighborhood makes me reflect on my positionality, as i belong to a demographic that is privileged in terms of economic status but underrepresented in terms of ethnicity. my economic status grants me access to established businesses that are owned and run by the community, as well as new establishments. however, community members who look like me but are not as economically privileged may not have the same access. figure 4 could represent the beginning of many things for the bushwick community, such as a new bar or business. however, there is reason to question the intentionality when new infrastructures appear, as figure 4 illustrates. “in what wilson (2018) terms the ‘racial development machine’, gentrification in once low-income communities of color become an intentional strategy to create capital accumulation as low-value properties are replaced by infrastructure valued by white newcomers” (harris et al., 2020, p. 3). the location of the building situated between two patrolled stations raises the question of whether there are any underlying reasons or advantages for those who support the presence of law enforcement beyond addressing low-level crimes. only time will reveal the true nature of this new infrastructure; however, the concerns and questions that arise within communities like bushwick represent the tension that gentrification presents and its links to police presence. redevelopment and police presence in bushwick ayana colvin figure 2. cops at subway. figure 3. additional cops at subway. figure 4. redevelopment. columbia social work review, vol. xxii | 105 104 | columbia social work review, vol. xxii impact on community economic effects new spaces may not be inclusive to people of color in gentrification. it is incumbent upon people of color to prove their credibility and justify their use of these new spaces. figures 4, 5, and 6 showcase the bushwick community and illustrate the impact of redevelopment in different ways. figure 5 depicts a woman bundled up for the cold morning weather and placing recyclable cans and bottles in plastic bags. a large shopping cart, which had come from a nearby grocery store, accompanied her. there are a few places in the neighborhood where one can exchange recyclables for money. what caught my attention the most about figure 5 was the size of the bags and the significant number of recyclables she had gathered. juxtaposed with myself as a fellow community member, the quality of life also comes into question. it again brings up how positionality plays a role in what is expected of us to navigate within our neighborhood. questions came to mind such as how long this woman had to work to collect as much as she had and how much she would be paid for her labor. as the cost of living continues to rise, the compensation for the number of cans collected in the reverse vending machine should shift to match a shifting economy. the current budget cuts are having a noticeable impact on city agencies which need help to provide essential benefits and services to new yorkers at historically high levels (honan, 2023). this will affect everyone, but the extent of the impact may vary depending on individual circumstances. increase in policing figure 6 shows a smoke and convenience shop, which has become a familiar sight across the city since the legalization of recreational marijuana in 2021. it is located on the same side of the street as the development site that is for sale. the shop faces a subway entrance that is regularly patrolled by law enforcement. the presence of police and ongoing redevelopment activities have no end in sight. an immigrant man from india owns this convenience shop. he was able to employ a recent immigrant as a store clerk. however, the store has faced numerous challenges from law enforcement since its inception. such attention can be detrimental to smaller businesses like this one which may lack the resources to recover from financial losses and the potential for increased surveillance. as eric adams enters another year as mayor, he remains focused on establishing robust policing (cramer & mays, 2023). figure 6 symbolizes his commitment to this promise. it highlights the impact of these changes on primarily black and brown neighborhoods, including their businesses. solidarity during my walk, i came across the contents of figure 7, which caught my attention. the scene depicted a painting, our lady of guadalupe (unknown, n.d), enclosed by candles, plants, and debris. although figure 7 does not relate directly to redevelopment or policing, it reflects the community's solidarity amidst the transformation. redevelopment and police presence in bushwick ayana colvin figure 5. woman recycling. figure 6. smoke shop. columbia social work review, vol. xxii | 107 106 | columbia social work review, vol. xxii "our lady of guadalupe" is a significant icon in mexican culture (janzen, 2020). it can be seen throughout the neighborhood as artwork in store windows or printed on candles in bodegas. when i see this symbol, i see the people in my community. the painting was placed outside the bushwick flea market and has been there for quite some time. the flea market is only open on certain days of the week and is home to many plant shops, record collections, antiques, and vintage finds. the flea market is one of the few places in the neighborhood where you may see people of all demographics existing in the same space as people who work and sell at the flea market are from the community. "our lady guadalupe" is ubiquitous within the neighborhood. the artwork stood out as a symbol of different cultures and an appreciation of those who have historically been here. part iv: discussion by showcasing the bushwick community, i aim to encourage conversations among those who find themselves at the intersection of representation within our communities. in various boroughs of new york city, you may encounter people who live their lives differently than you, and that is a chance to examine what privileges our social positions offer us. the photographs portray individuals from the community who may be negatively impacted by increased police presence and gentrification of their neighborhood. the community of bushwick in brooklyn has undergone multiple restructurings over time, and this article aims to shed light on the effects of redevelopment and policing in the area within the context of the broader changes taking place in new york city. the photovoice methodology provided me with a better understanding of the context of the images as the photos were taken in my neighborhood. the redevelopment of an area can have lasting impacts on the community and demographic composition. scholarly research has found a link between rising housing costs and increased policing spending, particularly order maintenance policing, which focuses on maintaining social order and monitoring minor offenses (beck, 2020). community members congregating outside may feel uncomfortable due to loitering interpretations and economic pressure from rising metro costs as aspects of daily life in the community are scrutinized more closely. communities often undergo changes which may result in individuals being marginalized and neglected, and there are opportunities to consider the privileges our social positions afford us, learn about our communities' history, and show solidarity with them in various boroughs of new york city. part v: limitations while this research method allows for an extended investigation beyond the location of a photo, which in turn provides more time for reflection and a thorough interpretation of the research data, some things could be improved by this methodology. one significant limitation is the risk that my own bias as the photographer and researcher affects how the data is collected and interpreted. therefore, there is a need to expand this methodology and incorporate the voices of the community to achieve a more comprehensive approach. i conducted my research in my neighborhood, which gave me a better understanding of the photos. i am familiar with the areas where the police are usually present and have witnessed people recycle cans at local stores. i have personally visited the locations that represent the tension and unity within the community. however, if the photographs are not analyzed in conjunction with scholarly research, they may not hold any significance. my insights might have differed if i had chosen to conduct research in a neighboring area. using this methodology redevelopment and police presence in bushwick ayana colvin figure 7. community art (source: unknown, n.d.). columbia social work review, vol. xxii | 109 108 | columbia social work review, vol. xxii challenged my positionality within bushwick, shifting from neighbor to voyeur. understanding one's social location and remaining cognizant throughout the process is crucial to avoid skewing the research. to enhance the understanding of the paper, it would be beneficial to involve long-term community members in the research process. part vi: conclusion this research sheds light on the relationship between redevelopment and policing in the growing neighborhood of bushwick, brooklyn. under current mayor adams, there has been an increase in officers on foot as part of his push to decrease crime; however, daily experiences are left out when understanding what this looks like on the ground. many scholars and researchers have found that police behavior tends to change as the demographics of a community change (beck, 2020; fayyad, 2017; harris et al., 2020). additionally, much of the focus of police work is on order maintenance policing, which perpetuates harmful and inaccurate narratives about black and brown community members in bushwick. photovoice aims to promote advocacy through images to better understand a community's daily experiences. the selection of images showcased various aspects of policing, such as preventing loitering and fare evasion as well as signs of redevelopment and daily life experiences of community members. by observing these images, we can gain insight into the effects of increased policing on the area. by capturing and sharing visual representations of communities around us, people can effectively humanize issues and convey the need for policies that are truly inclusive and considerate of citizen needs. as a researcher using the photovoice methodology, i was aware of my social identity and privileges and how they could affect the results and interpretations of the study. social work researchers like me must be mindful of our positionality when employing this methodology as photovoice can help document and advocate for overlooked individuals and communities, holding our legal systems accountable. including a participatory component for long-term community members would further enrich the paper's insights. ultimately, the paper emphasizes the potential of the photovoice method to generate critical knowledge so that the experiences of those often ignored can be heard. references beck, b. (2020). policing gentrification: stops and low–level arrests during demographic change and real estate reinvestment. city & community, 19(1), 245–272. https://doi. org/10.1111/cico.12473 cramer, m. (2024, january 10). n.y.p.d. will not face budget cuts after all, adams says. the new york times. https://www.nytimes.com/2024/01/10/nyregion/budget-adams-nypd. html cramer, m., & mays, j. c. (2023, november 9). in n.y.p.d.’s harsh tactics under adams, critics see a broken promise. the new york times. https://www.nytimes. com/2023/11/09/nyregion/eric-adams-nypd.html city of new york. (2006). bushwick. bushwick neighborhood plan dcp. https://www.nyc. gov/html/records/pdf/govpub/2748bushwick_initiative.pdf evans-agnew ra, rosemberg m-as. (2016). questioning photovoice research: whose voice? qualitative health research, 26(8), 1019–1030. https://doi. org/10.1177/1049732315624223 fayyad, a. (2017, dec 20). the criminalization of gentrifying neighborhoods. the atlantic. https://www.theatlantic.com/politics/archive/2017/12/the-criminalization-of-gentrifyingneighborhoods/548837/ goldenberg, s., & anuta, j. (2022, december 24). 'big brother is protecting you': eric adams pledges stronger policing, more technology in 2023. politico. retrieved march 5, 2023, from https://www.politico.com/news/2022/12/24/eric-adams-policingtechnology-new-york-00075359. harris, b., rigolon, a., & fernandez, m. (2020). “to them, we’re just kids from the hood”: citizen-based policing of youth of color, “white space,” and environmental gentrification. cities, 107, 102885. https://doi.org/10.1016/j.cities.2020.102885 honan, k. (2023, november 17). budget cuts hit preschools, cops, libraries as mayor blames migrants. the city nyc news. https://www.thecity.nyc/2023/11/16/budgetcuts-hit-city-hall-blames-migrant-crisis/ janzen, r. (2020, december 10). why the virgin of guadalupe is more than a religious icon to catholics in mexico. university of south carolina. https://sc.edu/uofsc/ posts/2020/12/12_conversation_guadalupe.php morales, m., & nickeas, p. (2022, january 27). the nypd has resurrected its controversial anti-crime unit. success will be determined by avoiding mistakes of the past. cnn. https://amp.cnn.com/cnn/2022/01/27/us/nypd-anti-crime-unit-eric-adams redevelopment and police presence in bushwick ayana colvin columbia social work review, vol. xxii | 111 110 | columbia social work review, vol. xxii murphy, j. (2019, july 14). bushwick +10: a changing neighborhood faces a tighter housing crunch. city limits. https://citylimits.org/2019/07/09/bushwick-10-a-changingneighborhood-faces-a-tighter-housing-crunch/ nyc planning. (2018). neighborhood snapshot. https://www.nyc.gov/assets/planning/ download/pdf/plans-studies/bushwick-neighborhood-plan/plan/03-bushwick-snapshot. pdf new york police department. (2024, january 4). nypd announces december 2023, endof-year citywide crime statistics. the official website of the city of new york. https:// www.nyc.gov/site/nypd/news/p00098/nypd-december-2023-end-of-year-citywidecrime-statistics parés, m., ospina, s., & frasier, c. (2017). bushwick: emerging innovations in a dramatically gentrified neighborhood. social innovation and democratic leadership, 93–118. https://doi.org/10.4337/9781785367885.00016 payne, d. (2021). white america: awakened?. politico. https://www.politico.com/ news/2021/05/25/white-people-racial-justice-activism-george-floyd-490545 saraniero, n. (2022). inside the abandoned beer vaults of a former bushwick brewery. untapped new york. https://untappedcities.com/2022/11/21/brooklyn-william-ulmerbrewery/ stabrowski, f. (2014). new-build gentrification and the everyday displacement of polish immigrant tenants in greenpoint, brooklyn. antipode, 46(3), 794–815. unknown. (n.d.). our lady of guadalupe. brooklyn, new york. valli, c. (2015). a sense of displacement: long‐time residents’ feelings of displacement in gentrifying bushwick, new york. international journal of urban and regional research, 39(6), 1191–1208. wilson, d. (2018). chicago's redevelopment machine and blues clubs. palgrave macmillan. redevelopment and police presence in bushwick ayana colvin journal2012    columbia social work review, volume iii        46  luckily he backed off: a mixed methods analysis  of undergraduate women’s consent, attitudes and  behaviors    kelsey power    women’s sexual beliefs and behaviors are influenced by the over­ arching demands of society. this paper discusses a portion of a  study completed at a small liberal arts institution in the north­ eastern united states. female undergraduates (n = 54) answered  an online questionnaire concerning their own sexual compliance  attitudes and behaviors. o’sullivan and allgeier (1998) define  sexual compliance as engaging in unwanted sexual activity. re­ sults from this mixed methods study indicate that participants  have engaged in sexual compliance (n = 25, 46%) in their own  lives. a series of three fictional vignettes of varying sexual sce­ narios prompted qualitative narratives from participants. female  respondents endorsed the female character’s use of verbal com­ munication over physical communication of lack of desire to en­ gage in sexual activity in the vignette. however, although women  regularly used verbal communication, they expressed reluctance  to do so in specific sexual situations out of fear of making them­ selves and their partners uncomfortable. results also indicate  that participants assigned women as the “gatekeepers” of sexual  activity by giving responsibility often wholly to the female char­ acter in the scenarios (simon & gagnon, 2005, p. 68). this paper  discusses how women’s agency in sexual interactions is a prevail­ ing discourse in american culture and is reflected in the compli­ ance behaviors of women. specific programming endeavors that  aim to change this predominant culture are also discussed.      the sexual communication behaviors of women reinforce  sexual scripts created by society that dictate roles for men and  women. these societal expectations of women can translate into  women’s own sexual behaviors and beliefs. one example of such  behavior is sexual compliance, which is defined as “consensual  participation in unwanted sexual activity” (o’sullivan & allgeier,  1998, p. 234).   luckily he backed off  47        columbia social work review, volume iii    the research discussed here is part of an independent pro­ ject conducted in the spring of 2011 that originally aimed to un­ derstand how rape myths operated through women’s sexual be­ haviors and attitudes. the purpose of the project was to create a  dialogue surrounding the issue of women’s sexuality and societal  expectations through both quantitative scales and qualitative nar­ ratives. however, the small number of participants led to a reli­ ance on the qualitative portion of the study rather than results  from the scales. sexual compliance appeared as a dominant theme  throughout participants’ narratives. the shift in focus to sexual  compliance was unexpected; it is a relatively unstudied topic de­ spite its relevance to today’s sexual culture. this paper will em­ phasize the qualitative portion of the larger mixed methods study.     the results presented are a condensed version of a com­ plex set of narratives and scales. participants’ responses are split  into comments regarding the behaviors of the characters in the  vignettes (named claire and matt) and the participants’ own ex­ periences with sexual compliance. the study addressed the com­ plexity of women’s sexuality by examining the manifestation of  society’s sexual scripts in female sexual communication styles,  and critically examined the agency of women ages 18 to 25 with  their sexual partners under an assessment of the dominant culture.  the purpose of this paper is to link gender role stereotypes and  women’s feelings about how they are permitted to communicate  their sexual needs. the paper will use the terms from phillips  (2000) ­ “together woman,” and “pleasing woman” ­ (p. 39) and  from simon & gagnon (2005) ­“gatekeeper” ­ to categorize re­ sults (p. 68). lastly, the paper suggests programming and future  work concerning women’s sexuality and sexual expression.     the complexity of women’s sexual agency    specific sexual roles are assigned to both men and women  in heterosexual relationships. simon and gagnon (1987) theorize  that when assuming a sexual role, women act as “gatekeepers” of  sexual activity. women are taught to determine the boundaries of  a relationship and men are taught to push those boundaries. these  roles exist interdependently­without one, the other would not ex­ power  columbia social work review, volume iii       48  ist. women’s navigation of their own sexual agency can be a  manifestation of a societal requirement to negotiate with the typi­ cal male role of initiation (humphreys & brousseau, 2010; hum­ phreys & herold, 2007; meston & o’sullivan, 2007; o’sullivan  & allgeier, 1998; o’sullivan & bryers, 1992; simon & gagnon,  2005; vannier & o’sullivan, 2010). to adhere to assigned gender  roles, a woman sometimes finds herself in situations where she  complies with sexual activity or intercourse in order to avoid dis­ pleasing a man.   phillips (2000) discusses certain trends in society that  dominate the definition of women’s sexual roles. she investigates  the dichotomous expectation that all women face of being ex­ pected to be a “together woman” and a “pleasing woman.” a  “together women” is sexually experienced, demands equality, and  has it all; in contrast, a “pleasing woman” ignores her needs for  those of her partner. if a woman does express her desires, this  communication is always indirect. the contradictory expectations  of being “together” and “pleasing” send mixed messages about  how women are permitted to act in sexual situations. women tend  to navigate these ideals by adopting a strategy in which a female  waits until her partner notices her displeasure rather than purpose­ ly communicating this displeasure (phillips, 2000).   gendered messages regarding sexuality are not always  defined by women’s behavior and communication. humphreys  and herold (2007) indicate that there are sexual scripts that in­ struct men to ignore the first act of resistance by women because  they have learned that it signifies a “token resistance” (p. 305).  initial resistance from women can be interpreted as a strategic  move in order to not be perceived as too sexually open, while al­ lowing women to indirectly voice sexual desire. therefore, wom­ en can be construed as being compliant with the accepted gender  stereotypes. men’s tendencies to push back on women’s verbal  responses imply that passive sexual communicative behaviors are  rewarded over a vocal sexual agency.     women’s responses to mixed messages      the gender roles described above shape how women navi­ luckily he backed off  49        columbia social work review, volume iii  gate sexual roles, which is directly related to the way women  communicate their sexual agency. phillips (2000) states “but  what she does—how she exercises that power—is shaped by her  sense of what is possible, appropriate, and desirable in hetero­ relations, as well as by the particularities of this specific relation­ ship” (p. 21). a lack of women’s agency based on society’s sexu­ al scripts can lead to sexually compliant behavior. this could be  more concretely related to a woman’s attitude toward consent as a  fixed decision rather than an assessment that is reflected on a con­ tinuum of sexual choices. this is related to the male sexual drive  discourse, which suggests that society views men’s sexuality as  most important and unstoppable. this discourse implies that a  woman must navigate her sexual choices around the dominant  sexual nature of her partner. through these messages, women are  not encouraged to explore their own sexual agency (hollway,  1985; phillips, 2000).    rates of sexual compliance are relatively high in the unit­ ed states. o’sullivan and allgeier (1998) reported that signifi­ cantly more women engage in sexual compliance than men. more  specifically, three studies found that compliance rates varied be­ tween men and women, with roughly half of women and one third  of men reporting having sex when they did not want to (impett &  peplau, 2002; katz & tirone, 2009; katz & tirone, 2010; vanni­ er & o’sullivan, 2010). impett and peplau (2002) also concluded  that the length of a relationship has no bearing on a woman’s  willingness to engage in undesired sexual activity. understanding  sexual compliance is a vital tool to combat the devaluation of  women’s agency. evidence suggests that women might engage in  sexual compliance out of pressure from society to fulfill certain  expectations, but there has been little dialogue on this issue. dis­ tinguishing between agency and compliance is essential to ensure  that women understand the positive value of making a choice in  sexual situations.    study      participants were given one hour to complete an online  survey with both qualitative and quantitative measures. they  power  columbia social work review, volume iii       50  were given verbal consent and a written debriefing from a female  researcher.    !"#$%&%'"($)*     fifty­four female undergraduate students, aged 18 to 24,  participated in the online questionnaire. participants ranged in  class year, including 30 freshmen, 11 sophomores, 6 juniors, and  6 seniors. racial backgrounds were not evenly distributed, and  included 33 caucasian, 4 biracial, 3 black, 1 asian, and 3 undis­ closed.     +%,(-$$-)*     three separate vignettes were given to participants depict­ ing a fictional sexual scenario in which claire, a woman, does not  wish to have sex with matt, a man. matt and claire are both un­ dergraduate students who attend the same institution. the vi­ gnettes have different versions of the encounter (appendix a).  the scenario describes matt and claire meeting at a party and go­ ing home together. matt puts his hand on claire’s breast and she  feels uncomfortable. the first vignette ends with claire feeling  uncomfortable.      the second vignette begins identically to the first; howev­ er, the scenario describes claire moving matt’s hand away from  her breast and hip, signaling with two physical moves that she  does not want to have sex. matt asks if claire wants to have sex  and claire says yes even though she does not really want to, be­ cause it was easier than saying no.      in the third and last vignette, claire verbally indicates that  she does not want to have sex with matt when he asks, but then  proceeds to have sex when matt asks a second time. vignette 3  differs from vignette 2 in that claire indicates verbally rather than  physically that she does not want to have sex. the scenarios in  vignette 2 and 3 exemplify sexual compliance.      participants were asked to judge whether the female and  male character should have acted differently in the three sexual  situations, for example, “should claire have done something dif­ luckily he backed off  51        columbia social work review, volume iii  ferently?” and “how should matt proceed?” the participants  were then asked whether they had been in a similar scenario, and  if so, how they had acted in those situations.     .-)/0$)*   claire’s behavior        the responses discussing claire’s behavior throughout the  three vignettes varied only slightly. for all three vignettes, most  participants suggested that claire voice her lack of desire to en­ gage in sexual intercourse. for instance, one participant respond­ ed that claire should have given verbal cues such as, “she can say  she does not want to have sex with him,” to convey to matt that  she does not want to have sex. however, participants responding  to the second vignette advised claire to be more forceful in gen­ eral. for instance, 49% of women (n = 26) indicated in vignette 2  that claire should have “said no” rather than proceed. these re­ sponses assigned responsibility to claire for expressing her true  desires.     interestingly, in both vignettes 1 and 2, participants ad­ vised claire to imply that sexual activity would occur at a later  time. one such response stated, “she could say that this was real­ ly as far as she wanted to go that evening.” similarly, participants  implied that claire should tell matt that although she did not want  to have sex now, other physical behaviors would be acceptable.  however, this was not a choice indicated in the vignette script.  participants seemed concerned with claire giving matt a clear  response or “shut down,” which directly contrasts the expecta­ tions of a “pleasing woman.” saying no to matt would violate the  expectation that women act indirectly in their sexual agency. if  claire were to say no, she would be both upfront about her sexual  desires and not pleasing to the dominant male.     although responses related to vignette 3 overwhelmingly  expressed that verbal communication was best, the responses had  a critical tone concerning the contradiction between claire’s ver­ bal consent and physical dissent. for instance, one participant  wrote, “she still should have said no since she didn’t want to  power  columbia social work review, volume iii       52  have sex with him the first time he asked.” other participants did  acknowledge claire’s first refusal by commenting that claire  should have “made it clear that she meant no the first time, and  respond with no the second time he asked her. be persistent.”      of the 23% of participants (n = 11) who commented that  claire should have been more assertive, we saw strong elements  of victim blame. victim blame places responsibility for a sexual  assault on the victim rather than the perpetrator. one participant  commented that claire had done herself a disservice by taking the  easy way out and telling matt that she didn’t feel like it, stating,  “yes, she should have sticked [sic] to her original answer and not  done the stupid decision of taking the easy path. it was her fault.”  this statement assigns claire the responsibility to provide the  correct signals rather than giving matt responsibility for misinter­ preting the signals she did give. these responses suggest that  claire is accountable for giving in. the “wait until he notices”  discourse presented by phillips (2000) discusses tactics that wom­ en use to help manage heterosexual relations (p.147). women rely  on a partner’s compassion in order to exit an uncomfortable situa­ tion. women must remain passive and “wait until he notices” in  order to still be a pleasing woman (phillips, 2000, p. 147).    matt’s behavior    fifty percent of participants in vignette 2 (n = 25) indicat­ ed that matt should “ask if she is sure,” whereas only 14% in vi­ gnette 3 (n = 7) indicated that matt should verbally ask claire  again if she wants to have sex. in the verbal responses of vignette  2 and 3, participants assigned responsibility to either claire or  matt, but not to both. for example, one participant commented,  “ask again because this girl obviously doesn’t know what she  wants.”   in both vignettes 2 and 3, participants addressed the con­ cept of consent and what consent means. participants indicated  that while matt should ask again, he does already have consent,  which means that he could just continue if he so wished. one par­ ticipant articulated clearly, “there is not much realistic choice for  matt if she actually said yes, although being sure that his partner  luckily he backed off  53        columbia social work review, volume iii  is comfortable and asking again would be the wisest/most caring  choice.” these responses mimic society’s intent on women being  the “gatekeepers” of sex and men trying to “go as far as possible.”  by assigning claire responsibility to stop sex, participants vali­ dated the concept that matt’s sexuality is uncontrollable.  moreover, 24% (n = 12) of participants indicated that in  vignette 2, matt should proceed with sex “since claire said yes.”  this trend that consent is a fixed decision and claire cannot  change her mind once she has given consent mirrors the respons­ es where participants advised matt to proceed with sex. for ex­ ample, a participant stated, “if claire said yes then matt should  have sex with her. he asked her.” another said, “have sex. she  gave consent.” this implies that once verbal consent is given,  physical cues are no longer as important. this could be interpret­ ed to mean that consent does not exist on a continuum but rather  as a fixed decision.   some participants put themselves in the position of a man  and described how men probably would act in this situation. this  indicates an acknowledgment of the disparity between how men  should act in this situation and how they might actually act. how­ ever, the lack of an overlap did not seem to affect the participants.  for example, one participant commented, “well, if i were in the  same position as matt, i would try to read body language and re­ alize that she really didn’t want to. however, most men don’t do  that especially when intoxicated so i would assume he would see  it was a green light.” the participant was not critical of this male  oversight.    only in vignette 3 did participants (n = 34, 69%) over­ whelmingly respond that matt should stop, “he shouldn’t have  sex with her because she said no the first time. he should have  not asked her again.” participants could have felt that claire’s use  of verbal signals in vignette 3 gave no legitimate room for matt to  ignore claire’s sexual role. this could be because participants  connected this clearer indication of sexual compliance to their  own experiences of sexual compliance rather than a situation that  allows more room to critique claire’s nonverbal, passive commu­ nication.  women’s own similar experiences  power  columbia social work review, volume iii       54      when describing their own use of sexual communication,  participants expressed pride concerning their sexual agency. of  the 50% (n = 27) of women who said they had been in a situation  similar to vignette 1, 63% (n = 17) of them indicated that they  had used verbal cues such as “i told them i wouldn’t have sex  with them and they respected it” to signal lack of desire. these  included participants just saying no, as in “i said no which i fealt  [sic] really good about.” other responses indicated that partici­ pants eventually said no after feeling uncomfortable for some  time.    thirty percent of those 27 women (n = 8) gave a physical  cue such as “a boy tried to finger me and i didn’t want to so i  moved his hand away.” participants indicated conveying their  discomfort through body language. lastly, two women (7%) indi­ cated that they used both physical and verbal cues such as “just  pushing the hand away usually gives them the memo however on  occasion i have had to say no and they have been respectful.”  this suggests that verbal communication was considered the last  resort for this participant.   other types of responses indicated that women had had  sex when they did not want to for various reasons. sixty­two per­ cent (n = 8) of the responses from vignette 2 described partici­ pants’ own sexual compliance. when the participants described  their own sexually compliant situations, they described knowing  that they did not want to but still continuing with sex either out of  obligation to a boyfriend or because it was easier than saying no  to their partner. for example, one participant wrote, “my boy­ friend. it was his birthday. didn’t want to say no. it didn’t really  bother me. i just wasn’t into it.” another participant described, “i  have said yes to a guy to having sex when i really didn’t want to  but did anyway because it would have been awkward if i said  no.” these responses indicate that these women appeared to con­ sent to unwanted sex out of caring about the traditional feminine  pleasing role. although participants took responsibility for their  part in consenting, they also presented with negative emotions  toward the encounter. one participant described being ashamed:   i was in a situation where i said no multiple times  luckily he backed off  55        columbia social work review, volume iii  but after months of saying no, i finally said yes... i  felt ashamed that i didn’t stick with my initial re­ sponse (no) and it kind of made me feel sick. but  at the same time i thought it would be a different  experience so i should try it.  after this participant explained her negative emotions surround­ ing her decision, she justified the experience and controlled these  negative emotions by rationalizing her decision.     1%)&/))%2(*   specific themes emerged consistently from participants’  responses that demonstrated a support of dominant gender role  stereotypes confirming previous research. there are some partici­ pant responses within this section that were not highlighted in the  results but are nevertheless relevant to the discussion. participants  assigned claire the role of the “gatekeeper” and critiqued her for  not being a “together woman.” one participant wrote that claire  lacked self­respect as a woman, stating, “yes, she shouldn’t have  been such an idiot, respected herself and not been so afraid to get  out of the situation fearing his opinion of her.” other women de­ fended matt by claiming that claire gave unrecognizable signals,  “matt should proceed to have sex with claire. as far as this story  goes, it appears that matt is not a mind reader.” lastly and more  clearly, participants concluded that the misunderstanding in the  situation was claire’s fault, “yes, she should have sticked [sic] to  her original answer and not done the stupid decision of taking the  easy path. it was her fault.”      in addition, many participants agreed that once verbal  consent was given, other types of consent or nonconsent were il­ legitimate or somehow not as important. one participant re­ marked, “if claire said yes then matt should have sex with her.  he asked her.” this response assigns matt no responsibility for  understanding the sexual desires of his partner, indicating that  consent is not permitted to be ambiguous or a process. this is  problematic, considering many of the responses given by the par­ ticipants themselves involve much ambiguity and confusion.   results demonstrate a disconnect between how women  power  columbia social work review, volume iii       56  behave and how they think other women should behave. partici­ pants were critical of claire while still making similar choices in  their own lives. the conflict that the participants might have felt  in their own lives probably biased the critical nature of their re­ sponses to claire. in essence, participants may actually have been  critical of the agency they did not always take in sexual situa­ tions, and this was displaced onto the character claire.   although participants indicated that claire should use ver­ bal communication skills over any other type of communication,  they expressed a discontent with using this method themselves  even though it was the most self­reported communication style.  one participant described this discomfort, “i said that i was not  ready to have sex but i felt uncomfortable having to say that.”  other participants described avoiding taking agency using the  word no by making excuses, “i tried making up excuses why i  couldn’t instead of just saying no.” lastly, one participant de­ scribed saying no as possibly spoiling the mood of the moment, “i  have said yes to a guy to having sex when i really didn’t want to  but did anyway because it would have been awkward if i said  no.”   the study originally aimed to link victim blame, sexual  compliance, and rape culture, but in the end the results spoke the  most about sexual compliance. this research can begin to change  the way society examines and discusses rape. as powell (2008)  suggested, we “overlook those experiences of pressured or co­ erced sex, wherein the line between consent and non­consent be­ comes for some, increasingly blurred” (p.169). society fails to  encompass the ambiguity of consent, which leads to a dominant  model of the concept of rape. as peterson and muehlenhard  (2007) agree, “rape victims who accept the narrow definition of  rape promoted by the dominant model and who had reasons for  wanting to have sex may believe that their experience does not  qualify as rape” (p.74). this leads to underreporting and the per­ sistence of a narrow definition of rape. the most problematic out­ come occurs when one does not acknowledge that a rape trauma  has occurred and the healing process is fragmented.    limitations and future directions  luckily he backed off  57        columbia social work review, volume iii    because the study aimed to provide both qualitative and  quantitative data, one limitation is the small sample size, which  does not allow for generalization of the results. while these an­ swers are valid and important, the power of this statistical test  creates results that are not applicable to all populations.   in addition, this research was based at an undergraduate,  upper­middle class, liberal arts college and focused only on het­ ero­normative behaviors. further research must focus on how  sexual compliance and sexual coercion are interrelated and can be  applied cross­culturally and within same­sex relationships. edu­ cation about these sexual scripts and ways women, perhaps un­ knowingly, control these expectations can reduce sexual compli­ ance rates and better our understanding of rape culture. moreover,  men’s sexuality and the discourses surrounding male dominance  should be investigated, as these roles reinforce problematic gen­ der role stereotypes for women.   changing this culture requires empowerment and educa­ tion. programs in high school and middle schools can lead to dia­ logue surrounding these issues at an early age. society must begin  to expand its idea of women’s sexual roles. giving females voices  concerning their own bodies and sexual agency is the first step  toward giving them power in sexual situations.  programs such as girls write now (gwn) can help give  females the dialogue and space to express their feelings concern­ ing their sexuality and role in society. gwn is an after school  creative arts program for high school girls living in new york  city. since 1998, gwn has been providing 3,500 women each  year with the opportunity to receive a mentoring relationship with  a creative writing community (http://www.girlswritenow.org/ gwn/). giving our youth the language to both understand these  messages and then voice their opinions is an important step in  changing our culture surrounding women’s sexual agency. the  understanding and breakdown of these messages can then help  spread awareness to other groups and other places. this can help  eliminate the behaviors, such as sexual compliance, that prevent  agency and promote victim blaming.     on a smaller scale, programs such as the crime victims  power  columbia social work review, volume iii       58  treatment center (cvtc) of roosevelt and st. luke’s hospitals  are safe spaces to receive free counseling for survivors of sexual  violence. cvtc is a program offered within hospitals in which  volunteers meet survivors during rape and domestic violence ex­ aminations. the cvtc staff then reaches out to the survivor for  support (http://www.cvtc­slr.org/). because our understanding of  victimhood is so limited, many individuals may feel as though  they do not count as a victim. instead of understanding the com­ plicated nature of sexual roles, victims are taught to blame them­ selves. the cvtc is a safe space for men and women to discuss  the ambiguity of sexual roles and activity in order to heal after a  traumatic sexual experience.  the effects of society’s mixed sexual expectations on both  the behaviors and thoughts of the female participants are evident  in the present study. participants were more understanding of  their own sexually compliant behaviors rather than the sexually  compliant behaviors of a fictitious woman. further research  should address this gap because it is difficult to measure the psy­ chological and social impact of consenting to unwanted sex. it is  impossible to fully understand how the impact of society’s con­ trol over female sexuality influences self­image. as social work­ ers, it is our ethical obligation to understand the oppressiveness of  social messages and provide opportunities for the empowerment  of our clients who are struggling to become agents in their sexual  experiences.      references    hollway, w. (1985). gender difference and the production of  subjectivity. psychology, social regulation, and subjec­ tivity, 2, 227–263.   girls write now. retrieved from http://www.girlswritenow.org/ gwn/.  humphreys, t. p., & brousseau, m. m. (2010). the sexual con­ sent scale­revised: development, reliability, and prelimi­ nary validity. journal of sex research, 47, 420–428.  humphreys, t., & herold, e. (2007). sexual consent in hetero­ sexual relationships: development of a new measure. sex  luckily he backed off  59        columbia social work review, volume iii  roles, 57, 305–315.   impett, e. a., & peplau, l. a. (2002). why some women consent  to unwanted sex with a dating partner: insights from at­ tachment theory. psychology of women quarterly, 26,  360–370.   katz, j., & tirone, v. (2009). women’s sexual compliance with  male dating partners: associations with investment in ide­ al womanhood and romantic well being. sex roles, 60,  347–356.   katz, j., & tirone, v. (2010). going along with it: sexually coer­ cive partner behavior predicts dating women’s compliance  with unwanted sex. violence against women, 16, 730– 742.   meston, c. m., & o’sullivan, l. f. (2007). such a tease: inten­ tional sexual provocation within heterosexual interactions.  archives of sexual behavior, 36, 531–542.   o’sullivan, l. f., & allgeier, e. r. (1998). feigning sexual de­ sire: consenting to unwanted sexual activity in heterosex­ ual dating relationships. journal of sex research, 35, 234 –243.   o’sullivan, l. f., & bryers, s. (1992). college students’ incorpo­ ration of initiator and restrictor roles in sexual dating in­ teractions. the journal of sex research, 29, 435–446.   peterson, z. d., & muehlenhard, c. l. (2007). conceptualization  the ‘wantedness’ of women’s consensual and nonconsen­ sual sexual experiences: implications for how women la­ bel their experiences with rape. journal of sex research,  44, 72–88.   phillips, l. m. (2000). flirting with danger: young women’s re­ flections on sexuality and domination. new york: new  york university press.   powell, a. (2008). amor fati?: gender habitus and young peo­ ple’s negotiation of (hetero)sexual consent. journal of so­ ciology, 44, 167–184.   simon, w. & gagnon, j.h (2005). postadolescent sexual devel­ opment. sexual conduct: the social sources of human sex­ uality. retrieved from: http://books.google.com/books? id=rycoagg5h_ic&printsec=frontcover&source=gbs_ge_ power  columbia social work review, volume iii       60  summary_r&cad=0#v=onepage&q&f=false  st. luke’s roosevelt hospital treatment center. retrieved from  http://cvtc­slr.org/.  vannier, s. a. and o’sullivan, l. f. (2010). sex without desire:  characteristics of occasions of sexual compliance in  young adults’ committed relationships. journal of sex re­ search, 47(5), 429­439    appendix a    +%,(-$$-*34*     claire was at a party drinking a few beers with her friends.  she started kissing matt, who is in her statistics class. they had  been flirting all week, and claire really liked him. matt asked  claire to come home with him, and she agreed. once they were in  matt’s room, they were kissing. matt started putting his hand on  her breast, which made claire feel uncomfortable because she  didn’t really want to have sex with matt that night.    how might claire communicate that she doesn’t want to have  sex?   have you ever been in a situation like this?   if so, how did you react?    +%,(-$$-*56*+-#)%2(*34*   claire was at a party drinking a few beers with her friends.  she started kissing matt, who is in her statistics class. they had  been flirting all week, and claire really liked him. matt asked  claire to come home with him, and she agreed. once they were in  matt’s room, they were kissing. matt started putting his hand on  her breast, which made claire feel uncomfortable. she moved his  hand to her hip. he continued to move his hand back to her  breast, and she continued to try to move him away. matt asked if  claire wanted to have sex, and claire said yes, even though she  didn’t really want to, because it was easier than saying no.  how should matt proceed?  luckily he backed off  61        columbia social work review, volume iii  should claire have done something differently?   have you ever been in a situation like this?   if so, how did you react?    +%,(-$$-*56*+-#)%2(*5*   claire was at a party drinking a few beers with her friends.  she started kissing matt, who is in her statistics class. they had  been flirting all week, and claire really liked him. matt asked  claire to come home with him, and she agreed. once they were in  matt’s room, they were kissing. matt started putting his hand on  her breast, which made claire feel uncomfortable. she moved his  hand to her hip. he continued to move his hand back to her  breast, and she continued to try to move him away. matt asked if  claire wanted to have sex, and claire said ok, even though she  didn’t really want to, because it was easier than saying no.    how should matt proceed?  should claire have done something differently?   have you ever been in a situation like this?   if so, how did you react?    +%,(-$$-*76*+-#)%2(*34*   claire was at a party drinking a few beers with her friends.  she started kissing matt, who is in her statistics class. they had  been flirting all week, and claire really liked him. matt asked  claire to come home with him, and she agreed. once they were in  matt’s room, they were kissing. matt started putting his hand on  her breast, which made claire feel uncomfortable. she moved his  hand to her hip. matt asked if claire wanted to have sex, and  claire responded, “i don’t feel like it.” he continued to move his  hand back to her breast, and she continued to try to move him  away. matt asked again if they could have sex, and claire said  yes, even though she didn’t really want to, because it was easier  than saying no.    how should matt proceed?  power  columbia social work review, volume iii       62  should claire have done something differently?   have you ever been in a situation like this?   if so, how did you react?    +%,(-$$-*76*+-#)%2(*5*   claire was at a party drinking a few beers with her friends.  she started kissing matt, who is in her statistics class. they had  been flirting all week, and claire really liked him. matt asked  claire to come home with him, and she agreed. once they were in  matt’s room, they were kissing. matt started putting his hand on  her breast, which made claire feel uncomfortable. she moved his  hand to her hip. matt asked if claire wanted to have sex, and  claire responded, “i don’t feel like it.” he continued to move his  hand back to her breast, and she continued to try to move him  away. matt asked again if they could have sex, and claire said  ok, even though she didn’t really want to, because it was easier  than saying no.    how should matt proceed?  should claire have done something differently?   have you ever been in a situation like this?   if so, how did you react?                          reactive attachment disorder (rad):  finalized digital files.pdf columbia social work review, vol. xxii | 53 52 | columbia social work review, vol. xxii inspiration for article as a hospital social worker for nearly ten years, i’ve worked with patients experiencing homelessness and was aware that solutions are sorely lacking. but it was only when i started working at the emergency department that i saw head-on the catastrophic outcomes of lives lived at the margins, without a safe place to stay. a few months into my new role, a patient arrived in critical condition. he presented with a high fever and was unconscious, appearing thin, soiled, wearing only boxers. the paramedic reported he was picked up from a tent encampment, and “who knew” how long he had been like this. it was jarring to see another human being in this shape. as with other patients in critical condition, i contacted the emergency contact, only to learn he had a loving family who lived out of state and had been unable to help him with severe substance use disorder. they were now distraught to hear about his condition. one of my co-workers said it best: “to someone out there, he is somebody.” this case became a catalyst for me to want to learn more, and – even if in small ways improve my practice with patients experiencing homelessness. i am a licensed clinical social worker in connecticut and a graduate of columbia university’s school of social work. my work experience includes yale child study center and yale university’s share program. presently i work at yale new haven hospital’s emergency service, both with adult and pediatric patients. cristina cantú, lcsw columbia social work review, vol. xxii | 55 54 | columbia social work review, vol. xxii what can social workers do to help the growing number of people experiencing homelessness? “homelessness is, in a way, just the visible tip of the iceberg of problems in the country. the affordable housing crisis, poverty, racial inequities, substance and drug abuse addictions, mental health. all of them are sort of manifest when you see people living in the streets. tackling homelessness is in fact a kind of triage, it’s just dealing with a part of these larger problems” (kimmelman, 2022, 0:55). cristina cantú, lcsw h omelessness is a growing problem nationwide. according to the u.s. department of housing and urban development (hud), the number of people experiencing homelessness rose 12% from 2022 to 2023 (hud exchange, 2024b). low vacancy rates, increased rent costs, and income inequality all comprise difficult structural factors locking people out of the housing market. those who most harshly bear the brunt of this crisis are people with social vulnerabilities. this paper analyzes the social problem of homelessness from the perspective of an urban hospital emergency department (ed), yale new haven hospital (ynhh) in new haven, connecticut. social workers in these settings have a dual role: working directly with individuals and families to connect them with available services and resources and advocating for structural interventions that can ultimately ease this problem. social workers are also at the forefront of combating any stigma unhoused persons face by both approaching patients experiencing homelessness with dignity and respect while educating others that this problem is not one of the individual, but is rather a consequence of multiple other social problems we have collectively failed to address. ed social workers are consulted to help address the entire spectrum of psychosocial problems being faced by patients. social workers are key team members in addressing cases of abuse and neglect and take primary responsibility for compliance with mandated reporting requirements. because ynhh is a level-1 trauma center, social workers also prioritize patients who arrive with full or modified traumas. those arriving as cardiac arrests or needing urgent life-saving measures are also referred to social work. in all these cases, social workers act as liaisons to family members and provide support while also assisting with next steps. the role of a social worker in the ed also involves addressing any issue that impacts effective care or treatment of a health problem. columbia social work review, vol. xxii | 57 56 | columbia social work review, vol. xxii prevalence, terminology, and demographics according to the u.s. department of housing and urban development, homelessness has steadily risen since 2017 (hud exchange, 2024b). based on the 2023 nationwide point-in-time (pit) count, 650,000 people were experiencing homelessness in the united states, and homelessness in families with children rose by 15.5% (hud exchange, 2024b). past studies have found, however, that flawed methodology and varying execution may lead to undercounting the persons who are homeless through the pit count, with the annual number of people who are homeless being 2.5 to 10.2 times greater (national law center on homelessness & poverty [nlchp], 2017). the pit count is a measure mandated by hud and seeks to count all sheltered and unsheltered people within a specific area one day per year. the most recent pit data available for the state of connecticut is from the january 24, 2023 count. the number of individuals found to be experiencing homelessness across connecticut at that time was 3,015, which represented a 2.9% increase from 2022 (advancing ct together [act], 2023). according to the count, the number of persons experiencing chronic homelessness remained stable at 117 (act, 2023). the pit count also found that homelessness among youth (ages 24 and younger) had increased by 7.06% (act, 2023). as of 2023, connecticut’s rate of homelessness was 8.1 people per 10,000, which was lower than the national rate of 18 out of 10,000 (national alliance to end homelessness [naeh], 2023a). hud categorizes types of homelessness into four groups: literally homeless, at imminent risk of homelessness, homeless under other federal statutes, and fleeing/attempting to flee domestic violence. literally homeless means having a primary nighttime residence not meant for human habitation, staying in a shelter, or a person being discharged from a facility where they remained less than 90 days and have no other residence (hud exchange, 2024c). imminent risk of homelessness is defined as a person who will be homeless within 14 days, with no place to go or resources to secure permanent housing (hud exchange, 2024c.). homeless under other federal statutes refers to unaccompanied youth less than 25 years of age or families with children and youth who do not otherwise qualify as literally homeless under hud, but may qualify under other federal programs (hud exchange, 2024c). for example, the department of education defines homelessness as lacking a “fixed, regular, and adequate nighttime residence” (parolin, 2021, p. 46), which may capture a wider number of people. finally, fleeing/attempting to flee domestic violence refers to an individual or a family fleeing intimate partner violence, including dating violence, sexual assault, stalking, and other dangerous or life-threatening conditions that relate to violence and having no place to go or resources to secure permanent housing (hud exchange, 2024c). hud also has a longer definition for persons categorized as chronically homeless: people who have been without a residence for extended periods of time. the definition, as delineated in section 401(9) of the mckinney-vento assistance act (42 u.s.c. 11360(9)) is as follows: lives in a place not meant for human habitation, a safe haven, or in an emergency shelter, and has been homeless and living as described for at least 12 months or on at least 4 separate occasions in the last 3 years, as long as the combined occasions equal at least 12 months and each break in homelessness separating the occasions included at least 7 consecutive nights of not living as described (hud exchange, 2024b, para. 4). people who are deemed chronically homeless qualify for specific hud programs. however, because of the intricacy of the definition, it is often difficult for people to provide proper evidence to qualify as chronically homeless with barriers such as difficulty obtaining identification or documentation and long wait periods (wusinich et al., 2019). further exploration of the demographics of homelessness makes it clear that “the hazard of experiencing homelessness is not uniformly distributed across different populations” (willison et al., 2023, p. 1). what can social workers do to help the growing number of people experiencing homelessness? cristina cantú, lcsw columbia social work review, vol. xxii | 59 58 | columbia social work review, vol. xxii according to the naeh, the marginalized groups with highest incidence of homelessness also have “extensive histories of experiencing oppression, including displacements from land and property and exclusions from housing opportunities” (2023a, para. 9). hud data from 2022 shows that rates of homelessness are highest among native hawaiian or other pacific islanders (121.2 out of 10,000), black or african american (48.2 out of 10,000) and american indian (44.9 out of 10,000) (naeh, 2023a). comparatively, the rate for the white population is 11.6 out of 10,000 (naeh, 2023a). in 2020, nearly 40% of those experiencing homelessness were black, and 23% were latino, while they comprise only 13% and 18% of the population, respectively (center on budget and policy priorities [cbpp], 2022). these numbers are not a new trend. homelessness data from 2007 to 2017 shows that blacks, american indians, and native hawaiians were at least twice as likely than whites to experience homelessness (willison et al., 2023). it is also worthwhile to explore the distinction between persons who are sheltered and unsheltered. being unsheltered means having a primary nighttime residence that is a public or private place not meant for human habitation; for example, a city sidewalk, vehicle, an abandoned building, a park, under a bridge, a train station, or a tent encampment (naeh, 2023a). a sheltered person is anyone who is temporarily residing at a publicly or privately operated shelter; for example, congregate shelters, transitional housing, a hotel or motel paid for by charitable organizations, or an institution such as a hospital or treatment facility. notably, anyone who is couch-surfing, doubled up with others, or paying for their own hotel room is not considered homeless but may be considered at-risk for homelessness (hud exchange, 2024a). persons who are unsheltered often have generally poorer health and face a higher risk of premature death when compared to those who are sheltered (richards & kuhn, 2022). the data also shows that those from marginalized communities have higher rates of being unsheltered, as noted below. according to hud 2022 data, native hawaiian or asian pacific islanders, asian americans, and native americans have the highest incidence of being unsheltered – with 53%-55% of their homeless population living unsheltered (naeh, 2023a). people of marginalized genders also have a higher incidence of being unsheltered, based on hud 2022 data, with 56% of transgender people who are homeless being unsheltered and 78% of homeless genderquestioning individuals being unsheltered (naeh, 2023a). connecticut law requires shelters to accept people based on their gender identity, regardless of sex assigned at birth. however, this law does not necessarily stymie the bias or microaggressions that people who are gender-nonconforming may experience in shelter settings. an analysis of the 2015 u.s. transgender survey by the williams institute at the ucla school of law found that close to 85% of transgender adults who are homeless reported not seeking shelter at a homeless facility because of concern for mistreatment (o’neill et al., 2020). contributing causes to homelessness what leads any one person or family to become homeless can be examined as the interplay of three types of factors: structural factors, precipitating or adverse life events, and individual vulnerabilities. structural factors can include rental market conditions, housing policy, income inequality, and the social safety net or lack thereof. adverse life or precipitating events may include sudden loss of income, catastrophic health problems, exposure to a natural disaster, loss of family member, divorce, or foreclosure, to name a few. individual vulnerabilities include non-heterosexual identity, low educational attainment, unemployment, veteran status, a history of incarceration, mental health and substance use disorders (nilsson et al., 2019), and involvement with child welfare and juvenile justice systems (naeh, 2023b). however, while individual factors increase the risk of becoming homeless, according to colburn and aldern (2022), the root causes of high rates of homelessness are primarily housing market characteristics–structural forces out of the control of any one person. simply stated by colburn, “in places that are expensive, homelessness is high, and in places that are cheap, homelessness is low” (kingcountytv, 2022, 5:03). what can social workers do to help the growing number of people experiencing homelessness? cristina cantú, lcsw columbia social work review, vol. xxii | 61 60 | columbia social work review, vol. xxii in their book homelessness is a housing problem, gregg colburn and clayton aldern (2022) made an exhaustive study of data comparing rates of homelessness across cities and counties along with factors usually associated with homelessness. they examined poverty rates, weather, mental illness rates, substance use, and areas with generous welfare benefits. the data clearly indicated that those factors did not correlate with rates of homelessness. colburn and aldern (2022) noted that, in fact, the areas with the highest wealth distribution paradoxically experience the highest rates of homelessness. conversely, a state such as west virginia, where the opioid epidemic has hit hardest, does not have the high rates of homelessness seen elsewhere (kingcountytv, 2022). at the same time, the vast majority of the 40 to 52 million people who experience substance use or psychiatric disorders are not homeless (pitkin, 2022). colburn and aldern (2022) showed that it was ultimately rent levels and rental vacancy rates that were most associated with regional rates of homelessness. this explains why places like san francisco and new york have such high numbers of homeless people–there are simply not enough affordable dwellings for people to inhabit. once this housing crunch is a set condition, like a game of musical chairs, those with vulnerabilities will be more likely to end up without a spot. while it is important to consider individual comorbidities, particularly when advocating for treatment, shifting the view to structural factors is helpful because it reduces the tendency to blame the individual for the problem they are experiencing, and it helps divert attention to structural interventions that can actually make a difference (colburn & aldern, 2022). when looking at structural or root causes of homelessness, it is worth examining how these factors contribute to minority communities being disproportionately affected by homelessness. the dynamics involved are complex, entrenched, and undeniable. centuries of discrimination, from slavery to segregation, weigh on present generations. racist policies such as neighborhood segregation and exclusion of blacks from federally-backed mortgages led to wealth disparities between white americans and people of color (willison et al., 2023). these wealth disparities now “exacerbate risks of housing insecurity and homelessness for people of color due to a lack of protections, including at community and family levels, to mitigate or bounce back in cases of financial hardship” (willison et al., 2023, p. 2). interventions intended to help–the systems of support for homeless persons–do not help black persons equitably (pitkin, 2022). the disproportionate presence of the child welfare and criminal justice systems in communities of color have long-term effects and carry risk into later adulthood (pitkin, 2022). other factors that contribute to housing instability among communities of color include higher cost burden among renters of color and the inadequacy of housing stock to meet the needs of multigenerational families of color (lake, 2020). based on an analysis of yearly hud surveys, desmond (2023) also finds that “black renters continue to face routine discrimination when searching for apartments” (p. 69). considering the sum total of these facts, perhaps this is why balasuriya et al. (2020) writes, “regardless of mental health status, people who are homeless generally have a history marked by poverty and social disadvantage… and they are likely to belong to an ethnic minority” (p. 3). homelessness, mental health, and substance use as discussed earlier, there is a public perception that mental health problems or substance use disorders are a direct pathway to homelessness (pitkin, 2022). in fact, the relationship between homelessness and mental health problems is more complex. studies have found a bidirectional association between homelessness and mental illness (nilsson et al., 2024). while mental illness may contribute to loss of housing or inability to remain housed (and is a vulnerability as discussed earlier), homelessness itself contributes to worsening mental health (padgett, 2020). it follows that depression, suicidal thoughts, symptoms of post-traumatic stress disorder, and substance misuse are more prevalent among the homeless population (substance abuse and mental health services administration [samhsa], 2011). rates of more severe mental illnesses, such as schizophrenia, are at 25%–30% among homeless persons (padgett, 2020) and were noted to be at 26.2% of all sheltered persons in 2010 (samhsa, 2011). what can social workers do to help the growing number of people experiencing homelessness? cristina cantú, lcsw columbia social work review, vol. xxii | 63 62 | columbia social work review, vol. xxii significantly, homeless and marginally housed individuals do appear to have a more than 50% rate of traumatic brain injury (tbi), which is much higher than the general population (padgett, 2020). tbi can influence a person’s executive function, for example increasing impulsivity and impairing working memory (ozga et al., 2018). deficits in executive function may complicate efforts to maintain stable housing and thus become a vulnerability. more than one-third of people experiencing homelessness have been found to have a substance use disorder (sud), with two-thirds of those individuals having a lifetime history of sud (polcin, 2016). again, as with other health problems, “the relationship between homelessness and substance abuse is complex, with studies suggesting that substance use can be both a cause and consequence of homelessness” (polcin, 2016, p. 2). one thing is clear: being homeless is not a condition that supports recovery. polcin (2016) argues for housing options that offer harm reduction and built-in options for treatment. health and healthcare barriers people experiencing homelessness contend with a higher burden of health problems (morris & gordon, 2006). canham et al. (2018) discuss tri-morbidity, meaning the confluence of physical health problems, mental health problems, and substance use disorders that leads to higher mortality rates. there are varied numbers describing mortality rates among people experiencing homelessness. franco et al. (2021) report that homeless patients have twice the mortality rate of nonhomeless cohorts. meanwhile, omerov et al. (2019) place the number much higher, describing excess mortality at eight times higher for men and twelve times higher for women, although this estimate also includes other high-risk groups, such as prisoners and sex workers. medical problems most heavily experienced by homeless patients include chronic pulmonary obstructive disease, arthritis, musculoskeletal disorders, seizures, hypertension, diabetes, liver diseases, tuberculosis, hepatitis c, hiv, dental problems, skin problems, and foot problems (canham et al., 2018). people experiencing homelessness also faced twice the mortality rate from covid-19 as compared with the general population (gavidia, 2022). conditions associated with homelessness have obvious adverse effects on health and can include exposure to the elements, living in crowded conditions, exposure to violence, poor nutrition and sleep, and lack of access to bathing. barriers to accessing healthcare, delays in seeking care, and difficulty adhering to treatment also contribute to poor health outcomes (canham et al., 2018). omerov et al. (2019) further describe barriers to care faced by homeless patients such as lack of health insurance, lack of identification, lack of mail or telephone service, poor transportation, and limited knowledge of where to receive resources. beyond these barriers, omerov et al. (2019) found that stigma and bias can also prevent adequate provision of healthcare to patients experiencing homelessness. based on a research review, unhelpful relations with medical providers and social care professionals were characterized by a lack of respect or empathy toward clients, judgment for appearance, patient feeling invisible, unrealistic follow-up advice, and restricting freedom or autonomy. they further highlight the problem of some healthcare professionals showing “insensitivity to ethnic disparities or the unique needs of people of color” (omerov et al., 2019, p. 6). on the flipside, omerov et al. (2019) also describe the experiences of homeless patients with professionals the patients believed were supportive. positive experiences include respectful social interactions, feeling comfortable showing vulnerability, being able to laugh together, flexibility regarding appointments, feeling listened to, providers remembering details of their lives, and when patients were given decision-making power. emergency department use given the wide range of health problems, and the propensity of these problems to worsen while homeless, these patients understandably have higher utilization of the ed. franco et al. (2021), who conducted what can social workers do to help the growing number of people experiencing homelessness? cristina cantú, lcsw columbia social work review, vol. xxii | 65 64 | columbia social work review, vol. xxii a study focusing on the ynhh ed and the greater new haven area, explain that people experiencing homelessness represent a disproportionate share of ed visits compared to housed cohorts. unhoused patients have approximately three times more usage and are four times more likely to return within three days as compared to housed individuals (franco et al., 2021). homeless patients are also more likely to present with injuries acquired while in the community; for example, assaults, both physical and sexual (morris & gordon, 2006). franco et al. (2021) describe the ed as a “de-facto shelter and sobering center [which] serves not only as medical but also social safety net” (p. 9). in effect, the ed provides respite from conditions faced in homelessness and serves as a 24-hour drop-in center. notwithstanding, franco et al. (2021) highlight that this higher frequency of ed care does not translate to improved health outcomes for homeless patients, and it places a strain on an already stressed system. franco et al. (2021) conclude that “homeless patients require social needs to be met alongside medical ones,” and that this can be best achieved through collaborations with community partners (p. 8). social workers are uniquely positioned to create those connections. role of social work in the emergency department ed social workers can play a role in improving outcomes for persons who are experiencing homelessness. in canham et al.’s (2018) article health supports needed for homeless persons transitioning from hospitals, the authors provide a clear guide as to the six realms of intervention that can make the most impact. they conducted a literature review and analysis and concluded that stopping the cycle of hospital discharge and readmission of homeless patients requires attention to a full range of needs–both medical and basic needs. canham et al. (2018) acknowledge that systems are insufficient to meet the needs of homeless patients; for example, lack of access to specialty health services, lack of affordable step-down care, and lack of rehabilitation beds. the efforts made by professionals can, at the very least, improve the probability of success. the six themes related to health support cited by canham et al. (2018) are a respectful and understanding approach to care, conducting housing assessments, communication/ coordination/navigation with outside providers, support for after-care, complex medical care, and medication management, basic needs, and transportation. drawing from personal experience as a social worker in the ed, the recommendations by canham et al. are an effective guide to direct practice. as mentioned earlier, people experiencing homelessness may arrive for care to the ed having experienced stigma and bias in the past (omerov et al., 2019). a respectful and understanding approach can counter this and helps to facilitate the development of a collaborative working relationship in which an effective housing assessment can be conducted. as delineated above, homelessness can be experienced in multiple ways, and a patient’s particular circumstances should drive specific recommendations. obtaining nuanced information is key in determining the appropriate next step. the same can be said for assisting patients in seeking services to address mental health services or substance use treatment. conversations that help identify possible barriers or obstacles to obtaining this care are important to avoid making unrealistic recommendations. the ynhh ed is located in a state which has an established hotline, 211, to assist callers with housing and other needs. the hotline is the entry point for services for people and families experiencing homelessness. the process entails an initial interview in which personal data is gathered and leads to an appointment for a housing assessment by a state-contracted agency. it is essential for social workers to understand the local system of support with clarity to be able to explain it to patients. likewise, being familiar with community resources is imperative, as is establishing relationships with community providers and maintaining upto-date information on service and resource availability. finally, a warm hand-off to community healthcare providers or other agencies, when possible, may improve chances that the patient will have continuity of care. what can social workers do to help the growing number of people experiencing homelessness? cristina cantú, lcsw columbia social work review, vol. xxii | 67 66 | columbia social work review, vol. xxii future trends two emerging demographic trends among the homeless population should be highlighted. first, as individuals with chronic patterns of homelessness age, they require more medical services and help with activities of daily living. while symptoms of severe mental health or substance abuse may become less acute through the lifespan, chronic health conditions progress and worsen. communities, states, and the federal government would be wise to begin planning to address this need today by perhaps investing in permanent supportive housing units for the elderly with healthcare personnel on hand. second, the number of young people experiencing homelessness is also growing at alarming rates. homeless youth may include young people who are part of families, head of households, or individuals (cbpp, 2022). young people with involvement in the child welfare or juvenile justice systems, those who identify as lgbtq, pregnant and parenting youth, young people with special needs, and young people of color may be at higher risk of homelessness (naeh, 2023). simultaneously, the current cohort of teens who are estranged from the educational system may struggle to become earners as young adults and will thus have greater vulnerability to becoming homeless. without comprehensive prevention and early intervention efforts by communities, states, and the federal government, this trend will result in a whole new generation of people with established patterns of homelessness. solutions ending homelessness is neither out of reach nor an impossible goal. the cbpp recommends expanding housing choice vouchers, including providing universal housing vouchers to reduce hardship for all families (2022). they further recommend shoring up the social safety net. more specifically, we know that for people with chronic homelessness or those having difficulty maintaining a residence, a permanent supportive housing model works, as it provides on-site support including case management and ease of access to healthcare, mental health, and substance use disorder treatment. for those experiencing transitional homelessness, a rapid-rehousing model with a rental subsidy, even if time-limited, is effective. partnering with developers to build affordable housing is also a critical component in easing a housing shortage. communities and states would be wise to begin today to expand all these programs. it will require financial resources and investment like any other federal, state and local initiative. in continuing to think about solutions to homelessness, it is crucial to hear the voices of people experiencing it as they are the primary stakeholders. a hopeful development occurred in new haven last fall when six tiny houses were installed in the area where tent encampments had been torn down (grace-flood, 2023). the prefabricated units were assembled and installed by former tent encampment residents and neighborhood volunteers. while small, it is a worthwhile effort that can perhaps be scaled up in the future, and it demonstrates that creative and grass-roots solutions can play a role in ending homelessness, one person at a time. conclusion social workers are uniquely positioned to contribute to positive solutions to help address homelessness. working directly with individuals to help address health, mental health, and substance use needs is important. helping folks problem-solve to exit homelessness and maintain housing is essential. providing guidance in navigating the complex systems set up to help is valuable. because a social worker is one strand in a community safety net, they can be most effective when partnering and collaborating with local resources. educating others regarding factors that contribute to homelessness is important, particularly when it comes to acknowledging system failures, housing market conditions, and entrenched inequities in our social environment. simultaneously, maintaining a view on the broader context and advocating for solutions on the macro-level has to take precedence. this problem will only be solved when communities, states, and the federal government make meaningful investments to increase affordable housing and fortify safety nets. what can social workers do to help the growing number of people experiencing homelessness? 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(2019). “if you’re gonna help me, help me:” barriers to housing among unsheltered homeless adults. evaluation and program planning, 76(c), 1-1. https://ideas.repec.org/a/eee/epplan/v76y2019ic13.html what can social workers do to help the growing number of people experiencing homelessness? cristina cantú, lcsw mental health courts: an interface between social work and criminal justice columbia social work review, volume i       36                  mental health courts: an interface   between social work and   criminal justice    leslie roberts    mental health courts (mhcs) are emerging as a critical element in the nation­ wide effort to counter overcrowding in the us prison system and more ade­ quately address the plight of offenders who are diagnosed with a mental ill­ ness. the goals of  mhcs, an example of problem­solving courts, are to im­ prove the quality of life for those involved in the criminal justice system, link  clients to community treatment resources, and reduce recidivism and crime  rates in a more cost­effective manner than within the traditional criminal jus­ tice process. this article provides a brief history of mhcs, including the ra­ tionale behind their initial implementation, an overview of their clientele and  process, a review of the role social workers play, arguments for and against  their broader introduction, and specific research recommendations to better  ascertain their current and future effectiveness. although mhcs are still too  nascent to draw broad conclusions about their rates of efficacy, early results  are promising.         over 7.3 million (1 in every 31) adults in the united states are under  criminal justice supervision, and for the first time in the nation's history, the  adult incarceration rate is 1 in 100 (warren, 2008). between 1997 and 2007,  the country’s prison population almost tripled. the department of justice re­ cently estimated that more than half of all individuals who are incarcerated  have been found to have mental health problems (james & glaze, 2006).      all too often, the us penal system, whose stated goal is to protect  society and punish those who have committed crimes, has instead taken the  place of community mental health services and in­patient psychiatric units by  housing large numbers of people living with mental illness. for instance, in  2008, the los angeles county jail system housed 1,400 people who required  daily mental health services, effectively making it the largest mental institution  in the country (montagne, 2008). the size and scope of the issue makes it all  the more difficult to devise a workable strategy for the mentally ill that does  not bust budgets.  the need for mhc can be directly connected to the deinstitutionaliza­ tion of psychiatric hospitals roughly 40 years ago, a social movement aimed at  releasing patients living with mental illness from deplorable conditions in state  psychiatric hospitals and transitioning them to community mental health cen­ ters to provide quality treatment. although this goal was commendable, the  subsequent lack of funding for continued community mental health actually  left this population without oversight (fields, 2006).     advocates in the us concurrently began to clamor for reductions in  37        columbia social work review, volume i    mental health courts  crime rates, and politicians consequently sent more people convicted of crimes  to jail, including many non­career criminals living with mental illness who  were in need of proper psychiatric care. the policies this decision has engen­ dered have led to overcrowded jails, a prohibitive rise in the cost of incarcera­ tion, and the ever­present likelihood of recidivism, which played a central role  in the creation of the “revolving door” of criminality (delcka, 2001).   as the number of people in the criminal justice system steadily in­ creases and financial resources become even more scarce, those living with  mental illness become less likely to receive the treatment they require. in fact,  adults living with mental illness are arrested for the same behavior twice as  often as people who are not diagnosed with a mental illness (teplin, 2000).  therefore, the size and scope of the issue makes it all the more difficult to de­ vise a workable strategy that is fiscally responsible. to wit, 47 percent of fed­ eral inmates and 42 percent of jailed inmates with diagnosed mental illness  have served three or more prior sentences (james & glaze, 2006).  these issues evoke equally strong sentiments from victims’ rights  groups and criminal justice advocates. among the rehabilitative responses that  have provoked rigorous debate are mhcs. this paper will provide a compre­ hensive overview of mhcs and discuss the benefits and drawbacks of this al­ ternative form of sentencing. finally, the paper will provide a series of large  and small­scale recommendations for social workers and researchers.      what is a mental health court?      the main goals of an mhc are: to provide necessary mental health  treatment, decrease recidivism, increase public safety, and reduce legal and  incarceration costs. judges, prosecuting attorneys, police officers, defense at­ torneys, and family members can all refer participants. most mhcs use a  model that re­routes participants into community mental health treatment in­ stead of the traditional criminal justice system. in some courts, pending  charges can be deferred as a judge monitors the person’s adherence to the  structure of the mhc. other mhcs require a guilty plea in order to become a  client.    mhc staff members include judges, attorneys, social workers, bail­ iffs, case managers, and court liaisons who have been trained in mental health.  this multi­disciplinary team works collaboratively to develop treatment plans  and sanctions for those who do not comply. this team also finds community­ based mental health providers for additional care, incorporates substance abuse  treatment, and locates housing and public benefit agencies. partnering with all  of these service providers builds a lasting support system for the client.    mental health court clientele    each mhc utilizes different criteria to determine its participants;  there is no nationally recognized standard. interestingly, research has demon­ strated that felony offenders in alternative­sentencing programs remain in treat­ columbia social work review, volume i        38  roberts  ment longer, successfully complete or “graduate from” those programs at  higher rates, and are much less likely to commit crimes post­completion pro­ vided they remain under court supervision (rempel & destefano, 2001). the  reasons for these higher success rates are two­fold: (1) felony offenders are  mandated to treatment, where they must remain for longer periods of time; and  (2) the stakes are higher since failure to complete the program will likely re­ sult in a long prison sentence (redlich, steadman, monahan, petrila, & griffin,  2005).       the history and rationale of mhcs    the us has yet to properly answer a fundamental question about its  penal system: are prisons meant to rehabilitate or simply house inmates?  there are numerous reasons behind the recent significant increase in the num­ ber of mentally ill offenders. inmates are often released without proper access  to necessary medications or referrals for adequate psychiatric care. in addition,  there has been a general decline in access to inexpensive psychiatric services  and public hospital beds (watson, hanrahan, luchins, & lurigio, 2001). to­ gether, issues like these conspire to push people living with mental illness  away from the treatment they require and toward anti­social behaviors they  might not be able to control.  the first mhc opened its doors in broward county, florida in 1997  in an attempt to address the issues of individuals diagnosed with mental illness  residing among the broader prison population (watson et al., 2001). the court  evolved from a taskforce established three years earlier by a local judge and  public defender, who were searching for specific solutions to the interrelated  problems of the increasing number of inmates with mental illness and over­ crowded jails. taskforce members consisted of community mental health treat­ ment providers, hospital administrators, a spokesperson for the public de­ fender, representatives of the state’s attorney, and county sheriff officers  (watson et al., 2001).        by linking people with a mental illness to alternative forms of incar­ ceration, many mhc advocates view these courts as a form of therapeutic ju­ risprudence, since they are expected to engender positive long­term lifestyle  changes that avert a life of crime. the concept of therapeutic jurisprudence  holds that “the law should be used, whenever possible, to promote the mental  and physical well­being of the people it affects” (slate & johnson, 2008, p.  432).     therapeutic jurisprudence seeks to focus attention on an often­ neglected variable necessary for mental health law and practice (wexler,  1993). the expectation of proponents of therapeutic jurisprudence is improved  psychiatric stability for offenders, which is believed to eventually translate into  better public safety, since these inmates should be less likely to commit crimes  after release from prison. therapeutic jurisprudence advocates argue that  mhcs are an effective alternative to incarceration, since they target an under­ served population but are not an easy way to avoid lengthy prison sentences.  39        columbia social work review, volume i    mental health courts    mhcs also offer practical benefits: they are less costly than incarcera­ tion. recent research regarding an mhc in allegheny county, pennsylvania  found that it saved 18,000 dollars per person verses the traditional criminal  justice system, translating to 3.6 million dollars in annual savings (ridgely et  al., 2007). given current governmental budgetary pressures, this is no small  issue. studies show that state prisoners with mental health illness served four  months longer than prisoners without mental health issues (james & glaze,  2006).     recent research has demonstrated that clients who are involved in  mhcs progress longer without a new criminal offense and are much less likely  to be arrested for a violent offense than offenders who are forced to navigate  the traditional criminal justice system. those who graduate the mhc have  lower rates of recidivism and commit fewer violent crimes even after direct  supervision has ceased (mcniel & binder, 2007).    the mental health court process      although the specific process of entry into a mhc varies from court  to court, there are significant similarities across the 250 currently in operation  across the us. post­arrest intake specialists at a jail assess an offender’s mental  state and competency. if the intake officer, offender, prosecuting attorney, de­ fense attorney, family member, or arresting officer report any symptoms of  mental illness, a social worker, psychologist, or psychiatrist immediately per­ forms a more thorough assessment. if an examiner deems the individual men­ tally ill and recommends him for participation, the case is eligible for transfer  to an mhc. all cases are reviewed thoroughly by the mhc team, which  makes a final, collaborative admission decision.       as noted earlier, in some courts, once an individual is recommended  to the court, he must plead guilty to charges to secure his/her spot. this  “guilty” plea is a useful tool: if a participant absconds, misses appointments, or  does not follow­through with their treatment plan, the previous guilty plea  means they will be sentenced immediately as they would have in the traditional  criminal justice system.    the court’s clients must pass a number of different stages with full  compliance to graduate. there is no nationally recognized number of stages,  although most of the 250 mhcs in the united states typically compel clients  to complete three to four stages (vleet, hickert, becker, & kunz, 2008). the  duration of each stage differs on an individual basis and from court to court,  although all require full compliance before completion. compliance means  attending all court­mandated counseling sessions and hearings, avoiding addi­ tional trouble with the law, and passing random drug tests. with the comple­ tion of each stage successful clients are rewarded with incentives that include a  reduced frequency of court appearances, placement on the “rocket docket,”  which allows them to appear before the judge at the beginning of status hear­ ings and leave court earlier than others (vleet et al., 2008), certificates of com­ pletion, and small gifts such as movie certificates or candy. it is hoped that  columbia social work review, volume i        40  roberts  these benefits incentivize clients to continue to work hard and successfully  complete the program (gonnerman, 2004).      over time, a client is given increasing freedom to ease his transition  back into society and to ensure that he can effectively cope outside of a struc­ tured environment. a judge’s level of personal involvement is often critical.  the judge is the final arbiter of a client’s performance and is therefore in a  unique position of determining an individual participant’s success or failure.     mental health courts: the positives and negatives      when assessing the efficacy of mhcs, it is critical to remember that  its clients are living with mental illness and in need of treatment. many have  received little to no psychiatric care prior to incarceration. consequently, ac­ cess to treatment is theoretically life­altering, particularly if the client accepts  and responds to care and stays with counseling and prescribed medications  after graduation. community mental health professionals, who are highly  skilled in psychiatric settings, typically provide regular treatment for clients  rather than court staff. when necessary, the mental health professionals can  recommend to the judge that clients be provided in­patient psychiatric treat­ ment.  ongoing arguments about who deserves to participate in these pro­ grams continue, as there are no national standards for admission. other ques­ tions include whether mhcs can legally force clients to use legal psychotropic  medications and how to codify proper sanctions for non­compliant behavior  (e.g. jail time, community service, additional courtroom appearances, or dis­ missal). some mental health professionals question whether mhcs violate a  client’s rights if he is forced to take prescribed medications and/or is remanded  to prison for failing to effectively deal with a debilitating mental illness. in  addition, some criminal justice advocates believe mhcs engender an unwel­ come stigma for clients as both criminals and mentally ill. conversely, victims’  rights advocates argue that many clients are not committed to getting better but  are instead finding a way to evade prison.      mental health courts and the social work interface    given social work’s ethical obligations to criminal justice, its unique  stance on social justice, respect for human dignity, and commitment to disen­ franchised/vulnerable populations, social workers are uniquely qualified and  well suited to make significant contributions to individuals and families in­ volved in the criminal justice system (national association of social workers,  1999).       social workers play a number of critical roles in a mhc. clinical di­ rectors, who typically have a graduate degree in social work, oversee a team of  social workers with forensic experience who conduct initial evaluations. social  workers also serve as treatment coordinators who maintain daily contact with  clients and also mental health providers who follow up on treatment plans and  41        columbia social work review, volume i    mental health courts  create reports for the judge to track a client’s progress. they are also charged  with the day­to­day responsibilities of providing clients with the skills to lead  productive lives and to provide for their basic needs, including substance abuse  treatment, psychiatric treatment options, housing, food, and medical care.  mhcs are an opportunity for social workers whose interests lie in criminal  justice, mental health, and social service systems to influence an emerging en­ terprise that is setting new standards and creating new solutions.   unfortunately, as the social work profession has evolved, it has  largely abandoned the field of criminal justice and corrections; neither the na­ tional association of social workers (nasw) nor the bureau of labor statis­ tics lists how many social workers currently or have previously worked in cor­ rections. in addition, the nasw does not regard corrections as one of its eight  specialty practice methods (nasw, 1999).   the social work field’s code of ethics mandates that social work pro­ fessionals maintain a commitment to social justice (nasw, 1999). unfortu­ nately, the lack of criminal justice curriculum in master­level social work pro­ grams is keeping future social workers from gaining the skills to address an  area of critical need, considering many students will work with clients affected  by crime, corrections and the justice system. recent studies indicate among the  95% of council on social work education­certified msw programs that had  field placements in the criminal justice arena, over half were specific to law  and social work and therefore did not include work within criminal justice set­ tings (epperson, roberts, tripodi, ivanoff, & gilmore, 2009).     research conclusions      researchers and advocates on all sides should remember that this is  still a relatively new initiative and documenting the performance of one mhc  should not be generalized to all.  therefore, researchers must be careful to al­ low the mhc initiative broad adoption before beginning to draw meaningful  conclusions.      specific research recommendations:       delay evaluations until a court has been fully implemented and proce­ dures have been standardized for measurement purposes.     ensure validity of the design. assess the effectiveness of a court by  using other innovative legal approaches dealing with clients who are  mentally ill and implement treatment other than typical processing. for  example, compare mhcs to other interventions, including mandatory  treatment as part of probation/parole requirements, pre­trial diversion  or assignment of a mental health advocate (almquist & dodd, 2009).    columbia social work review, volume i        42  roberts   collect information on the characteristics and percentages of clients  who are eligible but choose not to participate or reasons clients were  deemed ineligible for the mhc.       provide a clearer picture of the people, court systems, and communi­ ties most suited for a mhc, explaining clearly why one community or  client population might have better outcomes.    determine whether mhcs improve criminal justice outcomes by link­ ing participants to effective treatment, increased public safety, reduced  recidivism, and reduction of correction costs.  (almquist & dodd, 2009)      until we can begin to draw conclusions about the broader efficacy of  mhcs, judges and prosecutors must continue to vigilantly assess the viability  of each potential client, the failure to do so, given the possibility an offender  might commit additional crimes, could possibly derail the entire initiative.  mhcs offer an alternative to the criminal justice system, beyond standard plea  agreements or trials by jury, which might not be the proper course of legal  remedy for some offenders. as with virtually anything, mhcs will rise or fall  largely on the actions of those who populate them, from judges, to lawyers, to  social workers and, most crucially, to clients.     because initial evidence shows that mhcs are more cost­effective  and provide generally better client outcomes than traditional justice settings,  adoption is likely to become more widespread over the coming years. there­ fore, social workers, policy makers, and researchers must devise ways in which  to more fully involve themselves, ensure broader utilization, and make the en­ tire concept better and more workable for both clients and professionals.    references    almquist, l., & dodd, e. (2009). mental health courts: a guide to research­   informed policy and practice. new york: agency for healthcare re   search and quality.   assertive community treatment. retrieved april 30, 2008, from     http://www.omh.state.ny.us/omhweb/ebp/adult_act.htm  center for court innovation. mental health court section. retrieved april 22,  2008, from http://www.courtinnovation.org/ idex.cfmfuseaction=page.viewpage&pageid=511&documenttopicid =25  d’emic, m. (2007). the promise of mental health courts. criminal justice, 22    (3), 24­29.  denckla, d., & berman, g. (2001). rethinking the revolving door:  a look at     mental illness in the courts.  2­32. retrieved december 15, 2009,    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national association of social workers. (approved 1996, revised 1999). code  of ethics of the national association of social workers. retrieved  april 22, 2008, from http://www.naswdc.org/pubs/code/code.asp  pew center on the states. (2005). one in 100: behind bars in america  2008. washington, dc: author.   redlich, a., steadman, h., monahan, j. petrila j. & griffin, p. (2005). the  second generation of mental health courts. psychology, public policy,  and law, 11 (4), 527­538.    rempel, m., & destefano, c.d. (2001). redictors of engagement in court­ mandated treatment: findings at the brooklyn treatment court, 1996­ 2000. journal of offender rehabilitation, 33, 87­124  ridgely, s. engberg, j., greenber, m., turner, s. demartini, c., & dembosky,  j. (2007). an evaluation of the fiscal impact of allegheny county  mental health court. justice, treatment and cost. rand corporation  technical report series.        seltzer, t. (2005). mental health courts: a misguided attempt to address the  criminal justice system’s unfair treatment of people with mental ill­ ness. psychology, public policy, and law, 11(4), 570­586.  slate r.n., & johnson w.w. (2008). criminalization of mental illness. dur­ ham, nc: carolina academic press.  stephan, s., & winick b. (2005). a dialogue on mental health courts. psychol­ ogy, public policy, and law, 11(4), 507­526.    teplin, l. (2000). keeping the peace: police discretion and mentally ill per­ sons. national institute of justice, july, 12.    united states department of justice. (2006). mental health problems of prison     and jail inmates. bureau of justice statistics special report. wash­    ington, d.c.: james, d., & glaze, l.   vleet, r.k., hickert, a.o., becker, e.e., & kunz, c. (2008). evaluation of the  salt lake county mental health court: final report. salt lake city,  utah: utah criminal justice center.   watson, a., hanrahan, p., luchins, d., & lurigio, a. (2001). mental health  courts and the complex issue of mentally ill offenders. psychiatric  services. 52, 477­481.  columbia social work review, volume i        44  roberts  wexler, d. (1993). an orientation to therapeutic jurisprudence. new england  journal of criminal and civil confinement, 20, 529­530.  wolff, n., & pogorzelski. w. (2005). measuring the effectiveness of mental  health courts; challenges and recommendations. psychology, public  policy, and law. 11 (4), 539­569.  wortzel, h., binswanger, i., martinez, r. filley, c., anderson, c., et al.     (2007). crisis in the treatment of incompetence to proceed to trial:    harbinger of a systemic illness. the journal of the american     academy of psychiatry and the law, 35(3), 357­363.                                                          columbia social work review, vol. xxiii | 3 2 | columbia social work review, vol. xxiii this year, our country is experiencing a significant political transition. critical programs that support immigration, mental health, and other essential services are losing funding. at the same time, international relations are shifting and deepening the uncertainty. as divisions within society grow, it’s understandable that many—especially students—may feel hesitant to speak out. in such a polarized climate, it’s easy to wonder if our voices matter, or if change is possible. the truth is, systemic oppression has always existed. the events today are the result of deep-rooted historical trauma and inequality that have shaped society for generations. this reality can make many feel powerless and exhausted. yet, it is in these moments that the voices, passion, and commitment to social justice matter the most. in this 23rd edition of the columbia social work review, i hope to offer a glimpse of hope—that even in difficult times, progress is possible. our authors dive into the complexities of inequalities in mental health, disabilities, race, healthcare access, and housing—issues deeply embedded in our history. they offered policy alternatives, technological innovations, increased cultural sensitivity, and adaptive strategies to build a just and equitable future. this journal remains committed to elevating the voices of students and alumni, critiquing the status quo, and pushing for the rights of underserved populations. i hope that the review can continue to strive to be a platform where ideas for change can thrive, and where the fight for justice can continue, even in the smallest of steps. a personal reflection from editor-in-chief: stephanie cheng as you read through this edition, i hope you are reminded that your voice matters. no matter how small the step, every effort toward justice is a step forward. in community, stephanie cheng editor-in-chief, 2024-2025 columbia social work review columbia social work review, vol. xxiii | 1 over the past year, columbia has made one thing brutally clear: students—especially those at the school of social work—have been targeted and punished for daring to speak out. expulsion, suspension, eviction, and doxxing have become the cost of conscience. those who speak out for palestine, for abolition, for transformative change have often done so at great personal risk. as a student at the school of social work, i have watched the institution fail to protect the very values it claims to teach—transparency, accountability, and justice. in a program meant to prepare us to challenge systems of oppression, students have instead faced institutional retaliation. that contradiction has fractured the relationship between the school and the students it seeks to shape into ethical practitioners. for me, the review has become more than a publication—it has become a site of resistance. a student-led space where social work is reclaimed as a radical, liberatory practice. where we refuse the depoliticized, bureaucratic versions of the profession and instead uplift visions rooted in abolition, decolonization, mutual aid, and collective care. a space that makes room for political clarity, grief, imagination, and rage. i dedicate my work on this issue to all students who have been punished for embodying the true ethics of social work—ethics that demand we stand with the oppressed, even when it is inconvenient or unsafe. the work within these pages uplifts the voices of those most impacted by the very systems we are taught to critique—communities our profession has historically harmed and must now learn to serve with integrity. i believe the columbia school of social work must not only reckon with its complicity in systems of violence—it must rise to the challenge a personal reflection from editor-in-chief: halla anderson of transformation. it must become a space that honors its deepest commitments to justice and to the people social work was always meant to protect. in solidarity, and in defiance, *the views expressed here are solely my own and do not necessarily reflect the views of the columbia social work review, its editorial board, or the columbia school of social work. halla anderson editor-in-chief, 2024-2025 columbia social work review journal of student social work, volume vii 43 / scott shifting from social service to social change casa de esperanza (casa) is an influential domestic violence organization in st. paul, minnesota. upon examining the changes that have occurred within the organization since its inception, we have struggled with returning to the original mission of addressing domestic violence only in the latino/a community or remaining an agency that serves women from diverse backgrounds. casa has decided to remain an organization dedicated to serving women from diverse backgrounds, but will now place the community, rather than the individual, at the center of the organization. within the next ten years, casa will shift from providing direct social services to working toward broader social change. specific changes include phasing out direct services, mobilizing communities to fight violence against women as it intersects with other forms of violence, and advocating for legislative change. as part of the integrative capstone project at columbia university school of social work (cussw), we were assigned to evaluate a modified case study of casa de esperanza (casa). casa is an existing domestic violence (dv) agency located in st. paul, minnesota, that was struggling with the decision to either return to its original mission of addressing dv in the latino/a community or to remain an agency dedicated to serving women from diverse backgrounds. all information regarding casa in the paper is based solely on information provided in the case study (casa esperanza, 2009). this paper presents the changes that we propose the agency make, and is written from the perspective of casa as it is embarks on implementing these changes. in reality, none of the proposed changes have or will be implemented. from its inception, casa was guided by the mission to eliminate violence against women in the latino/a community. in spite of this initial target group, increasingly diverse groups of women have sought our assistance. upon analyzing data from organizational focus groups 44 / shifting from social service to social change caroline angle, shiral jindal, alpana patel additional contributors: alicia ayvas, katarzyna bogusiewicz, susan chittooran, melissa furdyn, julie nichols, ariel russo, zhanjie si, carla siri, jennifer stark, leah weinzimer, and tracee worley journal of student social work, volume vii and surveys, our stakeholders have determined that gaps in services provided by other organizations in the st. paul, minnesota area have positioned us to respond to the unique needs of women of color (casa esperanza, 2009). we have, therefore, decided to expand our focus in order to respond to women from all backgrounds, particularly women who are marginalized due to poverty, poor education, language barriers, and a fear of deportation, all of which increase the barriers to finding effective services (women of color network, 2006). our first priority is to re-conceptualize the women we serve as the center of our organization, what smith (2006) refers to as “recentering.” re-centering involves analyzing and organizing against dv in the context of its multiple layers of violence against communities of color (smith, 2006). we aim to reject the mainstream concept of feminism that was created in response to the circumstances and needs of white women, and upon which dv organizations are often modeled. by placing women of all backgrounds at the center of our organization, we are compelled to re-examine the division between social service and social change. according to kivel (2007), social service work addresses the needs of individuals who have experienced violence, while social change work addresses the root causes of violence. although we understand the need to provide direct social services, especially for those in crisis, we do not believe that these social services alone will eliminate violence against women. by working toward social change, casa can help women challenge societal notions of violence rather than simply managing the individual trauma of dv. the historic prioritizing of the individual over the community in traditional dv models has proven inadequate (crenshaw, 1993; bierra, 2007). casa is committed to resisting and confronting all violence and oppression, including, but not limited to, racism, sexism, classism, heterosexism, homophobia, transphobia, ableism, and ageism. intraorganizationally, we will adopt antioppressive language that brings attention to issues of power and privilege with our employees and clients, as well as with our stakeholders, funders, and other agencies with whom we collaborate. for instance, for as long as we continue to provide direct services, we will no longer assume that clients identify with traditional binary gender norms. instead of asking whether clients are male or female on our intake forms, we will ask clients how they define their gender. the goal of this change is to avoid revictimizing clients and to respect each client’s personal identity. in an effort to reorient and reorganize our focus to social change, our major recommendation is to place the community, rather than the individual, journal of student social work, volume vii 45 / angle, jindal, patel journal of student social work, volume vii 46 / shifting from social service to social change journal of student social work, volume vii at the center of our anti-violence work. our revised mission statement and vision to reflect our focus on social change are as follows: mission statement: the mission of casa de esperanza is to mobilize our communities to create a society founded on respect, equality, safety, and justice; a pursuit that requires the eradication of violence against women. guiding principles: (1) we serve women from diverse backgrounds that seek safety and protection from domestic violence; (2) we put women at the center of our organization, taking into account the complexities of gender-and sexuality-based violence as experienced by communities of color; and (3) we are an organization dedicated to social change, complemented by sustainable social services. organizational changes in order to develop an organizational structure that prioritizes survivors as potential community organizers, casa will reconceptualize our organizational chart to reflect helgelsen’s (2005) web of inclusion, an integrated and organic structure that places leadership at the center of an interconnected web. we aim to disrupt hierarchical boundaries between casa’s staff and constituents by developing leadership among our constituents, hiring constituents as interns and staff, placing constituents on the board of directors, and organizing regular community gatherings to facilitate community building among various stakeholders. we are not suggesting the dissolution of all boundaries between staff and constituents. we acknowledge that staff must maintain some level of institutional power in order to effectively organize. however, we are developing an organizational structure in which our constituents feel empowered to become an integral part of organizational change (bierra, 2007). restructuring our organization to become more integrated within our community will also require a number of human resource changes. our staff must begin to reflect the diversity of the communities we serve with regard to race, gender, culture, language, religion, sexual orientation, gender identity, age, and ability. a recruitment committee consisting of community members and volunteers will be central to our recruiting, hiring, evaluation, and retention processes (fong & gibbs, 1995). before recruiting new staff, job descriptions must be reviewed, evaluated, and re-written to include the ideals of our new mission. casa must implement activities to incorporate new journal of student social work, volume vii 46 / shifting from social service to social change staff members into an environment in which they feel comfortable working with existing staff (mor barak, 2000). evaluation of workers will be expanded to include feedback from other staff, survivors, and the broader community. russo (2001) notes that the professionalization of dv work has encouraged a hierarchical organizational structure within agencies, resulting in services that are provided by individuals who are increasingly removed from the violence and grassroots activism that initially spurred the dv movement. casa has been deeply impacted by the professionalization of our once community-based origins, and now aspires to shift away from such hierarchical leadership. we must reorganize our budget and diversify our funding sources. currently, 80 percent of our budget comes from state and federal revenue to provide social services (casa esperanza, 2009). the majority of government funding available is specifically for direct services. within that constraint, we are unable to serve women who do not have legal residency as our funding requires proof of legal residency or citizenship for each individual we serve. we cannot rely on these funds as we transition to a social change organization. we aim to reduce our dependency on government funding by half over the next five years. our revised fundraising plans include implementing smalland largescale fundraising programs, fostering individual community-based donors, soliciting foundation funding from progressive sources, and applying for a broader range of federal and state government grants, including funding to work with individuals who are undocumented. in order to incorporate all of these fundraising activities, the development department, which includes representation from casa’s community constituents, must be strengthened. fundraising efforts should be tied into community organizing strategies. outreach should pursue both diverse communities and political, philanthropic, religious, and educational leaders. we must re-brand and communicate our new identity to our stakeholders. following kotter’s (1996) process of change theory, we will anchor our new mission and vision within the agency’s culture by forming a community collaboration board of three to five community stakeholders. the board will communicate our mission and vision internally (stakeholder meetings, staff development) and externally (annual reports, direct mail, email, newsletters, and media communications). institutionalizing these innovative approaches into casa’s organizational culture will ensure that the new mission and vision are fully aligned. journal of student social work, volume vii 47 / angle, jindal, patel journal of student social work, volume vii micro-level changes casa’s programs will continue in the short-term to include comprehensive case management in which survivors are provided with shelter, information, and referrals to legal and medical services as well as public benefits. we envision a gradual phasing out of a significant portion of our direct services over the next five to ten years. sokoloff and pratt (2005) argue that the dv shelter system is often modeled similarly to the prison system. women’s activities are monitored and policed, and they are cut off from their friends and families. sokoloff and pratt write, “the shelter system mirrors the abusive patterns of control that women seek to leave in battering relationships and isolates women from their communities” (p. 145). we will continue in the short-term to conduct a needs assessment to ensure that we are addressing the needs of survivors by utilizing an empowerment approach to our direct services. to align services with casa’s revised mission, we will use as the primary practice modality a constructivist empowerment approach asserting that women are the experts in their own lives (peled, eisikovits, enosh, & winstok, 2000). advocates will be trained to defer to the choices that women make with respect to whether or not they leave abusive relationships and to focus on helping women gain resources and support. shelter care will be phased-out over the next five to ten years and the continued need for shelter care will be addressed through capacity building with other dv organizations that serve women in the st. paul area. mezzo-level changes historically, violence against women has been viewed as a private issue and women alone have been held accountable for protecting their children and rebuilding their lives. violence is a public issue that the entire community must be responsible for eradicating. sustainable violence prevention is contingent on a community’s willingness to challenge normative behaviors and attitudes. therefore, we are pursuing community organizing as the focal point of our struggle against dv (bowen, gwiasda, & brown, 2004). such an approach operates across underlying systemic issues that create inequalities in the distribution of power and resources that directly contribute to violence against women (crenshaw, 1993). journal of student social work, volume vii 48 / shifting from social service to social change to begin this process, we will conduct a thorough needs assessment of our community’s understanding of dv and its ability to respond to it. following hardina (2002), we will conduct semi-structured interviews and focus groups. these interviews will assess community resources, as well as community members’ understanding of the nature, causes, and potential responses to violence against women. focus groups will include women who have previously sought services for dv, and service providers and professionals in allied areas, such as the family and criminal court systems, hospitals, and schools. we will also involve stakeholders such as representatives from the media, local businesses, academics, and representatives from other groups who have not traditionally been active in the anti-dv movement. following an analysis of the needs assessment, casa will mobilize toward community activism. community outreach programs should be expanded to include programs for children, adolescents, women, and men about issues of dv. community organizing efforts will be twofold. the first strategy is to raise awareness within communities about violence towards women, its intersection with other forms of violence, and the impact dv has on individuals, families, and communities. the goal of this strategy is to break the silence and stigma surrounding dv and underscore that this is not just a “women’s problem” but a human rights issue that affects and oppresses all of our communities. the second strategy is to organize around specific community issues that hinder dv survivors and communities at large from overcoming cycles of violence. housing, financial security, and immigration are significant concerns. casa intends to address these issues through building coalitions with other anti-dv, human rights, and anti-oppression groups to spread awareness about these rights to members of the community. we will facilitate letter-writing campaigns, protests, rallies, and meetings with legislators and executive directors of non-profit organizations to bolster support. we will have a visible presence at community events, and we will provide educational awareness through public service announcements, radio and tv interviews, as well as presentations at schools, adult education centers, and community centers. macro-level changes in order to complement our community organizing approaches and to promote larger, systemic change, casa will join the movement that reframes dv as an international human rights issue. we will advocate for legislative changes that push beyond the current journal of student social work, volume vii 49 / angle, jindal, patel journal of student social work, volume vii limits in u.s. policies. the goal is to connect individually experienced dv to community violence, state-led violence, and other systems of oppression that perpetuate violence (bettinger-lopez, 2008). casa will unite with other human rights coalitions. in doing so, we will draw on our strengths and local experiences to inform national and international strategies for combating violence against women. we will also assist in leveraging the work of local, national and international organizations to bolster media coverage, educational outreach, and policy changes. casa will benefit from and contribute to advocacy efforts focused on social change at the individual, local community, national, and international levels. by connecting women’s experiences with dv at the local level to broader systemic issues, the injustices faced by the women we serve becomes the basis for bringing impact litigation, developing testimony for congressional hearings, lobbying for legislative change, and highlighting the systemic issues that exacerbate violence against women. conclusion the challenge casa faces with regards to leadership in the field of dv prevention lies in balancing the constant demands of direct social service provision with the rapidly changing macrolevel contexts. we have provided a framework for implementing changes at each of the micro, mezzo, and macro levels of social work services. reconsidering and restructuring casa’s mission will enable us to create an organization that truly addresses violence against women as it intersects with other forms of violence and impacts communities. community organizing to end dv entails active participation and the articulation of the clear message that all people have the responsibility to end violence (hart, 1995). by transforming from a social service to a social change organization, we can empower our community to eliminate violence against women. references bettinger-lopez, c. (2008). human rights at home: domestic violence as a human rights violation. columbia human rights law review. 40, 19-77. retrieved january 6, 2009 from http://ssrn.com/abstract=1310316. bhattacharjee, a. (2002). putting community back in the domestic violence movement. retrieved january 6, 2009 from http://popdev.hampshire.edu/projects/dt/15. bierra, a. (2007). pursing a radical anti-violence agenda inside/outside a non-profit s structure. in a. bierra (ed.), incite! women of color against violence: the revolution will not be funded (pp.151-164), cambridge, ma: south end press. journal of student social work, volume vii 50 / shifting from social service to social change bowen, l.k., gwiadsa, v., & brown, m.m. (2004). engaging community residents to prevent violence. journal of interpersonal violence, 19, 356-367. bringing human rights home lawyer’s network, columbia university law school. (2008). bringing human rights home lawyer’s network. retrieved january 6, 2009 from http://www.law.columbia.edu/centerprogram/humanrights/ hrinus/bhrhlawnet. “casa esperanza.” (2009). university of washington, daniel j. evans school of public affairs, the electronic hallway, https://hallway.org/index.php. crenshaw, k. (1993). race, gender, and violence against women. in m. minow (ed.), family matters: readings on family lives and the law (pp. 3-51). new york: new press. fong, l., & gibbs, j. (1995). facilitating services to multicultural communities in a dominant culture setting: an organizational perspective. administration in social work, 19, 1-24. froelich, k. (1999). diversification of revenue strategies: evolving resource dependence in nonprofit organizations. nonprofit and voluntary sector quarterly, 28, 246-268. hardina, d. (2002). needs assessment. in d. hardina (ed.), analytical skills for community organizational practice (pp.111-175).new york: columbia university press. hart, b.j. (1995). coordinated community approaches to domestic violence. retrieved january 6, 2009 from http://www.mincava.umn.edu/documents/hart/cca/cca.pdf helgeson, s. (1995). the web of inclusion: a new architecture for building organizations. new york: doubleday. hoskisson, r., hitt, m., & ireland, r. (2004). competing for advantage. mason, oh: south western. kivel, p. (2007). social service or social change. in a. bierra (ed.) incite! women of color against violence: the revolution will not be funded (pp. 129-149). cambridge, ma: south end press. kotter, j. (1996). leading change. boston, ma: harvard business school press. mor barak, m. e. (2000). the inclusive workplace: an ecosystem approach to diversity management. social work, 45, 339-352. peled, e., eisikovit, z., enosh, g., & winstok, z. (2000). choice and empowerment for battered women who stay: toward a constructivist model. social work, 45, 9-25. russo, a. (2001). taking back our lives: a call to action for the feminist movement. new york: routledge. smith, a. (2006). without bureaucracy, beyond inclusion: re-centering feminism. left turn, (20), 1-4. retrieved january 7, 2009 from the world wide web at:http://www.leftturn. org/?=node/396. sokoloff, n., & pratt, c. (2005). looking to the future: domestic violence, women of color, the state and social change. in sokoloff and pratt (eds.) domestic violence at the margins: readings on race, class, gender, and culture (pp. 416-419). rutgers, nj: rutgers university press. women of color network. (2006). facts & stats: domestic violence in communities of color. harrisburg, pa. retrieved january 6, 2009 from www.womenofcolornetwork.org/ factsheetsdvfactsheet.pdf. worth, m., & wagner, l. (2008). nonprofit management: principles and practice. thousandoaks, ca: sage. journal of student social work, volume vii 51 / angle, jindal, patel columbia social work review, vol. xix | 29 technological innovations in dementia care: the role of social work advocacy esther park columbia social work review, vol. xxiii | 31 30 | columbia social work review, vol. xxiii technological innovations in dementia care author’s note at the time of this paper’s writing, the u.s. federal government was undergoing a presidential transition. as a result, significant changes have been made to federal government websites, including the removal or modification of policies, webpages, and datasets. these limitations in information availability, along with policy shifts under the new administration, may affect some of the resources, government programs, and funding opportunities discussed in this paper. future research will be needed to evaluate the long-term impact of these changes on equitable access to dementia care technologies, public access to essential data for caregivers and healthcare professionals, and the role of social work advocacy in supporting affected communities. abstract according to the world health organization (2023), dementia affects over 55 million people across the globe, projected to increase to 139 million individuals by the year 2050. the caregiver burden, which compounds over the years of illness, includes emotional, physical, and financial challenges. these challenges disproportionately impact lowincome and minority communities (mickens et al., 2020). this research paper explores the role of technology in alleviating these challenges by improving the quality of life of both persons with dementia (pwds) and their caregivers. current technological tools, including healthcare monitoring tools, location-tracking devices, and reminiscence therapy platforms, are analyzed for their strengths in addressing the cognitive and safety needs of pwds. i also address limitations such as financial barriers, digital literacy gaps, and accessibility challenges among older adult populations. the study emphasizes the significant role of social workers in advocating for equitable, person-centered care through policy and community-level interventions. recommendations for social workers are provided, including promoting digital literacy programs, subsidizing assistive technology costs, and prioritizing user-centered designs to ensure equitable access to dementia care technologies. esther park innovations in dementia care: the role of technology and social work advocacy dementia, a progressive neurodegenerative condition, leads to a wide array of cognitive impairments, including memory loss, difficulty with language, and a reduced ability to perform daily activities (rahman & howard, 2018). globally, over 55 million people live with dementia, and this number is projected to reach 139 million by the year 2050 (world health organization [who], 2025). this significant increase emphasizes the urgent need to address the numerous challenges associated with dementia care. these concerns include ensuring the safety of persons with dementia (pwds), alleviating the caregiving burden on their caregivers, and improving the quality of life for both groups. understanding dementia dementia is an umbrella term for over 100 distinct conditions, with alzheimer’s disease being the most prevalent and well-known (mace & rabins, 2017). pwds experience a range of cognitive and noncognitive symptoms over time. cognitive issues, particularly in short-term memory and learning, are often early and generally well-known signs of the condition. noncognitive symptoms include neuropsychiatric conditions such as physical aggression and restlessness, wandering behaviors, decreased sexual drive, and inappropriate social behaviors like cursing or hoarding (biernacki, 2007). symptoms of dementia often begin on a mild level, such as forgetfulness or difficulty using precise diction; they eventually progress to more severe impairments. in the early stages of the condition, pwds may maintain some independence in daily life but begin to struggle with more complex tasks. as the condition advances, they often require assistance with basic activities such as dressing and eating. in its late stages, dementia leads to complete dependence on caregivers for all aspects of daily living (rahman & howard, 2018). given that these symptoms shift columbia social work review, vol. xxiii | 33 32 | columbia social work review, vol. xxiii over time, pwds often unwillingly experience emotional, cognitive, and social disruptions that decrease their quality of life. caregiver burden and trends the progressive and severe nature of dementia makes caregiving for pwds particularly demanding. according to the centers for disease control and prevention (cdc; 2024), 80% of people with dementia are cared for at home, with 16 million caregivers providing care to their family members and friends. one in three caregivers is 65 or older (cdc, 2024) and thus experiences the unique social, financial, and physical vulnerabilities that impact the older adult population. caregivers help manage activities of daily living (adls) for those affected by dementia, which include essential tasks like bathing, eating, and toileting, as well as more complex tasks like managing medications, finances, and transportation. a survey of 11.5 million families and other caregivers of individuals with dementia reported that these caregivers provide approximately 31 hours of unpaid help per week (alzheimer’s association, 2024). as a result, caregivers for pwds experience a range of challenges that may lead to burnout, defined as a state of physical, emotional, and mental exhaustion caused by the stressors and demands of caregiving (maslach & leiter, 2016). as they witness the gradual decline of their loved ones, caregivers often experience emotional challenges including grief, guilt, and depression (mace & rabins, 2017). physically, the caregiving role frequently leads to fatigue and health deterioration due to chronic stress and disruptions in regular sleep patterns (mace & rabins, 2017). financial challenges include significant costs of medical care and the potential loss of income due to caregiving responsibilities. these challenges make dementia one of the most costly conditions to manage (alzheimer’s association, 2019). for marginalized communities, these challenges are further compounded by systemic inequities, including limited access to healthcare, technological tools, and caregiver support services. research shows that racial and ethnic minority caregivers are more likely to experience higher caregiving burdens due to disparities in healthcare access and socioeconomic barriers (mickens et al., 2020). african americans are twice as likely as white americans to develop dementia, and hispanic americans are 1.5 times more likely (alzheimer’s association, 2019). yet these groups often experience significantly lower access to diagnostic services, treatment options, and caregiver support programs (gaugler et al., 2020). additionally, caregivers in low-income households are particularly vulnerable to financial stress. they also face additional barriers to accessing paid care services (andrén & elmståhl, 2007), thus increasing susceptibility to caregiver burnout. the present study in the context of these systemic and daily challenges faced by caregivers and individuals with dementia, technology significantly enhances dementia care. technological advancements provide increasing benefits for older individuals with dementia, as well as for their caregivers (allen, 2020). various technological tools, such as assistive devices and telehealth platforms (saragih et al., 2022), are being integrated into dementia care in increasing numbers, using innovation to address the needs and demands of dementia care. however, equitable access to such technology remains a challenge. caregivers’ willingness and ability to use these tools may be influenced by economic barriers, digital literacy, and the additional cognitive load required to learn new systems. older caregivers in particular may struggle with adopting unfamiliar digital platforms, while underserved populations may have less access to essential assistive technologies (leff et al., 2025). when implemented with an ethical and inclusive approach that prioritizes accessibility, affordability, and cultural sensitivity, technology can help manage the safety and cognitive symptoms of pwds while simultaneously alleviating caregiver burdens. thus, technology can play a significant role in increasing the quality of life of both individuals with dementia and their caregivers. technological innovations in dementia care esther park columbia social work review, vol. xxiii | 35 34 | columbia social work review, vol. xxiii the present study first delves into the strengths of various innovative tools currently being used in dementia care, such as healthcare technologies and location-tracking devices to address the wandering behaviors of pwds. next, the limitations of these technologies are discussed, followed by actionable strategies for social workers on policy and community-level interventions to promote inclusive, accessible solutions for integrating technology into dementia care. technological innovations in dementia care healthcare technologies for dementia care healthcare technologies for dementia care have numerous applications in both homes and care facilities, and have been shown to play a significant role in relieving stressors for both care recipients and caregivers (allen, 2020). from a medical standpoint, video monitoring technology supports the treatment of patients by providing useful content for care plan discussions with healthcare professionals and more immediate feedback for caregivers of individuals with dementia. additional healthcare technologies include the following, which collectively ensure the quality of treatments, general safety, and daily care for individuals with dementia (allen, 2020): • exit sensors to manage wandering behaviors • flood, carbon monoxide, and extreme temperature detectors to maintain environmental safety • bed occupancy sensors • medication reminders further technological innovations in clinical treatments for dementia have been identified in recent years, including those that address the complex socioemotional challenges associated with dementia. one such advance is the integration of technology into reminiscence therapy, a therapeutic approach used in dementia care that encourages individuals with dementia to recall and share memories from their past (woods et al., 2018). this approach has been demonstrated to improve emotional mood, social interactions, and cognitive functioning among pwds (woods et al., 2018). based on this evidence-based approach, researchers huldtgren, vormann, and geiger (2015a, 2015b) have explored methods of using a specially designed computerized mapping program to facilitate reminiscence therapy for people with dementia. tools like interactive mapping software assist in memory recall and strengthen bonds between pwds and their caregivers, contributing to a therapeutic environment and positive social connections. these e-health platforms incorporate multimedia elements such as photos, audio, and videos to provide personalized experiences for patients (huldtgren et al., 2015a, 2015b), further enhancing the intervention’s effectiveness. by enhancing reminiscence therapy with technology, these innovations provide significant emotional and psychological relief for both pwds and their caregivers. for pwds, reliving positive past experiences can improve mood, reduce anxiety, and strengthen cognitive function (woods et al., 2018). for caregivers, these tools offer an opportunity to engage with their loved ones in a structured and meaningful way, reducing the stress and emotional burden often associated with dementia care. these innovations play an important role in engaging pwds emotionally and cognitively, important aspects in maintaining cognitive health and mitigating the symptoms of dementia. meanwhile, caregivers also benefit from such technologies, as they help alleviate the physical and emotional burdens associated with caregiving. for instance, telehealth services and remote monitoring systems allow caregivers to oversee the health and safety of pwds while maintaining their own personal and professional commitments. smart medication dispensers ensure that pwds adhere to prescribed treatments without requiring constant reminders from caregivers, thus reducing stress and improving time management (patel et al., 2022). by allowing caregivers to maintain a sense of balance between personal and caregiving responsibilities, these tools support their mental health and ongoing resilience despite the strain of providing care to pwds (mace & rabins, 2017). technological innovations in dementia care esther park columbia social work review, vol. xxiii | 37 36 | columbia social work review, vol. xxiii technologies to manage wandering behaviors among the safety concerns surrounding pwds is the prevalence of wandering behaviors. research by algase et al. (2007) defines wandering as “a syndrome of dementia-related locomotion behaviour having a frequent, repetitive, temporally-disordered and/or spatially-disoriented nature that is manifested in lapping, random, and/or pacing patterns, some of which are associated with eloping” (p. 723). these behaviors have been observed to stem from a range of variables, such as immersion in unfamiliar environments, mood-related agitation caused by brain damage, or disorientation in general. research shows that wandering behavior substantially increases the risk of injury and/or fatalities, caused by, for example, being struck by vehicles or succumbing to environmental hazards (byard & langlois, 2019). as a result, pwds exhibiting wandering behaviors may find themselves in at-risk environments or become lost, leading to the potential for physical harm or even death. approximately 60% of individuals with dementia will experience wandering during the course of the disease (alzheimer’s association, 2022). this leads to additional challenges for a significant proportion of pwds and their caregivers, who may experience fearfulness and anxiety as a result. to address these concerns, several low-tech strategies are often implemented, such as pwds carrying reminders to remain calm and call home or wearing medical bracelets that provide critical health information and emergency contact numbers (mace & rabins, 2017). as technology has advanced, however, innovative products have been designed to both prevent and respond to wandering behaviors among pwds. in particular, wearable devices equipped with location tracking features, such as gps-enabled bracelets, watches, or even shoe inserts, allow caregivers to manage the location of pwds in real time. for example, gps smartsole is a water-resistant device discreetly embedded in the sole of a shoe. this technological tool was developed for individuals with dementia, autism, or traumatic brain injury who are prone to wandering. the product is recharged daily, offering real-time location updates and helping protect the safety of pwds (nunes, 2021). another innovative tool to address the risks of wandering behaviors is angelsense, a location tracker designed to securely attach to clothing. this device offers all-day monitoring of arrivals, departures, and travel speeds, along with automatic alerts when the individual enters unfamiliar geographic areas. additional features include a two-way voice function and a first-responder emergency alert, which enhances the safety of persons with dementia (angelsense, n.d.). in addition to these wearable, location-based devices, video monitoring systems have become increasingly popular. these systems allow caregivers to observe individuals remotely and intervene promptly during emergencies. features such as motion detection and automated alerts help maintain a balance between ensuring safety and promoting independence for pwds (allen, 2020). limitations in technological tools however, these technological tools are not without limitations. for example, a significant barrier to technology adoption among older adults is the pervasive gap in financial resources and digital literacy, defined as competence in one’s technical understanding of technology (vercruyssen, et al., 2023). this problem is exacerbated by insufficient access to training and resources. many older adults, particularly those from lowincome and minority populations (mccreadie & tinker, 2005), lack the digital skills or financial resources to navigate these technological tools, which limits their ability to benefit from digital innovations. this issue is particularly concerning because one-third of caregivers are older adults themselves, leaving both caregivers and those they support at a disadvantage in accessing these digital resources (costa & moniz, 2024). additionally, these technologies present challenges in meeting the diverse needs of users, such as older adults and caregivers, who are technological innovations in dementia care esther park columbia social work review, vol. xxiii | 39 38 | columbia social work review, vol. xxiii more susceptible to physical, sensory, or cognitive limitations. these issues arise in part from the lack of accessible design of these products, including poor usability, such as lacking help and search options and limited instructions, and not tailoring features to individual impairments and disabilities (hassan et al., 2022). consequently, the digital tools intended to enhance support for individuals with disabilities and their caregivers are often underused (hassan et al., 2022). moreover, current literature reveals a gap in examining the effectiveness of interventions, including technological tools, among communities of color. while existing academic research clearly establishes that ethnic minority caregivers of individuals with dementia experience disproportionately higher levels of caregiver burden, it also highlights significant limitations in understanding how these technological tools benefit marginalized populations, such as pwds and caregivers of color (kindratt et al., 2023; liu et al., 2022). further research is needed to analyze their unique barriers and needs related to technology utilization; only a few studies have explored how these tools can be adapted to better serve pwds and their caregivers. without such attention, disparities in access to and adoption of technological tools and interventions will likely persist. finally, implementing technological tools for pwds and their caregivers poses ethical concerns. from data privacy and informed consent for location-tracking technologies, to obstacles in the equitable distribution of resources, these concerns call for action that is grounded in the social justice–oriented principles of social work. social workers play a pivotal role in confronting these barriers for these vulnerable populations by promoting equitable access to caregiving technologies from program and policy-level standpoints. implications for social work practice several existing macro-level initiatives provide an excellent framework for social workers to address gaps in digital literacy and financial resources that lead to barriers in accessing technology for dementia care. for example, california’s access to technology program provided $48 million to communities and organizations to spearhead digital literacy initiatives, including digital literacy education programs and funding for technological devices, for adults with disabilities and older adults (california department of aging, n.d.). in addition, the federal communications commission (2021) offers the lifeline program, geared toward national broadband expansion. this program advocates for affordable internet access for underserved populations and communities, making it a solid example of promoting access to telehealth and digital tools. these programs could improve the personal autonomy and quality of life among pwds and their caregivers. social workers can play pivotal roles in bridging gaps among tech developers, policymakers, and caregiver and pwd communities. these programs are key examples of promoting the accessibility and affordability of assistive technologies for dementia care. subsidizing assistive technology promotes equitable access, improving the quality of life for low-income families. by referencing the advantages of these initiatives in community-level and policy-level advocacy, social workers may play a significant role in advocating for equitable digital knowledge, education, and resources in their communities. a key entry point for policy change involves integrating assistive technology funding into existing healthcare programs, such as medicaid and homeand community-based services, to provide financial support for families in need (kff, 2022). public-private partnerships between technology developers, healthcare institutions, and policymakers can facilitate the large-scale distribution of these tools, ensuring cost-effective and inclusive access. older adults and their caregivers who encounter physical and cognitive limitations need user-friendly technology design. when navigating these issues, social workers should turn to the model of person-centered care (national association of social workers, 2021), which prioritizes the dignity and autonomy of individuals, ensuring that care plans are personalized and that the individual’s voice remains central to decisiontechnological innovations in dementia care esther park columbia social work review, vol. xxiii | 41 40 | columbia social work review, vol. xxiii making. technological tools like the mindmate app (2018) are designed to offer interactive memory exercises and medication reminders for individuals with dementia and alzheimer’s disease. they are also individually tailored with input from users and patients, aligning with the principles of person-centered care that emphasize the voices of populations served. as technology plays an increasingly pivotal role in dementia care, future social work research and product development efforts must prioritize collaboration between social workers, product designers and engineers, and healthcare providers to create solutions that are not only effective in dementia care, but also equitable for marginalized populations. many older adults, particularly those with cognitive impairments, face challenges in interacting with complex technology. research should focus on creating intuitive, user-friendly interfaces that can accommodate the varying cognitive abilities of individuals with dementia (mccreadie & tinker, 2005), such as designs that incorporate large fonts, clear visuals, and voice-activated systems to promote independence while minimizing confusion. additionally, social workers may advocate for ongoing usability testing with target populations to ensure that the technology remains accessible, effective, and engaging for those with dementia, as well as their caregivers, and to ensure a personcentered care model in product development. through approaches like cross-disciplinary partnerships, social workers can help ensure that technological tools not only address the clinical aspects of dementia care but also uplift the voices and self-reported needs of individuals with dementia and their caregivers. to address the lack of existing research on ethnic minority engagement with technological interventions, future social work research should prioritize inclusivity in both study design and implementation. considering that users vary across sociodemographic factors such as race, ethnicity, and socioeconomic status, as well as their unique behavioral and cognitive manifestations of dementia (vollmer dahlke & ory, 2020), research must account for these complexities when evaluating the effectiveness of technological tools. a more comprehensive approach would involve engaging not only primary users, including individuals with dementia and their caregivers, but also secondary stakeholders, such as formal and informal caregivers and family members who play a significant role in the adoption and use of these technologies (vollmer dahlke & ory, 2020). conclusion social workers can advocate for policies and programs that ensure equitable access to these resources, working alongside community organizations and multidisciplinary professionals. the role of social workers in promoting inclusivity in both the design and distribution of dementia care technologies can contribute to a more just and supportive healthcare system for all individuals affected by dementia. by providing digital education to caregivers and pwds in the form of digital literacy education programs and classes and enhancing the reach of technological solutions, these efforts can ensure more equitable care for individuals with dementia and other disabilities, benefiting both families and society as a whole. technological 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(2022). effects of telehealth intervention for people with dementia and their carers: a systematic review and meta‐analysis of randomized controlled studies. journal of nursing scholarship, 54(6), 704–719. vercruyssen, a., schirmer, w., geerts, n., & mortelmans, d. (2023, september 12). how “basic” is basic digital literacy for older adults? insights from digital skills instructors. frontiers in education 8, 1231701. https://doi.org/10.3389/feduc.2023.1231701 technological innovations in dementia care esther park columbia social work review, vol. xxiii | 45 44 | columbia social work review, vol. xxiii vollmer dahlke, d., & ory, m. g. (2020). emerging issues of intelligent assistive technology use among people with dementia and their caregivers: a us perspective. frontiers in public health, 8, 191. woods, b., o’philbin, l., farrell, e. m., spector, a. e., & orrell, m. 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(2025). dementia [fact sheet]. https://www.who.int/news-room/factsheets/detail/dementia technological innovations in dementia care esther park columbia social work review, vol. xix | 117 116 | columbia social work review, vol. xix mandated reporting laws are pertinent to practitioners of “helping professions,” such as social workers, doctors, nurses, and teachers. these laws dictate that a professional or student in those fields must report suspected child maltreatment to the state for investigation. the report, as well as the investigation that follows, has the potential to result in removal and separation of children from their parents or caretakers. the child welfare system of which mandated reporting is a component has a cruel history of racism and white supremacy, as well as prejudice towards those experiencing poverty, disabilities, mental health concerns, homelessness, and substance use disorders. this research examines the disproportionate harm the child welfare system has on black and brown individuals, particularly in new york, and how the system has used mandated reporting laws to further marginalize oppressed communities since the 1970s. this research indicates the need to comprehensively reimagine the erroneously named “child welfare system” starting with repealing mandated reporting laws in the united states. time doesn’t heal all wounds: a call to end mandated reporting laws g inguanta, they/them catharine sciolla, she/her columbia social work review, vol. xix | 119 118 | columbia social work review, vol. xix time doesn’t heal all wounds time doesn’t heal all wounds: a call to end mandated reporting laws literature review the foundations of america’s modern family regulation system historically, the “family regulation system,” a term coined by dorothy roberts in 2020 for the industry more commonly known as the child welfare system1, dates back to the 1850s, informally starting with what is known as the orphan train movement. between 1854 and 1929, thousands of poor children from urban settings were kidnapped,2 and they were moved across the country to be housed with white, anglosaxon protestant parents (orphan train, 2020). even though the work of the orphan train movement was reformed through social welfare policy within the united states later on with legislation like the child abuse prevention and treatment act (capta), the destruction of families and removal of children from homes has long been a tradition in the united states. white saviorism3 and paternalism are the backbone of the family regulation system, whose foundational pillars also include the forced 1 in her 2020 article, roberts connected the child welfare system and the criminal justice system as two pawns playing in the larger carceral regime. she elaborates upon this notion: “the misnamed ‘child welfare’ system, like the misnamed ‘criminal justice’ system, is designed to regulate and punish black and other marginalized people. it could be more accurately referred to as the ‘family regulation system.’” (roberts, 2020). 2 the term kidnapped is not used as hyperbole. we believe this to be fact. when individuals move children across state lines it is considered kidnapping. why then does this definition not apply to the actions of the state as well? the state has a simultaneous monopoly on both violence and the conceptualization of violence (anter, 2019). children during the orphan train movement were taken out of their culture, families, and homes and shipped across the united states because one white man, charles loring brace, thought it would be best for them. oftentimes many children did not know or understand where they were being taken and in some cases were forced to end all contact with their birth families (brown et al., 2020). to understand the impact the orphan train movement had on children please visit: https://socialwelfare.library.vcu.edu/programs/childwelfarechild-labor/orphan-trains/ 3 white saviorism is a term used to describe white people who “help” black people and people of color in a self-serving manner. white saviorism is most commonly associated with individual acts that perpetuate colonialism and imperialism, particularly in the african continent: volunteer tourism and missionary work, for example. instead of allowing communities to make decisions for themselves, white people come in to “help” as a form of aid, perpetuating a dangerous narrative that white people must be centered in order for bipoc oppression to end. g inguanta & catharine sciolla sterilization of black, indigenous, people of color (bipoc) women and folks with disabilities, as well as eugenics (sterilization and social justice lab [ssjl]). this is the enduring legacy of our modern system: building blocks rooted in paternalism and white supremacy. the mentality of the orphan train movement of the 1850s was to “clean up” the streets of cities and produce “upstanding” citizens, while doing nothing to end the conditions of poverty those children endured. this mentality affects how americans think about and make laws regarding childhood, poverty, and what does or does not constitute abuse or neglect. in fact, the united states’ obsession with the “safety” and “protection” of its children is thinly veiled and coded language used to justify its true and more insidious nature: to destroy the black family (as well as native american families, brown families, and later immigrant families living in poverty). between 1929 and the 1960s, orphanages were replaced with foster care and programming to aid “poor children and families” (forestdale, n.d.). however, it was not until the 1960s that this mentality of “programming for the poor” and foster care became the framework of the modern day family regulation system and the “foster care industrial complex.” the modern family regulation system was developing parallel to the united states government’s assault on black, native american, brown, and immigrant communities; in some instances, this assault was on low-income white folks as well. key to the development of the modern family regulation system is the narrative of the “battered child syndrome.” in 1962, the term “battered child syndrome” was created to describe the clinical condition of severely abused, neglected, or maltreated children which could result in death (kempe et al., 1985). three years after the publication naming “battered child syndrome,” all fifty states had passed legislation requiring doctors to report suspected child abuse or neglect (melton, 2004). originating from the concept of “battered child syndrome,” as defined by kempe, mandated reporting initially focused on disseminating information to doctors about how to identify and properly report abuse columbia social work review, vol. xix | 121 120 | columbia social work review, vol. xix time doesn’t heal all wounds to authorities. kempe’s research was narrowly focused on the most severe forms of abuse (e.g., broken bones), but he generalized his findings to create a universal standard for any child suspected of experiencing abuse. this generalization was not only quite a leap, but was also dangerous. the family regulation system has become a tool of surveillance, which has been weaponized against black communities, communities of color, and communities living at or below the poverty line. shortly thereafter, capta was passed, which “provides federal funding and guidance to states in support of prevention, assessment, investigation, prosecution, and treatment activities” (child welfare information gateway, 2019, p. 1). around the same time, a feeling of moral superiority was being promoted through the creation of the “war on drugs” by president nixon in 1971. by 1980, president reagan had widely expanded the criminalization of drug use, particularly crack-cocaine, and the prison industrial complex (duvernay, 2016). importantly, nixon’s “war on drugs” invented the racialized myth of the crack-addicted baby, a pervasive stereotype that looms over the family regulation system to this day (wexler, 2019). mandated reporting laws were born out of a movement to “clean up” and rid city streets of “child gangs” (brown et al., 2020) and a nationwide panic around severe abuse observed in a small percentage of children (mandatory reporting study, 2020). instead of addressing some of the contributing factors to child abuse like historical trauma, patriarchy, and white supremacy, mandated reporting laws were passed that individualized issues of poverty and domestic violence as a failure of an individual or a family, rather than a failure of society to address the mental and physical well-being of its citizens. this attitude of moral superiority, paternalism, and victim blaming is one that continues to frame the family regulation system and has historically been used as a tool of political and economic agendas in america, including the war on drugs. in this paper we will review research and analyze the implications mandated reporting laws have had on black families (as well as native g inguanta & catharine sciolla american, brown and immigrant families, including but not limited to all families who live at or below the poverty line)4. we will recommend, based on our research and experiences serving in the legal and social service sector, to abolish the family regulation system by ending mandated reporting laws. we do not believe that ending the family regulation system and mandated reporting laws will put an end to all abuse, nor do we promote ignoring violence towards children. though the family regulation system purports and falsely claims to be about protecting children, when observing the experiences and realities of folks ensnared in the family regulation system and looking at data, we have concluded that the family regulation system is the largest perpetrator of violence, abuse, and neglect to children and families. our intention is to clarify and affirm the latter narrative in order to chip away at the legitimacy of institutions operating within the family regulation system and to take a critical look at mandated reporting as a tool of white supremacy. for far too long, black mothers and families have had to endure family separation while their voices were silenced by powerful and well-funded institutions. from our research on black scholars and the voices of black moms, we, as authors, have learned about the racial disproportionality of the current family regulation system. we must get rid of it and work towards creating a world where black voices and families have self determination over their own futures. this includes understanding how the terms “abuse” and “neglect” have been weaponized against black, native american, brown, immigrant, and low-income families. this means that we must slowly gut, defund, and transition away from our society’s reliance on punitive institutions like the state central registry--the “centralized” database of all child abuse, maltreatment, and neglect cases-and toward funding and handing over power to black, native american, brown, and immigrant communities 4 operationalized by christina bush, the theory of anti-blackness postulates that systemic racism in america exists “through the denigration, disenfranchisement, and disavowal of people racialized as black” (bush, n.d.). that anti-blackness permeates all aspects of society is evident when looking at systemically racist policies and practices, de-facto segregation, redlining, misogynoir, and police violence. columbia social work review, vol. xix | 123 122 | columbia social work review, vol. xix time doesn’t heal all wounds and families.5 a first step towards this goal is to end mandated reporting. the purposeful ambiguity of mandated reporting and its impacts mandated reporting is a relatively new concept for social workers, dating back less than 50 years to the inception of the child abuse prevention and treatment act in 1974. in its short life, however, the principle of mandated reporting has done significantly more harm than good. as previously stated, mandated reporting came about as a result of dr. kempe’s research on “battered child syndrome (bcs),” and the fear that ensued regarding child maltreatment, abuse, and neglect. “bcs” should be diagnosed when there is a presence “...of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swellings or skin bruising, in any child who dies suddenly, or where the degree and type of injury is at variance with the history given regarding the occurrence of the trauma” (kempe et al., 1962). it is noteworthy that federal mandated reporting legislation rests on abuse that is only the most serious, though due to the ambiguity of mandated reporting laws and the legal consequences of not reporting, over-reporting as a precaution dilutes what is actually a case of serious abuse and what is not. this overreporting disportionately affects black, indigenous, and latinx families.6 5 we would like to recognize that there are cases of severe and dire child abuse and neglect that, heartbreakingly, often go unstopped by governement entities, as interference only occurs when it is too late. thus, we align with the same ideology as the upend movement in that “we want to support the formation of communities and a society where harm does not occur in the first place and where harm does occur, communities are able to respond in ways that do not create more harm” (upend, faqs). 6 “in calendar year 2019, 41.4% of new york statewide central register of child abuse and maltreatment reports involved children in families who identified as black/african american, even though these children only make up about 23% of the nyc child population, and 45.4% of reports involved children in families who identified as latinx/hispanic, even though these children comprise 36.4% of the nyc child population. on the other hand, while 26.5% of nyc children are white and 14.1% of nyc children are asian/pacific islander, these families make up 8% and 5.3% respectively of reports to the scr” (oversight-racial disparities in the child welfare system, 2020, p. 5). g inguanta & catharine sciolla mandated reporters are often inconsistent about the reporting of suspected child abuse, neglect, and maltreatment, both because of the unclear guidelines set forth by national law and because of the incongruence between mandating reporting and professional ethics (feng et al., 2012). the threshold for mandated reporters in new york state is “any reasonable suspicion.” many professionals disagree on what constitutes reasonable suspicion, at what point to report, and how to go about this conversation with clients. the new york state office of children and family services summary guide for mandated reporters (2019) defines reasonable suspicion as “a suspicion that the parent or other person legally responsible for a child is responsible for harming that child or placing that child in imminent danger of harm. your suspicion can be as simple as distrusting an explanation for an injury” (2019, p.2). given the wide range of professions that fall under mandatory reporting laws– doctors, nurses, social workers, psychiatrists, teachers– it is understandable that there is no consensus on how to interpret “reasonable suspicion.” what that means to a doctor in a hospital setting is very different form what it means to a teacher in a kindergarten classroom, or a therapist in a counseling session. specifically for medical professionals, evidence reveals that providers are more likely to report families and individuals of color even when presenting with the same injuries and demographic factors as white families and individuals (hlavinka, 2021). this indicates that racial biases within the medical field are not limited to the care and compassion received by patients of color, but also extends to the trust and support they receive from their physicians and medical staff (hlavinka, 2021). furthermore, research also suggests that even within professions there is no agreement on the threshold of reasonable suspicion, noting that this can vary from person to person, department to department, and specialty to specialty (levi & crowell, 2011). this ambiguity is purposeful and creates an environment where racial bias thrives. this continues the destruction of black, native american, brown, immigrant, and low income families. columbia social work review, vol. xix | 125 124 | columbia social work review, vol. xix time doesn’t heal all wounds mandated reporting and the possibility of a report being made diminishes the strength of the therapeutic alliance and the clinical benefits of work between clinicians and their clients (and trust between doctors and medical staff and their patients). critics of mandated reporting have long argued that having clinicians as mandated reporters damages the work that clinicians can do by disrupting the therapeutic alliance. the potential of reporting may hinder the work that a clinician can do with a client, as the client may be monitoring and censoring what they say throughout sessions, causing a rupture in the therapeutic alliance and diminishing healing and growth as a result. critics note that this is a major concern for clinicians who utilize a psychodynamic or psychotherapeutic approach (kalichman, 1999). if a client discloses that harm is occurring, the clinician is in the position to successfully deliver an intervention and discuss the root causes of the abuse. to report, the clinician or professional must break confidentiality, which has harmful effects on the client-clinician relationship (kalichman, 1999). how do social work practitioners justify the harm done through the family regulation system’s mandating a report report while striving to achieve their code of ethics? can they? due to the legal ramifications of not reporting, does the mandated reporting law actually coerce professionals into reporting to prevent legal recourse? does this ultimately disproportionately favor reporting over not reporting at all? the argument to keep families together historically, the narrative of the family regulation system has been couched in language like “protecting children,” thus erasing the voices of directly impacted individuals and promoting stories that fit the narrative of white saviorism. if the social problem is framed as poverty or individual failure, then the intervention is separating families to preserve the child’s safety. however, research demonstrates that, in most cases, keeping a family together is best, and reporting can be harmful to families (kalichman, 1999). thompson and flood (2002) argued that the best way to protect children is to emphasize preventive and support services that would help with family preservation and maintaining g inguanta & catharine sciolla family ties, even when it is unsafe for children to live with their parents. research also indicates there is a specific pattern of cases that are reported and re-reported. the characteristics of these cases include, but are not limited to, social support deficits, family stress, and partner abuse (depanflis & zuravin, 2002). families who fit this profile but use the services provided have been shown to be 33% less likely to have another report placed for them (depanflis & zuravin, 2002). this indicates that identifying proper support services for families to participate in is effective in reducing re-reporting (depanflis & zuravin, 2002). given the main case characteristics, future considerations for increased support services should include aligning families with others to increase social support, psychoeducation around stress and abuse, and family violence intervention programs through a trauma-informed and culturally humble approach. in addition to the pattern of report and re-report, there is also evidence for a high correlation between re-reporting and specific “risk” factors. connell et al. (2006) found that family poverty was the strongest predictor of re-reporting. other predictors of re-reporting include community poverty level, family history of substance abuse, and domestic violence. this strongly suggests a correlation between socioeconomic status, income level, mental health, and victimization--all of which are dictated by race in the u.s.--and re-reporting. these “risk factors” further reveal mandated reporting’s continued legacy of oppression, systemic racism, and intergenerational trauma within the black community (hernández et al., 2005). modern day racism: effects of mandated reporting it is evident that white supremacy is the ideological backbone of the family regulation system. through the operation of the family regulation system, including the foster care system, the united states demonstrates that it believes the state will do a better job of parenting a child than those living in poverty, specifically black folks, indigenous individuals, immigrants, and people with disabilities. this is the intent of the family columbia social work review, vol. xix | 127 126 | columbia social work review, vol. xix time doesn’t heal all wounds regulation system and has been since its formation; it is by choice, not coincidence, as was seen in the orphan train’s movement to “clean up” urban communities. this kind of thinking has a dire legacy in the united states and must end. mandated reporting contributes to the racial disproportionality within the family regulation system at both state and federal levels. the first manuscript reporting racial disproportionality in the family regulation system dates back to 1972 (billingsley & giovannoni, 1972), and its findings continue to hold true 45 years later. in 2000, it was reported that black children represented 38% of the foster care system while being only 16% of the national population (national council of juvenile and family court judges [ncjfcj], 2017). between the years of 2000 and 2011, black children were twice as likely to be removed from their parents care as white children (sangoi, 2020). black children were overrepresented in foster care in 46 of the 50 states in 2015 (ncjfcj, 2017). in 2015-2018, only 9 out of every 1,000 cases in the united states reported to child protective services were confirmed cases of maltreatment (kids count, 2018). in 2017, in california and new york, black children were represented three times more in foster care than they were in the state’s population (ncjfcj, 2017). of cases that were confirmed as maltreatment, in 2018, 18% involved black families and 23% involved hispanic or latino families (kids count, 2018). thus, for 2018, children of color accounted for approximately 65% of all children in foster care throughout the united states (kids count, 2018). as of 2020, children that are black represent 23% of kids in the family regulation system while only representing 14% of the national population (kids count, 2020). while some states have universal reporting laws, others only require professional mandated reporters (krase & delong-hamilton, 2015). more than half of the 3.3 million reports of child maltreatment in 2011 were carried out by these professionals (united states department of health and human services, administration on children, youth, and families, 2012). g inguanta & catharine sciolla black families and caregivers are more likely to be reported for maltreatment than white families (miller, 2008; putnam-hornstein et al., 2013). in new york state, black families and caregivers are disproportionately reported for child maltreatment by school employees via mandated reporting (krase, 2015). the ongoing surveillance and involvement with the family regulation system reinforces negative stereotypes of black individuals and families, such as the lack of ability to take care of their children without government assistance (dettlaff et al., 2020). while the state claims to protect children, state intervention in family matters is insidious and has far-reaching consequences that further compound the trauma of living in a white supremacist society. additionally, the narrative that family separation benefits both children and parents is an outright falsehood disproven by research that indicates the negative impacts it has on the wellbeing of children and families (rethinking foster care, 2014). in addition to research that proves the long-lasting trauma families experience due to state intervention, there is also a robust amount of research that points to a clear pipeline between foster care and prison (center, 2018). as explained by dorothy roberts (2002), mandated reporting has reverberating effects at the local and personal levels. communities consisting of black families are plagued by mandated reporting, surveillance, and separation, thereby enduring harm to their individual and collective identities. each of these makes it difficult for people and families of color to build stable bonds and overcome additional disadvantages. roberts (2008) reported a lack of community involvement, as well as diminished social connection, lower quality friendships, and less supportive bonds due to fear of child welfare intervention by the state and fear of the possible calls and reports made by disgruntled neighbors as a result of other social conflicts. as black and other communities of color continuously suffer from racist systems and policies, their negative health outcomes and poor living conditions, caused by white supremacy and the cultural imperialism of columbia social work review, vol. xix | 129 128 | columbia social work review, vol. xix time doesn’t heal all wounds america, are then used against them in the form of mandated reporting and state-led interventions like child removal. this perpetuates the historically traumatic narrative of black families as unworthy or incapable. current practices of harm mandatory reporting laws do not account for a reporter’s own personal experiences, biases, or beliefs. there is a well-documented racial issue within the family regulation system, as discussed in the previous section. historically, white, anglo-saxon, upper middle-class individuals have dictated what is appropriate, what is inappropriate, and what is “right” when it comes to parenting and family values. this notion of the “white lens” is clearly evident in the family regulation system where we see families punished for not meeting upper middle-class, anglosaxon standards.7 it is clear that the immediate need of children and families dealing with the family regulation system is the abolition of the family regulation system. it should be replaced with the integration of community-based services that are preventative and promote child, family, and community wellbeing, as well as the acknowledgement of the race-based motivation behind the trauma inflicted on children, families, and communities of color under the guise of this system. we also believe that the family regulation system should be defunded and the money reinvested back into the community, with community members at the forefront of deciding what gets funded. viii. centering family success the family regulation system is made up of two arms: the legal industry and the social service industry. the entire industry sits below the legal and prosecutorial infrastructure that is dependent upon family court and reporting for its economic survival (rethinking foster care, 2014). ultimately, do families need more services, where they will come into 7 a recent example of this is the disproportionate number of marijuana-related reports on bipoc folks in low socio-economic neighborhoods, and the heraliding of marijuana use as a form of selfcare for white and upper-class parents (ketteringham, 2019). g inguanta & catharine sciolla contact with even more mandated reporters? or do researchers, activists, impacted parents, lawyers, and other advocates need to push towards abolishing the state intervention system all together, while fighting for social change that will put an end to racial trauma and disparities? between the years of 2015-2018, less than 1% of cases reported to child protective services were substantiated, or found to be confirmed cases of maltreatment (kids count, 2018). the most common finding nationwide in family court is one of neglect, not abuse (national child abuse statistics from nca, 2020). the charge of neglect is usually an indictment of the parent’s ability to meet a child’s needs due to poverty. the charge of neglect is how the family regulation system continuously punishes folks living at or below the poverty line, blaming them as an “individual failure,” rather than systemic failure. over and over research shows families involved in the family regulation system are most likely living at or below the federal poverty line (joyce, 2019). reports show that the family regulation industrial complex spends tens of billions of dollars each year, with estimates citing that between 2004 and 2014 spending of state, local, and federal dollars reached up to 32 billion dollars each year (sangoi, 2020). for scale, the state, local, and federal average annual spending on the women, infants, and children supplemental nutrition program, providing support and programs for children under three living in poverty, is 6 billion dollars (sangoi, 2020, p. 131). yet, with roughly five times as much being spent on the family regulation system, the dollars do not reach families and children in need of services and support; the vast majority of this spending was on “outof-home placement”: not keeping families together (sangoi, 2020, p. 131). the most appropriate use of resources for the family regulation system would be to develop services that “meet the needs of such families,” and “to reduce the risk of recurrent allegations among families faced with economic challenges’’ (connell et al., 2002, p. 584). in practice, this would mean prioritizing the voices of directly impacted individuals and communities by creating sustainable programs that are built around the demands of families involved in the family regulation columbia social work review, vol. xix | 131 130 | columbia social work review, vol. xix time doesn’t heal all wounds system. directly impacted individuals, families, and communities have argued for decades that decreasing surveillance and oppressive infrastructure operated through mandated reporting will lead to less childhood trauma, greater intra-community trust, disclosure amongst participants and care providers, and overall greater wellbeing (roberts, 2002). the state-mandated intervention systems have operated as a means through which to control, manipulate, and oppress communities of color and those living in poverty. it is time for change. building community resources and services would innately involve directly impacted individuals, families, and communities, who are the experts in their own lives and needs, by asking, “what do you need?” a call for change: abolish mandated reporting laws not only have we imagined, based on the voices of black folks who have worked as lawyers, scholars, and who have been impacted by the family regulation system, what a world without the family regulation system could look like, but we have also highlighted the harm that the current system does and the values that control the current decision making processes within the system. the “child welfare” system we currently have is not working to protect children and families, nor is it increasing child wellbeing. it is a system deeply rooted in oppression, surveillance, and punishment of bipoc communities and brutally enforces a white, anglo-saxon style of parenting. how do we prevent children and families from experiencing trauma at the hands of the family regulation system? what is a successful first step in abolishing the family regulation system? we narrowed our focus to abolishing mandated reporting laws, which was directly inspired by joyce mcmillan’s call to end mandated reporting. without mandated reporting laws, we believe that clients would disclose more openly and productively in clinical work, at the doctor, and with teachers. in doing so, folks can actually get the adequate mental and physical health care they need and deserve. for example, due g inguanta & catharine sciolla to mandated reporting at public hospitals, many pregnant people will not go to prenatal appointments for fear of a report being filed against them, especially due to any positive toxicology report (khan, 2019). without mandated reporting, birthing folks would more likely attend all prenatal sessions, which could in turn decrease the mother and infant mortality rates of both black and non-black birthing folks. in sum, trust can be built up between client and provider in systems that are historically oppressive and punitive, and clients will be able to get more out of services, because services will actually deliver their intended impact and interventions. children and families’ wellbeing will flourish because only cases that have actual merit or need will be reported and the fear of stateimposed trauma this system instills will be removed. a world without an added layer of surveillance from mandated reporting means a world where there will be: 1) increased child wellbeing in communities where the family regulation system’s presence is high; 2) less undue trauma to youth and families; 3) greater intercommunities and intra-community trust; and 4) less violence overall. as social workers, we also recognize the potential for less burn out and more time to work intimately with clients and community members. in this world, we imagine there will be greater collaboration amongst organizations, community entities, neighbors, and schools. without the fear of mandated reporting hindering access to care or trust in authority figures, greater fidelity to services can be provided, relationships between families and schools can improve, and medical well-visits can be regularly attended. in this world, we imagine self-determination for families and choices made with consent and knowledge rather than in fear. we imagine communities solving their own problems and service providers, like social workers, stepping in only if requested. love and justice are at the core of our call to end mandated reporting laws. the implications of this research suggest that change is needed at several levels, including the individual, family, community, state, and federal. we demand that advocates, social workers, and lawyers take the lead from those who have been most impacted: parents who have experienced the family regulation system and children whose lives have columbia social work review, vol. xix | 133 132 | columbia social work review, vol. xix time doesn’t heal all wounds been turned upside down due to family separation. our hope is that this paper can spark a conversation more broadly amongst providers, including those working within the family regulation system, social workers in schools and hospitals, medical staff, and people who are unaware of the serious harms the family regulation system commits everyday in the name of “child safety.” research limitations the researchers are passionate about contributing to this growing body of knowledge, and we want our scholarship to be used to bolster the existing advocacy of impacted parents to amend or abolish the family regulation system. as folks who have not been directly harmed by this particular system, we only understand the mechanisms through scholarly work and working directly with those most impacted. often, directly impacted individuals are not given the option to engage with or draw conclusions about the systemic issues behind the family regulation system, but are rather forced to do so. as white researchers and academics, we are a part of the systems of colonialism and white supremacy that continue to marginalize those most impacted by this issue. academia is predominantly an institution and tool of white supremacy, often stealing from and profiting off of the ideas and struggles of bipoc, immigrants, lgbt+ individuals, people with disabilities, and poor communities. it is our hope that this research can be used as a tool by those most impacted to advocate for themselves and their communities, and as a conversation starter for service providers and mandated reporters. dedication this research is dedicated to all of the children and families currently or formerly involved with the family regulation system. this research would not have been possible without the tireless support of many of our friends, family, and colleagues. a special thanks to dr. ellen lukens, who pushed this team to be what it is, to kls, without whom none of this would be possible, and to all of the people who volunteered their time g inguanta & catharine sciolla to share with us their experiences with the family regulation system: jw, mgo, ks, ald, nm, and dk. to our partners and loved ones who put up with our late nights and grammatical questions, thank you. to our editors, caitlin and sarah, we would not be here today without you. and, to joyce mcmillian, whose work continues to be a source of inspiration. for further education about the impact of mandated reporting on families or to get involved in the movement to end the family regulation system, we urge you to check out the following: movement for family power, jmacforfamilies, upend, and ancient song doula services. references a. 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(2011, october 25). incentives and cultural bias fuel foster system. npr. https://www.npr.org/2011/10/25/141662357/incentives-andcultural-bias-fuel-foster-system united states department of health and human services, administration on children, youth and families. (2012). child maltreatment. u.s. government printing office. wexler, r. (2019, january 11). decades after media, child welfare got “crack babies” wrong, damage to women of color lives on. youth today. https://youthtoday. org/2019/01/decades-after-media-child-welfare-got-crack-babies-wrong-damage-towomen-of-color-lives-on/ catharine sciolla (she/her), is a masters of science in social work candidate at columbia school of social work in advanced generalist practice and programming concentrating in contemporary social issues. catharine holds a bachelor of art in psychology from university of richmond. she is passionate about working with those who have experienced gender-based violence and those who have experienced homelessness. g inguanta (they/them) is an msw candidate expecting to graduate from the columbia school of social work this spring 2021. g is an agpp (advanced generalist practice and programming) student who focuses on contemporary social issues. while at cssw, g served at forestdale inc as a case planner for the strong mothers program and intern at the bronx defenders with healthy mothers, healthy babies in the family defense practice. g is interested in the intersection between race, gender and state sanctioned violence, thinking about implementing alternatives to capitalism imperialism and dreaming of/making a world where people are truly free. columbia social work review, vol. xix | 47 artificial intelligence-driven rent pricing tools & the housing crisis mckynzie clark, austin nelson, sanjana utiramerur columbia social work review, vol. xxiii | 49 48 | columbia social work review, vol. xxii kynzie (she/her) is a researcher and student based in new york city. eager to understand the growing intersection between technology, law, and networks of care, kynzie is pursuing a master of social work degree at columbia university as a fisher cummings fellow. in her studies, she hopes to leverage her experience in advocacy, research, and policy work to advance equity and systems change work. previously, kynzie studied political science and russian language at yale university. outside of classes, kynzie interns at the bronx defenders and works with the center for intimacy justice. mckynzie clark columbia social work review, vol. xxiii | 51 austin nelson (she/her) is a master of social work student at columbia university with a background in research, community engagement, and data ethics. her professional experience spans direct service with unhoused populations, trauma-informed youth programming, and nonprofit development. austin’s research interests center on the intersection of technology, equity, and housing justice, drawing from previous work on data ethics in the ict4d space and gender-based violence interventions. she brings a critical, justice-oriented lens to examining the role of ai in rental markets, with attention to accessibility, bias, and systemic inequality. 50 | columbia social work review, vol. xxii austin nelson columbia social work review, vol. xxiii | 53 sanjana is an msw student on the advanced clinical practice track at the school of social work. she is passionate about working with diverse populations navigating systemic inequity, particularly in healthcare. in the future, she hopes to attain her lcsw license and provide accessible trauma-informed therapy to marginalized communities. inspiration our interest in the intersection of ai and the housing crisis emerged from my broader focus on social justice and technology. as social work students passionate about policy and ethics, we were struck by how ai tools—often promoted as neutral or innovative—are increasingly shaping access to basic human rights like housing. we were inspired to write this piece after reading about biased tenant screening algorithms and models that reinforce housing discrimination. researching this topic was both eye-opening and frustrating. there was a wealth of information on ai development, but far less on how these tools impact low-income communities or exacerbate inequality. sanjana utiramerur columbia social work review, vol. xxiii | 55 54 | columbia social work review, vol. xxiii ai and the housing crisis abstract this policy brief explores the use of artificial intelligence (ai) in rent pricing tools that corporate landlords and property management companies use for rental housing, and its consequences for the housing market. across the united states, landlords have become increasingly reliant on ai-driven rent pricing tools to raise rents and boost their profits. this technology, which uses both sensitive proprietary data and publicly available information, is reducing housing accessibility, often driving tenants from their homes. as ai becomes increasingly pervasive in our everyday lives, it is essential that we interrogate its uses, especially in those that have as many collateral consequences as housing. we offer an overview of rent regulation history, the underlying ai technology, and existing policy, and make our own policy recommendations. keywords: artificial intelligence, housing policy, tenants’ rights, data rights, privacy mckynzie clark, austin nelson, & sanjana utiramerur artificial intelligence–driven rent pricing tools and the housing crisis rental housing, like other societal systems, has been increasingly shaped by artificial intelligence (ai) technology in recent years. this shift, however, is not just a technological evolution—it represents a radical departure from traditional rent-setting methods and carries significant implications for privacy and equity. this article argues that artificial intelligence, particularly through rent pricing tools, has adversely affected the already competitive rental housing markets in urban settings by exacerbating discrimination and enabling collusion between landlords. we start by exploring the history of how rental prices have traditionally been set in the united states as well as the evolution of machine learning and ai. then, we explain how ai-driven rent pricing tools, such as realpage, affect urban rental housing markets. finally, we look at policies regulating rental housing, data protection, and ai and offer our own policy recommendations. i. background context regarding rent in the u.s. historically, rent-setting in the united states has been shaped by a complex interplay of economic forces, housing regulations, and antiblack racism. before the 1930s, homeownership was less common than it is today, with most americans renting their homes due to high down payments and short loan terms that made buying property difficult (gordon, 2005). traditionally, rent-setting was a localized process where individual landlords determined rental prices based on property characteristics and neighborhood demand. the first rent control laws were adopted in the 1920s in response to urbanization, housing shortages, rent increases, and growing tenant advocacy following world war i (rajasekaran et al., 2019). during the great migration, which spanned most of the twentieth century, millions of african americans migrated to northern cities columbia social work review, vol. xxiii | 57 56 | columbia social work review, vol. xxiii in search of economic opportunities and to obtain freedom from oppressive jim crow laws in the south. however, these migrants were met with discriminatory housing policies that acted as barriers to wealth accumulation and homeownership. starting in the 1930s, the home owners loan corporation created color-coded maps that graded neighborhoods based on their perceived lending risk, which was often directly related to racial demographics (kaplan & valls, 2007). predominantly black neighborhoods were labeled “hazardous” and outlined in red, and the people living there were systematically denied access to credit, home loans, and mortgage financing. the practice led to the use of the term “redlining,” which was institutionalized by the federal housing administration mortgage insurance program. the program made homeownership far more affordable for white families by offering low-down-payment, long-term loans backed by government insurance (gordon, 2005). as a result of redlining practices, these loans were unavailable to black families, reinforcing racial segregation and discriminatory housing practices. additionally, racially restrictive covenants legally prevented black families from purchasing or renting homes in white neighborhoods (coates, 2014). when written into property deeds, these covenants explicitly prohibited sales to nonwhite buyers. therefore, black families were forced into overcrowded, deteriorating areas where landlords exploited high demand by charging inflated rent prices. redlining and other discriminatory housing policies created the conditions for predatory practices to thrive, further preventing black homeownership. contract selling was a deceptive home-buying scheme in which black families, denied access to traditional mortgages, were forced to purchase homes through high-risk installment contracts. unlike conventional home loans, these contracts did not grant the buyer equity, and missing even a single payment could result in immediate eviction, allowing the seller to retain the property and all previous payments. real estate agents used the tactic of blockbusting—spreading fear that black families moving into the neighborhood would cause property values to plummet. the tactic drove white homeowners to sell their properties at reduced prices. the agents would then resell these homes to black buyers at inflated prices, profiting from racial segregation and housing instability (coates, 2014; ross, 2008). enabled by federal housing administration loans and reinforced by these racist predatory practices, white families conducted “white flight,” moving to the suburbs to avoid integration after desegregation mandates. this practice further exacerbated economic and housing disparities. this migration deprived urban centers of crucial tax revenue, leading to deteriorating public services, housing conditions, and schools, all of which primarily impacted black residents (dilworth & gardner, 2019). the fair housing act (fha) of 1968, a direct outcome of the civil rights movement, aimed to eliminate discrimination in housing based on race, religion, or national origin. although this act made redlining illegal, the legacy of redlining continues to shape housing patterns, as black communities still often face disinvestment, limited access to credit, lower homeownership rates, and high rental costs (dilworth & gardner, 2019). many families of color remain in formerly redlined areas that suffer from underinvestment and gentrification pressures. the current renting population is increasingly diverse, with people of color, young adults, and low-income families making up significant portions (dilworth & gardner, 2019). context regarding artificial intelligence and data artificial intelligence refers broadly to inanimate machine operations designed to replicate human cognition. the field of ai is relatively new: the term was only coined in 1956 by dartmouth college professor john mccarthy, who explored “thinking machines” such as alan turing’s enigma (lawrence livermore national laboratory, n.d.). today, when people refer to ai, they are most often referring to a process known as machine learning or a specific type of machine learning called deep learning. according to mit sloan professor thomas w. malone, ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur columbia social work review, vol. xxiii | 59 58 | columbia social work review, vol. xxiii machine learning has become a critical method that has shaped most ai development for the last ten to fifteen years (brown, 2021). the logic behind machine and deep learning is relatively intuitive. machine learning (ml), simply put, is the process of training a computer program or system to perform tasks without explicit instructions. it uses simplistic structures, such as (but not limited to) decision trees and linear regressions. deep learning (dl) is more sophisticated and teaches computers to process data in a way that attempts to mimic human neural networks. dl tools require much larger datasets than their ml counterparts and can be used to recognize complex patterns in data across a number of dimensions to make new predictions or insights. while the complexity dl offers has proved tremendously helpful in a number of applications, it presents problems for others, especially for data containing social factors (such as socioeconomic status, race, gender, or sexuality). all ai algorithms, both ml and dl, are only as good as the data they are trained on, and biased inputs result in biased outputs. the problem of bias has dominated most critiques of ai technology, and fairly so. examples of “algorithmic bias” that either inadequately represent1 or even adversely affect people of color2 are in no short supply. bias presents an even bigger challenge to dl algorithms. bias can be deeply embedded within the training data required to make dl algorithms function, and the complexity of dl neural networks makes it extremely difficult to identify, let alone address, instances of bias. while there are many strategies to try to calibrate algorithms fairly with respect to factors such as race and gender, completely removing bias is not possible (kleinberg et al., 2017). in his book the alignment problem, programmer and researcher brian christian (2020) has referred to the 1 for example, google photos facial recognition has failed to identify black people as human. 2 for example, the correctional offender management profiling for alternative sanctions (compas) algorithm has produced results that disproportionately and negatively affected black men. impossibility of achieving perfect fairness as a “brute mathematical fact” for any means of classification, human or machine (p. 70). how does ai affect rental housing markets? so far, we have established two key elements of dl algorithms that will help us explain how ai affects rental markets: 1) they analyze patterns across datasets to make predictions, and 2) they can and will be biased, and that bias is practically impossible to remove. dl algorithms are mainly used in the rental housing market through aidriven rent pricing tools. these typically operate by analyzing data from various sources, such as recent rental listings in an area and sales data, to offer market predictions and suggest optimal rent levels to maximize landlord profits. prima facie, the process mirrors the way that most landlords and property managers determine rental rates without ai: they survey the area, consider competitor rates, and calculate other factors that affect what they think is the best rate for them to charge tenants (vicks, 2024; policy memo: rent-setting software algorithms, 2024). however, upon closer inspection, we find that dl rent pricing tools differ from traditional rent pricing in that: • they are able to process far higher volumes of data. • they are accessible to multiple landlords and property managers, leading to pricing collusion. • they bring an inflated perceived trustworthiness that ai tends to confer. • they are more prone to hard-to-find bias that disproportionately affects renters of color. we analyze these issues further using the realpage/yieldstar rent pricing tool as a case study due to its popularity and impact (vogell et al., 2022). realpage and yieldstar realpage is a texas-based property management software company ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur columbia social work review, vol. xxiii | 61 60 | columbia social work review, vol. xxiii that provides a technology platform that “enables real estate owners and managers to change how people experience and use rental space” across over 24 million units in north america, europe, and asia (realpage, n.d.). among the many products realpage offers is a tool called yieldstar, an “asset optimization system that enables owners and managers to optimize rents to achieve the overall highest yield, or combination of rent and occupancy, at each property” (realpage, n.d.). yieldstar aggregates both public and proprietary data to set rent prices across entire regions (policy memo: rent-setting software algorithms, 2024). this data includes tenants’ rent data, credit checks, criminal background information, survey data from landlords and competitors, historical data, and sales transaction data (realpage, n.d.). the result has been a sharp and sustained increase in rental costs nationwide, especially in cities like new york, where renters are made to spend upwards of 30% of their total income on rent (siegel & bram, 2024). the technology has also emboldened landlords to raise rates higher than they otherwise would. in the words of realpage executive andrew bowen, “i think [ai is] driving [rate increases], quite honestly … as a property manager, very few of us would be willing to actually raise rents double digits within a single month by doing it manually” (vogell et al., 2022). without meaningful intervention, these technologies will only deepen existing inequalities, further entrenching a system designed to prioritize profit over people’s right to a stable home. realpage allows landlords to circumvent price-fixing regulations by enabling them to access data from other landlords and companies without direct cooperation, effectively reducing competition and inflating the housing market. in 2024, the u.s. department of justice, in collaboration with eight state attorneys general, filed a civil suit against realpage for alleged unlawful monopolistic practices that reduce competition among landlords (u.s. department of justice, 2024). moreover, a federal suit in north carolina accuses the software of violating sections 1 and 2 of the sherman anti-trust act by monopolizing interstate commerce and restricting competition in the marketplace. this suit is ongoing and has been amended as of january 7, 2025, to include six apartment landlords as defendants (u.s. department of justice, 2025). ii. policy landscape rental policy prior to the introduction of ai pricing tools such as realpage, landlords determined rent pricing through market analysis and cost considerations, factoring in the economic climate. traditionally, property managers rely on comparable market analysis, a process that reviews rental prices for similar properties within a given region, to determine competitive rent pricing (pagourtzi et al., 2003). to ensure profitability, landlords and property managers must consider operational costs such as insurance, mortgage payments, and utilities. these factors, combined with a consideration of current economic conditions such as inflation and employment rates, would be used to set a rental price for each property (dias & duarte, 2019). in the united states, several federal regulations exist to protect against discrimination and monopolistic practices in the housing market. the aforementioned fha of 1986 prohibits housing discrimination on the basis of sex, race, religion, national origin, disability, or familial status (fair housing act [fha] 1968/2023). the u.s. department of housing and urban development (hud) enforces the fha and oversees affordability initiatives such as section 8 vouchers, which assist lowincome families seeking affordable housing. while hud specifies that ai tools for tenant screening, advertising, and mortgage decisions must comply with the fair housing act, there are no specific federal regulations regarding rent pricing tools. furthermore, the free housing market is largely protected by the sherman anti-trust act of 1890, which prohibits price-fixing agreements between competitors, exclusive contracts, and monopolizing a market for products or services (sherman anti-trust act, 1890). in accordance with this act, landlords and property managers are prohibited from sharing data about their rental units and colluding to inflate rental prices. but as previously mentioned, ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur columbia social work review, vol. xxiii | 63 62 | columbia social work review, vol. xxiii realpage has been accused of violating the sherman anti-trust act by allowing landlords and property managers to access rental data, effectively restricting competition and increasing inflation in rent pricing. tech policy artificial intelligence is relatively new and thus loosely regulated by federal law, leaving the majority of regulations to the state level. currently, the federal trade commission (ftc) and the national institute of standards and technology (nist) have issued broad guidelines regarding transparency and consumer protection in ai algorithms (federal trade commission, 2024). although the nist provides a suggested framework for transparency and data protection, no comprehensive legislation specifically addresses these concerns (nist, 2024). regarding ai tools in housing, rent pricing tools are loosely regulated through sector-specific policies by hud and the federal housing finance agency. however, concerns have risen that ai pricing tools may contribute to discrimination in the housing market by deriving algorithms that rely on historical data and patterns of discrimination against certain ethnic and socioeconomic subgroups. moreover, the use of artificial intelligence reduces human oversight and creates a lack of transparency on how pricing decisions are made. as consumers across the united states express concern over artificial intelligence, states have begun to introduce legislation around the use of ai tools in housing. as every state faces unique housing challenges, each state has taken a slightly different approach to regulating ai pricing tools. california is currently facing a housing crisis, as the state has one of the highest median rent and home prices in the nation. as of september 2024, the qualifications for a mortgage on a mid-tier home were more than double the median household income for the previous year (bentz, 2024). despite growing concerns, the state has not enacted comprehensive legislation to address ai pricing tools. currently, the data privacy of california residents is protected by the california consumer privacy act and the california privacy rights act, both of which restrict data sharing by businesses and grant consumers greater control over personal data collected by ai systems (california privacy protection agency, n.d.). connecticut and virginia have enacted similar legislation in an effort to increase transparency and protect consumers’ sensitive data. although no specific state legislation addresses ai tools in housing, broader civil rights regulations in california prohibit discriminatory practices in housing. for example, both the california fair employment and housing act and california government code section 12955 prohibit discrimination in housing and employment on the basis of race, color, religion, ancestry, national origin, disability, medical condition, marital status, sexual orientation, sex, or age (housing discrimination, 1980). while existing legislation is broad, these regulations make it unlawful for ai pricing tools to result in algorithmic discrimination. however, more specific legislation is required to combat price increases that affect the affordability of rent in california. as of now, colorado is the only state to enact comprehensive legislation on the development and distribution of artificial intelligence systems: the colorado artificial intelligence act (caia) will become effective february 1, 2026 (consumer protections for artificial intelligence, 2024). the caia targets high-risk artificial intelligence systems in sectors such as education, employment, housing, and healthcare to reinforce standards set by the fair housing act and protect against algorithmic discrimination, defined by unlawful differential treatment that disfavors groups based on protected classifications. the legislation imposes regulations on ai by requiring developers and deployers of highrisk ai systems to use reasonable care in protecting consumers against algorithmic discrimination. for example, developers would be required to provide documentation to deployers on data used to train the system, how it was evaluated, and its intended outputs and use. furthermore, developers and distributors are required to clearly display the potential risks of algorithmic discrimination on websites for public use. if the ai system presents a risk for algorithmic discrimination, the developer is required to notify the colorado attorney general within a 90-day period. ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur columbia social work review, vol. xxiii | 65 64 | columbia social work review, vol. xxiii these specific limitations on ai systems are designed to combat algorithmic discrimination but do not specifically address antitrust laws or monopolization of the market. ai pricing tools such as realpage remain in a gray area, where they must adhere to antidiscrimination laws but may still provide enough rental data that landlords and property managers may take advantage of it to manipulate rental prices. this gap in regulation raises concerns over what ai pricing tools may accomplish without stricter oversight. furthermore, the current administration has been very vocal about its intentions to continue using and developing ai technologies without “barriers” such as bias prevention or data protections (white house, 2025). the united states also refused to sign the international ai action statement at the paris ai action summit earlier this year (kleinman & mcmahon, 2025). iii. policy options there are a number of options that u.s. policymakers can and should consider to address issues stemming from ai-driven rent pricing. these options address various regulatory fields involved in the problem, including transparent use of ai, access to personal data, and housing. the three most prominent policy options—strengthening federal oversight of the fha, introducing ai and data regulation, and adopting rent controls—are outlined in this section. strengthening federal oversight of the fha instituting a federal mandate stating that landlords and property owners must disclose the use of ai pricing tools and other factors contributing to rent pricing to tenants could ameliorate some of the harmful results of ai-priced housing. with ensured disclosure, renters are presented with enough information to make calculated decisions on whether to utilize ai tools. additionally, a mandate could create a federal registry of ai systems used in the housing market, requiring developers to submit documentation to demonstrate compliance with antidiscrimination standards set by the fha (fha, 1968/2023). developers and distributors of ai housing tools would be subject to annual audits under the review of hud. the hud would then assess potential algorithmic bias, discriminatory outcomes, and data integrity. one advantage of a federal mandate is that it ensures a consistent national standard for ai tools and alignment with antidiscrimination laws in the housing market. a mandate in addition to a national registry would address gaps in sector-specific federal oversight. however, laws prohibiting algorithmic discrimination and requiring transparency may face lobbying or other pushback from ai developers and stakeholders, and significant federal resources may be needed to implement and enforce the mandate. ai and data regulation introducing financial incentives for states to adopt comprehensive legislation similar to caia could help address algorithmic discrimination and monopolization of ai pricing tools. in this scheme, federal grants would be provided to states that adopt comprehensive ai legislation. state incentives could encourage tailored solutions to state-specific issues in the housing market. however, without federal oversight, there may be inconsistent regulations and protections across states. rent control lastly, the issue of ai rent pricing tools would not exist if not for the state of the u.s. housing and rental market. one possible method for addressing the hypercompetitive nature of rental housing is through rent control and/or antigouging legislation (collectively, “rent regulations”). american cities are more susceptible to ai rent pricing tools because of the lack of policy limitations constraining the range of rent prices landlords can ask for. the u.s. housing market is relatively unregulated ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur columbia social work review, vol. xxiii | 67 66 | columbia social work review, vol. xxiii as a whole, especially in comparison to many western european nations. because ai-driven rent pricing tools encourage landlords to raise rents by higher amounts within shorter time frames, reducing the rate by which a landlord could increase rent would limit the potential impact of the ai recommendations on the rental market. state interventions in rent controls were quite common in socialist states to maintain the competitiveness of socialist economies on a global scale (lux et al., 2013). in postsocialist and primarily capitalist economies, state interventions in the rental housing market generally take the form of social housing or private rental-sector regulation. since world war ii, most of these interventions have been to the private rental sector. some of the strictest systems of state intervention in rental regulations can be found in sweden and denmark, where the state regulates rents for all running and newly signed leases (sardo, 2024, p. 228). of course, traditional rent control measures have faced criticism for their inflexibility and for their tendency to disincentivize upkeep and maintenance of units. new york city itself has a long history of rent controls that have been found to be less than successful. researchers at the wharton school found that a review of twentieth-century rent control policies revealed they had negative impacts on rental structure quality, especially in smaller prewar-constructed buildings (gyourko & linneman, 1990, p. 399). furthermore, socialized policies often fail to achieve popular support in the u.s., a country whose historic and cultural commitment to the free market is well established. while rent regulation policies may be difficult to enact at a federal level in the united states, it would be advisable for states or municipalities to adopt a larger role in reviewing lease agreements. moreover, state governments may consider a liberalization of private rent contracts in combination with rental regulation and tenant protections. this would address the volatility of the rental market, collusion concerns, and ostensibly concerns over abuse of private data. even requiring landlords to justify changes in rent would increase transparency in the rental market and could discourage opaque decision-making methods such as those fostered by rent pricing algorithms. iv. conclusion and recommendations addressing the impacts of ai-driven rent-setting tools, such as realpage, requires a strategy that balances ambition with practicality, combining strengthened federal oversight, state-level incentives, and well-designed rent control measures. federal oversight would provide a critical foundation, setting consistent nationwide standards in data protection and aligning ai systems with the existing fair housing act. requiring transparency, establishing a registry of ai tools, and conducting regular hud audits could create accountability and curb the negative effects of rent pricing tools. for this reason, and a host of other ai-based challenges we continue to face, it is more important than ever to develop a comprehensive policy framework addressing the use of ai and data privacy rights borrowing from the strong precedents set by the eu in the general data protection regulation (gdpr), digital services act (dsa), and ai act. however, achieving comprehensive federal legislation may face steep political challenges, so it is necessary to supplement these efforts with policies that can be implemented more readily at the state and local levels. state incentives offer a pragmatic way to drive meaningful change while respecting the unique challenges of local housing markets. by providing grants to states that adopt comprehensive ai legislation, like colorado’s artificial intelligence act, the federal government could empower states to innovate while remaining aligned with broader national goals. this approach allows for regionally tailored solutions that can be implemented without waiting for federal consensus, creating a framework where states lead the way in testing and refining policies to address algorithmic discrimination and monopolistic practices in the housing sector. rent control measures round out this strategy by directly addressing the ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur columbia social work review, vol. xxiii | 69 68 | columbia social work review, vol. xxiii immediate harms of ai-driven rent increases. these policies, which cap excessive rent hikes and require landlords to justify significant increases, protect tenants while remaining adaptable to local conditions. paired with complementary tools like housing vouchers and incentives for affordable housing development, they provide stability in the rental market and safeguard vulnerable populations. together, federal oversight, state-level innovation, and rent regulations form a cohesive and actionable plan to address both the systemic and immediate challenges posed by ai-driven housing systems. these approaches, both individually and collectively, would increase housing equity and decrease exploitative data practices. overall, localized rent control measures provide the best first step toward addressing long-standing systemic inequities in the rental housing market and preventing ai-driven rent pricing tools from exacerbating these inequities in the market. the recently severely reduced size of the federal government as well as polarized views about the extent to which ai should be regulated (if at all) play heavily into this recommendation. since rent controls have historically correlated with decreased quality of rental units, they should be introduced alongside stronger landlord accountability measures or increased enforcement of housing court decisions where rental habitability can be disputed. references bentz, alex. 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(2025, january 23). removing barriers to american leadership in artificial intelligence. https://www.whitehouse.gov/presidential-actions/2025/01/removing-barriers-to-americanleadership-in-artificial-intelligence/ ai and the housing crisis mckynzie clark, austin nelson, & sanjana utiramerur finalized digital files.pdf columbia social work review, vol. xxii | 115 114 | columbia social work review, vol. xxii inspiration for article after moving from the other side of the globe to the u.s., i realized i am viewed just as ‘asian’ here. it was as if all my cultural experiences and diverse ethnic backgrounds were deliberately ignored. after i started talking to other bipoc folks who are non-citizens, immigrants, or first-generation immigrants, i found that many feel the same as i did. eventually, i learned about different ethnicities that fall under the asian, latinx, and black umbrella terms and how different they are. for instance, it is rare to find an indonesian american to drink beyond their capacity due to the extremely conservative culture in indonesia. on the other hand, korean americans are likelier to drink because it is part of their culture in korea. this was basic knowledge for myself and many around me. hence, when finding that data collection in the u.s. disregards, i instinctively knew that many ethnic groups are currently overlooked, but also ironically very much acknowledged though only as a monolithic group. this inspired me to look into disparities in social and health issues impacting different ethnicities under the same racial umbrella. i’m a proud southeast asian, born and bred in indonesia. before pursuing a master’s in social work at columbia, i served as the youngest policy analyst in the governor’s delivery unit of jakarta, the capital of indonesia. my research interests are mainly in social and psychosocial determinants of health and empowerment of vulnerable communities. adela jansen columbia social work review, vol. xxii | 117 116 | columbia social work review, vol. xxii alcohol and substance use among east asian american youth adela jansen abstract this reading challenges the prevailing model minority myth perspective which influences the examination of substance use patterns among different subgroups of east asian american (eaa) youth. a disaggregated analysis of existing literature reveals significant variations in substance use across eaa subgroups. this article explores influencing factors such as acculturation, cultural norms, and peer dynamics, emphasizing distinctions between chinese americans, taiwanese americans, korean americans, and japanese americans. several eaa subgroups show a higher prevalence of cigarette or alcohol use than their white counterparts, a finding normally hidden by the aggregation of asian american data. these unrealized differences prompt a call for tailored and culturally appropriate treatment approaches. data shows eaa youth are more likely to not seek treatment or to drop out after beginning treatment (wang & kim, 2010 as cited in ong, 2023). understanding the typical family dynamics as well as the discrimination faced by eaa communities, including cultural stigma and culture-specific syndromes, plays a crucial role in improving treatment adherence. additionally, studies of treatment preferences show that implementing family-based programs, outreach efforts, and involving culturally attuned treatment providers is crucial to actively address the unique needs of youth of different eaa subgroups (lee et al., 2004). keywords: substance use, treatment approach, culturally appropriate care, east asian american, model minority asian americans (aa) are the fastest-growing minority group in the united states (budiman & ruiz, 2021). often referred to as the “model minority,” the aa community is perceived as a monolithic group that is successful and stays out of trouble. the model minority myth has created distortions and misperceptions about the actual struggles of many asian americans which range from mental health to other areas of health (blackburn, 2019). the stereotype that asian americans are “doing well” ignores how many asian american youth face dual exposure to strict parenting (i.e. tiger parenting with punishment and shaming tactics) and holding a bicultural identity, which can result in poor coping behaviors such as substance abuse (saraiya et al., 2019). in reality, a 2002 study shows that compared to girls of other ethnocultural groups, asian american girls have the largest increase in use of alcohol (from 9.5% to 28.4%), cigarettes (from 7.4% to 17.1%), marijuana (from 2.4% to 9.1%), and other stimulants (from 1.5% to 2.3%) from 8th to 12th grade (wallace et al., 2003). moreover, since research on alcohol and substance use often lumps all subgroups within the asian american (and sometimes pacific islander) community together, this aggregate data masks high rates of substance use within specific groups (kane et al., 2017). this creates an increased danger of overlooking and ignoring the needs of the aa community. east asian american (eaa) youth compared to other asian american subcultures, east asian americans currently fit the mold of the model minority myth the most. eaa ethnicities include chinese americans, hong kong americans, japanese americans, macau americans, mongolian americans, north korean americans, south korean americans, and taiwanese americans (asia society, n.d.). the 2019 american community survey (acs) data from the u.s. census bureau shows that the asian american groups with the highest median household income and the highest percentages of adults (age 25 and above) with at least a bachelor’s degree are mainly in the eaa category (jin, 2021). within this group, the taiwanese, chinese, columbia social work review, vol. xxii | 119 118 | columbia social work review, vol. xxii japanese, and korean american subgroups stand out the most in terms of economic and educational achievement. when referring to asian americans in the u.s., most only consider east asians, further perpetuating the misconception of asian americans as a “successful” monolithic model minority. the common perception is that asian americans in general are as successful as their white counterparts, at least from an economic and educational standpoint. this translates into a double-layered assumption that east asian americans are economically successful and, therefore, not at high risk of substance use. however, simply earning a high income or a bachelor’s degree does not define the population’s well-being, especially in terms of mental health and substance use. additionally, even if rates of substance use for asian americans are lower than other racial groups, most data do not show the variances among different asian american subgroups/ ethnicities nor their experiences of racial or minority stress (national survey on drug use and health, 2021). many east asian americans are from immigrant families where using certain substances, namely alcohol, is common or seen as a norm in their country of origin. this paper focuses on the high prevalence of substance use, especially alcohol and cigarette use, among some eaa subgroups. furthermore, cultural norms in the asian american community mean these groups are already less likely to seek professional help, and false assumptions of substance use among different eaa subgroups have further contributed to limited availability and accessibility to treatment for those who do need help (guarnotta, 2023). in general, public health researchers and practitioners have been led to deprioritize analyzing the patterns of substance use among east asian americans and asian americans (kane et al., 2017). hence, it is unsurprising that policies and programs tend to ignore the need for prevention and treatment for this population. the relationship between different subgroups of eaa youth and substance use, as well as treatment approaches appropriate for this population, should be examined. youth populations are prioritized in this paper since this is a crucial stage for intervention in the development of alcohol and substance use issues. factors influencing substance use across subgroups the 2019 acs data from the u.s. census bureau shows that the east asian american subgroup has the highest percentage population (8.6 million) in the u.s compared to other asian american subgroups. acknowledging the distribution of ethnicities of asian americans is crucial to understanding how current aggregated data concerning asian american substance use has created biases and oversight of substance use prevention and treatment for asian american subgroups that need them the most. alcohol and substance use among east asian american youth adela jansen table 1 ethnicities under the asian american umbrella p o p u la ti o n source: u.s. census bureau, 2019 american community survey as cited in jin’s (2021) article. columbia social work review, vol. xxii | 121 120 | columbia social work review, vol. xxii the 2013 u.s. national survey on drug use and health (nsduh) reveals that asian american youth have the lowest prevalence of pastmonth alcohol use and binge drinking compared to other races or ethnic groups (substance abuse and mental health services administration, 2013). however, data which combine all asian american sub ethnicities under one category hide and ignore the reality of high-risk groups. a 2017 study found prevalence estimates of alcohol use among korean, japanese, and filipino american adolescents were in fact very similar to other racial groups (i.e. white and black populations) that experience a high risk of alcohol use (kane et al., 2017). another study by cook et al. (2015) found the culture of drinking in the country of origin, namely korea, japan, and the philippines, predicted heavy episodic drinking among these young adults. low levels of alcohol use among chinese americans and asian indian americans–the two largest asian american subgroups in the united states, skew the data when evaluating alcohol use among asian americans as a whole (saraiya et al., 2019; u.s. census bureau, 2021). collectively, these findings accentuate the existing alcohol use amongst asian american youth and the importance of disaggregating this data by ethnicity. there is limited research on illicit substance use (e.g. cannabis, opioids, and illicit stimulants) among asian americans. the existing small body of research depicts japanese and korean ethnicities reporting higher use of illicit substances compared to other asian american ethnicities (ryabov, 2015; saraiya et al., 2019 as cited in ahmmad & adkins, 2021). chinese americans & taiwanese americans although chinese americans comprise over half of the east asian population in the u.s., this group consistently reports low alcohol use prevalence compared to other asian american subgroups (chang et al., 2008). however, this does not mean alcohol and substance use is nonexistent among chinese american youth. this phenomenon requires examining the process of acculturation–how closely one adheres to cultural norms in the u.s–which appears to be a strong predictor of substance use for other ethnicities. for instance, one study highlights how chinese americans are more influenced by specific cultural values (i.e., family obligation and expectations of autonomy). this means that chinese american youth with a higher internalized sense of these values engaged in less misconduct (juang & nguyen, 2009). although family values are a strong predictor of substance use in chinese american youth, it is important to note that substance use is part of chinese culture. moreover, chinese and taiwanese american youth are greatly impacted by the recent history of immigration in their families. immigration can greatly alter family dynamics and values and affect how these values contribute to substance use. in existing research on substance use in taiwanese americans, this group is often combined with chinese americans, perhaps due to the very similar culture and the comparatively lower population of taiwanese americans. a study on smoking behavior among chinese american and taiwanese american college students found personal meanings associated with smoking are powerful predictors of smoking for this population (spruijt-metz & hsia, 2003). specifically, participants of this study reported that personal feelings about smoking are closely related to culture and smoking customs in some regions in china and taiwan where smoking is socially accepted and even encouraged among men. in comparison, the personal feelings about smoking in female participants are more influenced by family education and parental attitudes compared to social customs. korean americans on the other hand, korean american college students are found to be drinking alcohol more frequently and in higher amounts compared to chinese american students. particularly, korean americans are more likely than chinese american students to view drinking as a socially acceptable practice and a way to facilitate social interactions (chang et al., 2008). the two most common environments where korean americans drank alcohol were drinking at night with friends or at parties (nakashima & wong, 2000). drinking behavior among korean alcohol and substance use among east asian american youth adela jansen columbia social work review, vol. xxii | 123 122 | columbia social work review, vol. xxii american students is closely associated with the drinking behaviors of their parents and friends. they are more likely to drink frequently when they have more spending money and are more likely to engage in substance misuse if their parents or friends use alcohol or tobacco (chang et al., 2008). similarly, along with their chinese american counterparts, acculturation is not a significant predictor of drinking for korean american teenagers. peer influence, scholastic achievement or aspirations, and current smoking habits are stronger predictors (cook et al., 2009). contrary to their chinese american counterparts, gender difference does not significantly change the measure of alcohol use among korean american teenagers. regarding smoking, a 2002 study (price et al.) found that 33.5% of korean americans use cigarettes, which is higher than the percentage of caucasian americans who do so (30%). moreover, from 2010 to 2013, the prevalence of cigarette use among korean americans was 20%, a number that is almost twice the average of the aggregate asian american population (10.9%) in the same period. this means the risk of cigarette smoking among korean americans is comparable to other higher-risk u.s. demographic groups (martell, garrett, and caraballo, 2016 as cited in ahmmad & adkins, 2021). japanese americans as discussed above, the use of alcohol among japanese american youth is prevalent (kane et al., 2017). the influence of acculturation to u.s. cultural norms is especially significant for japanese americans and their relationship with alcohol and substance use (ahmmad & adkins, 2021). the drinking culture of their country of origin is also a significant determining factor (cook et al., 2015). these findings are unsurprising since japan is to this day known for its drinking culture. the drinking culture in japan has become so normalized that the japanese government encouraged its younger generation to drink more to support the alcohol industry during the covid-19 pandemic, exacerbating the existing prolific drinking culture (hida & yoon, 2022). a separate study in hawaii indicates that the onset of smoking and drinking among japanese american students is closely associated with japanese culture. the findings emphasize that although acculturation is an influential factor, nationality and level of education have stronger associations with smoking, and education is a stronger predictor of alcohol use (tomioka & maddock, 2007). this research shows that social workers are needed to ensure a quality of education which centers the experiences of east asian americans, namely concerning their experience in american public education. multiethnicity asian americans & part-asian americans literature (cited in ahmmad & adkins, 2021) shows that marriages between two asian ethnicities and between asians and other racial or ethnic groups are increasing, resulting in more youth identifying as multiple asian ethnicities (e.g. vietnamese and chinese). these individuals often identify as multiracial (e.g. japanese and white); however, there is no research exploring the prevalence and patterns of substance use among these groups. the failure to consider asian identities beyond mono-ethnic and mono-racial studies will increasingly create confusion and misinterpretations regarding the relationships between race, ethnicity, and substance use. treatment challenges and recommended treatment approaches unfortunately, research on treatment approaches for asian americans, including east asian americans and particularly eaa youth, is limited. regardless, available studies do show that asian americans have certain preferences for substance use treatment (wang & kim, 2010). most studies group east asian americans with other asian american subgroups. regardless, there is a common denominator showing asian americans require culturally appropriate care and approaches that take into consideration discrimination based on race and ethnicity. alcohol and substance use among east asian american youth adela jansen columbia social work review, vol. xxii | 125 124 | columbia social work review, vol. xxii culturally-appropriate care research shows that when asian americans participate in therapy services, they are more likely to drop out than their white counterparts (wang & kim, 2010 as cited in ong, 2023). one potential explanation for this may be the cultural practice of shaming substance use and mental illness and the pressure to maintain the family’s image. these tendencies may cause families to encourage their youth to avoid going to professionals and choose to address these issues in private or deny their existence altogether (gateway foundation, n.d.; gemme, 2023). hence, the asian american population as a whole can benefit from family support for people who misuse substances, open discussion of the cultural stigma of substance-use problems, and culturally appropriate localized knowledge of drug misuse (lee et al., 2004). due to the aforementioned reasons, asian americans are less likely to seek help and treatment services compared to other racial groups (guarnotta, 2023; spencer et al., 2010). in fact, only 3.3% of asian americans needing substance abuse treatment receive such treatment (samhsa, 2019). compared to the rest of the country, asian americans are three times less likely to seek and receive treatment compared to the general population (samhsa, 2014 as cited in kaliszewski, 2022). therefore, more outreach efforts regarding treatment options and processes are needed in the communities of eaa youth. as such, asian americans would benefit from shame and stigma reduction programs. two studies in 2007 and 2013 on japanese american youth highlight the need for culturally specific interventions for japanese, japanese american, and part-japanese american teenagers and youth. culturally appropriate care requires therapy providers to better understand the influences and effects that culture, ethnicity, and regional customs have on alcohol and substance use among adolescents (tomioka & maddock, 2007; williams et al., 2013). as treatment adherence is also associated with how much the client can relate to and understand the treatment provider’s explanation of symptoms and illnesses, treatment providers should be trained in acknowledging and understanding the existence, prevalence, manifestation, and treatment of asian culture-specific syndromes. examples of these include: "hwa-byung" (korean syndrome similar to, yet different from dsm-iv major depression), "taijin kyofyusho" (japanese disorder similar to, yet different from dsm-iv social phobia), and "koro" (southeast asian syndrome now referred to as genital retraction syndrome in the global mental health literature) [which] are all psychological disorders that have been documented in asian-americans/pacific islanders. clinicians unaware of such disorders are at higher risk for misdiagnosing such problems and, thus, implementing culturally inappropriate interventions. (iwamasa, 2012, inadequacies section) additionally, american treatments and methodologies may be dismissive of culturally specific healing practices that are unknown or unfamiliar in the u.s. treatment providers must not only be aware of culturally specific practice, but also understand how asian healing practices have been ignored and looked down upon. asian american youth who grow up in the u.s. may have complicated feelings regarding these practices. all in all, providers can use this as an opportunity to explore the complexities of discrimination and healing instead of ignoring them. oppression and discrimination due to the myth of the model minority, oppression and racism can also be the causes of mental health issues and substance use among asian americans. asian americans and pacific islanders often experience discrimination in their places of employment, where they may experience the “glass ceiling effect:” although trained and competent, in many companies, asian americans and pacific islanders find it difficult to move beyond mid-level positions. stereotypes of asian-american/pacific alcohol and substance use among east asian american youth adela jansen columbia social work review, vol. xxii | 127 126 | columbia social work review, vol. xxii islander employees as being smart, hardworking, and reliable, yet passive and quiet, result in many individuals being passed over for much-deserved promotions and recognition. implications for negative effects on self-worth are clear. (iwamasa, 2012, oppression section) accordingly, the american psychological association recommends treatment providers serving the asian american population be aware of inaccurate historical stereotypes and myths of asian americans (e.g. the model minority myth). treatment providers should gain knowledge of the diversity in educational and occupational achievement, socioeconomic status, and the frequent need for family members to have multiple jobs to make ends meet among asian americans (iwamasa, 2012). as in treatments with any other racial group, treatment providers should not make assumptions regarding a client’s experiences and how much an asian american individual adheres to their cultural values and practices. thus, recruiting treatment providers who identify as east asian american and have lived experiences similar to eaa youth is extremely beneficial– although not always required. additionally, hiring treatment providers who speak east asian languages is important. although language barriers can generally be a challenge for asian americans who are recent immigrants as well as first-generation eaa youth, it may not be a challenge for second and third-generation eaa youth. lastly, treatment providers should be aware of the common substances used by eaa youth. for instance, between 2000 and 2010, methamphetamine and marijuana were the two most commonly reported illicit drugs among asian americans (samhsa, 2014 as cited in guarnotta, 2023). part of exercising due diligence in providing the best support for asian american youth includes recognizing the common causes of substance misuse among different eaa ethnicities as outlined in this paper. for example, alcohol misuse among korean american youth is mostly a peer-reinforced phenomenon (nakashima & wong, 2000). hence, strategies and goals have to be set accordingly depending on the tendencies of each population. preferences for prevention approaches resiliency-focused prevention programs a 2004 study on perceptions of substance use in asian american communities, namely the chinese, indian, korean, and vietnamese populations, shows that these populations lack interest in using support groups such as alcoholics anonymous or narcotics anonymous because of their cultural preferences to confide in family and friends (lee et al., 2004). the study recommends drug-prevention programs for the asian american population to focus on a range of other available treatment options as well as the pros, cons, and feasibility of using personal resources to address substance-use problems. also, asian american populations tend to respond favorably to topics such as wellness, health promotion, and resiliency (fang & schinke, 2013). as such, family-based prevention programs focusing on strength and resiliency rather than pathology and deficits may be particularly relevant to east asian americans. asian american participants in another study reported they would be more attracted to programs made specifically for asian americans, but very few such programs exist. schools and community centers (e.g., health clinics, ymca, etc.) were the most frequently mentioned locations to hold such a program. some participants felt an online program that targeted the asian community would be appropriate, and some also showed preferences for family-based programs (fang et al., 2011). however, other participants noted that asian parents’ “ordering” communication style tends to create a negative atmosphere and tense relationships with their children even in treatment settings. many also mentioned that asian american parents are generally more focused on their children’s academic performance than other supplemental or extracurricular activities, so parents may overlook the need for a familybased prevention program. alcohol and substance use among east asian american youth adela jansen columbia social work review, vol. xxii | 129 128 | columbia social work review, vol. xxii further research generally, there needs to be more research on the preferences of asian american individuals for prevention approaches. one consistent finding among most asian american subgroups is the importance of considering the perspectives of the family. consequently, ensuring that treatment approaches are aligned with an individual’s family preferences and culture is crucial. there is a lack of research on prevention among taiwanese americans and other ethnicities with smaller populations such as hong kong americans, macau americans, and mongolian americans. moreover, due to the minute population of north korean americans, the term korean americans generally refers to south korean americans, although north korean americans have distinctly different alcohol and substance use behaviors in their country of origin. there is minimal research and data on effective treatments for east asian americans, much less eaa youth. more and updated research, as well as disaggregated data alongside studies on appropriate treatment approaches, specifically on eaa youth, is needed for public health professionals, social workers, and treatment providers to create appropriate policies and programs to help eaa youth who require support. future research must look into separate asian american subgroups/ethnicities and consider the distinct cultural differences among these groups. research must also include south and southeast asian subgroups, especially groups with a high population in the u.s. (i.e. filipino americans and vietnamese americans). ultimately, efforts for further research are increasingly needed as these populations continue to grow. conclusion there are clear differences in substance use between ethnicities that fall under the east asian american term or identity, notwithstanding the similarities among chinese american, taiwanese american, korean american, and japanese american youth, which include less likelihood to seek help and a higher likelihood to drop out of therapy services compared to their white counterparts. differences such as drinking habits and social norms are influential determinants for higher-risk ethnicities such as korean americans and japanese americans. due to the history of systemic racism against asian americans, more advocacy and cultural representation in treatment, such as understanding culturespecific explanations of certain symptoms and illnesses, is necessary (gemme, 2023). on a macro level, efforts to dismantle stereotypes and the model minority myth are also necessary as these can lead to mental health issues and substance use among asian americans. lastly, the familiarity of providers with the treatment preferences of the asian american population may improve treatment adherence and willingness to continue treatment. consideration of family perspectives on treatment approaches and acknowledging the pressure from stigmatization of mental health among asian americans is crucial to the well-being of this community. references ahmmad, z., & adkins, d. e. 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(2010). therapist multicultural competence, asian american participants’ cultural values, and counseling process. journal of counseling psychology, 57(4), 394–401. https://doi.org/10.1037/a0020359 williams, j. k. y., else, ’iwalani r. n., goebert, d. a., nishimura, s. t., hishinuma, e. s., & andrade, n. n. (2013). a confirmatory model for substance use among japanese american and part-japanese american adolescents. journal of ethnicity in substance abuse. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3923518/ alcohol and substance use among east asian american youth adela jansen finalized digital files.pdf columbia social work review, vol. xxii | 29 28 | columbia social work review, vol. xxii inspiration for article i began writing this paper while writing my doctoral dissertation. i felt compelled to justify, in detail, why i choose to utilize latine in my writing instead of “latinx.” this led me to spend a lot of time going down a lot of research rabbit holes in search of the perfect citation, one that encompassed my full perspective on the need to use gender-inclusive – but not gender-neutral – language when referencing my pan-ethnicity. realizing that the empirical article i was looking for didn’t exist yet, i decided to write it myself. it was important to me to publish this piece in the columbia social work review because of the connections between cssw and the topic of my article. one thing i hope readers take away from it is a greater understanding of the term “latinx” including how it came to be and how its usage has grown. i’m really excited to see this paper in print and share it with family, friends, colleagues, and professional partners, in the hopes that it will provide them with a well-researched basis to explain why and how they choose labels of latinidad, without having to complete a systematic review of research like i did! jessica trejos was born and raised in new york city. she received her master of science in social work from columbia university, with a concentration in advanced generalist practice & programming, a specialization in family, youth & children’s services, and a minor in international social welfare & services to immigrants and refugees. her research interests draw greatly from her personal and professional experiences. jessica trejos columbia social work review, vol. xxii | 31 30 | columbia social work review, vol. xxii what’s in a “latinx?” abstract people of latin american origin use many different terms to self-identify their ethnicity. to date, there are very few scholarly articles that have investigated the growing use (and potential outcomes) of the term “latinx.” over the past decade, this pan-ethnic identifier has been wholly ascribed to a group of people who do not all identify with it. the dearth of empirical understanding on this topic is especially concerning given its significant implications on one’s positive identity development and overall psychosocial functioning. this conceptual essay is meant to introduce readers to the role that u.s. colleges and universities played in the promulgation of the word “latinx.” it also aims to stimulate discussion amongst readers who may question how “latinx” came to be the pan-ethnic identifier for this community as well as those who may question whether they should adopt or reject the label. to address the aforementioned inquiries, this composition includes a brief history of the most commonly used pan-ethnic terms for the latin american diaspora. the implications of ascribing gender-inclusive vs. gender-neutral labels on positive identity development, as well as recommendations and best practices for social work researchers, practitioners, and other stakeholders, are also discussed. jessica trejos t he first time i heard the word “latinx” was on september 6, 2011. it was my first day of classes in pursuit of a graduate degree at the columbia university school of social work. while a fellow first-year student was describing what brought them to the field of social work, i heard them say a phrase that sounded like “latines in this country.” i mistakenly attributed the pronunciation of this word to their regional accent, not to an intentional effort by a nonbinary person to utilize a gender-inclusive form of latinos. as someone who was born and raised in new york city, i have often observed that people can pronounce the same words in different ways. however, my new colleague informed me that, although they were from boston and spoke with a distinctive accent, they had indeed intended to say latines, not latinos. moreover, even though the word was pronounced with an e, it was spelled “latinx,” with an “x.” they also told me it was understandable if i had never heard the word “latinx” before; they had only ever heard it used amongst genderqueer people. over time, i heard more of my social work peers utilizing the word “latinx,” but enunciating it more like “latin ex.” this was distinct from the way i first heard my associate from boston pronounce it as someone who was a heritage speaker of spanish. moreover, i did not hear anyone besides other social workers using “latinx” until december of 2015 – when i began working at a university in the midwest. through my academic and vocational networks, i learned that “latinx” was quickly being adopted at institutions of higher education across the country at that time. however, i did not observe its usage in any other contexts, and i sought to comprehend why. columbia social work review, vol. xxii | 33 32 | columbia social work review, vol. xxii author’s positionality the lens through which i examine the usage of “latinx” is informed by my background in social work as a practitioner specializing in immigrant and refugee issues in addition to my background in education as both a scholar of psychosocial development and as an adolescent educator. i also carry the perspectives and biases that come as a result of over two decades of experience working with latina/e/o/x youth in both formal and informal learning environments. i self-identify as a cis-gender, heterosexual woman whose parents migrated to the u.s. as children after forced displacement from their homeland. my own process of self-identifying as a nicaraguan-american first, a central american second, and a latina third was shaped by having resided in six different cities across the u.s. (as well as in nicaragua) and the impact that interacting with other latinas in each of those places had on my own self-perception. in my personal and professional experiences, i have seen how my many intersectional identities frame not only how i have come to understand ethnic identity development but also how i continue to learn about labels of latinidad (which i translate as “latineity” – the quality or state of being latina/latine/latino/latinx). understanding “latinx” numerous studies have observed a correlation between one’s ethnic or gender identity development and many aspects of well-being. positive identity development is characterized as forming a healthy self-identity and a secure sense of self. this can be achieved at both the personal and the social level with beneficial outcomes such as high self-esteem, successfully engaging with others and developing/maintaining healthy relationships, and a positive sense of agency to accomplish goals (brandon-friedman, 2019). according to erikson’s (1963) theory of psychosocial development, which describes how an individual’s personality develops and how their social skills are learned, adolescents must confront the challenge of ego identity vs. role confusion. during this stage of development, the main tasks that need to be resolved for healthy outcomes include constructing one’s own unique sense of identity, finding social environments where one feels a sense of belonging, and establishing a confident sense of where one fits into society. one way that adolescents accomplish these tasks is by developing their ethnic identity which includes adopting an ethnic–or pan-ethnic– identifier. for example, “latinx” is a pan-ethnicity, a term that refers to the organization of ethnic subgroups perceived by outsiders to be homogenous under an umbrella category of collective interests and shared socio-political goals (espiritu, 2019). under this umbrella category, there are dozens of other ethnicities, such as central american and nuyorican. notably, there are very few scholarly articles that have investigated the growing use (and potential outcomes) of the term “latinx” as an ethnic identifier. this dearth of empirical understanding is especially alarming given the significant implications for one’s sense of self and ability to engage with others on identity development and overall psychosocial functioning (umaña-taylor et al., 2002). young people from across the latin american diaspora make up the second largest racial/ethnic group enrolled in k-12 schools (kidsdata, 2021) and post-secondary institutions (institute of education sciences, 2022) in the u.s. today. in addition, research demonstrates that students of latin american origin more often rely on schools than other systems as their primary provider of mental health services (franco, 2018). this should be of particular concern to social workers who make up the country’s largest group of mental health services providers according to the national association of social workers (nasw, n.d.). this conceptual essay is meant to introduce readers to the influential role that u.s. colleges and universities played in the promulgation of the word “latinx.” schools, as sites of socialization, are influential in the psychosocial development of students, including their racial identity, ethnic identity, gender identity, and sexual identity development. subsequently, the staff and other students at one’s school have the potential to support or hinder psychosocial functioning and what’s in a “latinx?” jessica trejos columbia social work review, vol. xxii | 35 34 | columbia social work review, vol. xxii development outcomes (verhoeven et al., 2019). it is therefore possible that the usage of “latinx” may have a developmental effect that we do not yet fully understand on students of latin american origin. i also aim to speak to readers who may question how “latinx” came to be the pan-ethnic identifier for this community as well as those who may question whether they should adopt or reject the label–which may be utilized by individuals or groups in different contexts and for different reasons. for example, in the past decade, i have spoken to dozens of people (whose heritage traces back to what is now called latin america) from all walks of life about their decision to use “latinx” or not. although the majority of them expressed that it would be ideal to have a unanimously-accepted identifier of latinidad that is non-patriarchal and inclusive of everyone in the community regardless of national origin, race, ethnicity, gender, sexual orientation, and sociolinguistic background, they felt that the umbrella of latinindad encompasses so much diversity that there may never be one term that is truly inclusive of all. ultimately, whenever they decided to utilize “latinx,” it was often based on the same strategies they usually employed while code-switching–they adjusted their word choice based on what they perceived their audience would find acceptable. my exploration of the propagation, and by whom, of the term “latinx” is not an argument against using it (see scharrón-del río & aja, 2020; milian, 2019; and guidottihernández, 2017 for further reading on the significance of the term). i wholeheartedly believe that gender-inclusive language is absolutely necessary not only in the field of social work but whenever the latin american diaspora is referenced. it is not at all my intention to argue otherwise. rather, i caution against the usage of “latinx” without critical self-reflection, particularly in a color-blind, gender-blind, and sexuality-blind fashion. i also call on and encourage my fellow social workers in particular, in accordance with our code of ethics (nasw, 2021), to not only seek out a nuanced understanding of the adoption and rejection of pan-ethnic labels of latinidad, but to advocate for practices that highlight our ethical obligation to both promote social justice and respect our clients’ right to selfdetermination. this includes enhancing each of our clients’ capacities to set their own boundaries regarding which, if any, pan-ethnic term we should use when referencing their identity. with that charge in mind, the following section offers a brief history of the most commonly used terms. background on pan-ethnic labels of latinidad hispanic although “latino” and “hispanic” are often used interchangeably in the literature, there are significant differences between the two. grace flores-hughes (1996), a self-identified mexican american who is credited with introducing the term “hispanic” to u.s. public policy, has said herself that it is not at all synonymous with “latino” (flores-hughes, 2006). the identifier “hispanic” was set in 1976 as the government term for anyone living in the u.s. whose origins can be traced to a country or territory where spanish is an official language (u.s. pub. l. no. 94311, 1976), including spain itself. at the time, that also included the philippines. however, a focus on spain makes this term eurocentric (mora, 2014), and people who are of african (gonzalez-barrera, 2022), asian (unidosus, 2021), and/or native american (parker et al., 2015) descent may not identify with “hispanic” (taylor et al., 2012) even if they are native spanish speakers (lopez et al., 2023). it is also important to note that many people do self-identify as hispanic even if they do not speak spanish; most adults who identify as hispanic say it is not necessary to speak spanish to be considered hispanic (mora & lopez, 2023). with the institutionalization of “hispanic” as a pan-ethnic identifier, both widespread adoption and resistance to the term developed soon after. many argued that the term represented an attachment to the spanish legacy of colonialism and genocide in the americas, and the utilization of the term “latino” (short for latinoamericano) as a more progressive alternative quickly grew in popularity. it is important to note that people what’s in a “latinx?” jessica trejos columbia social work review, vol. xxii | 37 36 | columbia social work review, vol. xxii of latin american origin living in the u.s. had been calling themselves latino since the years following the wars of independence in spain’s former colonies, and also in response to being sociopolitically ascribed an ethnic label that they did not identify with (gutiérrez, 2016). latino the identifier “latino” refers to any person whose origins can be traced to any country or territory in latin america. it was later added as a government term to “hispanic” (62 fr 58782, 1997), but the two terms have since been used interchangeably. as a result, in government directives (u.s. census bureau, 2022), “latino” also does not include anyone living in the u.s. with roots in countries or territories where spanish is not an official language. therefore, people who are from brazil, french guiana, guadeloupe, haiti, martinique, saint-barthelemy, and saint-martin are not considered “latino” by the u.s. government, even if people from these countries self-identify as such. pushback against the term “latino” also began in the 1970s from feminist communities in the u.s. who called for a less patriarchal, more gender-inclusive term. this opposition included the emergence of various new expressions such as “latin@” as alternatives, although widespread adoption would not take place for several decades. however, the specific origin of these alternatives are unknown. nonetheless, scholars agree that–with the advent of replacing spanish morphemes “o” and “a” with “e” or “x”–the initial usages of latine and “latinx” likely came soon afterward (papadopoulos, 2022). latine álvaro garcía meseguer (1976) argued that spanish–as a gendered language that defaulted to the usage of masculine terms even when referring to mixed-gender groups–was sexist, and there was a need for greater gender-inclusive usage. garcía meseguer further posited that, since “e” morphemes in spanish are already gender-inclusive, people should replace “o” and “a” morphemes with “e”s when referring to mixed groups as well as those who do not want their gender identified. morpheme replacements in words that refer to people (e.g. los niños/ las niñas ! les niñes; see lemus sandoval, 2001 and lamas, 2005 as scholarly examples from el salvador and mexico, respectively) have remained in use throughout latin america since the 1980s as well as the use of gender-inclusive ethnic identifiers such as latines (politi, 2020; vidal-ortiz & martínez, 2018). however, there is no definitive explanation for why, in the u.s., “latinx” was propagated instead. latinx the origins of the usage of “latinx” are undetermined. it was first seen in a published work by elizabeth horan (2004) where she used the identifier as an alternative to “latin@” without explaining why. although the intended audience of this publication were feminist scholars of hispanic and latin american studies, horan has stated (rivas, 2017) that the term’s usage began in online forums sometime in the 1990s (milian, 2017). the renowned queer scholar gloria anzaldúa (1990) has herself noted that the voices of women of color are often silenced in academia, and their perspectives are frequently disqualified and excluded from academic discourse. one can only presume that there may be a connection between the origins of replacing the “o” in “latino” with “x,” and the origins of replacing the “a” in “woman” with “x,” a practice first seen in 1971 at the university of california, davis in an effort to be inclusive of trans women and women of color (salinas & lozano, 2021). it is also unclear what the connection is between the emergence of “latinx” in the u.s. and the emergence of replacing “a” and “o” endings with “x” amongst spanish-speaking feminist circles in europe (see sau, 1998 for the earliest traced example), if there is any connection at all. nonetheless, scholars have found that when “x” morphemes were utilized, they were still pronounced as “e” since it is more easily pronounceable when replacing vowels in spanish (vidalortiz & martínez, 2018). in addition, throughout latin america, utilizing “e” morphemes was more common than using “x,” particularly because plural words with “x” endings are unreadable in spanish (alexgaias, 2014). what’s in a “latinx?” jessica trejos columbia social work review, vol. xxii | 39 38 | columbia social work review, vol. xxii “latinx” was first seen in a scholarly article by macarena gómezbarris and licia fiol-matta (2014) who argued for its usage “to signal a route out of gender binaries and normativities” (p. 504) and further posited that the use of “x” endings challenged the dichotomy of gender representations. in 2014, columbia university became the first known institution in the u.s. to formally utilize “latinx” when student members of the planning committee for their latino heritage month celebrations changed the name to latinx heritage month (salinas, 2020). student groups at other colleges and universities across the country swiftly followed suit, citing the need to use terminology that is inclusive of all gender identities (logue, 2015). according to a pew research center analysis (noe-bustamante et al., 2020) of google trends data, broader interest in the word “latinx” began increasing in june of 2016, which coincides with a variety of media reporting a mass shooting during a latin night event at pulse, a gay nightclub in orlando, florida (schneider, 2016). during interviews, many survivors used “latinx” to describe themselves. soon after, mainstream media (finkel, 2017) began utilizing “latinx” as well, and it was also added to the merriam-webster (n.d.) dictionary. with wider usage of “latinx” came an increase in documented reactions (de onís, 2017) to the word adoption, especially on college campuses (mora et al., 2022). by this point, the usage of “latinx” had become so common among students and faculty at academic institutions that education research articles and professional conference presentations usually utilized the term without defining it; it was implicit that anyone hearing or reading “latinx” would already know what the word meant (salinas & lozano, 2019). however, google trends (n.d.) data also shows that the most common search query related to “latinx” is still on the meaning of the term. it is therefore safe to assume that there are more people in the u.s. and across the world who are unsure of what “latinx” means than there are people who do know (salinas & lozano, 2019). lozano and colleagues (2023) have posited that the hasty adaptation of “latinx” can seem performative given the lack of a full examination and understanding of the term and greater input from the latina/e/o/x community. i agree with lozano and colleagues (2023) that it is consequently imperative to ask: how inclusive, and of whom, is the term “latinx?” identification vs. ascription, and the exclusivity of inclusivity a number of scholars have observed that in spite of its initial intentions to be gender-inclusive (i.e., affirming of all gender identities), “latinx” has come to be utilized more often as a gender-neutral (i.e. neutralizing or disassociating any reference to gender) term. this can perpetuate overlooking or even invalidating gender identity-based oppressions (contreras, 2017). for example, trans women–such as latina transgender rights activist silvia rivera–are women, and calling them “latinx” solely because they are transgender potentially ignores and denies their sociopolitical struggles and right to self-determination. when “latinx” is ascribed in such a way that neutralizes all gender identities and expressions, it may serve to further obscure the very people that “latinx” originally sought to give greater visibility and recognition (del río-gonzález, 2021; lozano et al., 2023). scholars posit that this shift in intentionality is a consequence of how “latinx” has been increasingly adopted over the past decade to categorize all peoples who identify with latinidad but without a thorough analysis of how “latinx” has been defined, used, or perceived and by whom (del río-gonzález, 2021; lozano et al., 2023). trujillo-pagán (2018) found that many people were utilizing “latinx” merely because they heard others doing so or because it is what “other universities do” (p. 400), and that her colleagues at other institutions felt obliged to utilize “latinx.” in addition, trujillo-pagán (2018) found multiple instances where the label had been applied to the scholarly work of others who had not employed the term, such as a book review that utilized “latinx” but the book’s authors did not, as well as other book advertisements that utilized “latinx” even though the authors themselves had not. what’s in a “latinx?” jessica trejos columbia social work review, vol. xxii | 41 40 | columbia social work review, vol. xxii trujillo-pagán (2018) argues that crossing out self-chosen gendered identifiers serves to perpetuate patriarchy at the expense of cisand trans women of color in particular; much like color-blind ideologies can operate to obscure systemic racism, gender-blind ideologies can operate to obscure structural sexism. even those who view “latinx” as a gender-inclusive term may still perceive it as excluding other social identities that are salient to them. in his study on how latina/e/o/x undergraduate students understand, relate to, and identify with the word “latinx,” salinas (2020) found that most participants used “latinx” within their school environment but not at all within their home communities. participants felt that since the word originated in academic and activist spaces of privilege, it might seem like they were imposing an agenda on family and friends who did not have the same access to those spaces or privileges. some participants also stated that they utilized “latinx” at their institutions because they felt compelled or pressured to do so (salinas, 2020). others may find “latinx” to be a term that excludes their racial or sociolinguistic identity. for example, the letter “x” does not exist in the quechua language, spoken by indigenous people of south america, nor in the garífuna language, spoken by afro-indigenous people of central america (salinas & lozano, 2021). furthermore, “latinx” has been utilized to be inclusive of queer identities but in a way that synonymizes gender with sexuality (contreras, 2017). this has the potential to lead to misunderstandings about gender nonconformity and sexual orientation, including the misguided assumption that all genderqueer people are inherently non-heterosexual (vidal-ortiz & martínez, 2018). interchanging gender with sexuality could result in further marginalization of people with gender identities and sexual identities that have been minoritized and oppressed. studies have shown that the more often an individual’s membership in the gender and sexuality group with which they identify is invalidated, the higher their risk of experiencing negative outcomes such as low selfesteem, anxiety and stress, and impacted health (howansky et al., 2022). self-concept, and consequently self-expression, can change over time and through experience. it is understandable that the terms one uses to self-identify can change over time as well. for instance, u.s. public policy and institutionalized definitions of ethnic and racial identifiers, in addition to mainstream media usage, can impact the acceptance or rejection of identifier terms, which in turn affect the ethnic and gender identity development of individuals. pew research center analysis (lopez et al., 2023) shows that significant changes can be seen in demographic data from one census count to the next, depending on how respondents’ understanding of the terms on the survey have changed within that particular decade. it is possible that even generational identity may play a role in how, for instance, members of the gen z cohort choose to self-identify racio-ethnically, compared with members of the gen x population–who were born and/or came of age during the rise of lgbt+ activism. similarly, scholars have shown that first-generation americans are more likely to self-identify with their national origin compared with their second-generation children who are more likely to self-identify with racial and pan-ethnic terms that have been institutionalized in the u.s. given their greater experience navigating u.s. institutions such as public schools (santos, 2017). very few studies have explored the intersection of social identities, and fewer have studied the intersectionality of racial identity development, ethnic identity development, gender identity development, and sexual identity development. the limited scholarship available demonstrates that, in alignment with intersectionality theory, our social identities work in concert with each other–we see our experiences of one social identity through the combined lenses of our other social identities (cerezo et al., 2020; rogers et al., 2015; veenstra, 2011). the very definition of the term “inclusive language” is that it does not exclude identities, and intentional efforts need to be made by practitioners, researchers, and affiliates of academic institutions from all fields to ensure that if and when “latinx” is utilized, it is done so in a way that clearly defines its usage as a gender-inclusive term, as well as its meaning and significance, with input from the latin a/e/o/x population and community. what’s in a “latinx?” jessica trejos columbia social work review, vol. xxii | 43 42 | columbia social work review, vol. xxii concluding thoughts none of these terms–hispanic, latino, latinx, latine–should be considered the (in)correct pan-ethnic identifier. instead, consideration should be taken to explicitly learn which term each individual prefers to utilize. social workers cannot assume that their understanding of the meaning of “latinx” is the same as that of their clients, and we cannot ascribe the term to any individual without knowing if they want to be referred to as such. adolescence is a critical period for identity development and is a phase when our self-concepts are flexible and impressionable. therefore, adolescence is also a critical period where caretakers, peers, educators, and practitioners can impact our perceptions and understandings of our intersectional social identities. research has already shown that positive identity development can lead to improved outcomes in physiological and psychological well-being which, in turn, can also lead to higher self-esteem. for ethnically minoritized groups in particular, healthy psychosocial functioning can strengthen one’s sense of agency in the face of adverse experiences such as discrimination. more research is needed to better understand the implications of ascribing an ethnic identifier to over 60 million people living in the u.s. and in such a way that potentially excludes the intersectionality of their multiple identities. it is imperative not only for social workers, but all stakeholders of all fields to understand why–and how–pan-ethnic identifiers of latinidad are used and promoted. a critical self-examination of the utilization of these terms is necessary to ensure that they are being used intentionally and not simply as a performative act. in other words, “latinx” should not be the only term you use to refer to people of the latin american diaspora, every time you reference them; latina(s), latino(s), latine(s), and other identifiers of latinidad can be the more accurate and appropriate term to utilize depending on the person/people being referenced. accordingly, i invite you to take some time to reflect on your responses to the following questions: • why have/do i use the word “latinx?” is it because i felt compelled to do so simply for the sake of political correctness? • how am i using the word “latinx?” am i using it to reference all latines or only the ones whose gender i don’t know? • when and where am i using the word “latinx?” am i using it in all social contexts or only in my academic/professional spaces? • most importantly–have i asked my latina/e/o/x clients how they would prefer to be called? utilizing gender-inclusive language is not only the ethical thing to do, but is necessary–and doing so appropriately requires that we each grapple with our own intersectional and privileged identities, our roles in dismantling social injustice, and gaining a deeper understanding of the complexities of pan-ethnic identifiers for a community with immense intra-group diversity. in sum, simply using “latinx” does not confront and eradicate the institutionalized oppressions that genderqueer people confront daily. what are you doing to challenge and address cisnormativity in your teaching, research, and/or practice? references alexgaias, a. 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(2018). latinx thoughts: latinidad with an x. latino studies, 16, 384-395. https://doi.org/10.1057/s41276-018-0137-8 what’s in a “latinx?” jessica trejos cswr spring 2022 columbia social work review, vol. xix | 47 improving communication among providers serving d/deaf populations in mental health settings imonie gwaltney 48 | columbia social work review, vol. xix improving communication among providers serving d/deaf populations abstract mental health is as critically important as physical health. the status of one’s mental health can be greatly impacted by environmental, social, psychological factors, and traumatic experiences that interfere with daily sp]pun��+lhm�wvw\sh[pvuz�^ov�\[pspal�(tlypjhu�:pnu�3hun\hnl��(:3��mvy� khps`�jvtt\upjh[pvu�mhjl�h�\upx\l�zl[�vm�viz[hjslz�[v�hjjlzzpun�x\hsp[`� tlu[hs�olhs[o�jhyl��huk�[ol�shjr�vm�hjjlzz�[v�lɉlj[p]l�jv\uzlspun�k\l� to linguistic barriers can contribute to the deterioration of mental health symptoms. this paper will guide non-d/deaf mental health clinicians to become more familiar with deaf culture and will underscore the potential of language accommodation to relieve burdens felt by deaf individuals. disclaimer: “deaf” will be used interchangeably with “deaf” to demonstrate inclusivity with the multiplicity of deaf identity; the d is jhwp[hspalk�[v�zov^�hɉsph[pvu�[v�h�j\s[\yhs�jvtt\up[`�huk�ohyk�vm� hearing people who primarily use asl for communication. columbia social work review, vol. xix | 49 imonie gwaltney w hile strides have been made toward enhancing linguistic access for the deaf population in the united :[h[lz��l�n���wyv]pkpun�jsvzlk�jhw[pvuz��\[pspapun� asl in real time for live reporting, establishing crisis hotlines, and improving internet usage for video remote interpreting [vri] services), access remains severely limited for those receiving mental health support (nad, 2022). there is a growing need for clinicians who are familiar with deaf culture and can competently serve members of the deaf population seeking mental health services. to address the gap between hearing practitioners and deaf patients as well as to luz\yl�lɉjhjpv\z�[ylh[tlu[��wyhj[p[pvulyz�t\z[�mhtpsphypal�[oltzls]lz� ^p[o�[vvsz�vm�lɉlj[p]l�jvtt\upjh[pvu�mvy�klhm�wh[plu[z��ptwsltlu[� inclusionary practices, and focus on increasing cultural knowledge. research has shown that clinicians who strive for and practice cultural o\tpsp[`�wyv]pkl�h�tvyl�lɉlj[p]l�[olyhwl\[pj�wyvjlzz�mvy�wh[plu[z�^p[o� kpɉlylu[�ihjrnyv\ukz��-pzoly�)vyul�l[�hs����������;opz�whwly�hptz�[v� assist clinicians in understanding the language needs and cultural \upx\lulzz�vm�[ol�klhm�wvw\sh[pvu��huk�[v�wyv]pkl�pu�klw[o�n\pkhujl� mvy�\[pspapun�(:3�pu[lywyl[h[pvu�pu�[olyhw`�zlzzpvuz�[v�lhzl�klhm�wh[plu[z»� hesitancy in accessing mental health services. the deaf population in united states around 30 million people living in the united states have hearing loss �/vɉthu�l[�hs����������;̂ lu[`�[oyll�wlyjlu[�vm�[ovzl����`lhyz�vy�vskly� have either mild or severe hearing loss, while moderate hearing loss is most prevalent in those who are 65 years old and older (goman & lin, 2016). the number of people who use asl as their primary form of communication is approximately 250,000-500,000, according to mitchell et al. (2006). the deaf and hard-of-hearing community remains largely underrepresented and underserved in mental health in the united states. in one research study, about 90 percent of people from the deaf 50 | columbia social work review, vol. xix community have observed that there were relatively few accessible mental health services for deaf individuals (feldman & gum, 2007). several studies have indicated a lack of understanding about deaf culture among mental health clinicians and the language barrier prevents [ol�klhm�wvw\sh[pvu�myvt�ilpun�hisl�[v�lɉlj[p]ls`�yljlp]l�hklx\h[l� support for social services (steinberg et al., 1998; mueller, 2006). a 1996 study found that, at that time, there were only 20 registered deaf psychologists in the country (pollard, 1996). as of 2001, there were 261 programs for the deaf population, including programs in outpatient settings, schools, psychiatric hospitals, and community mental health centers (cohen, 2001). however, this number may not accurately ylålj[�[ol�htv\u[�vm�tvklyu�tlu[hs�olhs[o�jspupjphuz�hisl�[v�wyv]pkl� culturally competent care to deaf patients in asl. indeed, the number of registered deaf mental health clinicians today is still low, which means that deaf clients are often referred to adjunct services such as programs with asl accommodation in social services. deaf culture, language usage, & misconceptions deaf culture +lhm�wlyzvuz�^ov�pklu[pm`�z[yvuns`�^p[o�+lhm�j\s[\yl�th`�pu[lyuhspal� belief systems about deaf customs more so than those who identify as deaf. deaf individuals may consider themselves members of the cultural and linguistic community rather than a disabled group (napier et al., 2017). in the author’s experience, the term “disabled” often feels like a forced label: deaf individuals can feel it gives the false message that all deaf persons are “inferior,” “hearing-impaired,” and that they need [v�il�¸ä_lk¹�pu�vykly�[v�il�jvuzpklylk�m\uj[pvuhs�tltilyz�vm�zvjpl[ �̀� the culture of deaf people includes an exclusive set of behavioral uvytz��]hs\lz��huk�ilsplmz�[oh[�kpɉly�myvt�[ol�nlulyhs�wvw\sh[pvu��.p]lu� that deaf individuals with profound hearing loss are unable to respond to sound without the assistance of auxiliary aids, such as cochlear implants (cis) and hearing aids, it is generally acceptable to tap an pukp]pk\hs»z�zov\skly��z[vtw�[ol�åvvy��vy�åpjr�[ol�spno[z��klwlukpun� on the situation, in order to get their attention. conversations can be pup[ph[lk�^p[o�h�nyll[pun�mvssv^lk�i`�äyz[�huk�shz[�uhtl�huk�zjovvs� improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 51 hɉsph[pvu��0[�pz�hszv�ptwvy[hu[�mvy�hu`�wlyzvu�lunhnpun�pu�h�jvu]lyzh[pvu� with a deaf individual to look at their facial expressions rather than their hands so as to be able to understand the message they are trying to convey. these are a few of the social expectations that deaf community members typically adhere to. language usage asl is a visual language consisting of its own grammatical rules and syntax, a structure that is fundamentally distinct from english. while signing, linguistic information is visibly transmitted and processed in the frontal lobe of the brain (evans et al., 2019). body movements, facial expressions, and the placement and location of the hands are important elements in conveying information. facial expressions can provide emphasis of interest or convey enthusiasm, depending on the nature of the conversation at hand. for example, if a lighthearted story or joke is being interpreted, it is acceptable—and even expected—that the interpreter smiles. in any situation, it is expected that the interpreter will duplicate the emotion and tone of the person being linguistically accommodated. misconceptions treatments in mental health counseling are predominantly designed to hjjvttvkh[l�olhypun�pukp]pk\hsz��:[hukhykpalk�[lz[pun�vy�l]hs\h[pvuz� rarely consider aspects of deafhood. deaf individuals are more likely to experience higher rates of social isolation due to the language barrier that contributes to the problem of accessing mental health care. ;ol�\upx\l�spun\pz[pj�hjjvttvkh[pvuz�klhm�jsplu[z�ylx\pyl�jhu�slh]l� providers reluctant to work with deaf people. psychotic disorders, along with other neurological development kpzvyklyz��hyl�tvyl�mylx\lu[s`�kphnuvzlk�pu�klhm�wz`joph[ypj�wh[plu[z� [ohu�pu�uvu�klhm�wh[plu[z��3hukzilynly� �+pha���������4pzkphnuvzlz� are more likely to occur when clinicians misinterpret aspects of a deaf person’s communication and associated behavior. deaf clients tend [v�ylzwvuk�[v�nlulyhs�x\lz[pvuz�pu�hu�lshivyh[l�thuuly��vm[lu�^p[o�h� imonie gwaltney 52 | columbia social work review, vol. xix narrative rather than giving a simple answer. this tendency is a common conversational pattern in the deaf community: for example, a deaf person explaining a traumatic experience to a therapist would focus on the nuances of the story, detailing every single plot point leading up to the event and demonstrating their reactions through facial expressions. a hearing clinician may interpret this behavior as “unwillingness to cooperate” or “inability to focus.” however, facial expressions that are crucial grammatical components of asl can be misconstrued hz�¸puhwwyvwyph[l�l_wylzzpvuz�vm�hɉlj[¹��7opsspwz��� �"�3lpno�������� w�������(z�h�ylz\s[�vm�[opz�tpzjohyhj[lypah[pvu��[ol�klhm�wvw\sh[pvu�pz� wyvul�[v�tpzkphnuvzpz�huk�tvyl�]\sulyhisl�[v�puz[p[\[pvuhspah[pvu"�thu`� deaf communities fear these outcomes and some avoid mental health services for this reason. (leigh, 2010). professional mental health care for deaf clients is further undermined by common assumptions and misconceptions about deafness. for example, practitioners often believe that lip reading/speech reading huk�uv[l�^yp[pun�wyv]pkl�lɉlj[p]l�olhs[o�jvtt\upjh[pvu��0laavup�l[�hs��� �������;olzl�jvtt\upjh[pvu�tvkhsp[plz�hyl�vm[lu�pulɉlj[p]l�mvy�wlvwsl� who were diagnosed profoundly deaf at birth, or who were not able [v�hjx\pyl�shun\hnl�h[�[ol�zhtl�sl]ls�hz�pukp]pk\hsz�^ov�ohk�`lhyz�vm� practiced lip-reading/speech-reading. deaf people who are familiar with zwvrlu�shun\hnl�hyl�[`wpjhss`�vus`�hisl�[v�\uklyz[huk�hiv\[���¶���� vm�zwvrlu�,unspzo��3pl\�l[�hs����������-\y[olytvyl��uv[l�^yp[pun�ylx\pylz� sp[lyhj`�wyväjpluj`�[v�jvtwyloluk�huk�pu[lywyl[�[v�[ol�ilz[�vm�vul»z� ruv^slknl�huk�ylzwvuk�jvolzp]ls �̀�i\[�h�klhm�wh[plu[�^ovzl�äyz[� language is asl may not be as literate with written language (pollard & barnett, 2009). smeijers and pfau (2009) further argue that using note^yp[pun�^p[o�h�uh[p]l�zpnuly��^ov�tpno[�uv[�il�å\lu[�pu�[ol�jvttvus`� used written language, can negatively impact ties of communication. using deaf culture as a foundation for understanding behavioral norms jhu�slzzlu�[ol�johujlz�vm�tpzjh[lnvypapun�jly[hpu�johyhj[lypz[pjz�hz� z`tw[vtz�vm�tlu[hs�pssulzz��<uklyz[hukpun�[ol�\upx\l�zl[�vm�]hs\lz� in deaf culture, alongside considering the linguistic needs of the deaf individual, alleviates medical distress. improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 53 effective communication the language needs of a deaf person vary, as deaf individuals exist on a spectrum: one may use oral speech and sign simultaneously, while another may not use oral communication and prefer to communicate exclusively in sign language. the nuances of preference in communication modalities should be taken into consideration when asl interpretation is an option. the 1990 americans with disabilities act (ada) states that accommodations must be paired with anti-discriminatory practices [oh[�wyvopip[�l_js\zpvu�huk�\ulx\hs�[ylh[tlu[��huk�[oh[�z\jo� accommodations are an institution or business’s responsibility to enact. areas of accommodation include architectural standards, wvspjplz�huk�wyv[vjvs�tvkpäjh[pvuz��huk�jvtt\upjh[pvu�hjjlzz��(+(�� 2021). this means that mental health care providers are responsible mvy�äukpun�huk�wh`pun�mvy�h�x\hspälk�(:3�pu[lywyl[ly��<ukly�[ol�(+(�� [ol�nvhs�vm�lɉlj[p]l�jvtt\upjh[pvu�pz�[v�luz\yl�iv[o�why[plz· [ovzl�^p[o�kpzhipsp[plz�huk�[ovzl�^p[ov\[·oh]l�lx\hs�hjjlzz�[v� legible communication. this underscores the importance of clear communication, acknowledging that the deaf client has the right to understand the nuances in which messages are conveyed without hindrance. �(�¸x\hspälk�(:3�pu[lywyl[ly¹�pz�kläulk�hz�zvtlvul�^ov�ohz�jvtwsl[lk� four years of an interpreting program at an accredited college, has yljlp]lk�h�jly[päjh[pvu�myvt�[ol�9lnpz[y`�vm�0u[lywyl[lyz�mvy�[ol�+lhm� �90+���huk�wvzzlzzlz�[ol�zrpssz�[v�pu[lywyl[�lɉlj[p]ls �̀�hjj\yh[ls �̀�huk� impartially. this includes the ability to decode and convey messages (both receptive and expressive) back to either parties involved, using hu`�uljlzzhy`�zwljphspalk�]vjhi\shy`��5(+��������� deaf individuals possess the legal right under the ada to obtain, through an institution or service provider, an asl interpreter for services [ol`�hyl�zllrpun��,ɉlj[p]l�jvtt\upjh[pvu�nylh[s`�puå\lujlz�wh[plu[� and client interaction. ensuring that the deaf individual has access to communication that is clear and transparent allows space for both wlyzvuz�pu]vs]lk�pu�[ol�[olyhw`�wyvjlzz�[v�il�lx\hss`�olhyk�huk� supported. imonie gwaltney 54 | columbia social work review, vol. xix building rapport with deaf patients establishing rapport with deaf and hard-of-hearing individuals is critical, as it lays a foundation of mutual trust and respect during sessions. a working alliance facilitates the developmental process of exploring reasons which bring a person to mental health services. )vukpun�lsltlu[z�z\jo�hz�¸ylzwlj[��sprpun��huk�[y\z[¹�pujylhzl�lɉlj[p]l� [olyhwl\[pj�jvsshivyh[pvu��.shkkpun��������w��������0u�hjjvykhujl�^p[o� lz[hispzopun�t\[\hs�lɉvy[z��tlu[hs�olhs[o�jspupjphuz�jhu�wyvtv[l�jsplu[z»� comfortability by acknowledging opposing worldviews in session and building the professional skills necessary to collaborate with culturally kpɉlylu[�jsplu[z�� cultivating a thorough understanding of deaf culture and learning [v�lɉlj[p]ls`�zly]l�[ol�klhm�wvw\sh[pvu�hyl�uv[�sptp[lk�[v�wyv]pkpun� spun\pz[pj�hjjvttvkh[pvuz��(szv�ylx\pylk�pz�hu�\uklyz[hukpun�vm� core values of deaf culture, along with an appreciation and respect mvy�[ol�\upx\lulzz�vm�lhjo�klhm�pukp]pk\hs��3lpno���������(�[olyhwpz[� who has some familiarity with deaf culture, but who has minimal asl knowledge, is not an appropriate substitute for an asl interpreter. in one report, several participants maintained that medical professionals with negligible sign language communication skills were willing to settle for a minimal level of communication with deaf clients which they would never tolerate with hearing patients (steingberg, 1998). comprehensible language provides the clinician with direct insight into the client’s life; however, when communication breaks down pu�[olyhw �̀�[ol�jsplu[»z�wyvnylzz�jhu�iljvtl�qlvwhykpalk��<[pspapun� asl interpretation for asl-literate deaf individuals can reduce communication disruptions during sessions and help avoid ruptures in the therapeutic alliance. impact of inaccessible assessments +lhm�wlvwsl�oh]l�h�zpnupäjhu[s`�tvyl�kpɉj\s[�[ptl�jvtt\upjh[pun� their health needs with primary care physicians and generally feel slzz�jvtmvy[hisl�nvpun�mvy�wo`zpjhs�olhs[o�joljr�\wz��ahav]l�l[�hs��� improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 55 1993). in one study, deaf individuals who did not already have some sl]ls�vm�olhypun�vy�shun\hnl�hjx\pzp[pvu�thkl�ml^ly�olhs[o�jhyl�]pzp[z� than those who did (barnett & franks, 2002). in another, patients with olhypun�svzz�ylwvy[lk�oh]pun�sv^ly�zh[pzmhj[pvu�^p[o�olhs[ojhyl�x\hsp[`� �0laavup�l[�hs����������7yv]pkpun�klhm�wh[plu[z�^p[o�(:3�pu[lywyl[h[pvu� whilst receiving treatment for psychiatric care and substance-use counseling is of utmost importance, as study participants who received (:3�pu[lywyl[h[pvu�\zlk�wyl]lu[p]l�zly]pjlz�tvyl�mylx\lu[s`�huk� ylwvy[lk�mllspun�tvyl�zh[pzälk�[ohu�[ovzl�^ov�^lyl�uv[�wyv]pklk�(:3� interpretation (mackinney et al., 1995). although research related to reading comprehension in deaf adults remains limited, it has been demonstrated that, on average, deaf students' reading levels did not exceed past grade four (traxler, 2000). considering the advancement of technology and recent emphasis on ipspun\hs�lk\jh[pvu��ov^l]ly��[opz�äukpun�th`�uv�svunly�il�hjj\yh[l�� instead, eliminating barriers of communication by identifying gaps in language and addressing misgivings, as many deaf clients are not properly informed of behavioral health care standards and procedures. :vtl�l_htwslz�pujs\kl�wyv]pkpun�jshypäjh[pvu�hyv\uk�tlkpjh[pvu� use and the need for follow-up care (hommes et al., 2018). however, deaf-inclusive clinical mental health services vary from state to state: sometimes no deaf services or clinicians are available at all, in which case members of the deaf community often have no choice but to opt to use hearing-based services. quality of care is necessarily diminished in these cases. since most mental health assessments do not include aspects of deaf culture, including asl, undesired results such as misdiagnosis may occur during treatments, or patients may experience discomfort and reluctance when accepting medical approaches. it is therefore essential that materials are translated into a tangible assessment that allows both the client and the therapist to determine the best outcomes for treatment. imonie gwaltney 56 | columbia social work review, vol. xix using asl interpreters *spupjhs�wyhj[p[pvulyz�hyl�mylx\lu[s`�\uh^hyl�vm�ov^�[v�lɉlj[p]ls`�\[pspal� interpreters in mental health settings. common mistakes include the clinician speaking too fast or addressing the interpreter instead of the jsplu[��:[huzälsk��� ��"�3lpno���������:wvrlu�huk�zpnulk�shun\hnl� interpreters share a similar fundamental goal of ensuring messages il[^llu�[ol�spz[luly�huk�zwlhrly�hyl�lɉlj[p]ls`�[yhuzsh[lk�pu�uh[p]l�huk� [hynl[�shun\hnlz��*oypz[vɉlsz�l[�hs��������!�p[�pz�ptwvy[hu[�mvy�[ol�jspupjphu� to understand that common goal. it is generally recommended that the clinician briefs the interpreter with information before sessions with deaf patients in order to ensure the following: 1. interpreter placement 1.1. the interpreter should be placed where they can be clearly viewed by the client without any visual interference, and where the interpreter's voice is audible to the therapist. ��� shun\hnl�jshypäjh[pvu� ����� 0m�hjyvu`tz��qhynvuz��\upx\l�]vjhi\shy`�vy�hu`�v[oly�\umhtpsphy�� � � [lytz�^pss�il�\zlk�k\ypun�zlzzpvuz��jshypäjh[pvu�pz�ullklk�� � before the session. ��� iyplm�yl]pl^�vm�jvuäklu[phsp[` ����� 0u[lywyl[lyz�hyl�ylx\pylk�uv[�[v�yl]lhs�pumvyth[pvu�kpzj\zzlk�pu�� � session with external sources. in addition, a break in session, though not generally common in spaces where clients are receiving direct support, is important when using interpreters; unlike clinicians, interpreters are rarely trained to “hold” and process intense emotional or relational experiences in the same way. a session break can occur with interpreter input: when the interpreter pz�oh]pun�h�kpɉj\s[�[ptl�klhspun�^p[o�[ol�jvu[lu[�vm�[ol�zlzzpvu�vy�pz� overwhelmed by the intensity and speed of the client’s statements, they may need a moment to collect themselves and it is not clinically inappropriate to allow them to do so. however, it may become clinically inappropriate if the clinician feels the interpreter’s emotional responses improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 57 hyl�pu[lymlypun�^p[o�[ol�jsplu[»z�x\hsp[`�vm�jhyl��;opz�pz�^o �̀�hz�kpzj\zzlk� earlier, establishing boundaries to avoid emotional inference during the session is important and best done beforehand. it is also imperative that interpreters comply and adhere to the code of conduct as stated by rid (2007): 7yvmlzzpvuhs�jvkl�vm�jvuk\j[�jly[pälk�huk�x\hspälk�pu[lywyl[lyz�t\z[!� ��� (kolyl�[v�z[hukhykz�vm�jvuäklu[phs�jvtt\upjh[pvu�� ��� 7vzzlzz�[ol�wyvmlzzpvuhs�zrpssz�huk�ruv^slknl�ylx\pylk�mvy�[ol�� � � zwljpäj�zp[\h[pvu�� ��� *vuk\j[�[oltzls]lz�pu�h�thuuly�hwwyvwyph[l�[v�[ol�zwljpäj�� � interpreting situation. ��� +ltvuz[yh[l�ylzwlj[�mvy�jvuz\tlyz�� 5. demonstrate respect for colleagues, interns, and students of the profession. 6. maintain ethical business practices. 7. engage in professional development. (u`�jvujlyuz�hiv\[�[ol�pu[lywyl[ly»z�hipsp[`�ylnhykpun�jvuäklu[phsp[`� should be addressed with the mental health center’s human resources department, if one exists. in addition to being ethical best practice, taking these steps before and during mental health sessions also removes the burden of providing interpreter guidance from the client, especially if they are in a place of emotional distress. +lhm�wlvwsl�ylx\pyl�spun\pz[pj�huk�j\s[\yhs�hkq\z[tlu[z�kpz[pun\pzohisl� from their hearing counterparts. practitioners familiar with deaf culture huk�^ov�\[pspal��ylhjo�v\[�[v��wh`�mvy��huk�kl]lsvw�^vyrpun�ylsh[pvuzopwz� with) asl interpretation to assist in communication are rare. integrating such practices allows the deaf individual to remain in the client role, which includes receiving comprehensive care from the clinician, while zpt\s[hulv\zs`�tpuptpapun�[ol�jspupjphu�z�\ujly[hpu[`�vm�[ol�pu[lywyl[ly�z� role prior to and after sessions. when clinicians become empowered to increase their familiarity with and cultural capacity for the varying and nuanced linguistic and cultural needs of the deaf population, they provide deaf people in their region with an important mental health resource that this population too often lacks. imonie gwaltney 58 | columbia social work review, vol. xix interpreter recommendations the recommendations for this section are optional but strongly lujv\yhnlk��*spupjphuz�th`�zjyllu�[ol�pu[lywyl[ly�mvy�[olpy�x\hspäjh[pvuz� by performing a brief check-in with the interpreter before the pu[lywyl[ly»z�äyz[�zlzzpvu��;opz�pu[lyhj[pvu�hssv^z�[ol�jspupjphu�[v� kl[lytpul�pm�[ol�pu[lywyl[ly�pz�h�nvvk�ä[�huk�pz�ltv[pvuhss`�lx\pwwlk� to handle ongoing sessions, given that discussions about the client’s trauma and adverse life experiences may be discussed. while interviewing interpreters, the clinician should decide if the interpreter has: �࠮ the ability to refrain from making personal statements during zlzzpvuz��l�n���vɉlypun�vwpupvuz�[oh[�[ol�klhm�jsplu[�th`�vy�th`�uv[� have expressed). �࠮ ;ol�hipsp[`�[v�lɉlj[p]ls`�kljvkl�tlzzhnlz�mvy�[ol�zwlhrly�huk� the listener and to accurately transcribe messages in spoken and signed language. �࠮ a neutral reputation in the deaf community of being able to remain unbiased and maintain anonymity. �࠮ a clear understanding of the roles involved (i.e., the role of the clinician, client, and the interpreter themselves). �࠮ the ability to remain professional; personal emotions should not impede the session. 0m��h�ul^�pu[lywyl[ly�pz�ullklk�mvy�hu`�ylhzvu��[ol�jspupjphu»z�äyz[�z[lwz� should be to inform the deaf/hoh client before their next session and [v�wyv]pkl�h�iyplm�l_wshuh[pvu�mvy�ylx\lz[pun�h�ul^�pu[lywyl[ly��huk�pm� possible allow for client input and feedback. the clinician should be transparent in their reasoning for the asl interpreter replacement, because transparency is the foundation of a trusting therapeutic alliance. allowing the client’s input in the decision-making process ensures the client’s autonomy is intact while making sure the interpreter chosen has the ability to remain impartial and maintain emotional boundaries. ;olyhwpz[z�jhu�hszv�jovvzl�[v�vw[ptpal�[ol�\zl�vm�[ol�pu[lywyl[pun�älsk�� as asl interpretation is not one-dimensional, and d/deaf individuals vary improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 59 pu�[olpy�l_wlyplujl�hjx\pypun�wyväjpluj`�pu�(:3"�zvtl�oh]l�[olpy�v^u� preferred communication style (national institute on deafness, 2019). depending on local availability, there can be a variety of interpreters ^p[o�zwljpäj�ruv^slknl�huk�zrpss�zl[z�[oh[�th`�il�\zlm\s�mvy�h�np]lu� jsplu[»z�zwljpäj�[olyhwl\[pj�jvu[l_[��9lx\lz[z�jhu�il�thkl�ihzlk�vu� cultural or linguistic needs, because some among the deaf population th`�ylx\pyl�hkkp[pvuhs�spun\pz[pj�huk�zvjpvj\s[\yhs�jvuzpklyh[pvu�� black american sign language (basl) is one example of an asl ]hyph[pvu��(�klhm�tlu[hs�olhs[o�jsplu[�^ov�pklu[pälz�hz�)shjr�vy� african-american may prefer to work with an interpreter who is from a similar racial group, not only because they may feel more comfortable communicating with them, but also because the client may feel the interpreter is more familiar with the nuances of basl. this preference jhu�hszv�hwws`�[v�klhm�tltilyz�vm�v[oly�thynpuhspalk�nyv\wz�^ov�zohyl� common cultural struggles and experiences. 0u[lywyl[lyz�jhu�zohyl�h�\upx\l�zluzl�vm�jsvzlulzz�^p[o�[ol�tlu[hs� health care client when they are from similar linguistic and cultural communities that experience social oppression and discrimination. having a connection to the person interpreting can result in greater empathy and trust between interpreter and client, since the interpreter jhu�ltwh[opal�^p[o�[ol�jsplu[�z�l_wlyplujl��0u�[oh[�jhzl��jvtt\upjh[pvu� between the interpreter, mental health care clinician, and client becomes tvyl�wyljpzl�huk�ohz�h�tvyl�jvtmvy[hisl�åv �̂� conclusion ;ol�tlu[hs�olhs[o�älsk�pz�iljvtpun�tvyl�h^hyl�vm�[ol�kllws`� kpzy\w[pun�ptwhj[z�[oh[�[yh\th[papun�l_wlyplujlz�jhu�jh\zl�hjyvzz�h� person’s experience of daily life, but more light needs to be shed on [ol�[yh\th[papun�lɉlj[�vm�uv[�oh]pun�wyvwly�hjjlzz�[v�tlu[hs�olhs[o� care due to discriminatory barriers. this experience is common and readily apparent with d/deaf populations in this country, and can have h�zpnupäjhu[�ulnh[p]l�ptwhj[�vu�[olpy�tlu[hs�olhs[o��(kkp[pvuhss �̀�np]lu� [ol�sptp[lk�ylzlhyjo�vu�lɉlj[p]ls`�zly]pun�klhm�wvw\sh[pvuz�huk�[ol� zovy[�z\wws`�vm�(:3�zwljpäj�spun\pz[pj�hjjvttvkh[pvuz�uh[pvu^pkl�� resources to ameliorate this issue remain scarce. the author calls for more research addressing linguistics gaps in mental health care on imonie gwaltney 60 | columbia social work review, vol. xix the following topics: providing accessible assessments for treatment wshuz��pujylhzpun�klhm�ylwylzlu[h[pvu�pu�[ol�tlu[hs�olhs[o�älsk�i`� hiring psychologists from a similar cultural background, and expanding resources for deaf populations to receive mental health support. ultimately, asl interpretation must be provided by behavioral health jhyl�wyv]pklyz�[v�luz\yl�lɉlj[p]l�jvtt\upjh[pvu�il[^llu�[ol�jsplu[� and therapist. it is also critical for clinicians to better accommodate the client by learning about cultural dissimilarities and determining treatment approaches with cultural considerations in mind. d/deaf and hardvm�olhypun�jsplu[z�ilulä[�^olu�tlu[hs�olhs[o�jhyl�jspupjphuz�lk\jh[l� themselves and thoughtfully provide culturally responsive care for this underserved population. references (tlypjhuz�>p[o�+pzhipsp[plz�(j[�vm�� ������<�:�*����������l[�zlx���� ����o[[wz!��^^ �̂ ada.gov/pubs/adastatute08.htm )hyul[[��:��� �-yhurz��7����������/lhs[o�jhyl�\[pspah[pvu�huk�hk\s[z�^ov�hyl�klhm!� relationship with age at onset of deafness. health services research, 37(1), 105–120. *oypz[vɉlsz��0��2��� �+l�.yvv[��(��4��)����������:pt\s[hulv\z�pu[lywyl[pun!�(�jvnup[p]l� perspective. in j. f. kroll and a. m. b. de groot (eds.), handbook of bilingualism: psycholinguistic approaches��ww�������� ���6_mvyk�<up]lyzp[`�7ylzz� cohen, c. b. (2001). individual psychotherapy with deaf and hard of hearing individuals: perceptions of the consumer (publication no. 9995982) [doctoral dissertation, smith college school of social work]. proquest dissertations publishing. ,]huz��:���7ypjl��*��1���+plkypjozlu��1���.\[plyyla�:pn\[��,��� �4hj:^llul �̀�4������ ���:pnu� and speech share partially overlapping conceptual representations. current biology, � ��������� ������ feldman, d. m., & gum, a. (2007). multigenerational perceptions of mental health services among deaf adults in florida. american annals of the deaf����������� ��� �� fisher-borne, m., cain, j. m., & martin, s. l. (2015). from mastery to accountability: cultural humility as an alternative to cultural competence. social work education��������� 165-181. improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 61 .shkkpun��:��;����������counseling: a comprehensive profession. pearson education. goman, a. m., & lin, f. r. (2016). prevalence of hearing loss by severity in the united states. american journal of public health, 106(10), 1820–1822. doi.org/10.2105/ ajph.2016.303299 /vɉthu�/��1���+vipl��9��(���3vzvuja �̀�2��.���;olthuu��*��3���-shttl��.�(���������� declining prevalence of hearing loss in us adults aged 20 to 69 years. jama otolaryngology—head & neck surgery �����������������kvp!��������qhthv[v���������� hommes, r., borash, a., hartwig, k., & degracia, d. 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(1995). improvements in preventive care and communication for deaf patients. journal of general internal medicine 10, 133–137. https://doi.org/10.1007/bf02599667 mitchell, r. e., young, t. a., bachelda, b., & karchmer, m. a. (2006). how many people use (:3�pu�[ol�<up[lk�:[h[lz&�>o`�lz[pth[lz�ullk�\wkh[pun��sign language studies, 6(3), 306–335. https://doi.org/10.1353/sls.2006.0019 5h[pvuhs�0uz[p[\[l�vu�+lhmulzz�huk�6[oly�*vtt\upjh[pvu�+pzvyklyz������ ���(tlypjhu�:pnu� language. nidcd fact sheet | hearing and balance american sign language. pollard, r. q. (1996). professional psychology and deaf people: the emergence of a discipline. american psychologist����������� ¶� �� pollard, r. q., & barnett, s. (2009). health-related vocabulary knowledge among deaf adults. rehabilitation psychology,�����������¶�����o[[wz!��kvp�vyn���������h������� 9lnpz[y`�vm�0u[lywyl[lyz�mvy�[ol�+lhm���������5(+�90+�*vkl�6m�7yvmlzzpvuhs�*vuk\j[��5(+f rid code of professional conduct.pdf imonie gwaltney 62 | columbia social work review, vol. xix :tlpqlyz��(��:��� �7mh\��9������ ���;v^hykz�h�[ylh[tlu[�mvy�[ylh[tlu[!�6u�jvtt\upjh[pvu� between general practitioners and their deaf patients. the sign language translator and interpreter,��������¶��� steinberg, a. g., sullivan, v. j., & loew, r. c. (1998). cultural and linguistic barriers to mental health service access: the deaf consumer's perspective. american journal of psychiatry���������� ��� ��� traxler, c. b. (2000). the stanford achievement test, 9th edition: national norming and performance standards for deaf and hard-of-hearing students. journal of deaf studies and deaf education�����������¶�����o[[wz!��kvp�vyn������ ��klhmlk�������� ahav]l��7���5plthuu��3��*���.vyluåv��+��>���*hythjr��*���4loy��+���*v`ul��1��*��� � (u[vu\jjp��;���� ����;ol�olhs[o�z[h[\z�huk�olhs[o�jhyl�\[pspah[pvu�vm�klhm�huk�ohyk� of-hearing persons. archives of family medicine�����������¶�����kvp�vyn��������� hyjomhtp�������� improving communication among providers serving d/deaf populations columbia social work review, vol. xix | 63 imonie gwaltney columbia social work review, vol. xix | 83 choosing a frame: how medusa tells the story of trauma and life after trauma ezra yurman-whyde 84 | columbia social work review, vol. xxi choosing a frame abstract this paper names the elements of the medusa myth that make it an uncanny allegory for trauma and examines the role of choice—both oh]pun�jovpjl�huk�vɉlypun�jovpjl·pu�[ol�[ylh[tlu[�vm�[yh\th��0[� jvuzpklyz�[^v�wlyzwlj[p]lz�vu�[ol�t`[o!�����4lk\zh�hz�h�jhw[p]l� object to the hero in the myth and (2) medusa as an autobiographer, the narrator of her own story, and a subject working to establish more control over her own experience. this myth translates to the social ^vyr�zwhjl��>olu�h�jspupjhs�zvjphs�^vyrly�hj[z�hz�[ol�spz[luly�vizly]ly� huk�h�wh[plu[�hz�uhyyh[vy�h\[vipvnyhwoly��[ol�zvjphs�^vyrly�pz�\upx\ls`� positioned to support the patient in reclaiming life after trauma. keywords: medusa, trauma, autobiography, freud, herman, cavarero columbia social work review, vol. xxi | 85 ezra yurman-whyde the gorgons turned men who looked into their living, venomous, snake-encrusted faces to stone. i wonder what might have happened if those men had known how to politely greet the dreadful chthonic ones (haraway, 2016, p. 54). to narrate is to edit and revise, to decide and imbue meaning. the narrator is the voice we hear, the voice which crafts our beginnings and endings and directs the process of mythmaking. the challenge of capturing one central myth of medusa, sometimes called the gorgon or gorgo, lies in the transience of myth, with its various versions compiled through written and oral histories, each with details slightly adjusted [v�jylh[l�h�ul^�t`[o��,hjo�ul^�t`[o�ohz�h�kpɉlylu[�tvyhs�vy�l[opjhs� alignment and narrative. medusa’s name refers originally to her role as a mindful ruler and guardian (gordon, 2014). her myth, captured by such classical authors as homer, hesiod, ovid, and lucan, likely originates from the classical greek period of 500 bce-336 bce (silverman, 2016). it is the story of a beautiful, mortal woman who is raped and turned into a monster. medusa, said to be even more attractive than aphrodite, draws the attention of poseidon, the god of the sea, who rapes medusa in the [ltwsl�vm�([oluh��;ol�]pynpuhs��hzl_\hs�nvkklzz�([oluh��vɉluklk�[oh[� her temple has been desecrated, punishes medusa by transforming her countenance from beauty to horror, giving her a head of snakes. it pz�zhpk�[oh[�hu`vul�^ov�khylz�svvr�h[�4lk\zh�^pss�il�wl[ypälk�pu�z[vul�� but the brave and cunning perseus, the hero of the story, uses a mirror [v�zov^�4lk\zh�oly�v^u�ylålj[pvu��)`�\zpun�oly�wv^ly�hnhpuz[�oly�� he turns her to stone and is able to decapitate her. perseus takes the head of medusa and wields it as a weapon along his journey, eventually gifting medusa’s head to athena and saving a princess. the story ends happily in marriage between our hero perseus and the princess, andromeda. 86 | columbia social work review, vol. xxi ;ol�jspupjhs�zvjphs�^vyrly�ilulä[z�myvt�yljvuzpklypun�[ol�olyv»z� perspective, particularly when approaching treatment with survivors of trauma. the clinical social worker may be tempted, consciously or \ujvuzjpv\zs �̀�[v�pklu[pm`�^p[o�[ol�olyv»z�uhyyh[p]l!�7lyzl\z��^ov�zl[� v\[�[v�jvux\ly�[ol�.vynvu��pz�h�tl[hwovy�mvy�[ol�^vyrly�zl[[pun�v\[�[v� alleviate the psychopathology of trauma. the clinical social worker, no matter their good intentions, runs the risk of overexerting control in the treatment of trauma if the patient’s sense of choice is not paramount. attempts to optimize healing, alleviate pain, prioritize treatment protocols, or evade the trauma dismiss the painful, yet necessary, process of the patient grappling with the loss of control they once experienced. in the treatment of trauma, hope lies in the ability of the clinical social worker to see the patient with open eyes, to align with the patient, to revisit dichotomies of self vs. other, and to understand the reestablishment of commonality as the ability to recognize oneself in another, to commune, and to feel seen. by considering the perspective of medusa, the clinical social worker comes closer to understanding [ol�z\y]p]vy�z�z[vy �̀�hssv^pun�[ol�^vyrly�[v�iljvtl�tvyl�hklw[�h[� supporting the survivor in more fully stepping into their role as narrator of their own story, autobiographer charting their own narrative arc. medusa as an object in psychoanalytic thought medusa’s long existence in the clinical imagination consists mostly of plucking her from context, creating an image on which to project tlhupun��-vy�:pnt\uk�-yl\k��� �������h���[ol�4lk\zh�t`[o�pz�h� tlhuz�mvy�pss\z[yh[pun�[ol�lɉlj[z�vm�[ol�mlthsl�ivk`·why[pj\shys`� the mother’s body—on the male subject. for the male onlooker, freud claims that the phallic snakes resting atop medusa’s head are themselves “a mitigation of the horror, for they replace the penis, the hizlujl�vm�^opjo�pz�[ol�jh\zl�vm�[ol�ovyyvy¹��-yl\k��� �������h��ww�� 84-85). freud’s framework positions medusa as an object to be gazed \wvu��hu�viqlj[�\zlm\s�vus`�mvy�p[z�lɉlj[z�vu�[ol�thsl�wz`jol��uv[�olyzlsm� a subject with an internal world. choosing a frame columbia social work review, vol. xxi | 87 freud positions himself within a tradition of seeing medusa as an object of horror. in tellings of the myth, medusa’s decapitated head is said to bring about the birth of pegasus, the winged horse, and the blood that drips from her head is said to fall to the ground, transforming into zuhrlz�[oh[�uv^�yvht�[ol�klzly[�vm�3pi`h��/lzpvk�������������;olzl� iterations of the myth have historically taken up medusa as a dead thing, not a person. freud, too, is interested only in medusa’s detached head. freud’s male subject sees medusa’s head and is reminded of opz�v^u�jhz[yh[pvu�jvtwsl_��p�l��¸[v�kljhwp[h[l�$�[v�jhz[yh[l¹"�-yl\k�� � �������h��w�������(z�h�svj\z�mvy�thsl�wz`jovzl_\hs�kl]lsvwtlu[�� medusa is made to symbolize an abject horror felt by a young boy zllpun�opz�tv[oly»z�nlup[hsph��-yl\k��� ���������� -ltpupz[�[opurly�:hyho�2vmthu��� ���������jh[lnvypalz�-yl\k»z�hjjv\u[� of medusa’s head symbolizing the embodiment of the mother’s genitalia as fetishism, because the account deals primarily with the symbolic meaning of medusa’s parts rather than her whole role as a character pu�[ol�t`[o��5v[�vus`�kvlz�-yl\k��� �������h��klhs�wypthyps`�^p[o� 4lk\zh»z�olhk�j\[�myvt�oly�ivk �̀�¸i\[�[ol�än\yl�olyzlsm�pz�j\[�h^h`� from, among other things, her relationship to her two sisters” (gordon, 2014, p. 116). in his analysis of her parts, freud names the various fragmented objects of medusa “uncanny.” he states that “severed heads” and female genitalia provoke the experience of the uncanny "double take," or an experience of seeing something so similar to zvtl[opun�lszl��`l[�kpɉlylu[��^opjo�jh\zlz�\ulhzl·l]lu�ovyyvy·pu�[ol� vusvvrly��-yl\k��� � �����i��ww������������ for the clinical social worker, freud’s reductive reading of medusa serves as a warning. by adopting a schema that aligns with the hero’s narrative, the clinician runs the risk of encouraging a framework which treats patients as clusters of symptoms (parts) and characterological traits to be overcome and changed (decapitated). particularly in work with patients who have survived trauma, the popularity of traumapumvytlk�thu\hspalk�[ylh[tlu[z�huk�[ol�thukh[l�mvy�lɉjhjpv\z� progress to predicate reimbursability are at odds with the process of uhyyh[pun!�[lsspun�huk�yl[lsspun��ylluhj[pun��tlhuklypun�huk�wh\zpun�� ezra yurman-whyde 88 | columbia social work review, vol. xxi wpjrpun�\w�h[�kpɉlylu[�wshjlz�[ohu�^olyl�vul�slm[�vɉ��jylh[pun�ul^� directions of memory and thought that previously lay dormant or didn’t previously exist. when the social worker ceases to see the patient as a human subject, instead favoring the proper operationalized intervention, the psychotherapeutic process becomes the actual uncanny thing—a forged replica, a capitalistic, hollowed endeavor that only hints at the original power of the therapeutic process that prioritizes connection. medusa as a subject and her traumatic experience medusa does not have to exist solely as an object in clinical discourse; nor should she. i propose a clinical approach that, as psychologist and wz`jovhuhs`z[�+vypz�:ps]lythu�w\[z�p[��h[[ltw[z�[v�¸äuk�h�spilyh[pun� ylm\nl�pu�h�z`tivspj�än\yl�^p[o�nylh[�huk�älyjl�wv^ly�huk�myllkvt¹� (2016, p. 117). to grapple with medusa as a subject is to see her as a person working through trauma. a reading of the myth that doesn’t account for her surviving a brutal rape is, to say the least, limited. a jsvzl�ylhkpun�vm�4lk\zh»z�t`[o�vɉlyz�[ol�vwwvy[\up[`�[v�wyvtv[l�oly� subjectivity, agency, and choice–-an approach which can be applied in the clinical setting. the frame with which the clinical social worker enters the therapeutic dyad tells its own narrative about the positionality of the worker and trauma survivor respectively. it is precisely the way of seeing self and other that has the capacity to empower and disempower and to promote commonality and separateness, connection and disconnection. the processes of telling one’s own story, working it out, and inhabiting a self-other relationship in which one tells and one listens serve as reparative acts that reintegrate the survivor’s sense of selfhood �z\iqlj[p]p[`��^p[opu�[ol�shynly�jvu[l_[�vm�[olpy�^vysk��;v�vɉly�h�z\y]p]vy� the choice of determining their own narrative is one attempt the clinical social worker can make to imbue power and promote commonality in the therapeutic dyad, and by extension, support the survivor’s reintegration into their everyday life. choosing a frame columbia social work review, vol. xxi | 89 in analyzing trauma, we can consider post-traumatic stress disorder as a culmination of uncanny experiences. the symptoms of ptsd include yl�l_wlyplujpun�[ol�[yh\th�[oyv\no�åhzoihjrz��zvth[pj�ylwspjh[pvu�vm� the arousal state experienced during the trauma (hyperarousal), and reliving the event through nightmares. these symptoms are uncanny because of the unease they strike in their subject. by alluding to something familiar, the subject is forced to recollect the moment of the inciting traumatic event. flashbacks are like memories, except they are disjointed relivings. flashbacks are not integrated parts of self that serve the construction of a cohesive narrative; rather, they are fragmented and activating. they are involuntary jolts out of the present state. in medusa’s myth, the scenes that move the hero’s narrative forward are wylkpjh[lk�vu�tlu�hj[pun�vu�4lk\zh!�mvy�l_htwsl��4lk\zh»z�jh]l�pz� lu[lylk�^p[ov\[�oly�wlytpzzpvu�i`�[ol�tlu�^ov�h[[ltw[�[v�jvux\ly�oly� constriction, hyperarousal, and intrusion are the major post-traumatic symptoms that an individual may experience in the aftermath of trauma (herman, 2015). hyperarousal, or having an “extreme startle response” and “intense reaction” to otherwise benign stimuli, is a striking concept when contextualized in the medusa myth, especially when it comes to the example of medusa’s decapitated head (herman, 2015, p. 36). her head, if we take freud’s view, is a horror, a frightening object that induces a startle response in the eyes of the onlooker. a defense tljohupzt�äyz[�uhtlk�i`�4lshupl�2slpu��wyvqlj[p]l�pklu[päjh[pvu��pz� klzjypilk�hz�h�[^v�z[lw�wyvjlzz!�äyz[��[ol�wh[plu[�wyvqlj[z�h�why[�vm� themself onto the other, and second, the other experiences “pressures” [v�mlls�huk�hj[�pu�hjjvykhujl�[v�[ol�jhz[�vɉ�why[��0zzhjohyvɉ��(�� �/\u[�� w., 1994, p. 593). for medusa, the act of looking is her act of projecting onto men the symptoms associated with trauma, notably the “intense startle response” of hyperarousal (herman, 2015, p. 36). while projective pklu[päjh[pvu�pz�uv[�johyhj[lypalk�hz�h�[yh\th�ylzwvuzl�i`�/lythu��zol� does detail the “involuntariness” of trauma responses, and notes that where there is involuntariness, there exist unconscious desires (herman, 2015, p. 41). hurt, isolated, and traumatized, medusa develops a desperate, unconscious desire to rid herself of athena’s curse. she ezra yurman-whyde 90 | columbia social work review, vol. xxi attempts to project her own fear and hyperarousal onto her onlookers in an attempt to free herself from reliving the traumatic experience. intrusion and its role in the lived experience of trauma appear when tlu�]pzp[�4lk\zh»z�jh]l�pu�hu�lɉvy[�[v�[htl�huk�jvux\ly�oly��;olpy� attempts to enter medusa’s cave can be read as an allusion to the rape [oh[�ilnpuz�[ol�t`[o!�hz�ylluhj[tlu[z�vm�oly�[yh\th��0u[y\zpvu�huk� constriction characterize medusa’s responses to these men.1 medusa is cast as the embodiment of her intrusive thoughts, faced with reliving her trauma each time a man forces himself into her cave. intrusive thoughts and the compulsion to repeat behaviors assign the survivor the role of the repeater. the survivor plays out the trauma over and over again, just as medusa involuntarily kills anyone attempting [v�jvux\ly�oly��;olpy�z[vul�jvywzlz�z[yl^u�hjyvzz�oly�jh]l�hyl� reminders of every attempt to enter her. here we glimpse constriction, vy�¸whyhs`zpz�vm�[ol�tpuk¹!�[ol�¸myvaluulzz¹�vm�4lk\zh»z�klz[pu`�vm� klz[p[\[pvu��/lythu��������ww����������6]pk��������������opnospno[z� these monuments to medusa’s trauma when describing perseus’s lu[yhujl�pu[v�[ol�jh]l!�¸(jyvzz�[ol�älskz�huk�hsvun�[ol�[yhjrz�ol�ohk� zllu�[ol���z[h[\lz���vm�tlu�huk�vm�ilhz[z�[yhuzmvytlk�[v�z[vul�h[�[ol� sight of medusa” (p. 170). she becomes a link in the chain of her own j`jsl�vm�]pvslujl��0ujhwhisl�vm�zlsm�kläup[pvu�vy�]vs\u[hy`�hj[pvu��zol� becomes unreachable, a woman whose gaze can never be met–-that is, whyhs`alk��z[\u[lk��huk�t\jo�sprl�[ol�wl[ypälk�z[h[\lz�vm�tlu� herman notes that navigating the legal, familial, and social services systems in the aftermath of trauma can be retraumatizing if the survivor’s sense of agency is not upheld. in the aftermath of medusa’s rape, she is punished by athena, who attributes the trauma to medusa’s beauty. once again, we see that medusa, as the survivor, is considered only as an object and is blamed for the trauma forced ��0u[y\zpvu�klhsz�^p[o�^oh[�1\kp[o�/lythu�jhssz�[ol�¸puklspisl�ptwypu[¹�vm��vy�ä_h[pvu�^p[o�� [ol�[yh\th[pj�tvtlu[��ww����������;ol�woluvtluvu�vm�jvuz[ypj[pvu�pz�kläulk�i`�[ol� ¸u\tipun�ylzwvuzl�¹�vy�^oh[�/lythu�x\v[lz�9vily[�1h`�3pz[vu�hz�uhtpun�h�¸whyhs`zpz�vm� the mind” (pp. 35-45). choosing a frame columbia social work review, vol. xxi | 91 upon her. medusa, in the aftermath of her trauma, is denied by athena [ol�vwwvy[\up[`�[v�]vpjl�huk�kläul�oly�yhwl�vu�oly�v^u�[lytz��0u�[ol� absence of choice and connection, medusa projects her trauma onto v[olyz!�^olu�4lk\zh�[\yuz�oly�^v\sk�il�jvux\lyvyz�[v�z[vul��zol� recreates a set of circumstances strikingly similar to her own. in one scene, perseus displays medusa’s head to freeze his foe, nileus, in ih[[sl! ¸;v�oh]l�z\jo�h�olyv�hz�tl�mvy�`v\y�rpssly���t\z[�z\yls`�jvuzvsl�`v\� htvunz[�[ol�]vpjlslzz�zohklz�¹�)\[���opz�äuhs���^vykz�^lyl�j\[�vɉ� hz�ol�zhpk�[olt��;v�q\knl�i`�opz�vwlu���spwz����`v\»k�z\wwvzl�[oh[� ol�^hu[lk�[v�zwlhr��i\[�[ol�zv\ukz���jv\sku»[�äuk�h�^h`�[oyv\no�� �6]pk��������������w������ ;ol�olhk�vm�4lk\zh�myllalz��z[pɉluz��huk�zpslujlz��7lyzl\z�z[vwz�opz� foe from speaking mid-sentence, demonstrating the power of medusa’s gaze to take away others’ agency through the act of silencing. deprived of having the chance to speak for herself, she prevents others from speaking, even post-mortem. :jovshy�vm�mltpupz[�uhyyh[p]l�[olvy`�;lylzh�+l�3h\yl[pz��� ��������� explores subjecthood through the medusa myth and posits that by inheriting the hero’s narrative from classical mythology, we restrict our ^h`z�vm�zllpun�^vthuovvk��+l�3h\yl[pz��� ���������[hrlz�\w�:[lwolu� heath’s assertion that seeing oneself through the other is a formula for z\iqlj[ovvk��4lk\zh�pz�w\yz\lk�hz�[ol�ovyypäj�viqlj[�why�l_jlsslujl�� the thing to be slain. as men approach her, they hold a preconceived uv[pvu�vm�^oh[�[ol`�^pss�äuk��;ol`�hyl�vu�lknl��svvrpun�hyv\uk�l]ly`� corner, expecting danger in their own state of hyperarousal. hesiod �����������nvlz�hz�mhy�hz�[v�klzjypil�4lk\zh�hz�¸\uhwwyvhjohisl¹� (p.12). upon noticing the presence of men, medusa looks. she cannot zll�[olzl�v[olyz�zllpun�oly��mvy�^olu�zol�svvrz��zol�äukz�olyzlsm� looking at stone, no one there to greet her gaze. heath states, “if the woman looks, the spectacle provokes, castration is in the air, the 4lk\zh»z�olhk�pz�uv[�mhy�vɉ"�[o\z��zol�t\z[�uv[�svvr��pz�hizvyilk�i`� ezra yurman-whyde 92 | columbia social work review, vol. xxi olyzlsm¯�¹��hz�jp[lk�pu�+l�3h\yl[pz��� ���������w��� ��� attached so closely to her trauma, medusa is denied a life in which she is able to contextualize her traumatic experience within a broader \uklyz[hukpun�vm�oly�pklu[p[ �̀�0uz[lhk��zol�iljvtlz�kläulk�i`�oly� [yh\th��jh\no[�huk�jvkpälk�pu�oly�v^u�t`[o��0u�[opz�z[h[l��zol�pz� z[ypwwlk�vm�oly�hnluj �̀�hsvul��\uhisl�[v�l_wlyplujl�[ol�z\iqlj[päjh[pvu� born from seeing another see her. in framing medusa as the monster and the men who come to tame her as the heroes, we are enabling a practice of limited perception and perpetuating the narrative of medusa as a monster. that is, we are preserving her isolation, framing her as v[oly�huk�hz�[ol�viqlj[�vm�[yh\th�wlyzvupälk��� medusa’s is the canonical gaze that turns others to stone; it is therefore the gaze that cannot seem to see itself. if medusa were to look at herself, would she not turn to stone? without the capacity to gaze upon olyzlsm��zol�jhuuv[�vɉly�olyzlsm�h�sv]pun�nhal��jvu[ltwsh[l�oly�v^u� narrative, acknowledge her own fragility, or place herself within the context of the life she has lived. without selfhood and the capacity to jvtt\ul�^p[o�oly�^vysk��4lk\zh�pz�h�zlyplz�vm�åhzoihjrz��jh\no[ulzz� incarnate, repeatedly reliving her trauma. without the ability to see her whole self or to see herself through the eyes of another, medusa is limited, if not completely inhibited, in her ability to gain self-awareness of her positionality in her world. psychoanalyst robert bosnak (2007) writes of the necessity of narrative [v�jvu[l_[\hspal�huk�h[[hjo�\z�[v�v\y�v^u�z[vy`!�¸,ukslzz��z[lylv[`wlk�� ä_lk�ylwl[p[pvu�pz�[ol�l_jlw[pvu��huk�z\jo�[yh\th�^pss�uv[�ylh[[hjo�[v� the renaissance patchwork of states, but will remain a body drifting in space” (p. 46). the ability to weave one’s experiences into the patchwork that is their life story is paramount for integration and healing from trauma. )vzuhr��������kpɉlylu[ph[lz�uhyyh[p]l�tltvy`�myvt�[yh\th[pj�tltvy �̀� ^opjo�pz�[ol�[ptlslzz��hopz[vypjhs��ls\zp]l��h[`wpjhs�åhzoihjr�[oh[�[ol� american psychiatric association (2013) names as a criterion in the choosing a frame columbia social work review, vol. xxi | 93 diagnosis of post-traumatic stress disorder. he writes, “flashback-type tltvy`�pz�jvtwsl[ls`�kpɉlylu[�myvt�[ol�kpzj\yzp]l��uhyyh[p]l�tltvy`�vm� ordinary waking consciousness” (bosnak, 2007, p. 46). he goes on to explain that the greek word for revelation is apokalupsis (apocalypse). the earth-shattering revelation of meaning, bosnak purports, is not mv\uk�pu�[ol�åhzoihjr��0uz[lhk��[ol�z[hy[sl��[ol�\ujhuu �̀�huk�[ol�[lyyvy� ilsvun�[v�[ol�ylhst�vm�[ol�[yh\th[pj!�[ol�ylhst�vm�4lk\zh��/lythu� (2015) takes up the notions of memory and time in her explication of the zvth[pj�hzwlj[z�vm�[yh\th��klzjypipun�[ol�x\hsp[`�vm�[yh\th[pj�tltvyplz� as “frozen” in time (p. 37). she goes on to describe the uncanny, h[ltwvyhs�x\hsp[plz�vm�ylluhj[tlu[z��/lythu�z[h[lz�[oh[�ylluhj[tlu[z� have feelings of “involuntariness,” that they are “driven, tenacious” pu�johyhj[ly��huk�[oh[�[ol`�m\säss�h�¸ylwl[p[pvu�jvtw\szpvu¹�huk�¸klh[o� instinct” (2015, p. 41). medusa’s reenactments and embodied traits of o`wlyhyv\zhs��jvuz[ypj[pvu��huk�pu[y\zpvu�l_ltwspm`�[ol�¸åhzoihjr�[`wl¹� memories that bosnak (2007) describes as not integrative, because there exists in them no revelation of meaning (p. 46). the act of gazing upon oneself to know oneself does not occur, because we do not see v\yzls]lz�pu�h�åhzoihjr"�^l�zll�^oh[�ohwwlulk�[v�\z��0[�pz�h�ylwl[p[p]l� z[\jrulzz!�[olyl�pz�uv�nvpun�mvy^hyk��uv�ul^�ruv^slknl��uv�tv\yupun� or grieving—only a reliving of what was. glimpsing healing through narrative reintegration a central complication of trauma is determining when something traumatic ceases to control the survivor and at what point the survivor is able to integrate their traumatic experience into the patchwork of their greater life experience. symptoms of trauma look a lot like the healing of [yh\th·\ujhuups`�zv��/lythu��������wvzp[z�[ol�äuhs�z[hnl�vm�yljv]ly`� for trauma survivors as reconnection. empowerment is the core experience of recovery, and this stage of reconnection is characterized by a readiness to incorporate the lessons of one’s traumatic experience into their life. the importance of agency and choice is highlighted in herman’s work concerning the stages of recovery for survivors of ezra yurman-whyde 94 | columbia social work review, vol. xxi [yh\th��zwljpäjhss`�¸[ol�jovpjl�[v�l_wvzl�vulzlsm�[v�khunly�¹�^opjo�� she states, can be understood as “another reenactment of trauma” (p. 197). the distinction between the stuckness of some reenactments and [ol�myllkvt�vm�[opz�zvy[�pz�[ol�]hyphisl�vm�jovpjl!�¸hu�h[[ltw[�[v�thz[ly� the traumatic experience” that is “undertaken consciously” (herman, 2015, p. 197). this conscious reenacting is a reclamation of one’s own spml·yljshptpun�[ol�[yh\th[pj�huk�ylkläupun�p[�vu�vul»z�v^u�[lytz·h� wyvjlzz�vm�äukpun�hs[lyuh[l�lukpunz�[oh[�hyl�kpɉlylu[�myvt�[ol�[yh\th[pj� tvtlu[�p[zlsm��0[�pz�hu�hzjypw[pvu�vm�ul^�tlhupun�il[^llu�zpnupäly�huk� zpnupälk� particularly for clinical social work, a therapeutic narrative reclamation vɉlyz�[ol�wh[plu[�[ol�johujl�[v�yllu[ly�[ol�yvsl�vm�uhyyh[vy�vm�[olpy�v^u� life. the philosopher adriana cavarero (2000) establishes a methodology for narrative reclamation by illustrating how the act of silencing is the preluding act to one taking on the role of narrator, in which one must ylthpu�x\pl[�mvy�[ol�v[oly�[v�zwlhr��vy�[oh[�vul�t\z[�zpslujl�pu�vykly�[v� il�olhyk��>p[o�[opz�wlyzwlj[p]l��^l�th`�x\lz[pvu�[ol�pu]vs\u[hypulzz�vm� medusa’s repetition compulsions and cast them instead as intentional reenactments—attempts to regain her voice and narrative. 0u�h[[ltw[pun�[v�kläul�[ol�z\iqlj[p]l�l_wlyplujl��[^v�jlu[yhs�x\lz[pvuz� hypzl!�¸who is speaking,” and “who is listening?” according to cavarero, [ol�hj[�vm�h\[vipvnyhwo`�zly]lz�[v�ltwv^ly�i`�vɉlypun�[ol�vwwvy[\up[`� for the narrator (self) to practice self-determination through the crafting of their own story. cavarero (2000) writes, “[t]o tell one’s own story is to distance oneself from oneself, to double oneself, to make oneself an other” (p. 84). this means seeing oneself in one’s memory and using recollection as a “separated mirror” (cavarero, 2000, p. 84). we gaze upon ourselves to know ourselves. it is the distance from ourselves that allows us the space to see with clear eyes, not in fragmented parts, but as a whole. it is through the practice of autobiography that we are vɉlylk�[ol�vwwvy[\up[`�[v�yl^yp[l�ilsplmz��hzjypil�ul^�tlhupunz��zll� ourselves without judgment, bear witness to our own fragility, and, in lɉlj[��[v�sv]l�v\yzls]lz! choosing a frame columbia social work review, vol. xxi | 95 (z�[ol�zh`pun�nvlz!�3v]l�pz�ispuk·uv[�iljh\zl�p[�[\yuz�\wvu� the invisible, but because it is without judgment with respect to that which others see. it experiences another type of gaze—a nhal�[oh[�jvtlz�myvt�[ol�hnvupapun�l_wlyplujl�vm�äup[l�ilpun»z� appearance, in its constitutive fragility. (cavarero, 2000, p. 112) *h]hylyv�kläulz�[ol�sv]pun�nhal�hz�zllpun�pu�zwp[l�vm�vy�svvrpun�whz[� judgment. there exists an intentionality to the loving gaze in choosing to see the other despite preconceived judgment. medusa’s myth holds potential for this kind of seeing. precisely as herman (2015) describes healing from trauma, awareness of reenactments is essential to healing. intentional reenactments, when repeated over and over again, are small steps toward re-working and re-wiring ourselves into subjects who, [oyv\no�wyhj[pjl�huk�[ptl��jvtl�[v�hjx\pyl�h�jly[hpu�jvtthuk�v]ly� our experience. we slowly and untidily become the narrators of our lives again. we can see the instance of the men’s stupor as the moment that the role of narrator and protagonist transfers to medusa. medusa’s intent to be seen and heard is what freezes the men. medusa’s act of being seen, turning her enemies to stone, and silencing them gives her a chance to reclaim the role of narrator and heroine. we see medusa’s intentionality in the climax of her battle with her heroic counterpart. perseus uses medusa’s own gaze against her to freeze and decapitate her. but there must be time between these two moments, freezing and decapitating, because as art critic and [olvypz[�*yhpn�6^luz�hzrz��¸ov^�jhu�7lyzl\z�j\[�vɉ�[ol�olhk�vm�h� z[vul�z[h[\l&¹�6^luz��� ���������[vvr�\w�[ol�3hjhuphu�jvujlw[�vm� suture�huk�yluhtlk�p[�[ol�¸4lk\zh�lɉlj[¹��w������!�[ol�wyvjlzz�vm� wzl\kv�pklu[päjh[pvu�pu�^opjo�[^v�[opunz�hyl�zllu�hz�vul�i\[�hyl�pu� mhj[�zlwhyh[l��p�l���[olyl�pz�h�kpɉlylujl�il[^llu�zllpun�zvtl[opun�huk� [ol�[opun�p[zlsm���6^luz�pklu[pälz�[ol�tvtlu[�4lk\zh�zllz�olyzlsm� pu�[ol�ylålj[pvu�vm�7lyzl\z»z�tpyyvylk�zoplsk�hz�lu[pyls`�kpɉlylu[�myvt� the moment when she turns herself to stone. if medusa is not in fact [\yulk�[v�z[vul�\wvu�zllpun�oly�ylålj[pvu�pu�7lyzl\z»z�zoplsk��zol�th`� have seen herself in the shields of her assailants all along. through ezra yurman-whyde 96 | columbia social work review, vol. xxi this reading, medusa is imbued with a freedom, an agency, and a satisfaction in seeing herself. if she can see herself, her capacity for inhabiting the role of narrator lives on. she owns her willingness to be seen. another kind of gaze ;ol�4lk\zh�lɉlj[�hssv^z�[ol�ylhkly�vm�[ol�t`[o�[v�nsptwzl� pu[lu[pvuhsp[`!�h�kljpzpvu�pz�thkl�^olu�4lk\zh�zov^z�olyzlsm��0m�[ol�hj[� vm�zllpun�olyzlsm�huk�vm�ilpun�zllu�hyl�zlwhyh[l�myvt�[oh[�x\pu[lzzlu[phs� tvtlu[�vm�z[pɉlupun��[olyl�l_pz[z�h�tvtlu[�vm�[ptl�mvy�h�kljpzpvu�[v�il� made—a moment for medusa to make “the choice to expose [her]self,” that is critical to her reentry into communing with the world (herman, 2015, p. 197). medusa can be our heroine, pushing forward her own narrative. gordon �������^yp[lz�vm�4lk\zh�hz�[ol�¸ilh\[pm\s�än\yl�b^ovd�jhu�vus`�^vukly�� x\paapjhss`¯^p[o�h�ztpsl��h[�[ol�my\z[yh[lk�tlu�^ov�^v\sk�[\yu�oly� beautiful hair into snakes, and her into a monster” (p. 123). medusa z[\wlälz�vus`�^olu�zol�hssv^z�olyzlsm�[v�il�zllu��7lyohwz��pu�svvrpun� at her straight on, we glimpse medusa looking at herself in a state of recollecting, as cavarero (2000) suggests—distanced enough from herself, telling and retelling her own story. we glimpse a woman trying to put pieces together. medusa is compelled by involuntary actions until [ol�z\[\yl��vy�4lk\zh�lɉlj[��pz�l_wvzlk�huk�\ukvul!�\u[ps�^l�zopm[�v\y� myhtl�huk�zll�oly�^p[o�kpɉlylu[�l`lz��(uk�^oh[�vm�4lk\zh�l_wlyplujpun� herself being seen through the eyes of another who is not afraid, not fetishizing her, but instead gazing upon her with “another kind of gaze,” gentle, without judgment, and intent on preserving her sense of choice (cavarero, 2000, p. 112)? a tender gaze that said i’m here with you? what if medusa could experience this communion with another? she might be “as the drop of rain in the sea” (herman, 2015, p. 236). what potentiality would exist for her then? commonality with other people carries with it all the meanings of the word common… it means having a feeling of familiarity, choosing a frame columbia social work review, vol. xxi | 97 of being known, of communion. it means taking part in the customary, the commonplace, the ordinary, and the everyday. (herman, 2015, p. 236) herman (2015) emphasizes the necessity for survivors of trauma to focus on the development of desire and initiative, as well as commonality, in the process of reintegration. telling one’s story is itself an act of searching for common experience. narrative is bridge-building, allowing one to escape the isolation of traumatic experience. there is wv[lu[phs�mvy�zvtlvul�vjj\w`pun�[ol�wh[plu[�yvsl�[v�äuk�ovwl�pu�[olpy� own choice to decide when, how, and for whom they become vulnerable or show themself after trauma. herman (2015) posits that healing is h[�slhz[�pu�why[�k\l�[v�[ol�pukp]pk\hs�z�hipsp[`�[v�hjx\pyl�h�t\s[p[\kl�vm� experiences—some mundane—after a trauma, which serves to help yljhspiyh[l�vul�z�zluzl�vm�hu�hwwyvwyph[l�z[ylzz�ylzwvuzl�[v�z[pt\sp�� a clinical social worker who consciously or unconsciously emulates the decapitation of medusa is one that promotes functioning in social and institutional systems founded on patriarchal power structures. the yhtpäjh[pvuz�vm�jvu[hpupun�[ol�\ujvu[hpuhisl�pu�ovwlz�vm�wyvtv[pun� acceptable modes of functioning for systems that are designed to vwwylzz�z[pål�zlsm�kläup[pvu�huk�jovpjl��0[�pz�4lk\zh»z�pu[lysvwlyz��huk� by extension, viewers who adopt the hero’s narrative, who objectify and mitigate the anticipated horror they perceive in medusa. it is perseus’ success in avoiding the act of facing medusa head-on that enables him [v�kljhwp[h[l�oly��;v�svvr�olhk�vu�pz�zvtl[opun�kpɉlylu[��/v^�[olu�jhu� the clinical social worker approach medusa with clear eyes and a loving gaze rather than with the impulse to contain and manage? medusa’s myth suggests that instead of being tempted to soothe all wounds, to rescue, and to make the trauma go away, the clinical social ^vyrly�ohz�h�k\[`�[v�zll�[ol�wh[plu[�hz�hɉlj[lk�i`�[olpy�[yh\th�i\[�uv[� kläulk�i`�p[��hz�zvtlvul�^ovzl�hj[pvuz�th`�[lz[��th`�w\zo�h^h �̀�huk� may try to imbue those around them with feelings that are not their own. ;opz�pz�[ol�wh[plu[�^vyrpun�p[�v\[��äukpun�[olpy�]vpjl��jhspiyh[pun��huk� learning to see themself and their world anew. as clinical social workers, ezra yurman-whyde 98 | columbia social work review, vol. xxi we are alongside our patients, attempting to always expose the medusa lɉlj[��jvu[pu\hss`�tv]pun�[v^hyk�[ol�zwhjl�pu�il[^llu�[ol�^vysk� and our understanding of it. it is in this space that the most important aspects of trauma treatment—choice, awareness, and intention—are seen. references american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). american psychiatric association. bosnak, r. (2007). embodiment: creative imagination in medicine, art and travel. taylor and francis. cavarero, a. (2000). relating narratives: storytelling and selfhood. routledge. de lauretis, t. (2003). desire in narrative. in m. garber & n. j. vickers (eds.), the medusa reader (pp. 198–200). routledge. (original work published in 1984) freud, s. (2003a). medusa’s head (j. strachey, trans.). in m. garber & n. j. vickers (eds.), the medusa reader (pp. 84–86). routledge. (original work published in 1922) freud, s. (2003b). the uncanny (d. mclintock, trans.). penguin books. (original work published 1919) .vykvu��7����������4lk\zh�yljhwp[�\s�h[lk!�-yl\k��mlthsl�nlup[hsph�huk�[ol�¸j\u[�yv]lyz`¹� at cu. psychoanalysis, culture & society, 19(2), 113–126. haraway, d. j. (2016). staying with the trouble: making kin in the chthulucene. duke university press. herman, j. l. 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(original work published 1984) :ps]lythu��+����������¸4lk\zh!�:l_\hsp[ �̀�wv^ly��thz[ly �̀�huk�zvtl�wz`jovhuhs`[pj� observations.” studies in gender and sexuality, 17 (2), 114–125. ezra yurman-whyde columbia social work review, vol. xix | 3 new york's directive for mental health involuntary removals: the intersectional risk for unhoused new yorkers with a serious mental illness lanya snyder 4 | columbia social work review, vol. xxi new york’s directive for mental health involuntary removals abstract behavioral health care, more commonly known as psychiatric care, has been a longstanding and complex issue, especially for marginalized new yorkers. healthcare policy addressing and caring for people diagnosed with a serious mental illness is fundamental to basic human rights; at the same time, it is a nuanced matter. policies surrounding economic issues of poverty and housing instability are inextricably linked to social issues of mental and physical healthcare. healthcare policy and the experience of homelessness are closely spurlk�mvy�[^v�ylhzvuz!�äyz[��[ol�opno�jvz[�vm�olhs[ojhyl�jvu[ypi\[lz�[v� poverty for many americans; and second, the poor and the aging are [ol�tvz[�sprls`�[v�z\ɉly�myvt�pssulzz�huk�opno�tlkpjhs�l_wluzlz��4hy[pu�� 2015). this paper will consider the intersectional risk for unhoused new york city residents with a serious mental illness in light of mayor eric adams’ recent directive for mental health involuntary removals. this new directive enables authorities to forcibly transport unhoused new yorkers to hospitals to remove them from public areas. although the current mayoral administration frames this as a moral obligation to act on behalf of new yorkers with a serious mental illness, it is far myvt�hu�lɉvy[�[v�luz\yl�[oh[�l]ly`vul�ohz�ov\zpun�huk�yljlp]lz�ihzpj� healthcare. adams’ misguided policy is a veiled attempt to make the city hwwlhy�zhmly�^opsl�kvpun�sp[[sl�[v�hzzpz[�[ovzl�^ov�hyl�z\ɉlypun�huk�mhpsz� [v�hkkylzz�pu[ly]lu[pvuz�mvy�[ol�ylhs�pzz\l�h[�ohuk!�ov\zpun� columbia social work review, vol. xxi | 5 lanya snyder o n the morning of january 15, 2022, michelle go, a 40-yearold chinese-american, was fatally pushed onto the subway [yhjrz�h[�;ptlz�:x\hyl��4hy[phs�:ptvu��[ol�pukp]pk\hs�^ov� committed this unprovoked act, emigrated to new york from haiti in his teens and had been experiencing homelessness for the past 18 years. he also has a longstanding history of schizophrenia, including approximately 20 prior hospitalizations. go’s death is sadly not [ol�äyz[�vm�p[z�rpuk��5l^�@vyr�ohz�z[y\nnslk�[v�luhj[�lɉlj[p]l�slnpzsh[pvu� governing the treatment of individuals with a chronic serious mental illness (smi) and, as a result, thousands of new yorkers like simon elude [ylh[tlu[��+p]lu���������(�:40�pz�kläulk�i`�[ol�5h[pvuhs�0uz[p[\[l�mvy� mental health (nimh) as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities (mental illness, n.d.). the timing of this violence impacted the political response. this tragedy occurred when hate crimes targeting asian americans were on the rise, and although police concluded that this particular incident was not racially motivated and there was no known prior connection between go and simon, the larger sociopolitical context may have fueled the hktpupz[yh[pvu�z�ullk�[v�ylzwvuk��pu�vykly�[v�luz\yl�w\ispj�z\wwvy[�� this particular incident happened following a slew of incidents in which people were pushed onto subway tracks, though none of the previous had been fatal. as of mid-march 2022, transit crime was up 80.3% compared with the same period in 2021, though this number may be zrl^lk�iljh\zl�vm�kljylhzlk�z\i^h`�ypklyzopw�k\ypun�[ol�äyz[�`lhy� of the covid-19 pandemic (gelinas, 2022). it also occurred during eric (khtz»�äyz[�^llr�hz�th`vy��;opz�[ptpun�htwspälk�pzz\lz�vm�yhjphss`� driven hate crimes, random acts of violence, and a perceived surge in subway crime, and it provided linkage to the deep-seated issues vm�\uov\zlk�5l^�@vyrlyz�^p[o�tlu[hs�pssulzz��zwljpäjhss`�[ovzl�^p[o� persistent and often treatment-resistant smi. 6 | columbia social work review, vol. xxi leaders in the public and private sectors have worked for decades to propose policies for those who struggle with homelessness and mental illness. hospitalization rates for new yorkers living with a smi are consistently higher than the national average (heun-johnson et al., 2018). while the percentage of people with a smi is a much smaller subset than those living with any mental illness, new york city has a disproportionately higher number of its population diagnosed with a smi compared to the national average and fewer resources to treat those needing inpatient psychiatric care. go’s death garnered widespread media attention and was the catalyst for the subway safety plan, a reaction outlined by the adams administration the month after the incident. this was followed by the mental health involuntary removal (mhir) policy directive, announced later in 2022. multifaceted sociopolitical issues in which mental health is just one kptluzpvu�luhisl�wvsp[pjphuz�[v�jp[l�tlu[hs�olhs[o�hz�hu�v]lyzptwspälk� q\z[päjh[pvu�^opsl�vtp[[pun�v[oly�jvu[ypi\[pun�mhj[vyz�[oh[�hyl�uv[�hz� politically compelling. adams’ mhir response to the issues at the mvylmyvu[��^ov�p[�hɉlj[z��huk�ov^�p[�^pss�il�ptwsltlu[lk�htv\u[�[v� uv[opun�tvyl�[ohu�jvtwhzzpvuh[l�^pukv^�kylzzpun�pu�hu�lɉvy[�[v� hwwlhy�[v\no�vu�jyptl��<zpun�w\ispj�zhml[`�hz�q\z[päjh[pvu��p[�wvpu[z� [ol�äunly�h[�\uov\zlk�pukp]pk\hsz�^ov�th`�oh]l�hu�\u[ylh[lk�tlu[hs� illness. if, as adams says, preventing unhoused new yorkers from living on city streets or in subway stations and “helping them heal” is the city’s objective, forcibly transporting them to an emergency department (ed) kvlz�sp[[sl�[v�zvs]l�[ol�pzz\l�vm�ov\zpun��(khtz����������!���� mental health involuntary removals (mhir) racial and ethnic minorities and immigrant populations in new york *p[`�oh]l�zpnupäjhu[s`�slzz�hjjlzz�[v�z[hisl�ov\zpun��sp]hisl�^hnlz��huk� physical and mental health resources compared to majority groups, w\[[pun�[olt�h[�h�opnoly�ypzr�mvy�hk]lyzl�tlu[hs�olhs[o�jvuzlx\lujlz� in the wake of traumatic experiences (rudenstine et al., 2020). on new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 7 november 28, 2022, adams announced his directive to remove unhoused individuals from the street and treat their smi. what was omitted in both adams’ speech and the policy is that not all unhoused individuals have a smi and there are often co-occurring determinants [oh[�ulnh[p]ls`�ptwhj[�[ol�wvw\sh[pvu�vm�pukp]pk\hsz�^p[o�:40!�yhjphs� discrimination, employment status, familial or community support systems, comorbidities, co-occurring psychological disorders, and a person’s health insurance or lack thereof. these are in addition to housing, the social determinant most closely linked to the mhir policy directive. -vy�jvu[l_[��vul�t\z[�äyz[�\uklyz[huk�[ol�l_pz[pun�5l^�@vyr�:[h[l� mental hygiene laws. article 9 of the mental hygiene law (mhl) is legislation from the new york state senate (2021) that sets mvy[o�z[hukhykz�huk�wyvjlk\ylz�mvy�wh[plu[z�^ov�ylx\pyl�puwh[plu[� hospitalization for a mental illness. the policy outlines emergency assessment for immediate observation, care, and treatment, powers vm�jly[hpu�wlhjl�vɉjlyz�huk�wvspjl�vɉjlyz��[yhuzwvy[�mvy�l]hs\h[pvu�� and powers of approved mobile crisis outreach teams (mental health involuntary removals [mhir], 2022). the directive for mhirs augments article 9 of the mhl by outlining roles huk�ylzwvuzpipsp[plz�mvy�pu]vs\u[hy`�yltv]hsz��(jjvykpun�[v�[ol�6ɉjl� of mental health’s (omh) directive, sections 9.41 and 9.59 of the mhl authorize the removal of a person who appears to be mentally ill and displays an inability to meet their basic living needs (mhir, 2022). the relaxed language of the mhir authorizes the removal of a person by force and involuntary transport to the closest hospital for a psychiatric evaluation, “even when no recent dangerous act has been observed” �4/09��������w������;ol�ä]l�whnl�4/09�wvspj`�lukz�hm[ly�v\[spupun�]hn\l� wyv[vjvsz�mvy�pu]vs\u[hy`�ovzwp[hs�[yhuzmlyz�^p[o�ylzwlj[�[v�kpɉlylu[� agencies tasked with enforcing this directive. the scant guidelines are l_wylzzlk�^p[o�v]ly�zptwspälk�shun\hnl�jvtwhylk�[v�^oh[�ohz�hs^h`z� been standard ed or comprehensive psychiatric emergency program �*7,7��wyvjlk\yl�mvy�yljlp]pun�olhs[ojhyl�mhjpsp[plz!�[hrl�ylzwvuzpipsp[`� lanya snyder 8 | columbia social work review, vol. xxi for the individual in the hospital, obtain collateral information, complete a comprehensive psychiatric evaluation for the removed individual, and a psychiatrist evaluates the individual for admission (mhir, 2022). there is no outline in the mhir for how a person, once removed from public areas and taken to a hospital, would receive long-term treatment for an ongoing smi or related social determinants. nor is there any guidance or resources if they are not admitted to the hospital and return to the streets. for individuals who meet the criteria to receive treatment through inpatient hospitalization, the mhir fails to address what happens once a person is discharged. the crisis of care—as in the case vm�4y��:ptvu��^ov��hjjvykpun�[v�2h\mthu���������yljlp]lk�ä]l�tvu[oz� of inpatient treatment at the bronx psychiatric center before discharge in july of 2021— is not an issue of whether new york hospital systems can compassionately treat someone experiencing a smi. medical facilities can and do stabilize hundreds of psychiatric patients every day. the gaping hole is an omission of policy that should but does not hkkylzz�[ol�jvu[pu\\t�vm�jhyl��pujs\kpun�lɉlj[p]l�ov\zpun�zvs\[pvuz�mvy� new yorkers with a smi. institutions affected by the mhir directive hospital-based emergency care is the only medical treatment to which americans have a legal right regardless of their ability to pay (barish et al., 2012). whether a particular hospital operates under public or private auspices is of critical importance in determining who yljlp]lz�wz`joph[ypj�zly]pjlz�huk�ov^�[ovzl�zly]pjlz�hyl�äuhujlk�� hospitalization rates for new yorkers living with a smi are consistently higher than the national average (heun-johnson et al., 2018). it is widely accepted that psychiatric units generate less revenue for healthcare z`z[ltz�jvtwhylk�[v�z\ynpjhs�\up[z"�[o\z��pu�jvuzpklyh[pvu�vm�äuhujphs� pressures, private hospitals divert psychiatric patients to city public hospitals (mueller, 2017). unhoused new yorkers are more likely to receive treatment through the city’s public hospital systems. new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 9 other relevant public policies the subway safety plan the mhir is an extension of the memorandum published on february 18, 2022 by the omh known as the subway safety plan. this was the äyz[�kpylj[p]l�myvt�[ol�(khtz�hktpupz[yh[pvu�mvy�wvspjl�huk�v[oly�vɉjphsz� to remove any person with a mental illness or any person who appears to be mentally ill, even when there is no recent dangerous act, and transport them to a hospital for a psychiatric evaluation. this lengthier wvspj`�x\hspälz�[ol�yh[pvuhsl�mvy�lumvyjltlu[��z[h[pun�[oh[�¸ovtlslzzulzz� in nyc has reached the highest levels since the great depression” �6ɉjl�vm�4lu[hs�/lhs[o�b64/d�l[�hs���������w������>oh[�pz�jvuzwpj\v\z� pz�[ol�jp[`»z�yh[pvuhsl�mvy�^o`�[opz�wvw\sh[pvu�pz�h[�ypzr!�¸joyvupjhss`� homeless individuals with smi often have symptoms and cognitive kpɉj\s[plz�[oh[�jvu[ypi\[l�[v�kpɉj\s[plz�hjjlzzpun�[ylh[tlu[�huk�ov\zpun� resources” (omh et al., 2022, p. 2). furthermore, the alternative agenda olyl�pz�opkpun�pu�wshpu�zpno[��(khtz�q\z[pälk�[opz�hnnylzzp]l�shun\hnl� to augment existing sections of the mhl under the guise of a moral obligation to help unhoused new yorkers in need of mental healthcare, ^opsl�zpt\s[hulv\zs`�\zpun�p[�[v�x\lss�w\ispj�zhml[`�jvujlyuz�hiv\[�jyptl� on the street and in the subway system. mhl section 9.60, known as kendra’s law after go’s death, adams pointed to new york mhl section 9.60, better known as kendra’s law, which assertively connects new yorkers experiencing a mental health emergency to medical treatment. section 9.60 was named after kendra webdale, who died in january 1999 when she was pushed in front of a nyc subway train by a person with untreated schizophrenia (pataki et al., 2005). similar to go’s case, the man who pushed webdale had just been released from a psychiatric hospital, and his actions resulted from medication non-compliance (diven, 2022). soon thereafter, in 1999, new york passed legislation to provide court-mandated assisted outpatient treatment (aot). this is a more humane and less restrictive alternative to inpatient commitment for lanya snyder 10 | columbia social work review, vol. xxi those who are unlikely to survive safely in the community without courtmandated supervision (pataki et al., 2005). per the u.s. department of justice (2022), aot programs are also responsible for the oversight and monitoring of service providers, including case management services or assertive community treatment (act) team services. case managers and act team members follow an aot recipient’s level of compliance and delivery of services by other providers pursuant to the court order (u.s. department of justice [doj], 2020). assisted outpatient treatment (aot) evaluation more than two decades have passed since the enactment of section 9.60 under new york’s mhl. critics of aot argue that court mandated medical compliance infringes on civil liberties and disproportionately targets people of color. others have studied the results and praised p[z�lɉlj[p]lulzz�pu�ylk\jpun�ohyt�[v�pukp]pk\hsz�huk�jvtt\up[plz�� appelbaum (2005) reviewed more than 10,000 new yorkers who were ylmlyylk�[v�(6;�k\ypun�[ol�ä]l�`lhy�zwhu�hm[ly�p[�^hz�äyz[�luhj[lk�� of the referrals, 93% of cases were granted court-ordered aot. in evaluating participation, appelbaum’s (2005) study examined the history of the individuals granted aot for three years prior to their court-ordered aot. it found that 97% had been previously hospitalized, 30% were arrested, 23% were incarcerated, and 19% were unhoused. even more lujv\yhnpun�^lyl�v\[jvtlz�hzzlzzlk�v]ly�ä]l�`lhyz�hm[ly�thukh[lk� treatment, which showed a 44% decrease in general harmful behaviors, including a 47% decrease in physical harm to others (appelbaum, 2005). furthermore, arrests, incarceration, psychiatric hospitalization, and homelessness collectively dropped by 74 to 87% (appelbaum, 2005). aot criticism kaufman (2023) notes that when simon left the hospital in july of 2021, social workers escorted him to a supportive housing apartment building in the bronx, where he could live with on-site services. they left him with a 30-day supply of medication and a next-day appointment with a psychiatrist. mr. simon never showed up to his outpatient psychiatry new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 11 appointment and is believed to have spent no more than two hours in opz�ul^�ovtl�^olyl�ol�slm[�vus`�h�[yhjl�vm�opz�wylzlujl!�h�iyv^u�whwly� ihn�z[\ɉlk�^p[o�[ol�z\wws`�vm�tlkpjh[pvuz��2h\mthu���������(6;�pz� not a life sentence; court orders can lapse after six months. the most mylx\lu[s`�jp[lk�ylhzvu�mvy�uvu�ylul^hs�vm�jv\y[�vyklyz��hjjvykpun�[v�[ol� nys-omh, is that the individual has improved and is no longer in need of court-ordered services. the paradox is that people likely improved because they were mandated to comply with medication, as was the case for simon. according to simon’s sister, treatment and medicine kept him going, and once he no longer posed a threat to himself or v[olyz��[ol�jv\y[�uv�svunly�ylx\pylk�opt�[v�[hrl�opz�tlkpjpul��+p]lu�� 2022). left to his own devices, he stopped taking his medication and his delusions resumed. �9hjphs�kpzwhyp[plz�wly]hkl�5l^�@vyr�z�(6;�wyvnyht��^p[o�)shjr�huk� hispanic people disproportionately subjected to its court orders. because of this, aot programs have arguably further marginalized and discriminated against new yorkers of color (rodríguez-roldán, 2020). during adams’ 2022 announcement, he called to make it easier to enforce kendra’s law as a means to improve ongoing mental health outpatient treatment compliance for those who cannot meet their needs v\[zpkl�vm�puz[p[\[pvuz��5l^�@vyr�4/3� �����v\[spulk�i`�1hɉl����� ��� stipulates that once a patient meets the threshold for aot eligibility, almost any person associated with that individual can petition for courtordered treatment. while hospital providers can and do apply for aot, (khtz��z[h[ltlu[�pz�tpzslhkpun��hz�p[�z\nnlz[z�2lukyh»z�3h^�jhu�vus`� be mandated through hospitalization. in fact, the petition can be initiated by any mental health providers, directors of community programs, z\wwvy[p]l�ov\zpun�kpylj[vyz��whyvsl�vy�wyvih[pvu�vɉjlyz��vy�hu`�zvjphs� service designee working with the individual. furthermore, aot is not an under-utilized resource as adams also infers. according to rascoe and lewis (2022), as of october, there was an 800-person waiting list for those eligible for aot. without additional funding for this supportive service, forcing aot creates a bottleneck for outpatient behavioral healthcare supportive services in the community. lanya snyder 12 | columbia social work review, vol. xxi >opsl�2lukyh»z�3h^�jhu�il�iluläjphs�mvy�[ovzl�^ov�kv�yljlp]l�(6;�� diven (2022) outlines its pitfalls. it fails to address the population at large, because it does not account for those who are not a threat to themselves or others. furthermore, the legal statute for obtaining a court order is based on prior acts demonstrating dangerousness and treatment non-compliance, which imposes a high burden of proof. a widespread misconception is that people who are hospitalized for psychiatric stabilization are simply discharged to the streets without shelter, follow-up outpatient care, medications, or other supportive services. according to a study of psychiatric inpatient discharge practices and aftercare appointments in new york state, smith et al. (2017) concluded that hospital providers, including social workers, reported having scheduled appointments for ongoing follow-up treatment for 85% of patients prior to discharge. the percentage of those found not to have psychiatric outpatient services were patients associated with having a co-occurring substance use disorder or other comorbid condition that took priority. this does not account for other social services secured for these patients in discharge planning. this study examined associations between routine discharge planning wyhj[pjlz�huk�[ptl�[v�[ylh[tlu[�mvssv^�\w�hm[ly�kpzjohynl��äukpun�[oh[� 45% of adults did not attend an initial aftercare appointment within 30 days of discharge (smith et al., 2017). the data illustrates a void in the continuum of care needed for outpatient support, such as intensive case management and services through act teams, during the transition from the inpatient setting to supportive housing. stakeholders for the mihr directive, stakeholders include community members, sh^�lumvyjltlu[�vɉjphsz��olhs[ojhyl�^vyrlyz�huk�hktpupz[yh[vyz�� lawmakers, and new york city residents. new yorkers with a smi are wypthy`�z[hrlovsklyz��jvuzpklypun�[opz�wvspj`�kpylj[s`�hɉlj[z�[olpy�zvjphs� welfare. at present, it is estimated that 250,000 adults have a smi, or 3% of the total population in new york city. among the unhoused population, which totals about 60,000 living in city shelters or on the new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 13 z[yll[z��[ol�504/»z�5l^�@vyr�johw[ly�lz[pth[lz�[oh[�vul�pu�ä]l�[v�vul� in six people live with a smi (kaufman, 2023). while the percentage of wlvwsl�^p[o�h�:40�pz�zpnupäjhu[s`�zthssly�[ohu�[ovzl�sp]pun�^p[o�v[oly� mental illnesses, new yorkers with a smi are disproportionately visible in the community given the longstanding systemic failures and lack of continuity in care. social determinants for primary stakeholders in addition to the linkage between poverty and housing insecurities, it should also be noted that much of the population in need of urgent psychiatric care already face racial stigma, injustice, and other vwwylzzp]l�z`z[ltpj�mvyjlz��;opz�wvw\sh[pvu�th`�z\ɉly�mvy�`lhyz�^p[ov\[� ilpun�[ylh[lk��huk�[olu�vm[lu�kv�uv[�oh]l�hɉvykhisl�mvssv^�\w�jhyl�vy� access to costly prescriptions. many unhoused patients with a smi also z\ɉly�myvt�jvtvyipkp[plz�z\jo�hz�z\iz[hujl�hi\zl��^opjo�pz�[v�zh`�[oh[� even if medication and therapeutic treatments are to stabilize the mental pssulzz��[olzl�5l^�@vyrlyz�z[pss�mhjl�hɋpj[pun�olhk^pukz��3vunz[hukpun� failures to address oppressive social determinants are why people often end up back in the ed or cpeps mere days after discharge from inpatient care. the lack of funding and resources for the continuum of care including housing—that is not predicated on drug testing, curfews, or a lapse in mental health care—exacerbates the syndemics of homelessness and mental illness. the problem: new york city’s current mayoral stance new york city is facing a crisis as those in power are using people l_wlyplujpun�ovtlslzzulzz��tvyl�zwljpäjhss`�[ovzl�^p[o�h�:40�vy�� now, even a perceived mental illness, as a means to ensure public safety. politicians like adams, a former nypd captain, turn to policing as a means to remove the unhoused from the streets. friedman (2022) hyn\lz�[oh[�wvsp[pjphuz�jvuåh[l�pzz\lz�vm�ovtlslzzulzz�huk�[ol�ullk� for public safety, utilizing law enforcement to unfairly target people lanya snyder 14 | columbia social work review, vol. xxi who are unhoused to ensure public safety. he points to how laws, particularly those in urban areas that wrest the “out of sight, out of mind” mantra, lessen public concerns for safety. there is an exhaustive list of legislation to keep those experiencing homelessness out of sight, including laws against living in public spaces, camping in cities, vagrancy and loitering, begging and panhandling, and sleeping in public. in the policy’s original version, adams claimed people with mental illness were largely responsible for an increase in subway crime, despite data suggesting most crimes were not committed by unhoused or mentally ill new yorkers (fitzsimmons & newman, 2022). the only x\hspäjh[pvu�mvy�yltv]hs��hjjvykpun�[v�[ol�4/09�kpylj[p]l��pz�[oh[�[ol� wlyzvu�pu�x\lz[pvu�jhuuv[�tll[�[olpy�ihzpj�ullkz��h�q\kntlu[�lu[pyls`� subjective and in the hands of those tasked with the person’s removal. critiques and considerations the mhir is an attempt to outstrip laws that already exist for people experiencing a psychiatric emergency in public, through its directive that police and emergency responders simply remove individuals from the streets and transport them to a hospital, whether or not the individual wvzlz�h�khunly�[v�[oltzls]lz�vy�[v�v[olyz��:\wlyäjphss �̀�[opz�ptwsplz� [oh[�hss�wlvwsl�^p[ov\[�wlythulu[�ov\zpun�t\z[�z\ɉly�myvt�hu�\u[ylh[lk� tlu[hs�pssulzz�huk�hyl�]pvslu[�pukp]pk\hsz��0u�hkkp[pvu�[v�[opz�åh^lk� presumption, politicians such as adams cite morality and responsibility to disguise policing as a means of confronting longstanding problems, instead of addressing the root causes of homelessness through substantive policy changes. the new york city civil liberties union (nyclu) has been a vocal critic of mhir and believes this directive violates fundamental legal rights for people living with any mental illness. the national alliance on mental health (nami) has been critical, too, suggesting involuntary detention does not solve the issue of supportive housing for those with any mental health crisis. adams points to court ordered aot as a successful law that should be enforced, yet is misleading regarding how this essential component of a functional new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 15 public mental health system can be implemented and to whom it applies (subway safety plan, 2022). admittedly, the 2019 nys-omh data for all inpatient new york *p[`�wz`joph[ypj�mhjpsp[plz�zov^�[oh[�vul�pu�ä]l�������wh[plu[z�^lyl� readmitted within 30 days, and nearly one in three (33%) were ylhktp[[lk�^p[opu� ��kh`z��([�ä]l�jp[`�ovzwp[hsz��[ol� ��kh`�wz`joph[ypj� ylhktpzzpvu�yh[lz�^lyl�zpnupäjhu[s`�opnoly��yhunpun�myvt�����[v� 64%. similar rates exist for those presenting to eds departments for psychiatric symptoms soon after inpatient discharge. on the surface, p[�pz�lhz`�mvy�wvsp[pjphuz�[v�wvpu[�[ol�äunly�h[�olhs[ojhyl�z`z[ltz�� when in actuality the data points to a system that relies on short-term [ylh[tlu[�vm�wz`joph[ypj�z`tw[vtz�yh[oly�[ohu�hklx\h[ls`�hkkylzzpun� long-term supportive care and social determinants for people with a smi (nortz, 2021). there is no formal healthcare policy, much less detailed plans or proposed guidance for actual treatment in the mhir other than a psychiatric evaluation. this policy does not acknowledge, let alone propose, solutions that largely contribute to why unhoused people do not have access to healthcare. and for those who do receive zvtl�puwh[plu[�[ylh[tlu[�[oyv\no�ovzwp[hspah[pvu��[olyl�hyl�puhklx\h[l� resources for the post-discharge continuum of care, which is essential for sustaining remission from chronic illness. opponents of the mayor’s mhir policy say not enough attention is kpylj[lk�[v^hykz�hjjlzzpisl�huk�hɉvykhisl�ov\zpun�huk�olhs[ojhyl��-vy� decades, unhoused new yorkers have been brought to eds by nypd and ems every night. in response to adams’ plan, many psychiatrists say this will not come close to solving the problem of untreated mental illness among those living on society’s margins (goldstein, 2022). /vzwp[hsz�hyl�uv[�h�wshjl�[v�mvyjpis`�[yhuzwvy[�huk�vɋvhk�wlvwsl�zptws`� to remove them from the streets. adams fails to acknowledge the longterm resources needed to address the interconnected medical and housing issues this policy directive purports to solve. when treating someone with a smi there is a disproportionate emphasis on symptom reduction using drug therapies and psychotherapy and not enough lanya snyder 16 | columbia social work review, vol. xxi attention and resources for the continuum of care that is practical and hɉvykhisl��;ol�tlu[hs�olhs[o�jypzpz�jp[lk�i`�wvsp[pjphuz�pz�uv[�z[ypj[s`� medical; the path to healing also involves interventions to address the social determinants. without ongoing follow-up appointments, supportive care, and rehabilitative services including housing, several days or even a few weeks of psychiatric hospitalization do little to break the cycle of chronic homelessness and smi. solution: housing reform the solution to the issue at the core of this crisis is to reform housing policies. social workers join other providers and advocates in lamenting the lack of service integration and the scarcity of resources available for adults who are experiencing comorbidities of homelessness and mental illness (padgett et al., 2006). however, studies have consistently found that only about 25%–30% of unhoused people have a smi (padgett, 2020). in just a handful of days, if a person receives proper nutrition, sleep regulation, social support, and consistent medication, their behavior changes and psychiatric symptoms diminish. during the public announcement for the subway safety plan, adams said, “it is cruel and inhumane to allow unhoused people to live on the subway, and unfair to paying passengers and transit workers who deserve a clean, orderly, and safe environment” (2022, february 18). if the mayor believes this, then the administration should consider redirecting resources toward policies that connect people with community-based systems such as act teams and adopt housing first (hf) policies. new york city relies on an overcrowded shelter system and a [ylh[tlu[�äyz[�hwwyvhjo��^opjo�ylx\pylz�\uov\zlk�pukp]pk\hsz�^p[o�h� :40�[v�jvtwsl[l�h�zlx\lujl�vm�z[lwz�[v�kltvuz[yh[l�ylhkpulzz�mvy� supportive housing. hf is a departure from this linear continuum of care model by providing immediate access to housing in independent hwhy[tlu[z��;opz�l]pklujl�ihzlk�ov\zpun�wvspj`�vɉlyz�[luhu[z�hu� array of services through interdisciplinary act teams consisting of social workers, psychiatrists, vocational trainers, and substance new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 17 hi\zl�jv\uzlsvyz��7hknl[[�l[�hs����������/-�kvlz�uv[�ylx\pyl�wlvwsl� experiencing homelessness to address their behavioral health or substance use before providing housing. the policy is predicated on the philosophy that housing is the foundation on which people can recover. additionally, studies have consistently shown access to housing generally results in cost savings for communities because housed people are less likely to use emergency services such as hospitals, jails, and emergency shelters (national alliance to end homelessness [naeh], 2022). waiting for individuals to receive and comply with medical treatment for a smi, then rewarding them with housing, perpetuates the never-ending cycle of homelessness, institutionalization, and incarceration. in short, it solves neither the housing nor the mental health crisis. during his mhir address, adams said his administration had a moral obligation to help [new yorkers] who “cycle in and out of hospitals and jails, and new yorkers rightly expect our city to help them and help [olt�^l�^pss¹��(khtz���������!�����0yvupjhss �̀�h�tlyl�[oyll�^llrz�ilmvyl� this speech, data was released showing that nearly 2,600 supportive housing apartments were vacant, which is enough to house the estimated 3,400 people living in streets or subways (newman, 2022). according to brand (2022), the city launched a new pilot program in early september of 2022, moving 80 formerly unhoused new yorkers into vacant supportive housing units in single-room occupancy (sro) buildings in brooklyn and manhattan. this pilot program, based on the hf model, enables residents to bypass the bureaucratic hurdles necessary to obtain supportive housing. while a start, the 80 units represent a paltry 3% of nyc’s empty units. furthermore, the program pz�ilpun�y\u�i`�[ol�uvuwyvä[�]vs\u[llyz��yh[oly�[ohu�i`�[ol�jp[ �̀�0m� the adams administration truly wanted to solve the issue of housing and provide compassionate care for those in need, it might consider adopting the evidence-based hf policies citywide in the other 97% of reportedly empty apartments. lanya snyder 18 | columbia social work review, vol. xxi conclusion adams’ mhir policy takes a page out of the political playbook that jvuåh[lz�pzz\lz�vm�w\ispj�zhml[`�^p[o�[ovzl�vm�tlu[hs�olhs[o��0m��hz�[ol� 4/09�kpylj[p]l�z[h[lz��[ol�vus`�x\hspäjh[pvu�mvy�yltv]hs�myvt�w\ispj� areas is that a person cannot meet their basic needs, then perhaps a tvyl�jvtwhzzpvuh[l�huk�lɉlj[p]l�^h`�[v�zvs]l�[ol�wyvislt�h[�ohuk� would be to pivot from “mental health” and reform current housing policies that enable individuals to meet these basic needs. policing unhoused new yorkers with a smi and forcibly transporting them to overcrowded healthcare systems in nyc do little to reduce the intersectional risks for this population. without reforming policies that address long-term care, namely social determinants and housing policies, forcibly hospitalizing unhoused new yorkers in need of wz`joph[ypj�[ylh[tlu[�pz�uv[�vus`�pulɉlj[p]l��i\[�wlywl[\h[lz�[opz� cycle. thus, it is reasonable to conclude that adams’ mhir directive is largely symbolic—optics for being tough on crime—while doing little to implement policy that provides actual relief and support to new yorkers who are unhoused and living with a chronic smi. references aclu of new york (nyclu). (2022, november 30). statement on nypd commissioner weakening police discipline. new york civil liberties union (nyclu). retrieved +ljltily� ��������myvt�o[[wz!��^^ �̂u`js\�vyn�lu�wylzz�ylslhzlz�u`js\�th`vy�hkhtzz� expansion-forcible-detentions-and-hospitalizations-mental-illness adams, e. (2022, november 29). mayor eric adams delivers address on mental health *ypzpz�pu�5l^�@vyr�*p[`�b:wlljo�h\kpv�yljvykpund��5@*�6ɉjl�vm�[ol�4h`vy��o[[wz!��^^ �̂ u`j�nv]�vɉjl�vm�[ol�th`vy�ul^z��������th`vy�hkhtz�wshu�wyv]pkl�jhyl�pukp]pk\hsz� z\ɉlypun�\u[ylh[lk�zl]lyl�tlu[hs �� (wwlsih\t��7��:����������3h^� �7z`joph[y`!�(zzlzzpun�2lukyh»z�3h^!�-p]l�@lhyz�vm� outpatient commitment in new york. psychiatric services���������� �¶� ���o[[wz!��kvp� vyn���������hwwp�wz������� � )hypzo��9��(���4j.h\s �̀�7��3��� �(yuvsk��;��*����������,tlynluj`�yvvt�jyv^kpun!�h�thyrly� of hospital health. transactions of the american clinical and climatological association, 123, 304–311. new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 19 brand, d. 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(2023, january 25). fatal neglect: homeless new yorkers with serious mental illness keep falling through the cracks despite billions in spending��*yhpu�z�5l^�@vyr� )\zpulzz��9l[ypl]lk�-liy\hy`�����������myvt�o[[wz!��^^ �̂jyhpuzul^`vyr�jvt�olhs[o� jhyl�ovtlslzz�ul^�`vyrlyz�zlypv\z�tlu[hs�pssulzz�rllw�mhsspun�[oyv\no�jyhjrz�klzwp[l 4hy[pu��,��1����������(ɉvykhisl�/v\zpun��/vtlslzzulzz��huk�4lu[hs�/lhs[o!�>oh[�/lhs[o� care policy needs to address. journal of health and human services administration, ���������¶� ��o[[wz!��^^ �̂qz[vy�vyn�z[hisl����� ��� mental health involuntary removals (mhir). (2022). in ;ol�6ɉjphs�>lizp[l�vm�[ol�*p[`�vm� new york��6ɉjl�vm�[ol�4h`vy��9l[ypl]lk�4hyjo����������myvt�o[[wz!��^^ �̂u`j�nv]� hzzl[z�ovtl�kv^usvhkz�wkm�wylzz�ylslhzlz������4lu[hs�/lhs[o�0u]vs\u[hy`�9ltv]hsz� pdf mayor adams releases subway safety plan, says safe subway is prerequisite for nyc’s recovery���������-liy\hy`������;ol�6ɉjphs�>lizp[l�vm�[ol�*p[`�vm�5l^�@vyr��o[[wz!�� ^^ �̂u`j�nv]�vɉjl�vm�[ol�th`vy�ul^z��������th`vy�hkhtz�ylslhzlz�z\i^h`�zhml[`� wshu�zh`z�zhml�z\i^h`�wylylx\pzp[l�ul^�`vyr�jp[`�z �� lanya snyder 20 | columbia social work review, vol. xxi mental illness���u�k����5h[pvuhs�0uz[p[\[l�vm�4lu[hs�/lhs[o��504/���o[[wz!��^^ �̂upto�upo�nv]� olhs[o�z[h[pz[pjz�tlu[hs�pssulzz mueller, b. (2017, august 22). public hospitals treat greater share of mental health patients��;ol�5l^�@vyr�;ptlz��9l[ypl]lk�4hyjo����������myvt�o[[wz!��^^ �̂u`[ptlz� jvt������������u`ylnpvu�ul^�`vyr�tlu[hs�olhs[o�ovzwp[hsz�o[ts national alliance to end homelessness (naeh). (2022, august). housing first fact sheet. washington, dc. new york state senate. (2021, august 6). legislation. legislation, article 9 hospitalization vm�7lyzvuz�>p[o�h�4lu[hs�0ssulzz��9l[ypl]lk�+ljltily����������myvt�o[[wz!��^^ �̂ u`zluh[l�nv]�slnpzsh[pvu�sh^z�4/@�;)( newman, a. (2022, november 4). nearly 2,600 apartments for mentally ill and homeless people sit vacant��;ol�5l^�@vyr�;ptlz��9l[ypl]lk�4hyjo����������myvt�o[[wz!��^^ �̂ u`[ptlz�jvt������������u`ylnpvu�ulhys`������hwhy[tlu[z�mvy�tlu[hss`�pss�huk� homeless-people-sit-vacant.html nortz, s. (2021, march 8). expanding forced commitments to hospital is wrong rx for the homeless and for most people��9l[ypl]lk�4hyjo����������myvt�o[[wz!��^^ �̂ jvhsp[pvumvy[olovtlslzz�vyn�wylzz�l_whukpun�mvyjlk�jvttp[tlu[z�[v�ovzwp[hs�pz� ^yvun�y_�mvy�[ol�ovtlslzz�huk�mvy�tvz[�wlvwsl� 6ɉjl�vm�4lu[hs�/lhs[o��64/���:\ssp]hu��(��4��;��� �:tp[o��;����������0u[lywyl[h[p]l� guidance for the involuntary and custodial transportation of individuals for emergency assessments and for emergency and involuntary inpatient psychiatric admissions. 5@:�64/��9l[ypl]lk�+ljltily����������myvt�o[[wz!��vto�u �̀nv]�vto^li�n\pkhujl� interpretative-guidance-involuntary-emergency-admissions.pdf. 7hknl[[��+��2����������/vtlslzzulzz��ov\zpun�puz[hipsp[`�huk�tlu[hs�olhs[o!�4hrpun�[ol� connections. bjpsych bulletin���������� �¶�����o[[wz!��kvp�vyn������ ��iqi������� padgett, d. k., gulcur, l., & tsemberis, s. (2006). housing first services for people who are homeless with co-occurring serious mental illness and substance abuse. research on social work practice�����������¶����o[[wz!��kvp� vyn������������ ���������� � 7h[hrp��.��,���*hywpulssv��:��,���9��5��7o��+��� �6ɉjl�vm�4lu[hs�/lhs[o����������2lukyh»z� 3h^!�-puhs�9lwvy[�vu�[ol�:[h[\z�vm�(zzpz[lk�6\[wh[plu[�;ylh[tlu[��in new york state 6ɉjl�vm�4lu[hs�/lhs[o��6ɉjl�vm�[ol�4h`vy��9l[ypl]lk�+ljltily����������myvt�o[[wz!�� t �̀vto�u �̀nv]�huhs`[pjz9lz��äslz�hv[�(6;-puhs�����wkm rascoe, a., & lewis, c. (2022, december 4). a new policy in new york city makes it easier for homeless people to be forcibly hospitalized. weekend edition npr wnyc. retrieved +ljltily�����������myvt�o[[wz!��^^ �̂uwy�vyn�����������������������h�ul^�wvspj`� in-new-york-city-makes-it-easier-for-homeless-people-to-be-forcibly new york’s directive for mental health involuntary removals columbia social work review, vol. xxi | 21 rodríguez-roldán, v. m. (2020). the racially disparate impacts of coercive outpatient 4lu[hs�/lhs[o�;ylh[tlu[!�;ol�*hzl�vm�(zzpz[lk�6\[wh[plu[�;ylh[tlu[�pu�5l^�@vyr�:[h[l�� drexel l. rev., 13, 945. rudenstine, s., mcneal, k., schulder, t., ettman, c. k., hernandez, m., gvozdieva, k., & .hslh��:����������+lwylzzpvu�huk�hu_pl[`�k\ypun�[ol�*6=0+ɫ� �whukltpj�pu�hu�\yihu�� low income public university sample. journal of traumatic stress�����������¶����o[[wz!�� kvp�vyn���������q[z������ smith, t. e., abraham, m., bolotnikova, n. v., donahue, s. a., essock, s. m., olfson, m., shao, w. s., wall, m. m., & radigan, m. (2017). psychiatric inpatient discharge planning practices and attendance at aftercare appointments. psychiatric services, 68(1), 92–95. o[[wz!��kvp�vyn���������hwwp�wz���������� the subway safety plan. (2022). in ;ol�6ɉjphs�>lizp[l�vm�[ol�*p[`�vm�5l^�@vyr��6ɉjl� vm�[ol�4h`vy��9l[ypl]lk�4hyjo����������myvt�o[[wz!��^^ �̂u`j�nv]�hzzl[z�ovtl� kv^usvhkz�wkm�wylzz�ylslhzlz������[ol�z\i^h`�zhml[`�wshu�wkm u.s. department of health and human services (usd-hhs). (2022, january). mental illness��5h[pvuhs�0uz[p[\[l�vm�4lu[hs�/lhs[o��9l[ypl]lk�+ljltily����������myvt�o[[wz!�� ^^ �̂upto�upo�nv]�olhs[o�z[h[pz[pjz�tlu[hs�pssulzz why[f���� <�:��+lwhy[tlu[�vm�1\z[pjl��+61��b6ɉjl�vm�1\z[pjl�7yvnyhtz�d���������6j[vily�� ��� 7yvnyht�7yväsl!�(zzpz[lk�6\[wh[plu[�;ylh[tlu[��(6;���5h[pvuhs�0uz[p[\[l�vm�1\z[pjl� *yptl�:vs\[pvuz��9l[ypl]lk�4hyjo����������myvt�o[[wz!��jyptlzvs\[pvuz�vqw�nv]� yh[lkwyvnyhtz���� lv lanya snyder columbia social work review, vol. xix | 45 44 | columbia social work review, vol. xix formal childcare has been in crisis since its inception. attempts at regulation and uniformity have been inadequate and culturally insensitive. seen as a women’s issue, it is rarely at the forefront of policy. the topic has recently gripped the national stage due to the ramifications of the covid-19 pandemic on the childcare industry and its effect on the middle class. while white families who struggle for childcare are currently receiving more attention, black women and other women of color have been unsupported by the industry. the inadequacy of childcare in the united states upholds racism and sexism. the intersectionality of gender, race, and socioeconomic status plays a large part in the inequitable experiences for black and brown children and childcare workers in the united states. the lack of progress in this arena has stifled generations of children, given that research shows quality early childhood education is an optimal vehicle for upward mobility and is correlated with more stable and prosperous adulthoods. mind the gap: addressing childcare inequalities for children and caregivers juliana pinto mckeen she/her mind the gap: addressing childcare inequalities for children and caregivers formal childcare in the united states has been in crisis since its inception. maternal employment is heavily moralized, affecting the way that childcare is prioritized. policies delineate clear lines between groups regarding which mothers should and should not work, with black mothers and other mothers of color being denied the same benefits and protections as white mothers. black mothers have been working in the united states since they were enslaved (dow, 2014). after black americans were freed, black mothers continued to work outside the home, often raising white children. because they were working and could not rear their own children, they leaned on community care for their children. examples of such community care providers include black caregivers, housekeepers, wet nurses, and caretakers across history. while widow’s pensions, a product of the progressive era, were instated to enable white mothers to stay home and care for their children, black mothers were denied access to these funds and this policy with the justification that they had been working and therefore “should not be encouraged to stay at home to rear their children” (michel, 2011). black women had to work because black people in america made less money for their labor than white people, a disparity that continues today. while white families could generally live off of the income from one adult, black families were forced to make ends meet with multiple employed adults. as bell hooks writes, “[b]lack women in the u.s. have always worked outside the home … that work gave meager financial compensation and often interfered with or prevented effective parenting” (hooks, 2015, p. 133). additionally, black families were denied the generational wealth owed to them because of slavery and institutional racism. this racism is clear in instances where black mothers were widowed and not afforded the same benefits under federal policy as white women. for generations, black families relied on community care, or fictive kin care, for their children. examples of such care include older and younger generations within the same family taking care of children, as juliana pinto mckeen columbia social work review, vol. xix | 47 46 | columbia social work review, vol. xix well as neighbors and friends, or mothers taking children to work, while workers take turns watching the children or everyone keeps an eye on them while labor continues. fictive kin care was a form of mutual aid and a “normative response to limited economic opportunity” (millercribbs & farber, 2008, p. 45). prior to childcare becoming regulated, and continuing to the present day, fictive kin care was often the only available option for black families, families of color, and other low-income groups who relied on the financial support of maternal employment. since middleand low-income white women joined the formal workforce, the discussion around the state’s role in childcare has grown. the industry has been in crisis because the united states has not definitively decided whether or not white mothers should work outside the home. a long debate regarding the employment of white mothers, who are often portrayed as selfish if they do work (michel, 2011), continues today and reflects the undervaluing of childcare in our society. black mothers and other mothers of color continue to experience financial and familial ramifications of generations of racist policies as politicians and the court of public opinion deliberate. while all parents and guardians are affected by the current state of childcare, this paper centers the experiences of mothers, especially black mothers and other mothers of color, who are most impacted by lack of access to childcare. the compounding forms of inequality experienced by women of color are pivotal to consider and mitigate. by centering the needs and experiences of black women and their children, the united states has an opportunity to create impactful childcare policies that benefit all. history of childcare in the united states as michel (2011) explains, childcare in the united states has seen several iterations since the progressive era, 1897-1920. as womens’ reforms gained traction, the nation began to discuss childcare. the first nurseries in the country were created by philanthropists and were privately funded through donations. the united states children’s bureau was created in 1912 and advocated for mothers’ pensions, which kept single mothers at home, solidifying the gender roles of the time. the mind the gap: addressing childcare inequalities for children and caregivers purpose of these pensions was to enable widows and divorced mothers to “raise their children properly by staying at home” (abramovitz, 2017, p. 140). the concept of traditional motherhood was seen as patriotic, sometimes compared to the sacrifice of soldiers. black mothers were denied access to these pensions due to institutional racism and continued to work outside the home. as dow (2014) states, “[a]lthough these policies generally only reduced, rather than eliminated, a poor woman’s need to work, these pensions underscored that, under ideal circumstances, white mothers should focus on their domestic duties” (p. 38). the concept of pensions was far more popular than the idea of creating childcare programs. ward (2005) states, “political support and motivation for mothers’ pensions was grounded not only on the sexist division of labor but on racial discrimination” (p. 50). the birth rate for native-born white children decreased from the nineteenth to twentieth century, coinciding with a large influx of immigrants to the united states. pensions served the ulterior motive of safeguarding the white middleand upper-class by ensuring that mothers could focus on mothering, thereby increasing the number of native-born white children. in the 1920s, the lack of childcare created hazards for children and families, as parents were forced to take children to unsafe work environments or leave them unattended in order to work. despite documented cases and the rising national problem, the children’s bureau continued to advocate for pensions over childcare because of the patriarchal notion that women needed to be in the home in order to raise healthy children (abramovitz, 2017). experts argued that working mothers were bad for children’s development, but they continued to have no issues with black mothers working outside the home (michel, 2011). the intersectionality (krenshaw, 2015) of being mothers and black women disqualified them from advances in policy. world war ii saw an increase in childcare programs as 6.5 million women entered the workforce (hartmann, 1998). in 1934, the new deal established emergency nursery schools, which were partial day programs that operated free of cost to parents. educators began juliana pinto mckeen columbia social work review, vol. xix | 49 48 | columbia social work review, vol. xix to consider early childhood pedagogy. while programs operated as childcare, they were designed as schools. by focusing on the benefits of pedagogy for childhood development, creators of these programs were able to sidestep the conversation around women’s right to work (michel, 1999). much like today, these programs were underfunded and had high staff turnaround, as educators became frustrated with the lack of resources and low wages (michel, 2011). the lanham act of 1943 approved federal funds for childcare— to this day the only federal law establishing a national childcare program (ertman, 2019). the investment was insufficient: by federal standards, there should have been one childcare slot for every ten female defense workers. however, as michel explains, “when the female labor force peaked at 19 million in 1944, only 3,000 child care centers were operating, with a capacity for 130,000 children—far short of the 2 million places that were theoretically needed” (michel, 2011). additionally, many programs failed to meet quality and safety standards. working mothers continued to be viewed as selfish by both society and the government, even as they supplied vital support to the war effort. after the war, the truman administration cut funding for childcare established under the lanham act, as this funding was explicitly tied to wartime needs. childcare programs were forced to close (ertman, 2019). the lanham act benefitted white mothers and their children, but failed to provide services for black mothers and families. the federal government introduced the childcare tax reduction in 1954, offering working families in the formal work force financial relief of childcare costs via a maximum $600 deduction in federal taxes (buehler, 1998). adults not in the formal work force did not receive this deduction: domestic workers, handy persons, and those performing forms of employment considered on-call or at-will were excluded. additionally, the act did nothing about “the supply, distribution, affordability, and quality of child care” (michel, 2011). the late 1950s saw the emergence of advocacy groups that continued to push for the creation of childcare programs. the inter-city committee for day care of children believed that childcare should be provided by the government instead of private mind the gap: addressing childcare inequalities for children and caregivers charity. they worked with government agencies to make this a reality by gaining federal support for publicly funded childcare (michel, 2011). president kennedy’s president’s commission on the status of women (pcsw), created in 1961, signaled the federal government’s willingness to discuss maternal employment and considered the developmental attributes of childcare, as well as its opportunity to advance integration. as opposed to previous policies that left out black and brown1 americans, the pcsw introduced the possibility of serving a representative “cross section” of the population for the benefit of “democratic social development” (front matter, 1963). subsequent administrations, such as nixon’s, only supported childcare efforts for low-income families, curtailing advocacy efforts while continuing to provide tax incentives to employers and middleand upperclass families. the reagan era saw far reaching cuts to welfare for lowincome families, while expenditures for middleand high-income families nearly doubled. these economic policies forced the childcare system to shift to for-profit models. the 1990s brought large investments in childcare via the child care and development fund (ccdf), but as before, these funds lacked supply and quality. this fund continues to be the main source of government investment in childcare, practically applied by allowing states “significant freedom to coordinate the child care support for low-income families in their state” (vesely & anderson, 2009, p. 41). childcare costs continued to rise, while tax credits did not. the ccdf was created in part as a response to the racialized idea of the “welfare queen” perpetuated by the reagan administration and exacerbated by clinton. these administrations were responsible for upholding this myth and exploiting “popular welfare racist attitudes that were well documented by polling and other data” (doran & roberts, 2002, p. 402). new policies required proof of work in order to receive benefits, but did not take into account the impact of systemic racism in families’ ability to enter the formal 1 this paper recognizes that labels and organizations of race and ethnicity cannot fully capture the myriad of racial and ethnic identities and lived experiences. the paper uses the following labels: black, brown, and white. the term "brown" is used to refer to non-black people of color. juliana pinto mckeen columbia social work review, vol. xix | 51 50 | columbia social work review, vol. xix labor market. politicians did not foresee that the childcare industry would become highly represented by black and brown women who are unable to afford the same care for their children that they provide for others. wages and lack of pay parity between teachers and childcare workers although childcare costs are rising for programs and consequently for families, workers’ wages are not. operating costs have a direct impact on the price point for enrolled families. while regulations and costs vary by state, costs largely include liability insurances, supplies, venue, food costs, and payroll. programs are required to hire the appropriate number of staff based upon the ages of the children served and state-mandated ratios of children to staff. costs also vary depending on geography. programs in urban areas cost more to operate than those in rural areas. on average, childcare workers nationwide make $24,600 per year less than k-12 teachers per year (interlandi, 2018). the issue of pay parity is at the forefront of advocacy in new york state, as childcare workers in department of education funded programs need to meet the same requirements as k-12 teachers but make a fraction of the income. the majority of grade school teachers are white women, while approximately 45% of childcare workers are black, latinx, or asian and are grossly underpaid for their labor (mueller, 2020). activist groups continuously demand more funding for subsidies and pay parity between childcare educators and childcare providers. these two professions are often compared and presented as antagonists, with childcare providers seen as inferior and paid as such. for example, in new york city, both early childhood educators working in programs licensed under article 47 of the health code and grade school teachers require a master’s degree and a state teaching certification. however, early childhood educators in new york city earn on average $20,000 less per year (krien & mason, 2019). this could be in large part because grade school relies on sizable government investment, while early childhood relies upon families to foot the bill. lack of wage theft regulation further compounds the problem. mind the gap: addressing childcare inequalities for children and caregivers childcare is not a profession that you can truly clock out from when your workday is over. if there are children left to watch, you cannot leave them alone. however, a lot of programs do not have overtime pay. while workplace protections do cover childcare workers, nonpayment for labor is commonplace. some programs are so small, serving less than twenty families, that they operate under the radar of regulators. childcare operators find themselves in a difficult position, wanting to pay their employees for their work, but knowing this would increase operating costs, which might cause a decrease in enrollment due to families seeking cheaper alternatives. if a program does not take private pay and only uses subsidies and vouchers, it is not their prerogative to offer overtime pay. calls to action on childcare exist, but have lacked pivotal investments. in 2019, the child care for working families act was introduced, which would provide funds for the child care and development block grant and revise it to “create a tiered and transparent system… [and] assure that copayments are based on a sliding scale,” among other improvements (child care for working families act, 2019). childcare champions do exist, such as senator elizabeth warren and representative rosa delauro, among others. this past july, the childcare is essential act passed in the house but has not made it to the senate floor. the bill called for $50 billion in federal funding for childcare (childcare is essential act, 2020). the biden administration released a plan for childcare as part of their coronavirus rescue package. in this plan, the administration proposes creating a $25 billion stabilization fund to support programs in danger of closing permanently, invest an additional $15 billion in the child care and development block grant program, and increase tax credits to cover the costs of childcare (fox, 2021). these efforts do not address the pay disparity in the industry, but they work to create stability and financial aid for families. the issue of low wages and lack of pay parity coincides with the representation of workers in these industries. the racial makeup of these workers is historically commensurate with the pay they receive, continuing to uphold systems of inequity and oppression. juliana pinto mckeen columbia social work review, vol. xix | 53 52 | columbia social work review, vol. xix childcare and social issues childcare continues to be a pain point for families across the nation, even as an estimated 51% of women were in the workforce in 2016 according to the department of labor (us department of labor, n.d.). large parts of the childcare system are operated as businesses because government funding is finite, leaving families to pay out of pocket and childcare programs to compete for clientele. a report by the economic policy institute found that in 2019, public spending on childcare and early childhood education totaled about $34 billion, while household spending totaled about $42 billion (gould & blair, 2020). the expense creates a push and pull between families and programs; programs constantly attempt to keep costs low for families and are thus unable to pay educators a fair wage. childcare costs vary from state to state and have been rising in recent years. for example, the cost of childcare for an infant in mississippi is $453 per month, versus $1,412 in california (economic policy institute, 2020). across the board, childcare workers are underpaid, with an average annual income of $28,000 per year, and only 15% have access to healthcare through their employers (interlandi, 2018). the issue of fair pay overwhelmingly affects black and brown women, who make up 45% of childcare workers. much like in previous generations, disadvantaged women take care of other people’s children, while their own children are denied this level of care. many childcare workers cannot afford to send their children to the same programs that employ them. generations of inequitable policies have forced two divergent options: upperand middle class families can send their children to early childhood programs designed to kickstart education using a myriad of different pedagogies and modalities, while lower-class families must rely on a social welfare system to help take care of their kids at sometimes questionable standards. this dynamic introduces another point of intersectionality: socioeconomic status. these options for care of very young children often fall along racial lines, with black and brown families most often being forced to utilize the second option. these two modes of care falsely separate care and education, while the two are inextricably linked. early education teachers indisputably care for their mind the gap: addressing childcare inequalities for children and caregivers students, and childcare providers undoubtedly educate the children for whom they provide care. this separation serves to drive a wedge between the professions and upholds pay discrepancies. a solution to disparities in care and education between racial groups and economic classes requires deep investments and culturally relevant pedagogies. the childcare industry is an afterthought in policy and financial decisions. this causes adverse consequences to children, families, and childcare providers. our society has not eradicated this problem because it is perceived as a women’s problem and a problem of low socioeconomic status, thus low priority. at its core, the trivializing of childcare in the united states is a sexist and racist societal policy. history and policies have shown that the nation has decided white mothers should remain at home and black and brown mothers should work (miller, 2019). quality early childhood education affords children great benefits long into adulthood and is a vehicle for upward mobility, but because many white families can afford childcare, policy makers have not been pushed to find a solution. early childhood education allows adults in the family to work outside the home if willing and able. it is a venue to help children develop their social skills, growing bodies, and to begin to acclimate to academic environments. the childcare system was unjustly created with white families in mind and continues to suit only their needs. childcare policies even well-intended broad policy attempts to regulate childcare, an industry that has community-dependent cultural implications, have had negative consequences. generally, the federal government provides minimal funds, via the child care and development block grant, to states to regulate how they see fit. states enact sweeping regulations that dictate which programs and families receive funding. within states, there are vast differences between communities and jurisdictions. broad rules do not have equal effects on all participants of the system, in the same way that one curriculum does not suit the needs of all children. the childcare system today is a result of disjointed funding and regulations that do not put children, families, and caregivers at the center. policies juliana pinto mckeen columbia social work review, vol. xix | 55 54 | columbia social work review, vol. xix have failed because they fragment the system and allocate insufficient funds. on a micro level, there is a significant impact on children and families. supply issues in parts of the country render quality programs hard to come by. regulations meant to assure a standard of care often increase red tape and create barriers to entry for prospective childcare providers. calls for reform and for early education programs that also serve as childcare, like pre-k for all, are good starts. however, because the system is fragmented, they often complicate operations for providers and continuously leave some behind. for example, since new york city implemented the universal pre-k program in 2014 many more children entered early childhood programs. this is beneficial to both the children and their families. pitfalls include the oversight by an additional agency, the department of education, to regulate programs previously only regulated by the department of health. sometimes these agencies have different regulations and both expect providers to meet their regulations, even at the cost of a citation from the other. in practice, this labyrinthine structure means that depending on which agency arrives for an inspection, providers can receive citations and fees for being out of compliance with one agency while abiding by the rules of another. for new york city children younger than four, families can receive subsidies they can use to pay for childcare. effectiveness of subsidies is reliant on state and local regulations. often, programs who accept subsidies are forced to accept less financial recompense for their service and/or be paid much later than the service was provided. programs that accept subsidies may choose to do so to serve their communities, if families require this aid. when the system works at its best, providers can depend on consistent payment from subsidies. subsidy payments require maneuvering bureaucracy and paperwork that not all programs have the bandwidth or knowledge to do. often, subsidies are more beneficial to families than providers (adams & snyder, 2003). on a macro level, there are severe consequences to the wellbeing and social mobility of large swaths of children in our nation. the mind the gap: addressing childcare inequalities for children and caregivers lack of access to quality early childhood education and childcare for all has economic repercussions for children long into adulthood, for parents–most often mothers--and for childcare providers. access to early childhood education affords children wellbeing and economic gains long after they have graduated from these programs. working mothers are good for our country and for mothers themselves. longitudinal studies have found that mothers’ continuous and full time employment is correlated with significantly better mental and physical health at age 40 than mothers who were unemployed, non-continuously employed, or not employed full time (frech & damaske, 2012). as discussed above, childcare workers are underpaid and as such, unable to experience social mobility themselves, continuing the cycle of inequality within their families and communities. additionally, communities often try to create other venues to provide childcare to those in need, such as legally exempt providers or unlicensed childcare groups. these types of programs mimic community care of past generations. low-income communities attempt to circumvent the regulations because compliance is often cost prohibitive to families and providers alike. licensing a program can take months of navigating ever-changing regulations. barriers to entry include the lack of capital funds, mandated education, and social capital. a lack of research exists on this demographic, perhaps in part due to the potential repercussions of operating an unlicensed program. childcare policies aimed at regulating funding and formalizing care impede some caregivers from providing care in legal ways. childcare policies should suit the needs of communities, as opposed to forcing communities to conform to policies that prevent adequate care. anti-racist approach to childcare: rethinking early childhood education quality early childhood care and education are great vehicles of upward mobility. longitudinal studies show that children who attended early childhood education programs were less likely to become teenage parents, more likely to graduate high school, and more likely to enroll in higher education. in some instances, adults who attended one of these juliana pinto mckeen columbia social work review, vol. xix | 57 56 | columbia social work review, vol. xix programs had higher median incomes, were less likely to be on welfare, and were less likely to have been arrested (interlandi, 2018). investments in children’s education, health, and wellbeing are generational investments; the government tends to receive a return on investment with additional capital gains (hendren & sprung-keyser, 2020). as the authors of these studies explain, investments in children have historically yielded the largest marginal value of public funds, meaning that the policies pay for themselves over time and actually produce money. equitable access to childcare would be a wise, anti-racist policy that would greatly impact the nation. an anti-racist approach to solving the issues documented here would be to craft a new system that places the child at the center, values childcare providers and educators, listens to them in the creation of a system, and places a hefty investment in such a system. by redressing past injustices, such as inequalities in access to care and financial aid to black and brown mothers, meeting the needs of children and families of color, supporting the whole family, and serving all children and families in need (minoff et al, 2020), policymakers and advocates can implement antiracist policies. all families and children should have access to childcare and early childhood education and to the myriad of pedagogies to best suit the child. by creating a system that does center children, families would have options. this is important because the solution is a not a cookie cutter curriculum for all childcare programs and looks different depending on the child, the family, and the community. there are beautiful models of what this could look like: afrocentric montessori programs, bilingual reggio emilia programs, and a lakota waldorf school. children have individual needs and learn better using different modalities. programs that make whole families feel welcome are better suited to meet these needs. the system currently in place was created solely with white families in mind. new policies should support efforts to create culturally relevant early childhood programs that are reflective of the communities they serve. with significant and continuous investment, we can pay childcare providers the wages they deserve. childcare should be accessible to everyone and should be seen as the mind the gap: addressing childcare inequalities for children and caregivers public good it really is (university of california, berkeley, 2018). after all, childcare allows parents to stimulate our economy and safeguards our future: children. childcare and the covid-19 pandemic the pandemic has gravely exacerbated the pitfalls of the childcare system. in july 2020, the national association for the education of young children (naeyc) (2020) completed a survey and estimated that 40% of all early childhood education programs would close their doors before the end of the year without government help (beer, 2020). the cares act earmarked a pittance for the struggling industry and made the disbursement at each state’s discretion. although it has never been fully funded by the public, the childcare industry costs around $10 billion per month. the cares act earmarked $3.5 billion total for childcare (bedrick & daily, 2020). the pandemic has decimated the childcare industry, with programs closing daily. a december 2020 survey by naeyc found that approximately 42% of programs that have permanently closed due to the pandemic were minority-owned (naeyc, 2020). in new york state, providers continue to wait for the remaining cares act funding that has yet to be disbursed while programs suffer. this existential crisis has pushed industry, legislators, and activists alike to action. the child care is essential act was a good start. this bill would have created a child care stabilization fund with $50 billion to offset the repercussions of the covid-19 pandemic on the industry (child care is essential act, 2020). seeing a bill of that magnitude pass in the house was a momentous event. senator elizabeth warren advocated for childcare on the campaign trail during her bid for the presidency and again during the 2020 democratic national convention. childcare has entered the national conversation. in response to the effects of the covid-19 pandemic, an exponential number of articles have been written by journalists, economists, pedagogues, and sociologists. topics include the effects of isolation on children, the effects of a lack of childcare on women in the workforce, and the disproportionate harm to an entire sector of the economy. folks have seen and felt what is to be juliana pinto mckeen columbia social work review, vol. xix | 59 58 | columbia social work review, vol. xix without childcare. as families sheltered in their homes for a year, there was a refreshed awareness of the importance of childcare. now, we must use the catalyst that was 2020 to create lasting changes for childcare. a covid-19 stimulus package signed into law in march 2021 included a large benefit to children nationwide: a large expansion to the existing child tax credit, which will benefit 93% of children nationwide (deparle, 2021). this new law includes provisions that will cut the child poverty rate in half and have an even bigger impact for black children (barbaro, 2021). families will receive monthly checks of up to $300 per child, regardless of the number of children in the family without negating other benefits families receive. the benefit diminishes only when families earn over $150,000 annually. there are no specifications for the ways families can choose to spend these funds. this type of welfare is revolutionary in the united states after the devastating effects of the “welfare queen” myth and the institution of aid contingent on parental employment. the child tax credit is directly tied to the child, as opposed to the guardian, whose actions will have no bearing on the funds. the stimulus package institutes this expansion for one year, after which its extension will require congressional action. conclusion childcare is a heavily moralized but vital service in the united states, and the inadequacy of childcare is intrinsically tied to race and class. formal and regulated childcare began in the public realm, was created for white families, and was funded by the government to support war efforts. a lack of necessary funding to childcare programs pushed the industry to privatization, which widened the inequities between white families and all other families. attempts to publicly fund childcare and early childhood education were seen as opportunities to integrate in the 1960s, but failed to meet this goal. in 2021, inequalities still exist in care between black and brown families and white families. the covid-19 pandemic has widened this gap and concurrently proven the worth of the industry. the march 2021 expansion of the child tax credit is a viable option for combating childhood poverty and simultaneously stabilizing childcare. the nation has an opportunity to reimagine a system that mind the gap: addressing childcare inequalities for children and caregivers serves our present and our future. failure to capitalize on this opportunity will further metastasize the generations-long impacts of inequality. the united states can ill-afford to continue to ignore the fact that early childhood education and childcare should serve and be accessible to all families and children. references abramovitz, m. 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(2020, july 15). 40% of u.s. child care centers say they’ll close permanently without public assistance. forbes. https://www.forbes.com/sites/ tommybeer/2020/07/14/40-of-us-child-care-centers-say-theyll-close-permanentlywithout-public-assistance/?sh=240eef8e6ad6 buehler, s. j. (1998). child care tax credits, the child tax credit, and the taxpayer relief act of 1997: congress’ missed opportunity to provide parents needed relief from the astronomical costs of child care. hastings women’s law journal, 9(2), 189-218. child care for working families act, h.r.1364, 116th cong. (2019). (u.s.). https:// www.congress.gov/bill/116th-congress/house-bill/1364/text child care is essential act, h.r.7027, 116th cong. (2020). (u.s.). https://www.congress. gov/bill/116th-congress/house-bill/7027 deparle, j. 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(2005). the white welfare state: the racialization of u.s. welfare policy. ann arbor: university of michigan press. doi:10.3998/mpub.22210 juliana pinto mckeen juliana pinto mckeen (she/her) is a masters of science in social work candidate at columbia school of social work in advanced generalist practice and programming track concentrating in contemporary social issues. juliana holds a bachelor of science in psychology and a minor in african american, puerto rican and latino studies from hunter college. prior to matriculating at columbia she co-founded and directed a small early childhood education program. juliana currently works as a social work intern at the legal aid society’s new york immigrant family unity project. she serves on the waldorf early childhood association of north america’s inclusion, diversity, equity, and access committee and is a founding member and the administrator for the brooklyn coalition of early childhood programs. originally from bogotá, colombia, juliana now lives in brooklyn, new york. columbia social work review, vol. xix | 23 digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china chenxi yang 24 | columbia social work review, vol. xxi digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china abstract for the past decade, the pace of china’s digital and technological development has been rapidly increasing. while this growth creates economic opportunities, it has negative impacts for chinese women who are marginalized at the intersections of gender, class, and geographic location. this paper adopts an intersectional feminist lens to examine how chinese women experience digital exclusion and gender oppression in the digital era. to do so, it discusses (1) existing [ljouvsvnplz�[oh[�ylålj[�huk�wlywl[\h[l�nlukly�z[lylv[`wlz�[oyv\no� gendered technology design, (2) digital spaces and media censorship that disenfranchise women, and (3) ai surveillance and unfair labor practices that oppress women. this paper calls for social work practices in digital feminism at the micro, tlaav��huk�thjyv�sl]lsz��zwljpäjhss`�pu�wyvtv[pun�nlukly�lx\hsp[`�pu� training and design, leading feminist initiatives, and promoting digital accessibility and data protection. keywords: digital feminism, feminism, digital age, gender, social work, intersectionality columbia social work review, vol. xxi | 25 chenxi yang as new technologies, digital innovations, online platforms, and technology companies emerge in china, women face increasing challenges and exclusions, such as the digital divide, barriers to access, underrepresentation in tech-related älskz��[ljouvsvn`�luhislk�]pvslujl��huk�wyp]hj`�jvujlyuz��<5,:*6�l[� al., 2022). given that china is ranked 102 out of 146 countries in gender pulx\hsp[`��>vysk�,jvuvtpj�-vy\t���������zvjphs�^vyrlyz�^ov�hk]vjh[l� for social and gender justice must take action to advocate for women in china who are excluded and oppressed in the digital age. this entails rethinking technologies and digital spaces and understanding patriarchy and other forces of oppression exacerbated by the digital age. this paper applies an intersectional feminist lens to examine how women in china experience digital exclusion and social oppression in the digital era and proposes social work practice interventions. legal [olvypz[�2ptilysl�*yluzoh^�äyz[�jvpulk�[ol�[lyt�¸pu[lyzlj[pvuhsp[ �̀¹� which explores discrimination based on race, gender, and other markers of identity. an intersectional framework acknowledges that people experience varying degrees of marginalization due to their multiple intersecting identities (bowleg, 2021). ;opz�whwly�^pss�\zl�u\tlyv\z�ylmlylujlz�[v�[ljoupjhs�kläup[pvuz��-pyz[�� digital exclusion describes a lack of access to the information and jvtt\upjh[pvu�[ljouvsvn`�ylx\pylk�mvy�m\ss�why[pjpwh[pvu�pu�zvjpl[`� (sanders, 2020), and it also refers to being marginalized by the design of technologies. second, feminism��hz�kläulk�i`�+»0nuhapv�huk�2slpu��pz�h� term for “the diverse and wide-ranging projects that name and challenge sexism and other forces of oppression, as well as those which seek [v�jylh[l�tvyl�q\z[��lx\p[hisl��huk�sp]hisl�m\[\ylz¹��������w������;opyk�� oppression includes “systematic mistreatment of certain groups of wlvwsl�i`�v[oly�nyv\wz¹�[oh[�vjj\yz�iljh\zl�vm�hu�\ulx\hs�kpz[ypi\[pvu� of power wherein one group controls the 26 | columbia social work review, vol. xxi institutions of “law, education, and culture, and uses its power to systematically exclude other groups” (d’ignazio & klein, 2020, p. 8). ;ol�äyz[�why[�vm�[opz�whwly�^pss�klzjypil�[ol�^h`z�pu�^opjo�[ljouvsvn`� kl]lsvwtlu[�pu�*opuh�ohz�ohk�ulnh[p]l�lɉlj[z�vu�*opulzl�^vtlu�� pujs\kpun�h�kpzj\zzpvu�vu�ov^�[ljouvsvnplz�ylålj[��wlywl[\h[l��huk� create gender oppression. the second part of the paper advocates for digital feminism, which means applying feminism in the digital context to combat patriarchy and other forms of oppression. this part also delineates how to lead feminist actions in digital technologies huk�z[yp]l�mvy�nlukly�lx\hsp[`�huk�zvjphs�pujs\zpvu�huk�v\[spulz�^h`z� in which social workers can help to empower women and challenge technological oppression. how do women experience gender oppression and digital exclusion? gender biases in new technologies are likely the result of the maledominated technology design industry in china (unesco et al., 2019). ;ol�iphzlz�ylålj[lk�pu�[olzl�[ljouvsvnplz�ohyt�^vtlu�i`�wlywl[\h[pun� gender norms. as one example, a proliferation of voice assistants (vas) designed by chinese technology companies such as alibaba, baidu, and xiaomi have dominated asian markets (kinsella, 2019). va speakers are designed for spoken interactions with users and mimic natural human speech on a day-to-day basis. baidu and xiaomi’s vas, which are projected as female both in name and sound of voice, interact with users in a cooperative and submissive manner (unesco et al., 2019). the feminization of vas is designed to cater to the needs of consumers who want to “be the bosses of it” and are therefore more likely to “opt for a female interface” (hempel, 2015, para. 9). vas further perpetuate discriminatory gender norms by sending a signal that women are “obliging, docile and eager-to-please helpers” and are “available at the touch of a button or with a blunt voice command like ‘hey’ or ‘ok’” (unesco et al., 2019, p. 106-107). this reinforces the cultural norm that women are tolerant of poor treatment and should be placed in a subordinated service position. digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 27 online sexual harassment and media censorship disenfranchising women in addition to technologies that perpetuate undesirable gender norms, online sexual harassment and media censorship greatly harm women. according to a 2017 survey with 1,277 chinese college student respondents, about 33.2% experienced some form of online sexual harassment, such as sexualized messages or non-consensual pornographic images; among these sexual harassment survivors, about ������pklu[pälk�hz�^vtlu��zov^pun�ov^�[ol�kpnp[hs�hnl�pujylhzlz�[ol� gendered risk of being sexually harassed (ye et al., 2018). additionally, the circulation of inappropriate content, such as ai-generated “deepfakes,” has been used to threaten, blackmail, and abuse women, in addition to harming their careers (lucas, 2022). numerous sellers on online platforms like baidu have developed e-commerce chains [oh[�vɉly�wlyzvuhspalk�kllwmhrlz�i`�z^hwwpun�[ol�mhjlz�vm�mlthsl� jlsliyp[plz�vy�wyp]h[l�jp]psphuz�pu�wvyuvnyhwopj�tv]plz�h[�hɉvykhisl� prices (chen, 2019). ninety-six percent of deepfake videos in the survey contained non-consensual pornographic images, and one hundred percent of these videos were of women (ajder et al., 2019). remote employment and digital platforms for coworker interactions have also increased incidents of sexual harassment toward women (unesco et al., 2022). in a survey titled sexual harassment experienced by female journalists��5$������������vm�[ol�^vtlu�z\y]l`lk� experienced gender-based harassment online, and 18.2% experienced p[�tvyl�[ohu�ä]l�[ptlz�pu�[ol�yltv[l�^vyrwshjl��4h�������� ai makes women vulnerable in the workplace the use of ai in the workplace contributes to a culture that does not consider workers’ personal data as separate from their professional sp]lz��(kkp[pvuhss �̀�p[�z[yh[pälz�ltwsv`llz�huk�ltwsv`lyz�hz�[ol�sh[[ly� group uses ai to track workplace permanence and make decisions about wages, promotions, and dismissals (bales & stone, 2020). these chenxi yang 28 | columbia social work review, vol. xxi employer-employee power dynamics further marginalize workers, and women in particular are the most vulnerable. although the civil code of the people's republic of china�ylx\pylz�ltwsv`lyz�[v�ptwsltlu[� informed consent of the collection and processing of employees’ personal data, workers hardly reject unfair labor practices for fear of retaliation (tang, 2021). retaliation from employers, which includes demotion or even termination from current work, further marginalizes vulnerable employees. in these situations, women may have the most to lose by challenging their employers. as previously mentioned, chinese women workers earn lower wages, receive less educational training, and are less likely to be promoted than men (world economic forum, 2022). this means women bear the devastating risks of retaliation more heavily and are more likely to accept unfair labor practices, including risks of personal data invasion. as a result of ai, women workers are especially vulnerable to [ol�lɉlj[z�vm�z[yh[päjh[pvu� how do social workers advocate for digital feminism? although digital technologies can increase an individual’s independence wvsp[pjhss �̀�zvjphss �̀�huk�äuhujphss �̀�[opz�jhu�vus`�ohwwlu�^olu�[ol`� are able to use technology autonomously (unesco et al., 2019). unfortunately, technologies, media, digital devices, and innovations in the digital age, which are rooted in an oppressive social structure, widen the power divide between men and women, government and citizens, urban people and rural people, and employers and employees. as previously stated, women who are marginalized at the intersections of gender, class, and geographic location are the most vulnerable in the digital age. they are negatively impacted by stereotypical gender norms coded into technologies, online sexual harassment and media censorship, the urban-rural digital divide, and ai surveillance. in these conditions, digital development reinforces patriarchal norms and perpetuates power asymmetry. digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 29 according to the code of ethics for social workers in china, social workers accept responsibility for advancing social justice and protecting human rights (zhu & wen, 2006). thus, social workers are encouraged to think from an intersectional feminist perspective in order [v�hkkylzz�[ol�yvv[�jh\zlz�vm�pzz\lz�pu�[ol�kpnp[hs�lyh!�wh[yphyjo`�huk� other oppressive forces created by culture, government, and society. social work interventions call for schools, corporations, ngos, and policy institutions in china to advocate for women’s representation in all spaces and to develop social welfare programs (fan, 2019; lu & bao, 2022). in the digital age, social workers should stand by women to challenge oppressive power and adopt digital feminist practices. strategies for digital feminism inside and outside digital spaces pujs\kl�jvuk\j[pun�nlukly�lx\hsp[`�[yhpupun��wyvtv[pun�klzpnu�q\z[pjl� in technologies, leading online initiatives, bridging the digital gap, and promoting personal data protection. limitations social workers may face in challenging digital oppression government censorship feminist activists in china have taken the initiative to challenge gender oppression through social media (ma, 2022). for example, since 2018, *opulzl�^vtlu�oh]l�lunhnlk�pu�[ol� 4l;vv�4v]ltlu[��h�ohzo[hn� campaign to challenge sexual violence, patriarchy, rape culture, and male-dominated values (han, 2018; yin & sun, 2021). the narratives of their experiences went viral on social media. in 2018, more than 36,000 vuspul�hy[pjslz�ylsh[lk�[v�[ol� 4l;vv�4v]ltlu[�^lyl�w\ispzolk�vu� chinese social media (ma, 2022). however, chinese authorities silenced the voices of survivors and activists before the movement was able to reach a wider audience. authorities became intolerant of the public outcry, which criticized [olpy�shjr�vm�lɉlj[p]l�ylzwvuzl�[v�zl_\hs�]pvslujl��huk�mlhylk�¸zvjphs� \uylz[¹�vy�[oh[�[ol�w\ispj�^v\sk�x\lz[pvu�[olpy�slnp[pthj �̀�*vuzlx\lu[s �̀� h\[ovyp[plz�yl[hpulk�[pno[�jvu[yvs�v]ly�[ol�åv^�vm�pumvyth[pvu�vu�zvjphs� chenxi yang 30 | columbia social work review, vol. xxi media platforms (ma, 2022) by blocking and removing “metoo” and “sexual assault” -related posts and closing activists’ social media accounts as a way to silence supporters (fileborn & loney-howes, ��� ���(z�h�ylz\s[��z\y]p]vyz�huk�hj[p]pz[z�z\ɉlylk�myvt�h�shjr�vm� institutional and legal support (yin & sun, 2021). the urban-rural digital divide the digital divide between urban and rural china has widened over the years, given that the rural population only represents 28% of chinese internet users (cnnic, 2022). this divide is pronounced for rural chinese women, who are more underprivileged and disenfranchised than urban middle-class women. in the digital age, rural women face increasingly more barriers to accessing information and communications technology due to poor infrastructure in technology, connection costs, pujylhzpun�ljvuvtpj�pulx\hsp[ �̀�kpnp[hs�sp[lyhj`�pzz\lz��uvytz� of perceived female inferiority, and a long history of rural-urban disparity (yang & du, 2021). the digital divide accelerates urban-rural nlukly�pulx\hsp[ �̀ the “gendered digital divide” and digital exclusion, which varies substantially between urban and rural areas, prevent rural women from ilulä[pun�myvt�kpnp[hs�puuv]h[pvuz��@hun� �+\��������w����������*opuh»z� major digital payment services and innovations have supported millions of small businesses and entrepreneurs in china. some examples include ant financial, a lender for small businesses that supports lowpujvtl�lhyulyz��huk�(spwh �̀�^opjo�vɉlyz�h�sv^�ypzr�tvul`�hjjv\u[�[v� provide investment for individuals (oecd, 2018). however, rural women without digital outlets are unable to access online loans and investments to support their businesses. without digital access, rural women will not be able to access these services, and as a result, urban-rural nlukly�pulx\hsp[`�pu�ylzv\yjlz��vwwvy[\up[ �̀�huk�jhwhipsp[`�^pss�jvu[pu\l� to widen. digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 31 gender equality in training and design this section suggests three digital feminist interventions to increase ^vtlu»z�ylwylzlu[h[pvu�pu�:;,4��(0��huk�jvkpun�wyvnyhttpun��^opjo� pujs\kl�����wyv]pkpun�nlukly�lx\hsp[`�[yhpupun�[oh[�hkkylzzlz�nlukly� stereotypes, (2) increasing women employees’ skill sets and readiness mvy�[ol�(0�älsk��huk�����luohujpun�^vtlu»z�yvslz�pu�[ol�[ljouvsvn`�älsk� [oyv\no�yljy\p[tlu[��lx\hs�^hnl��huk�wyvtv[pvu�vwwvy[\up[plz� micro practice interventions gender equality education gender norms suggesting that women are subordinate to men hinder ^vtlu�z�why[pjpwh[pvu�pu�:;,4�älskz��;ol`�slhk�wlvwsl�[v�ilspl]l� [oh[�[ol�:;,4�älsk�vwwvzlz�[olzl�nlukly�yvslz��;hukyh`lu�9hnvvi\y� �.vr\szpun��������huk�wlywl[\h[l�[ol�pklh�[oh[�^vtlu�zov\sk�äuk� secure jobs with regular working hours rather than working in highpu[luzp[`�lu]pyvutlu[z�[oh[�ylx\pyl�hk]hujlk�[ljoupjhs�zrpssz��?\�� 2020). furthermore, chinese higher education hardly provides courses addressing gender norms; these institutions overlook the importance of nlukly�lx\hsp[`�lk\jh[pvu��zpujl�[ol�wvz[�nyhk\h[pvu�ltwsv`tlu[�yh[l� pz�jvuzpklylk�[ol�kl�mhj[v�pukpjh[vy�vm�h�\up]lyzp[`»z�lk\jh[pvuhs�x\hsp[`� and outcome (zhang, 2020). :jovvs�zvjphs�^vyrlyz�t\z[�pu[ly]lul�i`�jylh[pun�nlukly�lx\hsp[`� training and advocating for institutions to include this type of training, ^opjo�^v\sk�[ypjrsl�pu[v�:;,4�älskz��.lukly�lx\hsp[`�[yhpupun�zov\sk�uv[� just be held in urban areas, but also in rural settings, given that gender norms are most detrimental in rural china (li, y., 2021). research has zov^u�[oh[�wyv]pkpun�nlukly�lx\hsp[`�[yhpupun�pz�lɉlj[p]l�pu�johunpun� students’ attitudes toward stem (ikkatai et al., 2021). school social workers should also help school curriculum decision-makers and lk\jh[pvu�klwhy[tlu[z�\uklyz[huk�ov^�nlukly�lx\hsp[`�[yhpupun� can improve female students’ competitiveness and interest in stem wyvmlzzpvuz�huk�[o\z�ptwyv]l�[ol�zjovvsz»�x\hsp[`�vm�lk\jh[pvu�huk� chenxi yang 32 | columbia social work review, vol. xxi wylz[pnl��;ol�w\ywvzl�vm�nlukly�lx\hsp[`�[yhpupun�pz�[v�olsw�z[\klu[z� have a better understanding of gender norms as well as the importance of education and careers for women. additionally, conducting gender lx\hsp[`�[yhpupun�mvy�[lhjolyz�jhu�thrl�[lhjolyz�h^hyl�vm�[olpy�v^u� subconscious biases and prevent them from perpetuating traditional gender stereotypes and sustaining the patriarchy. while stem education can increase students’ readiness and jvtwl[p[p]lulzz�pu�(0�älskz��0rrh[hp�l[�hs����������l_wvz\yl�[v�:;,4� careers can grow interest in pursuing careers involving technology and engineering (blotnicky et al., 2018). therefore, social workers should advocate for increasing stem educational resources in the form of jv\yzl^vyr��[lhjopun�z[hɉ��huk�jhylly�jv\uzlsvyz��;opz�hwwyvhjo�^pss� inspire more women students to challenge patriarchy and increase their competitiveness and interest in entering the technology industry. promoting design justice social workers can disrupt the male-dominated technology market by promoting design justice in technologies. design justice “rethinks design processes, centers people who are normally marginalized by design, and uses collaborative, creative practices to address the deepest challenges our communities face” (design justice network, 2018, para. 2). with a trained background in gender justice, data justice, and social inclusiveness, social workers can participate in software design. desmond u. patton (2019), a professor at columbia university school of social work, calls for bringing social work scholars to the ai table, and explains that ai designers need “community support and buy-in” (para. 5). social work scholars can utilize knowledge learned from social work school, such as understanding a person within a community context and uncovering any biases members may have toward that community (patton, 2019). social workers should also encourage companies to re-examine the gender biases encoded in digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 33 [ljouvsvnplz��;ol`�jv\sk�kv�[opz�[oyv\no�^vyrzovwz�vu�zwljpäj�[vwpjz� such as “gender norms reinforced by technologies” or by promoting accessible, gender-friendly technologies for diverse and inclusive communities. in addition to allowing social workers to participate in design, inviting women to the table is another form of digital feminism for enterprise social workers. voices should be heard not only from female scholars, engineers, and designers, but also from women who come from underprivileged, low-resourced communities. enterprise social workers collaborating with women helps empower and center the voices of women who have been directly impacted by the outcomes of the design process and helps them seek liberation from the oppressive patriarchal system (costanza-chock, 2018). mezzo practice interventions ai training for women 9hwpk�kpnp[hs�kl]lsvwtlu[�ylx\pylz�[oh[�ltwsv`llz�il�lx\pwwlk�^p[o� updated technical skills. therefore, those who do not receive technical [yhpupun�hyl�hk]lyzls`�hɉlj[lk��;olyl�pz�hsylhk`�h�shynl�nlukly�nhw�pu� ai skills training (li, j., 2021). on top of this, technology companies do uv[�wyv]pkl�lx\hs�(0�[yhpupun�mvy�^vtlu��ylz\s[pun�pu�h�nlukly�nhw�pu� promotions, positions, and roles. data from linkedin (2020) suggests [oh[�[ol�(0�zrpssz�wlul[yh[pvu�yh[l�mvy�^vtlu�[v�tlu��^opjo�ylålj[z�[ol� “prevalence of ai skills across occupations,” is about 0.85 to 1.02 in china (zhang et al., 2021, p. 218). a study conducted in manufacturing companies in shanghai, china discovered that the ai skills training per season for men [v�^vtlu�pz�hiv\[������[v�������opnospno[pun�ov^�äytz�pukpjh[l�h�nlukly� wylmlylujl�pu�z[hɉ�[yhpupun��3p��1����������3hjr�vm�[yhpupun�pz�h�ihyyply�mvy� women, as fewer women trained in ai means fewer women are eligible mvy�wyvtv[pvu�pu�[ljo�äytz��;opz�wlywl[\h[lz�thsl�kvtpuh[pvu�vm�[ol� tech industry as women are underrepresented and continue to hold less vital roles (unesco et al., 2022). chenxi yang 34 | columbia social work review, vol. xxi digital feminist practice includes intervening in the male-dominant industry by providing [ol�ylx\pylk�[yhpupun�mvy�^vtlu�thynpuhspalk�pu�[ol�^vyrwshjl�huk� underemployed due to lack of training or formal education. social workers from ngos and npos can seek partnerships with educational institutions that have expertise as one solution. they can provide training in diverse subjects, such as ai, software skills, management, and human resources. they can also assist women in earning wyvmlzzpvuhs�jly[päjh[pvuz�pu�pumvyth[pvu�[ljouvsvn`�huk�thuhnltlu[�� such as system architect, information system project manager, and project management professional��[v�pujylhzl�^vtlu»z�x\hspäjh[pvuz� for vital roles in companies. this training can be provided “after hours” to meet the needs of domestic housewives or women who work during business hours. increase women’s representation in the ai job market due to long-standing gender stereotypes in the male-dominant tech puk\z[y �̀�pujylhzpun�^vtlu»z�(0�zrpssz�jhuuv[�wyvtpzl�nlukly�lx\hs� opypun�v\[jvtlz��;ol�[vw����*opulzl�0u[lyul[�jvtwhuplz»�w\ispj�än\ylz� indicate that their ideal employees are as young, able-bodied males (li, c., 2021). to increase women’s representation in tech companies, social workers need to work in human resources to recruit women for senior roles and advocate for higher working conditions and opportunities for women. social workers can also help to correct gender bias during the hiring process, enhance implementation of anti-discrimination policies in the workplace, and advocate for increasing representation of female employees in areas of employment, leadership, management, and engineering. social workers not only support women in recruitment, but also advocate for better wages, working conditions, and promotion vwwvy[\up[plz�hz�h�^h`�[v�wyvtv[l�nlukly�lx\hsp[`�huk�pujs\zp]lulzz�pu� the workplace. digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 35 feminist activism micro practice interventions 9lnhykslzz�vm�[ol� 4l;vv�4v]ltlu[�ilpun�isvjrlk�vu�zvjphs�tlkph�i`� the government, social workers can still lead strategic digital feminist pup[ph[p]lz�[v�jylh[l�huk�z\z[hpu�h�tvyl�lx\p[hisl�lu]pyvutlu[�[v�luk� gender and power-based violence. they can do this through disrupting algorithms, online advocacy and prevention, and workplace innovation and regulation. disrupting the algorithm social workers are encouraged to come up with innovative ideas that allow more survivors of sexual abuse and activists’ voices to be heard in the digital space. one method is to embolden supporters of the 4l;vv�4v]ltlu[�[v�kpzy\w[�[ol�hsnvyp[ot��4h��������z\nnlz[z�^h`z� to avoid government surveillance tools by rotating the images of certain jluzvylk� 4l;vv�jhzlz�[v�[ypjr�vuspul�wsh[mvytz»�kl[lj[pvu�hsnvyp[otz�� putting censored content on a blockchain, and using open-source repository hosting services, like github. these innovations were helpful in circumventing censorship and thus supporting feminist movements (ma, 2022). online advocacy and prevention social workers should especially reach out to sexual violence survivors who lack access to digital outlets due to media censorship. social workers can support these survivors by creating advocacy projects that challenge forms of patriarchal and institutional oppression. they can also provide online service options such as virtual crisis and mental health counseling, intervention programs, support groups, and legal assistance. additionally, social workers should train survivor advocates and volunteer peer educators to respond to individuals who are experiencing sexual, intimate partner, and gender-based violence. trained advocates chenxi yang 36 | columbia social work review, vol. xxi will then assist survivors by safeguarding their rights and exploring ]hypv\z�vw[pvuz�[v�pklu[pm`�[olpy�\upx\l�ullkz��;olzl�[yhpulk�hk]vjh[lz� can also accompany individuals to report to law enforcement and guide them through the legal process. in addition, social workers can play a role in digital harm reduction. :vjphs�^vyrlyz�huk�[yhpulk�z[hɉ�jhu�ovz[�]py[\hs�zl_\hs�]pvslujl� response prevention programs, such as sexual assault awareness and relationship violence awareness events, prevention-focused training, and education workshops. the purpose of these programs would be to help resist the power of abuse and educate the community about healthy relationships and sexual health in an honest and judgment-free way (columbia health). social workers should also educate women hiv\[�kpɉlylu[�mvytz�vm�zl_\hs�]pvslujl�pu�vykly�[v�olsw�iylhr�[ol�zvjphs� stigma around rape culture. mezzo practice interventions workplace innovation and regulation as previously discussed, increasing remote work exposes women to higher risks of online sexual harassment. this is further exacerbated by the lack of actions and policies against online sexual harassment in chinese companies (ma, 2022). enterprise social workers are needed to develop digital innovations and write policies addressing the new risks of online sexual harassment. enterprise social workers can encourage companies to adopt ai systems that detect and track abusive, harassing language in company documents, emails, chats, texts, and comments. referring to practices from other countries, such as brazil-based think eva, an ai and human interaction combination that was designed to monitor and address harassment, and canada-based botler ai, which utilizes deep learning to provide free and accessible support to survivors, could be helpful for chinese companies in selecting an ai system to combat harassment (das, 2020). enterprise social workers can also encourage companies to digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 37 develop apps such as callisto and allvoice, which allow employees to report harassment (das, 2020). macro practice interventions policies and procedures for grievances enterprise social workers can write new policies and procedures, including reporting and grievance mechanisms, in order to support employees to take appropriate action, reassure survivors, accuse and punish perpetrators, and help prevent future online harassment. digital accessibility and data protection micro practice interventions connecting local communities to digital resources community social workers should connect low-income communities and individuals to local libraries which can expand electronic checkout services and technology learning courses. supporting individuals through technology training will help social workers engage with these populations. gibson et al. (2020) suggest that people will be more willing to use new technologies if they receive some type of formal training. digital literacy workshop and internet safety training for women community social workers should hold digital literacy workshops in community centers to teach women and other vulnerable groups how to navigate digital devices and use social media platforms. in addition, social workers must teach individuals how to protect their privacy and luz\yl�[olpy�zhml[`�iv[o�vuspul�huk�vɋpul��6ul�l_htwsl�vm�[opz�[`wl� of training material is called the empowering internet safety guide for women, produced by vpnmentor, which lists multiple ways to protect vul�z�wyp]hj`�huk�zhml[`�^opsl�uh]pnh[pun�zvjphs�tlkph�wsh[mvytz��vuspul� dating sites, and ride-sharing apps (levavi-eilat, 2018). chenxi yang 38 | columbia social work review, vol. xxi macro practice interventions social work scholars should advocate for high-speed, low-cost internet and accessible technological devices in rural areas for digitally excluded communities. ngos and npos should collaborate with large technology companies to provide discounted technology devices to rural women. 9lzlhyjo�ohz�zov^u�[oh[�0u[lyul[�\zl�ohz�h�zpnupäjhu[�ptwhj[�vu� accessing employment opportunities and reducing poverty in rural china (yang et al., 2021). data protection policy social workers and enterprise social workers should protect workers’ personal data through regulation and education in the labor market. policy social workers and social work scholars should refer to the case of )ȋyi\slzj\�]��9vthuph (2016), a milestone in the pursuit of protection for employees’ privacy, which established that an individual has a “reasonable expectation of privacy.” as another example, the u.s. constitution guarantees workers’ rights to the protection of intimate, private, and family life (article 26) as well as private correspondence (article 28). while employers have the right to monitor how employees complete professional tasks, employers have a responsibility to n\hyhu[ll�[ol�jvuäklu[phsp[`�vm�ltwsv`llz»�wlyzvuhs�kh[h��7lyzvuhs�kh[h� may only be processed “if the person concerned consented to it and it sets out a list of exceptions when consent is not necessary” ()ȋyi\slzj\� v. romania, 2016, para.16). advocates should refer to these countries’ wvspjplz�ylnhykpun�^vyrlyz��wlyzvuhs�kh[h�wyv[lj[pvu�hz�h�n\pkl�[v� promoting inclusive and safe laws in chinese institutions. policy advocacy for data protection meanwhile, enterprise social workers should play an important role in regulating ai usage and data protection in workplaces. enterprise social workers can do this by setting up ethical guidelines for employers who use employees’ social media data, supervising companies’ data digital exclusion, gender oppression, and how social workers can advocate for digital feminism in china columbia social work review, vol. xxi | 39 jvsslj[pvu�wyvjlzz�huk�kpzzltpuh[pvu�lɉvy[z��huk�hɉytpun�^vyrlyz»� reasonable expectations of privacy in the workplace. in addition to regulation, enterprise social workers need to educate both employers and employees about the importance of ethical usage of employees’ data monitoring. employees need to understand the importance of informed consent, the negative impact of personal data being misused or abused, and whether their companies have a legitimate reason to monitor their activities. conclusion women marginalized at the intersections of gender, class, and geographic locations are the most vulnerable to digital exclusion and gender oppression in the digital age. even though social workers face barriers in addressing digital exclusion and gender oppression issues in the patriarchal and political contexts in china, they can still advocate for human rights and digital feminism in creative ways. through promoting nlukly�lx\hsp[`�pu�[yhpupun�huk�klzpnu��slhkpun�mltpupz[�pup[ph[p]lz��huk� promoting digital accessibility and data protection, social workers can hk]vjh[l�mvy�h�tvyl�nlukly�lx\hs�huk�nlukly�pujs\zp]l�zvjpl[`�pu�*opuh� references (qkly��/���7h[ypup��.���*h]hssp��-��� �*\sslu��3������ ���;ol�z[h[l�vm�kllwmhrlz!� landscape, threats, and impact.�+llw[yhjl�3hiz��o[[wz!��ylntlkph�jv�\r���� ������� kllwmhrlfylwvy[�wkm )hslz��9��(�� �:[vul��2��=��>����������;ol�pu]pzpisl�^li�h[�^vyr!�(y[päjphs�pu[lsspnlujl�huk� electronic surveillance in the workplace. berkeley journal of employment & labor law, 41(19), 1. blotnicky, k. a., franz-odendaal, t., french, f., & joy, p. (2018). a study of the jvyylsh[pvu�il[^llu�:;,4�jhylly�ruv^slknl��th[olth[pjz�zlsm�lɉjhj �̀�jhylly� interests, and career activities on the likelihood of pursuing a stem career among middle school students. international journal of stem education, 5(1), 22. o[[wz!��kvp�vyn���������z��� ������������ )v^sln�3����������,]vs]pun�pu[lyzlj[pvuhsp[`�^p[opu�w\ispj�olhs[o!�-yvt�huhs`zpz�[v� action. american journal of public health������������¶ ���o[[wz!��kvp�vyn��������� ajph.2020.306031 chenxi yang 40 | columbia social work review, vol. xxi )ȋyi\slzj\�]��9vthuph����������,\yvwlhu�*v\y[�vm�/\thu�9pno[z��o[[wz!��o\kvj�ljoy�jvl� pu[�lun b���p[ltpk���!b��������� �����dd *olu��3������ ���*opuh�z�kllwmhrl�jlsliyp[`�wvyu�j\s[\yl�z[pyz�klih[l�hiv\[�hy[päjphs� intelligence use. south china morning post��o[[wz!��^^ �̂zjtw�jvt�ul^z�jopuh� zvjpl[`�hy[pjsl���� �� �jopuhz�kllwmhrl�jlsliyp[`�wvyu�j\s[\yl�z[pyz�klih[l�hiv\[ china internet network information center (cnnic). 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(2006). shehui gongzuo shiwu shouce [handbook of social work practice]. social sciences academic press. columbia social work review, vol. xix | 101 disability and self: critical factors in positive adjustment after the onset of disability in emerging adulthood natalie christensen 102 | columbia social work review, vol. xxi disability and self abstract 9lzpspluj �̀�zlsm�lɉjhj �̀�huk�zvjphs�z\wwvy[�hyl�rl`�mhj[vyz�puå\lujpun� adjustment following the onset of chronic disability. the presence or hizlujl�vm�[olzl�mhj[vyz�puå\lujlz�[ol�hɉlj[lk�wlyzvu»z�wlyjlw[pvuz�vm� zlsm��wlyjlw[pvuz�i`�v[olyz��huk�v]lyhss�spml�zh[pzmhj[pvu�huk�jvuäklujl� in their ability to achieve goals. this article assesses data collected from an open-ended interview with a single participant, d, organized i`�[olth[pj�huhs`zpz��0[�äukz�[oh[�+�z�ylzpspluj �̀�zlsm�lɉjhj �̀�huk�zvjphs� z\wwvy[�z`z[lt�zpnupäjhu[s`�puå\lujlk�oly�tpukzl[�huk�h[[p[\kl�[v^hyk� life after being diagnosed with multiple sclerosis (ms). the author l_wsvylz�ov^�[olzl�mhj[vyz�^lyl�puå\lujlk�i`�[ol�tpjyv���tlzv��� and macro-contexts in which d existed, focusing particularly on the context of her relationships with others. the paper concludes with recommendations for future research. columbia social work review, vol. xxi | 103 natalie christensen o ver 1 billion people live with some form of disability and that number is increasing (world health organization, 2021). some reports suggest that 15% of adults ages 60 and older report at least one functional limitation (infurna & wiest, 2016), while an estimated 5% of working americans experience a short-term disability each year (council for disability awareness, 2021). research indicates the life stage in which one develops a disability th`�puå\lujl�[olpy�kl]lsvwtlu[hs�[yhqlj[vy �̀�zpujl�pukp]pk\hsz�mhjl� kpɉlylu[�ylzwvuzpipsp[plz�huk�wypvyp[plz�[oyv\nov\[�[ol�spml�jv\yzl��(z� discussed by lachman (2004), in emerging adulthood, individuals are generally healthy and therefore focused on milestones related to their career and personal life. emerging adulthood is characterized as a time when young adults explore their newfound freedom and solidify their identities (arnett, 2000). developing a physical disability during emerging adulthood disrupts normative developmental trajectories and creates a stark contrast between life experiences gathered as an able-bodied person and life experiences following the onset of disability. ;ol�kl]lsvwtlu[�vm�h�kpzhipsp[`�uv[�vus`�puå\lujlz�ov^�h�wlyzvu�]pl^z� themselves, but also impacts their interactions with others and with society at large. ableism is a tangible experience for many people with disabilities who may experience judgment and marginalization. experiences of ableism can vary depending on the severity of symptoms, the individual’s own attitudes and perceptions, and the visibility of an individual’s disability. people with visible disability symptoms may be more likely to experience overt ableism, as their jvukp[pvuz�hyl�kpɉj\s[�vy�ptwvzzpisl�[v�opkl��*vukp[pvuz�johyhj[lypalk� by recurring-remitting symptomatology, such as multiple sclerosis (ms), hyl�\upx\l�pu�[oh[�[ol`�oh]l�h�zwlj[y\t�vm�z`tw[vt�zl]lyp[ �̀�4:�pz� an incurable neurodegenerative disease in which the body’s immune system attacks the myelin sheath, resulting in diverse and unpredictable manifestations of symptoms. an individual may be able to pass as able-bodied at times, depending on where they happen to be on the spectrum at that time. the choice to disclose or conceal disability 104 | columbia social work review, vol. xxi jhu�oh]l�wyhj[pjhs�huk�wz`jovsvnpjhs�jvuzlx\lujlz�[oh[�puå\lujl�h� person’s daily experiences (nario-redmond, 2020). studies by fong et al. (2006) and dalmonte et al. (2004) found that a “positive outlook, maintenance of social relationships, and an ability to adapt to the environment are critical to maintaining wellbeing” (ploughman et al., 2012, p. 7). the purpose of this study is to kltvuz[yh[l�ov^�h�wlyzvu�z�ylzpspluj �̀�zlsm�lɉjhj �̀�huk�zvjphs�z\wwvy[� z`z[lt�puå\lujl�iv[o�ov^�[ol`�]pl^�[oltzls]lz�huk�[olpy�hipsp[`�[v� thrive and achieve their goals after the onset of a physical disability. literature review ableism (islpzt�pz�kläulk�hz�wylq\kpjl�huk�kpzjyptpuh[pvu�ihzlk�vu�wo`zpjhs� huk�tlu[hs�kpzhipsp[`�jshzzpäjh[pvu��5hypv�9lktvuk���������5hypv� 9lktvuk��������pklu[pälz�hislpzt�hz�hɉlj[p]l�ltv[pvuz�vy�h[[p[\kpuhs� reactions, behavioral actions or practices, and cognitive beliefs and stereotypes that go beyond general negativity. there are nuances and degrees to which these three forms can manifest, and ableism exists at the internal, interpersonal, and institutional levels. internalized ableism incorporates ableist attitudes, beliefs, and practices in the minds of individuals who identify as disabled. this form of internalized oppression has been found to contribute to mental health concerns, including anxiety, depression, isolation, and feelings of inferiority (jóhannsdóttir et al., 2022). resiliency and multiple sclerosis after experiencing stress or trauma, some people adjust positively and establish a stable developmental trajectory; others respond maladaptively (herrman et al., 2011). an individual’s ability to recover myvt�z[ylzz�jhu�hɉlj[�kl]lsvwtlu[�huk�puå\lujl�olhs[o�v\[jvtlz�� 7sv\nothu�l[�hs��kläul�ylzpsplujl�hz�¸[ol�hipsp[`�[v�hjopl]l��yl[hpu��vy� regain a level of physical or emotional health after illness or loss, which is associated with successful coping and ‘bouncing back’ in spite of disability and self columbia social work review, vol. xxi | 105 substantial adversity” (2020, p. 2769). studies on the ability to maintain independence, adaptive lifestyle habits, social participation, and overall olhs[o�ylsh[lk�x\hsp[`�vm�spml�[oyv\no�z`tw[vt�thuhnltlu[�z\nnlz[�[oh[� resilience promotes healthy aging with ms (ploughman et al., 2020). higher psychological resilience is associated with better physical function in people with ms and with fewer neurological symptoms (jakimovksi et al., 2022). studies report a lifetime prevalence of depression in people with ms of up to 50%, and the development of depression is closely linked to coping style, positive adjustment, and resilience factors (ploughman et al., 2020). social connection closely pu[ly[^pulz�^p[o�[ol�jvujlw[�vm�ylzpspluj`!�nylh[ly�zvjphs�z\wwvy[�pz� associated with greater resiliency and more adaptive coping strategies in people with ms (jakimovksi et al., 2022). self-efficacy :lsm�lɉjhj`�ylmlyz�[v�hu�pukp]pk\hs»z�zluzl�vm�jvu[yvs�v]ly�[olpy� achievements and their capacity to respond to challenges and meet nvhsz��+pzhipsp[`�zlsm�lɉjhj`�pz�h�wlyzvu»z�ilsplm�[oh[�[ol`�jhu�thuhnl� their disability to achieve their goals (amtmann et al., 2012). there are zl]lyhs�^h`z�pu�^opjo�zlsm�lɉjhj`�ilsplmz�ptwhj[�iloh]pvy��pujs\kpun� the actions an individual chooses to take, as most opt for behaviors that result in feelings of competency and accomplishment. these beliefs hszv�puå\lujl�wlyzl]lyhujl�huk�wlyjlp]lk�z[ylzz�sl]lsz��(t[thuu�l[�hs��� �������0ukp]pk\hsz�^p[o�opnoly�sl]lsz�vm�zlsm�lɉjhj`�vm[lu�kltvuz[yh[l� sv^ly�sl]lsz�vm�hu_pl[`�huk�klwylzzpvu��^opjo�jhu�wvzp[p]ls`�puå\lujl� their outlook and adjustment to life following a diagnosis (tan-kristanto & kiropoulos, 2015). (kkp[pvuhss �̀�hu�pukp]pk\hs»z�svj\z�vm�jvu[yvs�puå\lujlz�ov^�[ol`�wlyjlp]l� life events. people with an external locus of control attribute events and jvuzlx\lujlz�[v�mvyjlz�v\[zpkl�vm�[oltzls]lz��z\jo�hz�v[olyz»�hj[pvuz�� while those with an internal locus of control feel that their actions are the catalysts for events. a health locus of control (hlc) refers to the perception individuals have of their options for symptom management natalie christensen 106 | columbia social work review, vol. xxi and disease control (wilski et al., 2019). the degree to which an pukp]pk\hs�mllsz�ylzwvuzpisl�mvy�[olpy�kpzhipsp[`�jhu�hɉlj[�ov^�[ol`� choose to cope with the limitations they experience. social support social support is associated with better psychological well-being, reduced stress levels, and improved emotional well-being and perception of happiness and success (king et al., 2000). jensen et al. (2014) found that perceived social support is associated with subjective well-being in people with physical disabilities. the corollary is that there is a strong association between lack of social support and depression. individuals with physical disabilities are at a higher risk of lacking perceived social support, as their mobility may be impaired and, as a result, their ability to engage with a broader community is limited. the type of social support people receive, whether from friends, family, or zpnupäjhu[�v[olyz��ohz�h�kpɉlylu[phs�ptwhj[�vu�klwylzzpvu�sl]lsz"�mypluk� support plays the largest role (jensen et al., 2014). the importance of mypluk�z\wwvy[�pukpjh[lz�[ol�puå\lujl�vm�[ol�iyvhkly�zvjphs�lu]pyvutlu[� on perceptions of self and happiness, demonstrating how essential having a diverse support system is to positive adjustment after an adverse life event. methods d is a 56-year-old heterosexual, cisgender, white female from new york ^ov�kl]lsvwlk�4:�h[�����;opz�z[\k`�hptz�[v�l_wsvyl�[ol�puå\lujl�[oh[� developing a disability in emerging adulthood has on an individual’s perception of themselves and their ability to live a fully-realized life and hjopl]l�[olpy�nvhsz��/h]pun�sp]lk�^p[ov\[�[opz�kpzhipsp[`�mvy�h�zpnupäjhu[� portion of her early life, as well as having experienced periods of yltpzzpvu�huk�åhyl�\wz��+�ohz�\upx\l�puzpno[�pu[v�[ol�zwlj[y\t�vm�4:�� ;opz�ylzlhyjo�mvj\zlz�vu�[ol�puå\lujl�vm�ylzpspluj �̀�zvjphs�z\wwvy[�� huk�zlsm�lɉjhj`�vu�+»z�wlyjlw[pvu�vm�oly�hipsp[plz�ilmvyl�huk�hm[ly�oly� diagnosis and into middle adulthood. disability and self columbia social work review, vol. xxi | 107 the student researcher arranged to interview d in person at her home. the student researcher made it clear before and throughout the interview that the participant could stop at any time and that d was \ukly�uv�vispnh[pvu�[v�huz^ly�x\lz[pvuz�^p[o�^opjo�zol�kpk�uv[�mlls� comfortable. the interview lasted approximately two hours and was recorded and transcribed via the otter app on the researcher’s phone. ;v�wyv[lj[�+»z�jvuäklu[phsp[ �̀�[olzl�yljvykpunz�^lyl�klsl[lk�\wvu� completion of the research paper. she was informed of her rights and signed an informed consent document indicating that she understood [ol�pu[ly]pl^»z�jvu[l_[��ylx\pyltlu[z��huk�v\[jvtl��8\v[lz�myvt�[ol� interview were organized using thematic analysis into topics related to self-perception, perception by others, resiliency, and social support. this study received irb approval prior to publication. results impact of disability on social support numerous protective factors were present in d’s childhood, including a strong sense of community, growing up in a middle-class family, oh]pun�hjjlzz�[v�x\hsp[`�lk\jh[pvu��huk�ilpun�^op[l�pu�h�ovtvnluv\z�� conservative town. concurrently, she experienced certain risk factors, particularly within her family dynamics. d shared that her role in the family, even as a child, was the peacemaker and “perfect child” who thkl�oly�whylu[z�wyv\k�huk�olswlk�[v�tp[pnh[l�[ol�jvuzlx\lujlz�vm� her sibling’s maladaptive behaviors. growing up with a brother who struggled with substance abuse and undiagnosed bipolar disorder, she iljhtl�mhtpsphy�^p[o�[ol�kpzhispun�lɉlj[z�vm�tlu[hs�huk�wo`zpjhs�pssulzz� when discussing her parents’ devastation over her diagnosis, she l_wylzzlk�mllspunz�vm�n\ps[!�¸0�mls[�h^m\s��0»t�uv[�[ol�vul�[oh[�iypunz� heartache into their life.” she experienced a transition from being an independent emerging adult to an emerging adult who relied heavily on the support of others. this sense of guilt carried over to other important relationships in d’s life, including that with her husband. she recalled her fears of becoming dependent on her husband at only 24, thinking at the time, “oh no, he’s going to have to take care of me, like i’m an old natalie christensen 108 | columbia social work review, vol. xxi woman." despite fears of being a burden, d shared that her husband huk�thyyphnl�hkhw[lk�x\pjrs`�[v�spml�hm[ly�oly�kphnuvzpz!�¸4`�o\zihuk� became even more devoted. he looked out for every detail, every detail that would make my life better and easier.” relocating far from home as an emerging adult, d found herself away myvt�mhtps`�huk�myplukz��/v^l]ly��zol�x\pjrs`�lz[hispzolk�jvuulj[pvuz� [oyv\no�oly�o\zihuk»z�^vyr��äukpun�h�jvovy[�vm�`v\un�hk\s[z�pu�zptpshy� situations as transplants to the area. i had just gotten married here in new york and immediately moved v\[�[v�3vz�(unlslz��:v�0�kpku�[�oh]l�h�^ovsl�nyv\w�vm�nvvk�myplukz� vy�hu`�mhtps �̀�)\[�l]ly`vul�myvt�t`�o\zihuk�z�jvtwhu`�^lyl� rpuk�vm�tpzä[z�ilpun�v\[�[olyl��oh]pun�uv�mhtps �̀�:v�^l�ohk�h�nvvk� social support system. she explained that her friends in california became skilled at adapting to her needs to the point that she experienced very few perceived limitations during that period. her disability became integrated into the ihjrkyvw�vm�oly�zvjphs�ylsh[pvuzopwz�^p[ov\[�kläupun�oly��;opz�^hz�thkl� especially clear as she described how her friends responded to her new limitations. ;ol`�yl�q\z[�sprl��vo��^l�ss�jhyy`�`v\�\w�[ol�opss��>lss��`v\�ruv �̂� [olyl�z�uv�ohukpjhwwlk�hjjlzz�olyl��0»ss�[oyv^�`v\�v]ly�t`� zov\skly��:v�`lho��pu�[oh[�ylzwlj[��p[�^hzu�[�h�z[pnth¯;ol`»k�zh`� kvu�[�^vyy �̀�>l�ss�nl[�`v\�[olyl� despite acknowledging the crucial role social support played in d’s perception of her limitations, she was highly resistant to becoming pu]vs]lk�^p[o�[ol�iyvhkly�4:�kpzhipsp[`�jvtt\up[ �̀�:ol�l_wshpulk� that she felt the disability community represented a “pity party” she jv\sk�uv[�hɉvyk�[v�nl[�pu]vs]lk�pu��0u�oly�v^u�^vykz��¸6\[�vm�zpno[�� out of mind.” d expressed that she felt no need to be involved with the community because she could get any information about her condition from her doctor or online, without hearing about other people’s problems. coming from a family that believed highly in taking disability and self columbia social work review, vol. xxi | 109 responsibility for one’s problems without outside help may have helped shape this attitude toward her disability. self-perception and disability +�z�wypvyp[plz�h[�kpɉlylu[�z[hnlz�pu�oly�spml�l]vs]lk�^p[o�ov^�zol� perceived herself and her abilities, roles, and goals. due to the relapsing-remitting nature of her ms, there were periods when she could live life essentially as an abled person and disconnect from her kphnuvzpz��/v^l]ly��k\ypun�z`tw[vt�åhyl�\wz��zol�jv\sk�uv[�pnuvyl�[ol� very real limitations that she was experiencing. she was also frustrated with herself for not having the capacity to do everything she wanted. 0up[phss �̀�huk�mvy�x\p[l�zvtl�[ptl��åhyl�\wz�^lyl�johyhj[lypalk�i`�zwprlz� in internalized ableist thoughts; d felt she was being denied the full experience of emerging adulthood. however, these attitudes would shift as she developed adaptive coping mechanisms and began to accept life as it was. d expressed that as a young adult, she struggled with comparing her experiences with those of her peers. watching her jvovy[�hk]hujl�[olpy�jhyllyz�^hz�kpɉj\s[��lzwljphss`�pu�jvuq\uj[pvu� with her health challenges. when d lost her job due to her symptoms, it zpnupäjhu[s`�ptwhj[lk�oly�zlsm�wlyjlw[pvu!�¸0�^hz�pujylkpis`�kpzhwwvpu[lk� with myself because i worked so hard to get where i was, and i had to leave it because of this stupid disease… i felt badly about myself because of that.” d expressed that she was also forced to confront the reality of her jvukp[pvu�^olu�oly�kvj[vy�wylzlu[lk�hu�\s[pth[\t!�il�h�sh^`ly�vy�il�h� mom. at this point, she had to reassess her goals and aspirations and recognize that she could not do everything. she cited this as another turning point in her acceptance that the real limitations imposed upon her by ms restricted some life paths. however, d took this as an opportunity to reevaluate her priorities and recognize that she valued starting a family over having a career. after the birth of her daughter, d had to again come to terms with her capabilities as she initially struggled to reconcile her new role as a mother with her physical limitations. natalie christensen 110 | columbia social work review, vol. xxi ;olyl�^lyl�[opunz�0�jv\sku�[�kv�^p[o�t`�kh\no[ly�^olu�zol�^hz� a baby. like i could never give her a bath by myself. those kinds of things…got to me, but then i hired a nurse to come and take her for a couple hours here and there. and she did all the things 0�jv\sku�[�kv��huk�0�q\z[�ohk�[v�il�vrh`�^p[o�[oh[�iljh\zl�[olu�0� could do other things… so that made it not so bad. it was just part of how we lived. ;ol�l_wlyplujl�vm�hnpun�hszv�puå\lujlz�h�wlyzvu»z�wlyjlw[pvu�vm� themselves. while d’s chronological age is 56, it is important to consider her biological age when discussing her perception of self. as h�ul\yvklnlulyh[p]l�kpzlhzl��4:�z[yvuns`�hɉlj[z�ipvsvnpjhs�hnpun�huk� physical deterioration, and d expressed concerns over both physical and cognitive decline as she ages and the disease progresses. when asked about considerations when planning for the future, she explained that she is much more practical about her capabilities now. well, now i have to absolutely face that if i stay in the physical condition i am in right now, there are things i won’t be able to do. for example, we are most likely taking the retirement cruise of v\y�spml[ptl�svun�ilmvyl�t`�o\zihuk�pz�yl[pypun¯0[�z�uv[opun�^l� planned on doing, but you know what? i might not be able to do p[�ul_[�`lhy��6y�l]ly��ypno[&�:v�0�t�q\z[�ylhspz[pj�hiv\[�p[� ;olzl�jvujlyuz�oh]l�hɉlj[lk�ov^�+�hwwyvhjolz�spml�huk�wlyjlp]lz� [ol�vwwvy[\up[plz�hɉvyklk�[v�oly��+l]lsvwpun�h�wyhnth[pj�]pl^�vm�oly� situation has been an empowering coping mechanism from the onset of her ms. self-efficacy d’s experiences and decisions since she developed ms are johyhj[lypalk�i`�h�z[yvun�zluzl�vm�zlsm�lɉjhj`�huk�hu�pu[lyuhs�svj\z� vm�jvu[yvs��^opjo�nylh[s`�puå\lujlk�ov^�zol�wlyjlp]lk�olyzlsm�huk�oly� vwwvy[\up[plz��:ol�l_wylzzlk�[oh[�zol�mylx\lu[s`�mhjlk�[ol�kljpzpvu�[v� either give into despair or forge ahead. d shared that after her mother disability and self columbia social work review, vol. xxi | 111 received a cancer diagnosis, her mother essentially decided life was over. from the day they gave her her diagnosis, not a positive word passed her lips. everything was miserable. everything was terrible. everything was awful. even good things that happened…i never wanted that, and i thought, ‘i got through all these years with the disease without becoming bitter.’ at a critical turning point in her life, d adopted a mindset that deliberately looked for the positive aspects of life because she viewed it as a decision within her control, demonstrating her strong sense of zlsm�lɉjhj �̀�;opz�tpukzl[�vm�wlyzl]lyhujl�[oyv\no�hk]lyzp[ �̀�tvklslk� by her father as he managed her brother’s struggles and family responsibilities, came to play a crucial role in how she tackled the challenges she faced as an emerging adult. resiliency and disability ¸0�[opur�[oh[�z�wyvihis`�[ol�ilz[�[opun�`v\�jhu�kv��1\z[�thrl�p[�h�why[�vm� ov^�`v\�sp]l�¹�;opz�zptwsl�z[h[ltlu[�i`�+�ylålj[z�h�wyvmv\uk�z[ylun[o� and resiliency that characterizes her experience with ms from her diagnosis up to the present day. throughout the interview, d made many comments about refusing to let her diagnosis “ruin [her] attitude.” i saw when my mother was so depressed and negative, what it did to the people around her, and i never wanted to do that to t`�mhtps`�huk�myplukz��(uk�[y\[om\ss �̀�p[�z�il[[ly�[v�oh]l�h�nvvk� attitude, and people want to make themselves miserable by seeing only the negative. d’s experience watching her mother battle cancer strengthened her already existing resiliency. some of d’s response may be rooted in the interpersonal role that she took on within her family from a young age, that of the dependable child who rose to meet challenges headvu��>olu�hzrlk�[v�pklu[pm`�oly�z[ylun[oz��+�ylålj[lk�vu�zvtl�vm�[ol� characteristics that informed her perspective on disability and adversity. natalie christensen 112 | columbia social work review, vol. xxi 0�[opur�0�t�]ly`�wyhnth[pj��(uk�0�[opur�[oh[�olswz�h�sv[��@v\�oh]l�[v� be practical. how can i make this better? you try it. does it make it better? maybe, maybe not. but you tried to make it better. and if p[�zptws`�jhu�[�il�kvul��`v\�tv]l�vu� d’s resilience manifests through a strong sense of practicality. her ability to bounce back after setbacks and challenges is integral to who she is, shaped in part by her self-determination. historical changes and social institutions +�hszv�ylålj[lk�vu�[ol�iyvhkly�zvjphs�johunlz�zol�^p[ulzzlk�v]ly�[ol� whz[�[oyll�kljhklz��>olu�+�^hz�äyz[�kphnuvzlk��[olyl�^lyl�sptp[lk� treatment options for ms, and she jumped on the opportunity to be a ¸n\pulh�wpn¹�mvy�l_wlyptlu[hs�tlkpjh[pvuz��>opsl�ylålj[pun�vu�kpzhipsp[`� accommodations and treatments for ms now, compared to when she was diagnosed, d expressed gratitude for the changes over the past decades. i think in the last 20 or 30 years it has been an amazing period of time for disabled people, with the ada rules being enforced and wlvwsl�iljvtpun�tvyl�h^hyl��:v�0�[opur�p[�z�h�il[[ly�^vysk�[ohu� ���`lhyz�hnv�^olu�0�^hz�äyz[�kphnuvzlk¯pm�0�ohk�illu����huk� sp]pun�pu�[opz�rpuk�vm�^vysk��th`il�0�^v\sku�[�oh]l�ohk�[v�thrl� [oh[�kljpzpvu�vm�º0�t�kpzhislk�»�vy�º0�t�uv[�kpzhislk�»�:v�0�[opur�p[�z� really wonderful. it is evident that societal perceptions of people with disabilities have shifted positively since d’s diagnosis, as have the accommodations and vwwvy[\up[plz�hɉvyklk�[v�[olt��;ol�hjjlzzpipsp[`�vm�w\ispj�zwhjlz�^hz� hszv�pklu[pälk�hz�h�^h`�pu�^opjo�[opunz�oh]l�iljvtl�¸l_wvulu[phss`� better” since her diagnosis. the increasing accommodations provided to her through her urban environment and the development of accessibility tools, such as her electronic gait stimulator and her portable wheelchair, have made it easier to maintain her current mobility and allow her more freedom. disability and self columbia social work review, vol. xxi | 113 experiences with ableism the complex interactions between achievement and disability wlyjlw[pvu�hyl�ylålj[lk�pu�+»z�[ov\no[z�vu�ov^�v[olyz»�vwpupvuz�oh]l� puå\lujlk�oly�spml��7lvwsl�q\knl�+�hz�lp[oly�hislk�vy�kpzhislk�ihzlk� on the severity and visibility of her symptoms, meaning that at times she could “pass” as able-bodied even if it took a physical or mental toll to do so. overall, d expressed that she is far less concerned with the perception of others than when she was younger and still coming to terms with her new reality. having to constantly decide between disclosing her condition or maintaining an abled persona characterized much of d’s early period with ms. (m[ly�oly�kphnuvzpz��+�jvu[pu\lk�^vyrpun�h[�h�*hspmvyuph�sh^�äyt��opkpun� her diagnosis from her bosses and coworkers as she recognized there were potential repercussions to disclosing her disability status. d recounted how she was forced to share her diagnosis after deteriorating to the point that her symptoms became visible. when her ms caused oly�[v�ylx\pyl�h�jhul�huk�^lhy�hu�l`lwh[jo��zol�^hz�hzrlk�[v�slh]l� her position. in this instance, the ableist perception of others directly resulted in limited career opportunities. d shared that as she has gotten older and her disease has progressed, zol�ohz�uv[pjlk�hj\[l�kpɉlylujlz�pu�pu[lyhj[pvuz�^p[o�hjx\hpu[hujlz�huk� strangers. d described feeling largely unbothered by the thought of how wlvwsl�zll�oly��klzwp[l�yljvnupapun�[oh[�v[olyz»�wlyjlw[pvuz�puå\lujl� how they interact with her. now, the choice to disclose her condition is no longer an option; symptoms such as a persistent limp provide visual indicators. responses to her disability are often characterized by ableist attitudes, whether they manifest as pity, discomfort, or dismissal. she emphasized how frustrating it can be when someone reduces her to oly�kpzhipsp[ �̀�+�hszv�ylålj[lk�vu�ov^�zol�ylzwvukz�[v�v[oly�wlvwsl»z� reactions now compared to when she was younger. ;ol�`v\unly�tl�wyvihis`�^v\sk�oh]l�jhylk��)\[�uv �̂�0�kvu�[�jhyl� if someone says, ‘oh, what is that,’ and they kind of push it, and natalie christensen 114 | columbia social work review, vol. xxi 0�[lss�[olt��º6o��`v\�ruv �̂�4\s[pwsl�:jslyvzpz�»�0[�ylhss`�kvlzu�[� matter to me what they say. what are you gonna do? rather than shying away from increasing visible indication of impairment over the years, d has embraced the realities of life with ms. not only did she share her gratitude for mobility aids such as her walker and wheelchair, she also described her assortment of “fabulous canes, vul�mvy�l]ly`�v\[ä[�¹�+�ylålj[lk�[oh[�^opsl�zol�jhuuv[�jvu[yvs�^ol[oly� people are aware of her disability, it is up to her to decide how she responds to them. discussion study of the factors that contribute to positive adjustment after the onset of disability is a crucial area of research that is only becoming more relevant, as more and more people are experiencing disability and living with their conditions for many years. as people with ms age, their expectations and priorities evolve with the progression of the disease. according to ploughman et al. (2012), many people diagnosed with ms mlls�[oh[�wo`zpjhs�sptp[h[pvuz�puå\lujl�[olpy�x\hsp[`�vm�spml�slzz�[ohu�[ol`� hɉlj[�zvjphs�huk�ltv[pvuhs�m\uj[pvupun��>l�jhu�jvujs\kl�[oh[�ylzpspluj �̀� zlsm�lɉjhj �̀�huk�zvjphs�z\wwvy[�hss�jvu[ypi\[l�[v�hu�pukp]pk\hs»z�zluzl� of agency and control over their condition and promote positive adjustment. d’s inner strength and belief in her ability to live a fully realized life helped her positively adjust to life with a disability and maintain an hkhw[p]l�kl]lsvwtlu[hs�[yhqlj[vy �̀�0umvytlk�i`�oly�whylu[z��ilsplmz� huk�iloh]pvyz�huk�oly�sv]lk�vulz��z\wwvy[��oly�tpukzl[�johyhj[lypalk� oly�zlsm�wlyjlw[pvu�huk�oly�lɉvy[z�[v�ylhjo�oly�nvhsz��;oyv\nov\[�[ol� interview, d expressed beliefs in resilience and resistance to despair. without this sense of control over how she responded to adversity, d th`�oh]l�mv\uk�p[�tvyl�kpɉj\s[�[v�jvwl�^p[o�oly�kphnuvzpz��why[pj\shys`� in the early stages. as ploughman et al. (2012) proposed, d experienced a transition from denial to acceptance to self-advocacy. this transition was not always linear, as ms’s relapsing-remitting nature caused her disability and self columbia social work review, vol. xxi | 115 to vacillate between denial and acceptance even as she learned to advocate for herself. individuals do not exist within a vacuum, and it is essential to look at the broader social contexts in which they exist. the development of kpzhipsp[`�hɉlj[z�hu�pukp]pk\hs»z�spml�[yhqlj[vy`�[oyv\no�[ol�pu[lyklwluklu[� lives of that individual and the people with whom they have relationships. d’s diagnosis of ms had a profound impact on herself and on dynamics with her parents, husband, and larger social network. d relied on the support of friends and family members while navigating life ^p[o�4:��:vjphs�z\wwvy[�wvzp[p]ls`�puå\lujlz�vul»z�zlslj[pvu�vm�jvwpun� skills, social life, sense of empowerment, and reduction in loneliness (forouzan et al., 2013). the importance of this support is underscored by the numerous references d made throughout the interview to the network of friends and family that emerged to help her manage ms. +»z�l_wlyplujlz�^p[o�4:�^lyl�hszv�puå\lujlk�i`�[ol�pu[lyzlj[pvu�vm�oly� identities and positionality. multidisciplinary research has consistently pukpjh[lk�zpnupäjhu[�olhs[o�kpzwhyp[plz�il[^llu�^op[lz�huk�yhjphs� ethnic minorities, with minority and socioeconomically disadvantaged populations up to three times as likely as other groups to experience disability at older ages (schoeni et al., 2005). however, research has pukpjh[lk�[oh[�thu`�vm�[olzl�kpɉlylujlz�hyl�spurlk�[v�kpzwhyp[plz� in income and education rather than biological distinctions (fullerthomson et al., 2009). as a middle-class woman, d had access to lhys`�jhyl��(s[ov\no�zol�l_wlyplujlk�äuhujphs�jvujlyuz�ylsh[pun�[v� her inability to work, she was at a lower risk of falling into poverty. she was fortunate enough to understand the healthcare options available [v�oly�huk�[v�jvuulj[�^p[o�wpvullyz�pu�[ol�4:�älsk�^ov�mhjpsp[h[lk�oly� involvement with novel treatments as they became available. limitations it must be noted that the data provided through this interview ylwylzlu[�h�zpunsl�wlyzvu�z�l_wlyplujl��;ol�ylz\s[pun�pu[lywyl[h[pvuz� may not accurately describe the experiences of other persons with natalie christensen 116 | columbia social work review, vol. xxi disabilities, even those who also developed ms at a young age. due to the subjective nature of disability, caution must be exercised when attempting to extrapolate one individual’s experience to a broader wvw\sh[pvu��;olyl�pz�h�wvzzpipsp[`�[oh[�[ol�woyhzpun�vm�zvtl�x\lz[pvuz� may have led d in a particular direction, even though open-ended x\lz[pvuz�^lyl�\zlk��(kkp[pvuhss �̀�kh[h�huhs`zpz�^hz�jhyyplk�v\[�i`�h� zpunsl�pukp]pk\hs�^p[ov\[�jvsshivyh[pvu�^p[o�v[olyz��/v^l]ly��l]ly`�lɉvy[� was made to ensure that conclusions regarding the roles of resiliency, zlsm�lɉjhj �̀�huk�zvjphs�z\wwvy[�pu�+»z�l_wlyplujl�vm�kpzhipsp[`�^lyl� rooted in evidence drawn from relevant, peer-reviewed research. future research directions -\[\yl�ylzlhyjo�kpylj[pvuz�th`�l_wsvyl�[ol�puå\lujl�vm�kpɉlylu[�[`wlz� of social support on an individual’s experience, investigating whether [olyl�hyl�kpɉlylu[phs�lɉlj[z�ihzlk�vu�[ol�zv\yjl�vm�z\wwvy[��(kkp[pvuhss �̀� researchers may be interested in studying how positive internal [yhp[z��z\jo�hz�ylzpspluj`�huk�zlsm�lɉjhj �̀�jhu�il�j\s[p]h[lk�[oyv\no� interventions. developing programs that encourage the adoption of health-promoting attitudes and behaviors may allow healthcare wyvmlzzpvuhsz�[v�wyv]pkl�ptwvy[hu[�zjhɉvskpun�mvy�jvwpun�tljohupztz� tv]pun�mvy^hyk��;olzl�pu[ly]lu[pvuz�jv\sk�zpnupäjhu[s`�ptwhj[�ov^� people with ms view themselves, their capabilities, and their life trajectory. references amtmann, d., bamer, a. m., cook, k. f., askew, r. l., noonan, v. k., & brockway, j. a. ��������<up]lyzp[`�vm�>hzopun[vu�zlsm�lɉjhj`�zjhsl!�(�ul^�zlsm�lɉjhj`�zjhsl�mvy�wlvwsl� with disabilities. archives of physical medicine and rehabilitation, 93(10), 1757–1765. o[[wz!��kvp�vyn���������q�hwty������������� (yul[[��1��1����������,tlynpun�hk\s[ovvk!�(�[olvy`�vm�kl]lsvwtlu[�myvt�[ol�sh[l� teens through the twenties. american psychologist����������� ¶�����o[[wz!��kvp� vyn�����������������_�������� �� council for disability awareness. (30 september 2021). disability statistics [fact sheet]. o[[wz!��kpzhipsp[`jhuohwwlu�vyn�kpzhipsp[`�z[h[pz[pj�� disability and self columbia social work review, vol. xxi | 117 +hs4vu[l��1���-push`zvu��4��� �/lsmypjo��*����������0u�[olpy�v^u�^vykz!�*vwpun�wyvjlzzlz� among women aging with multiple sclerosis. occupational therapy in health care, ����������¶�����o[[wz!��kvp�vyn���������q���]��u��f��� fong, t., finlayson, m., & peacock, n. (2006). the social experience of aging with a joyvupj�pssulzz!�7lyzwlj[p]lz�vm�vskly�hk\s[z�^p[o�t\s[pwsl�zjslyvzpz��disability and rehabilitation, 28(11), 695-705. fuller-thomson, e., nuru-jeter, a., minkler, m., & guralnik, j. m. (2009). black—white kpzwhyp[plz�pu�kpzhipsp[`�htvun�vskly�(tlypjhuz!�-\y[oly�\u[hunspun�[ol�yvsl�vm�yhjl�huk� socioeconomic status. journal of aging and health, 21(5), 677-698. herrman, h., stewart, d. e., diaz-granados, n., berger, e. l., jackson, b., & yuen, t. (2011). what is resilience? the canadian journal of psychiatry������������¶�����o[[wz!�� kvp�vyn����������������������������� 0um\yuh��-��1��� �>plz[��4����������;ol�lɉlj[�vm�kpzhipsp[`�vuzl[�hjyvzz�[ol�hk\s[�spml�zwhu�� the journals of gerontology: series b������������¶����o[[wz!��kvp�vyn������ ��nlyvui� gbw055 jakimovski, d., kavak, k. s., longbrake, e. e., levit, e., perrone, c. m., bar-or, a., benedict, r. h. b., riley, c. s., de jager, p. l., venkatesh, s., walker, e. l. s., xia, z., & weinstock-guttman, b. (2022). impact of resilience, social support, and wlyzvuhsp[`�[yhp[z�pu�wh[plu[z�^p[o�ul\yvpuåhtth[vy`�kpzlhzlz�k\ypun�[ol�*6=0+�� � pandemic. multiple sclerosis and related disorders������o[[wz!��kvp�vyn���������q� msard.2022.104235 jóhannsdóttir, á., egilson, s. þ., & haraldsdóttir, f. (2022). implications of internalised ableism for the health and wellbeing of disabled young people. sociology of health & illness������������¶�����o[[wz!��kvp�vyn�������������� ����������� king, g. a., cathers, t., polgar, j. m., mackinnon, e., & havens, l. (2000). success in life for older adolescents with cerebral palsy. qualitative health research, 10(6), 734–749. o[[wz!��kvp�vyn������������ ������� ���� �� lachman, m. e. (2004). development in midlife. annual review of psychology, 55(1), ���¶�����o[[wz!��kvp�vyn���������huu\yl]�wz`jo����� � ����������� nario-redmond, m. r. (2020). ableism: the causes and consequences of disability prejudice. wiley blackwell. ploughman, m., austin, m. w., murdoch, m., kearney, a., godwin, m., & stefanelli, m. ��������;ol�wh[o�[v�zlsm�thuhnltlu[!�(�x\hsp[h[p]l�z[\k`�pu]vs]pun�vskly�wlvwsl�^p[o� multiple sclerosis. physiotherapy canada����������¶����o[[wz!��kvp�vyn���������w[j������ 42 ploughman, m., downer, m. b., pretty, r. w., wallack, e. m., amirkhanian, s., & kirkland, m. c. (2020). the impact of resilience on healthy aging with multiple sclerosis. quality of life research��� ��������� ¶��� ��o[[wz!��kvp�vyn���������z������������������ natalie christensen 118 | columbia social work review, vol. xxi schoeni, r. f., martin, l. g., andreski, p. m., & freedman, v. a. (2005). persistent and nyv^pun�zvjpvljvuvtpj�kpzwhyp[plz�pu�kpzhipsp[`�htvun�[ol�lsklys`!�� ��¶������american journal of public health, 95(11), 2065-2070. ;hu�2ypz[hu[v��:��� �2pyvwv\svz��3��(����������9lzpsplujl��zlsm�lɉjhj �̀�jvwpun�z[`slz�huk� depressive and anxiety symptoms in those newly diagnosed with multiple sclerosis. psychology health and medicine������������¶�����o[[wz!��kvp�vyn�������������������� 14.999810 wilski, m., brola, w., & tomczak, m. (2019). health locus of control and mental health pu�wh[plu[z�^p[o�t\s[pwsl�zjslyvzpz!�4lkph[pun�lɉlj[�vm�jvwpun�z[yh[lnplz��research in nursing & health���������� �¶�����o[[wz!��kvp�vyn���������u\y��� ���� world health organization. (24 november 2021). disability and health�b-hj[�zoll[d��o[[wz!�� ^^ �̂^ov�pu[�ul^z�yvvt�mhj[�zoll[z�kl[hps�kpzhipsp[`�huk�olhs[o�� disability and self columbia social work review, vol. xix | 45 "small victories of survival in a deeply homophobic world": current realities and paths forward for substance use in the lgbtqia+ community kate orchard 46 | columbia social work review, vol. xxi "small victories of survival in a deeply homophobic world" abstract according to the national institute on drug abuse, members of the lgbtqia+ community are disproportionately impacted by problematic substance use (national institute on drug abuse, 2020). despite this well-documented reality, there is still limited funding and access to z\iz[hujl�\zl�[ylh[tlu[�mvy�x\lly�huk�[yhuz�wlvwsl��;opz�l_wsvyh[vy`� paper surveys the literature on the prevalence of substance use in the lgbtqia+ community in the united states (us), highlighting the historical and cultural realities leading to this trend within the context of the minority stress model. the article then outlines a path forward, suggesting the best treatment models for social workers in [ol�älsk��:\nnlz[pvuz�pujs\kl�pu[lnyh[lk�olhs[ojhyl��[yh\th�pumvytlk�� 3.);80(��zwljpäj�[ylh[tlu[�tvklsz��jvnup[p]l�iloh]pvyhs�[olyhw`� focusing on co-occurring post-traumatic stress disorder (ptsd) and substance use disorder, harm reduction, and crisis intervention outside of policing. 2l`^vykz!�z\iz[hujl�\zl�[ylh[tlu[��3.);80(���[yhuz�hɉytpun� healthcare, minority stress model, integrated behavioral healthcare, crisis intervention columbia social work review, vol. xxi | 47 kate orchard in a youtube video by brujas world (2019), a new york-based feminist street collective and streetwear brand, a group of young people of color stand watching a soccer game, passing around a joint. meanwhile, a new york city police department watch tower looms overhead. what starts as an everyday scene of friends hanging out and playing soccer suddenly morphs into a public health announcement. a powerful voice informs viewers that "deaths due to opioid-related overdoses nearly tripled in 2015" (brujas world, 2019, �!�����;ol�]vpjl�jvu[pu\lz!� ;opz�z����jvu[pu\lz�[v�rllw�)shjr�wlvwsl�� poor people, gay people, sick people, to keep us, punished for our ullk ��)y\qhz�>vysk����� ���!�����(�wsh`ly�vu�[ol�zvjjly�älsk�z\kklus`� looks dizzy, and their friends run over to help. the voice reminds ]pl^lyz!� *hss�`v\y�myplukz�pm�`v\�yl�\zpun�p[�hsvul��*hyy`�mlu[hu`s�z[ypwz� with you. give them to your loved ones. help them use them. when `v\�yl�v\[�[olyl��joljr�[v�zll�[oh[�zvtlvul�vu�[ol�z\i^h`�vy�zpkl^hsr� pz�iylh[opun ��)y\qhz�>vysk����� ���!���� according to the national institute on drug abuse (2020), lgbtqia+ pukp]pk\hsz�hyl�tvyl�sprls`�[v�z\ɉly�myvt�z\iz[hujl�\zl�kpzvyklyz� than the cisgender, heterosexual population. this paper explores the prevalence of substance use in the lgbtqia+ community, barriers to treatment, and suggested paths forward through the lens of the minority z[ylzz�tvkls��;ol�thynpuhspah[pvu�vm�x\lly�huk�[yhuz�wvw\sh[pvuz�slhkz� [v�tpuvyp[`�z[ylzz��^opjo�pz�h�[olvyl[pjhs�jvujlw[�kläulk�i`�4l`ly� (2003) as occurring when “stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems,” thus increasing the likelihood of substance use and its potential associated risks (p. 674). this model thus posits that minority stress increases the likelihood of substance use, as well as its potential associated risks. .p]lu�[ol�puz\ɉjplu[�ylzlhyjo�huk�shjr�vm�hwwyvwyph[l�zly]pjlz�mvy� lgbtqia+ individuals struggling with substance use, this paper argues 48 | columbia social work review, vol. xxi that treatment approaches must evolve. suggested approaches include pu[lnyh[lk�iloh]pvyhs�olhs[ojhyl��[yh\th�pumvytlk�3.);80(��zwljpäj� treatment models, strategies that address co-occurring post-traumatic stress disorder (ptsd) and substance use disorder (sud), harm reduction methods, and non-police crisis intervention. approaches with these considerations would better support the needs and well-being of 3.);80(��pukp]pk\hsz�huk�mvz[ly�tvyl�pujs\zp]l�huk�lx\p[hisl�jhyl� methods & limitations research for this article includes meta-analysis and thematic analysis of various sources from databases including columbia university library 6uspul�huk�7\i4lk��;ol�mvssv^pun�zlhyjo�[lytz�^lyl�\zlk!�¸z\iz[hujl� \zl�¹�¸z\iz[hujl�\zl�kpzvykly�¹�¸[yhuz�hɉytpun�olhs[ojhyl�¹�¸pu[lnyh[lk� behavioral healthcare,” “substance use treatment,” “crisis intervention,” “lgbtqia+ people of color,” “harm reduction,” and “minority stress tvkls�¹�:v\yjlz�pujs\kl�ä]l�vizly]h[pvuhs�z[\kplz��mv\y�tl[h�huhs`zlz�� one pilot study, six surveys, one sample study, one systematic review, 2 pieces of advocacy-oriented content, four creative pieces, and one educational training video. publication dates range from 2003 to 2023, with most from 2014 forward. with the intent of surveying the literature, this article analyzes 20 peerreviewed studies with evidence from 13 additional sources, such as prominent lgbtqia+ advocacy centers, healthcare facilities, harm reduction centers, news organizations, and companies. the available sources exhibit noticeable disparities in their demographic and topical foci. among the 20 peer-reviewed articles, 14 discussed substance use, while others explored topics such as minority stress, social services, and the health and mental health issues of these populations. fourteen articles broadly focused on the lgbtqia+ community, three on lgbtqia+ youth, three on the trans population, 2 on the lgb population, and one on the lgbtqia+ homeless population. concerning racial demographics, 9 sources on people of color are referenced, including 3 on the black population and 1 on the latinx population. two sources pertain to substance use among people of "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 49 color more broadly. finally, 8 articles discuss substance use in the lgbtqia+ population, with 1 focusing on youth within that category and 1 solely on trans substance users. limitations include a lack of research on substance use treatment in lgbtqia+ communities (glynn & van den berg, 2017). alarmingly, the national survey on drug use and health does not even include sexual orientation or gender identity in demographic surveys (glynn & van den )lyn����� ���:wljpäjhss �̀�kh[h�hiv\[�[yhuz�pukp]pk\hsz��lzwljphss`�[yhuz� men and trans women of color, is practically nonexistent. in addition, there is a huge gap in research on older adults in the community (crath et al., 2021; vareed & mendoza, 2019). lgbtqia+ history, culture, and realities concerning substance use in a youtube video from an event called "haha harm reduction,” del castillo (2017) describes an experiment in which a rat was locked in a cage and provided a water bowl containing heroin. quickly, the rat became addicted to heroin. when the scientists took the rat out of the cage, they gave it a jungle gym to climb on, lots of space to run, food, and water, and added other rats to the area. some rats tried heroin but remained disinterested in it; none of the rats in the second cage became addicted to heroin. in the words of del castillo, "is the problem the z\iz[hujl��vy�pz�p[�[ol�jhnl& ��+ls�*hz[pssv��������� !����� del castillo (2017) elaborates that for many lgbtqia+ individuals, substance use is not so much about the high, but instead about "the safe haven from a hostile world that would not otherwise embrace the rainbow," a statement that illustrates an experience of the minority z[ylzz�tvkls����!�����+ls�*hz[pssv��������l_wshpuz�[oh[�^olu�olhs[ojhyl� providers are aware of their patients’ gender identity or sexual orientation, the patients are more likely to build rapport with their providers and disclose health information, and the providers, in turn, are tvyl�sprls`�[v�zjyllu�mvy�huk�tvup[vy�olhs[o�pzz\lz��)\[�mvy�thu`�x\lly� and trans people, that is a luxury. while healthcare spaces have not kate orchard 50 | columbia social work review, vol. xxi always provided a safe space for the lgbtqia+ community, bars and clubs have always been a central part of the history of the lgbtqia+ tv]ltlu[��=hyllk� �4lukvah����� ���:v�t\jo�vm�x\lly�j\s[\yl�jlu[lyz� around relationships, connection, community, and chosen family. while bars and clubs can be a liberating source of joy, spaces centered around drugs and alcohol can also come with risks, especially for those with preexisting challenges related to substance use (vareed & mendoza, 2019). an example of this is the use of party and play (pnp), which is a term describing the use of party drugs, such as crystal meth and ecstasy, during sex among men who have sex with men (mallon, 2018). (kkp[pvuhss �̀�4hssvu��������äukz�[oh[�slziphuz�th`�il�why[pj\shys`�h[�ypzr� for developing substance use disorders. on this topic mallon (2018) states, "the role of oppression, being part of a marginalized population, and the importance women place on relationships are integral to understanding addiction among lesbian women" (p. 71). this suggests that lesbians may use substances as a way to relate to one another. therefore, mallon (2018) argues treatment interventions for people who identify as lesbians should focus on relationship development and “expression of the true self, examining both external and internal homophobia, including addressing shame or a lack of self-acceptance" �w�������>opsl�4hssvu�z�l_wshuh[pvu�jvu[hpuz�[punlz�vm�zl_pzt�huk� stereotyping of women, community building and building authentic connections are time-honored pieces of lgbtqia+ culture. unfortunately, in addition to high rates of substance use in the jvtt\up[ �̀�huv[oly�lwpkltpj��/0=�(0+:��ohz�thkl�h�zpnupäjhu[�thyr� on lgbtqia+ history. much work has been done around the trans population, for example, in the context of hiv risk due to the high wyl]hslujl�vm�ypzr�pu�[oh[�nyv\w��mvj\zpun�vu�/0=�(0+:�huk�z\iz[hujl� use within a syndemic framework (glynn & van den berg, 2017). the aids epidemic points not only to another collective trauma but also to co-occurring illnesses with the potential to be treated together. for example, a summary of 12 studies on lgb youth informs readers that "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 51 the most common risk factors for substance use include experiences of victimization, stress, and housing insecurity (goldbach et al., 2014). risk mhj[vyz�z\jo�hz�[olzl��pu�hkkp[pvu�[v�j\s[\yhs�huk�opz[vypjhs�puå\lujlz�vu� lgbtqia+ substance users, point toward the necessity for increased research, improved access to care, and treatment for this group. the prevalence of substance use in lgbtqia+ communities :\y]l`z�myvt�[ol�50+(��������jvuäyt�z\iz[hujl�\zl�pz�hu�pzz\l�[oh[� kpzwyvwvy[pvuh[ls`�ptwhj[z�[ol�x\lly�huk�[yhuz�jvtt\up[plz��/v^l]ly�� the organization elaborates that it is impossible to establish long-term trends on this topic because surveys only recently began to include gender identity and sexuality. much research on the topic orients this z[yh[päjh[pvu�^p[opu�[ol�tpuvyp[`�z[ylzz�tvkls��^opjo�wvz[\sh[lz�[oh[� exposure to discrimination over time by people in marginalized groups leads to higher rates of mental health and substance use challenges (glynn & van den berg, 2017). studies have shown that discrimination and substance use are correlated (glynn & van den berg, 2017). social stigma and discrimination increase the likelihood of harassment and violence. these sources of added stress expose the community to a greater risk of behavioral health vulnerabilities (nida, 2020). to compound matters, a disproportionate number of lgbtqia+ young people go without housing each year in the u.s. lgbtqia+ youth without housing have excessive rates of substance use issues and mental health challenges, higher rates of suicidal behavior and hiv risk, and are more likely to be victims of violence (keuroghlian et al., 2014). similarly, substance use is comparatively high within the trans community. among transgender individuals, there are higher rates of use for alcohol, illicit drugs, and non-medical prescription drugs compared with the cisgender population (glynn & van den berg, 2017). reasons for the higher prevalence of substance use among trans people include the prevalence of intimate partner violence, low-income status, housing instability, ptsd, and participation in sex work (keuroghlian et kate orchard 52 | columbia social work review, vol. xxi al., 2014). in fact, 35% of trans people who have experienced verbal harassment in school, physical or sexual assault, or have been expelled from school report using substances as a coping mechanism for these gender-related traumas (keuroghlian et al., 2014). furthermore, the psychological stress of disparities in healthcare access that trans people experience is another trauma that worsens mental health and increases the likelihood of substance use. this stress also leads to decreased healthcare utilization, which puts the trans population at increased risk under the minority stress model (keuroghlian et al., 2014). further disparities within lgbtqia+ substance use research despite well-documented disparities, research on the mental health outcomes of lgbtqia+ people of color lacks nuance and heterogeneity, with many studies grouping people of color into one singular group or looking only at black and hispanic populations (allen & leslie, 2020; eisenburg et al., 2022). however, people of color in the lgbtqia+ jvtt\up[`�ylx\pyl�k\l�kpspnlujl�huk�u\hujl�ylnhykpun�ylzlhyjo��-vy� example, drazdowski et al.’s (2020) study surveyed 200 lgbtqia+ people of color about their experiences with racism, lgbtqia+ discrimination, and substance use. the study found that being both a person of color and lgbtqia+ puts one at a higher likelihood of using all researched types of "illicit drugs," disaggregating data based on experiences of internalized racism, homophobia, and discrimination based on both identity groups (drazdowski et al., 2020). eisenburg et al.’s (2022) study displays that latinx and black trans youth are the group with the highest prevalence of substance misuse of their age group. the experiences of multiple marginalizations and minority stress, including racism from within the lgbtqia+ community, are likely to impact the prevalence of service utilization and completion (cyrus, 2017). therefore, a more thorough analysis of varied racial groups’ substance use trends, treatment access, and treatment outcomes may help improve health outcomes for those from diverse cultures and experiences. while advocacy groups like the trevor project and "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 53 aforementioned researchers are working toward expanding the research and data on this topic, the absence of earlier research suggests there is still a long way to go (2022 national survey on lgbtq youth mental health, 2022.; “substance use and suicide risk among lgbtq youth,” 2022). access to substance use treatment in the lgbtqia+ community the reasons canvassed above prove the necessity of using traumainformed, community-based, holistic, person-in-environment centered treatment modalities for substance use in lgbtqia+ populations. /v^l]ly��vus`�����vm�z\iz[hujl�\zl�[ylh[tlu[�jlu[lyz�wyv]pkl�x\lly� huk�[yhuz�zwljpäj�wyvnyhttpun��>pssphtz� �-pzo���������7s\z��p[�jhu�il� l]lu�tvyl�kpɉj\s[�v\[zpkl�vm�shynl�tl[yvwvsp[hu�hylhz�z\jo�hz�[ovzl�pu� 5l^�@vyr�huk�*hspmvyuph�[v�äuk�z\jo�wyvnyhtz��:luylpjo���������+lzwp[l� the clear need for these services, culturally competent substance use treatment remains scarce (williams & fish, 2020). +h[h�pz�shjrpun�vu�^ol[oly�hjjlzz�[v�x\lly�huk�[yhuz�zwljpäj�[ylh[tlu[� modalities has improved treatment outcomes compared to programming [oh[�pz�uv[�zwljpäj�mvy�[ol�3.);80(��wvw\sh[pvu��:luylpjo���������6ul� exception is a study which examined the outcomes of participants in an austin, texas-based recovery housing facility for men who have sex with men (mericle et al., 2020). the study displayed that relief from minority z[ylzz�mhj[vyz�^opsl�pu�h�x\lly�zwljpäj�[ylh[tlu[�mhjpsp[`�slk�[v�wvzp[p]l� v\[jvtlz�hjjvykpun�[v�x\hsp[h[p]l�huhs`zpz��z\nnlz[pun�[oh[�ylwspjhz� vm�z\jo�tvklsz�tpno[�il�iluläjphs��(kkp[pvuhs�l]pklujl�zov^z�[oh[� lgbtqia+ individuals have lower completion and abstinence rates on average in substance use treatment than their cisgender, heterosexual wllyz��k\l�[v�h�shjr�vm�hɉyth[pvu�vm�[olpy�zl_\hs�vyplu[h[pvu�pu�[ylh[tlu[� �:luylpjo����� ���=hypv\z�hzwlj[z�vm�[ol�x\lly�huk�[yhuz�l_wlyplujl� complicate the potential for success in traditional substance use-related services. twelve-step programs, such as alcoholics anonymous (aa), have higher success rates among those who identify as part of the group and believe in a higher power (vareed & mendoza, 2019). since kate orchard 54 | columbia social work review, vol. xxi lgbtqia+ people might be more uncomfortable with the religious aspect of 12-step programs due to the fear of certain religious groups displaying homophobia or transphobia (vareed & mendoza, 2019), olhs[ojhyl�wyv]pklyz�zov\sk�lujv\yhnl�zllrpun�v\[�3.);80(��zwljpäj� groups. 0u�h�äyz[�wlyzvu�hjjv\u[��1hpu����� ��klzjypilz�[olpy�l_wlyplujl�pu� h�8\lly�7lvwsl�vm�*vsvy�((�tll[pun�pu�[ol�:hu�-yhujpzjv�)h`�(ylh!� “aa is not the only model that responds to alcoholism. scholars of the history of the alcoholics anonymous program have pointed out that the program often eclipses harm reduction approaches. even as i dream of the abundance of those options,” jain adds, “i believe in that meeting. in the embodied warmth of the church room in oakland, in the happy ihiispun�vm�jopskylu��huk�pu�[ol�jshzwlk�ohukz�vm�x\lly�wlvwsl�jovvzpun� [v�zh]l�lhjo�v[oly¹��whyh�������(�z[\k`�pu�)yp[pzo�*vs\tiph�ylålj[lk� [ol�zlu[ptlu[��äukpun�[oh[�x\lly�huk�[yhuz�tlu�[ov\no[�[oh[�l]lu� existing harm reduction services in their area were usually inaccessible, unsafe, and a space where they experienced judgment from providers (goodyear et al., 2021). many participants feared they would face drug johynlz�k\l�[v�\zpun�zly]pjlz��-vy�l_htwsl��`v\un�x\lly�huk�[yhuz�tlu� sometimes chose not to use drug-checking services, which screen for the presence of risky substances, including fentanyl, because of the concern that the police would stop them (goodyear et al., 2021). since x\lly�huk�[yhuz�wlvwsl�oh]l�ohk�h�svun�opz[vy`�vm�z[y\nnsl�^p[o�wvspjl� harassment, drug criminalization is a massive issue for the lgbtqia+ population, especially for people of color, who are even more at risk of police harassment and violence (goodyear et al., 2021). professionals pu�[ol�älsk�zov\sk�jvuzpkly�[olzl�mhj[z�^olu�z[yp]pun�[v�jylh[l�tvyl� accessible substance-use services. best treatment practices ;ol�mvssv^pun�zlj[pvu�wylzlu[z�h�jhzl�mvy�ä]l�tvklsz�vm�jhyl�[oh[� have been shown to improve treatment utilization and outcomes i`�jvuzpklypun�z[h[pz[pjhs�kpɉlylujlz�pu�z\iz[hujl�\zl�htvun�[ol� lgbtqia+ population, historical and cultural themes of the people, "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 55 and treatment access trends. several models are discussed, including implementing integrated behavioral healthcare to improve access and utilization of care, implementing treatment models tailored for the trans population to address disparities, and providing treatment for co-occurring ptsd and sud. as these disorders are prevalent htvun�x\lly�huk�[yhuz�wlvwsl��hkvw[pun�ohyt�ylk\j[pvu�z[yh[lnplz� that account for cultural realities within the lgbtqia+ community and putting into action means of crisis de-escalation outside of policing z`z[ltz�hyl�ylx\pylk�hj[pvuz� behavioral health integration according to the integration academy, "integrated behavioral health care blends care in one setting for medical conditions and related iloh]pvyhs�olhs[o�mhj[vyz�[oh[�hɉlj[�olhs[o�huk�^lss�ilpun¹��¸>oh[�pz� integrated behavioral health? [wibh?],” n.d., para. 2). when working within an integrated care model, providers must recognize that physical and behavioral health are interrelated and that clinicians working on both sides of the healthcare sphere must work together to treat patients and help them meet their health goals (“wibh?”). this convenience makes it easier for patients to access behavioral healthcare treatment, ^opjo�pz�zpnupäjhu[�np]lu�johsslunlz�^p[o�hjjlzz�pu�[ol�[yhuz�jvtt\up[ �̀� however, most healthcare professionals have not received training to work in that system (“wibh?”). in the highest level of integrated care, there is complete collaboration between providers in a merged practice within the same building (keuroghlian, n.d.). advocating for more training huk�zly]pjlz�pu�3.);80(��zwljpäj�pu[lnyh[lk�iloh]pvyhs�olhs[ojhyl�pz� imperative in order to reduce the disproportionate risk of substance use. fenway health, a boston-based lgbtqia+-focused healthcare center, pz�h�slhkly�pu�[opz�älsk��-lu^h`�/lhs[o�wz`joph[ypz[�+y��2l\yvnosphu��u�k���� explains that fenway’s integrative behavioral healthcare improves the patient experience because its holistic approach reduces stigma around substance use and mental health while simultaneously improving access to treatment and reducing healthcare costs. in addition, keuroghlian hɉytz�[oh[�[ylh[pun�vwpvpk�\zl�huk�wz`joph[ypj�kpzvyklyz�zpt\s[hulv\zs`� has positively impacted outcomes. kate orchard 56 | columbia social work review, vol. xxi trauma-informed, lgbtqia+-specific treatment models the literature broadly suggests a person-in-environment model that is holistic and also trauma-informed is the best course of action. due to the disproportionate rates of substance use and lack of access among trans individuals, this section will focus on treatment models for trans substance users. as a treatment model, behavioral health integration for this population should take place in an environment tailored for the 3.);80(��jvtt\up[`�zwljpäjhss`��2l\yvnosphu��u�k����*spupjphuz�ullk� to be aware of the minority stress model and implement a traumainformed framework that centers on the realities faced by people impacted by minority stress and that highlights the strengths of the 3.);80(��jvtt\up[`��2l\yvnosphu�l[�hs����������.p]lu�[oh[�x\lly�huk� trans individuals are more susceptible to having a background of trauma associated with violence compared to the cisgender, heterosexual population, adopting trauma-informed practices is critical in mitigating the likelihood of substance use relapse (vareed & mendoza, 2019). hence, interventions should celebrate identity. treatment of co-occurring ptsd and substance use: the seeking safety study 3prl�pu�+y��+ls�*hz[pssv�z��������z[vy`�hiv\[�[ol�svuls`�yh[�pu�[ol�jhnl�� fostering relationships and community while acknowledging and mitigating the impacts of the societal "cage" of transphobia and homophobia can be essential factors in preventing substance misuse. :\wwvy[pun�pukp]pk\hsz�ptwhj[lk�i`�tpuvyp[`�z[ylzz�hszv�ylx\pylz�ilpun� [yh\th�pumvytlk��0u[lnyh[lk�[ylh[tlu[�mvy�wlvwsl�^ov�oh]l�z\ɉly� from both substance use disorders and ptsd is impactful in improving both diagnoses (keuroghlian, n.d.). a 2017 study called seeking safety sought to address substance use through a holistic model (empson et al., 2017). seeking safety is a treatment program that uses cognitive behavioral therapy for co-occurring ptsd and substance use disorder. it was tested in 12 sessions with a group of women of trans experience "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 57 ^ov�hyl�/0=�wvzp[p]l��;ol�z[\k`�ptwyv]lk�hss�[oyll�v\[jvtl�tlhz\ylz!� ptsd symptoms, alcoholism, and substance use (empson et al., 2017). this study shows the importance of confronting substance use in the trans community holistically, in line with the concept of integrated behavioral healthcare (empson et al., 2017). harm reduction /hyt�9lk\j[pvu�0u[lyuh[pvuhs�kläulz�ohyt�ylk\j[pvu�hz� wvspjplz�� programmes, and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug laws" (“what is harm reduction?” para. 1). harm reduction is a rightsbased approach that focuses on support without discrimination. this philosophy implies that models which do not prescribe harm-reduction strategies may involve discrimination, which explains why marginalized jvtt\up[plz�oh]l�opz[vypjhss`�slk�lɉvy[z�[v^hyk�ohyt�ylk\j[pvu��9pwsl`� soprano, one of the producers of the brujas world video, does this well with his production of harm reduction kits, which include practical tools for safer sex and drug use as well as more artistic items, such as a z[pjrly�[oh[�zh`z� z\jr�k�����jhyy`�5hyjhu ��2\^hihyh�)shujohyk�������� para. 6). according to soprano, "so much of harm reduction practices and theories came out of sex working communities, people who are chemically dependent, sick and disabled people, and communities of care made up of gay men of color and trans women of color" (kuwabara blanchard, 2020, para. 5). soprano expands by asking, "what if the ^ovsl�rp[�^hz�z\wly�]piyhu[�huk�kpku�[�svvr�zv�jspupjhs&�>oh[�pm�p[�^hz� both a piece of utility and a piece of political propaganda?" (kuwabara blanchard, 2020, para. 5). such creative approaches to harm reduction may reduce stigma and increase service utilization. another group which focuses on harm reduction education is queer appalachia (worlley, n.d.). their website explains that "with the disheartening and exponentially increasing rate of opioid use in (wwhshjoph��[olyl�pz�uvivk`�pu�[ol�ylnpvu�^ov�kvlzu�[�wsh`�h�yvsl � �>vyssl �̀�u�k���whyh������6u�x\llyulzz��[ol`�z[h[l�� (z�pm�ilpun�x\lly�pu� y\yhs�ylnpvuz�pzu�[�pzvsh[pun�huk�vz[yhjpapun�luv\no��[ol�hkkp[pvu�vm�[y`pun� kate orchard 58 | columbia social work review, vol. xxi to recover only further exacerbates these experiences" (worlley, n.d., whyh������-vy�x\lly�jvtt\up[plz��[ol�nv]lyutlu[�ohz�illu�\uz\jjlzzm\s� in providing impactful and accessible services when it comes to substance abuse treatment, especially if the intersection of race is considered (dradzowski et al., 2022). for this reason, communities have turned to harm reduction and mutual aid practices to support their loved ones and community members in a way that does not rely on government support. crisis intervention outside of policing the criminalization of substance use is intrinsically linked to the history of racism in the u.s., with disproportionate negative impacts on people of color. plus, as previously discussed, there is a collective trauma associated with police violence in the lgbtqia+ community. hence, building methods of crisis intervention that exist outside of the policing and carceral systems is another critical next step in supporting lgbtqia+ people who use substances (alang et al., 2017; atlas, 2021; bor et al., 2018; goodyear & knight, 2021). for example, implementation of crisis intervention models outside of policing has proven impactful among the general population in portland, oregon through the crisis intervention helping out on the streets program, which proved successful not only in de-escalating crises, but also reducing costs and leading to only a 1% need to obtain police backup (“cahoots media guide,” 2020). in addition, implementing this model in communities could increase access to care by drawing a direct line between communities and behavioral health providers, instead of a line between substance users and the carceral system. conclusion ;olyl�pz�z[pss�sptp[lk�nv]lyutlu[�m\ukpun�mvy�3.);80(��hɉyth[p]l� substance use-related services and higher substance user rates, helpseeking behaviors, and treatment completion rates (vareed & mendoza, 2019). from literature assessment, historical and cultural factors, and statistics, this paper concludes that while more research and funding "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 59 are certainly needed to support this vital issue, service models must additionally be rethought to best support lgbtqia+ communities. ,ɉlj[p]l�tvklsz�^opjo�th`�ylk\jl�[ol�kl[yptlu[hs�lɉlj[z�vm�tpuvyp[`� stress on those in the lgbtqia+ community who use drugs include pu[lnyh[lk�olhs[ojhyl��[yh\th�pumvytlk��3.);80(��zwljpäj�[ylh[tlu[� models, cognitive behavioral therapy focusing on co-occurring ptsd and substance use disorder, harm reduction, and crisis intervention v\[zpkl�vm�wvspjpun��0u�[ol�^vykz�vm�1hpu����� �!� what might it look like to build models of care for alcohol abuse [oh[��puz[lhk�vm�q\z[�pujs\kpun�x\lly�wlvwsl��ilnpu�^p[o�\z�pu� mind? models that recognize the interconnectedness of social marginalization and alcohol abuse instead of pathologizing alcoholism? that commemorate the small victories of survival in a deeply homophobic world? that to accept and even celebrate that sometimes, you have to hide parts of yourself? (para. 15) references 2022 national survey on lgbtq youth mental health. (n.d.). the trevor project. retrieved -liy\hy`�����������myvt�o[[wz!��^^ �̂[ol[yl]vywyvqlj[�vyn�z\y]l`������ alang, s., mcalpine, d., mccreedy, e., & hardeman, r. (2017). police brutality and black olhs[o!�:l[[pun�[ol�hnlukh�mvy�w\ispj�olhs[o�zjovshyz��american journal of public health, �����������¶�����o[[wz!��kvp�vyn���������(17/���������� � (sslu��:��/��� �3lzspl��3��(����������*vuzpklypun�x\lly�ol[lyvnlulp[`!�+v�pttpnyhu[�3h[pu_� sexual and gender minorities have poorer health outcomes than their u.s.-born counterparts? journal of gay & lesbian social services����������� ¶�����o[[wz!��kvp�vyn� ����������������������������� atlas, s. (2021). the health consequences of policing for people who use drugs [master’s ;olzpz��*vs\tiph�<up]lyzp[`d��*vs\tiph�(jhkltpj�*vttvuz��o[[wz!��kvp�vyn����� ��� k��[��x�uq�� brujas world. (2019, june 9). own goal brujas ss19. youtube. retrieved march 6, ������myvt�o[[wz!��^^ �̂`v\[\il�jvt�^h[jo&]$_,alhz.�:7n� bor, j., venkataramani, a. s., williams, d. r., & tsai, a. c. (2018). police killings and [olpy�zwpssv]ly�lɉlj[z�vu�[ol�tlu[hs�olhs[o�vm�ishjr�(tlypjhuz!�(�wvw\sh[pvu�ihzlk�� x\hzpl_wlyptlu[hs�z[\k �̀�the lancet��� �������������¶�����o[[wz!��kvp�vyn��������� s01406736(18)31130-9 kate orchard 60 | columbia social work review, vol. xxi “cahoots media guide white bird clinic.” white bird clinic��������o[[wz!��^op[lipykjspupj� vyn�^w�jvu[lu[�\wsvhkz���������*(/66;:�4lkph�.\pkl����������wkm�� crath, r., karpman, h., mull, j. j., & francis, l. a. (2021). theorizing black trans z\y]p]hujl�huk�jhyl�pu�[ol�jvu[l_[�vm�*6=0+�� !�(�jspupjhs�jhzl�z[\k �̀�smith college studies in social work�� ��������¶����o[[wz!��kvp�vyn������������������������������ *`y\z��2����������4\s[pwsl�tpuvyp[plz�hz�t\s[pws`�thynpuhspalk!�(wws`pun�[ol�tpuvyp[`� stress theory to lgbtq people of color. journal of gay & lesbian mental health, 21(3), � �¶�����o[[wz!��kvp�vyn���������� �� ��������������� del castillo, r. (2017, july 06). substance use and human connection in the lgbtq jvtt\up[`���+y��+ls�*hz[pssv��@v\[\il��9l[ypl]lk�(wyps�����������myvt�o[[wz!��^^ �̂ `v\[\il�jvt�^h[jo&]$_-_7it�5o,j spz[$33 pukl_$� drazdowski, t. k., perrin, p. b., trujillo, m., sutter, m., benotsch, e. g., & snipes, d. j. ��������:[y\j[\yhs�lx\h[pvu�tvklspun�vm�[ol�lɉlj[z�vm�yhjpzt��3.);8�kpzjyptpuh[pvu��huk� internalized oppression on illicit drug use in lgbtq people of color. drug and alcohol dependence���� �����¶�����o[[wz!��kvp�vyn���������q�ky\nhsjklw����������� eisenberg, m. e., gower, a. l., watson, r. j., rider, g. n., thomas, d., & russell, s. ;����������:\iz[hujl�\zl�iloh]pvyz�htvun�3.);8��`v\[o�vm�jvsvy!�0klu[päjh[pvu�vm� the populations bearing the greatest burden in three large samples. the journal of (kvslzjlu[�/lhs[o!�6ɉjphs�7\ispjh[pvu�vm�[ol�:vjpl[`�mvy�(kvslzjlu[�4lkpjpul, 71(3), ���¶�����o[[wz!��kvp�vyn���������q�qhkvolhs[o������������ empson, s., cuca, y. p., cocohoba, j., & dawson-rose, c. (2017, august 8). seeking safety group therapy for co-occurring substance use disorder and ptsd among [yhuznlukly�^vtlu�sp]pun�^p[o�/0=!�(�wpsv[�z[\k �̀�journal of psychoactive drugs, 49(4), ���������o[[wz!��kvp�vyn������������ ����������������� glynn, t. r., & van den berg, j. j. (2017). a systematic review of interventions to reduce wyvislth[pj�z\iz[hujl�\zl�htvun�[yhuznlukly�pukp]pk\hsz!�(�jhss�[v�hj[pvu��transgender health����������¶� ��o[[wz!��kvp�vyn������� �[yno����������� .vvk`lhy��;��� �2upno[��9���������1hu\hy`������0u�[ol�vwpvpk�jypzpz��`v\un�x\lly�huk�[yhuz� men are navigating risk reduction on their own. the conversation. retrieved february � ��������myvt�o[[wz!��[oljvu]lyzh[pvu�jvt�pu�[ol�vwpvpk�jypzpz�`v\un�x\lly�huk�[yhuz� men-are-navigating-risk-reduction-on-their-own-137679 goldbach, j. t., tanner-smith, e. e., bagwell, m., & dunlap, s. (2014). minority stress and z\iz[hujl�\zl�pu�zl_\hs�tpuvyp[`�hkvslzjlu[z!�(�tl[h�huhs`zpz��prevention science, ����������¶�����o[[wz!��kvp�vyn���������z������������ ��� 1hpu��:������ ��1\s`������4hyjopun�h[�[ol�luk�vm�h�]ly`�svun�whyhkl!�6u�ilpun�h�x\lly� alcoholic. autostraddle��9l[ypl]lk�-liy\hy`�� ��������myvt�o[[wz!��^^ �̂h\[vz[yhkksl� jvt�thyjopun�h[�[ol�luk�vm�h�]ly`�svun�whyhkl�vu�ilpun�h�x\lly�hsjvovspj� "small victories of survival in a deeply homophobic world" columbia social work review, vol. xxi | 61 2l\yvnosphu��(���:o[hzls��+��� �)hzz\r��,����������6\[�vu�[ol�z[yll[!�(�w\ispj�olhs[o�huk� policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. american journal of orthopsychiatry����������������o[[wz!��kvp�vyn���������o�� ����� keuroghlian, a. (n.d.). recorded webinar – addressing opioid use disorders among lgbt people through trauma-informed care and behavioral health integration. national lgbtia+ health education center.�9l[ypl]lk�(wyps� ��������myvt�o[[wz!��^^ �̂ sni[xpholhs[olk\jh[pvu�vyn�jv\yzlz�hkkylzzpun�vwpvpk�\zl�kpzvyklyz�htvun�sni[� wlvwsl�[oyv\no�[yh\th�pumvytlk�jhyl�huk�iloh]pvyhs�olhs[o�pu[lnyh[pvu�slzzvuz� recorded-webinar-addressing-opioid-use-disorders-among-lgbt-people-through[yh\th�pumvytlk�jhyl�huk�iloh]pvyhs�olhs[o�pu[lnyh[pvu� kuwabara blanchard, s. (2020, january 09). the artist making harm reduction gay again. filter��9l[ypl]lk�-liy\hy`�� ��������myvt�o[[wz!��äs[lythn�vyn�x\lly�hy[�ohyt�ylk\j[pvu� ypwsl`�zvwyhuv� mallon, g. p. (2018). social work practice with lesbian, gay, bisexual, and transgender people, (3rd ed.). routledge. mericle, a. a., carrico, a. w., hemberg, j., de guzman, r., & stall, r. (2020). several jvttvu�ivukz!�(kkylzzpun�[ol�ullkz�vm�nh`�huk�ipzl_\hs�tlu�pu�3.);�zwljpäj� recovery housing. journal of homosexuality,��������� �¶�����o[[wz!��kvp�vyn����������� 918369.2018.1555394 meyer, i. h. (2003). prejudice, social stress, and mental health in lesbian, gay, and bisexual wvw\sh[pvuz!�*vujlw[\hs�pzz\lz�huk�ylzlhyjo�l]pklujl��psychological bulletin, 129, ���¶� ���o[[wz!��kvp�vyn��������������� � ��� ������ 5h[pvuhs�0uz[p[\[l�vu�+y\n�(i\zl���������(\n\z[������:\iz[hujl�\zl�huk�:<+z�pu�3.);8�� populations. national institutes of health.�9l[ypl]lk�-liy\hy`�� ��������myvt�o[[wz!�� ^^ �̂ky\nhi\zl�nv]�ky\n�[vwpjz�z\iz[hujl�\zl�z\kz�pu�sni[x�wvw\sh[pvuz qeadan, f., akofua mensah, n., gu, l. y., barbeau, w. a., madden, e. f., porucznik, c. a., & english, k. (2022). factors associated with the availability of tailored programs for lgbt clients in substance use disorder treatment facilities in the u.s. from 2008 to 2018. journal of gay & lesbian social services������������¶�����o[[wz!��kvp�vyn��������� 10538720.2021.1954125 senreich, e. (2009). a comparison of perceptions, reported abstinence, and completion rates of gay, lesbian, bisexual, and heterosexual clients in substance abuse treatment. journal of gay & lesbian mental health������������¶�� ��o[[wz!��kvp� vyn���������� �� ��� �������� senreich, e. (2010). are specialized lgbt program components helpful for gay and bisexual men in substance abuse treatment? substance use & misuse����������� ����¶�� ���o[[wz!��kvp�vyn������� ��������� �������� substance use and suicide risk among lgbtq youth. (2022, january 27). the trevor project��o[[wz!��^^ �̂[ol[yl]vywyvqlj[�vyn�ylzlhyjo�iyplmz�z\iz[hujl�\zl�huk�z\pjpkl� ypzr�htvun�sni[x�`v\[o�qhu����� kate orchard 62 | columbia social work review, vol. xxi =hyllk��)��7��� �4lukvah��5��:������ ���:vjphs�^vyr�wyhj[pjl�^p[o�3.);8�jvtt\up[`!�;ol� intersection of history, health, mental health, and policy factors. journal of lgbt youth, ����������������o[[wz!��kvp�vyn�!��������� ���������� ��������s what is harm reduction? (n.d.). harm reduction international. retrieved february 19, ������myvt�o[[wz!��^^ �̂oyp�nsvihs�^oh[�pz�ohyt�ylk\j[pvu what is integrated behavioral health? (n.d.). agency for healthcare research and quality. 9l[ypl]lk�(wyps�����������myvt�o[[wz!��pu[lnyh[pvuhjhklt �̀hoyx�nv]�hiv\[�pu[lnyh[lk� behavioral-health >pssphtz��5��+��� �-pzo��1��5����������;ol�h]hpshipsp[`�vm�3.);�zwljpäj�tlu[hs�olhs[o�huk� substance abuse treatment in the united states. health services research, 55(6), ��¶ ����o[[wz!��kvp�vyn����������������������� worlley, g. (n.d.). harm reduction tips for the lgbtq+ community. queer appalachia. 9l[ypl]lk�-liy\hy`�� ��������myvt�o[[wz!��^^ �̂x\llyhwwhshjoph�jvt�ohyt�ylk\j[pvu "small victories of survival in a deeply homophobic world" columbia social work review, vol. xix | 121 where were the social workers? a historical overview of the social work profession’s complicity in the family policing system jasmine wali 122 | columbia social work review, vol. xxi where were the social workers? abstract in recent years, segments of the social work profession have highlighted the ways that social workers are complicit with carceral systems, including the foster care system. following the advocacy of impacted families and communities, social workers have increasingly called for the re-examination of standard social work practices such as mandated reporting. this paper seeks to strengthen the historical understanding of the social work profession’s complicity in the creation of the modern family policing system, commonly known as the child welfare system. in particular, this paper explores the impacts of the anti-communist movements on social work advocacy and practice during crucial periods of racial and economic reckoning, with an emphasis on the profession’s complicity with the 1960s-era criminalization of the black family structure. columbia social work review, vol. xxi | 123 jasmine wali u uklyz[hukpun�[ol�jvuå\lujl�vm�zvjphs�^vyr»z�z[hujlz�vu�jopsk� well-being, racial dynamics, poverty, and crime in the 1960s can strengthen the future of social work. the family policing system, commonly known as the child welfare system, disproportionately impacts black families. the social work profession played an important role in perpetuating anti-black beliefs about black families that contributed to the construction of the modern family policing system. as the profession grapples with its role in the carceral apparatus, understanding can guide practice by informing social workers of the legacy of resistance, confronting unjust practices, and activating the profession towards political advocacy. the social work profession’s role in the carceral apparatus is apparent through the family policing system’s criminalization of poverty. the majority of family policing investigations and family separations are for charges of parental neglect, which include the inability to provide food, clothing, housing, medical care, and childcare (burton & montauban, 2021). instead of being met with basic needs assistance and other anti-poverty measures, social workers often report families to child protective services (cps). implicit and explicit racial biases impact social service workers’ perceptions of families and contribute to the yhjphs�kpzwhyp[plz�]pzpisl�h[�l]ly`�z[hnl�vm�jopsk�^lsmhyl�kljpzpvu�thrpun!� reports, investigations, substantiations, family separation, court supervision, and termination of parental rights (hill, 2006; roberts & sangoi, 2018). 0ukllk��v]ly�äm[`�wlyjlu[�vm�)shjr�jopskylu�pu�[ol�<�:��^pss�l_wlyplujl� a child welfare investigation before their eighteenth birthday (kim et al., 2017). in addition, black families are disproportionately separated by the foster system and kept in the system for longer periods of time than their white counterparts (roberts & sangoi, 2018). black parents also experience termination of parental rights at higher rates than white parents (song, 2006). 124 | columbia social work review, vol. xxi families interact with social workers throughout the entire family court process—through mandated reporters, caseworkers, family defense social workers, and court-mandated service providers. however, social work educators have largely ignored the profession’s complicity in jylh[pun�huk�\wovskpun�[ol�tvklyu�mhtps`�wvspjpun�z`z[lt��zwljpäjhss`� ignoring the impact that anti-communism and mccarthyism have played in the profession’s shaping (andrews & reisch, 1997). the wave of mccarthyism in the mid-1900s, a period of fear-mongering in which individuals and communities who were accused of having ties or ideology sympathetic to communism or socialism were viewed as as treasonous and subversive, shaped social work research and scholarship for a generation, as the civil rights movement and backlash to it were in full swing. moreover, the complicity of the profession helped to popularize and perpetuate notions of individual and family diagnoses as the root of societal ills. these themes resonated in public discourse, amidst backlash to the civil rights movement, and guided the creation of the family policing system. in the decades of advocacy for the families and communities the family policing system has since impacted, social workers have grappled with the tension inherent in their roles as advocates and simultaneously participants in the larger carceral web of policing. this tension is visible pu�z[hukhyk�wyhj[pjlz�sprl�thukh[lk�ylwvy[pun��^opjo�slnhss`�ylx\pylz� all social workers to report any suspicion of child abuse or neglect. deepening the understanding of social work’s history, which includes forms of resistance employed by individual social workers, will further crystalize the profession’s obligations to advocate for families and will provide a roadmap for resisting harmful practices. shifting social work back towards the individual although the early social work profession used charitable models that mvj\zlk�vu�¸ä_pun¹�wvvy�jvtt\up[plz��pu�� ����-yhurspu�+��9vvzl]ls[� appointed several social workers to cabinet positions to help him shape and draft new deal legislation, representing a shift in domestic policy and social work advocacy toward basic government support for its where were the social workers? columbia social work review, vol. xxi | 125 citizens. the new deal was actively supported by many social workers and professional social work organizations (finn, 2016). a key piece of the new deal was the social security act of 1935, which created the aid to dependent children program (adc), later renamed aid families with +lwluklu[�*opskylu��(-+*���^opjo�wyv]pklk�^lsmhyl�ilulä[z�wypthyps`� to white widows who were not expected to work (roberts, 2017). the social security act also created a number of other social safety net programs to help elderly and unemployed citizens. this change within the social work profession paved the way for more robust debates and the rise of radical advocacy. radical and progressive social workers typically regarded the political-economic, social, and ideological structures of society as the root causes of individual, family, and jvtt\up[`�wyvisltz"�[olpy�mvj\z�pujs\klk�jyp[px\lz�vm�jhwp[hspzt�hz�h� social-economic system (andrews & reisch, 1997). however, “progressive” soon became a coded term for individuals linked to or sympathetic to the communist party (andrews & reisch, 1997). 0u�� ����:tp[o�*vsslnl�:jovvs�vm�:vjphs�>vyr�äylk�p[z�(zzvjph[l�+lhu�� bertha capen reynolds, a leading social work radical and the most published social work scholar of that decade, because of her marxist political views. in her work, she reframed beliefs about the causes of wv]ly[`�myvt�pukp]pk\hs�mhpspunz�[v�z[y\j[\yhs�kläjp[z��huk�jyp[px\lk�5l^� +lhs�zvjphs�ylmvytz�mvy�mhpspun�[v�hkkylzz�z[y\j[\yhs�pulx\hsp[plz��-puu�� �������-vssv^pun�oly�mvyjlk�ylzpnuh[pvu��9l`uvskz�^hz�mylx\lu[s`�[ol� target of government investigation and intrusion and was unable to obtain a position at another school of social work (reisch, 2018). by the 1950s, mccarthyism was at its peak. the infamous mccarthy “blacklists” of individuals and communities accused of holding “communist” beliefs, including reynolds and other scholars, impacted the profession of social work (abramovitz, 1998). even books that simply articulated the connection between human behavior and the administration of social welfare programs by explaining how psychological needs were connected to social forces were attacked for promoting a socialist agenda (finn, 2016). labor unions were labeled as communist and social work unions were crushed (abramovitz, 1998). jasmine wali 126 | columbia social work review, vol. xxi without the protection of unions and progressive leadership, social work faculty were dismissed at a number of universities, as well as public and private agencies (reisch, 2018). to avoid accusations by anticommunists, many white, liberal social workers distanced themselves from their radical colleagues. the profession as a whole experienced collective anxiety over its tenuous occupational status (andrews & reisch, 1997). )shjr�hj[p]pz[z��myllkvt�äno[lyz��huk�zvjphs�^vyrlyz��^ovzl�^vyr�pz� now acknowledged as foundational to the profession, were tied to jvtt\upzt!�^opsl�zvtl�jovzl�[v�w\ispjs`�z\wwvy[�[ol�*vtt\upz[� 7hy[ �̀�v[olyz�^lyl�shilslk�jvtt\upz[z�i`�nv]lyutlu[�vɉjphsz�iljh\zl� they criticized racial capitalism, or because they were black and advocated for community support and investment from the government (shepherd & pritzker, 2021). in the cold war and civil rights movement jspth[l�vm�[ol�� ��z�huk�� ��z��nv]lyutlu[�klwhy[tlu[z�huk�vɉjphsz� used these accusations against black liberation movements, whether real or not, to criminalize and surveil black social workers and activists (stanford, 2020). thus, for a generation, the organized social work profession, which consisted primarily of white women, largely withdrew from its previous hk]vjhj`�lɉvy[z�mvy�thynpuhspalk�nyv\wz��;ol�zvjphs�^vyr�wyvmlzzpvu� became increasingly passive on social issues, because “to propose a measure to relieve poverty or to combat racism was to risk being called ‘communist’” (ehrenreich, 1985, p. 142; andrews & reisch, 1997). instead, the profession redirected its research to safe issues like family dynamics, and focused internally on professionalization (reisch, 2018). textbooks written during and after the mccarthy era, which shaped a nlulyh[pvu�vm�wyhj[p[pvulyz��ltwohzpalk�[ol�¸hjx\pzp[pvu�vm�l_wly[pzl¹� and omitted “discussions of the ideological bases of practice” (andrews & reisch, 1997). this shift away from advocacy had a number of policy implications. the decline of social activism by the profession during the mccarthy period slowed the development of the welfare state, particularly regarding where were the social workers? columbia social work review, vol. xxi | 127 public assistance and health insurance, and facilitated government lɉvy[z�[v�[pno[lu�ylz[ypj[pvuz�huk�lspnpipsp[`�ylx\pyltlu[z�vm�l_pz[pun� programs (andrews & reisch, 1997). throughout the 1950s, social ^vyrlyz�huk�wvspj`thrlyz�wshjlk�slzz�ltwohzpz�vu�vɉlypun�th[lyphs� support to low income families and increasingly emphasized individually targeted rehabilitation services designed to encourage “independence” (kohler-hausmann, 2017). even during the height of the civil rights movement, leading social ^vyr�w\ispjh[pvuz�thkl�sp[[sl�ylmlylujl�[v�yhjpzt�vy�yhjphs�pulx\hsp[`� (simon, 1994). in fact, most social work research and policy advocacy focused, explicitly or implicitly, on the supposed deviant features of communities of color, thus providing the intellectual foundation for wvspjplz�[oh[�mvj\zlk�tvyl�vu�¸ä_pun¹�hsslnlk�j\s[\yhs�kläjplujplz�[ohu� on addressing the structural root of people’s problems (reisch, 2018). the “welfare crisis” the social work profession’s shift from viewing the impacts of racism huk�wv]ly[`�hz�zvjphs�woluvtluh�[v�]pl^pun�[olt�hz�h�ylålj[pvu�vm� j\s[\yhs�kläjpluj`�ylzvuh[lk�pu�w\ispj�zwolylz�pu�[ol�lhys`�� ��z��:[h[lz� had largely restricted black, latine, and other immigrant families from accessing the anti-poverty programs established by the new deal �2vosly�/h\zthuu���������;ol`�zwljpäjhss`�isvjrlk�)shjr�mhtpsplz�myvt� vi[hpupun�(+*�[oyv\no�h�u\tily�vm�h[[hjrz�vu�mhtps`�z[y\j[\yl!�jopskylu� born out-of-wedlock were deemed ineligible; in mississippi, common law marriages, which many black families obtained (perry, 1999), were outlawed as illicit marriages, thus dropping over 8,000 mostly black children from welfare rolls (perry, 1999; roberts, 2022). states hszv�ptwsltlu[lk�¸thu�pu�[ol�ov\zl¹�y\slz�[v�klu`�ilulä[z�[v�)shjr� mothers suspected of living with or having a sexual relationship with a thu�^ov�^v\sk�[olu�il�l_wlj[lk�[v�äuhujphss`�z\wwvy[�[ol�mhtps`�hz�h� “substitute father” (roberts, 2022). :vjphs�^vyrlyz�^lyl�\zlk�[v�ptwsltlu[�zvtl�vm�[olzl�wvspjplz!�pu�� ���� alameda county implemented “operation bedcheck,” deploying pairs jasmine wali 128 | columbia social work review, vol. xxi of social workers and welfare investigators to search homes of families on welfare for men in the home (kornbluh, 2007). the profession of social work, which had shifted to casework and professionalization in the 1950s, was so heavily associated with harming poor families on welfare that the national welfare rights organization, a leading group advocating for the rights of public welfare clients, targeted some of their advocacy towards social workers in administrative positions in the public welfare bureaucracy (marx, 2011). +lzwp[l�z[h[lz»�lɉvy[z�[v�isvjr�)shjr�mhtpsplz��(+*�nyl^�z\iz[hu[phss`� over the 1960s, from 3.1 million in 1960 to 10.8 million in 1974 (nadasen et al., 2009). this growth can be attributed to a multitude of factors, including federal oversight to ensure state compliance with racial protections, economic dislocations, increases in single-parent families, the mass migration of black families to the north and west, and poverty sh^`lyz»�huk�hj[p]pz[z»�lɉvy[z�[v�olsw�lspnpisl�mhtpsplz�vi[hpu�[olpy� entitlements (kohler-hausmann, 2017). indeed, in the early 1960s, about one-third of eligible families were enrolled in adc; by 1971, about 90 wlyjlu[�^lyl�yljlp]pun�ilulä[z��9llzl���������/v^l]ly��jyp[pjz�hjyvzz� the political spectrum interpreted this growth as a “welfare crisis” symptomatic of the pathology and laziness of the parents it served. barry goldwater’s campaign for presidency in 1964 shaped the welfare debate on a national stage. goldwater stated that the welfare state destroyed individualism and supported the growth of collectivism. many of his themes would later form the multiple bases for the new right’s attack on welfare. right-wing publications attacked the welfare state for undermining rugged individualism and private property, fostering immorality and non-productivity, contributing to crime—pointing to urban protests and the civil rights movement—and ultimately leading to communism (williams, 1997). adc became a lightning rod for frustration as white populations were confronted with the visibility of racial injustices highlighted by the civil rights movement, increased media attention to drugs and crime (and its racialized depictions), and a reckoning of women’s sexuality and role in the labor market (kohler-hausmann, 2017). journalists in mainstream where were the social workers? columbia social work review, vol. xxi | 129 news outlets such as the new york times charged that black and puerto rican families saw welfare as a “bank,” playing on deep-seated fears about a changing country (horowitz, 1969). debates about welfare dominated the media and political spheres. seeking to persuade the johnson administration to move swiftly to ptwyv]l�[ol�wspno[�vm�wvvy�)shjr�mhtpsplz�[oyv\no�mlklyhss`�äuhujlk�hu[p� wv]ly[`�wyvnyhtz��+hupls�7h[ypjr�4v`upohu�^yv[l�;ol�5lnyv�-htps`!�(� case for national action, commonly known as the moynihan report. while moynihan discusses the role of systemic racism in creating and \wovskpun�^lhs[o�pulx\hsp[ �̀�ol�hszv�hyn\lz�[oh[�[ol�pujylhzl�pu�^lsmhyl� dependency can be “taken as a measure of the steady disintegration of [ol�5lnyv�mhtps`�z[y\j[\yl�¹�/l�^yp[lz�hiv\[�)shjr�mhtpsplz! [t]he family structure of lower class negroes is highly unstable… the combined impact of poverty, failure, and isolation among negro youth has had the predictable outcome in a disastrous klspux\luj`�huk�jyptl�yh[l¯�b(d�uh[pvuhs�lɉvy[�[v^hykz�[ol� problems of negro americans must be directed towards the x\lz[pvu�vm�mhtps`�z[y\j[\yl��4v`upohu��� ���� the moynihan report cemented the issue of race to welfare and singlewhylu[�mhtpsplz�pu�h�^h`�[oh[�thkl�p[�kpɉj\s[�[v�[hsr�hiv\[�vul�^p[ov\[� [ol�v[olyz��huk�pu�kvpun�zv�puhk]ly[lu[s`�m\lslk�wvw\shy�ä_h[pvu�vu� black women’s sexuality and welfare receipt (nadasen, 2007). this ylwvy[�^hz�hu�puå\lu[phs�ylzwvuzl�pu�h�jyp[pjhs�tvtlu[�[v�[ol�o`z[lyph� around welfare and public demand for changes to adc and shaped how politicians and media portrayed and understood black children and black parenting. the saturday evening post commented, “today’s welfare child, raised in hopelessness and dependency, becomes tomorrow’s welfare adult, pauperized and helpless” (nadasen, 2007). u.s. news and world report declared in 1965 that the increasing number of “welfare babies” would “breed more criminals, more mental defectives, more unemployables of hstvz[�l]ly`�[`wl�¹�huk�wyväslk�h�[`wpjhs�(+*�yljpwplu[�pu�*opjhnv�hz� ¸(�wvvy�5lnyv�npys!���:ol�pz�puzlj\yl��\ulk\jh[lk��\uzvwopz[pjh[lk��huk� jasmine wali 130 | columbia social work review, vol. xxi frightened” (nadasen, 2007). the concerns about adc were shaped and portrayed to the public by racial ideology and existing racial stereotypes about black parents and children, and raised concerns around the alleged impact that black children would have on white america. the pathology of child abuse amidst the unfounded charges of an inherent pathology in the black family structure, concerns about child abuse were taking shape in the public. in 1962, pediatrician c. henry kempe and several colleagues published the battered child syndrome report. similar terms were used to describe black parents in the moynihan report as parents who physically abuse their children in the battered child syndrome. children in the reports were characterized as “illegitimate” or “unwanted.” substance abuse in the reports was described as “drunkenness” or “alcoholism.” parents were diagnosed as “pathologic” or “psychopathic and sociopathic.” dysfunctional families were characterized by “divorce, separation, and desertion, female family head, children in broken homes…family disorganization, juvenile klspux\luj �̀¹�vy�¸zl_\hs�wyvtpzj\p[ �̀�\uz[hisl�thyyphnlz��huk�q\]lupsl� klspux\luj`¹��>hsp�������� the authors of the battered child syndrome stated that there were no reports of successful psychotherapy, and thus the only safe remedy at the time of publication was the separation of children from their parents (kempe et al., 1962). they did, however, introduce the empirically unsupported idea of parental violence against children as a diagnosable and treatable medical condition or mental illness (burton & montauban, 2021). the individual-centered psychological and medical construction of the problem turned policymakers away from considering its structural causes and allowed for physicians to maintain ownership and guide interventions for child abuse (nelson, 1984; hacking, 1991). following the publication of the battered child syndrome, academics and popular media rushed to popularize the issue of child abuse. in where were the social workers? columbia social work review, vol. xxi | 131 the decade prior to the article’s appearance, doctors, lawyers, social workers, educators, and other researchers and practitioners published vus`�h�jvtipulk�upul�hy[pjslz�zwljpäjhss`�mvj\zpun�vu�jy\ls[`�[v�jopskylu"� in the decade after its publication, the professions produced 260 articles (nelson, 1984). mass-circulation magazines carried twenty-eight articles in the decade after kempe’s article, compared to only three in the kljhkl�ilmvyl��;lsl]pzpvu�zh^�h�zptpshy�[yluk!�jopsk�hi\zl�^hz�]py[\hss`� absent from early television scripts, whereas after bcs, soap operas and prime-time series alike created dramas based on the problem (nelson, 1984). the public embraced the individualized idea of the pathological and psychopathic parent who physically abused their children, as opposed to the parent whose capacity to nurture was limited by social factors (newberger, 1983). most seasoned professionals tasked with working with these families, who had experienced the anti-communist era’s push towards family dynamics and psychotherapy and away from social justice, embraced these individualized views (finn, 2016). for nearly a decade, lawmakers and the public had been inundated with messages about the supposed looming impacts of welfare babies, [ol�)shjr�mhtps`�z[y\j[\yl��huk�wo`zpjhs�jopsk�hi\zl��zwljpäjhss`�[olzl� children’s supposed propensity to commit crimes and drain government resources. racist depictions of the war on drugs and crime, attributed to drugs and civil rights protests, found its way to white americans’ dinner table discussions (kohler-hausmann, 2017). all of this helped to place a public outcry for child wellbeing interventions on the mainstream agenda as the 1970s approached. removing black children in 1961, the department of health, education, and welfare issued a directive that states could not deny adc based on suitable-home tests unless they took steps to rehabilitate the family. for families that could not be rehabilitated, federal funds were allocated to put the child in foster care. that year, congress amended title iv of the social security jasmine wali 132 | columbia social work review, vol. xxi act to provide federal funding to maintain these children apart from [olpy�mhtpsplz��0uz[lhk�vm�klu`pun�mhtpsplz�ilulä[z��z[h[l�(+*�lspnpipsp[`� workers began taking black children away from mothers deemed \uz\p[hisl!�pu�� ������������jopskylu�^lyl�wshjlk�pu�v\[�vm�ovtl�jhyl� (roberts, 2022). )l`vuk�[ol�mlklyhs�äuhujphs�pujlu[p]l�mvy�mhtps`�zlwhyh[pvu��wvspjplz� around child well-being and welfare were also shifting. for example, in response to the increase in black and latina women receiving welfare ilulä[z��wvspj`thrlyz�puz[p[\[lk�^vyr�ylx\pyltlu[z��5hkhzlu�������!� h�[hzr�kpɉj\s[�mvy�zpunsl�tv[olyz�^p[o�uv�jopskjhyl�vw[pvuz��)\[�h�� ��� bipartisan childcare bill was vetoed by president nixon, who called it “the most radical piece of legislation” to have ever crossed his desk, and charged that the bill represented a “communal approach to childrearing” and had “family-weakening implications” (rosenberg, 1992), echoing anti-communist terms and themes to describe and demonize a social welfare program. this intentional defunding of mesoand community-level support represented the prevailing conservative themes of the previous decades, and placed the onus for overcoming poverty and obtaining stability on the nuclear family, thereby detaching [ol�z[h[l�myvt�äuhujphs�ylzwvuzpipsp[`�mvy�jopskylu�huk�mhtpsplz��579�� 2016; the economist, 2021; rosenberg, 1992). the bill’s sponsor, senator mondale, understood that child well-being could not be tied to anti-poverty programs, but still felt the public demand for interventions for children. in response, mondale pursued the child abuse prevention and treatment act, or capta (wexler, 2018), which passed in 1974. narratives of parental responsibility and treating social issues as individual pathologic concerns had been promoted by the medical and social work communities over the previous few decades. this resonated in the 1970s. capta’s initial scope was broad and vague, and combined intentional acts and acts of omission pu[v�h�zpun\shy�woluvtluvu!�jopsk�hi\zl�huk�ulnslj[��;opz�jylh[lk� h�mhszl�lx\p]hslujl�il[^llu�pu[lu[pvuhs�wo`zpjhs�ohyt�[v�jopskylu� i`�[olpy�whylu[z�huk�jvukp[pvuz�vm�wv]ly[ �̀�lɉlj[p]ls`�[yhuzmvytpun� where were the social workers? columbia social work review, vol. xxi | 133 child poverty from a social, economic, and racial justice issue into a problem of individual parental pathology and deviant behavior. thus, the government was absolved from addressing structural, economic, and yhjphs�pulx\p[plz�[oh[�zohwlk�jopskylu»z�^lssilpun��)\y[vu� �4vu[h\ihu�� 2021). capta: a foundation capta is the foundation of the modern family policing system. capta ylx\pylz�lhjo�z[h[l�[v�oh]l�thukh[vy`�ylwvy[pun�wyv]pzpvuz��^opjo� train social workers and other medical, educational, and childcare wyvmlzzpvuhsz�[v�ylwvy[�hu`�z\zwpjpvu�vm�]hn\l�kläup[pvuz�vm�jopsk�hi\zl� vy�ulnslj[�huk�puz[p[\[lz�slnhs�huk�wyvmlzzpvuhs�jvuzlx\lujlz�mvy� failure to report. the practice is wrought with implicit and racial biases, resulting in disproportionate reporting of black families (inguanta & sciolla, 2021). the “prevention and treatment” of child abuse and ulnslj[�i\pskz�vu�[ol�[olvyl[pjhs�myhtl^vyr�vɉlylk�i`�[ol�zvjphs� work and medical communities from the 1950s through the 1970s by identifying risk factors in personalities and developing a treatment plan. mental health evaluations are used to this day when a family is investigated by cps, even though “searches for distinctive behavioral syndromes have proven elusive” (melton, 2005) after decades of government and foundation-funded research (burton & montauban, 2021). these mental health evaluations continue to be used in court proceedings and as grounds to separate families and terminate parental rights. instead of providing families with more resources, capta funds investigations into families and “treatment” services administered by zvjphs�^vyrlyz��huk�zl[z�[ol�z[h[\z�x\v�mvy�[ol�^h`�^l�hkkylzz�mhtpsplz� ensnared in the family policing system. implications for today’s social work practice an appreciation of history has been largely marginalized in u.s. social work (finn, 2016). social work scholar michael reisch claims that we are an ahistorical culture that has become accustomed to fragments of information, instead of the connective tissue (reisch, 1988). our current jasmine wali 134 | columbia social work review, vol. xxi cultural and political institutions, including the social work profession, perpetuate ignorance of the past in order to sustain the perception of the present as a given; this limits the range of societal choices for the future (reisch, 1993). the council on social work education must hkkylzz�zvjphs�^vyr�opz[vy �̀�mvy�^opjo�[olyl�pz�j\yylu[s`�uv�ylx\pyltlu[� for competency (finn, 2016). there is an inherent tension in the social work profession. the majority of the labor sector is still middle-class white women, while the clientele is largely black, indigenous, people of color, and low-income; these racial and class dynamics inform the implicit and explicit biases that impact communities. there is tension in the social worker’s power over families because of social workers’ participation in the family policing z`z[lt�[oyv\no�ylx\pyltlu[z�z\jo�hz�thukh[lk�ylwvy[pun�z\jo�hz� mandated reporting, case notes that impact court proceedings, and visitation supervision between parents and children. nevertheless, there are examples of resistance in the history of social work that show individual social workers refusing to participate in harmful practices and using their positionality to end them, and of students changing the path and the education of the profession. for example, “operation bedcheck” was deemed unconstitutional after a social worker refused to participate in a mass morning raid on the homes of alameda county’s welfare recipients and was dismissed from his job. in parrish v. civil service commission��[ol�wshpu[pɉ�hyn\lk� that such participation would have involved him in multiple violations of rights secured by the federal and state constitutions and that his superiors could not properly direct him to participate in illegal activity. following the lawsuit initiated by an individual social worker, the county z\izlx\lu[s`�hihukvulk�thzz�tvyupun�yhpkz�[v�kl[lytpul�^lsmhyl� eligibility and determined that such operations were forbidden by the applicable state and federal regulations. this raises room for envisioning other ways that social workers can push back against daily practices encouraged by their superiors and licensing boards and challenge their constitutionality and legality. where were the social workers? columbia social work review, vol. xxi | 135 -vy�l_htwsl��[ol������wyv[lz[z�mvy�yhjphs�lx\p[`�wyvtw[lk�[ol�jylh[pvu� of a group called mandated reporters against mandated reporting. they work to end the practice of mandated reporting that families have called the “stop-and-frisk of caretaking” (meiners & schenwar, 2017) by providing case processing spaces for peer feedback and informal supervision that they do not receive from their agencies. in addition, calls to abolish mandated reporting have strengthened within the social work profession (inguanta & sciolla, 2021; upend, n.d.). following 2020, cps caseworkers also saw the way that they were trained to coerce their way into homes without a court order, thus z\iqlj[pun�[ol�mhtps`�[v�hu�pu]hzp]l�wyvjlzz�[oh[�^hz�olh]ps`�puå\lujlk� by bias, and recommended that “miranda warning” practices be puz[p[\[lk�[v�ylx\pyl�[oh[�whylu[z�il�pttlkph[ls`�uv[pälk�vm�[olpy� constitutional rights (newman, 2022). social workers must fearlessly advocate from within the profession to challenge long-standing and harmful standards. student activism is crucial to the social work profession. after decades of social workers’ movement away from activism, the 1960s and the civil rights movement reinvigorated the profession’s social action—not of seasoned, white professionals, but of students and black social workers. students and black social workers organized for change i`�jyp[px\pun�[olpy�vynhupah[pvuz��^lsmhyl�i\ylh\jyhjplz��huk�zjovvs� curricula, and protested social work’s lack of response to black liberation movements (abramovitz, 1998). this led to the emergence of a systems perspective, which is now the foundation of a generalist approach to social work (finn, 2016). in the present day, students are continuing the legacy of activism. social work students rewrote and replaced the mandated reporting training with a “mandated supporting” curriculum that columbia school of social work students now receive (jmacforfamilies, 2022). students at uic jane addams college of social work developed an “alternatives to calling dcfs” guide for illinois social workers (shriver, 2021). jasmine wali 136 | columbia social work review, vol. xxi social workers have also increased their academic advocacy around robust anti-poverty programs through peer-reviewed research that countered narratives of personal responsibility and promoted the idea that governments should support families. these studies have found that the earned income tax credit and child tax credit, childcare subsidies, medicaid expansion, and an increased minimum wage all reduce reports of child maltreatment (biehl & hill, 2018; kovski et al., 2022; yang et al., 2019; brown et al., 2019; raissian & bullinger, 2017). most importantly, what social workers can do to end harmful practices in the profession is to listen and follow the lead of communities who have been most impacted by the profession and overlapping systems, using positionality to ensure their experiences and leadership are jlu[lylk��äukpun�ylzv\yjlz�[v�luz\yl�[oh[�jvtt\up[plz�hyl�pu]lz[lk�pu� and compensated for their labor, and being active in the community, not just working in it. the anti-communist movements impacted generations of social work practice and training and shaped the conditions under which the modern family policing system was formed. much of the profession was complicit in promoting ideas of personal responsibility and individual pathology, positing the profession as a solution to rectify deviant individuals, families, and communities amidst intentional policy choices that defunded family and community support. as social work continues to evolve, particularly in this crucial time period of the post�����yhjphs�yljrvupun��zvjphs�^vyrlyz�t\z[�ylzpz[�hnluj`�z[h[\z�x\v� when it is damaging and engage with macro-level advocacy to promote anti-poverty programs that strengthen community well-being and keep families safe and together. references (iyhtv]p[a��4���� ����:vjphs�^vyr�huk�zvjphs�ylmvyt!�(u�hyluh�vm�z[y\nnsl��social work, ����������¶�����o[[wz!��kvp�vyn������ ��z^��������� (ukyl^z��1��� �9lpzjo��4���� ����:vjphs�^vyr�huk�hu[p�jvtt\upzt!�(�opz[vypjhs�huhs`zpz� of the mccarthy era. journal of progressive human services��������� ¶� ��o[[wz!��kvp� vyn���������1�� ]��u��f�� where were the social workers? columbia social work review, vol. xxi | 137 biehl, a. m., & hill, b. (2018). foster care and the earned income tax credit. review of economics of the household������������¶�����o[[wz!��kvp�vyn���������z���������� 9381-1 brown, e. c. b., garrison, m. m., bao, h., qu, p., jenny, c., & rowhani-rahbar, a. (2019). assessment of rates of child maltreatment in states with medicaid expansion vs states without medicaid expansion. jama network open��������l� ��� ��o[[wz!��kvp� vyn���������qhthul[^vyrvwlu���� ���� )\y[vu��(��� �4vu[h\ihu��(����������;v^hyk�jvtt\up[`�jvu[yvs�vm�jopsk�^lsmhyl�m\ukpun!� repeal the child abuse prevention and treatment act and delink child protection from family well-being. columbia journal of race and law, 11(3). campbell, n. d. (2010). toward a critical neuroscience of ‘addiction.’ biosocieties, 5(1), � ¶�����o[[wz!��kvp�vyn���������ipvzvj���� �� chappell, m. (2010). the war on welfare: family, poverty, and politics in modern america. university of pennsylvania press. childs, m. (1970, november 23). drugs spreading from the ghettos. washington post. ehrenreich, j. (1985). the altruistic imagination: a history of social work and social policy in the united states. cornell university press. finn, j. l. (2016). just practice: a social justice approach to social work (3rd edition). oxford university press. floyd, i., pavetti, l., meyer, l., safawi, a., schott, l., bellew, e., & magnus, a. (2021). ;(5-�wvspjplz�ylålj[�yhjpz[�slnhj`�vm�jhzo�hzzpz[hujl!�9lpthnpulk�wyvnyht�zov\sk� center black mothers.�*lu[ly�vu�)\knl[�huk�7vspj`�7ypvyp[plz��o[[wz!��^^ �̂jiww�vyn� zp[lz�klmh\s[�äslz�������[hum�wkm .lu\zzh��3��(����������-yvt�mvz[ly�jhyl�[v�[ol�z[yll[z!�(�jhss�[v�z\wwvy[�)shjr��0ukpnluv\z�� and lgbtq+ youth in foster care. columbia social work review�����������¶����o[[wz!�� kvp�vyn����������jz^y�]��p�� ��� gordon, l. (1994). pitied but not entitled: single mothers and the history of welfare, 18901935. free press; maxwell macmillan canada; maxwell macmillan international. hacking, i. (1991). the making and molding of child abuse. critical inquiry, 17(2), 253–288. o[[wz!��^^ �̂qz[vy�vyn�z[hisl�������� hill, r. b. (2006). synthesis of research on disproportionality in child welfare: an update. 9l[ypl]lk�4hyjo�����������myvt�o[[wz!��jp[paluyl]pl^whulszu �̀vyn�kvj\tlu[z�tl[anlyf ^hollkfwv^lywvpu[�wkm horowitz, j. (1969, january 26). a portrait of new york’s welfare population—in one month, 50,000 persons were added to the city’s welfare rolls. the new york times magazine. o[[wz!��^^ �̂u`[ptlz�jvt�� � �������hyjop]lz�pu�vul�tvu[o�������wlyzvuz�^lyl� hkklk�[v�[ol�jp[`z�^lsmhyl�yvssz�h�o[ts&zlhyjo9lz\s[7vzp[pvu$�� jasmine wali 138 | columbia social work review, vol. xxi how america should spend on child care. (2021). the economist��o[[wz!��^^ �̂ljvuvtpz[� jvt�äuhujl�huk�ljvuvtpjz������� ����ov^�htlypjh�zov\sk�zwluk�vu�jopsk�jhyl 0un\hu[h��.��� �:jpvssh��*����������;ptl�kvlzu»[�olhs�hss�^v\ukz!�(�jhss�[v�luk�thukh[lk� reporting law. columbia social work review��� ��������¶�����o[[wz!��kvp�vyn�o[[wz!��kvp� vyn����������jz^y�]� p������ jmacforfamilies. (2021). mandated supporting��14(*mvy-htpsplz��o[[wz!��^^ �̂ qthjmvymhtpsplz�vyn�thukh[lk�z\wwvy[pun kempe, c. h., silverman, f. n., steele, b. f., droegemueller, w., & silver, h. k. (1962). battered child syndrome. journal of the american medical association, 181(1). kim, h., wildeman, c., jonson-reid, m., & drake, b. (2017). lifetime prevalence of investigating child maltreatment among us children. american journal of public health, �����������¶�����o[[wz!��kvp�vyn���������(17/������������� kohler-hausmann, j. (2017). getting tough: welfare and imprisonment in 1970s america. princeton university press. kornbluh, f. a. (2007). the battle for welfare rights: politics and poverty in modern america. university of pennsylvania press. kovski, n. l., hill, h. d., mooney, s. j., rivara, f. p., & rowhani-rahbar, a. (2022). short[lyt�lɉlj[z�vm�[h_�jylkp[z�vu�yh[lz�vm�jopsk�ths[ylh[tlu[�ylwvy[z�pu�[ol�\up[lk�z[h[lz�� pediatrics����������l������� � ��o[[wz!��kvp�vyn���������wlkz��������� � marx, j. d. (2011). american social policy in the 1960’s and 1970’s. social welfare history 7yvqlj[��o[[wz!��zvjphs^lsmhyl�spiyhy �̀]j\�lk\�^hy�vu�wv]ly[`�htlypjhu�zvjphs�wvspj`�pu� [ol���z�huk���z� 4lpulyz��,��� �:jolu^hy��4���������1\ul�� ���¸:[vw�huk�mypzr¹�mvy�jhylnp]lyz!�/v^� expanded mandated reporting laws hurt families. truthout��o[[wz!��[y\[ov\[�vyn�hy[pjslz� z[vw�huk�mypzr�mvy�jhylnp]lyz�ov^�l_whuklk�thukh[lk�ylwvy[pun�sh^z�o\y[�mhtpsplz� 4ls[vu��.��)����������4hukh[lk�ylwvy[pun!�(�wvspj`�^p[ov\[�ylhzvu��child abuse & neglect, � ����� ¶����o[[wz!��kvp�vyn���������q�jophi\������������ moynihan, d. p. (1965). the negro family: the case for national action. department of 3hivy��9l[ypl]lk�4hyjo�����������myvt�o[[wz!��^^ �̂kvs�nv]�nlulyhs�hiv\[kvs�opz[vy`� webid-moynihan 4\yhrh^h��5����������;ol�vypnpuz�vm�[ol�jhyjlyhs�jypzpz!�9hjphs�vykly�hz�¸sh^�huk�vykly�pu� postwar american politics.” in j. e. lowndes, j. novkov, & d. t. warren (eds.), race and american political development (1st ed., p. 105-127). routledge. 4\[hyp��,���7v^ly��4��� �-pnhy[��+��4����������5lp[oly�tv[olyz�uvy�iylhk^puulyz!�(mypjhu� american women’s exclusion from us minimum wage policies, 1912-1938. feminist economics��������� ��o[[wz!��kvp�vyn�o[[wz!��kvp�vyn����������������������� �� where were the social workers? columbia social work review, vol. xxi | 139 jasmine wali 5hkhzlu��7����������-yvt�^pkv^�[v�¸^lsmhyl�x\llu¹!�>lsmhyl�huk�[ol�wvsp[pjz�vm�yhjl�� black women, gender + families,���������¶����o[[wz!��^^ �̂qz[vy�vyn�z[hisl��������� blacwomegendfami.1.2.0052 nadasen, p., mittelstadt, j., & chappell, m. (2009). welfare in the united states: a history with documents, 1935-1996 (1st ed.). routledge. nelson, b. (1984). making an issue of child abuse: political agenda setting for social problems. the university of chicago press. neubeck, k., & cazenave, n. (2001). welfare racism: playing the race card against america’s poor. routledge. 5l^ilynly��,��/���� �����;ol�olswpun�ohuk�z[yprlz�hnhpu�¶�<upu[luklk�jvuzlx\lujlz�vm� child abuse reporting. journal of clinical child psychology, 12(3), 307-311. newman, a. (2022). is n. y. ’s child welfare system racist? some of its own workers say yes. the new york times��o[[wz!��^^ �̂u`[ptlz�jvt������������u`ylnpvu�u`j�hjz� racism-abuse-neglect.html npr. (2016). how politics killed universal child care in the 1970s. npr��o[[wz!��^^ �̂uwy� vyn������������� ����� ��ov^�wvsp[pjz�rpsslk�\up]lyzhs�jopskjhyl�pu�[ol�� ��z parker, m. (2022). >oh[�^l�svzl�^olu�^l�jvuåh[l�jopsk�¸hi\zl¹�huk�¸ulnslj[�¹ propublica. o[[wz!��^^ �̂wyvw\ispjh�vyn�hy[pjsl�^oh[�^l�svzl�^olu�^l�jvuåh[l�jopsk�hi\zl�huk� neglect 7lyy �̀�;���� ���9hjl�th[[lyz!�*ohunl��jovpjl��huk�mhtps`�sh^�h[�[ol�tpssluup\t��family law quarterly������������¶�����o[[wz!��^^ �̂qz[vy�vyn�z[hisl��������� 9hpzzphu��2��4��� �)\sspunly��3��9����������4vul`�th[[lyz!�+vlz�[ol�tpupt\t�^hnl�hɉlj[� child maltreatment rates? children and youth services review��������¶����o[[wz!��kvp� vyn���������q�jopsk`v\[o������� ���� reese, e. (2005). backlash against welfare mothers (1st ed.). university of california press. reisch, m. (1988). lessons from the history of social work for our time. the jewish social work forum, 29, 3-27. reisch, m. (1993). the social worker in politics as a multi-role group practitioner. social work with groups��������������¶�����o[[wz!��kvp�vyn���������1�� ]��u��f�� reisch, m. (2018). 1968: the turning point year when u.s. social work failed to turn. o[[wz!��kvp�vyn������������ �����?��� �������� roberts, d. (2022). torn apart: how the child welfare system destroys black families—and how abolition can build a safer world. basic books. roberts, d. e. (2017). killing the black body: race, reproduction, and the meaning of liberty (2nd vintage books edition). vintage books. 140 | columbia social work review, vol. xxi roberts, d., & sangoi, l. (2018). black families matter: how the child welfare system punishes poor families of color.�;ol�(wwlhs��o[[wz!��[olhwwlhs�vyn�ishjr�mhtpsplz�th[[ly� ov^�[ol�jopsk�^lsmhyl�z`z[lt�w\upzolz�wvvy�mhtpsplz�vm�jvsvy���hk��l����l� rosenberg, r. (1992). divided lives: american women in the twentieth century. macmillan. shepherd, d., & pritzker, s. (2021). political advocacy without a choice. advances in social work��������������¶�����o[[wz!��kvp�vyn���������������� shriver. (2021). before you call dcfs��:oyp]ly�*lu[ly�vu�7v]ly[`�3h �̂�o[[wz!��^^ �̂ wv]ly[`sh �̂vyn�hy[pjsl�ilmvyl�`v\�jhss�kjmz�� simon, b. l. (1994). the empowerment tradition in american social work: a history. columbia university press. song, m. (2006). termination of parental rights and adoption in foster care. :jovshys`*vttvuz��o[[wz!��ylwvzp[vy �̀\wluu�lk\�kpzzly[h[pvuz�((0�������� :wpul[[h��1��1��� �9pnsly��+���� �����;ol�jopsk�hi\zpun�whylu[!�(�wz`jovsvnpjhs�yl]pl �̂� psychological bulletin���������� �¶�����o[[wz!��kvp�vyn���������o������ � stanford university. (2020, august 4). communism. the martin luther king, jr., research huk�,k\jh[pvu�0uz[p[\[l��9l[ypl]lk�4hyjo�����������myvt�o[[wz!��rpunpuz[p[\[l�z[humvyk� lk\�luj`jsvwlkph�jvtt\upzt� tani, k. m. (2016). states of dependency: welfare, rights, and american governance, 19351972. cambridge university press. upend. (n.d.). end surveillance of families. upend movement. retrieved january 6, 2023, myvt�o[[wz!��\wluktv]ltlu[�vyn�luk�z\y]lpsshujl�mhtpsplz� wali, j. (2023, february 20). constructing immorality: abortion and family policing. cuny 3h^�9l]pl �̂�9l[ypl]lk�(wyps����������myvt�o[[wz!��^^ �̂j\u`sh^yl]pl �̂vyn�jvuz[y\j[pun� pttvyhsp[`�hivy[pvu�huk�mhtps`�wvspjpun�� williams, l. a. (1997). decades of distortion: the right's 30-year assault on welfare. 7vsp[pjhs�9lzlhyjo�(zzvjph[lz��9l[ypl]lk�myvt�o[[wz!��wvsp[pjhsylzlhyjo�vyn�zp[lz�klmh\s[� äslz���������+ljhklz�vm�+pz[vy[pvu�wkm�� >l_sly��9����������*(7;(�sh^�jvkpälz�l]ly`[opun�^yvun�^p[o�ov^�^l�ºäno[»�jopsk�hi\zl�� youth today��o[[wz!��`v\[o[vkh �̀vyn���������jhw[h�sh^�jvkpälz�l]ly`[opun�^yvun�^p[o� ov^�^l�äno[�jopsk�hi\zl� @hun��4���4hn\pylɫ1hjr��2���:ov^hs[ly��2���2pt��@��2��� �:shjr��2��:������ ���*opsk�jhyl� subsidy and child maltreatment. child & family social work������������¶�����o[[wz!��kvp� vyn���������jmz������ where were the social workers? cswr spring 2022 columbia social work review, vol. xix | 3 law enforcement and restorative circles: impacts on educational achievement gabriel bautista caitlin e. mello jennifer song richard a. unite 4 | columbia social work review, vol. xix law enforcement and restorative circles in schools abstract connections have been observed between police involvement in school kpzjpwspul�huk�[ol�\[pspah[pvu�vm�z\zwluzpvuz�hz�w\upzotlu[��>opsl� proponents of school surveillance believe that police are necessary [v�wyv]pkl�zhml[`�pu�zjovvsz��lk\jh[pvu�hk]vjh[lz�x\lz[pvu�z[\klu[z»� wlyjlw[pvu�vm�zhml[`�huk�p[z�lɉlj[z�vu�lk\jh[pvuhs�v\[jvtlz��;opz� hy[pjsl�l_htpulz�[ol�ylsh[pvuzopw�il[^llu�wvspjl�vɉjly�wylzlujl�huk� certain educational outcomes, including student attendance, access to opnoly�lk\jh[pvu��z[hukhykpalk�[lz[�zjvylz��huk�z\zwluzpvu�yh[lz��(szv� included in this analysis is an exploration of the relationships between these variables and classroom restorative circles used to manage jvuåpj[�huk�äuk�hs[lyuh[p]l�zvs\[pvuz�[v�zhml[ �̀�+vlz�wvspjl�wylzlujl� oh]l�h�zpnupäjhu[�ptwhj[�\wvu�h[[lukhujl��hjjlzz�[v�opnoly�lk\jh[pvu�� z[hukhykpalk�[lz[�zjvylz��huk�z\zwluzpvu�yh[lz�mvy�z[\klu[z&�+vlz�[ol� use of restorative circles at school, an alternative to traditional student kpzjpwspul��oh]l�h�zpnupäjhu[�ptwhj[�\wvu�h[[lukhujl��hjjlzz�[v�opnoly� lk\jh[pvu��z[hukhykpalk�[lz[�zjvylz��huk�z\zwluzpvu�yh[lz�mvy�z[\klu[z&� ;v�hkkylzz�[olzl�pux\pyplz��hu�6ykpuhy`�3lhz[�:x\hylz��63:��ylnylzzpvu� analysis is used on both predictors with the school survey on crime and :hml[`�jvsslj[lk�i`�[ol�<�:��+lwhy[tlu[�vm�,k\jh[pvu��+6,���9lz\s[z� kltvuz[yh[l�h�z[h[pz[pjhss`�zpnupäjhu[�ylsh[pvuzopw�il[^llu�wvspjl�vɉjly� presence and suspensions. restorative circle use in schools has a zpnupäjhu[�ptwhj[�\wvu�kljylhzlk�zjovvs�z\zwluzpvuz�huk�pujylhzlk� z[hukhykpalk�[lz[�zjvylz��;v�jvujs\kl�[ol�whwly��ylhs�^vysk�ptwspjh[pvuz� on school policy development are discussed. keywords: police in schools, suspension rates, educational outcomes, restorative justice circles, standardized test scores columbia social work review, vol. xix | 5 gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite s chool surveillance and the presence of law enforcement in schools contribute to the school-to-prison pipeline, a jvuulj[pvu�vm�z`z[ltz�tlhu[�[v�jyptpuhspal�wylkvtpuhu[s`� black and latine students at an early age (nance, 2016). by removing students from the classroom through suspension or arrests, students' academic performance and chances of graduating are severely impacted, ultimately causing complications in other life domains (nance, 2016). education advocates propose restorative circles and social-emotional learning (sel) as alternative solutions to promoting school safety and better educational outcomes (hulvershorn & mulholland, 2018). researchers have explored the relationship between school safety practices and student academic performance in order to understand better the possible impact of school surveillance huk�ylz[vyh[p]l�jpyjslz��;opz�whwly�huhs`alz�ylsl]hu[�kh[h�[v�l_wsvyl� this correlation and inform policy addressing academic performance and safety for students, especially black, indigenous, and people of jvsvy��)076*��z[\klu[z�kpzwyvwvy[pvuh[ls`�hɉlj[lk�i`�z\jo�kpzjpwspuhy`� practices. review of extant literature school policing and punishment police have had a presence in u.s. public schools since the 1950s, but gained prominence following several school shootings in the 1990s. >p[o�pujylhzlk�m\ukpun�myvt�[ol��+lwhy[tlu[�vm�1\z[pjl��+61���thu`� zjovvsz�oh]l�opylk�hkkp[pvuhs�wvspjl�vɉjlyz�[v�thpu[hpu�vykly�huk� protect students within classrooms (coon & travis, 2012; weiler & cray, 2011). many schools associate student safety with increased policing and the use of punishment to enforce school policy. while this method is prevalent, it does not always ensure student safety—especially when ¸zhml[`¹�pz�kläulk�hz�myll�vm�jhyjlyhs�mvyjl·huk�p[�jhu�oh]l�zpnupäjhu[� academic repercussions. (�zpkl�lɉlj[�vm�pujylhzlk�wvspjl�wylzlujl�pz�pujylhzlk�uvu]pvslu[� vɉluzlz�huk�l_js\zpvuhy`�w\upzotlu[��(������z[\k`�i`�.v[[mylkzvu�l[� 6 | columbia social work review, vol. xix al. observed 33 public california middle and high schools that increased [olpy�wvspjl�wylzlujl�i`�opypun�vɉjlyz�[oyv\no�[ol�+61»z�*vtt\up[`� 6yplu[lk�7vspjpun�:ly]pjlz�/pypun�7yvnyht��0u�[opz�svunp[\kpuhs�huhs`zpz�� the 33 schools were compared to 72 matched public schools within the state based on similar school characteristics, such as metropolitan status, percentage of students on free or reduced-priced lunch, and yh[l�vm�z\zwluzpvuz�mvy�[ol�`lhy�wypvy�[v�hu�pujylhzl�pu�:96�z[hɉ�� ;opz�z[\k`�\[pspalk�tvu[os`�kh[h�[v�l]hs\h[l�[ol�ptwhj[�vm�pujylhzlk� wvspjl�vɉjlyz�vu�[ol�zjovvs�lu]pyvutlu[�v]ly�[oyll�tvu[oz��-pukpunz� demonstrated a correlation between expanded police presence and pujylhzlk�pklu[pälk�ky\n�huk�^lhwvuz�ylsh[lk�vɉluzlz�jvtwhylk�[v� zjovvsz�[oh[�kpk�uv[�pujylhzl�wvspjl�z[hɉ��;ol�z[\k`�hszv�mv\uk�h�ypzl� in disciplinary action within schools that had increased police presence (gottfredson et al., 2020). with increased policing, students were more sprls`�[v�il�ylmlyylk�[v�sh^�lumvyjltlu[�mvy�uvu]pvslu[�vɉluzlz��(z�h� ylz\s[��w\upzolk�z[\klu[z�ohk�wv[lu[phs�slnhs�z`z[lt�jvuzlx\lujlz� at a younger age, increasing the risk of entering the school-to-prison pipeline. furthermore, it is essential to acknowledge that punishments involving removal from school settings impact academic achievement (tucker & vance, 2016). policing's disproportionate impact on black and latine students while this study does not address race due to data set limitations, the implications of increased policing and school punishment cannot be ignored when it comes to young students of color, particularly black and latine students. schools that primarily serve students of color are more likely to use strict surveillance measures than other schools, creating disproportionate suspension rates and arrests for students of color jvtwhylk�[v�[olpy�^op[l�jshzzth[lz��+6,���������;ol�<�:��+lwhy[tlu[� vm�,k\jh[pvu�kh[h�zuhwzov[�vm�zjovvs�kpzjpwspul�pu������ylwvy[lk�[oh[� “black students are suspended and expelled at a rate three times nylh[ly�[ohu�^op[l�z[\klu[z����+6,���������(�opnoly�z\zwluzpvu�yh[l� for students of color could cause a direct negative impact on their academic achievement. tucker and vance (2016) found that “school suspensions have been linked with academic disengagement, law enforcement and restorative circles in schools columbia social work review, vol. xix | 7 klspux\luj �̀�huk�zjovvs�kyvwv\[z¹��w�������0ujylhzpun�wvspjl�wylzlujl� pu�zjovvsz�lx\h[lz�[v�hu�pujylhzl�pu�w\up[p]l�tlhz\ylz�z\jo�hz� suspension, and could contribute to disparate impacts on black and latine students in u.s. public schools. perceptions of safety are also important to consider, especially for z[\klu[z�vm�jvsvy��1vouzvu�l[�hs���������z\y]l`lk��������z[\klu[z� from 98 middle and high schools in maryland to determine whether a correlation existed between observed security measures in school and z[\klu[z»�wlyjlw[pvuz�vm�zhml[ �̀�lx\p[ �̀�huk�z\wwvy[��:lj\yp[`�tlhz\ylz� included the addition of both internal and external surveillance cameras, hz�^lss�hz�wvspjl�vɉjlyz�pu�zjovvsz��;opz�z[\k`�mv\uk�[oh[�)shjr�huk� latine students felt less safe than their white counterparts in schools ^p[o�tvyl�wvspjl�vɉjlyz"�ov^l]ly��hss�z[\klu[z�z[pss�ohk�hu�v]lyhss�opnoly� perception of school safety. perceived school safety was low in schools with high numbers of low-income students of color, especially black students (johnson et al., 2018). even student perception regarding police presences was disparate, as it did not always make black and latine students feel safer in school. therefore, a new alternative for safety should be made that includes the safety of all students of color. school safety and academic performance *ohv[pj�vy�\uzhml�zjovvs�lu]pyvutlu[z�z[yvuns`�puå\lujl�[y\huj`� �.hzl�l[�hs����������(z�wyl]pv\zs`�uv[lk��[ol�kläup[pvu�vm�h�zhml�zjovvs� environment varies from student to student, and can be dependent on students’ identities. students might feel unsafe if they consider school policies to be violating their right to privacy or perceive school surveillance as having disciplinary motives. research has proven over the last twenty years that attendance in class and lectures correlates ^p[o�opnoly�opno�zjovvs�.7(z��z[hukhykpalk�[lz[�zjvylz��huk�l]lu� äuhs�nyhklz�pu�jvsslnl��.\tw������"�9luksltlu���������)hzlk�vu�[opz� research, it can be presumed that suspensions often lead to lower nyhklz�iljh\zl�[ol`�ylz\s[�pu�zpnupäjhu[�tpzzlk�jshzz�[ptl� furthermore, tanner-smith and fisher (2016) highlight the impact of visible school security measures, such as security guards, metal detectors, and cameras, on academic performance, attendance, and gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 8 | columbia social work review, vol. xix postsecondary aspirations. the data for this study came from the following two extensive national surveys: the school crime supplement [v�[ol�5h[pvuhs�*yptl�=pj[ptpah[pvu�:\y]l`��5�$��������z[\klu[z"����� thsl������^op[l��(nl�$��������huk�[ol�:jovvs�:\y]l`�vu�*yptl�huk� :hml[`��5�$��������zjovvsz"�����thsl������^op[l���9lz\s[z�pukpjh[lk� uv�jvuzpz[lu[�iluläjphs�lɉlj[z�vm�zlj\yp[`�tlhz\ylz�vu�hjhkltpj� outcomes. trends showed heavy surveillance had a moderately harmful impact on academic success in a small sample of high schools that contain a large low-income student population; however, visible security measures such as fences or cameras did not have any substantial wvzp[p]l�vy�ulnh[p]l�lɉlj[�vu�t\s[pwsl�lk\jh[pvu�v\[jvtlz��;huuly� smith & fisher, 2016). restorative practice in school settings: an alternative restorative justice, an alternative to the deeply rooted colonialism and white supremacy present in carcerality, has roots in indigenous cultures around the world and encourages reparation and accountability for wrongdoing in a non-punitive way (wachtel, 2016). schools are ilnpuupun�[v�\[pspal�[opz�wyhj[pjl�puz[lhk�vm�z\zwluzpvuz�huk�kl[lu[pvuz�� which remove students from the classroom. restorative circles provide space for students and teachers to develop relationships, build jvtt\up[ �̀�huk�thuhnl�jvuåpj[�[oyv\no�ovulz[�huk�jvuz[y\j[p]l� jvtt\upjh[pvu��6y[lnh�l[�hs����������(�ylz[vyh[p]l�jpyjsl�pz�h�tll[pun� between a student who has caused harm and individuals impacted by the student’s actions. such circles are facilitated by a moderator and can include teachers, school administrators, parents, and classmates. members of the circle take turns sharing how they felt harmed by the z[\klu[»z�iloh]pvy��;ol�z[\klu[�^ovzl�hj[pvuz�hyl�pu�x\lz[pvu�pz�np]lu�h� chance to discuss their decision-making, mitigate the harm they caused by taking accountability, and commit to changing their behavior to better meet the needs of their community. when performed in a group setting with a trained counselor, the restorative alternative enables everyone to be heard and has been used “to address truancy, bullying, disciplinary pzz\lz��huk�pu[lywlyzvuhs�jvuåpj[¹��6y[lnh�l[�hs���������� law enforcement and restorative circles in schools columbia social work review, vol. xix | 9 0u�[olpy�z[\k �̀�6y[lnh�l[�hs���������l_wsvylk�[ol�tp[pnh[pun�v\[jvtlz�vm� restorative circles on high school student and teacher experiences. this z[\k`�pujs\klk����z[\klu[z�huk����zjovvs�z[hɉ�huk�hktpupz[yh[vyz�myvt� a large city in the southeastern united states. restorative circles were mhjpsp[h[lk�pu�ylzwvuzl�[v�hk]lyzl�iloh]pvy�huk�x\hsp[h[p]l�pu[ly]pl^z� ^lyl�jvuk\j[lk�^p[o����vwlu�luklk�x\lz[pvuz�h[�[ol�pttlkph[l�luk�vm� lhjo�ylz[vyh[p]l�jpyjsl��0u[ly]pl^�x\lz[pvuz�mvj\zlk�iv[o�vu�[ol�jvuåpj[� huk�[ol�ylz[vyh[p]l�jpyjsl�l_wlyplujl�mvy�z[\klu[z�huk�zjovvs�z[hɉ��;opz� study produced the following favorable themes: supporting students in taking ownership and engaging with the reconciliation process, improving relationships, engaging in meaningful dialogue, preventing klz[y\j[p]l�^h`z�vm�lunhnpun�jvuåpj[��`plskpun�il[[ly�hjhkltpj�huk� social achievement, and interrupting the school-to-prison pipeline. there were two unfavorable outcomes discovered in the study, however: student frustration with the process and disappointment due to the inability for some students to be vulnerable in those spaces. the adults in this study believe comfort and trust could have been established pm�[olyl�^hz�¸[ptl�[v�i\psk�ylsh[pvuzopwz�^p[o�[ol�mhjpsp[h[vyz¹��6y[lnh� et al., 2016). despite this, the overall impact implies that less punitive tl[ovkz��z\jo�hz�\zpun�ylz[vyh[p]l�jpyjslz�[v�uh]pnh[l�jvuåpj[z�huk� iloh]pvyhs�wyvisltz��lɉlj[p]ls`�ylk\jl�iloh]pvyhs�pzz\lz�htvun� students. research questions and contributions 6\y�ylzlhyjo�x\lz[pvuz�pux\pylk�^ol[oly�[olyl�pz�h�ulnh[p]l�jvyylsh[pvu� il[^llu�[ol�wylzlujl�vm�zjovvs�zlj\yp[`�vɉjlyz�pu�zjovvsz�huk�z[\klu[� hjhkltpj�hjopl]ltlu[��:wljpäjhss �̀�[olzl�pux\pyplz�l_htpulk�^ol[oly� wvspjl�vɉjlyz�pu�zjovvsz�oh]l�h�zpnupäjhu[�ptwhj[�\wvu�h[[lukhujl�� z[\klu[z»�hjjlzz�[v�opnoly�lk\jh[pvu��z[hukhykpalk�[lz[�zjvylz��huk� suspension rates. this analysis also sought to determine whether [ol�\zl�vm�ylz[vyh[p]l�jpyjslz�pu�zjovvsz�ohz�h�zpnupäjhu[�ptwhj[�\wvu� h[[lukhujl��hjjlzz�[v�opnoly�lk\jh[pvu��z[hukhykpalk�[lz[�zjvylz��huk� suspension rates for students. finally, this statistical study explored implications for disciplinary alternatives that could prevent students from becoming involved in the criminal legal system and increase their access to the safety net of education. gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 10 | columbia social work review, vol. xix conceptual framework a regression model was used to identify and explore the relationship il[^llu�zjovvs�z\y]lpsshujl�huk�jvuåpj[�tlkph[pvu��huk�il[^llu� z[\klu[�hjhkltpj�wlymvythujl�huk�z\zwluzpvu��6ul�puklwluklu[� ]hyphisl�l_htpulk�pz�[ol�wylzlujl�vm�wvspjl�vɉjlyz�pu�zjovvs�� statistically controlling for crime at the school’s location and whether the school is in a metropolitan area. student involvement in restorative jpyjslz�pz�[ol�zljvuk�wylkpj[vy�huhs`alk��hm[ly�jvu[yvsspun�mvy�z^vyu� sh^�lumvyjltlu[�vɉjphsz»�why[pjpwh[pvu�pu�kpzjpwspul��[lhjoly�jypzpz� intervention training, and student sel. dependent variables include the average percentage of (1) daily attendance, (2) students likely to attend higher education after high school, (3) students who score below the ��[o�wlyjlu[psl�vu�z[hukhykpalk�[lz[z��huk�����z[\klu[z�yljlp]pun�v\[�vm� school suspension with no continuing school services provided for the remainder of the punishment. exploring these relationships will allow for better understanding of the connection between discipline and student performance. hypotheses (m[ly�huhs`apun�sp[lyh[\yl�hkkylzzpun�[^v�kpzjpwspuhy`�vw[pvuz�mvy�zjovvsz� and establishing the variables being tested, two hypotheses were mvyt\sh[lk��-pyz[��wvspjl�vɉjly�wylzlujl�kvlz�uv[�zpnupäjhu[s`�ylsh[l� directly to testing scores and access to higher education, but does have h�zpnupäjhu[�ulnh[p]l�ylsh[pvuzopw�^p[o�h[[lukhujl�huk�z\zwluzpvu�yh[lz�� :ljvuk��[ol�\zl�vm�ylz[vyh[p]l�jpyjslz�pu�zjovvs�ohz�h�zpnupäjhu[�wvzp[p]l� relationship with attendance, access to higher education, test scores, and a decrease in suspension rates. method data source and sample characteristics this study used the national center for education statistics’ (nces) :jovvs�:\y]l`�vu�*yptl�huk�:hml[`��::6*:���h�uh[pvuhss`�ylwylzlu[h[p]l� cross-sectional survey on u.s. k-12 public schools (padgett et al., �������;ol�::6*:�l_htpulz�zjovvs�jyptl�huk�zhml[`�pzz\lz��pujs\kpun� school policies and programs, disciplinary practices, parent/community law enforcement and restorative circles in schools columbia social work review, vol. xix | 11 pu]vs]ltlu[��zjovvs�zlj\yp[`�wylzlujl��huk�z[hɉ�[yhpupun��<zpun�::6*:� 2017-2018 data, the following analyses have examined the relationship between school academic achievement and the programs, procedures, and policies that schools implement to prevent and reduce crime. the data was collected between february 20, 2018 and july 18, 2018. method of analysis ;̂ v�63:�ylnylzzpvuz�^lyl�\zlk�[v�[lz[�[ol�wylkpj[hipsp[`�vm�h[[lukhujl�� hjjlzz�[v�opnoly�lk\jh[pvu��z[hukhykpalk�[lz[�zjvylz��huk�z\zwluzpvu� yh[lz��vul�ihzlk�vu�[ol�wylkpj[vy�vm�wvspjl�vɉjly�wylzlujl�vu�zjovvs� grounds and another on the use of restorative justice circles as an alternative to discipline. results table 1 addresses the descriptive statistics for each dependent and independent variable, without controlling for other factors. tables 2 and 3 display the regressions with controls to ensure a more accurate description of the correlation. police officer presence ;ol�pujs\klk�ylnylzzpvuz�`plsklk�]hy`pun�ylz\s[z��6u�h]lyhnl��^olu�h� wvspjl�vɉjly�^hz�wylzlu[�pu�zjovvsz��[olyl�^hz�uv�zpnupäjhu[�johunl�pu� h[[lukhujl�^p[o�h�wvpu[�lz[pth[l�vm���������������([[lukhujl�huk�vɉjly� wylzlujl�pu�[ol�zjovvs�ohk�h�z[h[pz[pjhss`�uvu�zpnupäjhu[�jvyylsh[pvu�� after controlling for crime rates in the school’s location and the school zl[[pun»z�wvw\sh[pvu�kluzp[ �̀�hz�zllu�pu�;hisl������ ���vm�[ol�]hyphujl�pu� h[[lukhujl�yh[lz�^hz�l_wshpulk�i`�[ol�wylzlujl�vm�wvspjl�vɉjlyz�pu�[ol� school setting, rate of crime in the area, and population density of the zjovvs�ulpnoivyovvk��([[lukhujl�ohk�h�z[yvun�z[h[pz[pjhss`�zpnupäjhu[� positive correlation with a low level of crime in the school neighborhood �w#�������:jovvsz�^p[o�wvspjl�vɉjly�wylzlujl�ohk��vu�h]lyhnl������ � (0.93) fewer students accessing higher education after controlling for crime rates in the school’s location and the school setting’s population kluzp[ �̀�7vspjl�vɉjly�wylzlujl�pu�[ol�zjovvs�zl[[pun��[ol�hylh»z�jyptl� yh[l��huk�[ol�zjovvs�ulpnoivyovvk»z�wvw\sh[pvu�kluzp[`�l_wshpu�������� gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 12 | columbia social work review, vol. xix of student variance in achieving higher education. higher education hjopl]ltlu[�huk�vɉjly�wylzlujl�pu�zjovvs�ohk�h�z[h[pz[pjhss`�uvu� zpnupäjhu[�jvyylsh[pvu��<[pspapun�opno�jyptl�yh[lz�hz�[ol�ylmlylujl� group, attending higher education was positively correlated with low and moderate crime levels in the school neighborhood, with a strong z[h[pz[pjhs�zpnupäjhujl��w#�������>olu�kluzls`�wvw\sh[lk�jp[plz�hyl�hszv� the reference group, students living in towns and rural communities were slzz�sprls`�[v�w\yz\l�h�opnoly�lk\jh[pvu��^p[o�h�z[h[pz[pjhss`�zpnupäjhu[� negative correlation (p<.001). ;hisl���pss\z[yh[lz�[oh[�zjovvsz�^p[o�wvspjl�vɉjly�wylzlujl�lhyulk���� � �������opnoly�vu�z[hukhykpalk�[lz[�zjvylz��vu�h]lyhnl��hm[ly�jvu[yvsspun� for crime rates at the school’s location and the school setting’s wvw\sh[pvu�kluzp[ �̀�;ol�]hyphujl�vm��������pu�z[hukhykpalk�[lz[�zjvylz� ^hz�l_wshpulk�i`�wvspjl�vɉjly�wylzlujl�pu�zjovvs�zl[[punz��yh[l�vm�jyptl� pu�[ol�hylh��huk�zjovvs�ulpnoivyovvk�wvw\sh[pvu�kluzp[ �̀�:[hukhykpalk� [lz[�zjvylz�huk�vɉjly�wylzlujl�pu�zjovvs�ohk�h�z[h[pz[pjhss`�uvu� zpnupäjhu[�jvyylsh[pvu��/pnoly�[lz[�zjvylz�ohk�h�z[yvun�z[h[pz[pjhss`� zpnupäjhu[�ulnh[p]l�jvyylsh[pvu�^p[o�sv^�huk�tvklyh[l�jyptl�sl]lsz�pu�[ol� school neighborhood (p<.001) when high crime rates were the reference group. with metropolitan cities as the reference group, suburbs and y\yhs�jvtt\up[plz�ohk�h�z[h[pz[pjhss`�zpnupäjhu[�ulnh[p]l�jvyylsh[pvu�^p[o� [ol�sprlspovvk�vm�oh]pun�opnoly�z[hukhykpalk�[lz[�zjvylz��w#������� after controlling for school crime rates and population density, there ^lyl�������������tvyl�z\zwluzpvuz�^olu�h�wvspjl�vɉjly�^hz�wylzlu[� pu�zjovvs��7vspjl�vɉjly�wylzlujl�pu�[ol�zjovvs��jyptl�yh[l�pu�[ol�hylh�� huk�wvw\sh[pvu�kluzp[`�vm�[ol�zjovvs�ulpnoivyovvk�l_wshpulk� ���vm� the variance in suspension rates. as shown in table 2, the number of z\zwluzpvuz�huk�[ol�wylzlujl�vm�vɉjlyz�h[�zjovvs�yl]lhslk�h�z[yvun�� z[h[pz[pjhss`�zpnupäjhu[�wvzp[p]l�jvyylsh[pvu���w#������>olu�tl[yvwvsp[hu� cities were the reference group, suspension rates were positively correlated with towns and rural communities, with a strong statistical zpnupäjhujl��w#������ restorative circles 9lnhykpun�ylz[vyh[p]l�jpyjslz��[lhjoly�[yhpupun��z[\klu[�:,3��huk�vɉjly� law enforcement and restorative circles in schools columbia social work review, vol. xix | 13 involvement in discipline, school attendance, could be determined with h�������]hyphujl��0u�;hisl����ylz[vyh[p]l�q\z[pjl�\zl�ohk�h�z[h[pz[pjhss`� uvu�zpnupäjhu[�jvyylsh[pvu�vm��������������^p[o�zjovvs�h[[lukhujl�� 9lz[vyh[p]l�q\z[pjl�\zl�ohk�h�z[h[pz[pjhss`�puzpnupäjhu[�wvzp[p]l�jvyylsh[pvu� with higher education attainment, as seen in table 3. teacher training pu�jypzpz�pu[ly]lu[pvu�huk�wyl]lu[pvu�ohk�h�z[h[pz[pjhss`�zpnupäjhu[� wvzp[p]l�ylsh[pvuzopw�vm�������������^p[o�opnoly�lk\jh[pvu�h[[lukhujl� �w#������:[\klu[�:,3�hszv�ohk�h�z[yvun�z[h[pz[pjhss`�zpnupäjhu[�wvzp[p]l� ylsh[pvuzopw�vm���������� ��^p[o�opnoly�lk\jh[pvu�h[[hputlu[�hjyvzz�[ol� zjovvs��w#�������7vspjl�vɉjlyz�pu]vs]lk�pu�z[\klu[�kpzjpwspul�ohk�h� z[h[pz[pjhss`�zpnupäjhu[�ulnh[p]l�jvyylsh[pvu�vm��������������^p[o�opnoly� education rates (p<.05). when examining interventions of restorative justice use, teacher [yhpupun��z[\klu[�:,3��huk�vɉjly�pu]vs]ltlu[�pu�kpzjpwspul�[v�kl[lytpul� z[hukhykpalk�[lz[�zjvylz��[olyl�^hz�h�������]hyphujl��9lz[vyh[p]l� q\z[pjl�\zl�ohk�h�z[yvun��z[h[pz[pjhss`�zpnupäjhu[�wvzp[p]l�jvyylsh[pvu�vm� ������������^p[o�opnoly�z[hukhykpalk�[lz[�zjvylz��w#�������9ljlu[�[lhjoly� [yhpupun�pu�jypzpz�pu[ly]lu[pvu�huk�wyl]lu[pvu�ohk�h�z[h[pz[pjhss`�zpnupäjhu[� ulnh[p]l�ylsh[pvuzopw�vm���������� ���^p[o�opnoly�z[hukhykpalk�[lz[�zjvylz� (p<.05). when changing the predictor and controls to restorative justice use, [lhjoly�[yhpupun��z[\klu[�:,3��huk�vɉjly�pu]vs]ltlu[�pu�kpzjpwspul�� [ol�z\zwluzpvu�yh[lz»�]hyphujl�^hz��������(z�zov^u�pu�;hisl����^olu� jvu[yvsspun�mvy�[lhjoly�[yhpupun��z[\klu[�:,3��huk�vɉjly�pu]vs]ltlu[�� ylz[vyh[p]l�jpyjslz�pu�[ol�jshzzyvvt�ohk�h�^lhr��z[h[pz[pjhss`�zpnupäjhu[� negative relationship of -0.05 (0.02) with high suspension rates (p<.05). :[\klu[�:,3�huk�vɉjly�pu]vs]ltlu[�pu�kpzjpwspul�hszv�ohk�z[h[pz[pjhss`� zpnupäjhu[�ylsh[pvuzopwz�^p[o�z\zwluzpvu�yh[lz��w#������4vyl�z[\klu[� :,3�tlhu[��������������ml^ly�z\zwluzpvuz��>olu�vɉjlyz�^lyl�pu]vs]lk� in discipline, suspension rates increased by 0.05 (0.02). discussion ;ol�wylzlujl�vm�wvspjl�pu�2����w\ispj�zjovvsz�äyz[�ilnhu�pu�[ol�� ��z� huk�ohz�ypzlu�z[lhkps`�zpujl�[ol�:hml�:jovvs�(j[�vm�� ���)yv^u������"� coon & travis, 2012). the authors are not aware of existing literature gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 14 | columbia social work review, vol. xix l_htpupun�[ol�sprlspovvk�vm�why[pj\shy�zjovvsz�opypun�wvspjl�vɉjlyz"� however, information on the demographics, prior disciplinary practices, and socio-economic statuses of schools most likely to incorporate law enforcement would be useful for future research. police presence in school is predictive of greater odds of suspension, which can push students through the school-to-prison pipeline (mckenna & white, 2017). alternatives to traditional discipline, such as ylz[vyh[p]l�q\z[pjl�jpyjslz��jhu�tp[pnh[l�[ol�lɉlj[z�[oh[�slhk�z[\klu[z�[v� entering this pipeline. this paper’s analysis demonstrates that the use of restorative justice, teacher training, and student sel had a positive correlation with higher education attainment and attendance and decreased suspension rates. -\y[olytvyl��wvspj`thrlyz��wvspjl�klwhy[tlu[z��huk�zjovvs�vɉjphsz� jvu[pu\l�[v�l_whuk�wvspjpun�wyvnyhtz�z\jo�hz�[ol�+61��*vtt\up[`� 6yplu[lk�7vspjpun�:ly]pjlz�wyvnyht��*67:���huk�tvyl��4j2luuh� � 7l[yvzpuv���������*67:��^opjo�pz�why[�vm�[ol�=pvslu[�*yptl�*vu[yvs�huk� 3h^�,umvyjltlu[�(j[�vm�� ���opylz�huk�[yhpuz�jvtt\up[`�wvspjpun� professionals through government funded grants (mckenna & petrosino, 2022). this money could potentially have been used instead to fund ylzlhyjo�z\wwvy[lk�wyvnyhtz�sprl�:,3��6]lyhss��vu�h�z`z[ltpj�sl]ls�� [ol�<�:��mlklyhs�nv]lyutlu[�pz�mhpspun�[v�wyv]pkl�hklx\h[l�ylzv\yjlz�[v� schools to properly educate the growing population of students with kpɉlypun�iloh]pvyhs�ullkz��+hyspun�/httvuk�������� investing millions of dollars in law enforcement programs may contribute to increasing student chances of criminal legal system involvement �.v[[mylkzvu�l[�hs����������;ol�zhtl�m\ukpun�jv\sk�il�\[pspalk�[v�wyvtv[l� restorative justice and alternative means of discipline that keep students pu�zjovvs��0[�pz�jy\jphs�[v�yljvnupal�tvyl�wlkhnvnpjhss`�zv\uk�wyhj[pjlz� [v�hkkylzz�zjovvs�]pvslujl�huk�olsw�z[\klu[z�th_ptpal�[olpy�lk\jh[pvuhs� opportunities, such as restorative circles, which were shown to decrease z\zwluzpvu�yh[lz�huk�pujylhzl�z[hukhykpalk�[lz[�zjvylz��7vspj`thrlyz� should enact legislation to provide students with counseling services, mental health services, and sel programs that promote angerthuhnltlu[�z[yh[lnplz�huk�jvuåpj[�ylzvs\[pvu��0twyv]pun�[ol�x\hsp[`� and strength of teaching approaches and classroom management skills law enforcement and restorative circles in schools columbia social work review, vol. xix | 15 oh]l�wyv]lu�[v�il�htvun�[ol�tvz[�lɉlj[p]l�^h`z�[v�luohujl�zjovvs� safety (nickerson et al., 2021). this paper’s analysis demonstrates that suspensions decrease when schools implement crisis prevention and intervention training, restorative q\z[pjl�wyhj[pjlz��huk�:,3�wyvnyhtz��(kkp[pvuhss �̀�[ol�äukpunz�pukpjh[l� [oh[�ylz[vyh[p]l�q\z[pjl�wyhj[pjlz�oh]l�h�wvzp[p]l�ptwhj[�vu�z[hukhykpalk� test scores. this reinforces themes presented in previous literature, such hz�[ol�jvuulj[pvuz�il[^llu�pujylhzlk�z\zwluzpvu��zjovvs�wvspjl�vɉjly� presence, and decreased access to higher education (petrosino et al., 2012; weisburst, 2019). this paper contributes to existing literature by tlhz\ypun�[ol�ptwhj[�vm�zjovvs�wvspjl�vɉjly�wylzlujl�huk�ylz[vyh[p]l� q\z[pjl�jpyjslz�vu�h[[lukhujl�huk�z[hukhykpalk�[lz[�zjvylz�� limitations police presence and restorative circles in schools were examined to build on existing literature addressing the school-to-prison pipeline and its disproportionately negative impact on students of color. unfortunately, student demographics were not available within the data set used, making it impossible to determine potential relationships outside of the area’s crime level and population density. the dataset kpk�uv[�pukpjh[l�[ol�z[\klu[�[v�zjovvs�wvspjl�vɉjly�yh[pv�vy�hu`�v[oly� pukpjh[pvu�vm�zjovvs�johyhj[lypz[pjz�[oh[�opylk�zjovvs�wvspjl�vɉjlyz�pu� percentages. the dataset only provided the number of public schools tabulated into school characteristics such as neighborhood crime level, zjovvs�zpal��kp]lyzp[ �̀�huk�z[\klu[�hwwyv_pth[l�ov\zlovsk�pujvtl� sl]ls��(kkp[pvuhs�sptp[h[pvuz�pujs\kl�[ol�]hy`pun�x\hsp[`�vm�ylz[vyh[p]l� justice circles across schools that participated in the survey, potentially hɉlj[pun�[ol�ylnylzzpvu�v\[jvtl�zpujl�mhjpsp[h[vy�jvtwl[luj`�jv\sk� shift the outcome of the restorative justice circles. conclusion ;ol�yvsl�wvspjl�vɉjlyz�wsh`�pu�zjovvsz�ulnh[p]ls`�ptwhj[z�z[\klu[� slhyupun��[olyli`�hɉlj[pun�[olpy�m\[\yl�lk\jh[pvuhs��ltwsv`tlu[��huk� criminal legal involvement. it is crucial to understand better ways to hold students accountable for their decisions, address school violence, and gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 16 | columbia social work review, vol. xix meet student needs. in order to engage students without perpetuating pathways to the juvenile legal system, schools need to provide sel wyvnyhtz�huk�yln\shy�[yhpupun�[v�[lhjolyz��wypujpwhsz��huk�z[hɉ�[v� support positive behavior. this analysis has shown that restorative q\z[pjl�\zl�^hz�[plk�[v�opnoly�z[hukhykpalk�[lz[pun�zjvylz�huk�ohz�[ol� ability to mitigate the impacts of suspension rates. considering the impact that the school-to-prison pipeline can have on youth, changes must be made to transition to pedagogically sound practices that are proven to improve academic outcomes. references )yv^u��)����������<uklyz[hukpun�huk�hzzlzzpun�zjovvs�wvspjl�vɉjlyz!�(�jvujlw[\hs�huk� methodological comment. journal of criminal justice���������� �������o[[wz!��kvp�vyn�� 10.1016/j.jcrimjus.2006.09.013 *vsvyhkv�:[h[l�<up]lyzp[`��u�k���>o`�3h[pu_�l&�o[[wz!��lsjlu[yv�jvsvz[h[l�lk\�hiv\[�^o`� latinx coon, j. k., & travis iii, l. f. (2012). the role of police in public schools: a comparison of principal and police reports of activities in schools. police practice and research, 13(1), 15-30. +hyspun�/httvuk��3����������9hjl��pulx\hsp[`�huk�lk\jh[pvuhs�hjjv\u[hipsp[`!�;ol�pyvu`� of ‘no child left behind.’ race ethnicity and education������������������o[[wz!��kvp� org/10.1080/13613320701503207 gase, l. n., defosset, a., perry, r., & kuo, t. (2016). youths' perspectives on the reasons underlying school truancy and opportunities to improve school attendance. the qualitative report���������� ��o[[wz!��zlhyjo�wyvx\lz[�jvt� vwlu]pl^��k�l�����h�hk�k���k h��k�j�jlɉ����&wx�vypnzp[l$nzjovshy jis$����� gottfredson, d. c., crosse, s., tang, z., bauer, e. l., harmon, m. a., hagen, c. a., �.yllul��(��+����������,ɉlj[z�vm�zjovvs�ylzv\yjl�vɉjlyz�vu�zjovvs�jyptl�huk� responses to school crime. criminology & public policy��� ����� ��� ����o[[wz!��kvp� vyn�������������� ���������� gump, s. (2005). the cost of cutting class: attendance as a predictor of student success. college teaching, 53(1), 21-26. http://www.jstor.org/stable/27559212 hulvershorn, k., & mulholland, s. (2018). restorative practices and the integration of social emotional learning as a path to positive school climates. journal of research in innovative teaching & learning. law enforcement and restorative circles in schools columbia social work review, vol. xix | 17 johnson, s. l., bottiani, j. h., waasdorp, t. e., & bradshaw, c. (2018). surveillance or zhmlrllwpun&�/v^�zjovvs�zlj\yp[`�vɉjly�huk�jhtlyh�wylzlujl�puå\lujl�z[\klu[z�� wlyjlw[pvuz�vm�zhml[ �̀�lx\p[ �̀�huk�z\wwvy[��;ol�1v\yuhs�vm�(kvslzjlu[�/lhs[o!�6ɉjphs� publication of the society for adolescent medicine, 63(6), 732-738. https://www.science kpylj[�jvt�zjplujl�hy[pjsl�wpp�:������ ?�������� mckenna, j. m., & petrosino, a. (2022). school policing programs: where we have been and where we need to go next. national institute of justice. https://www.ojp.gov/ wkɉslz��upq����� ��wkm mckenna, j. m., & white, s. r. (2017). examining the use of police in schools: how roles may impact responses to student misconduct. american journal of criminal justice, ����������¶�����o[[wz!��kvp�vyn���������z���������� ����� 5hujl��1��7����������:[\klu[�z\y]lpsshujl��yhjphs�pulx\hsp[plz��huk�ptwspjp[�yhjphs�iphz��emory law journal��������������������o[[wz!��zzyu�jvt�hiz[yhj[$������� nickerson, a. b., randa, r., jimerson, s., & guerra, n. g. (2021). safe places to learn: advances in school safety research and practice. school psychology review, 50(2-3), ���������o[[wz!��kvp�vyn������������� ��?���������� �� 6y[lnh��3���3`\ihuzr �̀�4���5l[[slz��:��� �,zwlshnl��+��3����������6\[jvtlz�vm�h�ylz[vyh[p]l� circles program in a high school setting. psychology of violence���������� ¶�����o[[wz!�� kvp�vyn���������]pv������� padgett, z., jackson, m., correa, s., kemp, j., gilary, a., meier, a., gbondo-tugbawa, k., and mcclure, t. (2020). school survey on crime and safety: 2017–18 public-use data [data set]. national center for education statistics, institute of education sciences, u.s. department of education. washington, dc. http://nces.ed.gov/pubsearch petrosino, a., guckenberg, s., & fronius, t. (2012). ‘policing schools’ strategies: a review of the evaluation evidence. journal of multidisciplinary evaluation, 8, 80–101. 9lukslthu��*��4����������+v�h[[lukhujl�wvspjplz�ptwyv]l�z[\klu[�wlymvythujl&�;ol� relationship among attendance, class policies, and grades. nacta journal,������������ �� ��o[[wz!��^^ �̂qz[vy�vyn�z[hisl� ������� tanner-smith, e. e., & fisher, b.w. (2017). visible school security measures and student academic performance, attendance, and postsecondary aspirations. journal of youth and adolescence���������� �������o[[w!��kvp�vyn���������z�� ������������� tucker, j. w., & vance, a. (2016). school surveillance: the consequences for equity and privacy��5h[pvuhs�(zzvjph[pvu�vm�:[h[l�)vhykz�vm�,k\jh[pvu��o[[wz!��äslz�lypj�lk�nv]�� fulltext/ed582102.pdf gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 18 | columbia social work review, vol. xix <�:��+lwhy[tlu[�vm�,k\jh[pvu��+6,�����������data snapshot: school discipline. https:// ocrdata. ed.gov/assets/downloads/crdc-school-discipline-snapshot.pdf wachtel, t. (2016). +läupun�ylz[vyh[p]l!�/pz[vy �̀ international institute for restorative 7yhj[pjlz��o[[wz!��^^ �̂ppyw�lk\�kläupun�ylz[vyh[p]l�opz[vy` weiler, s. c., & cray, m. (2011). police at school: a brief history and current status of zjovvs�ylzv\yjl�vɉjlyz��the clearing house: a journal of educational strategies, issues and ideas������������������o[[wz!��kvp�vyn������������ ������������� �� weisburst, e. k. (2019). patrolling public schools: the impact of funding for school police on student discipline and long-term education outcomes. journal of policy analysis and management, 38(2), 338-365. https://doi.org/10.1002/pam.22116 law enforcement and restorative circles in schools columbia social work review, vol. xix | 19 appendix a table 1: descriptive statistics variables total school resource 6ɉjlyz� participate in discipline no school resource 6ɉjlyz� participate in discipline student involvement in restorative circles no student involvement in restorative circles attendance 93.156 93.123 93.225 93.110 93.196 higher education 62.693 62.276 63.550 63.900 61.922 standardized tests 18.263 ������ 18.137 20.318 ��� � suspension rates ���� 0.508 ����� ����� 0.522 observations 2,762 1,859 903 1,077 1,685 gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite 20 | columbia social work review, vol. xix appendix b table 2: law enforcement and academic achievement variables attendance higher education standardized tests suspension rates sworn law enforcement participate in discipline -0.16 -1.69 0.79 0.06** (0.31) (0.93) (0.67) (0.02) moderate crime level 1.35+ 9.56*** -12.29*** 0.00 (0.69) (2.07) ���� � (0.05) low crime level 2.51*** 21.70*** -20.85*** 0.01 (0.65) (1.96) ������ ������ suburb locale ���� 1.51 �������� 0.00 (0.38) (1.15) (0.83) (0.03) town locale -0.01 -12.95*** -2.10+ 0.10** ���� � ���� � (1.07) (0.03) rural locale 0.19 ��������� �������� 0.08** ������ (1.31) ��� �� (0.03) constant 90.95*** � ������ 38.22*** ������� ������ (1.93) (1.39) ������ observations 2,762 2,762 2,762 2,762 r-squared 0.01 0.12 0.13 0.01 standard errors in parentheses *** p<0.001, ** p<0.01, * p<0.05, + p<0.10 law enforcement and restorative circles in schools columbia social work review, vol. xix | 21 appendix c table 3: restorative circles and academic achievement variables attendance higher education standardized tests suspension rates restorative circles ����� 1.38 ������� -0.05* (0.33) (1.16) (0.85) (0.02) teacher training -0.38 ����� -2.12* -0.05+ (0.38) (1.32) (0.97) (0.03) student sel -0.32 ������ 0.81 -0.08* ������ (1.59) (1.16) (0.03) sworn law enforcement ����� ������ 0.75 0.05* (0.32) (1.11) (0.81) (0.02) constant �� ���� 57.19*** �������� 0.66*** ���� � (1.70) ������ ������ observations 1,859 1,859 1,859 1,859 r-squared 0.00 0.01 0.02 0.01 standard errors in parentheses *** p<0.001, ** p<0.01, * p<0.05, + p<0.10 gabriel bautista, caitlin e. mello, jennifer song, and richard a. unite cswr spring 2022 columbia social work review, vol. xix | 23 from foster care to the streets: a call to support black, indigenous, and lgbtq+ youth in foster care lee ann genussa 24 | columbia social work review, vol. xix from foster care to the streets abstract the modern united states (u.s.) foster care system’s history is steeped in racism, violence, and oppression. today, black, indigenous, and lgbtq+ youth are overrepresented in the u.s. foster care system and oh]l�mhsslu�]pj[pt�[v�p[z�vwwylzzp]l�wyhj[pjlz��-vy�thu`�thynpuhspalk� youths, running away from foster care is perceived to be a more viable option than continuing to endure discrimination within the system despite the high risks of homelessness, unstable housing, human [yhɉjrpun��zl_\hs�l_wsvp[h[pvu��huk�v[oly�khunlyz�hzzvjph[lk�^p[o� elopement. for the purposes of this article the term elopement will be used to refer to runaway behavior. this article seeks to illustrate how the vwwylzzp]l�slnhj`�vm�[ol�mvz[ly�jhyl�z`z[lt�wylzly]lz�[ol�z[h[\z�x\v� i`�kpzpu[lnyh[pun�huk�yl[yh\th[papun�)shjr��0ukpnluv\z��huk�3.);8�� communities. the author explores the impacts of foster care on the tpjyv�huk�tlzv�sl]lsz��jyp[px\lz�j\yylu[�wvspj`�wyhj[pjlz��huk�vɉlyz� alternative perspectives for social workers to create a more just and genuine child welfare system. keywords: foster care, child welfare, elopement, racism, black youth, indigenous youth, lgbtq+ youth columbia social work review, vol. xix | 25 lee ann genussa t olyl�hyl�wylzlu[s`�tvyl�[ohu���������`v\[o�ylzpkpun�^p[opu� the u.s. foster care system, which includes non-relative and relative foster homes, group homes, and other residential institutions (children’s bureau, 2021). youth may be placed in foster care arrangements for a variety of reasons, including physical, emotional, and sexual abuse and neglect on the part of the youth’s caregivers. few of these removals are warranted, and data from several states has shown that about half of all removals occur without prior judicial review (inguanta & sciolla, 2021; simon, 2018). with the vulnerability of youth in mind, one might assume that foster care has been designed to create supportive, healthy, stable, and safe environments. before we make this assumption, however, we must hzr�v\yzls]lz�[^v�n\pkpun�x\lz[pvuz!�����^oh[�hyl�[ol�tvz[�wyvihisl� outcomes for youth placed in foster care, and (2) which groups does the <�:��jopsk�^lsmhyl�z`z[lt�nlu\puls`�ilulä[& ,hjo�`lhy��hwwyv_pth[ls`����vm�`v\[o�pu�mvz[ly�jhyl�y\u�h^h`�myvt�[olpy� foster care arrangements (children’s bureau, 2021). this leaves 5,000 children and adolescents formerly in foster care without stable housing, care, or resources every year. youth in foster care constitute a large portion of all runaway youth and are more than twice as likely to elope hz�jvtwhylk�[v�zhtl�hnlk�wllyz�uv[�sp]pun�pu�mvz[ly�jhyl��4vyl^p[a�� 2016). when considering the demographics of children in the welfare system, p[�pz�jy\jphs�[v�hjruv^slknl�[ol�zpnupäjhu[�kpzwhyp[plz�mhjlk�i`�zvjphss`� thynpuhspalk�nyv\wz��:[\kplz�oh]l�zov^u�[oh[�)shjr��0ukpnluv\z��huk� lgbtq+ youth are all disproportionately represented in the foster care system as compared to the general population (figure 1. ching-hsuan, 2012; harris & hackett, 2008; mccormick et al., 2017). in order to \uklyz[huk�^o`�[opz�pz�[ol�jhzl��p[�pz�ptwlyh[p]l�[v�huhs`al�[ol�opz[vypjhs� functions of foster care and the current role that social workers play in maintaining its legacy. 26 | columbia social work review, vol. xix a brief overview: the state of foster care past and present the history of modern foster care extends back to colonial america and its practices of indentured servitude. the american indentured shivy�z`z[lt�^hz�vypnpuhss`�klyp]lk�myvt�[ol�,unspzo�,spahil[ohu�7vvy� law’s concept of parens patriae, the idea that communities had some responsibility in protecting dependent, parentless children (rymph, 2017). however, this protection was not free: these children were expected to learn and perform labor to fund their own care (rymph, 2017). by the mid-19th century, shifts in public perceptions of slavery and zly]p[\kl��hz�^lss�hz�yhwpk�puk\z[yphspah[pvu��nh]l�^h`�[v�pujylhzpuns`� \yihu�wvw\sh[pvuz�vm�ovtlslzz�`v\[o��6ywohuhnlz�ilnhu�[v�ylwshjl� workhouses and were thought, at the time, to be a more humane and u\y[\ypun�hs[lyuh[p]l�[v�puklu[\ylk�zly]p[\kl��6ywohuhnlz�zl[�z[ypj[� criteria for their selection processes and often denied children on the basis of religion, race, and ethnicity (rymph, 2017). in 1853, theologian charles loring brace established the children’s (pk�:vjpl[`��*(:��pu�hu�pu[luklk�lɉvy[�[v�htlspvyh[l�[ol�^vyzlupun� jvukp[pvuz�vm�\yihu�spml�mvy�\uov\zlk�`v\[o��;ol�vynhupah[pvu�ilnhu� to send parentless and impoverished youth out west on what would uv[vypv\zs`�il�ylmlyylk�[v�hz�¸vywohu�[yhpuz¹�pu�hu�lɉvy[�[v�oh]l� them adopted by rural farmers and their families. the process was klo\thupapun!�jopskylu�\w�^lyl�spulk�\w�sprl�jh[[sl�[v�il�zlslj[lk�i`� mhytlyz�ihzlk�vu�[olpy�wo`zpx\l�huk�hwwhylu[�wo`zpjhs�olhs[o��)ljh\zl� of an emphasis on placing children out of their biological families, brace and cas are often cited as the foundations of modern foster care. by the early 20th century, the progressive era led to an array of new federal agencies including the u.s. children’s bureau, which remains involved in foster and adoption today (rymph, 2017). the racist praxis of the child welfare system has been documented mvy�kljhklz��:pujl�[ol�<�:�»z�ipy[o��)shjr�`v\[o�^lyl�\uhisl�[v�ilulä[� from child welfare services based on their race. growing support for integration in the 1950s led to the child welfare system abruptly from foster care to the streets columbia social work review, vol. xix | 27 adopting harsh, punitive rules in foster care as a new way to punish black youth, families, and communities (cooper, 2013). a similar legacy of state violence perpetrated by the child welfare system haunts indigenous youth and communities today. for over a century indigenous children were forcibly taken from their families and sent to boarding zjovvsz�pu�h�k\hs�lɉvy[�[v�hzzptpsh[l�[ol�jopskylu�[v�^op[l�(tlypjhu� culture while continuing the genocide of indigenous communities (cooper, 2013). today, black youth constitute nearly one third of the total population of mvz[ly�jhyl�`v\[o�klzwp[l�jvtwypzpun�vus`�����vm�[ol�nlulyhs�wvw\sh[pvu� (census bureau, 2020; children’s bureau, 2021). similarly, lgbtq+ `v\[o�thrl�\w�hiv\[� ����vm�[ol�nlulyhs�wvw\sh[pvu�jvtwhylk�[v� ����vm�[ol�mvz[ly�jhyl�wvw\sh[pvu��>p[o�ylzwlj[�[v�0ukpnluv\z�wlvwslz�� än\ylz�pss\z[yh[l�kv\isl�[ol�wvw\sh[pvu�vm�0ukpnluv\z�`v\[o�pu�mvz[ly�jhyl� in comparison to the general population (figure 2). given the violent and oppressive history of the child welfare system, we can begin to \uklyz[huk�^o`�jopskylu�huk�hkvslzjlu[z�^p[o�[olzl�zvjphs�pklu[pälyz� are more likely to run away from foster care compared to white, cisgender, heterosexual youth. in fact, black youth, especially black girls, in foster care are almost twice as likely to elope compared to their ^op[l��zhtl�hnlk�wllyz��>\sja`u�������� these statistics paint a concerning picture: the modern foster care system is a harmful entity that actively targets black, indigenous, and lgbtq+ youth and children. for decades, these communities have seen social workers unnecessarily remove black and indigenous youth with historical and generational trauma away from their families and place them in culturally incompetent foster care arrangements (brave /lhy[�l[�hs�������"�*y\[joälsk�l[�hs�������"�:ht\lsz� �3h9vzzh����� ��� likewise, social workers have removed lgbtq+ youth who have been pu]hspkh[lk�huk�kpzv^ulk�i`�[olpy�mhtpsplz��huk�z\izlx\lu[s`�wshjlk� them in care arrangements that perpetuate the very same invalidation and trauma (mccormick et al., 2017; mooney, 2017). for many youths, the abuse and neglect experienced before and during foster care are so unbearable that they choose to elope (mccormick l[�hs�������"�9lht� �-vynl���������;ol�kl[yptlu[hs�lɉlj[z�[oh[�[opz� lee ann genussa 28 | columbia social work review, vol. xix decision can have on youths’ wellbeing are numerous. youth who elope from foster care are more likely to experience homelessness, sexual l_wsvp[h[pvu��o\thu�[yhɉjrpun��ky\n�huk�hsjvovs�hi\zl��pu]vs]ltlu[�pu� jyptpuhs�hj[p]p[ �̀�huk�kpɉj\s[`�mvytpun�h[[hjotlu[�[v�hk\s[z��*yvzzshuk� �+\ushw������"�-lyuhuklz�(sjhu[hyh������"�3h[athu�l[�hs������ ���0[�pz� ptwlyh[p]l�[oh[�zvjphs�^vyrlyz�x\lz[pvu�[ol�lɉlj[p]lulzz�vm�[ol�mvz[ly� care system when thousands of black, indigenous, and lgbtq+ youth are willing to endure so much trauma and violence simply to avoid being in foster care. why youth elope youth in foster care may choose to run away for a myriad of reasons. :vtl�th`�slh]l�[v�lzjhwl�hi\zl�vy�pklu[p[`�jvuåpj[�^p[o�jhylnp]lyz�huk� wllyz"�v[olyz�th`�jovvzl�[v�åll�[v�nhpu�puklwluklujl�vy�yl\up[l�^p[o� biological family and friends. for simplicity’s sake, we can group these driving forces as push and pull factors, respectively (king et al., 2017; 3h[athu� �.piiz������"�7hnl���������)`�kläup[pvu��w\ss�mhj[vyz�pukpjh[l� the presence of some external force pulling the youth away from their care arrangement, such as the aforementioned desire to reunite with biological family members. in contrast, push factors allude to an internal force driving the youth away from their care arrangement—for example, abusive, authoritarian, homophobic, or racist foster parents and peers. while both factors play an important role in the decision to run away, )shjr��0ukpnluv\z��huk�3.);8��`v\[o�hyl�vm[lu�olh]ps`�puå\lujlk�i`� w\zo�yh[oly�[ohu�w\ss�mhj[vyz��2pun�l[�hs�������"�3h[athu� �.piiz������"� page, 2017). discrimination and abuse faced by lgbtq+ youth in foster care have been well documented (mccormick et al., 2017). prior to being placed, it is not uncommon for lgbtq+ youth to encounter social workers who lack an appropriate degree of cultural humility. as such, even before entering the foster care system many lgbtq+ youths are met ^p[o�hk\s[z�^ov�mhps�[v�\uklyz[huk�[olt�huk�wyv]pkl�hklx\h[l�z\wwvy[� and resources. if that were not damaging enough, without incurring repercussions, foster parents may legally refuse to house lgbtq+ youth �4j*vytpjr�l[�hs����������6ujl�pu�mvz[ly�jhyl��3.);8��`v\[o�lujv\u[ly� from foster care to the streets columbia social work review, vol. xix | 29 varied, usually deleterious, experiences. isolation, harassment, physical and sexual abuse, forced conversion, double standards in rules for straight peers, and a lack of acceptance are all common experiences for lgbtq+ youth living in foster care on the basis of their gender identities and sexualities (harris & hackett, 2008; mccormick et al., 2017; rymph, �������0u�mhj[��h�zpnupäjhu[�wvy[pvu�vm�3.);8��`v\[o�oh]l�ylwvy[lk�[oh[� they feel safer on the streets with their chosen family than in foster care �9lht� �-vynl�������� 3prl^pzl��)shjr��huk�0ukpnluv\z�`v\[o�oh]l�svun�ylwvy[lk�[yh\th[papun� experiences with peers, caregivers, and social workers in foster care who lack an appropriate degree of cultural humility and/or are outwardly racist. for instance, research has shown that indigenous youth in foster care are more likely to experience recurrent emotional, physical, sexual, and spiritual abuse when compared to their white peers, especially when they are assigned to white caregivers (landers et al., 2021). similar studies have revealed that black youth in foster care placements are disproportionately exposed to maltreatment compared to their white peers (scott et al., 2011). in fact, black boys in foster care experience j\s[\yhss`�pujvtwl[lu[�zvjphs�^vyrlyz�mylx\lu[s`�luv\no�[oh[�thu`�vm� these individuals depart from the child welfare system as young men with an even deeper distrust of mental health care providers than when they entered the system (scott et al., 2011). these trends suggest that the foster care system is failing black, indigenous, and lgbtq+ youth i`�jvu[ypi\[pun�[v��yh[oly�[ohu�htlspvyh[pun��[ol�[yh\th�puåpj[lk�\wvu� [olzl�thynpuhspalk�`v\[o� risks and impacts of elopement the micro level according to bowlby and ainsworth’s attachment theory, children rely on a caring, intimate, and undisrupted relationship with their adult caregivers in order to grow up mentally healthy (bretherton, 1992). with this in mind, it is natural to surmise that black, indigenous, and lgbtq+ youth who run away from foster care are unlikely to have formed healthy attachments with either their biological parents or foster parents. lee ann genussa 30 | columbia social work review, vol. xix coupled with the trauma that precedes and endures through the foster care experience, black, indigenous, and lgbtq+ youth are subjected to hu�hzzvy[tlu[�vm�khunlyz�\wvu�ållpun�myvt�[ol�z`z[lt��9\uh^h`�`v\[o� th`�z[y\nnsl�[v�äuk�hklx\h[l�ov\zpun�huk�hyl�tvyl�sprls`�[v�lunhnl� in risky behaviors such as substance use and unprotected commercial sexual contact for survival (fernandes-alcantara, 2018). additionally, youth who repeatedly run away face further risks of detachment from adult bonding, involvement in criminal and gang activity, and lack of lk\jh[pvu��*yvzzshuk� �+\ushw���������(yn\his`�tvz[�jvujlyupun�pz� [ol�ypzr�vm�o\thu�[yhɉjrpun��@v\[o�^ov�y\u�h^h`�myvt�mvz[ly�jhyl�oh]l� h�olpno[lulk�ypzr�vm�ilpun�[hynl[lk�i`�o\thu�[yhɉjrlyz�huk�zvsk�pu[v� zl_\hs�ivukhnl��3h[athu�l[�hs������ ���0u�mhj[��z[\kplz�oh]l�zov^u�[oh[� hz�thu`�hz�����vm�]pj[ptz�vm�zl_�[yhɉjrpun�^lyl�pu�mvz[ly�jhyl�h[�vul� point (dank et al., 2017). because many of these behaviors are labeled as criminal by the state, [olzl�thynpuhspalk�`v\[o�nyv\wz�hszv�mhjl�olpno[lulk�ypzr�vm�lu[lypun� the juvenile legal system. statistics show that the majority of youth who spend time in detention facilities will be arrested, convicted, huk�pujhyjlyh[lk�^p[opu�[ol�äyz[�zl]lyhs�`lhyz�mvssv^pun�ylslhzl��6ul� longitudinal study of 2,500 youth who were incarcerated in a juvenile kl[lu[pvu�mhjpsp[`�zov^lk�[oh[�yv\nos`�����vm�why[pjpwhu[z�^lyl� ylhyylz[lk�pu�[ol�äyz[�ä]l�`lhyz�mvssv^pun�[olpy�ylslhzl��(iyhtz�������� in addition to setting youth up for adult incarceration, the juvenile legal z`z[lt�hszv�jvu[ypi\[lz�[v�[ol�[yh\th[pah[pvu�huk�yl�[yh\th[pah[pvu�vm� black, indigenous, and lgbtq+ youth. reports of abuse, violence, and substandard care are common in juvenile detention facilities, particularly for black and indigenous youth who are both overrepresented in the juvenile legal system (abrams, 2013). moreover, studies have shown that, like foster care, spending time in the juvenile legal system further deteriorates youths’ mental health and impedes opportunities for educational attainment (abrams, 2013). the meso level impacted communities also feel the reverberations of elopement in mvz[ly�`v\[o��5v[�vus`�kv�q\]lupsl�kl[lu[pvu�mhjpsp[plz�[yh\th[pal�`v\[o� from foster care to the streets columbia social work review, vol. xix | 31 and increase their likelihood of adult incarceration, but they also pose h�[yltlukv\z�äuhujphs�ptwhj[�[v�thynpuhspalk�jvtt\up[plz�[oh[�hyl� already underfunded and under-resourced. juvenile incarceration costs an average of $200,000 per child per year, with some states spending more than half a million annually to incarcerate a single youth (justice policy institute, 2020). with more than 50,000 youth incarcerated, the u.s. may be spending more than $10 billion annually on juvenile incarceration (sawyer & wagner, 2020). in comparison, the federal i\knl[�wyvwvzhs�mvy�äzjhs�`lhy������ylx\lz[z�vus`������tpsspvu�mvy� kinship guardianship assistance—a $17 million cut from the year prior (congressional research service, 2021). transferring even a fraction of juvenile incarceration spending to kinship assistance programs for black, indigenous, and lgbtq+ youth could massively improve outcomes for youth while keeping families, and thereby communities, connected. it is also critical to consider the impacts that foster care and elopement have on the families of children who are in the system. in its current state, we have seen that the u.s. foster care system does little more than tear families apart. biological parents of children in state custody experience disproportionate rates of mental illness, particularly complex post traumatic stress disorder (suomi et al., 2021). studies have zov^u�[oh[�[ol�yltv]hs�vm�h�jopsk�i`�z[h[l�vɉjphsz�pz�vul�vm�[ol�tvz[� traumatic life experiences that one can endure and is often compared to experiencing the death of a child (askren & bloom, 1999; masson & dickens, 2015). following the removal, parents are often subjected to worsening symptoms of preexisting mental health conditions, which m\y[oly�olpno[luz�[ol�ypzr�vm�z\izlx\lu[�yltv]hsz��:\vtp�l[�hs���������� this cycle of violence illustrates how the racist foster care system impacts black and indigenous parents and communities just as much as their children. by removing new generations of black and indigenous youth from their cultures, the foster care system continues the nation’s legacy of punishment and genocide, thus preserving the race, gender, and class-based hierarchies that have served the nation since its advent (roberts, 2012). in order to further understand the experience vm�[olzl�mhtpsplz�huk�jvtt\up[plz��p[�pz�ptwvy[hu[�[v�huhs`al�[ol�^h`z� [oh[�jopsk�^lsmhyl�slnpzsh[pvu�wsh`z�zwljpäj�yvslz�pu�rllwpun�thynpuhspalk� communities disjointed. lee ann genussa 32 | columbia social work review, vol. xix a brief policy analysis the runaway and homeless youth act the runaway and homeless youth act (rhya), originally titled the 9\uh^h`�@v\[o�(j[��^hz�luhj[lk�i`�*vunylzz�pu�� ���pu�hu�lɉvy[�[v� rllw�]\sulyhisl�`v\[o�vɉ�[ol�z[yll[z�htpkz[�ypzpun�]pvslu[�jyptl�yh[lz� hjyvzz�[ol�uh[pvu��.\yy��� �����;ol�9/@(�h\[ovypalk�[ol�9\uh^h`� and homeless youth (rhy) program, which provides federal grant m\ukpun�mvy�[ol�jylh[pvu�vy�ivsz[lypun�vm�svjhs�w\ispj��uvu�wyvä[�jlu[lyz� dedicated to supporting runaway youth and their families. there are three main programs within the rhy program: the basic center program �)*7���[ol�;yhuzp[pvuhs�3p]pun�7yvnyht��;37���huk�[ol�:vjphs�6\[ylhjo� 7yvnyht��:67���(kkp[pvuhs�wyvnyhtz�pujs\kl�[ol�4h[lyup[`�.yv\w�/vtl� project and the 1-800-runaway hotline (family & youth services bureau, 2018). based on survey data collected from youth after service provision, each of the three main programs, in addition to the 1-800-runaway ov[spul��hwwlhy�[v�il�lɉlj[p]l�pu�z\wwvy[pun�`v\[o��;hisl�����0u������� ���vm�`v\[o�^ov�why[pjpwh[lk�pu�[ol�)*7�z\jjlzzm\ss`�[yhuzp[pvulk�[v� h�z[hisl�sp]pun�hyyhunltlu[��^opsl�����vm�`v\[o�^lyl�yl\up[lk�^p[o�[olpy� families (administration for children and families, 2015). in the same `lhy��:67�z[hɉ�huk�]vs\u[llyz�thkl�v]ly���������jvu[hj[z�^p[o�z[yll[� youth which resulted in 21,000 transitions to shelters for the evening. additionally, self-report surveys illustrated that the 1-800-runaway ov[spul�^hz�opnos`�lɉlj[p]l�pu�z\wwvy[pun�`v\[o�^ov�^lyl�jvu[ltwsh[pun� y\uupun�h^h �̀�0u������������vm�`v\[o�ylwvy[lk�[oh[�[ol`�^v\sk�jhss� again in the future for additional support (administration for children & families, 2015). critique and considerations although the rhya has provided support to thousands of youth since p[z�jvujlw[pvu��p[�pz�lx\hss`�ptwvy[hu[�[v�hjruv^slknl�[ol�wp[mhssz�vm�[ol� legislation. youth in foster care constitute a large portion of runaways, `l[�uv^olyl�pu�[ol�wyvnyht�slnpzsh[pvu�hyl�[olzl�`v\[o�pklu[pälk�hz� ilpun�lzwljphss`�]\sulyhisl�huk�pu�ullk�vm�z\wwvy[��4vyl�zwljpäjhss �̀� the legislation makes no mention of black, indigenous, and lgbtq+ from foster care to the streets columbia social work review, vol. xix | 33 foster youth even though they are disproportionately impacted by mvz[ly�jhyl�huk�tvyl�sprls`�[v�y\u�h^h �̀�;opz�shjr�vm�mvj\z�pz�ylålj[lk� in data collected from the program. for example, virtually no data was collected on lgbtq+ youth who received services from the program (administration for children & families, 2015). data collection accounted only for transgender youth, neglecting to assess for how many youths served were lesbian, gay, bisexual, nonbinary, gender non-conforming, l[j���klzwp[l�hu�lz[pth[lk�����vm�`v\[o�pklu[pm`pun�hz�3.);8�� (furguson & maccio, 2015). another important consideration is the legislation’s emphasis on education and job training. there is widespread acceptance that a jvu[pu\v\z�huk�x\hsp[`�lk\jh[pvu�pz�lzzlu[phs�mvy�`v\[o�[v�nyv^�\w� mentally healthy. quality education and job training provide important educational, developmental, and social milestones for children and `v\[o��0[�pz�lzwljphss`�ptwvy[hu[�[v�jvuzpkly�[ol�ptwhj[z�vm�wypvyp[papun� a future-focused mentality surrounding job training over youths’ immediate safety and wellbeing. experiencing homelessness in youth pz�[yh\th[papun��lzwljphss`�^olu�p[�pu]vs]lz�lsvwltlu[�myvt�h�jhylnp]ly�� by providing youth with stable housing, we can help to halt the cyclical pattern of poverty and incarceration, improve mental health outcomes, and empower youth with a sense of agency (naccarato et al., 2008). (jjlzz�[v�jvuzpz[lu[��x\hsp[`�pukp]pk\hs�jv\uzlspun�ohz�hszv�illu�wyv]lu� [v�zpnupäjhu[s`�ptwyv]l�tlu[hs�olhs[o�huk�kljylhzl�z\iz[hujl�hi\zl�pu� runaway and homeless youth (slesnick et al., 2008). for these reasons, p[�jv\sk�il�tvyl�iluläjphs�[v�zopm[�ylzv\yjlz�h^h`�myvt�qvi�[yhpupun�huk� toward counseling and housing. fostering connections to success and increasing adoptions act more recently, in 2008, the fostering connections to success and increasing adoptions act (fostering connections act) was passed in an lɉvy[�[v�tvklyupal�[ol�mvz[ly�jhyl�z`z[lt�i`�wyvtv[pun�rpuzopw�mvz[ly� wshjltlu[z�huk�hkvw[pvuz��ptwyv]pun�hjjlzz�[v�x\hsp[`�olhs[ojhyl�� huk�z\wwvy[pun�lk\jh[pvuhs�jvuzpz[luj �̀�;ol�slnpzsh[pvu�jvuzpz[z�vm�ä]l� sections that focus on connecting and supporting kinship caregivers, improving outcomes for youth in foster care, improving access to foster lee ann genussa 34 | columbia social work review, vol. xix care and adoption within indigenous communities, improving incentives mvy�hkvw[pvu��huk�jshypm`pun�h�\upmvyt�kläup[pvu�vm�[ol�[lyt�¸jopsk�¹�hz� well as other provisions (fostering connections act, 2008). some of the most prominent alterations in child welfare that have resulted from [opz�slnpzsh[pvu�pujs\kl�l_[lukpun�jopsk�^lsmhyl�ilulä[z�[v�`v\[o�\w�[v� the age of 21 as well as heightening the focus on transition planning for youth who are aging out. the logic is that by encouraging kinship foster care and providing welfare services until the age of 21, youth will have a more supportive and protracted transition into independent living (day & preston, 2013). in terms of implementation, varying degrees of intervention success can be seen on a state-to-state basis. the majority of u.s. states, including [ol�+pz[ypj[�vm�*vs\tiph��oh]l�\wkh[lk�jopsk�^lsmhyl�slnpzsh[pvu�[v�ylålj[� lsltlu[z�vm�[ol�-vz[lypun�*vuulj[pvuz�(j[��zwljpäjhss`�pu�[lytz�vm� educational stability, services to support said stability, and transition coordination. despite these successes, many jurisdictions have failed to hklx\h[ls`�pujvywvyh[l�hss�jvtwvulu[z�vm�[ol�mlklyhs�slnpzsh[pvu�lx\hss �̀� particularly elements such as educational services (perfect et al., 2013). critique and considerations like the rhya, the fostering connections act places a strong emphasis on job training and readiness to enter the workforce. this focus within the legislation highlights the inherent neoliberalism within u.s. law, based as it is on the idea that youth are responsible for iv[o�[olpy�pukp]pk\hs�jpyj\tz[hujlz�huk�äukpun�h�tlhuz�v\[�vm�[ovzl� circumstances by becoming a productive member of the workforce (schelbe, 2011). again, like the rhya, the fostering connections (j[�jv\sk�ilulä[�myvt�[hrpun�h�z[lw�h^h`�myvt�[olzl�uv[pvuz�vm� personal responsibility and job training, and instead focus on housing wyvj\yltlu[�huk�jvuzpz[lu[��x\hsp[`�jv\uzlspun��5hjjhyh[v�l[�hs��� 2008; slesink et al., 2008). the legislation is also inconsistent with its promotion of kinship care. although the core of the legislation is based on the idea that kinship care promotes improved outcomes, the slnpzsh[pvu�mhpsz�[v�ylx\pyl�olpno[lulk�ilulä[z��z\wwvy[��huk�hjjlzz�[v� resources for kinship caregivers (koh et al., 2021). from foster care to the streets columbia social work review, vol. xix | 35 structural and cultural changes the fostering connections act has brought about meaningful change by promoting kinship foster care. yet social workers will play an important role in advocating for further amendments to current legislation which will be crucial to providing black, indigenous, and lgbtq+ runaway foster youth with the support that they so vitally need and deserve. it is also important to acknowledge that any legislation is inherently a bandhpk�zvs\[pvu��>l�jhuuv[�l_wlj[�hs[lyh[pvuz�pu�slnpzsh[pvu�[v�il�lɉlj[p]l� until social workers collectively advocate for and implement large-scale shifts in the deeply rooted cultural norms and values within the u.s. when moving toward large-scale, structural changes, it is important for social workers to reconsider how the american patriarchal nuclear family structure has contributed to the creation of such an oppressive foster care system. decades of research suggest that the myth of the nuclear family is inappropriate, misleading, and detrimental to our understanding of family dynamics and appropriate therapeutic pu[ly]lu[pvuz��<avrh��� � ���;opz�tvkls�vm�mhtps`�z[y\j[\yl�pz�puolylu[s`� homophobic and misogynistic. it suggests that anything other than a cisgender, heterosexual marriage does not constitute a valid family unit, while reinforcing traditional gender roles: the husband as the provider, protector, and decision maker, and the wife as the domestic servant and childrearer (st. vil et al., 2019). in contrast to the patriarchal nuclear family structure, black and indigenous communities have historically placed a strong emphasis on communal mastery to promote positive outcomes in child-rearing (hobfoll et al., 2002). even today it is common mvy�jopskylhypun�[v�il�h�jvtt\uhs��mhtps`�lɉvy[�pu�[olzl�jvtt\up[plz�� this is primarily due to the mechanisms of mass incarceration which remove parents from their children's lives and heighten caregiver responsibilities for the co-parent and their relatives (the annie e. casey foundation, 2016; st. vil et al., 2019). >opsl�[ol�lɉjhj`�vm�jvsslj[p]pzt�ohz�illu�wyv]lu��[opz�z[`sl�vm� jhylnp]pun�pz�vm[lu�jshzzpälk�hz�whylu[hs�ulnslj[�^p[opu�h�>lz[lyu� jvujlw[\hspah[pvu�vm�jopsk�ylhypun��[o\z�slhkpun�[v�[ol�kpzwyvwvy[pvuh[l� removal of black and indigenous children from their families (hobfoll et al., 2002). for instance, studies have shown that youth placed in kinship lee ann genussa 36 | columbia social work review, vol. xix foster arrangements—most often with women of color—have similar physical, mental, and behavioral health outcomes to youth placed in non-kinship arrangements. this is true despite the fact that kinship foster parents are, on average, older, lower income, less healthy, and receive fewer services and lower payments from child welfare agencies jvtwhylk�[v�uvu�rpuzopw�mvz[ly�whylu[z��)lyypjr�l[�hs���� �"�2vo�l[�hs��� 2021). in other words, women of color in a kinship foster parent role produce similar outcomes for youth compared to white, non-kinship foster parents even though they are given fewer resources by child welfare agencies. in applying a collectivist approach to child-rearing, we may be able to create better outcomes for youth and their families by keeping families united and supported. implications for social work practice social workers have an important role in transforming the foster care system. with our code of ethics in mind, it is imperative that we continue to advocate for cultural changes that abandon the three pillars of capitalist oppression: white supremacy, colonialism, and heteropatriarchy. while social workers should strive to eliminate the need for runaway, homeless, and foster care youth services through large-scale j\s[\yhs�zopm[z�huk�hk]vjhj �̀�p[�pz�lx\hss`�ptwvy[hu[�[v�jvuzpkly�ov^� we can help youth who are already navigating through these systems right now. from a clinical perspective, it is crucial that social workers who serve )shjr��0ukpnluv\z��3.);8���huk�v[oly^pzl�thynpuhspalk�`v\[o�iv[o�pu� and outside of the child welfare system begin to operate from cultural humility, trauma-informed, and social justice lenses. the patterns of racism and oppression in the child welfare system are deeply woven into [ol�mhiypj�vm�[ol�<�:��huk�^pss�ylx\pyl�h�nylh[�klhs�vm�lɉvy[�[v�[lhy�v\[�� ;opz�jhuuv[�il�kvul�zptws`�i`�^vyrpun�mvy�thynpuhspalk�jvtt\up[plz�� but rather working in tandem with them to provide resources and to lujv\yhnl�vynhupah[pvu��\up[ �̀�huk�ltwv^lytlu[�htvun�[ol�uh[pvu»z� most historically oppressed and abused communities. from foster care to the streets columbia social work review, vol. xix | 37 conclusion ;ol�pu[lnyh[pvu�vm�kljhklz�vm�ylzlhyjo�pu[v�[ol�älsk�vm�jopsk�^lsmhyl�ohz� elucidated that the current u.s. foster care system has not strayed far from its oppressive origins. the foster care experience is commonly not a positive one for black, indigenous, and lgbtq+ youth. racism, ovtvwoviph��huk�[yhuzwoviph�puåpj[lk�i`�wllyz��mvz[ly�whylu[z��huk� even social workers are common experiences for youth with these zvjphs�pklu[pälyz��;ol�wo`zpjhs��ltv[pvuhs��huk�zl_\hs�hi\zl�[oh[�[olzl� `v\[o�hyl�z\iqlj[lk�[v�hyl�vm[lu�zv�klo\thupapun�[oh[�[ol`�hyl�^psspun� to risk further abuse, exploitation, trauma, and homelessness just to avoid their caregivers. instead of meeting the crucially important social huk�ltv[pvuhs�ullkz�vm�`v\[o��mvz[ly�jhyl�zly]lz�hu�lu[pyls`�kpɉlylu[� function for black, indigenous, and lgbtq+ youth: to continue the u.s.’s legacy of punishment and genocide. healing racial and cultural trauma in black, indigenous, and lgbtq+ communities is often kvul�tvz[�lɉlj[p]ls`�^olu�p[�ohwwluz�jvsslj[p]ls`��6y[lnh�>pssphtz� et al., 2021). by separating families and alienating lgbtq+ youth, the u.s. continues to prevent collective healing, ultimately keeping [olzl�thynpuhspalk�wlvwsl�^p[opu�[ol�jvuäulz�vm�z[h[l�vwwylzzpvu�� elopement from foster care may be a much deeper, more meaningful behavior than we think it is. perhaps youth elope not just to escape the vwwylzzp]l��[yh\th[papun�jvukp[pvuz�vm�mvz[ly�jhyl��i\[�[v�yl[\yu�ihjr�[v� the communities that birthed them and initiate collective healing. black, indigenous, and lgbtq+ communities are resilient, but they should not oh]l�[v�il��>l�jhuuv[�olsw�[v�spilyh[l�[olzl�jvtt\up[plz�^p[ov\[�äyz[� helping to free their future, the youth. references (iyhtz��3����������1\]lupsl�q\z[pjl�h[�h�jyvzzyvhkz!�:jplujl��l]pklujl��huk�[^lu[`�äyz[� century reform. social service review������������������o[[wz!��kvp�vyn��������������� administration for children & families. (2015). report to congress on the runaway and ovtlslzz�`v\[o�wyvnyht�mvy�äzjhs�`lhyz������huk������ https://www.acf.hhs.gov/fysb/ the annie e. casey foundation. (2016). a shared sentence: the devastating toll of parental incarceration on children, families and communities. https://www.aecf.org/resources/ashared-sentence lee ann genussa 38 | columbia social work review, vol. xix (zrylu��/��(��� �)svvt��2��*���� ���7vz[hkvw[p]l�ylhj[pvuz�vm�[ol�ylspux\pzopun�tv[oly!� a review. journal of obstetric, gynecologic & neonatal nursing���������� �¶�����o[[wz!�� doi.org/10.1111/j.1552-6909.1999.tb02008.x )lyypjr��1��+���)hy[o��9��7��� �5llklss��)���� ����(�jvtwhypzvu�vm�rpuzopw�mvz[ly�ovtlz� and foster family homes: implications for kinship foster care as family preservation. children and youth services review, 16(1-2), 33-62. https://doi.org/10.1016/0190��� � �� ����� brave heart, m.y.h., chase, j., elkins, j., & altschul, d. b. (2011). historical trauma among indigenous peoples of the americas: concepts, research, and clinical considerations. journal of psychoactive drugs�������������� ���kvp!������������ ������������� �� bretherton, i. (1992). the origins of attachment theory: john bowlby and mary ainsworth. developmental psychology����������� ������o[[wz!��kvp�vyn����������������� �������� census bureau. (2020). population and housing unit estimates. https://www.census.gov/ children’s bureau. (2021). foster care statistics 2019. https://www.childwelfare.gov/ pubpdfs ching-hsuan, l. (2012). children who run away from foster care: who are the children huk�^oh[�hyl�[ol�ypzr�mhj[vyz&�children and youth services review������������������ +60!��������q�jopsk`v\[o����������� congressional research service. (2021). child welfare in the president’s fy2022 budget request: in brief��o[[wz!��jyzylwvy[z�jvunylzz�nv]�wyvk\j[�wkm�9�9������ conron, k. j. 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(2013). racial bias in american foster care: the national debate. marquette law review�� ���������������o[[w!��zjovshyzopw�sh �̂thyx\l[[l�lk\�t\sy�]vs ��pzz���� *yvzshuk��2�� �+\ushw��.����������9\uupun�h^h`�myvt�mvz[ly�jhyl!�>oh[�kv�^l�ruv^�huk� ^oh[�kv�^l�kv&�journal of child and family studies�������������� ��������o[[wz!��kvp� vyn���������z���������� ���_ *y\[joälsk��1���/hss��1��*���6y[lnh�>pssphtz��(��� �>lii��:��3����������*vsvypzt�huk� the poetics of resistance among black youth: an application of the coloristhistorical trauma framework. journal of black studies, 51(8), 813-831. https://doi. vyn������������� ����� ���� +hur��4���@houly��1���@\��3���=hzx\la�5vyplnh��*���.lsh[[��1��� �7lynhtp[��4���������� 7yl[lz[pun�h�o\thu�[yhɉjrpun�zjyllupun�[vvs�pu�[ol�jopsk�^lsmhyl�huk�y\uh^h`�huk� homeless youth systems. the urban institute. https://www.urban.org/sites/default from foster care to the streets columbia social work review, vol. xix | 39 day, a. & preston, m. (2013). reevaluating the government’s role in parenting older foster care youth: an analysis of the fostering connections to success and increasing adoptions act of 2008 and its implementation in california and michigan. uc davis journal of juvenile law and policy���������o[[w!��^vyrz�ilwylzz�jvt�hunlspx\lfkh`��� family & youth services bureau. (2018). runaway & homeless youth program fact sheet. o[[wz!��^^ �̂hjm�ooz�nv]�zp[lz�klmh\s[�äslz�kvj\tlu[z� fernandes-alcantara, a. l. (2018). runaway and homeless youth: demographics and programs. congressional research service. https://sgp.fas.org/crs/misc/rl33785.pdf fostering connections to success and increasing adoptions act, publ. l. 110-351, 122 stat. 3950. (2008). https://www.govinfo.gov/content/pkg/plaw-110publ351/pdf/plaw110publ351.pdf furguson, k. m., & maccio, e. m. (2015). promising programs for lesbian, gay, bisexual, [yhuznlukly��huk�x\lly�x\lz[pvupun�y\uh^h`�huk�ovtlslzz�`v\[o��journal of social service research����������� ������o[[wz!��kvp�vyn����������������������������� gurr, t. r. (1981). historical trends in violent crime: a critical review of the evidence. crime and justice������ �������o[[wz!��^^ �̂qz[vy�vyn�z[hisl�������� harris, m. s., & hackett, w. (2008). decision points in child welfare: an action research model to address disproportionality. children and youth services review, 30(2), 199215. https://doi.org/10.1016/j.childyouth.2007.09.006 hobfoll, s. e., jackson, a., hobfoll, i., pierce, c. a., & young, s. (2002). the impact of communal mastery versus self-mastery on emotional outcomes during stressful conditions: a prospective study of native american women. american journal of community psychology������������������o[[wz!��kvp�vyn���������(!������ ������ inguanta, g. & sciolla, c. (2021). time doesn’t heal all wounds: a call to end mandated reporting laws. columbia social work review��� ��������������o[[wz!��kvp�vyn���������� jz^y�]� p������� justice policy institute. (2020). sticker shock 2020: the cost of youth incarceration. o[[wz!��^^ �̂uqqu�vyn�\wsvhkz�kpnp[hs�spiyhy`�:[pjrlyf:ovjrf�����wkm� king, b., abrego, d., narendorf, s., ha, y., & santa maria, d. (2017). representations of homelessness, home environments, and authority in the context of runaway behaviors reported by foster care youth residing in an emergency shelter. journal of social distress and the homeless������������������o[[wz!��kvp�vyn���������������� ��������� 0333 koh, e., ware, a., & lee, e. (2021). state implementation of the fostering connections to success and increasing adoptions act: exploratory study on kinship care. advances in lee ann genussa 40 | columbia social work review, vol. xix social work������������ ��o[[wz!��kvp�vyn������������ �� landers, a. l., danes, s. m., campbell, a. r., & white hawk, s. (2021). abuse after abuse: the recurrent maltreatment of american indian children in foster care and adoption. child abuse & neglect���������������o[[wz!��kvp�vyn���������q�jophi\������������ 3h[athu��5��,��� �.piiz��+��(����������examining the link: foster care runaway episodes huk�o\thu�[yhɉjrpun. rti international. https://www.rti.org/publication/examining-link 3h[athu��5��,���.piiz��+��(���-lpuilyn��9���2s\jrthu��4��5��� �(iv\s�/vzu��:�� ���� ���/\thu�[yhɉjrpun�]pj[ptpah[pvu�htvun�`v\[o�^ov�y\u�h^h`�myvt�mvz[ly� care. children and youth services review�� ������������o[[wz!��kvp�vyn���������q� childyouth.2018.12.022 masson, j., & dickens, j. (2015). protecting unborn and newborn babies. child abuse review������������¶�� ��o[[wz!��kvp�vyn���������jhy����� 4j*vytpjr��(���:jotpk[��2��� �;lyyhahz��:����������3.);8�`v\[o�pu�[ol�jopsk�^lsmhyl� system: an overview of research, practice, and policy. journal of public child welfare, ���������¶� ��o[[wz!��kvp�vyn������������������������������ 4vvul �̀�4����������9ljvnupapun��[ylh[pun��huk�wyl]lu[pun�[yh\th�pu�3.);8�`v\[o��journal of family strengths, 17(2), article 16. https://digitalcommons.library.tmc.edu/jfs/vol17/ iss2/16 4vyl^p[a��:��1����������runaway and homeless youth: new research and clinical perspectives. springer international publishing. 5hjjhyh[v��;���)yvwo �̀�4��� �/lyuhukla��3����������;ol�mvz[ly�`v\[o�ov\zpun�jypzpz!� literature, legislation, and looking ahead. journal of civil rights and economic development����������� ������ 6y[lnh�>pssphtz��(���)ls[ymu��9���:jo\s[a��2���9\�.sv�/luklyzvu��a���*vs}u��3��� �;l`yh��*�� (2021). an integrated historical trauma and posttraumatic growth framework: a crosscultural exploration. journal of trauma and dissociation,������������������o[[wz!��kvp�vyn� 10.1080/15299732.2020.1869106 page, m. (2017). forgotten youth: homeless lgbt youth of color and the runaway and homeless youth act. northwestern journal of law & social policy����������������o[[wz!�� scholarlycommons.law.northwestern.edu/njlsp/vol12/iss2/2/ perfect, m. m., stoll, k. a., thompson, k. c., & scott, r. e. (2013). analysis of state laws and policies following the implementation of the fostering connections to success and increasing adoptions act. school psychology forum��������������� 9lht��.��� �-vynl��5����������/vtlslzz�slziphu��nh �̀�ipzl_\hs��huk�[yhuznlukly��3.);�� `v\[o�pu�5l^�@vyr�*p[`!�0uzpno[z�myvt�[ol�älsk��child welfare, 93(2), 7–22. from foster care to the streets columbia social work review, vol. xix | 41 roberts, d. (2012). prison, foster care, and the systemic punishment of black mothers. ucla law review��� ����������������o[[wz!��^^ �̂\jshsh^yl]pl �̂vyn�wkm�� �����wkm rymph, c. e. (2017). raising government children: a history of foster care and the american welfare state. university of north carolina press. samuels, g. m., & larossa, r. (2009). “being raised by white people”: navigating racial kpɉlylujlz�htvun�hkvw[lk�t\s[pyhjphs�hk\s[z��journal of marriage and family, 71(1), 80 ���o[[wz!��kvp�vyn���������q����������������������_ sawyer, w., & wager, p. (2020). mass incarceration: the whole pie 2020. prison policy initiative. https://www.prisonpolicy.org/reports/pie2020.html schelbe, l. a. (2011). policy analysis of fostering connections to success and increasing adoptions act of 2008. journal of human behavior in the social environment, 21(5), ���������o[[wz!��kvp�vyn����������� ���� ������������� scott, l. d., mccoy, h., munson, m. r., snowden, l. r., & mcmillen, j. c. (2011). cultural mistrust of mental health professionals among black males transitioning from foster care. journal of child and family studies, 20, 605-613. https://doi.org/10.1007/s10826���� ����a� :ptvu��2��)����������*h[hs`apun�[ol�zlwhyh[pvu�vm�)shjr�mhtpsplz!�(�jyp[px\l�vm�mvz[ly�jhyl� placements without prior judicial review. columbia journal of law and social problems, ������������� � slesnick, n., ju kand, m., bonomi, a. e., & prestopnik, j. l. (2002). sixand twelve-month outcomes among homeless youth accessing therapy and case management services through an urban drop-in center. health services research,�������������� ��o[[wz!��kvp� vyn���������q����������������������_� st. vil, n. m., st. vil, c., & fairfax, c. n. (2019). posttraumatic slave syndrome, the patriarchal nuclear family, structure, and african american male-female relationships. social work,���������� ������o[[wz!��kvp�vyn������ ��z^�z^a���� suomi, a., bolton, s., & pasalich, d. (2021). the prevalence of post-traumatic stress disorder in birth parents in child protective services: systematic review and meta-analysis. trauma, violence, & abuse, 0(0), 1-15. https://doi. vyn�������������������������� <avrh��(��-���� � ���;ol�t`[o�vm�[ol�u\jslhy�mhtps`!�/pz[vypjhs�ihjrnyv\uk�huk�jspupjhs� implications. american psychologist������������ �¶������o[[wz!��kvp�vyn�������������� ���?��������� � >\sja`u��-����������9hjl�l[oupjp[`�huk�y\uupun�h^h`�myvt�mvz[ly�jhyl��children and youth services review���� �����������o[[wz!��kvp�vyn���������q�jopsk`v\[o������������ lee ann genussa 42 | columbia social work review, vol. xix figure 1 foster care and general population demographics by race percent of youth under 18 in the general and foster care populations 0 10 pe rc en t o f p op ul at io n (% ) 20 30 40 50 60 70 80 90 white black or african american aian asian hispanic or latino 76.3 44 13.4 23 1.3 5.9 2 1 18.5 21 general population foster care note. the percentage of youth under age 18 in the general and foster care populations are compared across race and ethnicity. data collected on indigenous americans is labeled “aian,” meaning american indian and alaskan natives (census bureau, 2020; children’s bureau, 2021). from foster care to the streets columbia social work review, vol. xix | 43 figure 2 lgbtq+ youth in the foster care and general populations percentage of lgbt youth in the general and foster care populations 0 5 pe rc en t o f p op ul at io n (% ) 10 15 20 25 30 35 foster care general population 30.4 9.54 note. the percentage of youth in the general and foster care populations are compared (census bureau, 2020; children’s bureau 2021; conron, 202). lee ann genussa 44 | columbia social work review, vol. xix ;hisl��!�,ɉjhj`�vm�9/@(�7yvnyhttpun funding ($) grantees females (%) males (%) black youth (%) indigenous youth (%) lgbtq+ youth (%) basic center program 53 mil. 296 52 �� 32 3 ~<1 transitional living program ���tps� 200 60 39 39 5 ~<1 street outreach program 17 mil. 101 n/a n/a n/a n/a n/a note. funding, number of grantees, and percentage of youth served relating to gender and race are jvtwhylk�hjyvzz�9/@(�wyvnyhttpun��0u�vykly�[v�wyv[lj[�jvuäklu[phsp[ �̀�:67�hk]vjh[lz�kv�uv[�jvsslj[� demographic data from youth served (administration for children & families, 2015). from foster care to the streets columbia social work review, vol. xix | 45 lee ann genussa columbia social work review, vol. xix | 5 replacing seclusion and restraint practices in psychiatry with sensory rooms emma costain columbia social work review, vol. xxiii | 7 6 | columbia social work review, vol. xxii inspiration my inspiration for this paper stems from both personal and professional experiences. the idea to replace seclusion and restraint (s/r) practices first took shape during my generalist year practicum at a behavioral health hospital. drawing on my background working with individuals with autism spectrum disorder and my expertise in behavioral health, i developed the concept of implementing sensory rooms as a humane and therapeutic alternative to s/r. i firmly believe that patients should have agency in their treatment and leave the hospital with transferable coping skills rather than traumatic memories. my work is grounded in advocating for patient rights and ensuring that individuals in acute psychiatric care are active participants in their own recovery. through this paper, i hope to highlight the urgent need for non-coercive interventions in mental health treatment and contribute to a shift toward more compassionate, patient-centered care. emma costain is a 2025 graduate of the columbia school of social work, specializing in policy practice and mental health. as a social worker, she is passionate about research and policy advising in the mental health field, with a particular focus on acute psychiatric inpatient care. having grown up in a military family, she embraces the idea that home is wherever the heart is.emma costain columbia social work review, vol. xxiii | 9 8 | columbia social work review, vol. xxiii replacing seclusion and restraint abstract the use of seclusion and restraint (s/r) in acute psychiatric inpatient settings persists as a controversial practice, causing significant harm to patients and stress to staff. this policy brief examines the ethical, financial, and systemic implications of s/r and advocates for replacing s/r with sensory rooms—an evidence-based approach fostering emotion regulation, patient autonomy, and trauma-informed care. recognizing that eliminating s/r may not be immediately feasible, this brief proposes an incremental approach through a hypothetical pilot program at jackson behavioral health hospital: converting an isolation room, or a room where a patient receives intervention separately from other patients, on each psychiatric inpatient unit into a sensory room, alongside incentives to reduce overall s/r usage. sensory rooms can then be evaluated as a humane and cost-effective alternative to s/r practices. this policy brief aims to advance knowledge on patient-centered interventions in mental health care and underscores the ethical imperatives and financial incentives for legislative and organizational policy reform in psychiatric care. keywords: seclusion, restraint, sensory rooms, psychiatric inpatient care, policy reform, trauma-informed care, social justice emma costain replacing seclusion and restraint practices in psychiatry with sensory rooms the field of mental health has progressed in many regards. however, the archaic practice of seclusion and restraint (s/r) still dominates acute psychiatric inpatient care, causing unnecessary trauma and distress for both patients and providers. the code of federal regulations (cfr) define seclusion and restraint as follows: • seclusion is “the involuntary confinement of a person alone in a room or area from which the person is physically prevented from leaving” (condition of participation: patient’s rights, 42 cfr 482.13(e)(1)(ii)). • restraint is “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body, or head freely” (condition of participation: patient’s rights, 42 cfr 482.13(e)(1)(i) (a)). this policy brief will not only exhibit the ethical and financial costs of s/r in psychiatric settings, but will also shed light on potential policy interventions that can significantly reduce the prevalence of s/r. by applying the concept of emotion regulation, often used for individuals with autism spectrum disorder, and integrating it with the principles of patient autonomy, acute psychiatric inpatient hospitals can replace seclusion rooms with designated sensory rooms (recovery ways, 2022). as discussed later in this brief, sensory rooms are spaces that provide patients with efficient, transferrable, and relevant distress tolerance skills that can be used both within the hospital and in their daily lives. background and historical context the use of s/r in western psychiatric medicine has a long and troubling history, with its inhumane and traumatizing use dating back to the 1700s. while historically rooted in the control and segregation of those columbia social work review, vol. xxiii | 11 10 | columbia social work review, vol. xxiii deemed “unmanageable,” these practices persist today, often justified as necessary for safety despite growing evidence of their harm and the availability of alternative interventions (weiss, 1998). eugenics in the late 19th and early 20th centuries, psychiatric practices were significantly influenced by the rise of eugenics theory—a discredited form of scientific racism that posited human beings could be perfected and social ills eliminated through genetics (e.g., national human genome research institute, n.d.). psychiatrists, frustrated by the lack of effective treatment for mental illness, turned to experimental interventions aimed at controlling and segregating individuals deemed “unfit” by societal standards (turda, 2022). one such intervention was the lobotomy, introduced in the 1930s as a means to manage patients with severe mental disorders. this procedure involved severing connections in the brain’s frontal lobe and was often performed without patient consent (mashour et al., 2005). electroconvulsive therapy (ect; also known as “shock therapy”) also emerged during this period, initially administered under coercive circumstances and without adequate evidence of its effects, further exemplifying the era’s inhumane treatment approaches (scull, 2022). similarly, s/r also originated as a means of controlling and isolating those deemed undesirable. though lobotomies were eventually discredited and abandoned due to their devastating consequences, ect and s/r persisted and were frequently misused as a means of social control rather than medical necessity, reflecting the broader pattern of psychiatric interventions being wielded as tools of oppression (larson, 2018). marginalized populations—including immigrant populations, people of color, impoverished people, and those who were mentally or physically disabled—disproportionately became the victims of eugenics experimentation by psychiatrists, often under the guise of medical advancement (e.g., larson, 2018; mashour et al., 2005). this targeting extended to the widespread and unchecked use of s/r, which was implemented as a means of control rather than care (larson, 2018). psychiatric care today decades later, s/r remains deeply entrenched in psychiatric treatment, disproportionately impacting the same marginalized communities that were historically subjected to these practices. studies have found that black patients are significantly more likely to be subjected to s/r than their white counterparts, in both emergency departments and inpatient psychiatric settings (eswaran et al., 2023; hawkins et al., 2022). this pattern is not incidental; it reflects the persistent biases and systemic inequities that continue to shape psychiatric care. the case of orville blackwood in 1991 serves as a tragic example: blackwood, a black psychiatric patient, died after being subjected to excessive restraint and medication. the case led to a national inquiry that revealed black patients were more likely to be misdiagnosed, overmedicated, and subjected to coercive psychiatric interventions (prins et al., 1993). these findings reinforce what many mental health professionals and advocates have long argued: s/r is not only a failure of psychiatric care but a practice that also reflects deeper patterns of racism, ableism, and classism embedded in the mental health system. according to international standards (un general assembly, 1992), the use of seclusion rooms and restraints are permitted exclusively in instances where the patient is in imminent danger of harming or killing themselves, another patient, or a staff member. however, research has shown that seclusion rooms are more often used as a form of punishment in response to a patient being loud, disruptive, or noncompliant with medications (substance abuse and mental health services administration [samhsa], 2010, p. 1). this misuse is not random: it reflects the same systemic biases and discriminatory patterns described earlier in this section, where marginalized patients are disproportionately subjected to control and punishment under the guise of care. the replacing seclusion and restraint emma costain columbia social work review, vol. xxiii | 13 12 | columbia social work review, vol. xxiii widespread practice of s/r demonstrates persistent systemic biases within psychiatric care, and is in direct violation of encouraging patient autonomy, providing trauma-informed care, and respecting the human dignity of every patient (e.g., national association of social workers, 2021). research also shows that patients subjected to s/r face increased risk of extended lengths of stay in psychiatric facilities and reduced likelihood of returning home upon discharge. despite its persistence, s/r is neither therapeutic nor necessary—rather, it is a remnant of outdated and oppressive psychiatric models that have disproportionately harmed vulnerable populations for centuries. what the research on seclusion and restraint shows in addition to the well-documented evidence of bias in its application, s/r has ethical and financial consequences as well. this section highlights not only the devastating impact of s/r on patient well-being but also the significant costs it imposes on hospitals. these consequences further reinforce the urgent need to adopt more humane, evidence-based alternatives that prioritize patient dignity, safety, and autonomy. research illustrates how s/r practices, shaped by the systemic biases and inequities outlined in the previous section, can result in devastating consequences for patients and the healthcare system as a whole. these harms are reflected in ethical failures, clinical outcomes, patient mortality rates, and financial costs, as explored in the rest of this section (recovery ways, 2022). s/r: patient treatment and consequences s/r can be applied to a wide range of psychiatric conditions, placing nearly any patient admitted for inpatient psychiatric care at risk regardless of their specific diagnosis. the diagnoses most commonly associated with the use of s/r include schizophrenia, schizoaffective disorder, and bipolar disorder; however, the application is not limited to those conditions (georgieva et al., 2020). research indicates that patients subjected to s/r face significantly worse clinical and systemic outcomes compared to those who are not restrained. the use of s/r in psychiatric settings is not only harmful but can also have fatal consequences. the substance abuse and mental health services administration (samhsa) (2010) has reported that “an estimated 50 to 150 individuals die each year as a result of seclusion and restraint practices in facilities, and countless others are injured or traumatized” (p. 1). other patients die from cardiac arrest triggered by the severe physiological stress of being forcibly restrained—a risk heightened for individuals with underlying medical conditions (lebel & goldstein, 2005). some patients have also died due to neglect, when they were placed in seclusion rooms without proper monitoring and experienced life-threatening medical issues or engaged in self-harm. ethical argument the use of s/r provides “no therapeutic value, [causes] human suffering, and frequently [results] in severe emotional and physical harm, and even death” (mental health america [mha], n.d., p. 1). the use of s/r exacerbates the suffering of patients who are already dealing with difficult mental health conditions. psychiatric hospitals should not further patient suffering by placing unconsenting patients in seclusion or restraints. many psychiatrists argue that s/r is a necessary tool within acute psychiatric inpatient settings because it allows for the management of behavioral issues related to a patient’s mental condition, but “there is little evidence that seclusion provides long-term benefits in terms of treating symptoms or reducing aggression” (newton-howes, 2013, p. 422). from an ethical perspective, s/r practices disregard a patient’s autonomy and directly contradict patient-focused and trauma-informed care. evidence of therapeutic benefits to seclusion rooms and restraints is lacking, so it is hard to ethically justify using either practice on a replacing seclusion and restraint emma costain columbia social work review, vol. xxiii | 15 14 | columbia social work review, vol. xxiii patient against their will. finally, the antiquated and cruel practices of s/r are not only violations of human dignity but also direct contributors to preventable deaths, serving as glaring symptoms of the poor quality of care, inadequate staff training, and misinformed public policy that continue to enable these abuses (grasso et al., 2007). financial argument significant organizational and healthcare costs also contribute to the argument against s/r. a single episode of either seclusion or restraint can cost the hospital “between $302 and $354” (samhsa, 2010, p. 2). beyond the economic costs, hospitals may have to consider legal costs as a consequence of using seclusion rooms and restraints, as patients or family members may take legal action against the hospital due to the harm, trauma, and in some cases preventable deaths that result from these interventions. hospitals must consider both patient safety and regulatory compliance when evaluating the use of s/r. under federal regulations, “all patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff” (condition of participation: patient’s rights, 42 cfr 482.13(e), 2008/2025). while s/r may be used to ensure “the immediate physical safety of the patient, a staff member, or others,” it must be discontinued at the earliest possible time (condition of participation: patient’s rights, 42 cfr 482.13(e)(2), 2008/2025). in addition to these protections, hospitals that receive medicare and medicaid are required to report deaths associated with s/r to the centers for medicare and medicaid services (cms), including “each death that occurs while a patient is in restraint or seclusion,” deaths occurring within 24 hours of removal, and cases where it is “reasonable to assume” that s/r contributed to a patient’s death (condition of participation: patient’s rights, 42 cfr 482.13(g)(1)(iii), 2008/2025). cms has emphasized the importance of preventing such adverse events, commonly referred to as never events, which are defined as “preventable medical errors that result in serious consequences for the patient” (cms, 2008, p.1). in response, cms has implemented payment policies that discourage preventable harm, stating that “never events cause serious injury or death to beneficiaries and result in unnecessary costs to medicare and medicaid due to the need to treat the consequences of the errors” (cms, 2008, p. 1). these regulations and policies reflect both the ethical obligation to protect patients from harm and the financial consequences hospitals may face when safety standards are not upheld. s/r can also significantly lengthen a patient’s hospital stay, placing additional financial burdens on both the hospital and the patient (lebel & goldstein, 2005). patients subjected to s/r experience prolonged hospitalization due to increased psychological distress, physical injuries, and disruption in their treatment process (newton-howes, 2013). instead of de-escalating crises, s/r has been found to increase agitation, aggression, and trauma symptoms in patients, leading to prolonged care requirements and, in some cases, readmissions (mha, n.d.). these extended hospitalizations not only delay recovery but also exacerbate healthcare costs, further burdening patients, hospitals, and insurance providers. these findings underscore that s/r is not a neutral intervention but a practice that actively contributes to deteriorating patient health, prolonged institutionalization, and increased systemic costs—all of which highlight the urgency for policy change. the use of s/r also contributes to workforce burnout and staff turnover, creating additional hidden costs for hospitals. the emotional toll on staff and the physical risks associated with managing aggressive incidents contribute to turnover rates as high as 62% in psychiatric facilities (mha, n.d.). the costs of recruiting, training, and retaining new staff further strain hospital budgets, making the reduction of s/r a financially sound decision. from a systemic perspective, it is clear that s/r is not only unethical but economically unsustainable. research consistently shows that reducing the use of s/r leads to better patient outcomes, lower healthcare costs, replacing seclusion and restraint emma costain columbia social work review, vol. xxiii | 17 16 | columbia social work review, vol. xxiii and fewer legal and liability expenses (lebel & goldstein, 2005). policy reformers must recognize that in a capitalist-driven society where financial arguments hold significant weight, demonstrating the economic inefficiency of s/r is a crucial strategy for policy change. the data overwhelmingly supports a transition toward alternative interventions, such as sensory rooms, which improve patient care, reduce hospital costs, and align with trauma-informed care principles (björkdahl et al., 2016). policy alternatives to seclusion and restraint given the well-documented harm and inefficiency of s/r, psychiatric facilities must adopt alternative interventions that prioritize patient autonomy, emotion regulation, and trauma-informed care. one such evidence-based alternative is the use of sensory rooms, which provide sensory modulation interventions (smis) to help individuals regulate their emotions in a safe and controlled environment. a sensory room offers patients a safe space where they can learn to regulate their emotions and gain skills they can use outside the hospital. sensory rooms have long been used to support individuals with autism spectrum disorder (asd) and other behavioral conditions by helping them regulate their bodies and better adapt to their environment. these rooms are commonly found in schools and educational settings, where they not only support emotion regulation but also improve how individuals with asd interact with teachers and peers. they foster the person’s independence and help them advocate for themselves when they are feeling overstimulated or overwhelmed (national autism resources, n.d.). if a hospital replaced its seclusion rooms with sensory rooms, patients could learn methods for emotion regulation that they could then easily transfer into the world outside the hospital. patients who are being discharged would have a set of skills that allow them to regulate their emotions rather than resorting to self-harm, aggression, or withdrawal. sensory stimulation methods empower patients by giving them the control and the autonomy to decide for themselves how they want to selfregulate, rather than confining them within prison-like isolation rooms at hospitals (haig & hallett, 2023). sensory rooms can also be used as a proactive intervention that helps prevent violent outbursts from escalating into crisis situations requiring s/r (haig & hallett, 2023). eliminating the practice of s/r would improve patient outcomes, lower the financial burden on psychiatric hospitals by reducing the average length of inpatient stays, and increase the likelihood of patients’ successful reintegration into their communities (ma et al., 2021). sensory modulation as a response to common s/r triggers as mentioned earlier, s/r is applied broadly to patients exhibiting certain behaviors, regardless of diagnosis (georgieva et al., 2020). individuals experiencing severe agitation, self-harming behaviors, physical aggression, or extreme emotional distress are the most likely to be restrained or secluded, even when alternative interventions could have prevented escalation (ma et al., 2021). sensory rooms are a proactive alternative that could help patients manage these behaviors before they reach a crisis point. the use of s/r remains prevalent across the globe, yet these practices are traumatizing for both patients and hospital staff. sensory rooms provide a viable alternative that allows psychiatric facilities to implement sensory modulation strategies in place of coercive interventions. haig and hallett (2023) explain that “sensory modulation refers to the personalisation of sensory input by controlling the environment, and use of equipment and/or activities designed to support an individual to self-regulate by achieving their optimum level of calm or alertness” (p. 55). patients who practice self-regulation inside a sensory room can carry those techniques into life outside the hospital and apply them in daily life to enhance healthy behavior. sensory modulation techniques (smts) can be used to help prevent replacing seclusion and restraint emma costain columbia social work review, vol. xxiii | 19 18 | columbia social work review, vol. xxiii behaviors that trigger s/r interventions. these techniques include: • tactile: weighted blankets, fidget tools, or textured surfaces to reduce distress and ground patients. • auditory: sound machines, white noise, or calming music to lower arousal levels. • visual: soft lighting, visual projection tools, or soothing imagery to decrease anxiety. • olfactory: aromatherapy using calming scents like lavender to help regulate mood. • proprioceptive: deep pressure input through body movement, such as via rocking chairs, yoga balls, or stretching, to improve emotional control (recovery ways, 2022). by offering self-directed and patient-centered regulation strategies, sensory rooms reduce the need for coercive interventions that strip patients of their agency and dignity (haig & hallett, 2023). these strategies are not only less harmful but are also therapeutic, as they equip patients with new coping skills that promote long-term emotion regulation and autonomy beyond the hospital setting. sensory rooms as a proven intervention ongoing research within acute psychiatric care is developing the best possible interventions for reducing s/r in inpatient facilities. one intervention suggests treating “patients as active participants in seclusion reduction interventions” (gaskin et al., 2007, p. 298). one of the many benefits of implementing sensory rooms as an intervention against s/r is that it allows the patient to remain in full control of how they choose to regulate their emotions and manage their distress, thereby making them “active participants” in their own treatment. psychiatric staff must shift their perspective from treatment happening to a patient to treatment happening with a patient, thereby reinforcing collaborative care models rather than coercion-based interventions. table 1 and 2 show some of the benefits of using sensory rooms instead of s/r in psychiatric care, along with considerations when switching to this model. while there are currently no sensory rooms in inpatient psychiatric settings in the united states, psychiatric hospitals in sweden have begun exploring this solution. although staff in such hospitals were initially ambivalent about implementing sensory rooms, over time they observed meaningful improvements, including patients becoming more independent in managing their emotions, building greater confidence in their ability to care for themselves, and experiencing enhanced overall well-being (björkdahl et. al., 2016). sensory rooms supported “the important principles of person-centered nursing and recovery-oriented mental health and the ability of staff to implement these principles” (björkdahl et. al., 2016, p. 472). implementing sensory rooms in psychiatric inpatient settings aims to help patients regain their individual autonomy within the treatment they receive, as they learn ways to selfsoothe and choose which sensory stimulation methods and tools to use. implementation of sensory rooms before implementing sensory rooms as a matter of state or federal policy in the u.s., this brief recommends identifying one acute psychiatric inpatient hospital to implement sensory rooms as a replacement for s/r. over the course of one year, research would be conducted within the identified hospital to track the results of the sensory rooms. at the conclusion of the year-long research project, the evidence collected could be brought to governmental bodies to propose policy changes regarding seclusion and restraint practices within acute psychiatric inpatient hospital settings. jackson behavioral health hospital (jbhh), located in miami, florida, could be used to implement the recommended intervention due to its existing inpatient psychiatric infrastructure. each of the psychiatric inpatient units at jbhh has two rooms designated as observation replacing seclusion and restraint emma costain columbia social work review, vol. xxiii | 21 20 | columbia social work review, vol. xxiii rooms, or rooms used exclusively for s/r. for the duration of the yearlong research project, one of the adult behavioral health units at jbhh could transform one of their two observation rooms into a designated sensory room. all staff within the unit would be educated on how to use the sensory room when a patient is overstimulated. the patient would be instructed to use the coping tools in the sensory room before staff considered using seclusion and restraint. to successfully create a sensory room, the room needs to be filled with a variety of objects that appeal to the different senses. there should be multiple options for each of the five senses so that the patient can choose what works best for them as they learn emotion regulation and distress tolerance. table 3 offers examples of different objects and tools within the sensory room that will provide a sensory experience for each of the five senses. given the nature of behavioral health hospitals, the objects in the sensory room cannot put the patient at risk of suicide or self-harm. for example, headphones must be wireless, and there cannot be any sharp objects. in addition to providing tools that appeal to the five senses, the sensory room can contain resources such as books, journals, and handouts that allow the patient to occupy their mind while simultaneously doing something therapeutic. the sensory room should shift away from the traditionally all-white walls of a psychiatric hospital and include decor such as soft carpets and light paint colors, which have been shown to create a calming atmosphere and support patient well-being (eminovic et al., 2022). sensory rooms are not just a theoretical alternative—they represent a research-based intervention that can replace outdated and harmful s/r practices. the transition from coercive interventions to sensory modulation techniques is a necessary step toward ethical, patientcentered psychiatric care. conclusion and policy recommendations the goal of acute psychiatric inpatient treatment is to ensure that the patient is stable enough to return to their community without being at risk for self-neglect or self-harm. as such, acute psychiatric care seeks to help patients reintegrate with their communities upon discharge. giving patients access to sensory rooms while still admitted to inpatient psychiatric care will show patients the variety of ways in which they can self-soothe and self-regulate, through a variety of sensory modalities that they will be able to carry over into the world outside the hospital after being discharged. sensory rooms can eliminate the use of seclusion and restraint in psychiatry by making the patients active participants in their treatment and equipping them with necessary distress tolerance and emotion regulation skills. learning such skills will give patients transferable, relevant, and effective methods of coping, both inside the hospital and in their communities after discharge. however, achieving systemic change requires collective action at all levels of psychiatric care, not just from policymakers. social workers play a crucial role in advocating for and implementing alternative interventions within their own workplaces and communities. even social workers who do not hold policy making roles can educate hospital administrators, clinical teams, and leadership about the proven benefits of sensory rooms. by advocating for pilot programs within psychiatric facilities, conducting data-driven evaluations of sensory room effectiveness, and documenting reductions in s/r use, social workers can generate the evidence needed to push for larger-scale policy reforms. if multiple hospitals implement sensory room interventions and gather compelling research on their impact, this evidence could influence national mental health policies and establish sensory rooms as the standard of care in inpatient psychiatry. sensory rooms are not just an abstract recommendation—they are a practical, evidence-based solution that can replace outdated and harmful replacing seclusion and restraint emma costain columbia social work review, vol. xxiii | 23 22 | columbia social work review, vol. xxiii psychiatric interventions. through advocacy, education, and research, social workers at all levels of practice can contribute to a fundamental shift in psychiatric care, ensuring that patients receive compassionate, trauma-informed, and effective treatment. replacing seclusion and restraint emma costain references björkdahl, a., perseius, k., samuelsson, m., & lindberg, m. h. (2016). sensory rooms in psychiatric inpatient care: staff experiences. international journal of mental health nursing, 25(5), 472–479. https://doi-org.ezproxy.cul.columbia.edu/10.1111/inm.12205 centers for medicare and medicaid services (cms). (2008, july 31). medicare and medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events [press release]. https://www.cms.gov/newsroom/press-releases/medicare-and-medicaid-moveaggressively-encourage-greater-patient-safety-hospitals-and-reduce-never condition of participation: patient’s rights, 42 cfr 482.13 (2008/2025). https://www.ecfr.gov/ current/title-42/chapter-iv/subchapter-g/part-482/subpart-b/section-482.13 eminovic, s., vincze, g., fink, a., fischerauer, s. f., sadoghi, p., leithner, a., kamolz, l. p., tscheliessnigg, k., & bernhardt, g. a. (2022). positive effect of colors and art in patient rooms on patient recovery after total hip or knee arthroplasty: a randomized controlled trial. wiener klinische wochenschrift, 134(5–6), 221–226. https://doi.org/10.1007/s00508-021-01936-6 eswaran, v., molina, m. f., hwong, a. r., dillon, d. g., alvarez, l., allen, i. e., & wang, r. c. (2023). racial disparities in emergency department physical restraint use: a systematic review and meta-analysis. jama internal medicine, 183(11), 1229–1237. https://doi.org/10.1001/ jamainternmed.2023.4832 gaskin, c., elsom, s., & happell, b. (2007). interventions for reducing the use of seclusion in psychiatric facilities: review of the literature. the british journal of psychiatry, 191(4), 298–303. https://doi.org/10.1192/bjp.bp.106.034538 georgieva, i., mulder, c. l., & whittington, r. (2020). effects of seclusion and restraint in adult psychiatry: a systematic review. frontiers in psychiatry, 11, 119. https://doi.org/10.3389/ fpsyt.2020.00119 grasso, b. c., shore, m. f., clary, c. m., eng, b., huckshorn, k. a., & parks, j. j. (2007). medication errors and patient safety in mental health. medscape cme. https://www.medscape. org/viewarticle/563039 haig, s., & hallett, n. (2023). use of sensory rooms in adult psychiatric inpatient settings: a systematic review and narrative synthesis. international journal of mental health nursing, 32(1), 54–75. https://doi.org/10.1111/inm.13065 hawkins, m. a., sinha, s., & carter, p. m. (2022). association of black race with physical and chemical restraint use among patients undergoing psychiatric evaluation. psychiatric services, 73(2), 123–129. https://pubmed.ncbi.nlm.nih.gov/34932385/ larson, z. (2018). america’s long-suffering mental health system. origins: current events in historical perspectives. https://origins.osu.edu/article/americas-long-suffering-mental-healthsystem lebel, j., & goldstein, r. (2005). the economic cost of using restraint and the value added by restraint reduction or elimination. psychiatric services, 56(9), 1109–1114. https://doi.org/10.1176/ appi.ps.56.9.1109 ma, d., su, j., wang, h., zhao, y., li, h., li, y., zhang, x., qi, y., & sun, j. (2021). sensorybased approaches in psychiatric care: a systematic mixed-methods review. journal of advanced nursing, 77(10), 3991–4004. https://doi.org/10.1111/jan.14884 columbia social work review, vol. xxiii | 25 24 | columbia social work review, vol. xxiii replacing seclusion and restraint emma costain table 1 benefits related to sensory rooms benefits of sensory rooms empowers patients sensory rooms encourage self-regulation and autonomy by allowing patients to choose their own coping mechanisms, reducing trauma from coercion-based interventions (haig & hallett, 2023). reduces aggression and violence sensory rooms provide a proactive, nonrestrictive intervention that can de-escalate situations before they reach a crisis leading to the use of s/r (björkdahl et al., 2016). improves patient outcomes sensory rooms reduce the need for s/r, decrease inpatient stays, and enhance emotional well-being, leading to greater patient stability post-discharge (georgieva et al., 2020). space requirements hospitals can use existing rooms designated for s/r to create sensory rooms. cost-effective for hospitals lower reliance on s/r reduces hospital costs associated with longer inpatient stays, lawsuits, staff injuries, and insurance penalties. mashour, g. a., walker, e. e., & martuza, r. l. (2005). psychosurgery: past, present, and future. brain research reviews, 48(3), 409–419. https://doi.org/10.1016/j.brainresrev.2004.09.002 mental health america (mha). (n.d.). position statement 24: seclusion and restraints. https:// mhanational.org/issues/seclusion-and-restraints national association of social workers. (2021). code of ethics of the national association of social workers. https://www.socialworkers.org/about/ethics/code-of-ethics/code-of-ethics-english national autism resources. (n.d.). school sensory rooms. https://nationalautismresources.com/ school-sensory-rooms/ national human genome research institute. (n.d.). eugenics and scientific racism. https://www. genome.gov/about-genomics/fact-sheets/eugenics-and-scientific-racism newton-howes, g. (2013). use of seclusion for managing behavioural disturbance in patients. advances in psychiatric treatment, 19(6), 422–428. https://doi.org/10.1192/apt.bp.112.011114 prins, h., backer-holst, t., francis, e., & keitch, i. (1993). report of the inquiry into the death of orville blackwood. midlands centre for criminology and criminal justice, department of health, afro-caribbean mental health association, & institute of criminology at cambridge university. https://www.mentalhealthlaw.co.uk/media/1993_shsa_blackwood_inquiry_report. pdf recovery ways. (2022, august 26). sensory-based strategies for self-regulation. https://www. recoveryways.com/rehab-blog/sensory-based-strategies-for-self-regulation scull, a. (2022). desperate remedies: psychiatry’s turbulent quest to cure mental illness. harvard university press. https://doi.org/10.4159/9780674276475 substance abuse and mental health services administration. (2010, march). promoting alternatives to the use of seclusion and restraint issue brief #4: making the business case. https://www. samhsa.gov/sites/default/files/topics/trauma_and_violence/seclusion-restraints-4.pdf turda, m. (2022, october 24). exploring the legacies of eugenics in psychiatry—part i. history, archives and library blog. royal college of psychiatrists. https://www.rcpsych.ac.uk/news-andfeatures/blogs/detail/history-archives-and-library-blog/2022/10/24/eugenics-in-psychiatry-partone united nations general assembly. (1992, february 18). the protection of persons with mental illness and the improvement of mental health care: resolution / adopted by the general assembly. united nations digital library. https://digitallibrary.un.org/record/135851 weiss, e. m., altimari, d., blint, d. f., & megan, k. (1998, october 15). deadly restraint: a nationwide pattern of death. the hartford courant. https://www.charlydmiller.com/ lib05/1998hartfordcourant11.html columbia social work review, vol. xxiii | 27 26 | columbia social work review, vol. xxiii replacing seclusion and restraint emma costain table 3 sensory rooms and the five senses sensory rooms and the five senses taste • sour candies • cold ice cubes • calming tea (available upon request) touch • cold washcloths • kinetic sand • weighted blankets • calm strips • fidget toys smell • essential oils • scented markers • scented play-doh sight • tv screen with calming visuals such as nature walks, relaxing ocean waves, and gentle rain • posters with breathing techniques hearing • ambient music • wireless noise-canceling headphones table 2 considerations related to sensory rooms considerations for sensory rooms initial resistance from staff some staff members may struggle with relinquishing control and adapting to a less authoritative model of care (björkdahl et al., 2016). not a one-size-fits-all solution sensory interventions must be tailored to individual needs, and not every patient will respond equally well to the same sensory modulation techniques (georgieva et al., 2020). need for staff training effective implementation relies on welltrained staff who understand how to guide patients in using sensory tools effectively rather than reverting to traditional control-based interventions (haig & hallett, 2023). columbia social work review, vol. xix | 159 158 | columbia social work review, vol. xix disproportionate levels of violence, disappearance, and murder are endemic among indigenous women in the united states (u.s.). the prevalence of such violence has persisted for centuries, with little direct action taken to elevate the issue, protect indigenous women, and hold individual and systemic perpetrators accountable. as a result, indigenous women in the u.s. face various forms of violence at 2.5 times the rate of non-indigenous women, with murder being the third leading cause of death. a staggering 94% of indigenous women experience sexual violence in their lifetime (urban health institute, 2019). through an analysis of existing and new legislation aimed at addressing the issue of violence against indigenous women, we reveal the ways in which policies have fallen critically short of achieving this mission, highlight the strengths of recently enacted legislation, and provide recommendations for implementation in order to truly prevent violence, and therefore to protect and empower indigenous women. violence against indigenous women in the united states: a policy analysis annie benjamin, she/her elizabeth d. gillette, she/her columbia social work review, vol. xix | 161 160 | columbia social work review, vol. xix violence against indigenous women in the united states annie benjamin & elizabeth d. gillette violence against indigenous women in the united states: a policy analysis indigenous women are experiencing endemic-levels of violence, disappearance, and murder, yet there is little to no accountability for the violence being inflicted upon them (salam, 2019). furthermore, a lack of awareness of these human rights abuses, among the public and policymakers alike, has led to far too few efforts toward protection from and prevention of such violence. it is time for indigenous women to be guaranteed their rights to protections under the united states (u.s.) government, ensuring justice and safety in all jurisdictions. this paper will examine the lack of protection for indigenous women and girls under u.s. government policy, and the characteristics, context, and responses to violence and abuses against them. no person should ever experience psychological or physical harm. any act of violence is a violation against humanity. the united nations recognizes violence against women to be “any act of gender-based violence that is likely to result in physical, sexual, or mental harm or suffering to women, including threats, coercion or deprivation of liberty, whether occurring in public or in private life” (united nations interagency support group on indigenous peoples’ issues, 2014, p. 1). in a brief review of the literature on violence against indigenous women, this paper will first present the prevalence and severity of this social problem, and then evaluate new and existing protections for indigenous women under current u.s. law. building on these protections, this paper will make recommendations for further changes and approaches to implementation necessary to advance the rights, health, and safety of indigenous women. for the purposes of this paper, we use the term “indigenous” to refer to native american, american indian, and alaska native women. violence against indigenous women: a severe yet ignored social problem indigenous women’s and girls’ experiences of violence are a reflection of the u.s. history of colonization, extreme poverty, and the exclusion of their wider communities—best contextualized in terms of the intersections of race, disability, age, sex, and location, in addition to mutually reinforcing forms of inequities. these conditions ensure that they do not benefit to the same extent as their non-indigenous counterparts from services which would otherwise protect them from violence and support their ability to seek redress when it does occur (inter-agency support group on indigenous peoples’ issues, 2014). rates of violence towards indigenous women are 2.5 times higher than the rate of violence towards non-indigenous women in the u.s., with estimates ranging from 46-91% of indigenous women compared with 7-51% of non-indigenous women (burnette & cannon, 2014). the indian law resource center (2020), a leading non-profit legal and advocacy resource organization for indigenous people, found that four out of five american indian and alaska native women experience violence, and more than one in two experience sexual violence (p. 1). these experiences of violence lead to significant trauma, substance use, depression, and other mental and physical health issues (loerzel, 2020). additionally, children of indigenous women who experience intimate violence also experience high stress and anxiety, low self-esteem, and aggressive behaviors (burnette & cannon, 2014). a key contributor to such violence is the fact that cases have not received attention or interventions whatsoever from any authoritative agency in centuries. while indigenous women were once held in high esteem, given great respect and reverence among their tribes, the cultural erosion of indigenous societies as a whole has been cited as a precursor to the violence indigenous women face in their communities today (burnette & hefflinger, 2017). the u.s. colonial government system has failed to appreciate, preserve, and affirm the humanity, cultures, lands, territories, and resources of indigenous peoples. historical trauma refers to the cumulative emotional and psychological wounding over lifespans and across generations, emanating from massive group trauma experience (brave heart, 2003). since multigenerational trauma continues as a consequence of such historical oppression, this trauma is seen as both a cause and a consequence of the normalization of violence towards indigenous women in society (burnette & hefflinger, 2017). columbia social work review, vol. xix | 163 162 | columbia social work review, vol. xix violence against indigenous women in the united states indigenous peoples all over the globe experience cultural and individual oppression. identifying the best way to restore indigenous women’s rights to safety, health, and autonomy is not only crucial to empowering indigenous women, but to empowering indigenous culture as well. indigenous women and girls play essential roles in maintaining community resilience and wellbeing, acting as vital keepers of cultural identity and tradition. when their rights are violated through violence and coercion, such human rights violations “[constitute] a violation of the sanctity of the ecological, spiritual and cultural identity of indigenous peoples as a whole” (inter-agency support group on indigenous peoples’ issues, 2014, p. 2). for indigenous culture to flourish, programs must go beyond merely solving crimes against indigenous women to preventing these crimes altogether. by focusing on how to empower and protect indigenous women in the u.s., we can learn more about how to protect indigenous peoples, cultures, and traditions worldwide. current policy intended to empower indigenous women: the violence against women act (vawa) a key policy aimed at empowering indigenous women is the violence against women act (vawa). vawa was introduced in 1994 as the first federal bill of its kind, acknowledging and addressing domestic violence and sexual assault as crimes. this paved the way for increased protections and support for women at federal, state, and local levels (nnedv, 2020). the bill requires reauthorization every five years, and each renewal brings about key expansions in support for enhanced or newly-specified priorities, such as housing programs for victims of domestic violence or the implementation of culturally-competent services (nnedv, 2020). the bill is key in raising awareness of violence against women and increasing support for victims and those impacted by sexual assault, stalking, rape, trafficking, and domestic violence. the violence against women reauthorization act of 2005 was the first to introduce plans to address violence experienced by indigenous women and girls, specifically acknowledging the disproportionate level at which indigenous women experience gender-based violence (burnette & cannon, 2014). as a result, section 903 was added to the bill, mandating the attorney general (ag) to consult with indian tribal governments on a yearly basis. these consultations afford an opportunity to provide recommendations to the ag regarding the federal administration of tribal funding for programs offered under vawa, enhancing protection of indigenous women from various forms of violence by improving the federal response—or lack thereof—to such violence (salam, 2019; national indigenous resource center, 2020). the next iteration of the bill—the violence against women reauthorization act of 2013—strengthened protections for native american women and girls as a result of collaboration among the indian law resource center, the national congress for american indians task force on violence against women, clan star, inc., and the national indigenous women’s resource center (indian law resource center, n.d.). specifically, provisions were added to restore tribal criminal authorities to target and address violence inflicted upon indigenous women and girls by non-indian perpetrators on tribal land. this provision, known as the special domestic violence court jurisdiction (sdvcj), was instrumental in ensuring that indian nations can effectively investigate, punish, and hold perpetrators of violence—indian and nonindian alike—accountable for the harm they cause towards indigenous women on tribal lands (indian law resource center, n.d.). while the important addition of sdvcj could benefit tribes in the 48 contiguous u.s. states, because of restrictive land resettlement laws, the federal government does not recognize tribal land as “indian country” in alaska (indian law resource center, n.d.). under 18 u.s.c. § 1151 and 40 c.f.r. § 171.3, indian country is defined as: a. all land within the limits of any indian reservation under the jurisdiction of the united states government, notwithstanding the issuance of any patent, and, including rights-of-way running through the reservation; b. all dependent indian communities within the borders of the united states whether within the original or subsequently acquired territory thereof, and whether within or without the limits of a state; and annie benjamin & elizabeth d. gillette columbia social work review, vol. xix | 165 164 | columbia social work review, vol. xix violence against indigenous women in the united states c. all indian allotments, the indian titles to which have not been extinguished, including rights-of-way running through the same. (u.s. environmental protection agency, n.d.) because alaskan tribal land does not fit this definition, section 910 of vawa 2013 cites special rule for the state of alaska (s.47-violence against women reauthorization act of 2013). as a result, the sdvcj currently applies to only one of 229 alaskan tribes, thus excluding 40% of federally recognized tribes from these reforms (indian law resource center, n.d.). jurisdictional complexities, in addition to insufficient resources for investigating and prosecuting those who commit crimes, add to the already high levels of vulnerability of alaska native women and girls,who make up 19% of the state population, but 47% of reported rape victims (alaska native women’s resource center, 2019). the violence against women reauthorization act of 2019 (hr 1585), which is currently awaiting consideration in the senate (congress.gov, 2019), addresses this issue by introducing a pilot program that would allow five alaska native tribes to exercise sdvcj (alaska native women’s resource center, 2019). vawa 2019 will also add sexual violence, sex trafficking, stalking, and assault of law enforcement or corrections officers to the list of crimes indian nations can prosecute (indian law resource center, 2019). current policy’s lack of effectiveness in protecting indigenous women’s rights the vawa limits tribal prosecution of non-indian perpetrators to those with prior connections to the tribe, but should expand to include those who commit any act of violence that is likely to result in physical, sexual, or mental harm or suffering to women or girls. although evidence is limited, available studies indicate that this legislation is not achieving its intended goal of addressing and prosecuting crimes with the specific intent of increasing protections for women and girls (nnedv, 2020). for example, while vawa 2013 introduced legislation allowing tribes to charge non-indian perpetrators of violence against women for their crimes, crepelle (2020) highlights that tribes only have the authority to prosecute such perpetrators for three specific crimes: domestic violence, dating violence, and protective order violations (p. 60). due to this limitation, tribes lack authority in prosecuting additional crimes committed during these same circumstances, such as child abuse, stalking, and other violent crimes, which often include children, women, and men, with sometimes dramatic consequences for entire tribes (crepelle, 2020). these circumstances are exacerbated by a preexisting lack of protections for indigenous women, including high rates of poverty and limited resources for law enforcement to put towards prevention efforts (creppelle, 2020, p. 63). vawa also neglects to uphold and advance tribal sovereignty, a necessary facet of indigenous women’s well-being. vawa lacks substantial compatibility with united states legal processes and procedures (allison, 2019). this not only constitutes a significant burden on tribes to exercise civil jurisdiction but also helps to bring into focus the scope of oppression imposed by the united states government. vawa does not provide any sense of consideration for historical oppression and genocide against indigenous women, nor is it inclusive of indigenous perspectives or demonstrate cultural reverence. as it does not include support for the safeguarding of sovereignty, vawa seeks to strengthen a legacy of white supremacy and heteropatriarchy. as a result, vawa does not adequately address the significance of violence towards indigenous women, and fails to address the systemic causes and mediators of genderbased violence and genocide (maxwell & robinson, 2019). while vawa has come a long way since its introduction in 1994, it is clear that more work is needed based on the disproportionate levels of violence faced by indigenous women throughout history and still today (burnette & cannon, 2014; creppelle, 2020). as the sdvcj does not apply to all tribes, most indigenous women are not afforded the protections that the vawa 2013 amendment celebrates (allison, 2019). despite increasing the list of crimes indian nations can charge against (indian law resource center), vawa 2019 does not provide a means of preventing the overwhelming levels of violence, abuse, and genocide imposed upon indigenous women. in order to ensure safety and annie benjamin & elizabeth d. gillette columbia social work review, vol. xix | 167 166 | columbia social work review, vol. xix violence against indigenous women in the united states empowerment of indigenous women, the scope of protections should include violence prevention efforts as well as accountability measures that apply to all tribal jurisdictions. urgent solutions: savannah’s act, not invisible act, and changes to vawa 2013 historically, criminal justice systems on reservations and in indian country have created more barriers to investigating crime than to attaining solutions. prevention, investigation, and prosecution of crimes against indigenous women are often inconsistent or incomplete due to several different agencies—including the fbi, tribal police, and u.s. attorneys—working with conflicting protocol (pao, 2020). in this section, we first review two recent acts that aim to combine and coordinate efforts to better protect indigenous women and then propose a change to vawa 2013 that would strengthen the ability to hold perpetrators of violence accountable. two recent acts aiming to better protect indigenous women in response to the inconsistency that has allowed abuse, disappearance, and murder of indigenous women to continue, two acts were recently signed into law to enhance cohesion and diligence in protecting indigenous women. specifically, the first law, savannah’s act (public law no: 116-165), signed into law in october 2020, requires the department of justice to create a task force made up of members from various agency bodies to ensure all teams are collaborating and can devise a concrete plan to investigate a crime. in creating a task force, the department of justice will also be required to conduct trainings for each agency, from the bureau of indian affairs police all the way to the fbi, in order to establish each agency’s role in locating missing women on and off tribal lands or investigating crimes against indigenous women (pao, 2020). savannah’s act also requires transparency from the department of justice through recording data and reporting statistics on missing and murdered indigenous women (congress.gov, 2020). the second law recently enacted is the not invisible act (public law no: 116-166), which was also signed into law in october 2020. also working to increase coordination efforts, this act focuses on establishing more robust efforts to prevent murder, trafficking, and violence towards indigenous women. mandated by law, the department of the interior will designate an official from the bureau of indian affairs to spearhead prevention by establishing grants, programs, and recommendations to combat violence towards indigenous peoples (sanchez, 2020). furthermore, the act creates an advisory committee on violent crime comprised of survivors, service providers, and members of law enforcement. a new direction: proposed changes to vawa 2013 in order for these two laws to be effective, criminal authority must be restored to indian nations. according to a study by the national institute of justice, 97% of indigenous women have been victims of violence at the hands of at least one non-indian perpetrator during their lifetime (rosay, 2016). if we truly aim to protect and provide justice for indigenous women, girls, and their families, the special domestic violence court jurisdiction (sdvcj) provision introduced in vawa 2013 must be implemented in all indian nations. as mentioned earlier, while vawa 2019 proposes a pilot program to introduce and exercise the sdvcj in five alaska native tribes (alaska native women’s resource center, 2019), it is critical that the sdvcj be implemented in all tribes and reservations as soon as possible. until then, non-indian perpetrators will not be held accountable, and indigenous women and girls will still be vulnerable to endemic-level violence, murder, and disappearance. implementation of approaches: recommendations for protecting indigenous women’s rights as evident in this review of literature, it is important not only to pass laws, but also to implement them effectively and equitably so that the rights, health, and safety of indigenous women can be protected and advanced. the two new laws—savannah’s act and the not invisible act—complement each other to streamline prevention efforts among annie benjamin & elizabeth d. gillette columbia social work review, vol. xix | 169 168 | columbia social work review, vol. xix violence against indigenous women in the united states federal, state, and tribal officials to strengthen justice and public safety in tribal communities. as both laws were passed with wide bipartisan support and sponsorship, it is promising to see that this crisis is being recognized and prioritized across party lines. through grant funding from the u.s. depratment of justice’s office on violence against women, savannah’s act incentivizes tribal communities by providing increased funding to jurisdictions that implement guidelines created by the act (the navajo nation, office of the president and vice president, 2020; department of justice office on violence against women). grant funds can be used towards training for law enforcement officers and data collection and reporting to the attorney general (s.227-savanna’s act, 2020). increased funding to ensure the act is implemented shows that policy makers recognize the potential impact of the act on protecting indigenous women. as savannah’s act and the not invisible act are both newly signed into law, their efficacy will depend greatly on how the laws are implemented. one key determinant of successful implementation will be the involvement of indigenous women, including survivors of violence and family members of survivors, victims, and missing women—key stakeholders in the fight for justice. the not invisible act mandates the creation of an advisory committee on violent crimes. in addition to tribal leaders and law enforcement, the act indicates the committee is to be made up of survivors and service providers who will work together to issue recommendations to the department of justice and department of the interior (the navajo nation, office of the president and vice president, 2020). another key to implementation is respect for indigenous culture and tradition. under savannah’s act, agencies are tasked with ensuring that culturally appropriate services are available for victims of violence and trafficking, such as access to culturally-aligned mental and physical health providers. additionally, the act requires the “[c]ulturally appropriate identification and handling of human remains identified as belonging to american indians” (2020). guaranteeing that indigenous women, survivors, families, and service providers have a say in how these two acts are adopted on the ground is vital in making sure the efforts to protect and provide justice for indigenous women and girls are not only effective, but sustainable and appropriate as well. it must also be noted that for both of these laws to be effective, the vawa 2019 reauthorization bill must expand the implementation of the sdvcj provision. whereas non-indian perpetrators are “above the law” (creppelle, 2020, p. 1) in territories where the sdvcj is not in effect—that is, they cannot be prosecuted by tribes for crimes committed in indian country—the provision ensures that all perpetrators of violence are appropriately held responsible for their crimes, which, most pressingly include violence against women (creppelle, 2020). this provision will also support efforts to prevent violence against indigenous women in the first place. discussion savannah’s act and the not invisible act have the potential to amplify awareness of the crisis of missing and murdered indigenous women, while also putting into action concrete strategies to prevent violence, conduct investigations, and provide services for survivors and their families. despite the acts both including best practice recommendations for searching for missing native persons on and off tribal land (the navajo nation, office of the president and vice president, 2020), a key challenge that persists is the lack of universality in the application of sdvcj in tribal courts. without the ability to appropriately hold non-indian perpetrators accountable for crimes against indigenous women, these acts will not be able to provide the level of justice indigenous women deserve. additionally, as the department of justice did not release crime data regarding native peoples until 1999 (pao, 2020), the scope of the crisis and therefore best approaches to protecting indigenous women have not been thoroughly or justly explored. efforts to protect indigenous women and ensure their ability to live with safety and dignity must not stop at the passage of these acts. future community-based, participatory action research should evaluate annie benjamin & elizabeth d. gillette columbia social work review, vol. xix | 171 170 | columbia social work review, vol. xix violence against indigenous women in the united states implementation of the acts, as including indigenous women in the guidance and maintenance of the process will be vital to the success and survival of indigenous women. additionally, researchers and advocates should evaluate the potential impacts of expanding the sdvcj provision to all jurisdictions. ongoing evaluation will also be necessary in order to secure justice, violence prevention, and ongoing support for all indigenous women. conclusion the lack of protections in place for indigenous women and girls throughout history has led to endemic levels of physical and sexual violence, missing women, and generational trauma. murder is the third leading cause of death among this population, and rates of violence towards indigenous women are 2.5 times higher than the rate of violence towards non-indigenous women in the united states, with estimates ranging from 46-91% of indigenous women having experienced these forms of violence, compared with 7-51% of non-indigenous women (the navajo nation, office of the president and vice president, 2020; burnette & cannon, 2014). the indian law resource center (2020) found that four out of five american indian and alaska native women experience violence and more than one of every two women experience sexual violence. at the same time, there has been little focus on holding perpetrators accountable, ensuring indigenous women their rights to safety and adequate services, or implementing best practices to effectively investigate and prevent such levels of violence. according to a 2018 survey conducted by the urban indian health institute, of 5,712 missing alaska native and american indian women and girls, only 116 were registered in the department of justice database (the navajo nation, office of the president and vice president, 2020). savannah’s act specifically allocates the resources needed to efficiently collect and enter data into national databases and further prevent and investigate crimes against indigenous women. when 97% native women experience physical, sexual, and psychological abuse at the hands of nonindians, compared with 35% at the hands of indian perpetrators (rosay, 2016), it is critical that tribal courts be able to prosecute all perpetrators of violence in order to truly protect women and girls. despite laws in place such as vawa which aim to protect women from violence, specific protections for indigenous women have fallen short. while it is too soon to tell whether the not invisible act and savannah’s act will effectively address the issues discussed in this paper, with proper implementation they offer alternatives to a lack of protections and policies that have previously allowed violence towards indigenous women to continue at disproportionate levels. it is time for indigenous women and girls to be free of the human rights violations they have been subject to for far too long. references alaska native women’s resource center. (2019, march 8). reauthorization of vawa house bill 1585 introduced. https://www.aknwrc.org/reauthorization-of-vawahouse-bill-1585-introduced/ allison, jessica. (2019). beyond vawa: protecting native women from sexual violence within existing tribal jurisdictional structures. 90 u. colo. l. rev. 225. brave heart, m.y.h. 2003. the historical trauma response among natives and its relationship with substance abuse: a lakota illustration. journal of psychoactive drugs, 35(1): 7–13. burnette, c. e. & cannon, c. (2014). it will always continue unless we can change something: consequences of intimate partner violence for indigenous women, children, and families. european journal of psychotraumatology, 5(1), doi: 10.3402/ ejpt.v5.24585 burnette, c. e. & hefflinger, t.s. (2017). identifying community risk factors for violence against indigenous women: a framework of historical oppression and resilience. journal of community psychology, 45(5): p587-600. doi: 10.1002/jcop.21879 crepelle, a. 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(2019). safety for american indian women: an indigenousfocused policy analysis of violence against women act-title ix. retrieved october 20, 2020, from https://doi.org/10.18060/22608. national indigenous women’s resource center. (2020, september 20). tribal consultation on violence against indian women (vawa 2013, section 903). https:// www.niwrc.org/resources/webinar-tribal-consultation-violence-against-indianwomen-vawa-2013-section-903 national network to end domestic violence. (2019). violence against women act. https://nnedv.org/content/violence-against-women-act/ pao, m. (2020, september 28). savannah’s act addresses alarming numbers of missing or killed native women. npr. https://www.npr.org/sections/live-updates-protests-forracial-justice/2020/09/28/917807372/savannas-act-addresses-alarming-numbers-ofmissing-or-murdered-native-women rosay, a. b. (2016). violence against american indian and alaska native women and men. national institute of justice. https://www.ncjrs.gov/pdffiles1/nij/249822.pdf s.227 savanna’s act. (2020, october 10). congress.gov. retrieved from https://www. congress.gov/bill/116th-congress/senate-bill/227 s.47 violence against women reauthorization act of 2013. (2013, march 7). congress. gov. retrieved from https://www.congress.gov/bill/113th-congress/senate-bill/47/ text salam, m. (2019, april 12). native american women are facing a crisis. the new york times. https://www.nytimes.com/2019/04/12/us/native-american-women-violence. html sanchez, c. (2020, september 28). congress just passed two bills that are intended to protect native women from violence. harper’s bazaar. https://www.harpersbazaar. com/culture/politics/a34145742/savannas-not-invisible-act-murdered-missingindigenous-women/ the navajo nation, office of the president and vice president. (2020, october 10). savanna’s act and not invisible act signed into law to help address the missing and murdered indigenous women crisis [press release]. retrieved from https://www. navajo-nsn.gov/news%20releases/opvp/2020/oct/for%20immediate%20 release%20-%20savanna_s%20act%20and%20not%20invisible%20act%20 signed%20into%20law%20to%20help%20address%20the%20missing%20and%20murdered%20indigenous%20women%20crisis.pdf united nations inter-agency support group on indigenous peoples’ issues. (2014). elimination and responses to violence, exploitation and abuse of indigenous girls, adolescents, and young women. united nations declaration on the elimination of violence against women. https://www.un.org/en/ga/69/meetings/indigenous/ pdf/iasg%20thematic%20paper_%20violence%20against%20girls%20and%20 women%20-%20rev1.pdf urban indian health institute. (2019, may 9). sexual violence among native women: a public health emergency. urban indian health institute. https://www.uihi.org/ resources/sexual-violence-among-native-women-a-public-health-emergency/ u.s. environmental protection agency. (n.d.). definition of indian country. retrieved from https://www.epa.gov/pesticide-applicator-certification-indian-country/ definition-indian-country annie benjamin & elizabeth d. gillette annie benjamin (she/her) is a masters of science in social work candidate at the columbia school of social work in policy practice, concentrating in contemporary social issues. annie holds a bachelor of science in sociology from ithaca college. she is currently a social work intern at the open society foundations global drug policy program. elizabeth gillette (she/her) is a masters of science candidate at the columbia school of social work in advanced policy practice, concentrating in international social welfare. a fervid advocate for indigenous people’s rights, children and women, and racial economic justice, she presently is a research assistant at the center on poverty and social policy at columbia university. she serves as senator in the columbia university senate, where she is a member of the commission on the status of women, the commission on diversity, the presidential advisory committee on sexual assault, and chairs the student affairs subcommittee on anti-racist education. elizabeth holds a ba from the university of texas at dallas. columbia social work review, vol. xix | 21 20 | columbia social work review, vol. xix in the face of socio-political marginalization, frontline communities reclaim power by harnessing peer wisdom and resilience. the year 2020 marked the confluence of a global pandemic and widespread resistance against anti-black racism and police violence, highlighting the value of peer voices and community perspectives. to dismantle and transcend carceral approaches to community care, the field of social work is invited to join a larger anti-carceral mental health movement that honors lived experience and works alongside peers to build identity-affirming structures of mental health care. this article examines the ways in which frontline communities benefit from expanded access to anti-carceral formal and informal peer support as a mental health safety net that interrupts harm and prioritizes agency, consent, and self-determination. this paper broadens social work’s conceptualization of peer support through theoretical frameworks of anti-carceral social work, abolition, and intersectionality. social work and its adjacent fields are called to urgently center black liberation, collective healing, and community care by advocating for the integration of formal and informal peer support into mental health policy and practice. this paper strategically leans into a lineage of critical peer thought scholarship by utilizing footnotes and citations to model the ethical acknowledgment of peer labor within human rights movements. this intentional structure promotes radical solidarity that resists the exploitation of people with lived experience. keywords: social work, peer support, mental health, anti-carceral, lived experience peer support as a tool for community care: “nothing about us, without us” shinjini bakshi they, them guest on ancestral lands of the indigenous chinook peoples columbia social work review, vol. xix | 23 22 | columbia social work review, vol. xix peer support1 as a tool for community care: “nothing about us, without us”2 the expression “nothing about us, without us” has long been used as a cornerstone of social justice movements. the united states (u.s.) disability justice movement first utilized this expression in the 1990s to amplify historically silenced voices and promote community-based empowerment (charlton, 1998; franits, 2005). social work activists from frontline communities3 continue to highlight the need for policy initiatives and social change movements to be catalyzed by peers4 with lived experience and culturally specific understandings of community care. this rallying cry demands that black liberation and anti-carceral5 approaches to mental health center black communities and those most impacted by carceral systems. this anchoring socio-political demand serves as a guide for the field of social work to organize and mobilize itself towards community-led social change and collective liberation. in 2020, black, indigenous, and other people of color (bipoc)6 labored at the forefront of the liberation struggle against racial, 1 “peer support” will refer to empathy, encouragement, and assistance related to emotional wellness (penney, 2020). 2 in critical disability studies, activists use this declaration to ensure frontline communities have direct access to shaping policy. this phrase also demands that policymakers remain accountable to communities that have the most at stake regarding carceral approaches to care (yarbrough, 2020). 3 “frontline communities,” a term originating from the environmental justice movement, will refer to communities facing the direct impacts of racial and social injustices from oppressive systems (front and centered, 2020). 4 the term “peer” refers to individuals with “lived experience,” or first-hand knowledge gained from mental health difference or disability (mental health america [mha], n.d.). 5 “anti-carceral” mental health uses an abolitionist lens to reject punitive responses to disability or difference, and centers black liberation (the self-determination of black people) (kim, 2018; critical resistance, n.d.). “anti-carceral” frameworks actively interrogate carcerality, defined in critical carceral studies as dominant societal structures featuring punishment, discipline, social control, and surveillance (graby, 2015). 6 acknowledging that the popularized term “bipoc” does not capture the vast nuance across different racialized experiences of racism, this paper will utilize this term in place of “communities (or people) of color” to decenter whiteness and highlight the distinct differences present in black and indigenous experiences of race and racism. economic, and gender injustice created by white supremacy. in response to the horrific murders of george floyd, breonna taylor, and countless other black individuals, black activists sparked a global call-to-action to dismantle white supremacy, prompting a national uprising against the racist u.s. policing system. indigenous, black, and pacific islander individuals tragically suffered vastly disproportionate impacts from covid-19. u.s. failure to respond to this racialized public health crisis caused widespread outcry as members from these communities turned to mutual aid7 to confront legacies of medical racism and working-class struggle (apm, n.d.). trans and gender expansive (tge) young people demanded responses to the epidemic of fatal individual and state violence fueled by “anti-black transmisogyny”8 (human rights campaign, 2020). resilient communities on the frontlines of racial, economic, and gender oppression build power through grassroots coalitions oriented towards collective liberation that affirms humanity and provides access to resources. the black lives matter (blm) movement bridged these social concerns, generating cross-movement solidarity by putting a spotlight on the nation’s systems rooted in white supremacy—including the u.s. mental health system. as a socio-political movement for human rights, blm exposes the ways in which carceral responses to mental health crises limit individuals’ freedom and rights to self-determination through involuntary psychiatric hospitalization, seclusion, physical or chemical restraint, and forced medication compliance. in 2015, people unable to access mental health resources were 16 times more likely than other individuals to be fatally shot during an encounter with police, yet armed police officers were still the default response to people experiencing emotional distress (fuller, et al., 2015). a 2019 study conducted among 7 “mutual aid” is a political action and organizing strategy that resists capitalist and colonialist forces through networks of radical community care that provide crisis relief to under-resourced communities (spade, 2020). 8 “anti-black transmisogyny” refers to the targeting of black, transgender feminine (trans femme) and trans and gender-expansive (tge) individuals (human rights campaign, 2020). despite discrimination, prejudice, and inequity, black trans femme activist-organizers continue to lead innovative social change initiatives (ware, 2017). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 25 24 | columbia social work review, vol. xix young black men in baltimore found that individuals with mental health diagnoses were more likely to experience police brutality (smith lee, 2019). anti-carceral logic proposes a radically different approach to the mental health movement, embracing traditions of interdependence and emphasizing social connectedness while utilizing a critical systems analysis to interrupt carceral response. social work’s purpose in an anti-carceral mental health movement must be not only to center the wellness of those most impacted by violence and oppression, but also to uproot methods of carceral intervention, prioritize self-determination in mental health policy, and reimagine the role of peers in new community structures of life-affirming care (jacobs et al., 2020). amplifying lived experience: “existence is resistance”9 there have long been challenges within the field of mental health to standardize the definition of “peer” and to evaluate the benefits of peer roles in care settings. in formal treatment or recovery settings, a peer supporter is “someone who has experienced the healing process of recovery from psychiatric, traumatic, or substance use challenges and, as a result, offers support to promote recovery in traditional mental health settings” (inaps, 2013, p. 9). while most formalized systems in society do not favor positioning peers as leaders, social work can abandon the status quo of institutionalized definitions by advocating for the inclusion of peers in all forms of mental health care delivery. drafting definitions – the role of the peer in an attempt to highlight the value of peer perspectives in social work policy and practice, social work professionals often use the term “embodied knowing” to refer to knowledge that is gained through and residing within the body (sodhi & cohen, 2011; fox, 2016). this paper defines a “peer” as an equal, or “someone like me [(or you)],” with shared social or demographic identity and lived experience (shalaby, 9 this phrase honors trans activists who have resisted and continue to resist social erasure by bringing visibility to socially marginalized and politically disenfranchised communities (seidman, 2019). 2020; okoro, 2018, p. 2; penney, 2020). this definition has been criticized for being too broad, as it universalizes and essentializes peer identity and oversimplifies group identity, overlooking differences to meet certain goals (voronka, 2016). however, this working definition’s broad nature intentionally resists urges to professionalize this distinct identity and allows individuals to articulate lived experiences. centering justice: “rhythm without the blues”10 social work will benefit from following an intersectional disability justice approach, operating from the awareness that those “most impacted by the legacies of anti-black racism, colonialism, heterosexism, white supremacy, patriarchal capitalism are the ones furthest from justice and access to self-determination” (white, 2020). created by disabled11 queer, transgender, black, indigenous, people of color (qtbipoc) activists, disability justice frameworks aim to dismantle “intersecting legacies of white supremacy, colonial capitalism, gendered oppression, and ableism” (project lets, n.d., para. 3). in her matrix of domination theory, patricia hill collins demonstrates how ableism interlocks with other forms of oppression (2000). through the adjacent intersectionality theory, black feminists and critical race theorists assert that carceral ableism (socially constructed ideas of difference or divergence) criminalizes and devalues bodies and minds (crenshaw, 1991; lewis, 2020; berne, 2015). embracing anti-carceral social work: “the water we are swimming in”12 social work has been slow to recognize and implement liberatory 10 this phrase has inspired community resilience, validating lived experience of bipoc and tge individuals and highlighting the black feminist movement’s spirit and message (collins, 2000). 11 following leadership from disabled peers in the disability justice movement, this paper uses identity-first language, positioning disability as an identity to affirm the lived experiences of peers (people with disability, n.d.). 12 this phrase provides insight into the pervasive anti-black racism and white supremacy culture in the u.s. and embodies a call to dismantle systems of oppression through social activism (finn & jacobson, 2003). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 27 26 | columbia social work review, vol. xix potentials of anti-carcerality and calls for an empowerment-focused paradigm shift to abolitionist praxis13 (richie & martensen, 2019; finn & jacobson, 2003). the field continues to uphold and perpetuate white supremacy by utilizing carceral interventions through mental health, criminal-legal, child welfare, and even non-profit systems. anti-carceral social work interrupts the carceral state, not only addressing prisons, jails, and policing, but also carceral cultures of social control embedded within mental health systems. police brutality is a social determinant of health impacting the emotional well-being of racialized individuals and contributing to mistrust of medical institutions (alang et al., 2020; bor et al., 2018; mcleod et al., 2019). narrative accounts of young black men ages 18-24 summarize feelings of mental anguish related to police violence, stating that police are their “number one fear in life” (smith lee, 2019, p. 156). disabled bipoc students and adults experience a disproportionate use of physical restraint compared to their white counterparts (katsiyannis et al., 2020; cusack et al., 2018). black liberation challenges theories of crime and punishment by building anti-carceral, peer-led systems of community mental health care. critically conscious methodology: “people not profit”14 this theoretical article aims to expand the concept of “peer support” by examining narrow, rigid, and de-politicized applications of the term in empirical research. search criteria included “formal peer support,” service providers in mental health settings, and “informal peer support,” 13 “abolition” is a long-term political vision, organizing tool, and broad strategy aiming to eliminate imprisonment and policing while creating lasting alternatives to violence and harm (critical resistance, n.d.). abolitionists do not support any extension of carceral punishment, including in mental health settings. 14 this phrase serves as a reminder that academic knowledge production is not neutral, and academia must side with frontline communities over institutional, elite, or corporate interests. in anti-colonial, anti-carceral academia, margins of society should not be a “site for domination but a place of resistance” (hooks, 1990, p. 343). social workers break norms of scientific exploitation in under-resourced communities by concentrating efforts towards shifting power to peers with lived experience. community-based providers in non-traditional mental health programs. this analysis explores the theory base (specifically within the english language) on disability justice and carceral ableism, qualitative data related to the provision of peer support in mental health contexts, and organizational patterns present in past and current social justice movements. the complexities within both the ongoing blm movement and current socio-political climate influenced the range of literature reviewed for this article. reframing positionality: “the personal is political”15 individuals involved in “peer-run” organizations, such as the consumer voices are born (cvab)-reach center, exemplify the invaluable power of peer-based feedback, perspective, and approaches to care: we did not learn about mental health from a textbook, but from our own lived experience. we use this mutuality of experience to connect with others and help our community to see that recovery is an achievable reality. (reach center, n.d., para. 1) elevating lived experience and acknowledging power dynamics present in empirical knowledge production is crucial in engaging anti-racist work within academia. intersections of race, gender, mental health, and disability are not just theoretical and academic subjects on which i write, but also experiences i live. writing this article required my own emotional labor to survive professionally in taxing academic and clinical spaces, and to emotionally synthesize information from personal lived experience related to carceral culture in psychiatric institutions and harm within mental health care systems. as a guest on indigenous chinook land and a queer, non-binary person with class privilege and fluctuating 15 critical discourses within feminist and student movements encourage scholars to reject the “myth of objectivity” and “hierarchy of credibility” by actively acknowledging positionality and access to power (yarbrough, 2020). while frontline communities have been historically excluded from decision making processes that traditionally center voices of (often socially-removed) political stakeholders, this revolutionary saying positions peers as valuable leaders in community care (barker, 2017). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 29 28 | columbia social work review, vol. xix uplifting the peer: “solidarity not charity”16 when mental health is viewed as a sociopolitical and ideological movement, in addition to a scientific discipline, social workers can interrogate oppressive legacies, contextualize harm in bipoc communities, and evaluate transformative potential (bertolote, 2008). despite a recent surge in political participation, activist-organizers must be aware of pre-existing feminist, indigenous, and disability justice movements being co-opted by individuals without lived experience. as the peer workforce grows, social work must contextualize the anti-carceral mental health movement to prevent tokenization and performative inclusion of peers. unpacking formal peer support: “integrating into a burning house”17 with roots in the consumer mental health movement, which worked to expand traditional mental health treatment, peer support has always been tied to a legacy of activism (van tosh, 2006). formal peers validate distinctive emotional distress related to structural experiences of inequity and injustice (beresford & russo, 2015). community-based participatory research has found peers provide support when systems fail to respond to black community needs in culturally-appropriate ways (corrigan et al., 2015). because peers often “speak the same language” (both literally and socioculturally), trusted companionship of empathetic peers more effectively validates experiences of structural oppression, marginalization, and exclusion (repper, 2013, p. 6; faulkner & basset, 2012). peer support services are proven to provide culturally and developmentally appropriate care for young people (ages 16-24) with serious mental illness (ojeda et al., 2020). additionally, a u.s. clinical trial surveyed adults with mental illness who had been hospitalized three or more times in 18 months and were at risk for recurrent psychiatric hospitalizations. compared to 16 this phrase underscores the importance of mutual aid community organizing in times of crisis (spade, 2020). 17 this quote from dr. martin luther king jr., questions the sustainability of social reform movements that do not build social structures anew (alfieri, 2011). abilities, i am a consumer-provider of mental health care invested in expanding access to anti-carceral frameworks that prioritize freedom of choice in service of inter generational healing.. i am not directly impacted by anti-black police violence, nor have i personally experienced poverty or carcerality in the legal system. due to the inherent shortcomings in my perspective associated with these positionalities, my work remains accountable to peers most impacted by anti-black racism and carceral ableism. this paper pushes back against dominant societal and institutional impulses to pathologize resistance by utilizing social work’s tradition of “professional resistance” to illuminate counter-narratives, mobilize scholars to interrogate the academic norm of upholding white supremacy, and confront unequal institutional power relations (strier & bershtling, 2016). in an act of solidarity following professor ericka hart’s february 2021 announcement of unjust termination from columbia school of social work, this paper was intentionally restructured to amplify the wisdom of lived experience (hart, 2021). this updated version is intended to be an active form of professional resistance against upholding anti-black racism, white supremacy, and transphobia as the status quo in academia. professor hart’s stated lived experience of antiblack racism mirrors the experiences of many unnamed qtbipoc and disabled scholars and peers who have also endured traumatic silencing by white supremacist institutions. in academic contexts, such silencing impacts the most marginalized scholars and derails our scholarly efforts. this damaging phenomenon in academia is indicative of a larger social trend in which systemic, institutional, and intersecting personal traumas are overlooked, minimized, and made invisible. professional resistance counters the ways institutions exert and maintain power, practice coercive control over black and brown bodies, police our minds, and render us disposable. i offer my peer perspective from the margins to invite others to “see and create, to imagine alternatives, new worlds” (hooks, 1990, p. 341). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 31 30 | columbia social work review, vol. xix those receiving only standard care, individuals with peer support had fewer readmissions and were hospitalized for nine fewer days (sledge et al., 2011). peer insight on clinical teams improved relationships with providers, increased engagement with treatment, reduced symptoms of depression, and improved general recovery outcomes for those with severe mental illness (puschner et al., 2019; chinman et al., 2014). finally, inclusion of peers in social work education has also proven to expand professional compassion and shift clinical faculty attitudes (repper & watson, 2012). examining the credibility gap: “power in the people”18 some recipients of care prefer working with licensed mental health professionals due to the notion that such clinicians are more competent in providing care than practitioners with lived experience (known as professionalized peers). due to lingering stigma, many mental health providers with lived experience choose not to self-disclose commonality (harris et al., 2016). clinicians with lived experience are often labeled as “unreliable, dangerous, vulnerable, unpredictable, and lack[ing in] the capacity to occupy esteemed roles such as educators” or contribute meaningfully in clinical and academic settings (dorozenko et al., 2016, p. 906). peers with professional competency or clinical skills can be seen as unrepresentative of others experiencing marginalization within mental health systems (fox, 2020). licensed and professionalized clinicians without lived experience often perpetuate stigma by expressing skepticism about the integrity and safety of professionalized peers. this devaluing, by both individuals seeking treatment and other clinicians, silences peer voices in academia and clinical practice. clinical use of diagnostic criteria from the diagnostic and statistical manual of mental disorders (dsm) further reinforces “risk consciousness,” referring to the hyper-medicalized focus on solely assessing and managing mental health risk factors, as opposed to also 18 variations of this organizing phrase have encouraged communities and individuals globally to build collective community power and to funnel resources into the margins of society (lisson, 2018). harnessing protective factors such as community and cultural strength (davidson et al., 2016). the societal shift back to the risk rhetoric of the early mental health movement demonstrates a stronghold of oppressive “one size fits all” western norms and ableist and colonialist belief systems on mental health practice (ostrow & adams, 2012). formal treatment or recovery settings require the peer workforce to abandon more radical peer philosophies, such as the right to refuse treatment, forcing instead adherence to standard medical models that prioritize identifying dysfunction, managing crisis, and eradicating mental health symptoms. evaluating informal peer support: “the revolution will not be funded” 19 when larger social systems fail to ensure equitable access to mental health support, peer-led mutual aid provides (and has historically provided) prevention-centered crisis relief without reliance on harmful systems. with roots in the psychiatric survivor movement,20 informal peer support operates outside of institutions, non-profits, and other service delivery systems, and aligns with politically radical legacies of community-led mutual aid (emerick, 1991; gagne et al., 2018). informal peer support is a unique method of engagement for people who have historically distrusted more formal resources or felt alienated from traditional health services (simpson et al., 2018; watson, 2017). informal peer relationships utilize shared power to normalize neurodiversity,21 challenge social stigma, and strengthen community ties (gillard et al., 2015). relationships with informal peers who have shared cultural backgrounds or values are helpful in navigating systems that continue to perpetuate ableism and social stigma (faulkner & basset, 19 bipoc feminists in the anti-violence movement criticize the de-mobilizing effects of nonprofit involvement in social justice movements—a phenomenon known as the non-profit industrial complex (smith, 2007). 20 stemming from 1960s civil rights movement, the psychiatric survivor movement addressed people’s experiences of violence in traditional carceral mental health institutions and served as a catalyst, organizing individuals to advocate for the right to refuse treatment and freedom to choose alternatives that centered self-determination, agency, and consent (mclean, 2000). 21 the neurodiversity movement has roots in the disability justice and mental health survivor movements, promoting the need for disability solidarity and recognition of variations in neurocognition (graby, 2015). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 33 32 | columbia social work review, vol. xix aligns with the socio-political peer philosophy of preserving the right to self-determination above all else. tge callers consistently report feeling unsafe calling other crisis lines due to fears around denial of treatment, police interaction, harassment in hospitals, and general transphobic violence. this intentional anti-carceral approach allows tge callers to affirm the relational importance of reaching out for support, as opposed to avoiding any form of care for fear of harm. serving as a poignant example of anti-carceral peer-developed alternatives built through grassroots funding, trans lifeline is the only u.s. mental health line that has implemented an effective policy against non-consensual active rescue (trans lifeline, 2020b). inviting discussion: “dismantle, build, change”23 communities continue to be “sites for prevention, intervention, and transformation, spaces where interventions can be imagined, initiated, and implemented” (kim, 2018, p. 227). with five million black and “latine”24 people predicted to lose health insurance due to a loss of employment from covid-19, the pandemic highlights ongoing racism present in the accessibility of behavioral healthcare (samhsa, n.d.; sloan et al., 2020). the mental health field is pressed to tend to psychosocial needs of frontline communities coping with compounding threats to well-being (fisher et al., 2020; jadwisiak, 2020). as social support is a protective factor for well-being, peer support is wellpositioned to address limited access to culturally-responsive mental health care (faulkner & basset, 2012). peer support is culturally beneficial to minoritized adolescents with adverse childhood experiences, as well as to those experiencing suicidality (brinker, 2017). making radical changes to systemic structures acknowledges histories of empowered bipoc communities pushing for social liberation. 23 this phrase grew out of abolitionist frameworks to dismantle the prison industrial complex (critical resistance, n.d.). in mental health, it includes building sustainable alternatives that value community-wide healing. 24 as opposed to “latinx,” “latine” is a non-anglicized, gender-neutral term describing latin american people (gutierrez, 2020). 2012). one study found black college students preferred informal peer support over formal counseling, as peer support honored their culturallyspecific coping styles (grier-reed, 2013). as evidenced by this qualitative data, social work must create pathways for peer innovation. envisioning liberatory futures: “show me what community looks like”22 in 2015, 75% of people who called the national suicide prevention hotline were able to actively engage and collaborate with volunteers, as well as de-escalate risk level, despite being initially labeled as an imminent risk of completing suicide (draper et al., 2015). by contrast, most u.s. crisis hotlines maintain policies for initiating in-person police response for their callers—a protocol known as “active rescue” (trans lifeline, 2020b). because research suggests that effective crisis intervention and de-escalation often render police intervention unnecessary, frontline communities continue to develop anti-carceral, peer-led mental health care alternatives rooted in mutual aid (leach et al., 2019). in bipoc communities, peer-led mutual aid has always been a central survival strategy to interrupt institutional harm, prioritizing community care over carceral response, and building momentum towards liberation (crane et al., 2020; spade, 2020). following a peer-led approach, trans lifeline developed a crisis line “for the trans community, by the trans community” (trans lifeline, 2020a, para. 1). tge peers intimately understand that police response to disabled peers experiencing mental health crisis yields a high likelihood of police use of harm, forced hospitalization, and deadly force (trans lifeline, 2020b). trans lifeline demonstrates how to “informally” fill a culturally-specific mental health need through use of radical collective care policy. the line mitigates violent policing of the trans community through a consensual active rescue policy, never involving police in mental health crises without a caller’s explicit consent. although other crisis lines argue that trans lifeline’s policy poses liability risks, this policy 22 this variation of the bedrock protest slogan “this is what democracy looks like” merges organizing and activism efforts to mobilize communities towards collective change (gillum, 2019). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 35 34 | columbia social work review, vol. xix to intersecting identities, and navigate oppressive mental health care systems. although developing clear models of peer support would aid future studies, professionalizing peer support may restrict the healing nature of holistic relational dynamics (faulkner & basset, 2012). independent of current failing systems, communities will continue developing structures of mutual aid-based informal peer support, warranting urgent advocacy to include peer support in all mental health care delivery. engaging radical imaginations: “pandemic as portal”27 anti-carceral social work aligns with the assertion that “there can be no health equity when certain groups fear the harm and murder of their families and community by the state” (jacobs, et al., 2020, p. 19). engaging true mutuality with one another requires shifting leadership structures from dominant groups to those most impacted by ableism, anti-black racism, and transphobia. peer support is both an abolitionist act of care and an embodiment of mutual aid. moving forward, social workers are called to interrogate the currently existing frameworks around mental health by examining sociopolitical influences preventing peers from being cultural agents of change (gillard, 2019). social workers are invited to apply an anti-colonialist, anti-carceral lens to qualitative inquiry and to uplift the work of peers (yarbrough, 2020; archer-kuhn, 2020). social policy experts consider how an informal peer support safety net may alleviate burdens and costs of mental health care delivery through public health saving (puschner et al., 2019; young, 2020). clinicians have the power to break from reliance on policing and carceral interventions. until there are more sustainable solutions to compounding social crises, social workers can ensure frontline communities are leading conversations about anti-carceral care. 27 arundhati roy’s april 2020 piece in the financial times provides global context of the pandemic and encourages a break with the past, collectively reimagining a more liberatory future. exposing limitations: “silence is violence”25 while extant literature speaks to the lived experiences of some marginalized groups, the overall dearth of research within this area misrepresents and distorts unique individual experiences of people with multiple marginalized identities. the divide between academic scholarship and community needs directly relates to how colonialist research institutions continue to objectify, extract from, and profit off of bipoc without tending to their unique socio-political demands. this alarming observation overshadows drawbacks in the literature, which include vague understandings of peer support mechanisms. solidarity research26 specifically engages frontline communities in critical political dialogue and change-oriented goal setting, while empirical research generally upholds harmful colonialist notions of objectivity and scientific expertise, thus preventing peers with lived experience from producing knowledge within academic systems (yarbrough, 2019). honoring expertise gained through lived experience and legitimizing labor involved in informal peer support does not necessitate empirical evidence. due to this lack of empirical “expertise,” it is unlikely informal peer support will receive access to certain funding streams. communities will continue to build solidarity in the margins and will respond in the ways they always have when systems have failed them: by determining what works best for them culturally, regardless of an empirical evidence base. the limited empirical literature on crisis work is predominantly written through a white cisgender lens. such a lens produces underdeveloped theories that inadequately respond to the specific needs of disabled qtbipoc and fail to acknowledge the unique ways individuals within this demographic experience complex trauma, relate 25 despite social work’s ethical obligation to social justice, the field has perpetuated white supremacy through silence on ongoing anti-black racism (national association of social workers north carolina chapter [nasw-nc], 2020). this saying speaks to the colonialist roots of anti-black racism and violence in research (women scientists leadership, 2020). 26 “solidarity research” diverges from participatory action research in that it resists tokenization by affirming marginalized groups as experts and by focusing data collection and political analysis on critical dialogue of policy-relevant “structural sources of group-differentiated stratification and harm” (yarbrough, 2019, p. 62). peer support as a tool for community care shinjini bakshi columbia social work review, vol. xix | 37 36 | columbia social work review, vol. xix peer support as a tool for community care shinjini bakshi drawing conclusions: “black trans lives matter”28 anti-carceral social work policy and practice require acknowledgment of the radical political contributions of peers with lived experience, willingness to shift power to frontline communities, and investment in black futures. with new insights into the added sociopolitical benefit of integrating a peer support safety net into structures of community care, social workers can push the field of mental health towards its anti-carceral future. individuals with lived experience are not only worthy of dignity, care, and healing, but they are also paramount in driving innovation and leading movements towards liberation. integrating this ideological truth into practice will help future generations of social workers and mental health practitioners minimize emotional distress, repair social harm, and dismantle white supremacy. social workers rally behind peers and frontline communities to honor the lives of black trans ancestors and build new liberatory structures of care in which peers can use their collective wisdom, knowledge, and skills to facilitate intergenerational healing. references alang, s., mcalpine, d. d., & hardeman, r. 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(2017). all power to all people?: black lgbtti2qq activism, remembrance, and archiving in toronto. tsq: transgender studies quarterly, 4(2), 170–180. https://doi.org/10.1215/23289252-3814961 watson, e. (2017). the mechanisms underpinning peer support: a literature review. journal of mental health, 28(6), 677–688. https://doi.org/10.1080/09638237.2017.14 17559 white, r. j. (presenter). (2020, august 10). dismantling racism. lecture presented at ywca, portland, or, united states. women scientists leadership. (2020). silence is never neutral; neither is science. scientific american blog network. https://blogs.scientificamerican.com/voices/silence-isnever-neutral-neither-is-science/ young, c. l. (2020). there are clear, race-based inequalities in health insurance and health outcomes. brookings. https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health policy/2020/02/19/there-are-clear-race-based-inequalities-in-health-insurance-andhealth-outcomes/ peer support as a tool for community care shinjini bakshi shinjini bakshi (they/them) is a clinical social worker with lived experience who graduated from columbia university in 2020 with a master of science in social work. shinjini holds bachelor degrees in psychology and criminology from schreyer honors college at the pennsylvania state university. shinjini currently works as a co-occurring therapist at achieving change together (act) northwest, a peer-based adolescent recovery program. finalized digital files.pdf columbia social work review, vol. xxii | 75 74 | columbia social work review, vol. xxii inspiration for article my practicum is at nationwide children’s hospital in columbus, ohio, where i am a social work intern in the division of pulmonary medicine. nationwide children’s is home to one of the highest ranked cystic fibrosis centers in the country and serves around 500 people with cf in ohio, west virginia, and kentucky. through this placement, i have worked with many people of all ages who have cf, and have recognized the psychosocial impact that new, revolutionary medications have had on the lives of these individuals. i have been so inspired by the resilience and strength of those that i have worked with. as there is limited research on this topic, i hope this paper becomes part of a larger conversation on how we can support the unique experiences of people with cf. i am a 2024 graduate from the columbia school of social work on the integrated practice and programming track and specializing in the study of health, mental health, and disabilities. i am currently living in columbus, ohio, and excited to see where this field takes me next. abigail nikiforovs columbia social work review, vol. xxii | 77 76 | columbia social work review, vol. xxii “diagnosed with new health” abigail nikiforovs abstract cystic fibrosis (cf) is a chronic, progressive, genetic, and lifelimiting lung disease that impacts approximately 105,000 individuals globally, including 40,000 individuals in the united states. in 2019, a revolutionary new drug, elexacaftor/ivacaftor/tezacaftor (eti), was approved to manage some of the major symptoms of cf and dramatically increase the lifespan of people with cystic fibrosis (pwcf). many individuals with cf cannot work full time and require medicaid, supplemental security income (ssi), social security disability insurance (ssdi), and other financial assistance programs to pay for treatments and medical expenses. yet in recent years, pwcf who are on eti have been increasingly losing benefits. a possible explanation for this is the effectiveness of eti in improving lung function, creating the perception that pwcf are no longer disabled by their condition. even with this “miracle” drug, pwcf continue to experience significant complications and vulnerabilities to their physical and mental health as well as limitations on daily living and employment. the compounded vulnerabilities these individuals experience leave them without a safety net. social security policies for pwcf require revisions to prevent further biopsychosocial damage to this population. two policies will be recommended: leniency in redetermination, and cf education for those who make determination decisions. introduction to cystic fibrosis care “what do you do when you’ve lived your whole life diagnosed with a terminal illness and then are suddenly diagnosed with new health? for me, it was not a whimsical or magical moment.” luisa palazola (bionews staff, 2021, para. 4). c ystic fibrosis (cf) is a chronic, progressive, and life-limiting multisystemic genetic disorder, impacting approximately 105,000 individuals globally, including 40,000 individuals in the united states (cystic fibrosis foundation [cff], n.d.-a). impacting the lungs, pancreas, gastrointestinal (gi) system, reproductive system, and other organs, cf presents differently from person to person but commonly causes coughing, difficulty breathing, frequent lung and sinus infections, and poor weight gain. managing a demanding condition like cf brings significant social, physical, and psychological challenges. socially, it is an isolating disease, as people with cf (pwcf) are not allowed to share spaces due to their susceptibility to bacterial infections and the risk of spreading infections to other pwcf. this, in turn, prevents community building through means such as in-person group therapy or sharing classes in schools. physically, pwcf typically need to spend several hours per day managing their condition, whether through administering medications and lung therapies, preparing special diets, or attending doctors’ appointments. mentally, this heavy treatment burden can take a psychological toll, putting pwcf at increased risk for developing a mental illness, while the required isolation creates additional psychosocial challenges (vines et al., 2018; bathgate et al., 2022). in 2019, a revolutionary new drug, elexacaftor/ivacaftor/tezacaftor (eti), which targets the genetic cause of cf, was approved by the food and drug administration (fda) under the brand name, trikafta (u.s. food and drug administration [fda], 2019). cf is caused by mutations in a gene called the cystic fibrosis transmembrane conductance regulator columbia social work review, vol. xxii | 79 78 | columbia social work review, vol. xxii (cftr). all people possess two copies of the cftr gene, but for pwcf these genes are mutated, leading to dysfunctional cftr proteins that interfere with proper cell hydration, causing the mucus covering these cells to thicken (cff, n.d.-a). eti combines three types of cftr modulators to help correct these protein defects (fda, 2019; cff, n.d.-d). this new medication has dramatically increased life expectancy for pwcf. prior to the emergence of eti and similar therapies, the projected lifespan for pwcf was approximately 37 years old (lopez et al., 2023). if eti is started between the ages of 12 and 17 and taken as directed by a patient with good lung health, eti will nearly double one’s projected lifespan to 82.5 years old (lopez et al., 2023; fda, 2019; ladores & polen, 2021). in addition to life expectancy, eti also increases pwcf’s ability to get pregnant and improves pulmonary function to the extent that patients are able to withdraw from lung transplant waitlists (ladores & polen, 2021). an estimated 90% of pwcf have the f508del gene mutation that makes them eligible to take eti, while around 10% of other pwcf have different gene mutations that make eti and other modulator therapies ineffective (fda, 2019). eti and other modulator therapies are treatments, not cures. this means that despite these remarkable medical advances, cf remains a complex and often disabling condition requiring frequent medical checks and a high level of medication and diet adherence while continuing to pose an increased risk of lung infections and other physical and mental health issues. as a result, many individuals with cf require medicaid, supplemental security income (ssi), social security disability insurance (ssdi), and other financial assistance programs to maintain a stable foundation (cff, n.d.-b; cff, n.d.-c). medicaid is a critical resource and can help cover ongoing costs of treatment for pwcf, including eti’s hefty price tag of more than $300,000 per year in the united states (mcconnell et al., 2020; wexler, 2023). yet medicaid does not cover anything beyond what is considered medical care (cff, n.d.-b). this means ssi and ssdi are crucial supports for individuals disabled by cf-related conditions, particularly those who remain unable to work (cff, n.d.-c). as a social work intern at a cf center at a hospital in ohio, i have been exposed to the countless biopsychosocial struggles of pwcf and have had many questions about what can be done to support this population. one trend identified by patients at this hospital in the last few years has been a significant increase of pwcf on eti losing their social security administration (ssa) benefits. the multidisciplinary hospital team attributes this to eti’s effectiveness in improving lung function so much that on the surface, pwcf appear to be no longer disabled by the disease. this trend raises concerns since, even while taking this “miracle” drug, pwcf continue to experience considerable physical and psychological challenges and vulnerabilities and are frequently still admitted to hospitals for surgeries, pulmonary exacerbations, lung infections, gi issues, and other complications. since eti is not a cure, adults with years of lung scarring may only see minor improvements in lung function or simply may not see further damage (k. pasley, personal communication, march 22, 2024). for many on eti, they are not thriving, just surviving. while official data on rates of removal of financial benefits are limited, the increase in first-hand accounts is alarming, and cf social workers and other professionals who have observed the financial consequences of losing this support have struggled to identify resources to help pwcf (cbs news, 2019). this population has struggled with this disease for their entire lives, and because cf was previously considered a “death sentence,” they were not adequately prepared for such an increase in life expectancy without financial support. their previous prognoses meant they often did not invest in their education, personal relationships, financial investments, and careers, and as a coping strategy “often ‘do things now rather then [sic] later’ as a strategy to experience their limited and precious lifetime to the fullest” (moola, 2019, p. 360). now that the ssa appears to be increasingly “diagnosed with new health” abigail nikiforovs columbia social work review, vol. xxii | 81 80 | columbia social work review, vol. xxii removing benefits for those on eti, those impacted are forced to seek employment. however, due to the nature of the disease, the demands of daily treatment, and having limited lung function, many are physically unable to attend school or work full time. the compounded vulnerabilities these individuals continue to experience make the loss of a safety net even more challenging. social security policies pertaining to pwcf need to be revised to prevent further biopsychosocial damage to this population. two case studies from ohio will be shared to provide further insight into the struggles these individuals face as they transition to this new era with eti. policy recommendations will then be discussed, including leniency in ssi and ssdi redetermination and cf education for those who make determination decisions. lastly, social work implications will be discussed, including disparities and best practices for supporting this population with the life changes that accompany eti therapy. case studies from ohio one individual seen in the cf clinic at a hospital in ohio exemplifies why vulnerable pwcf benefit from social security coverage even as their health improves (k. pasley, personal communication, november 11, 2023). this individual is a 24-year-old who grew up thinking he would die young due to this disease. he struggled to get an education, never learned how to adequately take care of himself, and was unable to generally thrive. he was 22 years old when eti became available. after eti dramatically improved his respiratory health, he lost social security benefits. he has not been able to maintain a steady job as his lifelong illness prevented him from learning critical skills, and, despite his improved lung function, he has struggled to regularly attend work hours due to being sick, often taking leaves of absence. as a result, his financial situation remains unstable and he has continued to rely on the financial safety net of social security. another individual seen in the cf clinic, a 50-year-old male with cf, was able to work for years before becoming disabled by his illness. he had never experienced any interruptions to receiving ssdi benefits until eti became available. he was the first person in this cf clinic to raise concerns about what might happen to his ssdi if he became healthier when he took eti. at 50 years old, he was accustomed to his quality of life with ssdi and was not interested in trying to re-enter the workforce due to his age and health. he said that he would even choose to stay off of eti in order to keep his benefits. these stories have become increasingly common. in 2019, an attorney who runs the cystic fibrosis legal hotline noted, we’ve seen a five-times increase in the number of people with cystic fibrosis that have been reviewed in the past 18 months. and we think that social security is targeting young people with chronic illness in an effort to reduce the number of people getting benefits (cbs news, 2019, 2:45). given this pattern, many pwcf are understandably concerned about choosing between their health, their job, and social security benefits. rationale for action benefits of social security as a safety net financial benefits, including ssi and ssdi, are an important lifeline for pwcf. ssi redetermination, which evaluates financial resources and living arrangements, occurs every 1 to 6 years, and continuing disability review (cdr), which evaluates the medical condition of ssi and ssdi recipients, occurs every 1 to 3 years (social security administration [ssa], 2024a; ssa, 2024b; ssa, n.d.-c). if one has a medical condition that is not expected to improve, such as cf, ssdi redetermination will occur every five to seven years, though usually seven years for pwcf (ssa, 2024b; cff, n.d.-c). redetermination considers whether one’s health has improved over 12 months; financial benefits are rescinded if one’s health has improved to a point where one can work (cff, n.d.-c). the ssa also discontinues benefits if someone earns more than $1,550 per month (ssa, 2024c). if a person with cf earns more than the “diagnosed with new health” abigail nikiforovs columbia social work review, vol. xxii | 83 82 | columbia social work review, vol. xxii maximum limit, even if their health is still precarious, they lose benefits, and if their illness later prevents them from working, they become financially vulnerable. a social and financial safety net is therefore vital for improving employment and housing stability, maintaining continuity of health care, and avoiding added financial stress (crane et al., 2019). ssi and ssdi programs provide this much-needed safety net while the loss of benefits puts an already vulnerable population at even greater risk. mental health concerns for pwcf transitioning to a longer life expectancy a number of studies have found eti to impact mental health and social functioning in pwcf in complicated and even paradoxical ways. several studies found, for example, that improved pulmonary health was correlated with improved mental health (hjelm et al., 2023). however, some studies looking at the effects of eti found that, while the medication improved physical symptoms, eti was correlated with worsening mental health symptoms, sleep issues, and increased rates of changing or initiating psychiatric medication (zhang et al., 2022; bathgate et al., 2022). other studies found paradoxical results on eti’s impact on mental health (mccoy et al., 2023; piehler et al., 2023; zhang et al., 2022), and some found no statistically significant improvements in anxiety scores, depression scores, emotional functioning, or perception of body image (zhang et al., 2022; finlay et al., 2021). one explanation for this lack of improvement or worsening of mental health symptoms may be the sudden change in longevity and quality of life. prior to these new modulator therapies, cf was known as a “child killer,” and many pwcf were told from a young age they would have a limited lifespan (kempner, 2022). one individual reflected, “i was just living day-to-day instead of planning for the future,” (kempner, 2022, p.3) while another stated she had “never pictured a future for herself beyond the next five years” (kempner, 2022, p.1). as a result, many pwcf who grew up without these new modulators have not invested in their life, health, education, or careers. they may not have created long-term goals nor developed independence or coping skills. this is exacerbated by the fact that many pwcf experience high rates of comorbid mental health diagnoses, including depression, anxiety, obsessive-compulsive disorder (ocd), medical traumatic stress (mts), attention-deficit hyperactivity disorder (adhd), autism spectrum disorder (asd), oppositional defiant disorder (odd), and disordered eating (bathgate et al., 2022; lord et al., 2022; guta et al., 2021). having grown up with a terminal illness mindset, many are now struggling to establish long-term goals as they adjust to a sudden and unexpected increase in life expectancy. additionally, the risk of early mortality did little to motivate pwcf to establish positive health habits such as routines around eating, sleeping, and cf medical care. this adjustment is also compounded by the fact that, even with eti, pwcf often have difficulty completing instrumental activities of daily living (iadls), which include managing medications, money, and transportation. this makes full-time work challenging, leading to lower employment rates and, consequently, lower rates of employment-based insurance (callahan & cooper, 2007). pwcf who do work often end up needing to take long leaves of absence due to susceptibility to illness, cf exacerbations, and hospitalizations. as a result, they rely on social security benefits to help cover living and medical expenses. a 2019 study on the experiences of ohioans with co-occurring chronic health conditions and mental health impairments found many experienced financial hardships such as unemployment and/or financial instability and, in turn, had difficulties paying for food, rent, and other necessities (crane et al., 2019). according to one individual with cf who started eti as a young adult, “to fathom what life would look like with stable health was incomprehensible to someone who never had that” (bionews staff, 2021, para 3). one study found that an individual who began eti “encountered unanticipated internal turmoil” due to this change in life expectancy and no longer being seriously chronically ill (ladores and polen, 2021, p. 2). this individual elaborated that this transition period caused them anxiety as they thought that eti would stop working: “i’m “diagnosed with new health” abigail nikiforovs columbia social work review, vol. xxii | 85 84 | columbia social work review, vol. xxii so nervous because i feel so good and i’m not used to living this way, and i’m so afraid i’m gonna lose it” (ladores and polen, 2021, p. 3). the cystic fibrosis foundation recommends that pwcf ages 6 and older be seen by an accredited cf clinic at least 4 times per year (cff, n.d.-e). there are more than 130 accredited cf clinics throughout the united states, each with a multidisciplinary team of doctors, nurses, nutritionists, respiratory therapists, social workers, and psychologists to provide comprehensive care for cf patients. these appointments require patience through a lengthy process of medical tests, scans, blood tests, and pulmonary function tests (finlay et al., 2021). social workers on these teams play an important role in identifying psychosocial and transitional needs of pwcf, meeting with patients yearly to conduct psychosocial reviews and assist with resource navigation and support (finlay et al., 2021). now, with these new modulator therapies, social workers are faced with the additional challenge of supporting a cf population as they adjust to the prospect of a longer life than they ever anticipated. proposed policy options to improve the livelihoods of pwcf, two policies are proposed in the state of ohio which could be adapted across the country based on each state’s specific ssa policies. the first is a higher level of leniency when redetermining eligibility for social security (ssi/ssdi). the second is a cf-specific training for consultative examination (ce) providers who complete ssdi evaluations and redeterminations. currently, ssi/ ssdi recipients who disagree with a reconsideration determination can request a hearing to appeal the decision (ssa, n.d.-a). however, this puts an undue burden on pwcf who may be physically unable to file the appeal or attend the hearing due to their condition and struggles with adls. policy #1 leniency a standard that allows for more leniency would help protect this vulnerable population from losing ssi or ssdi benefits simply because they have been more physically healthy since beginning eti or other modulators. as seen in research studies, improved physical health when taking a modulator does not necessarily mean one’s mental health or ability to work will improve (mccoy et al., 2023; bathgate et al., 2022). as this population transitions to having longer lives, a financial safety net would alleviate stress by providing stable resources to be used for basic necessities. to implement this, the ssa would alter the qualifying definitions of “severity” and “frequency” of cf symptoms to make the removal of benefits a more medically-informed and thorough process. this change would occur in the ssa’s evaluation manual at the state and local ssa offices in ohio. the ssa does not publicly release eligibility criteria and only provides a “listing of impairments,” which broadly mentions that the ssa will consider past work experience, severity of medical conditions, age, education, and work skills (ssa, n.d.-a). due to this ambiguity in criteria, approval varies by each ce evaluator. to improve this system, eligibility requirements could be amended to include a section for pwcf that takes into account their age when beginning a modulator therapy, long-term goal planning, pulmonary function test levels, and other relevant medical complications. these factors would provide a more comprehensive picture of one’s health and how they are coping with the transition to taking a modulator and having an extended lifespan. when considering job history, the criteria could be changed from “ability/inability” to work to “stability/instability” in work. this subtle yet significant change in language would expand eligibility to include those who experience leaves of absence due to cf-related medical issues. this more holistic framing better addresses the complexity of this disease and the careful management it requires. policy #2 training in each state, disability claims are reviewed by ce providers, made up of physicians, psychologists, and other health professionals recruited by the ssa's professional relations officers (ssa, n.d.-b). although these providers undergo extensive training, they are not experts in “diagnosed with new health” abigail nikiforovs columbia social work review, vol. xxii | 87 86 | columbia social work review, vol. xxii every disease and its respective challenges. without training in cf specifically, they are unlikely to recognize that, although on paper the health improvements from eti therapy may give the impression that someone with cf can work full time, the mental and physical effects of their illness often remain debilitating. a second policy recommendation, therefore, is a one-time cf-specific training for ce providers to help them understand the nuances of this complex, lifelong disease and how important ssdi is for someone trying to manage it. to implement this second recommendation, a committee from the cystic fibrosis foundation (cff) would select medical professionals in ohio to provide training to the ce providers who process ssdi determinations and redeterminations. these one-time training sessions would be an hour long to remain cost-effective and would include subject matter experts (smes) who work with pwcf. ce providers who receive this training would be certified in cf redetermination and be primarily responsible for reviewing cf cases. the end goal would be to help evaluators make more informed decisions. the cff would work with the ssa to continually monitor and review ssdi cases to ensure that pwcf are receiving proper support. allowing the most vulnerable pwcf to remain on social security would reduce costly hospitalizations and additional medical care. someone who has their ssi/ssdi revoked will be forced to work more, putting them at increased risk of stress and infection. the safety net of social security allows them to work as much as they can within their own limitations, helping to reduce that risk. social work implications social workers have continually played an important role in providing support to pwcf, and now with eti, they must rise to the additional challenge of helping this population navigate the adjustment to a longer lifespan. one important way social workers can do this is by providing career counseling to pwcf who have a newly extended life expectancy and did not anticipate having to plan for a long-term career. social workers follow the guiding principles of competence, challenging social injustice, and promoting the dignity and worth of all people as they work to address social problems such as health inequity (national association of social workers, 2021). as such, there is an important role for them to play in confronting racial and economic disparities among pwcf as treatments and technology improve. because of the health disparities caused by structural racism, people of color with cf experience: overall lower lung function, nearly doubled rates of death before the age of 18, delayed diagnosis, higher rates of pulmonary infections, limited access to care, lower access to lung transplants, lower rates of health literacy, and are less likely to be represented in clinical research (zampoli, 2023; cff, 2020). in terms of economic disparities, many low-income countries have less access to modulator therapies; in fact, only an estimated 12% of pwcf globally have access to cftr modulators, like eti (guo et al., 2022, as cited in zampoli, 2023). low to middle-income countries in central america, south america, the middle east, south asia, and southern africa have not been prioritized for negotiating contracts for accessing eti (zampoli, 2023). while the u.s. does have contracts for manufacturing and distributing eti, the u.s. government does not negotiate prices with drug manufacturers, leading to exorbitant costs (martins, 2020; ginsburg & lieberman, 2021). the yearly $300,000 list price for eti is not feasible for the vast majority, leaving pwcf to rely on crucial government-funded insurance or employment-based insurance to afford this life-saving treatment. in addition, the multidisciplinary team at the cf center where i intern has noticed that several insurances are no longer covering eti, creating an even greater need for these cost-assistance programs. social workers must work to lessen these disparities by centering the experiences of disproportionately impacted populations, providing education to care teams, and advocating for healthcare equity. finally, it is important for social workers to continue studying the unique psychosocial needs of this population. the current best measure of “diagnosed with new health” abigail nikiforovs columbia social work review, vol. xxii | 89 88 | columbia social work review, vol. xxii psychosocial functioning for pwcf is the cystic fibrosis questionnairerevised (cfq-r), which includes assessment questions for physical health as well as social-emotional health. yet this does not include questions on the effects of taking eti. social workers can advocate for questions on the impacts of this transition to eti to be included in the assessment, which should then be used in clinical trials for any new cftr modulator therapies. accounting for these psychosocial factors can provide a more comprehensive picture of how the whole person is affected, moving beyond a narrow physiological perspective. lastly, social workers should make sure to facilitate transparent and sensitive conversations with pwcf about potential and unanticipated impacts these life-altering medications may have (ladores and polen, 2021). conclusion there are many unknowns about the quality of life for young people with cf who will grow up with these new medications. it is hoped that they will adjust well, need fewer safety nets, and plan and achieve long-term goals. however, it is clear that the current cf cohort who are suddenly facing a longer lifespan will need additional support. social security, including ssi and ssdi, has long provided a stable foundation for these individuals and should not be prematurely taken away. advocates, such as social workers, should appeal to the ssa to be more lenient in redetermining eligibility and promote and provide cf-specific training to the ce providers who are assessing these cases. if this vulnerable population continues to lose benefits, it will have detrimental impacts on their physical and mental health and their overall quality of life. because the successful increase in longevity from eti treatment had the unintended consequence of creating new mental health challenges, the impacts of the stressors, real-life complications, and financial burdens associated with this drug should be studied further. additionally, more research should be prioritized to understand racial and economic disparities of access to care for pwcf. while eti has been revolutionary in improving the lives of people with cystic fibrosis, more work at the policy level must be done to show these individuals 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(2022). impact of elexacaftor/tezacaftor/ ivacaftor on depression and anxiety in cystic fibrosis. therapeutic advances in respiratory disease, 16. https://doi.org/10.1177/17534666221144211 “diagnosed with new health” abigail nikiforovs columbia social work review, vol. xix | 65 enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders yinan chen, lily gabay, and catherine stampfli 66 | columbia social work review, vol. xxi enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders abstract eating disorders (ed) have some of the highest mortality rates of any mental health condition due to medical complications and high rates of suicidality. black, indigenous, and people of color (bipoc) adolescent girls and women are at especially high risk for developing eds, which jhu�oh]l�u\tlyv\z�ulnh[p]l�tlu[hs�huk�wo`zpjhs�olhs[o�jvuzlx\lujlz�� enhanced cognitive behavior therapy (cbt-e) is a transdiagnostic cognitive behavioral treatment for eds that, although originally designed [v�^vyr�^p[o�hk\s[z��ohz�illu�zov^u�[v�il�lɉlj[p]l�^p[o�hkvslzjlu[z�� +lzwp[l�*);�,»z�wyv]lu�lɉjhj`�hjyvzz�hnl�wvw\sh[pvuz��[olyl�pz�sptp[lk� ylzlhyjo�vu�p[z�lɉlj[p]lulzz�^p[o�)076*�pukp]pk\hsz��>l�hyn\l�[oh[�^p[o� culturally informed, competent, and sensitive clinicians, cbt-e can be used to treat underdiagnosed and undertreated bipoc adolescent girls, whose eds have been unjustly overlooked. columbia social work review, vol. xxi | 67 yinan chen, lily gabay, and catherine stampfli eating disorders (eds) are serious mental health diagnoses within the united states, warranting the attention of social workers and clinicians due to their high mortality rates (arcelus et al., 2011; johnson et al., 2002; national institute of mental health, 2021; striegel-moore & bulik, 2007). many eds begin in adolescence huk�jhu�oh]l�ulnh[p]l�jvuzlx\lujlz�vu�tlu[hs�huk�wo`zpjhs�olhs[o� (micali et al., 2014; verschueren et al., 2020). women and adolescent girls are especially at risk due to societal pressure to conform to the “thin ideal” (striegel-moore & bulik, 2007). black, indigenous, and people of color (bipoc) women and girls are even more vulnerable because the existence of eds among them has been ignored by researchers and practitioners alike, leading to a general lack of research and treatment (gilbert, 2003; rodgers et al., 2017; sonneville & lipson, 2018; striegel-moore & bulik, 2007; talleyrand, 2015). 0[�pz�]p[hs�[oh[�zvjphs�^vyrlyz�oh]l�hu�hklx\h[l��l]pklujlk�ihzlk� intervention to address the gap in treatment for bipoc adolescent girls. this paper proposes enhanced cognitive behavioral therapy (cbt-e) as hu�lɉlj[p]l�pu[ly]lu[pvu�mvy�[ylh[pun�)076*�hkvslzjlu[z�^p[o�,+z��hz�p[� pz�opnos`�hkhw[hisl�huk�ohz�illu�zov^u�[v�il�lɉlj[p]l�^p[o�hkvslzjlu[z� (fairburn, 2008; cooper & grave, 2017). although there is little research vu�*);�,»z�lɉlj[p]lulzz�^p[o�)076*�pukp]pk\hsz��^l�hyn\l�[oh[�[ol� inclusion of culturally competent care will allow for accessible and lɉlj[p]l�[ylh[tlu[� eating disorders eating disorders (eds) are a serious mental health concern globally and within the united states. about nine percent of all americans will be diagnosed with an ed at some point in their life, and more than a x\hy[ly�vm�pukp]pk\hsz�^p[o�hu�,+�^pss�h[[ltw[�z\pjpkl��(yjls\z�l[�hs��� 2011; deloitte access economics, 2020). eds are more prevalent among women than men, mostly due to societal pressures placed on them. 68 | columbia social work review, vol. xxi although men are also faced with pressure to conform to an ideal body type, women face constant exposure to society’s “thin ideal,” or the notion that worth and beauty are dependent upon body size and shape (striegel-moore & bulik, 2007). this pressure can cause women mental distress about their current weight and body shape, which can lead to the development of extreme and unhealthy attitudes or behaviors around food and eating habits. there are multiple types of eds, the three most common being binge eating disorder, anorexia nervosa, and bulimia nervosa (national institute of mental health, n.d.). eating disorder types of the multiple ed diagnoses in the dsm-5, anorexia nervosa and bulimia nervosa are most likely to begin in adolescence (striegel-moore & bulik, 2007). anorexia nervosa, which has the highest mortality rate of all eds, is commonly characterized by extremely restrictive eating and mvvk�h]vpkhujl��hu�vizlzzpvu�^p[o�vul»z�^lpno[��huk�h�zpnupäjhu[s`�sv^� body weight (arcelus et al., 2011; johnson et al., 2002; national institute of mental health, 2021; striegel-moore & bulik, 2007). there are two z\ijh[lnvyplz�vm�huvyl_ph�uly]vzh!�ylz[ypj[p]l�[`wl��^opjo�pz�klzjypilk� hiv]l��huk�ipunl�lh[pun�w\ynpun�[`wl��^opjo�pujs\klz�lwpzvklz�vm� binging—consumption of a large amount of food in a short amount of time—and purging through vomiting, laxatives, or diuretic use (national institute of mental health, 2021). bulimia nervosa is characterized by episodes of eating large amounts of food in a short period of time followed by purging through vomiting or use of laxatives or diuretics, fasting, or excessive exercise. binge eating disorder, which is the most common ed in the united states, is characterized by an individual losing control and eating a large amount of food in an unusually short time, without any form of purging, fasting, or excessive exercising afterwards. adolescents ed symptoms often begin to present in adolescence (micali et al., 2014; verschueren et al., 2020). adolescent girls experience the dual stressors of societal pressure to ascribe to the “thin ideal” and a natural enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 69 increase in weight as they transition through puberty, which may lead to discontent with their body shape (verschueren et al., 2020). thus, ed symptoms such as body dissatisfaction, restrictive eating, and purging begin to appear. adolescents are particularly at risk if they z\ɉly�myvt�wlymlj[pvupzt�vy�sv^�zlsm�lz[llt��^opjo�jhu�pujylhzl�[ol� likelihood of internalizing the “thin ideal” due to an increased reliance on the opinions of others (keel & forney, 2013). social media exposure huk�wlly�puå\lujlz��uhtls`�[oyv\no�[ol�zlslj[pvu�vm�wllyz�^p[o�zohylk� insecurities about weight and body shape, also work to perpetuate eds by reinforcing these insecurities. the onset of eds in adolescence can have numerous negative jvuzlx\lujlz�vu�hu�pukp]pk\hs»z�tlu[hs�olhs[o��4pjhsp�l[�hs�������"� johnson et al., 2002; verschueren et al., 2020). for example, eds are closely correlated with anxiety and depression in what appears to be a cyclical relationship, wherein one perpetuates the other (verschueren et hs����������(kvslzjlu[z�^p[o�,+z�hyl�hszv�tvyl�sprls`�[v�oh]l�kpɉj\s[`� regulating their own behavior, as well as having a dysfunctional selfevaluation caused by placing too much value on their body weight and shape. eds are also related to feelings of being a burden to one’s family and can negatively impact one’s social relationships (micali et al., 2014). finally, eds are associated with higher levels of suicidality and mortality (johnson et al., 2002). bipoc considerations historically, researchers have falsely believed that eds are most common among white, upper-class women (striegel-moore & bulik, �������;opz�ilsplm�pz�pu�why[�iljh\zl�,+�z`tw[vtz�jhu�kpɉly�i`�yhjl�vy� l[oupjp[`"�zvtl�ylzlhyjolyz�hyn\l�[oh[�[opz�wlyjlp]lk�kpɉlylujl�pu�[ol� prevalence of eds between white women and bipoc women may be k\l�[v�j\s[\yhs�kpɉlylujlz�pu�ilh\[`�z[hukhykz�huk�pklhs�ivk`�[`wlz�� with white cultures placing more value on the “thin ideal,” resulting pu�kpɉlylujlz�pu�ivk`�kpzzh[pzmhj[pvu�huk�pklhs�ivk`�^lpno[��.psily[�� 2003; striegel-moore & bulik, 2007; talleyrand, 2015). symptoms th`�[olylmvyl�thupmlz[�kpɉlylu[s`�mvy�)076*�^vtlu�[ohu�[ol`�kv�mvy� yinan chen, lily gabay, and catherine stampfli 70 | columbia social work review, vol. xxi white women (talleyrand, 2015). however, many experts posit that globalization and the spread of western culture will cause the thin ideal [v�iljvtl�tvyl�wyl]hslu[��[olyli`�kptpupzopun�j\s[\yhs�kpɉlylujlz�pu� rates of eds (striegel-moore & bulik, 2007). the false belief that eds exist only among white women has led to a lack of research on eds in the bipoc community (striegel-moore & bulik, 2007). bipoc women and girls are also less likely to seek or receive treatment for an ed for a variety of reasons, including clinician stereotyping or bias, limited resources, and mistrust of the health and mental health systems (gilbert, 2003; sonneville & lipson, 2018; striegel-moore & bulik, 2007; talleyrand, 2015). in addition, black and latinx adults and children have the highest rates of obesity in the us and are therefore less likely to be diagnosed with eds, as clinicians working with overweight women often focus on weight loss and therefore fail to recognize symptoms of eds among this population (stierman et al., 2021). despite the fact that bipoc women have comparable rates of eds [v�>op[l�^vtlu��thu`�ypzr�mhj[vyz�hyl�zwljpäj�[v�)076*�^vtlu� (talleyrand, 2015). these include level of acculturation, low levels of racial or ethnic identity, and experiences with racial oppression. high levels of acculturation appear to be a risk factor for latina women, for example, because their culture of origin may place less value on thinness than mainstream white american culture, while the opposite appears to be true for asian american women (gilbert, 2003; talleyrand, 2015). high levels of racial and ethnic identity, on the other hand, may protect women from mainstream white beauty standards, while experiences of oppression can create feelings of powerlessness that may result in the development of eds as a coping mechanism (talleyrand, 2015). thus, the presentation of eds for bipoc women th`�kpɉly�myvt�[ol�j\yylu[�jspupjhs�\uklyz[hukpun��^opjo�jlu[lyz�[ol� experiences of white, upper-class women. more research is needed to understand the complexities of eds and best treatments for bipoc women. enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 71 research limitations there is little research available regarding eds among bipoc adolescent girls. rodgers et al. (2017) studied the prevalence and expression of eds among overweight adolescent girls and found that overweight asian american girls, compared to black, latina, and white girls, had the highest risk of overeating; white overweight girls had the second highest risk. black overweight girls were most at risk for partaking in unhealthy behaviors such as fasting, purging, and food restriction to control their weight, and latina and white overweight girls had the highest rates vm�kpl[pun��0u[lylz[puns �̀�[ol�äukpunz�z\nnlz[�[oh[�)shjr�npysz�th`�il� at greater risk for binge eating in early adolescence, while risk among white girls increases with age. overall, it appears that bipoc women and adolescent girls experience eds at similar rates to their white counterparts. despite an increase in the number of studies that are beginning to demonstrate this fact, bipoc women are still underdiagnosed and undertreated, due to a variety of factors (gilbert, 2003; sonneville & lipson, 2018; striegelmoore & bulik, 2007; talleyrand, 2015). it is vital to understand the kpɉlylu[�^h`z�,+z�kl]lsvw�huk�wylzlu[�ihzlk�vu�hu�pukp]pk\hs»z� j\s[\yl��yhjl��vy�l[oupjp[`�pu�vykly�[v�tvyl�lɉlj[p]ls`�[ylh[�[ol�kp]lyzl� women and girls who experience eds. this is especially important for adolescent girls, who are in a highly vulnerable developmental period at the age that eds often begin (micali et al., 2013; verschueren et hs����������:[\kplz�z\nnlz[�[oh[�hkvslzjlu[�npysz�hyl�h[�lx\hs��pm�uv[� higher, risk for developing such disorders compared with adult women (rodgers et al., 2017). enhanced cognitive behavioral therapy (cbt-e) enhanced cognitive behavior therapy (cbt-e) is a leading empirically supported transdiagnostic cognitive behavioral treatment for eds (fairburn, 2008). the transdiagnostic theory of eds is based on the äukpun�[oh[�[ol�wypthy`�thpu[hpupun�wyvjlzzlz�mvy�lhjo�,+�kphnuvzpz� largely overlap (atwood & friedman, 2020). because of this, cbt-e yinan chen, lily gabay, and catherine stampfli 72 | columbia social work review, vol. xxi was developed to address the psychopathology of eds as a whole. it is a treatment for all forms of eds, including anorexia nervosa, bulimia nervosa, and binge eating disorder (fairburn, 2008). cbt-e also allows patients with eds to learn how their disorder functions, how it is maintained, and how to disrupt the self-reinforcing cycle of the ed (murphy et al., 2010). cbt-e was initially developed for individuals in outpatient treatment settings, but there are also guidelines for implementation as an intensive form of day treatment, inpatient treatment, or group therapy (fairburn, 2008). according to the centers for disease control and prevention �*+*���hk\s[z����`lhyz�vsk�huk�vskly�^p[o�h�)40�\ukly������rn�t�� are considered underweight (cdc, 2022). individuals with a bmi of �����rn�t��vy�tvyl��^ov�hyl�uv[�zpnupäjhu[s`�\ukly^lpno[��4\ywo`�l[� al., 2010), are advised to attend twenty therapy sessions over twenty ^llrz��-vy�pukp]pk\hsz�^p[o�h�)40�il[^llu������huk������rn�t���^ov� hyl�zpnupäjhu[s`�\ukly^lpno[�huk�hyl�z\iqlj[�[v�thyrlk�wo`zpjhs�huk� wz`jovzvjphs�lɉlj[z��-hpyi\yu���������^lpno[�ylz[vyh[pvu�pz�[ol�thpu� treatment aim, and forty sessions over forty weeks are advised. similar to other evidence-based cbt treatments, cbt-e is highly individualized, ^opjo�ylx\pylz�wh[plu[z�huk�jspupjphuz�[v�^vyr�[vnl[oly�[v�kl]lsvw�h� personalized treatment plan based on an individual’s symptoms, core pathology, and triggers. the psychoeducation component of cbt-e addresses the distorted beliefs that contribute to patients’ eds. treatment steps of cbt-e according to fairburn (2008), cbt-e usually starts with a one-and-a-half [v�[^v�ov\y�l]hs\h[pvu�zlzzpvu��mvssv^lk�i`�[^lu[`�äm[`�tpu\[l�[olyhw`� zlzzpvuz�v]ly�[ol�jv\yzl�vm�[^lu[`�^llrz��;ol�äyz[�lpno[�zlzzpvuz�� including the evaluation session, are held twice a week, followed by ten ^llrs`�zlzzpvuz�huk�[oyll�äuhs�zlzzpvuz�l]ly`�v[oly�^llr� there are four stages associated with cbt-e (fairburn, 2008). stage one is the intensive initial stage, called “starting well.” during this stage, patients meet clinicians twice a week for four weeks. they spend enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 73 [ol�äyz[�ml^�^llrz�vm�[ol�[ylh[tlu[�nh[olypun�pumvyth[pvu�hiv\[�[ol� disorders and carefully considering the reasons for and against change. then an individualized treatment plan is developed, and patients are informed of its utility, structure, and homework. research on eds has zov^u�[ol�thnup[\kl�vm�johunl�pu�[ol�äyz[�ml^�^llrz�vm�[ylh[tlu[�pz� a strong predictor of treatment outcomes, so these initial weeks are especially crucial. sessions in stage one include weekly weigh-ins to help patients \uklyz[huk�uh[\yhs�å\j[\h[pvuz�pu�^lpno["�[opz�kh[h�pz�wsv[[lk�vu�h� graph to give individuals a better understanding of weight trends. patients may not weigh themselves outside of these sessions (fairburn, 2008). homework between sessions includes self-monitoring forms to record everything consumed, cognitions and emotions while eating, any excessive eating or drinking, use of laxatives or diuretics, bouts of purging, and any compensatory actions in response to eating. selfmonitoring forms not only increase patients’ self-awareness around eating behaviors, but also provide a structured log for practicing skills so they can address any barriers. clinicians also introduce regular eating to patients, which entails eating three meals and three snacks per day in regular intervals, not exceeding four hours without eating. stage two of the treatment, the transitional stage, is called “taking stock” (fairburn, 2008). in these sessions, clinicians review progress and help patients identify and address any barriers they encountered between sessions, such as resistance to change, not prioritizing the treatment, depression, poor planning, and low self-esteem. then, clinicians and patients review and modify the initial formulation of the disorder based on the information collected over several weeks of selfmonitoring. for example, if patients are not able to follow their dietary plan when they are angry or anxious, they would need to add mood changes as a trigger for binge eating to their existing formulation. after modifying the initial formulation, clinicians and patients must decide whether to use a broad or focused version of cbt-e for the remainder of the treatment (fairburn, 2008). the focused version yinan chen, lily gabay, and catherine stampfli 74 | columbia social work review, vol. xxi exclusively addresses ed psychopathology, while the broad version is only recommended if one or more external mechanisms, such as clinical perfectionism, core low self-esteem, or marked interpersonal kpɉj\s[plz��hyl�pklu[pälk�[v�il�thpu[hpupun�[ol�kpzvykly�huk�wyl]lu[pun� change (cooper & grave, 2017). normally, the focused form is the klmh\s[�iljh\zl�p[�pz�tvyl�lɉlj[p]l�huk�lhzply�[v�ptwsltlu["�p[�pz�\zlk� with most patients who can be safely managed as outpatients. once clinicians and patients determine which mechanisms to address and in what order, based on the patient’s needs and presentation, they develop a treatment plan (fairburn, 2008). in stage three, the intensive treatment stage which comprises eight weekly sessions, clinicians and patients address key mechanisms [oh[�thpu[hpu�[ol�,+!�ivk`�pthnl"�kpl[hy`�ylz[yhpu["�huk�l]lu[z�� moods, and eating (fairburn, 2008). the clinician addresses patients’ overvaluation of body shape and weight by providing psychoeducation hiv\[�v]ly]hs\h[pvu�huk�p[z�jvuzlx\lujlz��;opz�olswz�[v�kl]lsvw� formerly ignored domains of self-evaluation; reduce unhelpful body checking and avoidance (e.g., mirror checking and comparing bodies); relabel unhelpful thoughts (e.g., feeling fat); examine the origins of the overvaluation; and learn to identify and modify the mindset surrounding the ed (cooper & grave, 2017). additionally, clinicians help patients johunl�ypnpk�kpl[hy`�y\slz�pu[v�ål_pisl�n\pklspulz�mvy�lh[pun��pu[yvk\jl� previously avoided foods, and develop problem-solving and moodregulation skills. if clinicians decide to use the broad version mentioned in stage two of the treatment, they address the external mechanism in addition to the general psychopathology. :[hnl�mv\y��jhsslk�¸lukpun�^lss�¹�pz�[ol�äuhs�z[hnl�vm�*);�,��-hpyi\yu�� 2008). it consists of three sessions that take place every other week. +\ypun�[ol�äuhs�why[�vm�z[hnl�[oyll�huk�pu�z[hnl�mv\y��[ol�ltwohzpz� shifts from treating the existing problem to looking toward the future. in this stage, patients work with clinicians to address their reactions and jvujlyuz�hiv\[�lukpun�[ylh[tlu[�huk�äuk�^h`z�[v�thpu[hpu�wyvnylzz�� the goal is for patients to be able to apply learned skills independently, enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 75 so as to handle setbacks and maintain the changes that have already been made in order to minimize the risk of relapse. together they devise a short-term maintenance plan for patients to utilize until their review hwwvpu[tlu[��^opjo�vjj\yz�[^lu[`�^llrz�hm[ly�[ol�äuhs�zlzzpvu�� in stage four, clinicians help patients phase out treatment procedures and homework (fairburn, 2008). for example, patients stop selfmonitoring records and in-session weighing in week eighteen. patients learn to be aware of what they eat, what happens throughout the day, and their urges to engage in ed behaviors without the aid of selfmonitoring forms. patients also start to weigh themselves at home with an open mind about their weight and identify strategies to prevent relapse, including listening to joyful music, reaching out to friends and family for support, exercising (cbt-e, n.d.), and engaging in relaxation [ljoupx\lz��z\jo�hz�kllw�iylh[opun�huk�tpukm\sulzz�wyhj[pjlz��;ol`� may also identify helpful preventive strategies such as avoiding certain people, places, or stimuli when they experience urges to binge eat. -puhss �̀�k\ypun�[opz�äuhs�z[hnl��jspupjphuz�lk\jh[l�wh[plu[z�hiv\[�ylhspz[pj� expectations for recovery, devise a long-term maintenance plan to deal with setbacks, and encourage patients to seek help from professionals to address these issues (fairburn, 2008). twenty weeks after the conclusion of treatment, patients are asked to return for a post-treatment review session (cooper & grave, 2017). a x\lz[pvuuhpyl�pz�\zlk�[v�hzzlzz�[ol�wylzlu[�z[h[l�vm�[ol�,+�huk�^ol[oly� daily function is impaired by the ed (fairburn & beglin, 1994; bohn & fairburn, 2008). in addition to the assessment, the review also includes a recap of patients’ progress throughout the entire treatment, a shortterm plan for how patients can continue to address the remaining symptoms, and strategies to handle setbacks. clinicians also review the long-term maintenance plan with patients to see if any necessary changes are needed (fairburn, 2008). yinan chen, lily gabay, and catherine stampfli 76 | columbia social work review, vol. xxi evaluation and measurement in cbt-e in cbt-e, patient outcomes are observed through preand postassessments as well as session-by-session symptom measurements. these measures include the eating disorder examination (ede), with versions available for both children and adults (cooper & fairburn, 1987; hilbert et al., 2013); the eating disorder examination questionnaire (ede-q; fairburn, 2008); the clinical impairment assessment (cia; bohn & fairburn, 2008); the clinical perfectionism questionnaire (cpq; fairburn et al., 2003); the eating problem checklist (epcl; dalle grave et al., 2019); and the starvation symptoms inventory (ssi; calugi et al., 2017). cbt-e with adolescents the content of cbt-e for adolescents is similar to that of adults, although it tends to be shorter because adolescents are typically capable of changing their behaviors faster than adults (cooper & grave, 2017). for example, underweight adolescent patients may only need thirty sessions to complete the treatment, instead of the typical mvy[`�zlzzpvuz��(�thqvy�tvkpäjh[pvu�vm�[ol�[ylh[tlu[�mvy�hkvslzjlu[z� pz�whylu[hs�pu]vs]ltlu[��)ljh\zl�h�zpnupäjhu[�u\tily�vm�hkvslzjlu[z� receiving treatment are younger than eighteen, parental involvement pz�uljlzzhy �̀�0u�[ol�äyz[�[^v�^llrz�vm�[ol�[ylh[tlu[��[ol�jspupjphu�ohz� hzzlzztlu[�zlzzpvuz�hsvul�^p[o�[ol�whylu[z��(m[ly^hyk��äm[llu��[v� twenty-minute joint sessions with the adolescent and parents are conducted throughout the course of treatment to update parents on treatment progress. the joint sessions also educate parents about the nature of their child’s ed, the rationale of treatment interventions, and how they can help their child during the treatment process. the u\tily�huk�mylx\luj`�vm�[olzl�qvpu[�zlzzpvuz�klwluk�vu�lhjo�wh[plu[»z� situation. enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 77 effectiveness and limitations of cbt-e there are many reasons cbt-e is useful in both clinical and social work wyhj[pjl!�p[�jhu�il�\zlk�pu�iv[o�puwh[plu[�huk�v\[wh[plu[�zl[[punz��ohz�h� ä_lk�slun[o��huk�\zlz�zwljpälk�z[yh[lnplz�huk�wyvjlk\ylz�[v�hkkylzz� ,+�wz`jovwh[ovsvn`�[oyv\no�mv\y�^lss�kläulk�z[hnlz��-hpyi\yu�� 2008). additionally, it encourages the establishment of "therapeutic momentum" that is needed early in treatment to make inroads in addressing the ed, helps ensure clinicians and patients keep working to achieve change, and increases the likelihood that treatment will have a formal ending. (kkp[pvuhss �̀�hs[ov\no�[olyl�pz�sptp[lk�ylzlhyjo�vu�[ol�lɉlj[p]lulzz� of cbt-e among younger patients, many considerations support the proposal that cbt-e might be especially suitable for them (cooper & grave, 2017). cbt-e is designed to increase patients’ self-control, which jhu�ilulä[�tvz[�hkvslzjlu[z��huk�luohujl�tv[p]h[pvu��h�nvhs�[oh[�pz� particularly relevant for underweight adolescent patients. cbt-e also hkvw[z�h�ål_pisl�huk�pukp]pk\hspalk�hwwyvhjo�[oh[�pz�lhzps`�hkhw[hisl� to the needs of adolescents’ cognitive development; moreover, it promotes autonomy, which is particularly relevant to adolescents, who respond favorably to collaborative treatment. finally, cbt-e has been adapted for adolescents in a way that takes their physical health into account because the prevalence of medical complications associated with eds is particularly severe for adolescents. as a result, there is a sv^ly�mylx\luj`�vm�ovzwp[hs�hktpzzpvuz�htvun�hkvslzjlu[z�pu�*);�,� treatment. :[\kplz�vu�*);�,�^p[o�hkvslzjlu[z�oh]l�zov^u�h�zpnupäjhu[� improvement in the bmi in adolescent participants with anorexia nervosa, as well as decreases in their clinical impairment scores, ed psychopathology, and general psychopathology scores (dalle grave et al., 2013; dalle grave et al., 2020; de jong et al., 2020). they have also demonstrated that patients are able to maintain improvements even after treatment is completed (signorini et al., 2018). although this yinan chen, lily gabay, and catherine stampfli 78 | columbia social work review, vol. xxi research is primarily focused on anorexia nervosa, the transdiagnostic mlh[\yl�vm�*);�,�z\nnlz[z�p[z�lɉlj[p]lulzz�^p[o�hss�,+z� ,]lu�^p[o�[ol�thu`�ilulä[z�vm�*);�,��zvtl�sptp[h[pvuz�ullk�[v�il� addressed through additional research. despite a low remission rate for individuals who participate in cbt-e, it does not work for everyone. around 50% of individuals do not fully recover using cbt-e, with some showing no improvements at all (linardon et al., 2018). similarly, around 25% of individuals drop out of treatment prematurely due to kpzzh[pzmhj[pvu��;ol�j\yylu[�ylzlhyjo�kvlz�uv[�zwljpäjhss`�hkkylzz� multiple comorbidities that individuals with eds may experience and does not address other relevant factors to the disorder, such as shame or trauma. more importantly, there is a lack of evidence that cbt-e treatment works across ethnic, racial, and socioeconomic groups. +lzwp[l�[ol�shjr�vm�ylzlhyjo�vu�[ol�lɉlj[p]lulzz�vm�*);�,�^p[o�)076*� individuals, we argue that the individualized and cooperative nature of the treatment allows clinicians to assist individuals in constructing culturally appropriate treatments. as such, we suggest adding a component during the initial planning stage that addresses patients’ culture and beliefs around mental health and eds. this addition would hssv^�wh[plu[z�[v�iypun�\w�hu`�j\s[\yhss`�zwljpäj�jvujlyuz��ihyyplyz�� or accommodations they would like to include in their treatment. in the case of bipoc adolescents, this component would involve parent and caregiver input as well. it is also vital for all clinicians working with bipoc individuals to receive cultural competency training and speak the same language as those they are working with, preferably the client’s äyz[�shun\hnl��[v�th_ptpal�lɉlj[p]lulzz� conclusion evidence-based treatments such as cbt-e are crucial for addressing ,+z�huk�[olpy�z`tw[vtz��^opjo�jhu�slhk�[v�mh[hs�jvuzlx\lujlz��>l� hyn\l�[oh[�*);�,�pz�lɉjhjpv\z�pu�[ylh[pun�hkvslzjlu[z�iljh\zl�p[�pz� highly individualized and promotes engagement in order to produce change. we believe our recommendations would aid in improving enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 79 [ol�x\hsp[`�vm�jhyl�mvy�)076*�hkvslzjlu[�npysz�huk�\s[pth[ls`�ylk\jl� further negative outcomes. however, due to a lack of evidence on the lɉlj[p]lulzz�vm�*);�,�mvy�)076*�hkvslzjlu[�npysz�pu�why[pj\shy��m\y[oly� ylzlhyjo�pz�ullklk�[v�l_htpul�[ol�lɉjhj`�vm�[ol�[ylh[tlu[�huk�[v� develop cbt-e to be more culturally competent. references arcelus, j., mitchell, a. j., wales, j., & nielsen, s. (2011). mortality rates in patients with huvyl_ph�uly]vzh�huk�v[oly�lh[pun�kpzvyklyz!�(�tl[h�huhs`zpz�vm����z[\kplz��archives of general psychiatry,�����������¶�����o[[wz!��kvp�vyn���������hyjonluwz`joph[y �̀�������� atwood, m. e., & friedman, a. (2020). a systematic review of enhanced cognitive behavioral therapy (cbt-e) for eating disorders. international journal of eating disorders������������¶�����o[[wz!��kvp�vyn���������lh[������� )vou��2��� �-hpyi\yu��*��.����������;ol�jspupjhs�ptwhpytlu[�hzzlzztlu[�x\lz[pvuuhpyl��*0(��� in c. g. fairburn (ed.), cognitive behavioral therapy for eating disorders (pp. 315-317). guilford publications. calugi, s., miniati, m., milanese, c., sartirana, m., el ghoch, m., & dalle grave, r. ��������;ol�z[hy]h[pvu�z`tw[vt�pu]lu[vy`!�+l]lsvwtlu[�huk�wz`jovtl[ypj�wyvwly[plz�� nutrients�� � ��� ����o[[wz!��kvp�vyn������ ��u\ � � ��� cbt-e: how it works & what to expect. (n.d.). choosing therapy. retrieved november 27, ������myvt�o[[wz!��^^ �̂jovvzpun[olyhw �̀jvt�ji[�l�� cdc. (2022, june 3). all about adult bmi. centers for disease control and prevention. o[[wz!��^^ �̂jkj�nv]�olhs[o`^lpno[�hzzlzzpun�itp�hk\s[fitp�pukl_�o[ts *vvwly��a��� �-hpyi\yu��*���� �����;ol�lh[pun�kpzvykly�l_htpuh[pvu!�(�zltpɫz[y\j[\ylk� pu[ly]pl^�mvy�[ol�hzzlzztlu[�vm�[ol�zwljpäj�wz`jovwh[ovsvn`�vm�lh[pun�kpzvyklyz�� international journal of eating disorders,������������o[[wz!��kvp�vyn����������� �� ���?�� ������!�#�!!(0+�,(;����������%����*6"�� � *vvwly��a��� �.yh]l��9��+����������,h[pun�kpzvyklyz!�;yhuzkphnuvz[pj�[olvy`�huk�[ylh[tlu[�� in s. g. hofmann & g. j. g. asmundson (eds.), the science of cognitive behavioral therapy��ww�����¶������(jhkltpj�7ylzz��o[[wz!��kvp�vyn���������) ��������������� 6.00014-3 dalle grave, r., calugi, s., doll, h. a., & fairburn, c. g. 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(2013). psychometric evaluation of the eating disorder examination adapted for children. european eating disorders review��������������� ��o[[wz!��kvp�vyn���������ly]������ johnson, j. g., cohen, p., kasen, s., & brook, j.s. (2002). eating disorders during adolescence and the risk for physical and mental disorders during early adulthood. archives of general psychiatry��� ��������¶�����o[[wz!��kvp�vyn��������� archpsyc.59.6.545 keel, p. k., & forney, k. j. (2013). psychosocial risk factors for eating disorders. international journal of eating disorders������������ ��o[[wz!��kvp�vyn���������lh[���� �� 3puhykvu��1���-hpyi\yu��*��.���-p[azpttvuz�*yhm[��,��,���>psål �̀�+��,��� �)yluuhu��3���������� the empirical status of the third-wave behaviour therapies for the treatment of eating kpzvyklyz!�(�z`z[lth[pj�yl]pl �̂�clinical psychology review�������������o[[wz!��kvp� vyn���������q�jwy������������ murphy, r., straebler, s., cooper, z., & fairburn, c. g. (2010). cognitive behavioral therapy for eating disorders. the psychiatric clinics of north america������������¶�����o[[wz!�� kvp�vyn���������q�wzj������������ enhanced cognitive behavioral therapy (cbt-e) as an intervention for bipoc adolescent girls with eating disorders columbia social work review, vol. xxi | 81 4pjhsp��5���7sv\ipkpz��.���+l�:[h]vsh��)���:ptvuvɉ��,��� �;ylhz\yl��1����������-ylx\luj`� and patterns of eating disorder symptoms in early adolescence. journal of adolescent health������������������o[[wz!��kvp�vyn���������q�qhkvolhs[o������������� national institute of mental health. (n.d.-a). statistics: eating disorders��o[[wz!��^^ �̂upto� upo�nv]�olhs[o�z[h[pz[pjz�lh[pun�kpzvyklyz why[f����� national eating disorders association. (n.d.-b). warning signs and symptoms��o[[wz!��^^ �̂ uh[pvuhslh[punkpzvyklyz�vyn�^hyupun�zpnuz�huk�z`tw[vtz�� national institute of mental health. (2021, december). health topics: eating disorders. o[[wz!��^^ �̂upto�upo�nv]�olhs[o�[vwpjz�lh[pun�kpzvyklyz� rodgers, r. f., watts, a. w., austin, s. b., haines, j., & neumark-sztainer, d. (2017). disordered eating in ethnic minority adolescents with overweight. international journal of eating disorders���������¶������o[[wz!��kvp�vyn���������lh[������� :pnuvypup��9���:olɉlsk��1���9ovklz��5���-sltpun��*��� �>hyk��>����������;ol�lɉlj[p]lulzz� vm�luohujlk�jvnup[p]l�iloh]pv\yhs�[olyhw`��*);�,�!�(�uh[\yhspz[pj�z[\k`�^p[opu�hu�v\[� patient eating disorder service. behavioural and cognitive psychotherapy, 46(1), 21-34. o[[wz!��kvp�vyn���������:����������������� sonneville, k. r., & lipson, s. k. (2018). disparities in eating disorder diagnosis and [ylh[tlu[�hjjvykpun�[v�^lpno[�z[h[\z��yhjl�l[oupjp[ �̀�zvjpvljvuvtpj�ihjrnyv\uk��huk� sex among college students. international journal of eating disorders, 51, 518– 526. o[[wz!��kvp�vyn���������lh[������� :[plythu��)���(ɉ\s��1���*hyyvss��4��+���*olu��;�*���+h] �̀�6���-pur��:���-y`hy��*��+���.\��8��� hales, c. m., hughes, j. p., ostchega, y., storandt, r. j., & akinbami, l. j. (2021). national health and nutrition examination survey: 2017–march 2020 prepandemic data -pslz·+l]lsvwtlu[�vm�äslz�huk�wyl]hslujl�lz[pth[lz�mvy�zlslj[lk�olhs[o�v\[jvtlz� �5/:9�5v��������5h[pvuhs�*lu[ly�mvy�/lhs[o�:[h[pz[pjz��<�:����o[[wz!��z[hjrz�jkj�nv]� ]pl^�jkj��������� striegel-moore, r. h., & bulik, c. m. (2007). risk factors for eating disorders. american psychologist,�����������¶� ���o[[wz!��kvp�vyn�����������������?���������� ;hssl`yhuk��9��4����������*splu[z�vm�jvsvy�huk�lh[pun�kpzvyklyz!�*\s[\yhs�jvuzpklyh[pvuz�� in l. h. choate (ed.), eating disorders and obesity (pp. 45-68). american counseling (zzvjph[pvu��o[[wz!��kvp�vyn��������� ����� �������jo�� verschueren, m., claes, l., palmeroni, n., bogaerts, a., gandhi, a., moons, p., & luyckx, 2����������,h[pun�kpzvykly�z`tw[vth[vsvn`�pu�hkvslzjlu[�iv`z�huk�npysz!�0klu[pm`pun� distinct developmental trajectory classes. journal of youth and adolescence, 49, ���¶�����o[[wz!��kvp�vyn���������z�� ����� �������� yinan chen, lily gabay, and catherine stampfli columbia social work review_2024_digital.pdf columbia social work review, vol. xxii | 5 4 | columbia social work review, vol. xxii inspiration for article when my mother died in 2018, i became one of many people throughout human history irrevocably impacted by grief, and a reverent student of its power to disrupt, transform, and heal. when the covid pandemic began, i supported people in the throes of grief and worked with people at the end of life. i heard patients and families inquire about medical aid in dying during my second-year practicum in oncology social work. i wrote my final research paper on the topic for dr. hara’s policy course because i wanted to better serve patients and their loved ones. although i have my own views on the topic, it was important to me to write this article with a social work lens, and with respect for multiple perspectives and lived experiences. it is my hope that readers see the humanity of multiple perspectives when reading it. thank you to the primary editing team who made this publication a reality: angelyn, chloe, and claragrace. thank you also to the editors-in-chief brenna and mackenzie. i dedicate this article to my beautiful mother, cherylyn smith, for bringing me into this world and for teaching me so much when she left it. originally from california, i am focusing on integrated practice and programming at cssw. i work as a research assistant at the center for prolonged grief, where i interview survivors of the 2001 world trade center attack about their grief experiences. my goal is to work as a medical social worker and provide psychotherapy to bereaved people and communities. stephanie veronica smith columbia social work review, vol. xxii | 7 6 | columbia social work review, vol. xxii social work and the new york state medical aid in dying act abstract medical aid in dying (maid) is garnering increasing attention throughout the world. since 1998, 14 states and washington d.c. have maid laws in the united states. for the eighth time in as many years, the new york state legislature has introduced maid legislation, and the medical aid in dying act is currently in committee in both the assembly and the senate. although this legislation has failed in new york state in the past, it is increasingly supported by new york voters (granquist, 2024). the maid debates in new york state, along with data from u.s. jurisdictions with maid laws, highlight important considerations about end-of-life choices and how they intersect with social work values. social workers can gain valuable insight into supporting people at the end of life, engage in self-reflection on their own beliefs and biases related to endof-life choices, encourage self-reflection of medical professionals, and advocate for equity in healthcare within medical institutions and through social welfare policy (schroepfer et al., 2022). this discourse can benefit patients interacting with the health care system regardless of maid’s outcome in new york state. stephanie veronica smith a s of april 2024, the medical aid in dying (maid) act is in committee in both the state assembly and senate (a995/ s2445) in new york state (n.y. legis. assemb, 2023). it proposes the legalization of a process by which terminally ill people can access medication that will end their life. the maid act specifies that this option is only available to people diagnosed with a terminal illness, which is defined as a physician determining they will live six months or less due to their illness. multiple safeguards are defined in the legislation to prevent coercion from medical institutions and people who might benefit financially or otherwise from a person’s death. for example, maid outlines the process by which terminally ill patients can request medication: patients must make both an oral and written request to a physician, the physician will then examine the patient to confirm whether they are terminally ill and have the capacity to make the decision, and a consulting physician must confirm. though it is not a requirement, if physicians have concerns about any patient’s capacity to make the decision, they are recommended to refer the patient to a licensed psychiatrist or psychologist to assess the patient’s mental health and capacity (n.y. legis. assemb, 2023). there are also guidelines governing how physicians engage in consultations with potential maid patients. these include a requirement for physicians to provide education about the patient’s treatment options and alternatives to maid such as hospice and palliative care. if prescribed the medication, there are strict guidelines that a patient must administer the medication to themselves and ingest it, and it must not be taken in a public space. patients can also revoke their request for the medication at any time or simply elect to not take the medication even if they receive it. physicians also have the right to choose not to incorporate maid in their practice or refer any patient who is interested in maid to another physician (n.y. legis. assemb, 2023). columbia social work review, vol. xxii | 9 8 | columbia social work review, vol. xxii the maid act aims to ethically expand the options for people at the end of life when they are terminally ill so they can die with choice and dignity. although it is not explicitly stated in the act, maid also attempts to address the problem of society’s limited conceptualization of autonomy at the end of life, especially as it relates to suicide. as a result, part of what is being addressed is a societal exploration of what is ethically permissible when choosing to end one’s life. the maid act aims to address these problems through collaboration with patients, healthcare providers, and policymakers in new york state (n.y. legis. assemb, 2023). although social workers are not explicitly mentioned in the maid act, the policy impacts the role of social workers and their engagement with people they serve. whether or not maid passes in new york, the related discourse is crucial for social workers to understand. this paper will explore the nuances of the maid debate and its interaction with social work values. it will also provide information about the spectrum of end-of-life options currently available to new york residents, how social workers can prepare individually and within their workplaces for end-of-life conversations, and advocacy possibilities for a just and equitable healthcare system. maid considerations the discourse about maid and suicide a major maid debate involves its relationship to suicide. some people classify maid under the umbrella term “physician-assisted suicide,” which includes practices like euthanasia that are completed by physicians rather than the patient (schroepfer et al., 2022, p.820). proponents of the act generally argue that maid is distinct from suicide. on a practical level, characterizing a death by maid as suicide can prevent life insurance beneficiaries from receiving claims (parker et al., 2004), meaning that a patient’s end-of-life wishes may not be honored. conflating maid with suicide also means that prescribing physicians might be vulnerable to legal ramifications including felony charges. although suicide is no longer considered illegal in any state, there are state laws, including in new york, that outlaw aiding suicide. new york penal law deems “a person guilty of promoting a suicide attempt when he intentionally causes or aids another person to attempt suicide” and classifies it as a class e felony with a 2-to-5-year sentence in prison (promoting a suicide attempt, 2014). by distinguishing maid from suicide in legal documentation, a patient’s end-of-life wishes are more likely to be honored, and there will be less liability for physicians and healthcare institutions if they choose to engage in maid. beyond practical considerations, framing maid deaths as suicides reflects deep sociohistorical ties to western nations' perspectives on suicide. the legal codification of suicide enforced government control over what constituted sin, crime, and property rights. while there are efforts by mental health professionals to avoid stigmatizing language such as “committing suicide” in modern times, the language of “commit” is rooted in the idea that ending one’s life is a crime with legal consequences. historically, this included government forfeiture of property to the detriment of non-elite families and communities (chang, 2018). social stigma was generally a horrific byproduct for the people most impacted by a suicide death, and this legacy persists for many people. attempts to conflate maid with suicide–and potentially punish the patients, communities, and physicians who prescribe maid medications–perpetuates stigma for people suffering from a terminal illness who seek options at the end of their lives. opposition to maid new york state legislators who voted against maid prevailed in past legislative sessions. it most recently failed in 2022 despite polls indicating voter support. according to a 2021 poll of new york voters, 58% supported maid, 37% opposed, and 5% were unsure (marist college, 2021). opponents of maid, primarily disability rights organizations such as the center for disability rights in new york (cdrnys) and not dead yet, advocate against maid and argue it should be categorized as suicide. cdrnys calls the bill an “existential social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 11 10 | columbia social work review, vol. xxii threat to disabled new yorkers,” claiming that the government will “abdicate its responsibility” to equal protection related to suicide prevention services for people living with disabilities if it is passed (cdrnys, 2022). not dead yet echoes these concerns, stating that people living with disabilities will experience increasing levels of coercion to end their lives rather than seek life-saving care, especially those of low socio-economic status who cannot afford expensive medical treatment (not dead yet, 2022). the new york state catholic conference joins these organizations, claiming that “ambiguous” aspects of the bill weaken accountability for healthcare professionals, diminish protections for people living with disabilities, and create further risks for those choosing to live with a terminal diagnosis despite treatment possibilities available to them (new york state catholic conference, 2024). organizations such as cdrnys distrust the safeguards put in place to ensure coercion is not active in maid. experts from the united nations (un) join them in warning about a global slippery slope toward eugenicinfluenced pressures and ableist assumptions in medical practices that may eventually engulf low-income, terminally ill people along with other people living with disabilities. these warnings were issued in 2021 as a response to canada’s decision to expand maid to people with disabilities in addition to people with “grievous and irremediable conditions” (quinn et al., 2021, p.1). even before the expansion of canadian maid laws, a 2019 un report that investigated maid practices in canada determined that “there is no protocol in place to demonstrate that persons with disabilities deemed eligible for assistive dying have been provided with viable alternatives” (devandas-aguilar, 2019, p. 13). there were also reports from people living with disabilities in institutions regarding pressure to seek maid. u.s. disability rights organizations echo similar concerns to those from canadian activists. cdrnys (2022) states that the current language of the new york maid legislation deems people living with disabilities and conditions which could be life-threatening without treatment, such as diabetes, eligible for maid even if treatment options exist. they argue that people who cannot afford expensive treatments may experience financial pressure to pursue maid. as such, many disability rights advocates do not welcome an expansion of end-of-life options to include maid (cdrnys, 2022). while it is not yet possible to know how maid will impact new york, statistics from other states with similar laws provide insight. kozlov et al. (2022) analyzed 23 years of aggregated data across 14 states and washington d.c. the data determined that patients who died by maid “tend to be older, white, educated, and diagnosed with cancer across all jurisdictions where maid is legal” (p. 3042). these statistics are consistent in new york’s neighboring state new jersey where maid has been legal since 2019. according to a 2022 maid data report from the chief state medical examiner’s office, 90% of people who received medication for maid were white, 83% were over the age of 65, and 58% had at least a bachelor’s degree. the report also states, “heart disease was the leading cause of death in the general population in new jersey…followed closely by [cancer]. however, for those participating in the [maid] program in new jersey, [cancer] is the leading underlying illness accounting for 48% of cases,” while cardiovascular disease accounted for 14% of cases (the office of the chief state medical examiner, 2023, p.6). maid advocates interpret this data as evidence that maid is neither abused or misused to target people living with disabilities in states where it is legal. perhaps what is more important than countering maid opponents’ critiques and conjectures with statistics from other states is to understand and acknowledge their concerns. the eugenics movement that swept the world through the late 19th and early 20th centuries had an indelible impact on the united states. the disability rights groups that oppose maid are speaking to the history of forced institutionalization, sterilization, and euthanasia rooted in a pseudoscientific endeavor to undermine people with disabilities as less worthy of dignity and autonomy (everybody, 2013). recounting this history leads disability social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 13 12 | columbia social work review, vol. xxii rights groups to draw parallels between the past and the present when legislation such as maid arises. part of their concern also stems from international aid-in-dying practices. in addition to un experts’ concerns in canada, disability rights groups look to examples in europe. the netherlands has practiced euthanasia since 1985. it was initially an unofficial but tolerated practice and was eventually codified into dutch law in 2002 (groenewoud et al., 2021). the dutch have expanded their practice from focusing solely on terminally ill people to include people suffering from psychiatric disorders that are deemed “unbearable and irremediable,” and many of which are considered disabilities in the united states (van veen et al., 2022, p.1). in april 2023, the dutch law expanded to include children of all ages who have a terminal illness (the guardian, 2023). although many safeguards are part of maid laws in u.s. jurisdictions, including age restrictions, disability rights groups view the evolution of dutch laws as an example of a gradual return of eugenics. support for maid the maid act is sponsored by the assembly health committee chair amy paulin in the new york state assembly with 50 co-sponsors, and the new york senate judiciary chair brad hoylman-sigal with 12 cosponsors. the reintroduction of the bill in 2021 (then a.4321/s.6471) led to unprecedented advocacy with supporters sending more than 3,600 letters to state lawmakers (granquist, 2024). although the act did not pass in 2022, a 2021 marist poll showed that 58% of new york voters supported maid at that time (marist college, 2021, p.27). recent polling data conducted by yougov and commissioned by death with dignity and completed life initiative revealed that 72% of new york voters support maid, 23% oppose, and 6% are not sure (hoffman, 2024). the poll shows that support is consistent across demographics. this includes catholics (65%) and people with disabilities (73%) even though catholic leaders and disability rights organizations are maid’s most vocal opponents. maid is also supported in new york by organizations who seek to expand options to terminally ill people at the end of life, including end of life choices new york (2021) and compassion and choices (2024). as the names of organizations who support maid emphasize, they view the legislation as empathetic support for terminally ill people who wish to die with choice and dignity. they also make a distinction between maid and suicide. death with dignity (2024) defines the difference by explaining that suicide is “the act of taking one’s own life voluntarily and intentionally,” whereas maid involves “an adult patient with terminal illness who is deemed mentally competent [who] chooses to hasten their death through a physician’s assistance.” some national professional associations agree with these distinctions. the american public health association (2014) explains that maid is part of a “patient’s right to self-determination,” and that a terminally ill person can assess what constitutes a “good death” according to their circumstances. the american medical women’s association and the american medical student association also emphasize maid as part of patient autonomy (schroepfer et al., 2022). in january 2024, the new york state bar association (nysba) task force on medical aid in dying released its report and recommendations on maid in new york. the report included a summary of statements from a public hearing conducted in november 2023. advocates included people living with life-threatening illnesses who described their fears of not having maid available if treatment is no longer viable or desirable. others were family members and loved ones of people who died with terminal illnesses while experiencing excruciating pain. some described the attempts, completions, or requests from their now deceased loved ones to end their own lives knowing that maid was not an option in new york and the trauma they experienced as part of their bereavement. other supporters were family members and loved ones of people who were able to utilize maid as residents in states where it is legal. they described the dignity, peace, and community support these people were able to experience by having more control over the circumstances of their death (new york state bar association, 2024). social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 15 14 | columbia social work review, vol. xxii while the nysba task force ultimately endorsed the new york maid act, the final report contained recommendations for safeguards for “special populations,” as well as funding, insurance, and training for healthcare professionals (p.6). the overall aims of these recommendations are to ensure that patients fully understand their rights and end-of-life options and that maid is an equitable option available to people with terminal illnesses despite their insurance coverage or socioeconomic status. this last concern is based on federal laws that prohibit federal funding to pay for maid prescriptions which precludes people dependent on federal insurance options such as medicare and medicaid from utilizing maid. while this recommendation is counter to the concerns of opponents who worry that low-income people will be coerced into utilizing maid, the nysba supports the recommendation with data indicating there are people interested in utilizing maid in states where it is legal but are unable to do so because the prescription is prohibitively expensive. furthermore, the report points to biases and inequities throughout the healthcare system that prevent adequate access and education about end-of-life options to people from lower socio-economic and socially-marginalized groups. they claim these inequities largely contribute to underutilization of maid in marginalized communities (p. 29). current end-of-life options in new york state there exists a spectrum of end-of-life choices for patients to legally explore in new york, and social workers already engage in conversations and practices with patients around these choices. if maid passes in new york, social workers are likely to be instrumental in providing education and support to patients through maid. fujioka et al. (2018) conducted a literature review from jurisdictions where maid is legal, and concluded, “social workers… are integral in the execution of maid in tandem with physicians and adopt a wide range of roles” (p. 1572). as such, social workers and the communities they serve can benefit from understanding patient rights and the spectrum of end-of-life options for terminally ill patients regardless of maid’s success in new york. the best-known options related to end-of-life care are advanced directives. advanced directives are documents that explain a person’s medical care choices if they are unable to communicate them. this includes orders that can be specified in a living will such as do not resuscitate (dnr) and do not intubate (dni) orders as well as medical orders for life-sustaining treatment (molst) that guide families and medical professionals in determining whether life-saving measures should be utilized for a patient during critical situations. another advanced directive is the health care proxy, which cedes control to one or more persons whom the patient appoints to make medical decisions on their behalf if they cannot communicate their wishes. health care proxies can use a living will to carry out a person’s wishes, but if no living will exists, they can still legally make decisions on behalf of the patient (new york state attorney general, n.d.). if a health care proxy is not assigned and a person cannot communicate their wishes, state laws determine who can make decisions on behalf of a patient (u.s. department of health and human services, 2022). in new york state, that person would likely be a legal guardian, a spouse or domestic partner, or an adult child (new york state department of health, n.d.). health care professionals such as social workers can provide education and serve as witnesses for advanced directives. hospice and palliative care services are also available to terminally ill new yorkers. hospice provides support to patients who are terminally ill when curative approaches are either not desired by the patient or are not available to the patient at any point from diagnosis through treatment. it includes comprehensive services such as nursing, pain management, social work, and spiritual care. palliative care is available to patients with chronic illnesses that are not necessarily terminal and who desire pain management assistance and other supportive services either with or without treatment (u.s. department of health and human services, 2021). both services are fully covered by medicare and medicaid and are generally fully covered by private insurance plans as well (vitas healthcare, n.d.). social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 17 16 | columbia social work review, vol. xxii two new york state laws, the palliative care information act (pcia) and the palliative care access act (pcaa) require physicians, nurse practitioners, general hospitals, nursing homes, home care agencies, enhanced assisted living residences, and special needs assisted living residences to offer information and counseling concerning palliative care and end-of-life options and facilitate access to such care. despite these laws, new york state ranks last in the united states for hospice utilization with reports that pcia and pcaa are largely ignored and unenforced (new york state bar association, 2024). when education, counseling, and referrals to palliative care and hospice do occur, social workers are generally involved in some or all stages of the process. robust and consistent practices in providing education about hospice and palliative care are recognized as crucial maid safeguards for proponents and opponents alike. another legal option for terminally ill patients is voluntary stopping of eating and drinking (vsed). although vsed is not without controversy, it is generally protected as a patient’s right to determine their own treatment, including refraining from treatment. it is an option that can be specified in an advanced directive, which includes refusal of feeding tubes to sustain a patient’s life (end of life choices new york, 2021). although it is generally differentiated from suicide, there is no standardization about how it is characterized on a death certificate which can impact a patient’s life insurance policy and end-of-life wishes (uemura et al., 2023). it is also a difficult, physically grueling process that requires a strong will on the part of a patient and their caregivers. as such, some families of new yorkers who died by vsed are strong advocates for maid (new york state bar association, 2024). if a terminally ill new york resident is interested in pursuing maid, it is possible to travel to another state or country where maid is legal. while most other states require a person to be a resident, oregon and vermont lifted the ban on non-residents in 2023 (paine, 2023). traveling for maid is not ideal for many people at the end of life, primarily because it can be emotionally difficult, which is a major impetus for proponents of the law in new york state (n.y. legis. assemb, 2023). it is also prohibitively expensive for many people and requires time, planning, and resources that many people at the end of their lives may not have. families of new yorkers who suffered because they were unable to travel for maid are also strong advocates for the legislation (new york state bar association, 2024). maid and social work social work associations and maid there are currently neither standards about social workers’ engagement with maid nor specifications in the new york maid act about social workers’ roles. most social work associations do not take an official position on the issue but affirm that the profession’s ethics and values support and advocate for patients’ rights and end-of-life choices. the national association for social workers (nasw) standards for practice in palliative & end of life care states, social workers working in palliative and end of life care are expected to be familiar with the common and complex bioethical considerations and legal issues [including maid]. end of life issues are recognized as controversial because they reflect the varied value systems of different groups (nasw, 2004). this statement emphasizes the holistic nature of social work in navigating the complexities of end-of-life issues with individuals and families. cultural awareness and sensitivity are upheld as important aspects for social workers engaging in palliative and end-of-life care. the association of oncology social work (aosw) expands on the nasw statement by upholding “the right of every patient to make decisions about living and dying that are reflective of their goals and values and are consistent with the law of their jurisdiction” (schroepfer et al., 2022, p. 823). both associations highlight the importance of self-reflection in social work when supporting individuals and families addressing end-of-life concerns. although these statements point social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 19 18 | columbia social work review, vol. xxii to social work values, they do not explicitly explore end-of-life care options, including maid, through the lens of social work values. such an exploration reveals that some social work values align with maid policies and practices while others do not. social work values aligned with maid arguments in favor of maid emphasize it as an end-of-life choice that promotes a patient’s dignity. this directly relates to the social work value of upholding the dignity and worth of a person (nasw, 2021). a 2022 comprehensive review of data from oregon, collected from the time the law passed in 1998, reveals that these values are consistent with utilization of maid in the state. the main concerns reported by oregonians who utilized maid related mostly to their loss of autonomy and dignity and their inability to engage in activities that made life enjoyable (oregon health authority: public health division, 2023). this indicates that maid is serving terminally ill oregonians as intended by centering and upholding their choices and dignity. the maid act also respects the desires of many terminally ill people to experience their end of life within the meaningful and comfortable environment of their own home. the new york maid act explicitly mentions the highly publicized death of brittany maynard, a 29-year-old resident of california who died from a brain tumor. maynard traveled to oregon for maid and advocated for its enactment in california as she was dying so that others could have the option to die at home. her advocacy strongly contributed to the enactment of california’s law in 2015 (n.y. legis. assemb, 2023). citing the example of brittany maynard, proponents of the law aim to support terminally ill new york residents so they do not have to cross state lines to receive maid. this resonates with statistical data showing that terminally ill people generally prefer to die at home. roughly 93% of maid participants in oregon have chosen to die at home since the law was passed (oregon health authority: public health division, 2023). new jersey reported similar statistics in 2022 with 92% of patients utilizing maid dying at home (the office of the chief state medical examiner, 2023). the new york bill contains similar language to oregon’s law and is likely to promote dignity for terminally ill people who utilize it in new york as well. social work values unaligned with maid there are also social work values that do not align with maid, particularly with regard to social justice. oppositional arguments cautioning against a slippery slope towards eugenicist practices resonate with some communities of color who have been impacted by abuses of the eugenics movement. a comparison of two recent polls of new york voters demonstrate a correlation between trust in medical providers and support for maid, particularly among black voters. a 2023 siena college poll found 58% of respondents support “legislation that would allow a doctor to prescribe lethal drugs that a terminally ill patient with demonstrated decision-making capacity could take on their own in order to end their own life” (siena college research institute, 2023, p. 5). just two months later in january 2024, a poll conducted by yougov found 72% of respondents support pending legislation that “would allow a terminally ill patient–for whom two doctors have determined has under six months to live–the right to request and receive a prescription for medication to end their life” (hoffman, 2024, p. 1). support for maid among new yorkers proved far higher in the yougov poll (2024) emphasizing patient autonomy compared to the siena college poll (2023), which highlights doctors prescribing “lethal drugs” to patients. black voters were particularly attuned to the nuances of each poll’s phrasing: 66% of black voters stated that they support maid in the yougov poll (hoffman, 2024) while only 28% stated that they support maid in the siena college poll (2023). although it is significant for new york voters in general that the maid act centers patient autonomy over the power of medical providers, this is especially true for black americans who have historically suffered, and continue to suffer, life-threatening and sometimes fatal harms at the hands of medical institutions. social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 21 20 | columbia social work review, vol. xxii considering social workers’ commitment to social justice, it is crucial to examine these nuances and their implications. structural racism in health care is deeply rooted in u.s. history. harriet washington’s book medical apartheid (2008), for example, illustrates the lack of transparency, medical experimentation, intentional harm, and even murder of black americans throughout history at the hands of medical institutions and how this history reverberates across the u.s. healthcare system today. a 2019 study by cain & mccleskey further emphasized the impact of structural racism in u.s. healthcare. by conducting focus groups in los angeles, california, they determined that while there are a variety of nuanced opinions based on race and ethnicity, african american and latino participants who opposed maid highlighted structural racism in healthcare as a major reason (cain & mccleskey, 2019, p. 1185). in light of this history and its enduring impact, maid raises complex social justice concerns related to inequitable healthcare access for people of color, both across the lifespan and in end-of-life options. data show people of color generally do not utilize maid in states where it is legal, with 95.6% of those who do identifying as white. this seems to refute opponents’ concerns about race-based coercion into maid on the part of healthcare institutions. at the same time, it is worth noting that similar disparities exist in hospice and palliative care, which are also underutilized by people of color (teano, 2020). this is especially true in new york state which has the lowest hospice utilization rate in the nation (new york state bar association, 2024). both proponents and opponents of maid point to this data, but for different reasons. maid proponents argue that structural racism in health care leads to physicians not discussing hospice and palliative care options with patients of color, even though this information is generally shared, understood, and accessible for white patients. maid opponents, however, claim that the underutilization of hospice and palliative care relates to a lack of trust between physicians and communities of color. overall, this complex landscape indicates that despite low rates of maid utilization among communities of color, constant vigilance is needed to ensure misuse does not emerge and to promote social justice in end-oflife care. social workers have a key role to play in this endeavor. preparations for maid among new york social workers given the increasing support for maid in new york, it is prudent for social workers to consider their role in relation to this issue. understanding the maid laws in the context of history, cultural considerations and nuances, social work values, and other end-of-life options available to new york residents covers many crucial elements. the nasw and aosw encourage social workers to engage in selfreflection to understand whether they can ethically serve a client and to refer them elsewhere if they are unable to do so. social workers must therefore reflect on their own beliefs and attitudes toward end of life experiences and care and how this shapes their personal views of maid (schroepfer et al., 2022). if they are able to ethically engage, social workers can also explore navigating cultural nuances and different belief systems in relation to maid with patients and their families. the holistic perspective of social work provides a unique opportunity to serve as additional safeguards against misuse and abuse of maid. by understanding the concerns of proponents and opponents alike, social workers are equipped to ethically discuss maid while centering the dignity and rights of all patients, regardless of their medical and end-oflife choices. social workers should also encourage and support self-reflection, education, and advocacy on the interdisciplinary teams in which they work. given maid’s complex relationship with social justice, it is important for other professionals who engage in conversations about end-of-life options to investigate their own beliefs, biases, and ethics. social work associations and social workers engaging in end-of-life care can prepare training workshops and materials to guide health care professionals through education and self-reflection on topics such as ableism and racial biases in medicine. they can also collaborate social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 23 22 | columbia social work review, vol. xxii compassion & choices. (2024). status of end-of-life legislation. https://www. compassionandchoices.org/in-your-state/new-york death with dignity. (2024, january 31). a glossary of terms for discussion. https:// deathwithdignity.org/resources/assisted-dying-glossary/ devandas-aguilar, c. (2019, december 19). visit to canada: report of the special rapporteur on the rights of persons with disabilities. united nations. https://www. ohchr.org/en/documents/country-reports/ahrc4341add2-visit-canada-report-specialrapporteur-rights-persons end of life choices new york. (2021, march 22). vsed: voluntarily stopping eating & drinking end of life choices new york. https://endoflifechoicesny.org/education/ resources/vsed/vsed_overview/ everybody. (2013, march 20). eugenics. everybody: an artifact history of disability in america. https://everybody.si.edu/citizens/eugenics fujioka, j., mirza, r., mcdonald, p., & klinger, c. (2018). implementation of medical assistance in dying: a scoping review of health care providers’ perspectives. journal of pain and symptom management, 55(6), 1564-1576. https://doi.org/10.1016/j. jpainsymman.2018.02.011 granquist, e. (2024, february 8). new york death with dignity: options at the end of life. death with dignity. https://deathwithdignity.org/states/new-york/ groenewoud, a. s., atsma, f., arvin, m., westert, g. p., & boer, t. a. (2021). euthanasia in the netherlands: a claims data cross-sectional study of geographical variation. bmj supportive & palliative care. https://doi.org/10.1136/bmjspcare-2020-002573 the guardian. (2023, april 14). netherlands to broaden euthanasia rules to cover children of all ages. https://www.theguardian.com/society/2023/apr/14/netherlands-to-broadeneuthanasia-rules-to-cover-children-of-all-ages hoffman, b. (2024, february 8). new york state polling collaboration on medical aid in dying. death with dignity. https://deathwithdignity.org/wp-content/uploads/2024/02/ maid_ny_base_sample_jan_2024_crosstabs-public.pdfabs-public.pdf kozlov, e., nowels, m., gusmano, m. k., habib, m. h., & duberstein, p. r. (2022). aggregating 23 years of data on medical aid in dying in the united states. journal of the american geriatrics society, 70(10), 3040–3044. https://doi.org/10.1111/jgs.17925 marist college. (2021, october). marist poll of 822 new york state adults. marist poll. https://maristpoll.marist.edu/wp-content/uploads/2021/10/marist-poll_nys-nos-andtables_202110110852.pdf national association of social workers. (2021). nasw code of ethics (guide to the everyday professional conduct of social workers). https://www.socialworkers.org/ about/ethics/code-of-ethics/code-of-ethics-english on interdisciplinary practices and procedures in relation to end-oflife options and conversations with patients. providing opportunities for stronger interdisciplinary teams that are informed and equipped to navigate the nuances of challenging end-of-life conversations can provide a stronger support system for patients, increase possibilities for patient-centered collaboration, and provide more robust advocacy for patients engaging with interdisciplinary healthcare teams. given the social justice concerns and underutilization of hospice and palliative care in new york, social workers can also strengthen their advocacy roles in relation to maid. they can work to inform patients about their rights and the spectrum of end-of-life options available to them while also advocating for more equitable healthcare for patients in general. while proponents and opponents of maid come to different conclusions about whether the law should pass, they agree that healthcare equity is a strong safeguard against maid abuses. by strengthening equity in the health care system through advocacy, social workers can serve not only as a unifying force in the divide around maid but also as social justice leaders serving to remedy longstanding structural inequities in the united states. references american public health association. (2008, october 8). patients’ rights to selfdetermination at the end of life. https://www.apha.org/policies-and-advocacy/publichealth-policy-statements/policy-database/2014/07/29/13/28/patients-rights-to-selfdetermination-at-the-end-of-life cain, c., & mccleskey, s. (2019, april 4). expanded definitions of the ‘good death’? race, ethnicity and medical aid in dying. sociology of health and illness, 41(6), 1175–1191. https://doi.org/10.1111/1467-9566.12903 cdrnys. (2022, april 27). physician assisted suicide deadly for disabled. center for disability rights. https://cdrnys.org/blog/press-releases/physician-assisted-suicidedeadly-for-disabled/ chang, h. (2018). a brief history of anglo-western suicide: from legal wrong to civil right. southern university law review, 46(1). https://digitalcommons.law.ggu.edu/cgi/ viewcontent.cgi?article=1854&context=pubs social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xxii | 25 24 | columbia social work review, vol. xxii nasw. (2004). standards for palliative and end-of-life care. national association of social workers. https://www.socialworkers.org/practice/nasw-practice-standardsguidelines/standards-for-palliative-and-end-of-life-care n.y. legis. assemb. a995. reg. sess. 2023-2024 (2023). https://www.nysenate.gov/ legislation/bills/2023/a995/amendment/a new york state attorney general. advanced directives: making your wishes known and honored [brochure]. https://ag.ny.gov/sites/default/files/advancedirectives.pdf new york state bar association. (2024, january 19). report and recommendations of the new york state bar association task force on medical aid in dying. https://nysba.org/ app/uploads/2022/03/2024-january-hod-approved-report-on-medical-aid-in-dyingmaid.pdf new york state catholic conference. (2024, february 1). physician-assisted suicide new york state catholic conference. https://www.nyscatholic.org/assisted-suicide-memo/ new york state department of health. (n.d.). deciding about health care: a guide for patients and families. https://www.health.ny.gov/publications/1503.pdf not dead yet. (2022, july 20). why we oppose assisted suicide laws. https://notdeadyet. org/assisted-suicide-talking-points oregon health authority: public health division. (2023, march 8). oregon death with dignity act: 2022 data summary. https://www.oregon.gov/oha/ph/ providerpartnerresources/evaluationresearch/deathwithdignityact/ documents/year25.pdf paine, d. (2023, october 12). traveling to oregon and vermont to access maid. death with dignity. https://deathwithdignity.org/resources/traveling-to-oregon-and-vermontto/ parker, f. r., rubin, h. w., & winslade, w. j. (2004, september 13). life insurance, living benefits, and physician-assisted death. behavioral sciences & the law, 22(5), 615–626. https://doi.org/10.1002/bsl.614 promoting a suicide attempt, n.y. assault and related offenses law § 120.30 (2014). https://www.nysenate.gov/legislation/laws/pen/120.30 quinn, g., mahler, c., & de schutter, o. (2021, february 3). mandates of the special rapporteur on the rights of persons with disabilities; the independent expert on the enjoyment of all human rights by older persons; and the special rapporteur on extreme poverty and human rights. office of the high commission for human rights (ol can 2/2021). https://spcommreports.ohchr.org/tmresultsbase/ downloadpubliccommunicationfile?gid=26002 schroepfer, t., goldberg, j., & wladowski, s. (2022, march). hospice and palliative social work’s ethical challenge. oxford university press (pp. 819–831). https://doi.org/10.1093/ med/9780197537855.003.0091 siena college research institute. (2023, november 15). siena college poll. https://scri. siena.edu/wp-content/uploads/2023/11/sny1123-crosstabs.pdf teano, t. (2020, october 28). study documents racial differences in u.s. hospice use and end-of-life care preferences. johns hopkins medicine. https://www.hopkinsmedicine. org/news/newsroom/news-releases/2020/10/study-documents-racial-differences-in-ushospice-use-and-end-of-life-care-preferences the office of the chief state medical examiner. (2023). new jersey medical aid in dying for the terminally ill act: 2022 data summary. https://www.nj.gov/health/ advancedirective/documents/maid/maidannualreport2022.pdf uemura, t., krohmal, b. j., & higuchi, m. (2023). challenges in completing a death certificate after voluntary stopping of eating and drinking (vsed). journal of the american medical directors association, 24(10), 1442–1446. https://doi.org/10.1016/j. jamda.2023.06.022 u.s. department of health and human services. (2021, may 14). what are palliative care and hospice care? national institute on aging. https://www.nia.nih.gov/health/hospiceand-palliative-care/what-are-palliative-care-and-hospice-care u.s. department of health and human services. (2022, october 31). advance care planning: advance directives for health care. national institute on aging. https://www. nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directiveshealth-care van veen, s., widdershoven, g., beekman, a., & evans, n. (2022, june 19). physician assisted death for psychiatric suffering: experiences in the netherlands. frontiers in psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.895387 vitas healthcare. (n.d.). does insurance cover hospice? https://www.vitas.com/hospiceand-palliative-care-basics/paying-for-hospice/insurance-and-hospice washington, h. a. (2008). medical apartheid: the dark history of medical experimentation on black americans from colonial times to the present. social work and the new york state medical aid in dying act stephanie veronica smith columbia social work review, vol. xix | 73 understudied and underserved: advancing inclusive mental health care for individuals with intellectual and developmental disabilities shayna delvecchio, lmsw columbia social work review, vol. xxiii | 77 76 | columbia social work review, vol. xxiii understudied and underserved abstract individuals with intellectual and developmental disabilities (idd) face profound inequities in accessing and receiving quality mental health care despite being at increased risk for psychological distress. this paper examines the historical and systemic barriers that perpetuate these disparities—including financial limitations, imbalances within the healthcare system, provider shortages, inadequate research funding, and persistent misconceptions about the therapeutic potential of individuals with idd. the exclusion of individuals with idd from research and psychotherapy further exacerbates these challenges, creating significant gaps in clinical knowledge and guidance. in addition, individuals with idd face disproportionately severe mental health challenges, including heightened exposure to trauma, diagnostic overshadowing, and the impact of social stigma. in response, inclusive strategies are proposed to improve care by addressing the unique cognitive, communicative, and emotional needs of this population. central to these recommendations is a shift toward person-centered, dignity-affirming care that recognizes individuals with idd as autonomous participants in their own treatment. to advance equity in mental health care, it is imperative to pursue transformative change through inclusive research, targeted provider training, and evidence-based therapeutic adaptations. by amplifying the voices of individuals with idd and addressing the systemic factors that have long excluded them, it will be possible to move toward a more equitable and responsive mental health care system for this underserved community. keywords: intellectual and developmental disabilities (idd), mental health disparities, diagnostic overshadowing, person-centered therapy, trauma-informed care, inclusive psychotherapy, disability advocacy shayna delvecchio, lmsw understudied and underserved: advancing inclusive mental health care for individuals with intellectual and developmental disabilities individuals with intellectual and developmental disabilities (idd) are multidimensional human beings with rich emotional lives and significant capabilities, yet they are often inadequately recognized as such. despite growing awareness and advocacy efforts, outdated perceptions continue to shape societal attitudes, policies, and clinical practices. as a result, individuals with idd frequently encounter barriers that limit their autonomy, access to care, and overall well-being. idd encompasses a broad range of conditions characterized by impairments in intellectual functioning and adaptive behavior that emerge during development and persist throughout a person’s lifetime (eunice kennedy shriver national institute of child health and human development [nichd], n.d.). per the nichd (n.d.), these differences can impact multiple domains, including: • cognitive and learning abilities—reasoning, problem-solving, communication. • behavioral and social functioning—social skills, emotional regulation, self-care. • physical ability and motor skills—mobility, coordination. idd includes chromosomal conditions such as down syndrome and fragile x syndrome, as well as neurodevelopmental conditions including autism spectrum disorder and fetal alcohol syndrome (nichd, n.d.). compared to the general population, individuals with idd are more vulnerable to experiencing mental health challenges, including anxiety, depression, and ptsd—yet they remain far less likely to access appropriate resources and support (lineberry et al., 2023). multiple factors contribute to the inequitable access to mental health care for individuals with idd, including systemic barriers, research columbia social work review, vol. xxiii | 79 78 | columbia social work review, vol. xxiii gaps, and long-standing misconceptions. systemic challenges such as financial inequities, a shortage of trained providers, and a lack of accessible services create considerable obstacles to receiving appropriate care. individuals with idd also face a heightened risk of trauma and psychological distress, yet their mental health concerns are frequently overlooked due to diagnostic overshadowing and the impact of stigma. these interconnected forces continue to perpetuate the disparities individuals with idd experience in mental health care. despite increased need, this population remains vastly underrepresented in psychological research, limiting the development of effective, evidence-based interventions. as a result, care often fails to reflect the diverse needs of the idd community, leading to inadequate support and reinforcing an ongoing pattern of excluding them from active participation in their own care. this paper examines the systemic disadvantages that individuals with idd experience in mental health care, highlights the intersecting barriers to equitable treatment, and proposes recommendations to foster greater inclusion and accessibility in therapeutic settings and beyond. systemic barriers to equitable mental health care individuals with disabilities face systemic marginalization across various facets of their lives, limiting their access, opportunities, and inclusion. deeply rooted historical discrimination and ongoing barriers have led to profound inequities—particularly in financial stability, access to mental and physical health care, and funding for research. these challenges significantly contribute to negative mental health outcomes. historical context beginning in the 19th century and continuing well into the 20th century, the widespread institutionalization of people with disabilities led to their forced removal from society. within these institutions, individuals were often subjected to dehumanizing conditions (davis, 2015). this systemic othering contributed to the exclusionary view of individuals with disabilities as burdensome or even dangerous (davis, 2015). these perceptions worsened as the eugenics movement gained traction between the 1900s and 1940s, when policymakers and medical professionals advocated for the forced sterilization of individuals with disabilities, further entrenching the belief that they were inherently flawed (o’brien, 2023, chapter 3). this deprivation of fundamental human rights had a detrimental impact on the mental health of individuals with idd, though their psychological well-being was largely disregarded by institutions at the time (burns, 2009). while the latter half of the 20th century saw monumental shifts away from this harrowing past with the rise of the disability rights movement and landmark legal reforms, substantial barriers remain in addressing the injustices and ongoing challenges faced by individuals with idd (burns, 2009; davis, 2015). financial inequities that limit opportunity the consequences of this long history of discrimination manifest in various forms, including stark economic disparities that limit access to essential resources and opportunities. according to the national disability institute (2020), 26% of individuals with a disability live below the poverty line, compared to 11% of individuals without a disability. structural barriers—including limited educational resources, discrimination in hiring, physically inaccessible workplaces, and inadequate social support—hinder financial stability (world bank, 2023). this is further compounded by higher rates of unemployment, limited employment opportunities, and wage inequalities: under section 14(c) of the fair labor standards act, individuals with idd can legally be paid subminimum wages, with median earnings as low as $3.50 per hour (wage and hour division, 2024). these inequities make financial independence exceptionally difficult to attain. additionally, individuals receiving supplemental security income (ssi) face asset limits in which they risk losing crucial benefits, including medicaid, if they save understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 81 80 | columbia social work review, vol. xxiii more than $2,000 (musumeci & orgera, 2021). this cycle of financial precarity impacts mental health, as financial instability contributes to chronic stress and limits access to resources—further deepening systemic disadvantages for individuals with disabilities (houtrow et al., 2023). limitations in healthcare healthcare access remains a major barrier for individuals with idd, who often receive lower-quality medical and mental health care and face obstacles that impede comprehensive treatment (krahn et al., 2015). an estimated 50% to 70% of individuals with idd who require mental health services do not receive them, in part due to the lack of appropriate services covered by funded programs (harris et al., 2018). medicaid, the primary funding source for idd care, covers approximately 77% of essential services for individuals with idd, including homeand community-based supports and general healthcare. however, it often provides only limited coverage for mental health services. these limitations include restrictions on specialized therapy, session frequency, and provider availability (barth, 2021). medicaidfunded programs tend to prioritize behavioral interventions over psychotherapy, reflecting outdated assumptions about the psychological needs of this population (barth, 2021). while strictly behavioral interventions can be effective for managing specific concerns, neglecting emotional well-being leaves many individuals with idd struggling with undiagnosed or untreated psychological issues (mcnally et al., 2021). healthcare disparities extend beyond mental health to physical health. individuals with idd are more than twice as likely to experience chronic, preventable conditions—such as obesity, diabetes, heart disease, stroke, and other cardiovascular diseases—compared to those without disabilities (dixon-ibarra & horner-johnson, 2014). this elevated risk is often linked to systemic barriers, including inadequate access to routine and preventive care such as screenings, early interventions, and health education (escudé, 2022; gréaux et al., 2023). these structural shortcomings not only affect physical health but can also intensify mental health difficulties, creating a cycle in which one condition exacerbates the other (division of population health, 2012). limited research funding beyond service access and coverage, another major challenge lies in the limited research infrastructure supporting idd mental health care. research on the mental health needs of individuals with idd remains severely underfunded (hassiotis et al., 2022). government investment in this area is limited, partly due to systemic oversight and the minimization of idd-related concerns within broader mental health policy agendas (hassiotis et al., 2022). as a result, many initiatives depend on short-term grants from nonprofit organizations and private foundations (hassiotis et al., 2022). despite the substantial, well-documented needs of individuals with idd, research specific to this population has historically received a disproportionately small fraction of overall mental health funding (national institutes of health, n.d.). while nonprofit organizations play a vital role in supporting these efforts, their financial resources are far more limited than those of public institutions (frumkin & kim, 2001). this has made it difficult to initiate and sustain large-scale, long-term studies—limiting both the generalizability of findings and the ability to produce insights that are responsive to the varied needs within the idd community (frumkin & kim, 2001). the scarcity of dedicated funding hinders scientific progress and restricts the development of effective, evidence-based interventions. these funding gaps contribute to the continued exclusion of individuals with idd from both research and clinical care—reflecting and reinforcing broader patterns of systemic neglect. lack of trained providers even when care is otherwise accessible, another major limitation is the shortage of trained professionals equipped to provide mental health treatment to individuals with idd. effective therapy for this population requires clinicians with specialized expertise in the psychological, biological, and sociocultural dimensions of idd (american understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 83 82 | columbia social work review, vol. xxiii psychological association [apa], 2022). however, many clinicians lack the necessary training and confidence to diagnose and treat mental health conditions in this community (hinde & mason, 2020). although training opportunities are increasing, they remain insufficient to meet the growing demand (lamar, 2020). many states report a shortage of specialized providers, which causes long wait times: some individuals face wait periods of three to six months before receiving mental health care (lamar, 2020). these delays are particularly harmful to individuals with idd who require timely support. existing clinicians often become overextended due to the shortage of trained professionals, the backlog of cases, and high caseloads. this overextension often dilutes the time and attention spent on each client. this, in turn, increases the likelihood of burnout and reduces the capacity to provide individualized care (hinde & mason, 2020). as a result, the quality of care suffers as clinicians struggle to meet the diverse needs of each client, which can contribute to worsening symptoms and diminished outcomes (hinde & mason, 2020). this issue highlights the critical need for both more specialized training and a greater number of qualified professionals to effectively address the unmet mental health needs of individuals with idd. the consequences of these systemic barriers are grave. limited access to routine healthcare, higher prevalence of preventable physical conditions, elevated rates of mental health difficulties, and broader social determinants of health—such as economic instability and social exclusion—all culminate in an average 15to 20-year reduction in life expectancy for individuals with idd (white et al., 2023). a staggering 42% of deaths among individuals with idd result from potentially preventable causes—nearly double the rate in the general population, 22% (cooper et al., 2020). these disparities necessitate a multifaceted and systemic approach—one that addresses not only individual mental health needs but also the broader social, economic, and structural factors contributing to poorer health outcomes. exclusion from research and evidence-based practice barriers to participation in psychological research equitable care is not possible without a strong research foundation, yet the persistent exclusion of individuals with idd from the research landscape has severely limited the understanding of their mental health needs and hindered the development of effective, evidence-based interventions (decormier plosky et al., 2022). individuals with idd remain critically underrepresented in mental health research and clinical trials, resulting in a limited evidence base to guide psychological care (decormier plosky et al., 2022; friedman & spassiani, 2024). researchers have historically deemed controlled studies involving this population too difficult due to lingering misconceptions and various methodological challenges (friedman & spassiani, 2024). these challenges include participant recruitment, ethical concerns around ensuring informed consent, and the need for accessible accommodations, which can be costly (friedman & spassiani, 2024). without appropriate infrastructure, researchers have often viewed such studies as too logistically challenging to pursue—inadvertently excluding this population even further. however, recent efforts to rectify this historical exclusion have focused on increasing awareness of ethical research practices and actively addressing logistical barriers to participation. these efforts have led to the adoption of more inclusive methodologies, such as participatory research approaches (sadler, 2023). these methods involve integrating individuals with idd as active participants in the design and execution of studies, taking on collaborative roles such as co-researchers and advisors (sadler, 2023). by showcasing the lived experiences of individuals with idd, these approaches produce more accurate and contextually relevant findings, while helping counteract the historical exclusion of this community from research (sadler, 2023). understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 85 84 | columbia social work review, vol. xxiii disparities in global research representation while this progress is promising, there is a significant gap in research on how disability intersects with different racial, ethnic, and socioeconomic backgrounds, particularly in lowand middle-income countries (magaña et al, 2022; susanty et al., 2020). cultural adaptations of psychosocial interventions are necessary to deliver effective support across diverse populations; however, such adaptations remain limited and underdeveloped (susanty et al., 2020). approximately 80% of people with disabilities globally live in developing countries, yet the vast majority of psychosocial interventions and research on idd have been concentrated in high-income, western countries, where the resources and frameworks for conducting such studies are more readily available (susanty et al., 2020). this inequity places the vast majority of individuals with idd at an even greater disadvantage, as most interventions designed in high-income countries fail to account for the cultural, socioeconomic, and contextual factors that shape their psychological needs. interventions must be designed to be both effective and accessible for individuals in resource-constrained settings, ultimately contributing to the reduction of global inequalities in disability care. true inclusivity cannot be achieved while much of the global idd population remains especially overlooked. only when these disparities—both between high and low-income countries and across cultural groups—are addressed will meaningful equity in disability mental health care be within reach. the exclusion of individuals with idd from research is both a symptom and a driver of broader systemic inequities—rooted in inadequate funding, limited infrastructure, and ingrained biases within the research field. as a result, individuals with idd continue to be left out of the very systems intended to support their well-being, perpetuating exclusion in both knowledge and care. barriers to psychotherapy: misconceptions and emerging progress legacy of exclusion in mental health treatment although participatory research approaches and more inclusive research have improved representation in mental health studies, misconceptions about the emotional experiences and therapeutic potential of individuals with idd continue to limit their access to appropriate mental health care. historically, disabilities were treated as illnesses requiring a cure rather than inherent parts of a person’s experience (linton, 1998). as psychology and western psychotherapy emerged as formal disciplines in the late 19th and early 20th centuries, individuals with disabilities were systematically excluded due to prevailing discriminatory beliefs that viewed them as intellectually inferior (linton, 1998). this “therapeutic disdain” (bender, 1993) was rooted in assumptions that individuals with idd lacked awareness of their mental health and were incapable of participating in their own psychological treatment. these beliefs persisted into the 1990s and early 2000s, reinforcing the notion that psychotherapy was not a viable option for individuals with idd. for decades prior, many professionals believed that individuals with idd lacked the cognitive capacity to benefit from self-reflection or insight-based therapies (bender, 1993). as a result, mental health treatment primarily followed the medical model, which focused on symptom management and modifying external factors, often without addressing deeper psychological needs (olkin, 2022; willner & lindsay, 2016). within this framework, concerns were predominantly addressed through pharmacological treatments, hospitalization, and strictly behavioral interventions (olkin, 2022; willner & lindsay, 2016). these interventions were frequently administered by third parties—such as healthcare providers without mental health training or caregivers—often without the individual’s consent (willner & lindsay, 2016). understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 87 86 | columbia social work review, vol. xxiii misconceptions about the cognitive capacity and self-efficacy of individuals with idd led many professionals to assume they were incapable of making informed decisions about their own care (bender, 1993). consequently, treatment plans were often imposed rather than developed with their collaboration or consent, further stripping individuals of agency in their mental health treatment (dunkley et al., 2018). such methods distanced the individual from their own emotions and volition, reducing them to passive recipients of care and leaving mental health concerns inadequately addressed. when individuals with idd are excluded from decisions about their care, it can lead to feelings of disempowerment and a reluctance to seek help in the future (dunkley et al., 2018). this can contribute to medical trauma, worsen psychological distress, and deepen disparities in mental health support (bradbury-jones et al., 2020). progress toward inclusive and empowering care the long-standing belief that individuals with idd cannot benefit from psychotherapy has begun to dissolve as research and advocacy efforts expand (shepherd & beail, 2017). in the late 1990s and early 2000s, emerging research began to demonstrate the effectiveness of adapted psychotherapeutic approaches, such as modified cognitive behavioral therapy—prompting a gradual shift in professional attitudes (willner, 2005). psychotherapy is now more widely recognized as an effective treatment for individuals with idd (porcelan et al., 2019; shepherd & beail, 2017). informed mental health and disability professionals acknowledge that, with appropriate resources and support, individuals with idd are wholly capable of growth, change, and recovery from mental illness through psychotherapy (porcelan et al., 2019). this understanding has catalyzed positive change, prompting the integration of cognitive principles into behavioral therapy, creating a more comprehensive model that addresses potential behavioral challenges and the emotional experiences of individuals with idd. while many past misconceptions have been dispelled, remnants of these beliefs remain, and considerable progress is still needed to achieve truly equitable mental health care. since psychotherapy for individuals with idd is still a relatively new and evolving field, continued research is essential to refine and enhance treatment methods. addressing research gaps and promoting integrated treatment approaches are key to strengthening the knowledge base needed to better support individuals with idd. a crucial part of this effort involves amplifying the voices of individuals with idd in both psychological research and clinical care, as inclusive mental health care cannot exist without their representation and participation. mental health experiences and treatment increased risk of trauma and adverse childhood experiences the systemic inequities that limit access to inclusive care also contribute to the significantly higher rates of trauma, abuse, and mental health challenges experienced by individuals with idd compared to the general population (didden & mevissen, 2022; lunsky & lake, 2019). individuals with idd are also more likely to experience multiple disabilities and comorbidities: between 39% and 52% of people with idd have a co-occurring psychiatric condition, such as anxiety or mood disorders (healthy minds policy initiative, 2024). individuals with idd are disproportionately exposed to adverse childhood experiences (aces)—stressful or traumatic events experienced in childhood that can have lasting effects on an individual’s physical, emotional, and mental health. this further compounds their risk of psychological distress (division of violence prevention, 2019; mcnally et al., 2021). approximately 44% of people with idd have experienced at least four aces, compared to just 13% of the general population (national core indicators, 2023). some of the traumas individuals with idd are more likely to experience include physical and emotional abuse and neglect at the hands of caregivers, as well as social challenges such as bullying, understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 89 88 | columbia social work review, vol. xxiii isolation, and exclusion (didden & mevissen, 2022; national council on disability, 2022). individuals with idd also experience higher rates of sexual abuse, coercion, and exploitation, as others may wrongly assume they lack decision-making capacity and exploit their trust, reliance on support, or limited access to resources (beadle-brown et al., 2010; nixon et al., 2017). the cumulative impact of these experiences during crucial developmental years increases vulnerability to long-term mental health challenges, chronic health conditions, and persistent social isolation (national core indicators, 2023). diagnostic overshadowing an additional barrier to effective mental health care for individuals with idd is the tendency for providers to minimize or disregard their mental health challenges, or attribute them entirely to their disability. a pervasive issue known as diagnostic overshadowing occurs when symptoms are misattributed solely to a person’s disability. this involves overemphasizing or focusing excessively on the disability while overlooking other important aspects of the individual’s life, including life events, strengths and capabilities, and additional factors related to the client’s presenting concerns (apa task force, 2022; hallyburton, 2022). this bias results in individuals being perceived almost exclusively through the lens of their disability, often overshadowing their broader identity (apa task force, 2022). while challenges associated with disabilities can contribute to mental distress, they are not the sole explanation for these individuals’ difficulties. disability may be an important and meaningful aspect of their identity, but it does not encompass the entirety of it. unlike individuals without disabilities, who are typically viewed holistically by mental health professionals, individuals with idd are frequently viewed through the restrictive framework of their condition (apa task force, 2022). without proper training, many clinicians struggle to recognize how mental health conditions may present differently in individuals with idd (fletcher et al., 2016). although clinicians generally mean well and are often motivated by a desire to help, the lack of sufficient training and awareness can unintentionally result in diagnostic overshadowing. the implications of this phenomenon are profound: professionals often overlook or dismiss symptoms of anxiety, depression, ptsd, and other mental health disorders, leaving diagnosable and treatable mental health conditions unaddressed (lunsky & lake, 2019). to effectively combat diagnostic overshadowing, treatment should aim to bridge the gap between the internal experiences and outward expressions of individuals with idd. it is important for clinicians to have a foundational understanding that disabilities can profoundly affect mental health, while also recognizing that individuals often present with concerns unrelated to their disability. this awareness should inform the therapeutic process, wherein clinicians actively explore both disability-related and independent mental health challenges. this more nuanced perspective enhances diagnostic accuracy and fosters more compassionate, individualized care that addresses the full spectrum of challenges experienced by individuals with idd. impact of social stigma social stigma and isolation may also harm the mental health of individuals with idd. although stigmatization has decreased in recent years due to growing awareness and advocacy efforts, residual stigma remains deeply ingrained in societal perceptions. many individuals with disabilities unconsciously internalize these negative views, increasing their risk of psychological distress—particularly anxiety and depression—and contributing to social withdrawal and a decreased likelihood of seeking support (dagnan & waring, 2004). in addition to stigma, factors such as low self-esteem, negative selfconcept, unfavorable social comparisons, feelings of hopelessness, and limited social support have all been linked to heightened mental health difficulties among this population (evans & randle-phillips, 2018). these psychosocial stressors, coupled with the ongoing lack of accessible mental health care, have been associated with increased suicide risk. individuals with idd are three times more likely to face suicide risks understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 91 90 | columbia social work review, vol. xxiii than the general population, and those on the autism spectrum are particularly vulnerable (santomauro et al., 2024). these disparities underscore the urgent need for accessible, traumainformed mental health care that not only addresses the varied needs of individuals with idd but also actively combats stigma and promotes psychological well-being. without a nuanced understanding of how mental health conditions uniquely impact this population, clinical approaches risk overlooking the complex interplay between disability, trauma, stigma, and emotional well-being. to meaningfully improve care, it is vital to center the voices and lived experiences of individuals with idd. their perspectives offer invaluable insight into how mental health services can become more accessible, affirming, and responsive— ultimately contributing to a more inclusive and equitable mental health system. recommendations: therapeutic modifications for inclusive care adapting therapy for individuals with idd traditional psychotherapeutic models often fail to address the unique cognitive, communicative, and social needs of individuals with idd. meaningful adaptations are integral to promoting engagement, enhancing comprehension, and creating a more empowering, supportive therapeutic experience. therapy is most effective when tailored to the individual’s developmental level, support needs, and cognitive and verbal abilities (porcelan et al., 2019). clinicians should account for differences in how individuals with idd communicate, express their emotions, process information, and use cognitive functions, such as emotional literacy, memory, and executive functioning (porcelan et al., 2019). to support these differences, therapy can be modified in terms of time frame, session pace, and complexity of content. for example, therapists can adjust their speech, use visual aids to convey emotions or experiences, and alter the number of themes addressed in a single session to suit the individual’s needs (kneuer, 2024). additionally, therapists should encourage multimodal communication as needed—using a variety of methods to accommodate different communication preferences and abilities—by incorporating assistive technology, gestures, or alternative methods (communication community, n.d.). language considerations in addition to adapting therapeutic techniques, clinicians should also be intentional with their language and use terms that respect individual preferences to ensure inclusive therapy (bui et al., 2018). preferences for person-first language (pfl) and identity-first language (ifl) vary within the disability community (apa task force, 2022). person-first language (e.g., “a person with idd”) prioritizes the individual and their personhood first, framing disability as one aspect of identity rather than a defining feature. identity-first language (e.g., “an autistic person”) places disability at the forefront, recognizing it as a core and inseparable aspect of identity. many individuals with down syndrome prefer pfl, whereas many autistic individuals advocate for ifl, though preferences are personal and not universal (national down syndrome society, 2022; taboas et al., 2022). clinicians should ask clients about their language preferences to ensure that therapeutic conversations align with their sense of self. sensitivity to language use fosters stronger relationships, validates identity, and challenges stigma (bui et al., 2018). while honoring personal preferences, clinicians should also be mindful of how broader language choices can unintentionally reinforce ableist assumptions. using disability-friendly, inclusive language that is free from stereotypes and bias is necessary to promote equitable care. language plays a powerful role in shaping public attitudes toward people with disabilities. recognizing and working to counter implicit ableism is crucial to prevent harm to clients and avoid perpetuating societal stigma (friedman, 2019). terms like “heroic,” “suffering from,” understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 93 92 | columbia social work review, vol. xxiii or “wheelchair bound” reflect and reinforce limiting perceptions, while euphemisms such as “special needs” can diminish the reality of disability and contribute to discomfort and stigma (apa task force, 2022). it is imperative to focus on the whole person, and using respectful language— avoiding both overly idealized and stigmatizing terms—is an essential part of that commitment. promoting autonomy and dignity in therapeutic practice clinicians must also consider how their tone and behavior may affect a client’s therapeutic experience. one common concern in therapeutic settings is the risk of infantilizing clients with idd. infantilization occurs when adults with idd are treated and spoken to as if they are younger than their actual age, often with an unintentionally patronizing tone (robey et al., 2006). assuming individuals with idd lack agency and competency can undermine their autonomy and diminish their selfesteem (schuengel et al., 2020). such assumptions can lead to learned helplessness—where an individual feels powerless to enact change, resulting in passivity and dependence (van der molen et al., 2017). infantilization may also contribute to internalized feelings of inferiority among clients with idd (robey et al., 2006). clinicians should encourage independence, bolster selfconfidence, and treat individuals as equals to eliminate harmful power dynamics and ensure dignity in therapeutic relationships. clients have noted that the aspects of psychotherapy they most appreciate include feeling valued, validated, and treated like adults by their therapists (pert et al., 2012). feeling empowered and autonomous, along with engaging in meaningful conversations and observing changes taking place, significantly enhances their experience and outcomes (pert et al., 2012). implementing strengths-based care beyond avoiding infantilization and promoting autonomy, clinicians can support clients with idd by employing a compassionate, strengthsbased approach to therapy. interventions that center personal strengths have been shown to promote positive mental health outcomes and help individuals with idd experience a deeper sense of fulfillment and wellbeing (flückiger et al., 2023). by recognizing and emphasizing clients’ strengths, clinicians can help bring about increased empowerment, resilience, and a sense of self-worth (dunn & dougherty, 2005). this approach encourages individuals with idd to build on their existing capabilities, reinforcing their agency and capacity to navigate life’s complexities (apa task force, 2022). clinicians can strike a thoughtful balance—giving ample space to share and process difficult emotions while also highlighting clients’ inherent strengths. by remaining perceptive, offering validation, and allowing the client to guide the therapeutic process, clinicians can better attune to each person’s needs and provide life-enhancing care. centering the client while collaborating with caregivers and family effective therapy for individuals with idd begins by centering the client as the primary participant, while involving caregivers as supportive partners when appropriate. collaborating with family members and caregivers from residential or day programs can greatly enhance the therapeutic process, as their involvement helps individuals practice skills in natural, familiar settings (rogers et al., 2024). in addition to reinforcing skills, family members often play a critical role in supporting emotional regulation and facilitating effective communication outside of sessions (rogers et al., 2024). strong, trusting relationships with caregivers and support systems promote emotional well-being and foster a greater sense of safety, consistency, and belonging (hughes et al., 2023; mestre et al., 2024). while caregivers can be valuable supports, they should not become understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 95 94 | columbia social work review, vol. xxiii the primary focus of treatment. less informed clinicians may engage almost exclusively with caregivers, unintentionally excluding the client (apa task force, 2022). however, therapy sessions should not just be about the client—they must actively involve and prioritize the client in their own treatment. for all clients, including nonspeaking individuals and those who use alternative communication methods, it is crucial that therapists directly address them and engage them in the conversation. support members can assist as needed, but excluding clients from their treatment can be invalidating and disempowering (pert et al., 2012). an especially vital adaptation in therapeutic practice with individuals with idd is a deliberate shift toward actively involving them throughout the process—recognizing that they are the experts in their own experiences. collectively, these modifications help establish a therapeutic environment that honors dignity, promotes engagement, and empowers individuals with idd as active participants in their care. when thoughtfully adapted to meet individual needs, psychotherapy can be a powerful and healing process (porcelan et al., 2019). although such practices are not yet standard in many therapeutic settings, implementing them consistently can help shift the field toward more responsive and person-centered models of care. looking ahead: future considerations to address the long-standing injustices faced by the idd community, inclusion must be promoted at every level—with a strong focus on the mental health field. individuals with idd have experienced acute and enduring societal and institutional barriers that impact both access to and quality of care. substantive progress requires increased research, education, advocacy, and awareness to promote a deeper understanding of their needs. mental health professionals, social workers, and advocates must commit to ongoing learning and inclusive practices. at the heart of this work, advocacy efforts must center and elevate the voices of individuals with idd—ensuring their needs and perspectives are heard and actively shape the future of care. at the macro level, systemic change is fundamental. policy reform must directly address the pervasive inequities in mental health care for individuals with idd. this includes advocating for medicaid coverage that prioritizes inclusive mental health services and expanding funding for clinician training programs. advocacy efforts should highlight both the critical importance and the rewarding nature of idd mental health care. raising awareness of the urgent need—and the profound impact— of this work can inspire more providers to enter the field and help build a more prepared and responsive workforce. progress also requires increased investment in research to better understand the needs of individuals with idd, close gaps in care, and enhance the quality of evidence-based interventions available to this population. policies must mandate inclusive practices across healthcare settings, from ensuring equitable access to enforcing antidiscrimination standards. additionally, addressing global disparities in mental health care for individuals with idd should remain a key priority to advance equitable treatment for those who have been historically underserved. at the micro level, meaningful change begins in clinical practice. clinicians must adapt care to the individual and adopt a person-centered approach that honors agency and autonomy. therapists and social workers should cultivate therapeutic environments characterized by empathy, dignity, and mutual respect, where individuals with idd remain central to their own treatment. when professionals see and support the whole person, they contribute to better mental health outcomes and improved quality of life. these efforts help lay the groundwork for a society in which individuals with idd are truly valued, included, and equipped with the resources they need to thrive. looking ahead, the goal is for individuals with idd to be able to readily access therapy when needed and to be recognized as people with a wide breadth of life experiences—not reduced to individuals defined solely by their disabilities. achieving this vision requires moving away from understudied and underserved shayna delvecchio, lmsw columbia social work review, vol. xxiii | 97 96 | columbia social work review, vol. xxiii references american psychological association (apa) task force on guidelines for assessment and intervention with persons with disabilities. 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(2006). implicit infantilizing attitudes about disability. journal of developmental and physical disabilities, 18(4), 441–453. https://doi.org/10.1007/ s10882-006-9027-3 understudied and underserved shayna delvecchio, lmsw cswr spring 2022 columbia social work review, vol. xix | 109 transracial adoption as continued oppression: modern practice in context anisa joy leonard 110 | columbia social work review, vol. xix transracial adoption as oppression abstract transracial adoption has existed as a mode of forced displacement and oppression throughout the history of the united states. starting ^p[o�0[hsphu�jopskylu��^ov�^lyl�vujl�yhjphspalk�hz�uvu�^op[l��uvu�^op[l� children in the united states have undergone systemic oppression resulting in forced separation from their biological parents. the displaced children have typically been placed with white parents ^ov�oh]l�uv[�illu�hklx\h[ls`�wylwhylk�[v�wyv]pkl�[ol�j\s[\yhss`� competent, trauma-informed care that the children need. as a result, transracially adopted children have historically struggled to form a sense of identity and have faced a wide range of physical and mental health vulnerabilities. part i of this paper will present an overview of how transracial adoption has been implemented throughout u.s. opz[vy �̀�kpzj\zzpun�iv[o�whz[�tvklsz��z\jo�hz�[ol�6ywohu�;yhpu��huk� contemporary models (such as the foster care system, domestic private adoptions, and the global adoption industry). part ii will draw connections between past and present implementations of transracial adoption, illustrating that the phenomenon is best understood as a continuation of previous forms of oppression. part iii will propose a number of recommendations for social workers to facilitate better outcomes for transracial adoptees. columbia social work review, vol. xix | 111 anisa joy leonard i n order to understand the current landscape of transracial adoption, p[�pz�ptwvy[hu[�[v�\uklyz[huk�[ol�opz[vypjhs�jvu[l_[�vm�[ol�6ywohu� ;yhpu��^opjo�wyv]pklk�vul�vm�[ol�äyz[�l_htwslz�vm�yln\sh[lk�� systemic transracial adoption. at the beginning of the 19th century, [ol�<up[lk�:[h[lz�tv]lk�[v^hykz�puz[p[\[pvuhspapun�jopskylu�^ov�^lyl� without care (hill, 2006). children were placed into poor houses, vm[lu�zohypun�x\hy[lyz�^p[o�hk\s[�jyptpuhsz�huk�pu[lsslj[\hss`�kpzhislk� pukp]pk\hsz��0u�������[ol�5l^�@vyr�/v\zl�vm�9lm\nl�mvy�1\]lupsl� 6ɉluklyz�^hz�jylh[lk�i`�[ol�:vjpl[`�mvy�[ol�9lmvyth[pvu�vm�1\]lupsl� +lspux\lu[z��(z�[ol�äyz[�z\wly]pzlk�sp]pun�zwhjl�mvy�jopskylu�^p[ov\[� jhyl��[ol�5l^�@vyr�/v\zl�vm�9lm\nl�mvy�1\]lupsl�6ɉluklyz�zly]lk�hz� a model for other states looking to improve the wellbeing of children. 0uz[p[\[pvuz�zptpshy�[v�vywohuhnlz�^lyl�jylh[lk�zwljpäjhss`�mvy�jopskylu�� although it is worth noting that very few orphanages were created to serve black children. while black individuals south of the mason-dixon line were enslaved, free black children in the north often found care in informal kinship networks amongst other black individuals (mcgowan, 2010; woodward, 2016). as a result, black children were excluded myvt�[opz�lhys`�tv]l�[v^hykz�[ol�puz[p[\[pvuhspah[pvu�vm�jopskylu�^p[ov\[� caregivers. 0u�������*ohyslz�3vypun�)yhjl��mv\ukly�vm�[ol�5l^�@vyr�*opskylu»z�(pk� :vjpl[ �̀�z[hy[lk�^oh[�^v\sk�sh[ly�iljvtl�ruv^u�hz�[ol�6ywohu�;yhpu�� brace and his contemporaries sent impoverished white children, some of whom were orphans, to live with families primarily in the midwest �4j.v^hu���������6]ly�[ol�ul_[�zl]lu�kljhklz��k\ypun�^opjo�[ol� nation saw the civil war, reconstruction, and world war i, almost 200,000 white children journeyed from densely populated eastern cities [v�y\yhs�tpk^lz[lyu�[v^uz��)yhjl»z�lɉvy[�[v�wshjl�jopskylu�pu[v�ovtlz� was replicated in numerous cities across the u.s. part i: historic overview of transracial adoption previous models of adoption the orphan train 112 | columbia social work review, vol. xix (s[ov\no�hu�ptwyv]ltlu[�myvt�wyl]pv\z�tvklsz��[ol�6ywohu�;yhpu�pz� uv[�^p[ov\[�p[z�jyp[pjpztz��4hu`�jopskylu�^ov�qv\yul`lk�vu�[ol�6ywohu� trains were impoverished irish and italian immigrants departing from kl]lsvwpun�uvy[olhz[lyu�jp[plz��;oyv\no�[ol�6ywohu�;yhpu��jopskylu�^ov� were mostly catholic were placed into protestant homes across the midwest (mcgowan, 2010). not only were these children displaced myvt�[olpy�ovtlz�pu[v�hu�lu]pyvutlu[�^p[o�kpɉlylu[�ylspnpv\z�ilsplmz�� but many experienced socioeconomic challenges, severe abuse, and overwhelming pressures of assimilation (graham & gray, 1995). while some shared fond memories, many described intense isolation and bewilderment (graham & gray, 1995). it is also worth noting that irish huk�0[hsphu�(tlypjhuz�^lyl�yhjphspalk�hz�uvu�^op[l�\u[ps�[ol�lhys`�� ��z� (luconi, 2021). irish and italian children were forced to assimilate to unfamiliar families and culture, and experienced a power imbalance ^p[opu�[olpy�hkvw[p]l�mhtpsplz��6wwvulu[z�vm�)yhjl»z�lɉvy[z�jvu[luk� [oh[�zlukpun�jopskylu�vu�[ol�6ywohu�;yhpu�^hz�zptpshy�[v�mvyjpun�`v\[o� into indentured servitude (gray & graham, 1995). they also note that the families that received the children did not provide the means for the children to grow in their own religious faith, causing further cultural disruption (mcgowan, 2010). this criticism continues to be echoed in contemporary accounts of trauma within the private adoption industry (roberts, 2020). slavery and jim crow laws while italians and irish people were regarded as non-white in the age vm�[ol�6ywohu�;yhpu��)shjr�huk�0ukpnluv\z�jopskylu�l_wlyplujlk�l]lu� greater forms of abuse, isolation, and displacement. for black people, the history of transracial adoption can be traced to slavery. since the forced arrival of black people into this country, black children have z`z[lth[pjhss`�illu�zlwhyh[lk�myvt�[olpy�whylu[z�mvy�[ol�ilulä[�vm�^op[l� enslavers. black children living amidst the horrors of enslavement were viewed as chattel and often cared for by kinship networks rather than their biological parents (mcgowan, 2010). hundreds of thousands of black children were separated from their biological parents or orphaned by the practices of slavery. though the number of free black people in northeastern cities greatly increased in the late 1800s, black children transracial adoption as oppression columbia social work review, vol. xix | 113 ^lyl�l_js\klk�myvt�[ol�6ywohu�;yhpu��huk�]ly`�ml^�vywohuhnlz�l_pz[lk� to explicitly serve black children. black children were instead cared for informally by other members of their community. it is important to understand this historical context of forced separation as we continue to discuss transracial adoption and its impact on black people. jim crow laws and racism prevented the transracial placement of black children until the late 1960s. after the jim crow era, transracial hkvw[pvu�l_whuklk�zpnupäjhu[s �̀�^p[o�)shjr�jopskylu�thrpun�\w�h�thqvy� contingent of adoptees in the 1970s. the number of black children in white homes increased so much that in 1972, the national association of black social workers (nabsw) released a statement warning that transracial adoption would prevent black children from developing a “total sense of themselves” and “sound projection of their future” (national association of black social workers, 1972, p.1). as a result, many policies allowing transracial placement of black children were yl]lyzlk�\u[ps�� ���^olu�[ol�4\s[pl[oupj�7shjltlu[�(j[�^hz�whzzlk� (barn, 2013; quadagno, 1996). native american boarding schools and the indian adoption project indigenous persons have been victims of genocide, forced displacement, and family disruption since the creation of what is now known as the united states. however, it was not until the 1860s that [ol�)\ylh\�vm�0ukphu�(ɉhpyz�mvythss`�jylh[lk�p[z�äyz[�ylzpklu[phs�zjovvs�� indigenous children were abducted by government workers and forced to attend residential schools whose primary function was to forcibly assimilate the children through “killing the indian” (gram, 2016; bombay l[�hs���������w��������4hu`�^lyl�[hrlu�myvt�[olpy�whylu[z�huk�hkvw[lk�i`� white families, often without notifying the child’s family or tribe. these h[yvjp[plz�jh\zlk�shz[pun��zpnupäjhu[�ohyt!�ylzpklu[phs�zjovvs�h[[lukhujl� has been linked to increased substance use and mental health problems for both survivors and their descendants (kawamoto, 2001). from 1959 to 1967, the united states children’s bureau worked with the child welfare league of america to increase the number of children available to be adopted through the creation of the indian adoption anisa joy leonard 114 | columbia social work review, vol. xix project (engel, 2012). due to an increase in demand by white couples without children and decreased numbers of white infants in need of adoption, the bureau and the child welfare league worked to satisfy the needs of white couples by removing roughly 700 indigenous children from their homes and placing them into the homes of white parents ylhk`�[v�hkvw[��,unls���������;ov\no�[ol�wyvnyht�vɉjphss`�luklk� in 1967, the prevalence of placing indigenous children transracially continued for almost another decade. unfortunately, records of adoptions during this time period confound the exact number of children, so the total number of children displaced may never be known (engel, 2012). the indian adoption project aimed to facilitate transracial placements of indigenous children during a time when same-race placements were considered general practice. 6m�[ol�jhzlz�kvj\tlu[lk�pu�� ���[oyv\no�� � ��[ol�(zzvjph[pvu�vu� (tlypjhu�0ukphu�(ɉhpyz�mv\uk�[oh[�ulhys`�h�[opyk�vm�0ukpnluv\z�jopskylu� ^lyl�zlwhyh[lk�myvt�[olpy�mhtpsplz��-\y[olytvyl�� ���vm�[olzl�jopskylu� ^lyl�wshjlk�pu�^op[l�ovtlz��*yvmvv[� �/hyypz���������;olpy�äukpunz�� coupled with political action from the american indian movement, led to the 1978 passing of the indian child welfare act (barn, 2013; engel, 2012). the indian child welfare act (icwa) provided an avenue for tribes to actively engage in the cases of indigenous children to “protect the best interest and promote the stability and security of indian tribes” (indian child welfare act, 1978). this legislation ensures the livelihood of indigenous tribes and traditions by creating protections for indigenous children and legally obligating caseworkers to notify and involve the child’s parents and tribe in court proceedings. current models of adoption in some respects, the landscape of transracial adoption in 2022 has changed since the models proposed in the previous section. the 6ywohu�;yhpu��[ol�0ukphu�)vhykpun�:jovvsz��huk�[ol�0ukphu�(kvw[pvu� project have been largely replaced by the foster care system and the private adoption industry. in the 21st century, international adoptions (especially from east asia) have also become prominent (budiman & 3vwla���������/v^l]ly��[ol�v]lyhss�k`uhtpj�vm�mvyjlk�kpzwshjltlu[� transracial adoption as oppression columbia social work review, vol. xix | 115 and assimilation continues to the present day and historic cycles of harm continue to be replicated in the present. the following section will discuss contemporary forms of adoption and draw parallels between the harms committed in both current and past models. the system the child welfare system is responsible for promoting and preserving the wellbeing of children (roberts, 2020). while each state has its own w\ispj�hnlujplz��[olzl�hnlujplz�vm[lu�why[uly�^p[o�wyp]h[l�vynhupah[pvuz� to provide services to children and their families. central to the system pz�thukh[lk�ylwvy[pun��^opjo�ylx\pylz�zwljpäj�wyvmlzzpvuhsz�z\jo�hz� educators, coaches, medical professionals, and others who work with children to report to their state any suspected instances of child abuse or neglect (harris & hackett, 2008; fluke et al., 2003). reports are then investigated by social service personnel who may develop safety plans for the children. safety plans may involve minimal interventions, such as the provision of services, or potentially drastic interventions, including the removal of the child (hill, 2006). while in modern times, a stronger ltwohzpz�pz�wshjlk�\wvu�yl\upäjh[pvu��wvspjplz�sprl�[ol�(kvw[pvu�huk� :hml�-htpsplz�(j[�thrl�yl\upäjh[pvu�johsslunpun�i`�wyv]pkpun�äuhujphs� bonuses to state agencies for placing children into adoptive homes (cilia, 2021). due to its past record of separating families, the child welfare system has been referred to as the “family regulation system” by civil rights activist dorothy roberts, who advocates for the abolition of the child welfare system entirely (roberts, 2020). demographics of the foster care system 6m�[ovzl�pu�mvz[ly�jhyl��[^v�wlyjlu[�hyl�(tlypjhu�0ukphu�(shzrhu�5h[p]l�� vul�wlyjlu[�hyl�(zphu������hyl�)shjr�vy�(mypjhu�(tlypjhu��huk�����hyl� hispanic (children’s bureau, 2020). these racial ethnic groups make up �������� ���������huk�������vm�jopskylu�pu�mvz[ly�jhyl�ylzwlj[p]ls`� (united states census bureau, 2021). these proportions are similarly ylålj[lk�pu�[ol�kltvnyhwopjz�vm�jopskylu�^hp[pun�[v�il�hkvw[lk��6m� children who were adopted with public agency involvement in the ��� �äzjhs�`lhy������^lyl�uvu�^op[l��hs[ov\no�^op[l�wlvwsl�thrl�\w� v]ly�����vm�[ol�<up[lk�:[h[lz�wvw\sh[pvu��*opskylu»z�)\ylh\��������� anisa joy leonard 116 | columbia social work review, vol. xix 6m�jopskylu�hkvw[lk�myvt�mvz[ly�jhyl�shz[�`lhy������^lyl�[yhuzyhjphs� hkvw[pvuz��h�����pujylhzl�zpujl�������(zzpz[hu[�:ljyl[hy`�mvy�7shuupun� and intervention, 2020). racially skewed participation rates in the foster care system can at least partially be attributed to biased investigation into accusations of ulnslj[�huk�wo`zpjhs�hi\zl��/hyypz� �/hjrl[������"�+l[[shɉ�l[�hs���������� latinx families, and to an even greater extent black families, are more likely to be investigated than their white counterparts (hill, 2006; fluke et al., 2003). even when comparing only children who have experienced ths[ylh[tlu[��)shjr�jopskylu�hyl�z[pss�hstvz[�����tvyl�sprls`�[v�il� removed from their homes than their white counterparts (hill, 2006). harris and hacket (2008) discuss how subjectivity in the assessment of cases creates opportunities for racial bias, ultimately impacting case outcomes in nearly every interaction within the family regulation system. by the early 1990s, the number of african-american and indigenous jopskylu�pu�mvz[ly�jhyl�nylh[s`�pujylhzlk��<s[pth[ls �̀�pu�� ���k\l� to the large number of children in need of care and shifting racial ideologies, the multiethnic placement act (mepa) was passed. after much contested debate from stakeholders in all racial ethnic groups, especially the nabsw, mepa was passed to facilitate the timely placement of children removed from their homes (barn, 2013; quadagno, 1996). the act prohibits agencies from refusing placements due to the race, nationality and ethnicity of either the child or the prospective parents. impact of foster care system (u�\upu[luklk�jvuzlx\lujl�vm�4,7(»z�jvsvyispuk�z[hujl�pz�[oh[� foster care agencies are unable to assess prospective white parents’ cultural and racial responsiveness. while mepa only applies to foster care agencies, the convention of colorblind adoption spread to other institutions. private adoption agencies, social workers, and other professionals are hesitant to discuss the implications of forming mixedrace families with white prospective parents because the practice depends on the continued recruitment of prospective parents. as a result, “keeping white parents comfortable becomes a priority” (raleigh, 2018). transracial adoption as oppression columbia social work review, vol. xix | 117 9hjl�th[[lyz�huk�[ol�yhjphs�l[oupj�zvjphspah[pvu�vm�)shjr�huk�0ukpnluv\z� children of color raised by white families has and continues to be highly contested (barn, 2013; quadagno, 1996). some scholars of adoption argue that “children, whenever possible, should be placed ^p[o�whylu[z�vm�[ol�zhtl�yhjl�vy�l[oupjp[`¹��(uk\qv��� ���w�������� >olu�z\jo�wshjltlu[z�hyl�uv[�wvzzpisl��ip�j\s[\yhspzt�vɉlyz�hu� hs[lyuh[p]l�hwwyvhjo�[v�yhjphs�l[oupj�zvjphspah[pvu��)p�j\s[\yhspzt��pu� which the culture(s) of adopted children are integrated into the adoptive household, leads to the development of ecological competence both in white and non-white environments for the non-white child. similarly, deberry et al. (2003) found that transracial adoptees whose adoptive parents fostered connection to their birth culture had better psychological adjustment and positive experiences regarding the process of developing their racial and ethnic identities. though white adoptive parents have begun to shift away from ltwohzpapun�hzzptpsh[pvu�huk�jvsvyispukulzz��puz[lhk�hjruv^slknpun� the importance of racial identity formation, there is still much to be concerned about (barn, 2013; lee, 2003). adoption is a fundamentally traumatic experience. verrier (1993) stated that separation has a detrimental impact on adoptees’ relationships throughout their lives. adoptees are also four times more likely to attempt to take their life than their non-adopted counterparts (keyes et al., 2013). possible suicide risk factors impacting adoptees include mental illness, substance use, trauma experienced by biological parents, trauma experienced by the adoptee early in their life, and decreased sense of belonging (keyes et al., 2013). a decreased sense of belonging contributes to depression and increases the risk of suicide (fisher et al., 2015). adoption has a long history of shame and secrecy, and transracial adoption is the most visible form of adoption (lee, 2003). transracial adoptees face many challenges in regards to racial identity formation, huk�thu`�z[y\nnsl�[v�äuk�ilsvunpun��(uk\qv��� ���mv\uk�h�kpylj[� jvyylsh[pvu�il[^llu�[ol�hkvw[ll�z�wvzp[p]l�zluzl�vm�zlsm�huk�[ol�lɉvy[z� [olpy�hkvw[p]l�whylu[z�[vvr�[v�mhjpsp[h[l�zvjphspah[pvu�^p[o�pukp]pk\hsz� from the adoptee's own racial or ethnic group. deberry et al. (1996) found a positive correlation between connection to birth culture and anisa joy leonard 118 | columbia social work review, vol. xix psychological wellbeing when studying african-american transracial adoptees. similarly, yoon (2000) found that in korean-born adoptees, parental support of the adoptee’s racial ethnic identity development predicted more positive psychological adjustment of the adoptee. 9ljlu[�z[\kplz�]hspkh[l�[olzl�äukpunz��hz�4vu[nvtly`�huk�1vykhu� (2018) found in their systematic research synthesis. ultimately, raciall[oupj�zvjphspah[pvu�wyhj[pjlz�[oh[�jlsliyh[l�kpɉlylujlz��wylwhyl�jopskylu� to navigate racial discrimination, and encourage building relationships with one’s birth culture are linked to healthy adoptee outcomes (montgomery & jordan, 2018). it is this understanding of the nature of adoption that underscores the importance of the third mandate of mepa. ;ol�[opyk�huk�äuhs�thukh[l�vm�4,7(�ylx\pylz�hnlujplz�[v�yljy\p[�yhjphss`� kp]lyzl�wyvzwlj[p]l�whylu[z��ylålj[pun�[ol�kltvnyhwopjz�vm�jopskylu� in care (barn, 2013; quadagno, 1996). in order to become licensed care providers, prospective parents must have strong references and must meet standards regarding income, health status, and legal history (raleigh, 2018). as the nabsw pointed out several decades hnv��z`z[ltpj�yhjphs�ihyyplyz�sprl�zvjpv�ljvuvtpj�pulx\hsp[`�huk�thzz� incarceration, coupled with fears of surveillance and outright racial discrimination from agencies, continue to deter or prevent black and 0ukpnluv\z�7lyzvuz�vm�*vsvy��)076*��myvt�iljvtpun�mvyths�mvz[ly� or adoptive parents (national association of black social workers, 1972; woodward, 2016). despite this, informal kinship networks within jvtt\up[plz��hz�hu�hs[lyuh[p]l�[v�[yhuzyhjphs�hkvw[pvu��jvu[pu\l�[v�vɉly� transracially adopted children a means to mature and be cared for within their own cultural contexts (mcgowen, 2010). pt ii: parallels between past and present models despite changes to the way transracial adoption is implemented, the historic harms of the adoption process continue to be perpetuated. transracial adoption today serves as an institution that continues the mvyjlk�hzzptpsh[pvu�huk�j\s[\yhs�nluvjpkl�vm�thynpuhspalk�nyv\wz��hz�p[� severs all legal and cultural ties children may have to their birth families and culture. the following section will draw connections between the [yh\thz�puåpj[lk�pu�opz[vypj�huk�j\yylu[�tvklz�vm�hkvw[pvu� transracial adoption as oppression columbia social work review, vol. xix | 119 meeting parents’ interests the core purpose of adoption should be to provide displaced children with safe and loving homes. yet, adoption historically and currently has illu�w\ispjpalk�hz�h�^h`�mvy�wv[lu[phs�whylu[z�[v�ilulä[��-vy�l_htwsl�� during midwest labor shortages in the 1860s, adoption was advertised hz�h�^h`�mvy�mhtpsplz�[v�hjx\pyl�hkkp[pvuhs�hzzpz[hujl�vu�[olpy�mhytz� (graham & gray, 1995). adoption has always been advertised as a way for parents to have children, without always encouraging understanding of the traumatic circumstances that led to children experiencing separation from their birth families. 6ul�tvklyu�kl]lsvwtlu[�pu�[opz�ylnhyk�pz�[ol�,]hunlspjhs�6ywohu� care movement, which started in 2000. this movement is rooted in the new testament passage james 1:7, which advocates for adoption hz�[ol�kp]puls`�thukh[lk�zvs\[pvu�[v�[ol�nsvihs� 6ywohu�*ypzpz� �@l[� ironically, out of the eight million children currently living in orphanages, p[�pz�lz[pth[lk�[oh[� ���oh]l�h[�slhz[�vul�sp]pun�whylu[��=hu�+vvyl�� �������;olyl�hyl�jvuzpklyhisl�[olvsvnpjhs�jyp[px\lz�vm�[opz�]pl �̂�wlyohwz� tvz[�zpnupäjhu[s`�[oh[�pu�jvu[yhz[�[v�[ol�slnhs�hkvw[pvu�z`z[lt�pu� the united states, in biblical narratives of adoption, the adoptee's biological connection to their lineage is maintained (smolin, 2012). regardless, the evangelical movement’s impact has been undeniable huk�[ol�*oypz[phu�(ssphujl�mvy�6ywohuz��^opjo�why[ulyz�^p[o�v]ly� [^v�o\ukylk�vynhupah[pvuz��ylwvy[lk�mhjpsp[h[pun�huk�ptwhj[pun�[ol� formation of “foster, adoption and orphan care ministries” at over 800 jo\yjolz�pu�������*oypz[phu�(ssphujl�mvy�6ywohuz���������<umvy[\uh[ls �̀� [ol�tv]ltlu[�hz�h�^ovsl�ohz�mhpslk�[v�jyp[px\l�[ol�jvlyjpvu�huk� jvttvkpäjh[pvu�wylzlu[�^p[opu�[ol�mvz[ly�huk�hkvw[pvu�puk\z[y �̀� instead clinging to a narrative that purports the legal and cultural cultural separation of children from their biological families to be “god’s plan” for the creation of their own families (smolin, 2012). this mindset betrays the fundamental purpose of adoption: to provide displaced children with safe, permanent homes. coercion +\ypun�[ol�6ywohu�;yhpu�lyh��ipvsvnpjhs�tv[olyz�^lyl�wylzz\ylk�vy� anisa joy leonard 120 | columbia social work review, vol. xix forced into giving up their children (mcgowan, 2010). today, similar experiences of coercion can be found in the stories of birth mothers considering the private adoption industry. coercion can take the form of withholding information or resources, as well as subtle or explicit pressure to make a certain choice. this coercion can come from individuals within the pregnant person's personal life, or from service wyv]pklyz�z\jo�hz�zvjphs�^vyrlyz��*hz[sl���������0u�yljlu[�`lhyz��[olyl� has been a growing number of claims and sensational headlines hzzly[pun�[oh[�ipy[o�tv[olyz�pu�[ol�<up[lk�:[h[lz�^ov�yljlp]lk�äuhujphs� support during their pregnancies from prospective adoptive parents felt [ol`�ohk�[v�nv�[oyv\no�^p[o�ylspux\pzotlu[�hnhpuz[�[olpy�^pzolz��9vv[�� 2021). some mothers in closed adoptions also express regret that [ol`�vus`�slhyulk�[ol�m\ss�slnhs�yhtpäjh[pvuz�vm�ylspux\pzotlu[�hm[ly�[ol� wyvjlk\yl�ohk�illu�äuhspalk��>lssly� �/vzlr���������:ptpshy�z[vyplz�jhu� be found around the globe, where medical bills or fraud may be used to jvlyjl�tv[olyz�pu[v�np]pun�\w�[olpy�jopskylu��.yhɉ���������;opz�jvlyjpvu�� similar to that experienced by impoverished parents whose children ^lyl�zlu[�vu�6ywohu�;yhpuz��pz�hss�[vv�jvttvu� commodification to this day, black children remain the cheapest children to adopt, as ^lss�hz�[ol�tvz[�hi\ukhu[�pu�[ol�mvz[ly�jhyl�z`z[lt��8\pyva������"� woodward, 2016). surveys of white parents indicate hesitation to adopt black children, as some view the divide between black and white too vast. in response, white parents have opted to domestically adopt “multicultural” children or to adopt non-white children from asia or south and central america (sweeney, 2013; woodward, 2016). kubo (2010) suggested that adoptive parents may view adoption of foreign children as “baggage free,” and that their foreignness allows adoptive parents to incorrectly perceive them as raceless and thus closer to whiteness (p. 269). white adoptive parents desiring children who are wyv_pths�[v�^op[lulzz�pz�iv[o�h�wlywl[\h[pvu�huk�h�jvuzlx\lujl�vm�h� racial hierarchy that posits blackness at the bottom (sweeney, 2013). numerous adoption agencies even list percentages of the child’s racial and ethnic makeup to pander to a growing preference for multiracial children, in the process clearly distinguishing multiracial from black �:^llul �̀�����"�>vvk^hyk���������:\jo�spz[punz�huk�äuhujphs�pujlu[p]lz� transracial adoption as oppression columbia social work review, vol. xix | 121 not only commodify children in a manner eerily similar to the auction isvjr��i\[�[ol`�hszv�wyv]pkl�h�jvujyl[l�]pz\hspah[pvu�vm�jvu[pu\lk�yhjphs� kpzwhyp[plz�kpzylnhykpun�[oh[�hss�tlu�hyl�jylh[lk�lx\hs��huk�pss\z[yh[l�ov^� the domestic and international adoption system caters to white interests (raleigh, 2012). international transracial adoptive placements grew in popularity after the vietnam war, during which u.s imperialism led not only to ^pklzwylhk�klz[hipspah[pvu�i\[�hszv�[ol�vywohupun�vm�u\tlyv\z�jopskylu� who were to eventually become international transracial adoptees (barn, 2013). widespread adoption of asian-born children, alongside the civil rights movement, shifted societal views of what families could look like. concurrently, domestic adoptions involving indigenous and african-american black children began to become more commonplace (lee, 2003). despite mixed-race families becoming more common, there remains a strong demand among prospective adoptive parents for white infants (woodward, 2016). since unmarried motherhood has become more socially acceptable in the united states, the amount of adoptable white babies has dramatically decreased and prospective parents seeking infants continue to turn abroad to adopt (international adoption rate in u.s. doubled in the 1990s, 2003). however, international adoptions have been declining in the last ten years, due in part to concerns about the ethics of the practice, including the creation of “paper orphans,” children forcibly taken and sold to orphanages in order to satisfy demand for babies (van doore, 2016). pt. iii recommendations for social work practice as families are formed and are constantly changing, so too must our rhetoric and practices regarding transracial adoption change. to start, within social work education there must be explicit recognition vm�[ol�älsk�z�opz[vypj�huk�jvu[pu\lk�jvtwspjp[`�pu�huk�wlywl[\h[pvu�vm� the oppression of children and families of color through surveillance, jvttvkpäjh[pvu��mvyjlk�kpzwshjltlu[�huk�yltv]hs��huk�mhps\yl�[v� jvuzpkly�[ol�zvjpv�ltv[pvuhs�yhtpäjh[pvuz�vm�[yhuzyhjphs�wshjltlu[� �+l[[shɉ�l[�hs����������-vy�mhy�[vv�svun��[ol�z\iqlj[p]l�iphzlz�vm� service providers have impacted the experiences of families of color coming into contact with the family regulation system, leading to anisa joy leonard 122 | columbia social work review, vol. xix disproportionate removals and devaluing the importance of biological human relationships, thus disregarding social work core values (harris & hackett, 2008). social workers must work to unlearn and unpack their biases as well as to critically interrogate their role in the adoption process, from the removal of children to placement. much has been written about the lack of culturally competent services available to parents of color struggling with substance use or mental health problems. many scholars have touted family preservation services as a means to decrease the amount of children in need of out of home care (harris & hackett, 2008). unfortunately, service providers oh]l�mhpslk�[v�ltwv^ly�huk�lx\pw�)076*�mvsrz�[v�jhyl�mvy�tltilyz�vm� their own communities in need. in fact, many have done the opposite, jh\zpun�ohyt�huk�hk]lyzl�lɉlj[z�[v�[olzl�jvtt\up[plz��9vily[z�� �������6ul�t\z[�il�jvnupahu[�vm�[ol�mhj[�[oh[�[ol�jhyjlyhs�z\y]lpsshu[� nature of the family regulation system poses a real threat to the safety vm�hss�)076*�mvsrz�^ov�jvtl�pu�jvu[hj[�^p[o�p[��l]lu�wyvzwlj[p]l�mvz[ly� or adoptive parents. the fact of the matter is that there remains a zpnupäjhu[�u\tily�vm�)076*�jopskylu�pu�ullk�vm�jhyl��+l[[shɉ�l[�hs��� 2020). social workers and other service providers should then work not vus`�[v�m\säss�[ol�[opyk�thukh[l�vm�4,7(��i\[�hszv�[v�^vyr�[v�lsptpuh[l� the previously named racial barriers through abolition of the prison industrial system and major economic overhaul through the expansion vm�zhml[`�ul[z��+l[[shɉ�l[�hs���������� in regards to placement, social workers must reject colorblindness and attitudes of racial ambivalence which act as a form of violent erasure (american psychological association, 2017). instead, social workers zov\sk�hjruv^slknl�[ol�hk]lyzl�lɉlj[z�vm�[yhuzyhjphs�wshjltlu[�vu� racial ethnic identity formation. when transracial placements do occur, zvjphs�^vyrlyz�oh]l�h�k\[`�[v�lx\pw�^op[l�whylu[z�[v�tvyl�lɉlj[p]ls`� adopt attitudes of biculturalism and underscore the importance of active anti-racist and trauma-informed parenting. social workers, as current iyvrlyz�vm�wshjltlu[z�huk�hkvw[pvuz��hyl�\upx\ls`�wvzp[pvulk�[v�olsw� white parents deconstruct attitudes of white saviorism and unlearn racist behaviors (raleigh, 2018). transracially placed and adopted children are not responsible for their white parents’ education. transracially placed adopted children, like all children, are deserving of safety and security. transracial adoption as oppression columbia social work review, vol. xix | 123 social workers are often held as “experts'' in the child welfare and hkvw[pvu�älsk�i`�[ol�nlulyhs�w\ispj��/v^l]ly��[ol�wyvmlzzpvu�z�ylsphujl� on academia can lead to discounting the true experts of adoption: adoptees. this is not to ignore the vital impact of abolitionist scholars such as roberts in the discourse regarding child-welfare and transracial wshjltlu[z��uvy�[v�pnuvyl�[ol�v\[jvtlz�vm�hk]vjhj`�myvt�vynhupah[pvuz� like the upend movement that seek to abolish the family regulation system, but rather to say that the common narrative around transracial hkvw[pvu�t\z[�il�zohwlk�äyz[�huk�mvyltvz[�i`�[ovzl�^ov�oh]l� l_wlyplujlk�[yhuzyhjphs�hkvw[pvu��+l[[shɉ�l[�hs�������"�9vily[z��������� social workers must actively look outside the ivory tower, and elevate the voices and wisdom of transracial adoptees themselves. the lived experiences of adoptees have long served as sources of entertainment; however these popular narratives tend to focus on the nvvk�mllspun�why[z�vm�hkvw[pvu�huk�zlskvt�pz�jyp[px\l�np]lu�[v�[ol� circumstances leading to initial separations (mckee, 2019). similarly, adoptees themselves must constantly mitigate and negotiate their own understanding of their lived experiences and origins, due to a lack of information regarding their own histories (mckee, 2019; wills, 2015). however, through the creation of self0narratives, such as life-writings— that is, the recordings of memories and experiences—adoptees can ¸kl�lzzlu[phspal�[y\[o�jshptz�¹�^opjo�pz�uljlzzhy`�mvy�ulnv[ph[pun�[olpy� understanding of self in the absence of factual knowledge of their origins (wills, 2015). the creation of zines, a form of participatory media, can also facilitate development of personal and collective agency and deepen identity formation. a recent example is you are holding this, an ¸hivsp[pvupz[�apul�mvy�huk�i`�hkvw[lk�huk�mvz[lylk�wlvwsl¹��4hy[pu������"� artes et al., 2021). in addition to reclaiming narratives for themselves through the written word and artistic expression, adoptees also have taken to social media platforms to express their feelings and seek belonging and community. adoptees can be found speaking out under hashtags such as #adopteevoices and #adopteevisibility. suh (2021) found korean adoptees used instagram to refocus adoption narratives on their own agency, as well as to reclaim that agency for themselves. the same can anisa joy leonard 124 | columbia social work review, vol. xix be said for transracial adoptees of other races, especially after years of intense racial justice movements in response to anti-black police violence and anti-immigrant rhetoric, as evidenced in viral articles in slhkpun�<�:��ul^zwhwlyz��/h[apwhuhnvz�������� conclusion children of color end up in white families in numerous ways: placement through a private domestic adoption agency, adoption out of foster care, or adoption internationally. in each case, adoption is trauma (verrier, 1993). understanding the impact of adoption trauma and focusing on the survivors of this trauma–-adoptees—is crucial to reshaping and kljvsvupapun�[ol�uhyyh[p]lz�vm�[yhuzyhjphs�hkvw[pvu��(z�svun�hz�hkvw[pvu� remains a multimillion dollar industry driven by predominantly white couples of higher socioeconomic status and impacted by foreign and domestic policies, the practice of transracial adoption is impossible to separate from cultural genocide, forced assimilation, and imperialism (raleigh, 2018; lee, 2003). transracial adoption must be understood as a continuation of historical modes of oppression. references american psychological association. 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(2013). ‘doing the right thing’: transracial adoption in the usa. ethnic and racial studies�������������¶�� ���o[[wz!��kvp�vyn������������� ��������������� transracial adoption as oppression columbia social work review, vol. xix | 125 )vtih �̀�(���4h[olzvu��2��� �(upzthu��/����������;ol�pu[lynlulyh[pvuhs�lɉlj[z�vm�0ukphu� residential schools: implications for the concept of historical trauma. transcultural psychiatry������������¶�����o[[wz!��kvp�vyn������������������������� )\kpthu��(��� �3vwla��4��/���������6j[vily������international adoptions to u.s. declined in 2016. pew research center. https://www.pewresearch.org/fact-tank/2017/10/17/ htpk�kljspul�pu�pu[lyuh[pvuhs�hkvw[pvuz�[v�\�z�iv`z�v\[u\tily�npysz�mvy�[ol�äyz[�[ptl� *hz[sl��7����������;ol�l_wlyplujl�vm�jovpjl�pu�]vs\u[hy`�ylspux\pzotlu[�� family matters��� ��������o[[wz!��spur�nhsl�jvt�hwwz�kvj�(��� ��� � (65,&\$jvs\tiph\ zpk$z\ttvu _pk$ �k����� children’s bureau. 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(2003). disproportionate representation of race and ethnicity in child maltreatment: investigation and ]pj[ptpah[pvu��children and youth services review, 25, 359–373. https://doi.org/10.1016/ :�� ����� ����������� .yhɉ��,��1���������5v]���the lie we love. foreign policy, 169, 59-66. https://www. wyvx\lz[�jvt�thnhapulz�spl�^l�sv]l�kvj]pl^�����������zl��&hjjv\u[pk$����� .yhoht��1�� �.yh �̀�,���� ���5v]ltily������(tlypjhu�,_wlyplujl!�;ol�6ywohu�;yhpuz��:�� ,����in the american experience. wgbh. gram, j.r. (2016). acting out assimilation: playing indian and becoming american in the federal indian boarding schools. american indian quarterly������������¶�����o[[wz!��kvp� vyn���������htlypukpx\hy���������� harris, m.s. & hackett, w. (2008). decision points in child welfare: an action research model to address disproportionality. children and youth services review, 30(2), 199215. /h[apwhuhnvz��9���������+ljltily������i know my parents love me but they don’t love my people. washington post. https://www.washingtonpost.com/nation/interactive/2021/ transracial-adoption-racial-reckoning/ hill, r.b. (2006). synthesis of research on disproportionality in child welfare: an update. 7hwly�wylwhylk�mvy�*hzl`�*::7�(ssphujl�mvy�9hjphs�,x\p[ �̀�>hzopun[vu��+�*��o[[w!�� ^^ �̂yhjlth[[lyzjvuzvy[p\t�vyn�kvjz�)vi/pss7hwlyf-05(3�wkm� international adoption rate in u.s. doubled in the 1990s. (2003, january 13). popular reference bureau. https://www.prb.org/resources/international-adoption-rate-in-u-sdoubled-in-the-1990s/ kawamoto, w. t. (2001). community mental health and family issues in sociohistorical jvu[l_[!�;ol�jvumlklyh[lk�[ypilz�vm�jvvz��sv^ly�\twx\h��zp\zsh^�pukphuz!� 796+��the american behavioral scientist����� ���������� ���o[[w!��kvp� vyn�������������������� �� �� keyes, m. a., malone, s. m., sharma, a., iacono, w. g., & mcgue, m. (2013). risk of z\pjpkl�h[[ltw[�pu�hkvw[lk�huk�uvuhkvw[lk�vɉzwypun��pediatrics������������ ¶����� o[[wz!��kvp�vyn���������wlkz���������� 2\iv��2����������+lzpyhisl�kpɉlylujl!�;ol�zohkv^�vm�yhjphs�z[lylv[`wlz�pu�jylh[pun� transracial families through transnational adoption. sociology compass����������������� o[[wz!��kvp�vyn���������q������ ���������������_� lee, r. m. (2003). the transracial adoption paradox: history, research, and counseling ptwspjh[pvuz�vm�j\s[\yhs�zvjphspah[pvu��the counseling psychologist������������¶����� https://doi.org/10.1177/0011000003258087 transracial adoption as oppression columbia social work review, vol. xix | 127 luconi, s. (2021). italian immigrants, whiteness and race: a regional perspective. italian american review���������������o[[wz!��kvp�vyn���������p[hshtlyyl]p���������� martin, b. (2020). promoting student agency in the middle school classroom through apulz��literacy learning: the middle years, 28(2), 23-28. https://search.informit.org/doi/ hiz���������pumvytp[����������������� mcgowan, b.g. (2010). an historical perspective on child welfare. adapted from: historical evolution of child welfare services. in g.p. mallon & p. m. hess (eds.), child welfare for [ol�[^lu[`�äyz[�jlu[\y`!�(�ohukivvr�vm�wyhj[pjlz��wvspjplz��huk�wyvnyhtz��ww���������� columbia university press. mckee, k. (2019). the consumption of adoption and adoptees in american middlebrow culture. biography����������� �� ���o[[wz!��kvp�vyn����������ipv���� ������ 4vu[nvtly �̀�1�,��� �1vykhu��5�(����������9hjphs¶l[oupj�zvjphspah[pvu�huk�[yhuzyhjphs� adoptee outcomes: a systematic research synthesis. child adolescent social work journal����������� ¶�����o[[wz!��kvp�vyn���������z��������������� � national association of black social workers (1972). national association of black social workers position statement on trans-racial adoptions. https://www.nabsw.org/page/ positionstatements quadagno, j. (1996). the color of welfare: how racism undermined the war on poverty. 6_mvyk�<up]lyzp[`�7ylzz�� 8\pyva��7��(����������-yvt�yhjl�th[jopun�[v�[yhuzyhjphs�hkvw[pvu!�9hjl�huk�[ol�johunpun� discourse of us adoption. critical discourse studies,��������� ������o[[w!��kvp� vyn�������������� ������������ raleigh, e. (2018). transracial adoption as a market calculation. in selling transracial adoption: families, markets, and the color line��ww�� �¶������;ltwsl�<up]lyzp[`�7ylzz�� o[[wz!��kvp�vyn���������q�j[[�����_���� roberts, d. e. (2008). the racial geography of child welfare: toward a new research paradigm. child welfare������������¶�����o[[wz!��^^ �̂qz[vy�vyn�z[hisl��������� roberts, d. (2020, june 16). abolishing policing also means abolishing family regulation. the imprint. https://imprintnews.org/child-welfare-2/abolishing-policing-also-meanshivspzopun�mhtps`�yln\sh[pvu������ root, t. (2021, june 3). inside america’s murky private-adoption industry.�;ptl�4hnhapul� https://time.com/6051811/private-adoption-america/ :tvspu��+��4����������6m�vywohuz�huk�hkvw[pvu��whylu[z�huk�[ol�wvvy��l_wsvp[h[pvu�huk� ylzj\l!�(�zjypw[\yhs�huk�[olvsvnpjhs�jyp[px\l�vm�[ol�,]hunlspjhs�*oypz[phu�hkvw[pvu�huk� orphan care movement. regent journal of international law�����������������o[[wz!�� anisa joy leonard 128 | columbia social work review, vol. xix olpuvuspul�vyn�/63�7&o$olpu�qv\yuhsz�ylnqps� p$��� suh, e. (2021). adoptees speak: a multimodal critical discourse analysis of korean adopted person’s adoption narratives on instagram. critical inquiry on language studies����������������o[[wz!��kvp�vyn������������������������� ���� sweeney, k. a. (2013). race-conscious adoption choices, multiraciality, and color-blind racial ideology. family relations�����������¶����o[[w!��^^ �̂qz[vy�vyn�z[hisl��������� united states census bureau (2021, august 12). racial and ethnic diversity in the united states: 2010 census and 2020 census [infographic]. https://www.census.gov/library/ ]pz\hspah[pvuz�pu[lyhj[p]l�yhjphs�huk�l[oupj�kp]lyzp[`�pu�[ol�\up[lk�z[h[lz������huk� 2020-census.html =hu�+vvyl��2��,����������7hwly�vywohuz!�,_wsvypun�jopsk�[yhɉjrpun�mvy�[ol�w\ywvzl�vm� orphanages. international journal of children’s rights������������¶�����o[[wz!��kvp�vyn� lawyv_ �̀j\s�jvs\tiph�lk\�������������������������� verrier, n. n. (1993). the primal wound: understanding the adopted child. gateway press. weller, m. r. & hosek, a. m. (2020). birth mothers’ experiences of privacy turbulence in relation to closed adoption information. journal of family communication, 20(3), 250�����o[[w!��kvp�vyn������������������������������� wills, j. h. (2015). fictional and fragmented truths in korean adoptee life writing. asian american literature: discourses & pedagogies������������ ��o[[wz!��zjovshy^vyrz�zqz\� edu/aaldp/vol6/iss1/7 woodward, k. (2016). marketing black babies versus recruiting black families: ;ol�yhjphspalk�z[yh[lnplz�wyp]h[l�hkvw[pvu�hnlujplz�\zl�[v�äuk�ovtlz�mvy� black babies. sociology of race and ethnicity�����������¶� ���o[[wz!��kvp� vyn��������������� ��������� yoon, d.p. (2000). causal modeling predicting psychological adjustment of korean-born adolescent adoptees. journal of human behavior in the social environment������������� ����o[[wz!��kvp�vyn���������1���]��u��f�� transracial adoption as oppression columbia social work review, vol. xix | 129 anisa joy leonard cswr spring 2022 columbia social work review, vol. xix | 87 a tri-country analysis of the effects of white supremacy in mental health practice and proposed policy alternatives kristen m. folkerts isra merchant chenxi yang 88 | columbia social work review, vol. xix white supremacy in mental health practice abstract the goal of this paper is to take a closer look at mental health care policies in nigeria, china, and the united states. these nations were selected for their demographic diversity as well as for the shared puå\lujl�[oh[�,\yvwlhu�jvsvupah[pvu��ptwlyphspzt��huk�^op[l�z\wylthj`� j\s[\yl�oh]l�ohk�vu�[olpy�lx\hss`�kp]lyzl�tlu[hs�olhs[o�wvspjplz�huk� wyhj[pjlz��/v^�kv�opz[vypjhs�huk�j\s[\yhs�wlyzwlj[p]lz�hɉlj[�kpɉlylu[� nations’ mental health policies and approaches (via a multi-nation jvtwhypzvu�&�;opz�huhs`zpz�hptz�[v�[hjrsl�[opz�x\lz[pvu��kpzj\zzpun� how cultural humility both currently and historically informs mental health treatment for non-white populations within the united state. in addition it examines imperialist and colonial mental health treatment of local populations in china and nigeria. finally, a global policy strategy is presented to promote the practice of cultural humility on a multinational scale. keywords: cultural humility, decolonization, white supremacy, global policy, global mental health columbia social work review, vol. xix | 89 kristen m. folkerts, isra merchant, chenxi yang w estern-oriented psychotherapy1 and mental health treatment have long held a dominant global position, while practices rooted in non-white cultures have been diminished or erased. as such, modern psychotherapy, kpj[h[lk�wypthyps`�i`�(unsv�(tlypjhuz�huk�,\yvwlhuz��pz�puhklx\h[l� to meet the needs of a diverse clientele in many countries and creates a gap between the intent of mental health policies—to provide mental olhs[o�zly]pjlz�[oh[�tll[�[ol�\upx\l�ullkz�vm�hss�wlvwsl·huk�[olpy� practice (koç & kafa., 2019). with a culturally humble clinical approach, ^l�jhu�yljvnupal�[ol�ptwvzzpipsp[`�vm�m\ss`�jvtwylolukpun�hss�j\s[\yhs� nuances and traditions and respect therapeutic alliances between clinicians and culturally diverse clientele. we use this frame to discuss [ol�ulnh[p]l�ptwhj[z�vm�>lz[lyupalk�tlu[hs�olhs[o�wvspjplz�huk� approaches in nigeria, china, and the united states (u.s.), and provide suggestions to address these issues. this paper posits that the current mental health policies and practices of nigeria, china, and the u.s. do not fully support the mental wellbeing of [olpy�jp[paluz��;ol�jvsvuphs�huk�ptwlyphspz[�opz[vyplz�vm�5pnlyph�huk�*opuh�� respectively, have fostered perspectives built upon white supremacist pklhz�^opjo�oh]l�ohk�shz[pun�lɉlj[z��5pnlyph»z�shjr�vm�\wkh[lk�tlu[hs� health legislation and funding for state-operated western psychiatric hospitals leave a backlog of patients with a limited number of providers to help (abdulmalik et al., 2016). china’s underfunding of traditional mental health practice and dearth of eligible providers in rural locations slh]l�jp[paluz�pu�[ovzl�hylhz�^p[ov\[�hjjlzzpisl�tlu[hs�olhs[o�jhyl�� these phenomena are the result of increased hospital-based care following the introduction of western-style psychiatric hospitals by 1898 and the gradual diminishing of community mental health programs ��¸>lz[lyu�wz`jov[olyhw`¹�pz�h�[lyt�\zlk�[v�ylmly�[v�[ol�puå\lujl�[oh[�>lz[lyu�j\s[\ylz�� zwljpäjhss`�[ol�<�:���oh]l�ohk�vu�wz`jov[olyhw`�wyhj[pjl��;opz�wyhj[pjl�pz�puå\lujlk�i`� such historical and cultural values as individuality, reductionism, measurement, materihspzt��huk�viqlj[p]p[ �̀�0[�hszv�opz[vypjhss`�ltwohzpalz�h�mvj\z�vu�wz`jovwh[ovsvn`�huk� reliance on a medical model of alleviating symptoms (koç & kafa, 2019). 90 | columbia social work review, vol. xix during the 1966-76 cultural revolution (liu et al., 2011).2 the united states struggles with a lack of culturally conscious providers for those who are non-white, due to the high number of white providers pu�[ol�älsk�hz�^lss�hz�lk\jh[pvu�puå\lujlk�i`�^op[l�z\wylthj �̀� many non-white researchers and practitioners are actively working to incorporate culturally humble practices, but still the majority of mental health practices in the three focal countries undermine alternatives �l�n���uvu�>lz[lyupalk�wyhj[pjlz�huk�j\s[\yhss`�[yhkp[pvuhs�wyhj[pjlz"� gopalkrishnan, 2018). cultural humility is a critical consideration, both currently and historically, for mental health treatment for non-white populations within the united states, as well as for those living in nations with imperialist and colonist roots, such as china and nigeria. current practice in lhjo�vm�[olzl�jv\u[yplz�wypvyp[palz�^op[l�jlu[ypj�tlu[hs�olhs[o�]hs\lz�� jvuzlx\lu[s`�klslnp[ptpapun�[yhkp[pvuhs�tlu[hs�olhs[o�wyhj[pjlz��;opz� whwly�yl]pl^z�wvspjplz�w\[�pu�wshjl�i`�t\s[puh[pvuhs�vynhupah[pvuz�� huhs`apun�[olpy�ptwhj[�vu�kpylj[�wyhj[pjl�pu�[ol�<up[lk�:[h[lz��*opuh��huk� nigeria, as well as the extent of such policy implementation within these countries. the term “traditional” will be used to encompass any mental olhs[o�wyhj[pjl�[oh[�pz�uv[�¸>lz[lyupalk¹�vy�wyhj[pjlk�i`�jvsvupalyz�huk� that does not center white supremacist values. the term “western” will be used to describe any practice that is eurocentric in nature and centers/is the result of white supremacist values.3 background nigeria /pz[vypjhss �̀�wz`joph[y`�wyhj[pjlk�pu�jvsvupalk�jv\u[yplz��vy�jvsvuphs� wz`joph[y �̀��ylwylzlu[lk�[ol�äyz[�h[[ltw[�[v�z`z[ltpjhss`�pu[lywyl[� 2 mental health system in china: history, recent service reform and future challenges is a source used for historical information and context. this source is not used for statistical data or present-day information. 3 “eurocentric” refers to the tendency to interpret the world from the perspective of eurowlhu�vy�(unsv�(tlypjhu�]hs\lz�huk�l_wlyplujlz��4lyypht�>liz[ly���(z�hu�l_htwsl�� ��� of the mental health research published in the top six american psychological association journals have focused on either americans or europeans (koç & kafa, 2019). white supremacy in mental health practice columbia social work review, vol. xix | 91 psychiatric symptoms through the lens of white supremacy in cultures that were traditionally non-western in nature (studer, 2015). colonial wz`joph[y`�zly]lk�hz�vul�vm�[ol�äyz[�puz[hujlz�vm�wvsp[pjhs�jvu[yvs��hz� the british used reports from nigerian psychiatric hospitals to maintain dominance over the colonies (buoli, 2021). the introduction of western culture and medicine produced an ideological culture clash and z\izlx\lu[�\ulx\hs�wv^ly�k`uhtpjz�il[^llu�>lz[lyu�huk�pukpnluv\z� 5pnlyphu�tlkpjpul��:lhypno[���������0ukp]pk\hsz�^p[o�tlu[hs�olhs[o� challenges often sought care from traditional healers known for treating clients holistically and reconnecting people with social and emotional resources rooted in community rules and relationships (searight, �������/v^l]ly��tlu[hs�olhs[o�johsslunlz�^lyl�mylx\lu[s`�h[[ypi\[lk�[v� supernatural or religious causes—causes colonial powers perceived as \uzjplu[päj��6klip`p��� �����6]ly�[ptl��>lz[lyu�tl[ovkz�kvtpuh[lk� )lnpuupun�^p[o�)yp[pzo�jvsvupah[pvu�pu�5pnlyph��wlvwsl�^p[o�tlu[hs� olhs[o�pssulzz�^lyl��thkl�pu]pzpipspal�huk�^lyl�ylz[yhpulk�vy�kl[hpulk� �6u`ltls\r^l���������(z`s\tz5 were introduced in 1906, aimed to house the growing number of houseless so-called “lunatics”6 in urban centers (faleye, 2017, p. 137). today, the nigerian government is unable [v�jvttp[�[v�[ol�\[pspah[pvu�vm�[yhkp[pvuhs�tl[ovkz��;ov\no�5pnlyph� hjopl]lk�puklwluklujl�myvt�.ylh[�)yp[hpu�pu�� ����jvsvupz[�puå\lujl� wlyzpz[z��:lhypno[���������;ol�nv]lyutlu[�ohz�thkl�nylh[�lɉvy[z�[v� train health personnel and provide modern health facilities, largely disregarding their country’s traditional healers (gureje et al., 2015). >lz[lyupalk�wz`joph[ypj�mhjpsp[plz�^p[o�jspupjphuz�[yhpulk�pu�tl[ovkvsvnplz� yvv[lk�pu�^op[l�z\wylthjpz[�pklhz�hyl�puhklx\h[l�[v�tll[�[ol�ullkz�vm� hss�5pnlyphuz��;olzl�puhklx\hjplz�pujs\kl�h�shjr�vm�yljvnup[pvu�vm�[ol� ^h`�ylspnpvu�huk�zwpyp[\hsp[`�puå\lujl�[ol�wz`jovzvth[pj�l_wlyplujlz� vm�thu`�wlvwsl��9lzlhyjo�ohz�mv\uk�[oh[�jp[paluz�l_wlyplujl�mllspunz� of alienation and dissatisfaction toward government policies, including ��appraisal of the mental health care policy in nigeria is a source used for its historical information and context. this source is not used for statistical data or present-day information. 5 centers for those with mental health challenges were historically referred to as asylums, which is now acknowledged to be a derogatory term. ��(�klyvnh[vy`�[lyt�\zlk�[v�kläul�[ovzl�^p[o�tlu[hs�olhs[o�johsslunlz� kristen m. folkerts, isra merchant, chenxi yang 92 | columbia social work review, vol. xix healthcare policy, a result of decades of economic exploitation during )yp[pzo�jvsvupah[pvu��6klip`p��� ���w������;opz�j\s[\yhs�kpzylnhyk� discourages nigerians from seeking mainstream therapeutic facilities �6klip`p��� ���� though mental healthcare-promoting bills have been proposed, such as the mental health and substance abuse bill in 2020, there have ultimately been few positive legal developments (ugochukwu et al., �������(������>vysk�/lhs[o�6ynhupah[pvu��>/6��ylwvy[�zov^lk�[oh[� hiv\[�zl]lu�tpsspvu�wlvwsl�pu�5pnlyph�hyl�z\ɉlypun�myvt�klwylzzp]l� kpzvyklyz��huk�����tpsspvu�wlvwsl�hyl�z\ɉlypun�myvt�hu_pl[`�kpzvyklyz� (depression and other common mental disorders: global health estimates���������-\y[oly�äukpunz�oh]l�zov^u�[oh[�ml^ly�[ohu���� percent of those with mental health challenges have access to healthcare due largely to the country’s outdated laws and poor budgetary allocation that can be tied back to the economic exploitation and management of the colonial era (soroye et al., 2021). china traditional chinese medicine encourages individuals to keep a dynamic balance of yin and yang to achieve a psychological and physiological state of stability (zhang & chi, 2013). many traditional methods were developed to maintain this balance, such as massage, acupuncture, and physical and breathing exercises (zhang & chi, 2013). in the 19th century, traditional methods diminished from mainstream practice in *opuh��(m[ly�svzpun�[ol�:ljvuk�6wp\t�>hy��*opuh�^hz�\uhisl�[v�ylzpz[� [ol�ljvuvtpj��wvsp[pjhs��huk�j\s[\yhs�puå\lujl�vm�^op[l�ptwlyphspz[�mvyjlz� �)vyn���������6]ly^olstlk�i`�>lz[lyu�ptwlyphspzt��*opulzl�ylmvytlyz� held events like the “hundred days’ reform” in 1898 and advocated reforming previous political systems and, instead, studying western ideology and technology (kerr & wright, 2015). during the 19th century, facilities for individuals with mental health challenges did not exist. due to limited resources and a lack of hjjlzz�[v�tlu[hs�olhs[o�z\wwvy[��thu`�mhtpsplz�pu�*opuh�jvuäulk� relatives with mental health challenges to their homes (chiang, 2016). in 1898, american medical missionaries established and funded a white supremacy in mental health practice columbia social work review, vol. xix | 93 wz`joph[ypj�ovzwp[hs��;opz�zl[�[ol�z[hnl�mvy�h�jvuzvspkh[lk�>lz[lyupalk� tlkpjhspah[pvu�huk�puz[p[\[pvuhspah[pvu�vm�tlu[hs�olhs[o��3p� �9hu��������� starting in 1966, the cultural revolution informed china’s building of psychiatric hospitals throughout the country and the closure of many community-based programs (li & ran, 2021). as a result, traditional chinese mental health practices continued to decrease, huk�>lz[lyupalk�tl[ovkz�l_whuklk��0u�������[ol�.lulyhs�6ɉjl�vm� china’s state council issued a national mental health work plan which proposed a comprehensive coordination strategy focused on the improvement of the service system as a whole (wang, 2017). in addition to value discrepancies across mental health services, china hszv�mhjlz�hu�pulx\p[hisl�kpz[ypi\[pvu�vm�tlu[hs�olhs[o�ylzv\yjlz��0u�^lss� resourced areas, the mental health system is rapidly reforming, whereas in under-resourced areas, such reforms are lacking (liu et al., 2011). 6]ly�[ol�shz[�[^v�kljhklz��[ol�*opulzl�nv]lyutlu[�ohz�wypvyp[palk� community-based mental health practice, allocating funding to rural provinces. however, the country still faces issues of stigma attached to mental health providers, and general physicians lack the knowledge and skills for basic mental health treatment (liu et al., 2011). united states the u.s. is considered a melting pot, with a populace of diverse racial, l[oupj��ylspnpv\z��huk�j\s[\yhs�ihjrnyv\ukz��/v^l]ly��[ol�\ipx\p[`�vm� racism in the u.s. guarantees policies deeply entrenched in white supremacist perspectives and values. in mental health settings, non^op[l�jvtt\up[plz�hyl�\uklyylwylzlu[lk��jspupjphuz�shjr�wyväjpluj`�pu� culturally humble practice, and academic and training institutions fail [v�hklx\h[ls`�pu[lnyh[l�j\s[\yhss`�h[[\ulk�wlkhnvn`��.vwhsrypzouhu�� �������4lu[hs�olhs[o�ylzv\yjlz�hyl�kpz[ypi\[lk�\ulx\hss`�huk�[yhkp[pvuhs� approaches are seldom applied in treatment. u.s. mental healthcare has been historically shaped by white-centric practices, with the majority of treatment occurring in asylums and hospitals until the early 20th century. in the early 1800s, patients with mental health challenges were punished by practitioners who tied kristen m. folkerts, isra merchant, chenxi yang 94 | columbia social work review, vol. xix [olpy�z\ɉlypun�jh\zhss`�[v�zpu��:\jo�wyhj[pjlz�kh[l�ihjr�[v�7yv[lz[hu[� traditions that determined the worth of and punished those in poverty. (z�h�ylz\s[��wlvwsl�^p[o�tlu[hs�olhs[o�johsslunlz�z\ɉlylk�puo\thul� jvuäultlu[�huk�jvu[pu\lk�z[pnth[pah[pvu��-sv`k����� "�(unspu�l[��hs�� 2006). until the emergence of mental health institutions, families often sent relatives with mental health challenges to almshouses: residential hjjvttvkh[pvuz�ilsvunpun�[v�johyp[`�vynhupah[pvuz��>pszvu���������0u� the mid-1800s, the federal government responded to ongoing advocacy lɉvy[z�i`�zl[[pun�\w����z[h[l�wz`joph[ypj�ovzwp[hsz��/v^l]ly��[olzl� ovzwp[hsz�^lyl�vm[lu�\uklyz[hɉlk�huk�\uklym\uklk��z\iqlj[pun�wh[plu[z� to human rights violations including a severe lack of informed consent, \ujslhu�sp]pun�x\hy[lyz��ths[ylh[tlu[��huk�hi\zl��4mvhmv�4»*hy[o`� �/\sz���������0u�ylzwvuzl��hk]vjh[lz��pujs\kpun�zvjphs�^vyrlyz�� collaborated with policymakers to establish more humane mental olhs[o�zly]pjlz��\s[pth[ls`�klpuz[p[\[pvuhspapun�wz`joph[ypj�ovzwp[hsz�huk� diverting funding to community-based mental health services. the 1963 community mental health act cemented the closure of these hospitals, instating a policy that reserved admittance to state facilities for patients who posed imminent danger to themselves or others (testa & wilson, 2021). while this legislation marked progress, the standards for those within the aforementioned high-risk demographic continue to pose concern today. many social workers and activists believe these standards of imminent danger are harmful to individuals admitted to state facilities, citing a lack of informed consent and autonomy (substance abuse and mental health services administration, 2019). colonial mental healthcare, and resulting western psychotherapy practices, continue to dominate u.s. practice, despite their failure to attend to diverse lifestyles and ideologies. an example is the use of diagnostic criteria in clinical settings, which often fails to account for j\s[\yhs�huk�zvjphs�jshzz�kpɉlylujlz�hjyvzz�yhjphs�huk�l[oupj�nyv\wz�� gambrill’s work has supported this argument, asserting that the +phnuvz[pj�huk�:[h[pz[pjhs�4hu\hs�vm�4lu[hs�+pzvyklyz��+:4�������� klo\thupalz�pukp]pk\hsz�i`�z[ypwwpun�[olpy�sp]lk�l_wlyplujl�huk�[yh\th� from environmental (social, political, and economic) context. in addition, mental health clinicians in the u.s. are disproportionately white supremacy in mental health practice columbia social work review, vol. xix | 95 white and their perceptions of non-white patients tend to be limited, often causing inaccurate stereotypes regarding type and degree of mental health challenges to be imposed (luona et al., 2018). black wh[plu[z�hyl�vm[lu�vu�[ol�yljlp]pun�luk�vm�[olzl�\ukly�x\hspälk� clinicians’ services, and are perceived as less intelligent, more likely to abuse alcohol and substances, and less likely to be rational and comply with prescriptions (yeager et al., 2013). white clinicians are also more sprls`�[v�jvujlw[\hspal�uvu�^op[l�tlu[hs�olhs[o�johsslunlz�hz�yvv[lk�pu� pukp]pk\hs�zovy[jvtpunz�yh[oly�[ohu�zvjphs�z[y\j[\yhs�pulx\p[plz��@lhnly� et al., 2013). tendencies favoring white supremacist views on mental health johsslunlz�oh]l�klsl[lypv\z�lɉlj[z�vu�[ol�tlu[hs�olhs[o�v\[jvtlz� of non-white individuals in the united states. in white-centric mental healthcare, non-white individuals often encounter microaggressions they do not encounter with clinicians from similar cultural, racial, or ethnic backgrounds. many patients of color report that they are not carefully listened to or given proper explanations, are denied respect, and struggle to communicate with white clinicians (yeager et al., 2013). this lack of cultural humility in services further causes non-white jvtt\up[plz�[v�svzl�jvuäklujl�pu�tlu[hs�olhs[ojhyl�zly]pjlz�� though mental health treatment has continued to improve, about one pu�ä]l�(tlypjhu�hk\s[z�z\ɉly�myvt�tlu[hs�olhs[o�johsslunlz�lhjo�`lhy� and about 1 in 20 experience serious mental health challenges. despite [olzl�hshytpun�z[h[pz[pjz��vus`�����^p[o�tlu[hs�olhs[o�johsslunlz�huk� ����^p[o�zlypv\z�tlu[hs�olhs[o�johsslunlz�yljlp]l�[ylh[tlu[�pu�h�np]lu� year (mental health by the numbers, 2020). additionally, as of 2020, hwwyv_pth[ls`�����tpsspvu�(tlypjhuz��e�����sp]lk�pu�hylhz�^p[o�zjhyjl� access to mental healthcare, highlighting an urban-rural resource divide �4lu[hs�/lhs[o�i`�[ol�5\tilyz���������0u�[ol�zhtl�`lhy������vm�<�:�� counties did not have a single practicing psychiatrist (mental health by the numbers, 2020). though the u.s. boasts a wide variety of mental health providers (psychiatrists, psychologists, licensed social workers, etc.), most are concentrated in and around urban areas. kristen m. folkerts, isra merchant, chenxi yang 96 | columbia social work review, vol. xix country variation in policy nigeria’s government is based on democratic principles, with balanced power at the federal, state, and local levels. mental health treatment is overseen by the federal government’s national health policy, from which mental health is largely excluded (abdulmalik et al., 2016). given the country’s status as a lowto middle-income country, health spending pz�zthss�huk�shynls`�wypvyp[palz�uvujvtt\upjhisl�kpzlhzlz��5*+z��� ^opjo�hyl�ylzwvuzpisl�mvy�����vm�klh[oz�^vysk^pkl��5*+z�kv�uv[� include mental health challenges; prynn et al., 2019). as a result, mental health is not a priority. abdumalik et al. (2016) found that unlike china, ^opjo�wyv]pklz�jv]lyhnl�mvy� ���vm�p[z�jp[paluz��5pnlyph»z�uh[pvuhs� puz\yhujl�jv]lyhnl�vus`�jv]lyz�hiv\[����vm�[ol�wvw\sh[pvu��^p[o� minimal coverage for mental health conditions (finch, 2013). although community-based insurance schemes and state and local social welfare pu[ly]lu[pvuz�l_pz[��tvz[�tlu[hs�olhs[o�[ylh[tlu[�ylx\pylz�v\[�vm�wvjrl[� payment. treatment also most often occurs within primary care facilities, supplied by general practitioners trained to prescribe a limited array of psychotropic medications (abdumalik et al., 2016). in china, prior to the introduction of psychiatric hospitals, communitybased healthcare in the form of support from families, friends, and/or community healers was common practice (liu et al., 2011). today, most chinese mental health treatment remains hospital-based. with a highly jlu[yhspalk�nv]lyutlu[��*opuh�ohz�iv[o�wyp]h[l�huk�w\ispj�olhs[ojhyl� facilities and insurance providers; however, more research is needed to determine the true extent of mental health coverage from both public and private insurance. according to the most recent data in 2013, the costs for inpatient and outpatient psychiatric treatment was an average vm�� ������wly�pukp]pk\hs�huk�����vm�[ovzl�^p[o�zl]lyl�tlu[hs�kpzvyklyz� pu�*opuh�^lyl�\uhisl�[v�hɉvyk�[ol�uljlzzhy`�[ylh[tlu[��hz�[ol`�sp]lk� below the poverty line of $1.00 per day (liang et al., 2017). 6iz[hjslz�[v�jhyl�pu�*opuh�hyl�l_hjlyih[lk�i`�[ol�nhw�il[^llu�[ol� magnitude of mental health needs and available treatment. close to ���vm�*opulzl�jp[paluz�ylwvy[�ul]ly�oh]pun�yljlp]lk�tlu[hs�olhs[o�jhyl� (liu et al., 2011). with psychiatric hospitals receiving a majority of the white supremacy in mental health practice columbia social work review, vol. xix | 97 government’s budget for mental health care, individuals experiencing more common mental health challenges such as depression and anxiety are left with few resources to access treatment. china has less than a x\hy[ly�vm�[ol�u\tily�vm�wz`joph[ypj�wyv]pklyz�[ol�<�:��ohz��huk�]py[\hss`� no counselors or social workers, as “social work” constitutes an entirely kpɉlylu[�älsk�pu�*opuh�[ohu�pu�[ol�<�:���-hun�l[�hs���������� the capitalistic system in the u.s. impacts mental healthcare through high treatment costs only occasionally covered by insurance. mental health costs are primarily associated with outpatient care and wz`jov[yvwpj�tlkpjh[pvu�yh[oly�[ohu�ovzwp[hspah[pvu��hkkylzzpun�[ol� symptoms of mental illness but failing to address its root causes. u.s. tlu[hs�olhs[o�[ylh[tlu[�ohz�shynls`�illu�i\ps[�hyv\uk�z\jo�¸x\pjr� ä_lz�¹�pukp]pk\hs�[ylh[tlu[��huk�opno�tlkpjh[pvu�jvz[z��3hyzvu���������0u� ������hwwyv_pth[ls`� ���vm�(tlypjhuz�ohk�lp[oly�w\ispj�vy�wyp]h[l� olhs[o�puz\yhujl��2lpzsly�:[hyrl`�l[�hs����������/v^l]ly��vus`�����vm� psychiatrists in the u.s. accept commercial insurance, and governmentzwvuzvylk�puz\yhujl�wshuz�sprl�4lkpjhyl�vus`�jv]ly�hiv\[�����vm� psychiatrists (leonhardt, 2021). this phenomenon renders mental health treatment only accessible to those with economic means. 0u�[ol�<�:���kpɉlylu[phs�hjjlzz�[v�[ylh[tlu[�vm[lu�pu[lyzlj[z�^p[o�yhjphs� identity. systemic oppression inhibits many americans of color, most uv[his`�)shjr�(tlypjhuz��myvt�hjjlzzpun�lɉlj[p]l�tlu[hs�olhs[ojhyl� (cook et. al, 2017). in this country, mental health challenges often coalesce with housing insecurity, incarceration, and racism, yet mental health treatment remains unacknowledged as a social justice issue. instead, it is viewed as a privilege to which only some have access. further indicating the extreme need for increased access to mental healthcare, a study published in 2018 revealed the staggering statistic [oh[��������vm�(tlypjhuz�^p[o�tlu[hs�olhs[o�johsslunlz�^pss�il� pujhyjlyh[lk�pu�[olpy�spml[ptl��3hyzvu���������*vtwhyh[p]ls �̀�����vm� people in state and federal prisons have been diagnosed with a mental illness (prison policy initiative, 2022). these statistics demonstrate the zlypv\z�ypzr�[oh[�\upumvytlk��puhklx\h[l�tlu[hs�olhs[o�jhyl�wvspj`�jhu� pose to the lives of individuals in the united states. when compared to the u.s., nigeria and china experience a greater kristen m. folkerts, isra merchant, chenxi yang 98 | columbia social work review, vol. xix zovy[hnl�vm�ylzv\yjlz��>opsl�5pnlyph�shjrz�hu�hklx\h[l�u\tily�vm� tlu[hs�olhs[o�jspupjphuz��*opuh�z[y\nnslz�^p[o�[ol�z[pnth[pah[pvu�vm� [ol�wyvmlzzpvu�hz�h�^ovsl��thrpun�wlvwsl�olzp[hu[�[v�lu[ly�[ol�älsk�vm� mental health (zhou et al., 2019). across all three countries, an extreme disparity in access to care exists between urban and rural areas. 6ul�lsltlu[�\upx\l�[v�5pnlyph�pz�[oh[��hjjvykpun�[v�p[z�jvuz[p[\[pvu�� mental health treatment is seen as a right and a social justice issue (abdulmalik et al., 2016). the nigerian government acknowledges that tlu[hs�olhs[o�johsslunlz�vm[lu�pu[lyzlj[�^p[o�kpzhipsp[`�[v�ptwhj[�x\hsp[`� and length of life. conversely, the chinese government has not deemed tlu[hs�olhs[ojhyl�h�ypno[�huk�]pl^z�pu]vs\u[hy`�ovzwp[hspah[pvu�hz�h� why[�vm�wh[plu[�jhyl��5pnlyph��i`�jvu[yhz[��jvuzpklyz�z\jo�ovzwp[hspah[pvu� a human rights violation; abdulmalik et al., 2016). finally, though vynhupah[pvuz�sprl�[ol�(7(�pu�[ol�<�:��oh]l�yljvnupalk�tlu[hs�olhs[o� hz�h�o\thu�ypno[��[ol�<�:��nv]lyutlu[�ohz�`l[�[v�yljvnupal�olhs[o�hz�h� human right, let alone mental health (gerisch, 2018). current global initiatives 4\s[puh[pvuhs�vynhupah[pvuz�z\jo�hz�[ol�<up[lk�5h[pvuz��<5��huk�[ol� >/6�oh]l�kl]lsvwlk�pup[ph[p]lz�zwhuupun�t\s[pwsl�jvu[pulu[z�[v�z\wwvy[� the expansion and development of mental health policy (department vm�,jvuvtpj�huk�:vjphs�(ɉhpyz, 2015; mhap���������0u�������[ol�>/6� initiated a global mental health action plan (mhap) to be completed in 2020 with the purpose of guiding nations to increase the availability huk�x\hsp[`�vm�tlu[hs�olhs[ojhyl��mhap, 2013). dr. margaret chan, +pylj[vy�.lulyhs�vm�[ol�>/6��z[h[lk�[oh[�¸[opz�jvtwyloluzp]l�hj[pvu� wshu�yljvnupalz�[ol�lzzlu[phs�yvsl�vm�tlu[hs�olhs[o�pu�hjopl]pun�olhs[o� for all people” (mhap, 2013, p.5). this approach focuses on the interconnections of both biological and social factors in one’s life in order to understand the broader context of mental health needs, and is intended to result in more accurate diagnosis and treatment with a social justice lens (susser et al., 2013). the mhap is founded on the principle that mental health is a core element of individual and community health and is intrinsically linked to physical health (mhap, 2013). this plan addresses the disparities between nation preparedness white supremacy in mental health practice columbia social work review, vol. xix | 99 and execution of mental health treatment plans and legislation, primarily focusing on lowand middle-income nations such as nigeria and china. alternatively, high-income nations, such as the u.s., see greater progress in mental health care legislation (mhap, 2013). nearly every aspect of the mhap incorporates collaborative programs, community-based initiatives, and integrated care (mhap, 2013). this plan calls on legislators to incorporate mental healthcare into lɉvy[z�[v^hyk�wv]ly[`�ylk\j[pvu�huk�kl]lsvwtlu[�z[yh[lnplz�huk� practices, providing a collaborative and comprehensive approach to improving global mental healthcare. comprehensive by nature, the plan incorporates “religious leaders, faith healers, [and] traditional healers” into policy guidelines and practice criteria (mhap, 2013, w�������;opz�wyhj[p[pvuly�pujs\zpvu�hjruv^slknlz�[ol�zpnupäjhujl�vm� traditional healing methods and provides lawmakers and leaders with tangible reasons to incorporate centuries-old practices into modern-day legislation and programming. additionally, it highlights the importance of cultural humility in addressing the mental health needs of populations negatively impacted by white-centric approaches. in addition to the mhap, in 2015 the un added mental health to its sustainable development goals and included in its declaration a call to lu]pzpvu�h�^vysk�^olyl�lx\p[hisl�hjjlzz�[v�jhyl�pz�[ol�uvyt��=v[y\ih� l[�hs����������0u�vykly�[v�hjopl]l�[opz�nsvihss`�pujs\zp]l��lx\p[hisl� access, the un divided its mental health approach into three major areas: reducing premature mortality via care for mental well-being, preventing and treating drug use disorders, and achieving universal lɉlj[p]l��x\hsp[`�olhs[o�jv]lyhnl��=v[y\ih��l[�hs����������;ol�<5�hszv� jhsslk�mvy�jvsshivyh[p]l�hwwyvhjolz��lujv\yhnpun�5.6z�huk�jp]ps�zvjpl[`� vynhupah[pvuz�[v�^vyr�^p[o�uh[pvuhs�nv]lyutlu[z�[v�kl]pzl�lx\p[hisl� mental health legislation (votruba et al., 2016). currently, global foundations of mental health education are based on western practice and methodology, inhibiting non-western nations from uvythspapun�[yhkp[pvuhs�z`z[ltz�vm�wyhj[pjl�huk�jhyl��;v�hkkylzz�nsvihs� tlu[hs�olhs[o�jhyl�pulx\p[plz�tvz[�lɉlj[p]ls �̀�tlu[hs�olhs[o�lk\jh[pvu� and treatment should integrate traditional and western practices in a fashion that best supports the mental and social liberation of those kristen m. folkerts, isra merchant, chenxi yang 100 | columbia social work review, vol. xix ilpun�zly]lk��-vy�t\s[puh[pvuhs�hwwyvhjolz�[v�lɉlj[p]ls`�ptwyv]l� tlu[hs�olhs[ojhyl��p[�pz�ptwlyh[p]l�[oh[�[ol`�ltwohzpal�kp]lyzp[`�vm� wyhj[pjl��slnp[pthj`�vm�[yhkp[pvuhs�jhyl��huk�kpzy\w[pvu�vm�puz[p[\[pvuhspalk� oppression and social stigma across the globe. policy alternatives ;v�ylzwvuk�[v�[ol�puå\lujlz�vm�jvsvupah[pvu��>lz[lyupah[pvu��^op[l� supremacy, and racism present in mental health treatment in nigeria, china, and the u.s., governments must respond with new policies and approaches to training mental health clinicians. in nigeria and china, this includes centering traditional cultures, values, and methods. in the u.s., this includes more culturally humble and inclusive mental health practices centering non-white clientele. possible policy alternatives in these countries are vast. increasing behavioral healthcare options in rural, under-resourced communities is one proposed approach. this could be achieved through government incentive programs for mental healthcare specialists to allocate time and resources in these areas. however, such programs will be costly, ylx\pypun�h�nv]lyutlu[hs�jvttp[tlu[�[v�svun�[lyt�m\ukpun��lzwljphss`� in lower-to-middle income countries like nigeria. increased homeand community-based services, commonly found [v�il�jvz[�lɉlj[p]l��pz�hszv�lujv\yhnlk��5l^jvtlyl[�hs����������6ul� example would be implementing family-run groups that would support individuals with mental health challenges and their family members. still, this approach could be challenging due to hospitals' incentives to wyv]pkl�jvz[s`�puwh[plu[�jhyl!�slnpzsh[pvu�hssvjh[pun�z\ɉjplu[�m\ukz�^v\sk� be necessary. given these policy alternatives, a policy recommendation is proposed to address a combination of the outlined global needs. we recommend [oh[�h�olhs[o�mvj\zlk�t\s[puh[pvuhs�vynhupah[pvu��z\jo�hz�[ol�<5�vy�[ol� >/6��pu]lz[�pu�hu�l]pklujl�ihzlk�ylzv\yjl�z`z[lt�hssv^pun�jv\u[yplz� around the world to bolster their mental treatment plans. this is especially important for middleto low-income countries to build upon their existing resources and ensure their most vulnerable populations experience increased access to mental healthcare. white supremacy in mental health practice columbia social work review, vol. xix | 101 ;opz�wvspj`�yljvttlukh[pvu�^v\sk�ylx\pyl�tlu[hs�olhs[o�l_wly[z�vm� diverse identities to collaboratively gather baseline evidence on needed jv\u[y`�zwljpäj�ylzv\yjlz��5llkz�^v\sk�[olu�il�jh[lnvypalk�hjjvykpun� to priority, and treatment plans outlined for countries to access based on their own needs. countries with low funding but high religious association, such as nigeria, could access a plan that recommends collaboration between government entities and religious leadership to hkkylzz�ihzlspul�tlu[hs�olhs[o�pzz\lz��*v\u[yplz�^ov�oh]l�wypvyp[palk� psychiatric care as opposed to outpatient care, such as china, could access a plan to increase investment in community-based mental health treatment. countries with a history of racial, ethnic, or religious oppression, such as the u.s., could access recommendations on how to dismantle such systems. with collaboration between international clinicians, researchers, academics, and other health personnel, this policy recommendation aims to integrate western and traditional practices. beyond a moral incentive for countries to support this initiative, countries would also il�pujlu[p]palk�[v�puz[p[\[l�tvyl�lɉlj[p]l�tlu[hs�olhs[o�[ylh[tlu[� htvun�[olpy�jp[paluz�[v^hyk�[ol�nvhs�vm�wyl]lu[pun�m\[\yl�huk�svun�[lyt� healthcare costs associated with mental health disorders and their ylz\s[pun�wo`zpjhs�zpkl�lɉlj[z��;oyv\nov\[�ptwsltlu[h[pvu�p[�^pss�il� especially important to assess the power dynamics of those involved in the planning and research process. careful consideration would need to be given to identifying global mental health “experts,” including entities such as the american psychiatric association, whose votes determine the disorders and jyp[lyph�pujs\klk�pu�[ol�+:4��0[�pz�lzzlu[phs�[oh[�thynpuhspalk�wvw\sh[pvuz�� voices, and lenses beyond national borders be centered throughout the implementation process. all parties involved would have the power and agency to determine criteria for evidence-based practice and diagnosis pu�kpɉlylu[�j\s[\yhs�jvu[l_[z�� the proposed system will need to be nimble and responsive to global population shifts and constantly changing mental health issues and wypvyp[plz��;opz�wvspj`�yljvttlukh[pvu�vɉlyz�h�wv[lu[phs�zvs\[pvu� lujvtwhzzpun�h�kljvsvupah[pvu�myhtl^vyr�^opsl�thpu[hpupun�h�z[yvun� kristen m. folkerts, isra merchant, chenxi yang 102 | columbia social work review, vol. xix sense of cultural humility in its approach. the result would be a global 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("they can cut all the flowers, but they cannot stop the spring.") this paper is my contribution to ensuring that our community’s resilience and potential continue to bloom, no matter the obstacles in our path. xavier salas columbia social work review, vol. xxiii | 107 106 | columbia social work review, vol. xxiii mereces todo lo bonito abstract this research explains the critical need to diversify queer latinx mental health professionals to support the healthy formation of gay male latinos’ sexual identity. gay male latinos go through unique difficulties in their process of identity formation, shaped by cultural concepts such as familismo, machismo, and religion, and economic constraints that hinder access to helpful care. these obstacles fuel greater mental health risks, including depression, anxiety, and internalized homophobia. the underrepresentation of queer latinx professionals in mental health, however, is not an isolated issue—it is a symptom of a broader breakdown in the system: other groups of marginalized individuals are also often unable to access culturally competent care. increased diversity in the mental health field is essential not only for gay latino men but also for other lgbtq+ and bipoc individuals who face similar disparities. queer latinx mental health professionals bring with them distinct lived experiences that enrich therapeutic relationships, deepen client outcomes, and strengthen research, policy, and clinical practice by interrupting prevailing eurocentric models of therapy. these benefits are undermined by political efforts to dismantle diversity, equity, and inclusion (dei) initiatives, further stigmatizing communities in need of affirming care. despite these challenges, interventions such as pipeline programs, policy activism, and community organizing provide options for attaining and sustaining diversity in mental health. committing to recruit and retain queer latinx mental health professionals allows us to bring about systemwide change that benefits not just gay male latinos but the mental health field as a whole. as the saying goes, “mereces todo lo bonito”— you deserve everything beautiful—and that begins with access to care that understands, knows, and confirms identity. “our brown skin does not limit us but empowers us for greatness.” —brian saucedo xavier salas mereces todo lo bonito: queer latinx mental health professionals and gay latino identity development many clients, particularly gay latino men, have challenges finding the right mental health professional to meet their needs, as effective therapy requires both cultural competence and an understanding of sexual identity development. this research examines the unique challenges that gay male latinos face during sexual identity development and the lack of queer latinx mental health professionals who can provide identityaffirming, culturally competent care. overall, this research seeks to answer the following three questions: 1. what are the specific issues for gay male latinos in sexual identity formation? 2. how does a dearth of queer latinx mental health professionals impact services for this population? 3. what are the potential implications of increasing the visibility of queer latinx professionals in the mental health profession? sexual identity refers to one’s lifelong sense of self as a sexual being within cultural categories (levy, 2009). cultural and socioeconomic factors shape sexual identity development for latino gay men, influenced by family, religion, and traditional norms such as machismo, caballerismo, and familismo. machismo is defined as “a set of values, attitudes, and beliefs about masculinity, or what it is to be a man” (nuñez et al., 2016, p. 3) and caballerismo is “comprised of chivalry, familial ties, and is associated with emotional connectedness” (rivera et al., 2021, p. 3). in alignment with caballerismo, familismo is where the “higher emphasis is placed on the family unit in terms of respect, support, obligation, and reference” (valdivieso-mora et al., 2016, p. 1). the cultural and socioeconomic factors that shape sexual identity development for gay latino men are unique and require culturally competent care practices. the scarcity of queer latinx mental health professionals limits access to empathetic and culturally informed columbia social work review, vol. xxiii | 109 108 | columbia social work review, vol. xxiii care. overburdened mental health systems can lead to incomplete sexual identity development and internalized homophobia. this underrepresentation is problematic, especially given the high levels of mental health challenges within the lgbtq+ community. as a result, culturally relevant support becomes vital. to fully grasp the impact of this underrepresentation, it is crucial to examine theoretical models that address sexual identity development. these theoretical models help to describe individuals transitioning through identities in sociocultural contexts and provide an underlying structure that we can apply to analyze the facilitators and inhibitors of integration into one’s identity. from the use of these frameworks, we can better appreciate the intersection and effects of cultural values, family, and external societal pressures upon the lives of gay latino men. theoretical models, like the developmental model of the closet, examine the role of concealing minority sexual orientations and its effect on identity development (cass, 1984). cass’s (1984) six-stage model delineates the movement from identity confusion to identity synthesis, where a homosexual identity becomes integrated into the broader selfconcept. queerness disrupts traditional sexual identities with fluidity and inclusivity (heasley & crane, 2003). this upheaval defies strict social norms, provoking resistance from conservative institutions that preserve binary understandings of gender and sexuality (wade & ferree, 2015). in considering the critique of the gender binary, it becomes clear how it falls short of an artificially established ideology. nevertheless, this critique also facilitates an expanded system that legitimates multiple identities and experiences, gradually expanding the sphere for self-expression and acceptance among queer and mainstream communities (butler, 1990). this research aims to add to the literature regarding gay male latinos’ difficulties in sexual identity formation, while highlighting the important role queer latinx mental health professionals can have in the process. gay male latinos face unique challenges based on cultural, religious, and economic considerations that contribute to high rates of mental health stressors. increasing the number of queer latinx mental health professionals promotes gay male latinos’ mental well-being through tighter therapeutic relationships, role modeling, and intersectional, identity-congruent care. furthermore, this research highlights the importance of cultural competence in mental health and demands greater representation of queer latinx professionals, ensuring gay latinos receive the affirming care they deserve. the unique challenges faced by gay latino men in sexual identity development cultural factors gay male latinos face unique challenges with sexual identity development due to traditional latinx gender norms like machismo and caballerismo. as rosenberg et al. (2024) states, people identifying with these norms are more likely to self-identify as exclusively heterosexual rather than gay, bisexual, or queer. sexual identity development may involve efforts to align with community and family expectations. gay latino men may avoid openly identifying as gbq (gay, bisexual, queer) to conform to machismo’s emphasis on hypermasculinity, prioritizing acceptance within their cultural environment. moreover, emotional responsibility in the form of caballerismo may lead individuals to conceal their gbq identity to uphold family values that conflict with nonheteronormative orientations. machismo and caballerismo are institutionally embedded in latinx family structures, religious ideology, and cultural imperatives, which collectively constitute a complex environment for the construction of sexual identity. machismo emphasizes strength, superiority, and heterosexual masculinity, and is often promoted by fathers and father figures who want their sons to meet these standards. conversely, caballerismo, which calls for responsibility, honor, and respect, creates a sense of obligation to maintain family unity by not engaging in any form of activity that may cause perceived shame. cultural norms, such as machismo, familismo, and heterosexism, provide the context for the mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 111 110 | columbia social work review, vol. xxiii process of coming out, and may result in feelings of rejection and the use of coping mechanisms such as alcohol and other drugs (gerena, 2021a). this triad of gender roles, familial duty, and societal expectations may lead to deeply internalized homophobia, complicating or inhibiting the integration of identity (meyer, 2003). additional complexities that emerge in the development of individual identity include family and religious institutions. family, central to latino culture, often lacks support for lgbtq+ identities, particularly when influenced by spiritual institutions like the catholic church. religious beliefs, especially within catholic and evangelical communities, often promote heteronormativity as a moral and spiritual duty, intensifying the intrapsychic conflict experienced by gay latino men. garcia (2014) states that this lack of support may present challenges for gay latino men in finding a balance between their sexual identity and their cultural and religious traditions. culturally competent care addresses such a set of complexities, reducing health disparities and improving patient satisfaction. collaboration with bilingual and bicultural professionals helps avoid issues such as misdiagnosis and less inclusive or responsive services. patients who receive culturally sensitive care have shown higher satisfaction rates, with better long-term outcomes (moyce et al., 2022; robles et al., 2020). for this reason, mental health professionals working with latino gay men should be aware of the cultural factors affecting this population. culturally sensitive care may help promote the healthy development of sexual identity for this population and decrease the impact of traditional norms. by integrating cultural sensitivity into the therapeutic relationship, mental health professionals can establish trust, validate lived experiences, and address the particular stressors of latino gay men, such as familismo, religious context, and expectations of masculinity. this not only enhances treatment participation in mental health, but also enables individuals to navigate their identities more assertively and resiliently. socioeconomic factors socioeconomic factors strongly influence the mental health and identity development of latino gay men. poverty, immigration status, and education affect individuals’ access to mental health services and shape their identities. as such, challenges can arise when an individual tries reconciling gay and latino identities within rigid familial and cultural expectations that are encased in strong patriarchal and gender roles and often accompanied by identity confusion, isolation, and internalized homophobia (zea et al., 2003). negotiation strategies for managing socioeconomic factors within these intersectional identities are common, alongside feelings of exclusion and isolation. while cultural expectations shape self-identity and social acceptance, financial and structural barriers limit access to affirming mental health care, compounding the challenges faced by latino gay men (meyer, 2003). economic barriers further exacerbate mental health disparities among latino gay men, including a lack of insurance; limited geographic access to affirming providers, particularly in rural areas; and complicating factors such as transportation and immigration status. these barriers contribute to the underuse of mental health services by latinos, with latino gay men suffering higher psychiatric distress due to intersectional oppressions (gerena, 2021a). the mental health system has prevented latinx people from gaining adequate access to resources in a wide-ranging scope. disparities tied to race and socioeconomic status worsen the problem, particularly within rural areas where mental health resources are scarce (mcgregor et al., 2019; moyce et al., 2022). for some latino gay men from immigrant families, balancing sexual identity with acceptance from their family involves “moral management” strategies, meaning they subtly challenge their parents about negative views while focusing on educational and career successes (ocampo, 2013). these approaches are generally aligned with the aforementioned traditional latinx gender constructs of machismo and caballerismo, which serve as both obstacles and resources in negotiating cultural mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 113 112 | columbia social work review, vol. xxiii and familial expectations. machismo’s emphasis on masculinity and toughness may lead some latino gay men to take on hypermasculine habits, or to repress sexual identity in the interest of maintaining familial respect. conversely, caballerismo’s emphasis on duty, fidelity, and emotional connection allows these men to re-create their sexual identity on terms that highlight factors including being good sons and providers, and that their successes in school and/or career are part of their family duty. these values enable them to court parental approval and gradually work on the conversations that challenge strict gender and sexual expectations. the intersection of racial and socioeconomic challenges, including discrimination and marginalization, along with overlapping identities in race, ethnicity, and sexual orientation, underscore the need for culturally competent or adapted mental health services that reflect the lived experiences of this population. despite the negative effects of these challenges, resiliencies and support networks play an important role in helping participants make informed and positive decisions in their identity development within the latino gay male community (harper et al., 2016). issues such as the intersectionality of multiple marginalized identities place latino gay men in peculiarly challenging positions that impact their mental health outcomes. these intersecting identities often exacerbate feelings of exclusion and isolation due to the discrimination perpetuated by mainstream society, but most notably from within their own ethnic and lgbtq+ communities. this intersectionality leads to different mental health challenges that demand a deeper understanding of their experiences. a thorough examination of the deeper layers of identity may yield a more specific picture of how latino gay men navigate the dynamics of their mental health, family dynamics, and cultural expectations; it also points to the need for tailored mental health interventions. latino gay men often face what scholars describe as “double minority stress,” the intersectional effect of racial and sexual minority identities that exacerbates dangers to mental health (salas et al., 2023). they frequently traverse a cultural terrain where homophobia is present within latinx communities and where they also face racism in lgbtq+ spaces, resulting in a loss of their sense of belonging (velez et al., 2019). within their families, acceptance can be conditional, with some relatives able to tolerate their identity as long as it is not ostentatious, thus maintaining their sense of invisibility (morales-chicas & cokley, 2021). other latino gay men feel that their lived experiences of being latino are frequently reduced to a caricature in predominantly white lgbtq+ spaces, where they are seen as objects of racial fetishization or tokenization, leaving them feeling out of place (han & ayala, 2018). these stressors lead to elevated levels of depression, anxiety, and substance use among latino gay men—rates significantly higher than in their white lgbtq+ counterparts (díaz et al., 2022). these combined factors contribute to the limited ability to obtain culturally competent services for their mental health needs, magnifying an already inequitable gap (zea et al., 2003). an intersectional lens filtering in the cultural, family, and systemic contexts of gay latino males’ experiences will be critical to dealing with these challenges. mental health implications gay latino men suffer from potentially serious health and psychological problems because of discrimination at the intersection of racism, cultural norms, and family rejection (díaz et al., 2001). these hardships often manifest as substance dependence, risky sexual behaviors, and psychiatric distress (meyer, 2003). racism within lgbtq+ communities exacerbates low self-esteem, leading to higher levels of depression and anxiety compared to their white peers (santos & vandaalen, 2016). racialized stereotypes perpetuate body dissatisfaction, anabolic steroid misuse, and eating disorders. disrespectful treatment by and mistrust of the medical system further increase health disparities and decrease access to care (le et al., 2024). societal and familial pressures—in the form of the fear of ostracism or internalized shame—faced by gay latino men increase their degree of emotional distress and raise the risk of depression and suicidal ideation (tajón, 2009). these challenges are best mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 115 114 | columbia social work review, vol. xxiii addressed through a comprehensive approach in which intersectional experiences are considered and culturally competent mental health care is promoted. the intersection of ethnic and sexual minority statuses means gay latino men bear a heavier burden of stigma and discrimination from both mainstream society and the latino community, often resulting in a higher prevalence of psychiatric distress. cultural stigma also contributes to the underuse of mental health services, which can worsen untreated conditions and threaten long-term well-being (gerena, 2021b). cultural norms enforcing heterosexual conformity, coupled with discrimination and stigma against lgbtq+ individuals, increase psychiatric distress and the prevalence of psychiatric disorders (yarber & sayad, 2018). family rejection, particularly from fathers, seriously impacts mental health, increasing anxiety, depression, suicidal ideation; substance use as a coping mechanism; and difficulty forming long-term healthy relationships due to internalized homonegativity. the role of queer latinx mental health professionals in sexual identity development the importance of affirmative therapy affirmative therapy is an essential component in the treatment of members of the lgbtq+ community, particularly gay latino males. it contributes to positive identity development and decreases stigma. it is a form of psychotherapy aimed at confirming and advocating on issues affecting minorities in sexual and gender identity (hinrichs & donaldson, 2017). this framework helps to navigate the intersections of ethnic, cultural, and sexual identities to address mental health. coming out is especially challenging for gay latino men due to cultural and family factors such as machismo, caballerismo, and familismo. all these cultural pressures can contribute to significant fear of rejection and opposition to nonconformity with traditional gender role expectations. all this means that therapists must build a solid working alliance with their clients by promoting trust, practicing cultural competence, and confirming the client’s intersecting identities. a robust therapeutic alliance here involves the creation of a safe, nonjudgmental environment where the client is heard and validated, and the use of culturally responsive interventions that respect the client’s values and experiences (johnson, 2012). this builds rapport and encourages open discussion about identity, family, and mental health concerns. research indicates that understanding a client’s coming out narrative strengthens the therapeutic relationship—the sense of trust, collaboration, and emotional connection between a client and therapist—and therapy satisfaction, which refers to the client’s perception of how well therapy meets their needs and promotes personal growth (bachelor, 1995; bordin, 1979). in this regard, a minority stress-focused cognitive behavioral therapy (cbt) treatment tool called the esteem intervention decreased anxiety and substance use for latino gay and bisexual men, underscoring the importance of culturally tailored treatments (keefe et al., 2023). by addressing minority stress and anchoring cultural identity, this intervention likely established trust, validation, and rapport— essential elements that strengthen the therapeutic alliance. similarly, culturally adapted cbt in the case of a depressed gay latino adolescent improved depressive symptoms and family dynamics by integrating values from culture and self-hood (duarté-vélez et al., 2010). this culturally responsive intervention not only addressed clinical concerns but also created a safe space for identity exploration, solidifying the client-therapist alliance and resulting in greater therapy satisfaction. while the definition and validation of affirmative therapy are still elusive, there is empirical support for its efficacy in addressing the needs of lgbtq+ individuals from racial and ethnic minorities. studies have shown that affirmative therapy techniques—such as fostering positive identity development, validating cultural values, and addressing experiences of discrimination—lead to improved mental health outcomes, including reduced depression, anxiety, and internalized homophobia (crisp & mccave, 2007). therefore, future research should mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 117 116 | columbia social work review, vol. xxiii focus on refining and validating affirmative methods to determine their continued efficacy and cultural competence among racial and ethnic minorities (johnson, 2012). the limitations of current mental health services gay latino males face disparities in access to mental health services due to a lack of cultural competency from therapists who are not latinx. barriers include the limited availability of culturally and linguistically appropriate services and institutional mistrust. integrated care remains limited due to the lack of standard measures and empirical research (bhui et al., 2007; mcgregor et al., 2019). these challenges stem largely from cultural misalignment, language barriers, and resource limitations. many mental health assessments fail to account for the unique experiences of gay latino men. besides the lack of access to spanish-language services and bilingual providers, financial constraints serve as additional barriers to obtaining high-quality mental health care (aguilar-gaxiola et al., 2012; cerezo et al., 2020; moyce et al., 2022). gay latino males’ mistrust of mental health care is rooted in discrimination, compounded by providers’ inadequate training in cultural humility and intersectionality (dawes et al., 2023). barriers related to the cost of care and a lack of appropriate lgbtq+ cultural competency are also associated with limitations in access to services for this demographic group (aguilar-gaxiola et al., 2012; fish et al., 2022). immigration further exacerbates the social isolation and barriers to health services faced by latinx people, requiring culturally competent approaches in social work (furman et al., 2009). for the majority of latinx immigrants, poor language skills, deportation fear, and unawareness of available services are some of the factors that lead them to feel excluded and deny them access to vital mental health services. undocumented individuals also tend to avoid visiting healthcare providers due to suspicion or legal concerns. solutions may involve enhancing provider cultural competence through training in immigration-related stressors, acculturation problems, and intersectional sexual and cultural identities. increased access to services may involve the creation of bilingual mental health services, recruitment of diverse providers, and culturally competent outreach among immigrant communities. policy-level advocacy to reduce disparities must work on healthcare coverage for undocumented people, funding for community-based organizations that serve immigrant and lgbtq+ communities, and protecting vulnerable populations from healthcare discrimination. the need for and benefits of queer latinx mental health professionals queer latinx mental health professionals play an important role in the development of trust and understanding among gay latino men. their shared cultural and sexual identity builds stronger therapeutic alliances, leading to culturally relevant care (gerena, 2021b; gerena & rodriguez, 2023). gay latino men often face a tension between familismo and their sexual identity. this tension occurs when the desire to preserve traditional family roles collides with the expression of sexual orientation without restraint, leading to emotional tension and fear of rejection. social workers must be culturally sensitive, assess family support, and promote open communication to decrease stigma and improve mental health. this is particularly pertinent in light of the reality that machismo as a cultural phenomenon attached to conventional masculine dominance and pride tends to reinforce stringent gender roles, which accumulate internalized homophobia and social isolation (gerena, 2021b). through providing safe spaces, inclusive language, and respect for client identities, queer latinx professionals normalize discussions of sexual orientation and trauma while ensuring confidentiality (gerena & rodriguez, 2023). the acceptance of gay latino men by their fathers is particularly significant, making family dynamics an important area for professionals to master, in addition to cultural competence (gerena, 2021a). this acceptance is significant because fathers may express traditional patriarchal values in latino households, where masculinity mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 119 118 | columbia social work review, vol. xxiii and gender are valued. for gay latino men, acceptance by their fathers can affirm their identity, reduce internalized homophobia, and make them feel more valuable as people. good father-son relationships have been linked with improved mental health status, including lower depression and anxiety rates (morales et al., 2012). fathers who openly declare acceptance of their sons can also affect broader family acceptance, a ripple effect that strengthens family bonds and reduces stigma. enhancing cultural competency cultural competency among health professionals is essential for enhancing the quality of care in diverse populations, including gay latino males. queer latinx professionals offer insight into cultural nuances, using their own experiences to foster empathy and challenge stereotypes, thereby making care more culturally competent (rosenberg et al., 2024). awareness of these challenges helps clinicians provide safe environments for gay latino men to explore their personal experiences without shame (rosenberg et al., 2024). lived experiences of queer latinx professionals enhance rapport-building and strengthen patientprovider relationships, reducing health disparities. provider training should include knowledge of belief systems and culturally sensitive care planning that fosters improved collaboration with clients and families (bhui et al., 2007). increasing workforce diversity in terms of bilingual and bicultural professionals is critical. pipeline programs are needed to address the shortage of providers familiar with the needs of diverse communities (aguilar-gaxiola et al., 2012). language access and tracking inequities are additional strategies that promote health equity (flórez et al., 2021). the significance of culturally competent care is widely acknowledged. providing a specific example of a successful culturally adapted mental health intervention can illustrate its impact in practice. for instance, the chief emphasis in narrative therapy for gay latino men is to develop the skills necessary to help the client reframe his experiences of cultural conflict and familial rejection, by building strength and resilience. similarly, traditional healing practices, such as curanderismo (a holistic healing practice), could be included, or community leaders, such as promotores (community mental health workers), could be brought into mainstream mental health care to help bridge the gap between mainstream services and cultural beliefs. this could make interventions more acceptable and accessible to latino clients (cutshall, 2024; johnson et al., 2013). these culturally adapted therapeutic approaches, incorporated with affirmative therapy, allow a deeper understanding of how mental health care can be adapted to meet the needs of gay latino men, showing in practice what culturally competent care looks like and how it can improve mental health outcomes. queer latinx professionals are integral to improving cultural competency, therapeutic relationships, and culturally relevant care. in addition to institutionalizing cultural competence education for all providers, increasing the availability of such professionals would lead to better health outcomes and greater equity for gay latino men and other underserved groups. promoting positive role models gay latino males and other marginalized communities depend on positive role models for self-acceptance and growth. individuals relate better to those who share their cultural and sexual identity, which fosters a sense of belonging and raises self-esteem (zea et al., 2003). queer latinx mental health professionals can serve as powerful role models by demonstrating how to integrate sexual identity with cultural expectations while overcoming internalized homophobia. one important element in the therapeutic relationship is managing transference and countertransference. the feelings a client may hold toward their role models can be transferred onto the therapist. while this positive attitude can be helpful, it must be carefully managed to maintain balance in the therapeutic relationship. the therapist should recognize countertransference and use supervision and self-reflection to manage these dynamics. mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 121 120 | columbia social work review, vol. xxiii improving mental health outcomes representation in mental health settings fosters trust between service recipients and providers. greater representation among professionals— especially those who have similar backgrounds to or share a language with their clients—creates an atmosphere of greater inclusiveness and better outcomes for latino patients (flórez et al., 2021). while the evidence for effectiveness continues to evolve, cultural competency training has been associated with positive staff attitudes and clinician satisfaction. however, further research is needed to assess its impact on patient outcomes (bhui et al., 2007). quantifiable statistics regarding the number of queer latinx mental health providers, compared with the higher rates of mental health issues in lgbtq+ latinx populations, might create demand for more practitioners within this area. although demand for culturally competent care is growing across lgbtq+ communities, very few practicing mental health professionals identify as lgbtq+ or latinx. according to the american psychological association (2022a), less than 5% of the psychology workforce is composed of latinx individuals; still fewer are lgbt. these low numbers, arguably, have contributed to disparities in mental health outcomes, with lgbtq+ latinx individuals having higher rates of major depressive disorder, generalized anxiety, and suicidal ideation than their white counterparts (national center for hiv, viral hepatitis, std, and tb prevention, 2021). increasing the number of queer latinx practitioners may help bridge these disparities and improve overall mental health outcomes. broader impacts of increased queer latinx mental health professionals an increased presence of queer latinx mental health professionals extends beyond individualized care to influence research, policy, and clinical practice in a meaningful manner. their unique standpoints enhance an understanding of the intersectionality of culture, sexuality, and mental health, creating more representative and inclusive research. scholarship from queer latinx scholars tends to encapsulate the multifaceted experiences of gay latino men, addressing gaps in the literature and combating dominant discourses that overlook their specific mental health issues (salgado et al., 2022). by producing culturally relevant research, these researchers are helping create evidencebased interventions that are tailored to the lived experiences of their communities, ultimately improving mental health outcomes on a larger scale. in terms of policy, queer latinx mental health professionals have an important part to play in shaping legislative agendas to dismantle structural impediments to mental health care. through experience and clinical awareness, they can highlight the unique issues gay latino men face, while encouraging policymakers to place culturally attuned care and workforce diversity at the forefront. their work played a crucial role in the enactment of bills such as the mental health workforce and language access act of 2023, which allocates funds to recruit bilingual and bicultural mental health professionals and to increase culturally appropriate services (rodriguez & santiago, 2023). additionally, their leadership positions in professional organizations—such as the national latinx psychological association and the apa’s division 44 (society for the psychology of sexual orientation and gender diversity)—expand queer latinx voices in state and national policymaking. in becoming directly engaged with these causes, queer latinx professionals drive systemic change toward greater inclusivity and accessibility of mental healthcare. this policy work has already shown positive effects. for example, in its first year, the mental health workforce and language access act has assisted more than 200 new bilingual mental health professionals employed in federally qualified health centers, increasing service availability for latinx communities (rodriguez & santiago, 2024). in another example, california and new york made a direct investment in workforce diversity initiatives and reported a 15% rate of growth in the number of latinx-identified mental health professionals in public health settings, contributing to improved patient satisfaction and engagement mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 123 122 | columbia social work review, vol. xxiii in therapy (sanchez et al., 2024). furthermore, organizations such as the national latinx psychological association stepped up mentorship efforts, resulting in a 20% boost in latinx applicants to graduate mental health training programs (american psychological association [apa], 2024). these preliminary results reflect the actual returns on policy investment—bridging gaps and creating a more representative mental health workforce. growth in the number of queer latinx mental health professionals leads to a broader cultural shift in mental health organizations. their presence disrupts the traditional eurocentric models of therapy through the introduction of models that emphasize collectivism over individualistic values, intersectionality, and culturally affirming approaches. when queer latinx mental health professionals are included as educators and mentors in training curricula, they equip future practitioners to work with diverse populations, reducing the stigma that keeps gay latino men from seeking care (gonzalez et al., 2021). their leadership within health systems also fosters organizational change that promotes equity, including by implementing inclusive intake assessments and developing trauma-informed, lgbtq+-affirmative treatment plans. through their influence on practice, policy, and research, queer latinx mental health professionals play a radical role in reshaping mental health care to improve therapeutic outcomes at the individual level. they also instigate change at the systemic level that improves outcomes among broader lgbtq+ latinx communities. potential criticisms cultural competence training alone cannot address the mental health needs of gay latino men. lived experience provides a higher level of insight that cannot be replaced with training. queer latinx mental health professionals possess a unique perspective that facilitates increased trust, reduces fears of cultural misunderstandings, and enhances therapeutic rapport (morales et al., 2021). evidence-based literature states that clients from marginalized communities are more willing to disclose personal problems to therapists from the same cultural background, leading to better treatment acceptance and outcomes (santos & valdez, 2020). critics argue that prioritizing representation in mental health treatment can enable racial or ethnic matching in ways that minimize client choice or put up unnecessary barriers to care. the goal is not exclusion; rather, it is to ensure that lgbtq+ latinx clients can access providers who understand their unique issues. the apa (2022a) emphasizes that representative diversity for mental health professions is a matter not of preference but of equity, given it directly influences disparities in access and quality of care. moreover, when mental health professionals have meaningful cultural similarities with clients, they are better able to address the intersectional experience of discrimination, rejection by the family, and internalized stigma (guzmán et al., 2019). rather than suggesting that gay latino men can only be treated by queer latinx mental health professionals, the emphasis should be placed on getting more such professionals into practice to ensure equal access to culturally competent care. by integrating recruitment and retention strategies for these professionals, mental health centers can move beyond superficial cultural competence gestures and toward a systemic approach that meets the needs of gay latino men. strategies for increasing the number of queer latinx mental health professionals education and training delivering culturally competent care to gay latino males (or any other lgbtq+ individuals) requires an expansion of recruitment and training programs for queer latinx mental health professionals. these programs should prioritize the development of queer latinx professionals in a way that allows them to deliver culturally competent and trauma-sensitive care with an understanding of intersectional identities in service delivery to lgbtq+ individuals. mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 125 124 | columbia social work review, vol. xxiii the inclusion of more queer latinx professionals creates avenues for systems of inclusivity and equity within the profession that may inspire future generations and provide the profession with increasingly diverse perspectives. success in these programs will depend on an inclusive organizational culture, external pressures like continuing education requirements, and strong leadership (fish et al., 2022). furthermore, mentors are imperative for supporting queer latinx professionals in their career paths by offering advice and a sense of community. these initiatives are important in helping the mental health system become more inclusive and improving outcomes for lgbtq+ latinx clients. policy recommendations recent legislation, including the mental health workforce and language access act of 2023 and the care for mental health professionals act, introduced in 2023, provides critical opportunities to advance diversity in the mental health workforce. the mental health workforce and language access act aims to improve language access in mental health care by authorizing grants to recruit professionals who speak languages other than english and promote culturally competent care. the care act, if enacted, will strengthen the mental health workforce through practices across state lines and by including in the workforce essential but often marginalized groups, such as queer latinx professionals, who are necessary to provide culturally sensitive care. these acts also offer financial resources to support the recruitment and retention of queer latinx students in mental health professions, creating more inclusive work environments. for example, professionals who are queer and latinx can join institutions like the national association of social workers (nasw) or the apa, either individually or in groups, to advocate for policy changes. they may also be able to secure grants to promote diversity within the mental health workforce overall and specifically within their profession. in this vein, organizations and authorities can make a significant impact by implementing concrete initiatives focused on attracting and retaining queer latinx professionals. pipeline programs such as mental and behavioral health education and training and the health careers opportunity program, both funded by the u.s. health resources and services administration, have successfully recruited underrepresented groups into health careers through financial aid, culturally sensitive training, and mentorship (nivet et al., 2016). meanwhile, more farreaching enforcement of laws offering incentives to hire bilingual and bicultural mental health therapists could lead to gains like those seen in new york and california. active hiring and retention focus on expanding mental health care system services, similar to international initiatives like canada’s promoting health equity: mental health of black canadians fund (public health agency of canada, 2023). these examples indicate the need for collaboration between educational institutions, government agencies, and professional organizations to facilitate a diverse workforce. countering anti-dei efforts despite recent anti–diversity, equity, and inclusion (dei) efforts, such as the u.s. administration’s rescissions of federal funding, there remains potential—and a necessity—to continue with policies that enable the recruitment and retention of queer latinx mental health professionals. some state and federal organizations and nonprofits can still independently implement internal policies to promote workplace diversity (williams et al., 2023). the nasw and the apa can enhance scholarship and mentorship programs aimed at underrepresented groups without intervention from the government. foundations such as the robert wood johnson foundation and kff remain committed to healthy equity programs that facilitate hiring and retaining diverse mental health practitioners (garcía & hardy, 2024). public agencies may face legal and political difficulties in embracing explicit dei efforts, but they can prioritize inclusive recruitment in other ways. for instance, language-access policies remain legally permitted under title vi of the civil rights act of 1964, and clinics and hospitals can rationalize the hiring of bilingual and bicultural providers as a requirement for effective patient care (sanchez et al., 2022). similarly, mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 127 126 | columbia social work review, vol. xxiii belonging, and access to vital support as individuals navigate their sexual and cultural identities. through activists, local lgbtq+ organizations provide safe spaces, counseling, peer support, and educational workshops, all specifically geared toward the needs of gay male latinos. by addressing stigma, these resources help create an environment where individuals can thrive and reach their full potential. this is further supported by local programs, including pride movements, cultural festivals, and affirming church services, that provide lgbtq+ individuals with opportunities for connection and mutual support. these spaces also enable discussions on salient issues affecting gay latino males. family support is also crucial. when families are accepting, it can have a significantly positive impact on a person’s mental health. educating family members on lgbtq+ issues and calling for free, open conversations will cultivate understanding and close these gaps— specifically, the lack of culturally informed understanding about sexual identity, mental health stigma, and misconceptions rooted in traditional values. collaborations among mental health workers, community organizations, and local advocates are necessary to develop effective support systems: these partnerships enable the creation of culturally relevant programs and services that address the diverse needs of gay latino men, helping them build confidence and resilience in their identities. community organizations serve an immensely important function in the mental health of gay latino men through a myriad of services: peer mentoring, advocacy, and legal support. in this light, peer mentoring programs offer them the opportunity to interact with others who may share similar experiences and provide advice to alleviate loneliness. advocacy efforts led by community organizations help reduce stigma and promote systemic changes to guarantee lgbtq+ people’s rights and access to care, these organizations may also provide legal support, particularly in cases involving discrimination or immigration, which may be harmful to mental health (meyer, 2003). successful collaborations between mental health providers and community organizations have some states with strong labor protections, like california and new york, have persisted in promoting the hiring of diverse mental health professionals even in the wake of shifting federal policies (rodriguez & nguyen, 2024). other health institutions have also embraced dei principles within cultural competency and workplace development, giving programs new titles to suit evolving legal mandates while retaining their impact. for job seekers pursuing employment in mental health programs amid anti-dei efforts, personal narratives and anecdotes remain powerful weapons. most organizations continue to allow personal statements in resumes, where job seekers can articulate how their own experiences and unique identities serve the field. this allows queer latinx job seekers to highlight the strengths of their backgrounds and activism without explicitly using dei terminology (perez et al., 2023). lastly, professional networks within affinity groups such as the national latino behavioral health association or the lgbtq+ health equity initiative (american public health association) can establish systems of support independent of formal dei efforts so that mentorship and community-building are sustained no matter the policy shifts. as dei policy is increasingly curtailed, policymakers, advocacy organizations, and mental health institutions must come together in pursuit of flexible solutions for serving underrepresented professionals. with access to private funding, legal defense of language access policies, and narrative capacities in hiring and admission processes, stakeholders can continue to incentivize a diversified mental health workforce. these efforts not only circumvent anti-dei policies but also affirm the determination and priority of representation in mental health care. community engagement and support community engagement and support resources help heal and validate the experiences of gay latino men, particularly in fostering positive sexual identity development. these resources offer encouragement, mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 129 128 | columbia social work review, vol. xxiii services, typically because of language barriers, lack of enough culturally competent providers, and fears of discrimination in healthcare centers (crisp & mccave, 2007). as such, the population tends to have disproportionately high rates of depression, anxiety, and suicidal ideation. yet despite these issues, the current mental health system remains considerably unresponsive to them. queer latinx mental health professionals are crucial to closing these gaps. due to their identity, they can build credibility, provide culturally affirming treatment, and validate the sexual identities of gay latino men in ways that traditional practitioners cannot. they can provide affirmative therapy without fear of rejection. furthermore, their policy campaigning and research help supplement institutional initiatives toward culturally sensitive and adaptive mental health interventions addressing latinx lgbtq+ issues. however, such progress is under immediate threat by the current presidential administration’s reversal of dei policies. diversification of mental health personnel is being undone through funding policies that limit culturally competent training and discourage hiring queer latinx mental health professionals. the trend places affirming care out of reach and exacerbates the existing disparities in mental health care, particularly among already underresourced, marginalized communities. without active resistance, these political measures will create further significant barriers to care for gay latino men. more urgently than ever, schools, policymakers, and community-based organizations must move to protect and expand programs that support queer latinx mental health professionals. that involves maintaining pipeline initiatives, advocating for funding protections, and creating community-based interventions that provide direct support to lgbtq+ latinx individuals. representation in mental health care is not a privilege; it is a necessity. investing in representation ensures that the next generations of gay latino men receive the culturally affirming care they will need. shown that culturally relevant care works. for example, joint efforts between lgbtq+ community centers and healthcare providers have established various culturally adapted programs and workshops for counseling, where issues like internalized homophobia and identity development can be evaluated in a nonjudgmental setting (crisp & mccave, 2007). this helps build a continuous network of support where the mental, emotional, and legal needs of gay male latinos are addressed. case studies of lgbtq+-affirming community interventions offer proof of the positive impact of these programs for gay male latino mental and health outcomes. for instance, o’donnell, sánchez, and grant (2021) explored the role of mentoring in latinx adolescents, and they demonstrated that mentoring can build trust and improve psychological well-being, such as lowering anxiety and depression. the contribution of their work was that it found positive mentoring relationships to be best in fostering self-esteem and emotional resilience among latinx youth, including sexuality minority youth. another study, familias con orgullo, had a family center intervention focus to improve communication and eradicate depressive symptoms among latinx sexual minority youth (estrada et al., 2024). the intervention, by the way of family counseling and education, helped families become more accepting of their lgbtq+ children and reduce mental health problems such as depression. these studies emphasize the importance culturally appropriate interventions to enhance mental health and reduce internalized homophobia, loneliness, and conflict in interpersonal relationships among gay latino men. conclusion psychological well-being issues in gay latino men are products of intersecting economic, cultural, and structural barriers that render sexual identity complex to form. cultural values of familismo, machismo, and caballerismo, combined with religious conservatism, result in internalized homophobia, family rejection, and financial inequalities. there is also a limit to gay latino men’s ability to seek affirmative mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 131 130 | columbia social work review, vol. xxiii references aguilar-gaxiola, a., loera, g., méndez, l., & sala, m. 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(2023). experiences of queer people of color in mental health care and substance use treatment: a systematic review. journal of the society for social work and research, 14(3), 721–755. https://doi.org/10.1086/721454 this work is not just about statistics, policy changes, or workforce development—it is about real people. it is about a young latino boy sitting in church, praying for his socially unacceptable feelings to disappear. it is about a teenager who rehearses his coming-out speech a hundred times but never finds the courage to say it aloud. it is about the man who has spent years hiding, only to realize he has been hiding from himself. these individuals deserve to see mental health professionals who understand and affirm them, and a world that embraces them. this paper is a call to action, a plea to ensure that no gay latino man ever feels alone in this journey. at last, mereces todo lo bonito—you deserve everything beautiful. gay latino men deserve mental health care that understands them, honors their struggles, and supports them toward healing. a fortification of queer latinx mental health professionals’ visibility is not just a move toward equity—it is a prerequisite for justice. the fight for representation in mental health persists, to ensure that every single one of those individuals has access to practitioners who fully understand and care for them. “there are millions of us, and we’re strong and we’re loved. you don’t have to sacrifice being latino or being lgbt to be part of both communities.”—ruben gonzales mereces todo lo bonito xavier salas columbia social work review, vol. xxiii | 133 132 | columbia social work review, vol. xxiii díaz, r. m., ayala, g., bein, e., henne, j., & marin, b. v. 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