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O

A
OUTSTANDING
ACADEMIC
PAPERS BY
STUDENTS
A collaborative, international program

P
by academic research libraries
to encourage, recognize, and preserve
excellence in student scholarship

S 2010
USC LIBRARIES | USC SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
OAPS
O U T S TA NDING
AC A D E MIC
PA P E R S BY
S T U D E N TS
APRIL 2010

USC LIBRARIES
USC SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
USC LIBRARIES
USC SCHOOL OF SOCIAL WORK

Published by
Figueroa Press
840 Childs Way, 3rd Floor
University of Southern California
Los Angeles, CA 90089-2540

© 2010 USC Libraries


All rights reserved

No part of this book may be used or reproduced in any manner without written permission
from the publisher, except in the context of reviews.

ISBN-10: 1-932800-65-4
Library of Congress Control Number: 2010925616

Library of Congress Cataloging-in-Publication Data

USC Libraries
USC School of Social Work
OAPS: Outstanding Academic Papers by Students
Contents

4 FOREWORD Catherine Quinlan

6 INTRODUCTION Marilyn Flynn

8 TRAUMA: A THEORETICAL PERSPECTIVE Amelia Abernathy

28 REVIEW OF THREE APPROACHES TO PLAY THERAPY:


CHILD-CENTERED PLAY THERAPY, FILIAL THERAPY,
AND SANDPLAY THERAPY Deborah Bauman

48 EVALUATION RESEARCH DESIGN IN THE IMMIGRANTS’


RIGHTS PROJECT Erin Dowler

66 CONCEPTUALIZING PEDOPHILIA THROUGH THEORY,


NEUROBIOLOGY, AND CULTURE Jennifer Gebauer

90 CROSS-CULTURAL SKILLS BUILDING TRAINING PROGRAM


FOR THE PROGRAM FOR TORTURE VICTIMS CLINICAL STAFF
Lorene Gingerich

116 SUCCESSFUL AGING AND ITS IMPLICATIONS FOR CHINESE


COMMUNITIES Sarah Jacobus

128 SOCIAL WORK AND THE PATIENT-CENTERED MEDICAL HOME


Carolina Rodriguez

142 HEAD START AND DCFS Heather Stephens

156 POLICY ANALYSIS OF THE GANG VIOLENCE AND JUVENILE


CRIME PREVENTION ACT Iman A. Turner

168 CHILDHOOD OBESITY IN AMERICA Krystal Wang


Foreword

CATHERINE QUINLAN
Dean, USC Libraries
7

The Outstanding Academic Papers by Students (OAPS) program showcases excellent


student research on a global stage and underscores the library’s role in the achieve-
ments of scholars-in-training. USC is the first North American institution to participate
in this international endeavor with 11 Asian universities. We are very proud to present
these ambitious explorations by USC School of Social Work students in our inaugural
OAPS publication.

Research libraries are necessarily global entities. In order to help our university com-
munities achieve their goals, we develop collections that are as international as they are
interdisciplinary. We build digital libraries that reach beyond the oceans and across the
continents. We welcome researchers from nations far and wide to our home campuses,
where treasures unique to each of our libraries inform the creation of new knowledge.
As we help our students become citizens of the world, libraries must be increasingly col-
laborative keepers and effective communicators of the global body of knowledge. OAPS
is one expression of that imperative.

The USC School of Social Work—through its China Program, the Center for Asian-Pacific
Leadership, and Global Immersion initiatives—prepares students for successful practice
and leadership on an international scale. With such an expansive, international vision, the
school is an exemplary partner in this project of cross-cultural exchange and understand-
ing. I thank Dean Marilyn Flynn and the students and faculty of the School of Social
Work for joining the USC Libraries as we introduce OAPS to the University of Southern
California.

I also would like to express my great appreciation to Professor Steve Ching, university
librarian of the City University of Hong Kong, who began OAPS in 2005. Under his
energetic leadership, it has become an emblem of vital collaboration among research
libraries. As we look to expand OAPS to other schools at USC, I hope we are as suc-
cessful as Professor Ching has been in inspiring participation in this rewarding and
prestigious program.
Introduction

MARILYN FLYNN
Dean and Professor, USC School of Social Work
9

It is with great pleasure that I present the University of Southern California School of
Social Work’s inaugural collection of Outstanding Academic Papers by Students (OAPS) in
partnership with USC Libraries. The USC School of Social Work is honored to partner with
USC Libraries as the first North American university in this prestigious project and to be
included with some of the finest academic institutions in Asia who are participants.

Ten outstanding student papers were selected for publication in this collection by USC
faculty and a review committee for their superior research, writing, and presentation.
Faculty recommended papers based on their students’ exceptional ability to analyze and
apply social work theories and their expertise in conceptualizing and pursuing their own
evidence-based research. Recognition was given to papers that achieved excellence in
scholarly output.

The USC School of Social Work believes there is significant value in sharing these
outstanding papers with international researchers and students along with our own stu-
dents, faculty, administrators, and OAPS partner institutions. We hope other people can
learn from this research and that it will enable them to better understand others’ diverse
experiences and different cultures.

The OAPS project aims to help students acquire proper research and writing skills and
instill in them academic honesty and respect for intellectual property. It also provides an
avenue for building a collection of distinguished student writing to share with partner
institutions and to promote readership worldwide. The USC Libraries and USC School
of Social Work collection includes term papers and projects, reports, case studies, and
research from a diverse group of graduate courses.

We believe this partnership is a great opportunity for our students to receive recognition
and for the USC Libraries and the USC School of Social Work to highlight the quality of
our students’ work. Not only does this partnership promote scholarly communications,
but it allows online access to exceptional research papers from the USC community and
other OAPS institutions. We are committed to OAPS’s goals and look forward to collabo-
rating with other universities around the world to promote distinguished student papers.
Trauma:
A Theoretical Perspective

AMELIA ABERNATHY
Human Development and Mental Health
Professor Doni Whitsett
11

INTRODUCTION
With the country still recovering from the devastating effects of Hurricane Katrina, as
military personnel begin to return home from a war ignited by an act of terror, and
while domestic violence and child abuse continue to persist, the concept of trauma is
becoming increasingly pertinent to mental health professionals. Judith Herman (1992)
describes psychological trauma as “an affliction of the powerless” (p. 33). Traumatic
events can include everything from interpersonal violence to witnessing fellow soldiers
die in an IED explosion. Cozolino (2002) argues that trauma can even include events
such as separating from a parent (for a child) or loss of a pet (for an adult); trauma
may even result from a stressed environment in utero. While these events may not be
traumatizing for all individuals, mental health professionals must be aware of the extent
to which events such as these can negatively impact a person’s overall functioning and
well-being. In the following paper I will provide a description of trauma and its possible
consequences. Next, I will explain trauma through three theoretical lenses: behavioral
theory, cognitive theory, and neurobiological theory. Lastly, I will present cultural
considerations when working with individuals coping with traumas and a brief treatment
section on a widely used intervention for treating traumatized individuals.

TRAUMA AND THE TRAUMA RESPONSE


Trauma is the exposure to, or experience of, events that involve severe stressors (Basham,
2008) that overwhelm the individual’s capacity to adaptively function (Herman, 1992).
Lenore Terr (1991) proposes two types of childhood trauma that assist in understanding
the trauma response. Type I traumas include events such as rape, an earthquake, a car
accident, witnessing death, and loss of a loved one (Basham, 2008). These are single,
shocking and terrifying events in which the individual experiences symptoms that usually
meet diagnostic criteria for Posttraumatic Stress Disorder (PTSD) (i.e. re-experiencing,
avoidance, hyperarousal). Type II traumas, on the other hand, are traumas in which
children have repeatedly been exposed to trauma. Child sexual or physical abuse and
ongoing witnessing of domestic violence are examples of this. Reactions to this type
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of trauma involve rage, denial and psychic numbing, or self-hypnosis and dissociation
(Terr, 1991). One may even argue that military personnel repeatedly exposed to
death, mutilation, and possibly sexual assault may develop the same sense of learned
helplessness that many children exposed to Type II traumas experience. While trauma
may encompass a variety of reactions that involve a strain on one’s mental health,
Westernized societies have come to understand trauma within the context of a clinical
diagnosis—PTSD (Breslau, 2004).

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text-
Revision (DSM-IV-TR) defines trauma within the anxiety disorder PTSD. PTSD defines
trauma as the exposure to an event in which: “(1) the person experienced, witnessed,
or was confronted with an event or events that involved actual or threatened death
or serious injury, or a threat to the physical integrity of self or others,” and “(2) the
person’s response involved intense fear, helplessness, or horror” (American Psychological
Association (APA), 2000, p. 467). There are three clusters of symptom criteria under
which individuals diagnosed with PTSD must meet: re-experiencing (e.g. flashbacks,
nightmares, intrusive thoughts), avoidance/numbing (e.g. avoidance of thoughts, places,
or people reminiscent of the trauma, an inability to recall specifics of the traumatic
event, restricted range of affect), and arousal (e.g. sleep difficulties, outbursts of anger,
hypervigilance). The symptoms must be experienced for more than four weeks and must
cause clinically significant disruption in functioning.

A less severe disorder that may also develop in individuals who have been exposed
to a traumatic event is Acute Stress Disorder (ASD) (APA, 2000). ASD shares a similar
clinical picture to PTSD. However, the duration of symptoms is less than one month, and
individuals must only meet three dissociative symptom criteria (e.g. lack of emotional
response, depersonalization, and inability to access traumatic memory). It is important
to keep in mind various diagnoses that may mask symptoms of PTSD and ASD when
assessing for trauma (e.g. Adjustment Disorder and mood or anxiety disorders) (APA,
13

2000). Lastly, the clinician must also keep in mind that while PTSD and ASD are indicative
of exposure to a traumatic response, they are not the only consequences of trauma.
Other effects of trauma may include: self-mutilation, re-victimization, sexual dysfunction,
dissociation, alexythymia, and psychosomatic illness (personal communication, 2009).

Reactions within both trauma types and diagnostic criteria involve features that
comprise what Herman (1992) refers to as the Dialectic of Trauma. She recognizes three
trauma responses: hyperarousal (i.e. a continual state of alert), intrusion (i.e. repeated
interruption of the traumatic event usually in the form of flashbacks and dreams), and
constriction (i.e. a state of helplessness and/or surrender). Herman proposes that the
intrusive and constrictive reactions to trauma “establish an oscillating rhythm” (p. 47).
That is, because neither of these responses allows the individual to amalgamate the
traumatic event into one piece, the individual is constantly attempting to find a middle
ground between these two extremes. For example, a woman, raped by her father, may
vacillate back and forth between intrusive flashbacks of the horrifying event in which she
feels the fear, rage, and panic to feelings of detachment, inability to emotionally connect
with others, and at times a lack of feelings altogether (numbing). This switching back and
forth, between a reliving mode and a denial mode, perpetuates the individual’s inability
to integrate the trauma, and may thus cause more complex problems to arise.

THEORETICAL EXPLANATIONS
I will now discuss three theoretical perspectives from which trauma/PTSD can be
understood: behavioral theory, cognitive theory, and a theory of neurobiology. PTSD will
be included in this discussion as many of the reactions to trauma are embodied in the
diagnostic criteria of this disorder. However, it is important to remember that trauma
is a subjective experience. Individuals may respond to trauma in different ways, all of
which may or may not interfere with functioning. For purposes of this paper, it will be
assumed that the examples provided to highlight theoretical underpinnings are of clinical
significance and are traumatic in nature.
14

BEHAVORIAL THEORY: CLASSICAL AND OPERANT CONDITIONING


Behavioral theory is comprised of two types of conditioning, both of which can be used
to explain the development of trauma/PTSD. Classical conditioning stems from the
work of Ivan Pavlov and involves particular behaviors that emerge as a response to a
particular stimulus (Zastrow & Kirst-Ashman, 2007). A neutral stimulus (NS) is paired
with an unconditioned stimulus (UCS) which elicits an unconditioned response (UCR).
Unconditioned stimuli produce respondent behavior; this behavior is unlearned and
naturally occurs in response to the UCS (Zastrow & Kirst-Ashman, 2007). Even after the
UCS is removed, the individual associates the NS with the UCS and develops a conditioned
response (CR). This NS then becomes a conditioned stimulus (CS) which now elicits a CR.
This can be more easily understood within the context of a traumatic event.

For example, consider a woman (Mary) who was raped in a public restroom. During the
rape Mary experienced intense fear and felt as though her rapist might kill her. To this
day, Mary cannot return to that bathroom without experiencing those same reactions she
felt in response to the unexpected attack. The rape was the UCS that produced a natural
response of fear and horror (UCR). This was paired with the public restroom which served
as the NS. However, following the trauma, Mary has now learned to pair the restroom
(the CS) with the same feelings she experienced from her trauma (CR). Additionally,
Mary fears not only that specific public restroom in which she was violated, but all public
restrooms. This phenomenon, known in behavioral theory, is called generalization (Robbins,
Chatterjee, & Canda 2006). Mary has linked the CR (intense feelings of fear and death)
with the stimuli that are similar to the CS (public restroom). This example illustrates the
ways in which an individual exposed to a traumatic event can associate the event with
multiple areas of life, thus impairing the individual’s ability to function normally.

One can see how some of the features of PTSD, as indicated in the DSM-IV-TR (APA,
2000) may be explained through this type of learning. Intense psychological distress or
physiological reactivity (CR) may generalize and arise when exposed to a reminder or
15

symbolized object of the traumatic event (CS); as was the case with Mary and all public
restrooms. Individuals may also avoid places, people, or activities that remind them of
the traumatic experience due to the intolerable CR. Still, others may experience a startle
response (CR) in reaction to a noise (CS) that they associate with the trauma (e.g. a
soldier hears a helicopter (CS) which elicits the startle response (CR) due to threat of
death by enemy helicopters). However, there is another type of learning that can assist
in understanding the trauma response.

Operant conditioning is a type of learning in which behaviors are reinforced (Robbins


et al., 2006). This type of learning can best be used to explain the avoidance symptom
of clusters within PTSD. There are two types of reinforcement: positive, which increases
the frequency of behavior through positive consequences experienced immediately
following the action, and negative, which increases the frequency of behavior by removing
aversive stimuli (Zastrow & Kirst-Ashman, 2007). Negative reinforcement can primarily
be used in examining the effects of trauma. Negative reinforcement can be used by
examining the vignette of Mary, discussed above. Avoidance of public restrooms serves to
negatively reinforce Mary’s fearful memories and physiological reactions to the trauma.
By steering clear of public restrooms, reactions to the trauma reminder subside or are
avoided completely, and thus increase Mary’s association of the restroom with her trauma
response as well as Mary’s likelihood of avoidant behaviors in the future. Through both
Classical and Operant Conditioning techniques, many of the symptoms that arise in the
trauma response can be explained. However, this theory is less useful when attempting to
explain emotional trauma responses other than fear, the deficits in trauma memory recall,
and the nature of intrusive re-experiencing (Brewin & Holmes, 2003).

COGNITIVE THEORY
Cognitive theory allows for a different perception of the effects of trauma/PTSD.
Cognitive theories include models that address the ways in which individuals think and
understand (Zastrow & Kirst-Ashman, 2007). Within this theoretical framework, it is not
16

the traumatic event itself that elicits symptoms of trauma/PTSD, but the appraisal of the
event (Brewin & Holmes, 2003). One of the consequences of the negative appraisals,
which many traumatized individuals generate post-trauma, is the shattering of belief
systems (Janoff-Bulman, 1992 as cited in Brewin & Holmes, 2003). In a study done
on victims of assault, Dunmore, Clark, & Ehlers (1999) describe ten cognitive factors
they found to be associated with PTSD symptoms. These factors centered on negatively
appraised views of the self, the world, and others (Dunmore et al., 1999). Globally,
negatively-held beliefs include thoughts such as “There is no goodness in the world,”
or, “The world is unjust.” Trauma likewise affected individuals’ views of others, creating
thoughts such as “No one can be trusted,” or, “There is no safe place.” Lastly, negative
appraisals of the self incite beliefs such as “I am disgusting,” or, “No one will ever love
me again.”

Dunmore et al. (1999) additionally discuss the role of what Ehlers et al. (1998) refer to
as “mental defeat.” This concept refers to an individual having completely given up in
his/her mind, and thereby feels defeated, convinced that he/she can no longer protect
him/herself (Ehlers et al., 1998). This is a phenomenon often seen in trauma victims
and speaks to some of the avoidance symptoms seen in PTSD. Mental defeat may
cause an individual not only to feel hopeless and helpless, but to feel that they can
no longer trust themselves, let alone others or the world. This may in turn cause these
individuals to avoid people, places, or activities that will trigger trauma reminders
and put them in a place in which they “know” they will be unable to protect
themselves (Dunmore et al., 1999). Additionally, Dunmore et al. discuss the ways in
which individuals interpret their symptoms of PTSD, and how this can reinforce the
persistence of the trauma reaction.

Ehlers & Clark (2000) propose a cognitive theory that specifically addresses the
persistence of PTSD symptoms. While this theory does not explain the ways in which
cognition influences an individual’s response to trauma, it is useful in understanding how
17

symptoms of trauma continue to plague traumatized individuals. Ehlers & Clark speak
to the paradoxical nature of PTSD as an anxiety disorder, in that individuals suffering
from PTSD are anxious about threats to the self in the future, despite the trauma being
rooted in the past (Ehlers & Clark, 2000; Brewin & Holmes, 2003). Thus, Ehlers & Clark
suggest that individuals are unable to see the trauma event as time-limited and process
the traumatic event as though there is a current threat to the self and that this threat will
persist into the future.

Ehlers & Clark (2000) state that individuals suffering from PTSD will negatively appraise
the traumatic event, leading the individual to believe that the threat is not one of the
past, but one of the present and future. Threats can be both internal (to the self) and
external (of the world). There are various types of appraisals: appraisals of the traumatic
event, appraises of the consequences of the trauma (i.e. initial PTSD symptoms, others’
reactions to the trauma, and various other life consequences of the trauma), and
appraisals of the individual’s emotional response to the trauma. In conjunction with the
evidence provided above, the cognitions of traumatized individuals are often comprised
of negative appraisals that are made toward the self, the world, and the future (Ehlers
& Clark, 2000). In this model, negative appraisals of the symptoms of PTSD perpetuate
the perceived and impending threat. For example, an adolescent boy has been sexually
abused by his older brother. One symptom of PTSD he may experience is psychic
numbing, in which he detaches emotionally from others. Ehlers & Clark posit that this
boy may then negatively appraise this symptom to the self stating, “I’ll never be able to
love anyone,” or while negatively appraising to others, “No one will be able to love me.”
This negative appraisal creates the perception that the threat is one of the present and
future, not of the past where the trauma actually lies. Ehlers & Clark (2000) have created
a list of negative appraisals that reinforce the persistence of PTSD symptoms.

Cognitive theory is useful in understanding the helplessness, hopelessness, and mental


defeat that individuals exposed to trauma may experience. However, it seems to be more
18

useful in explaining the persistence of the trauma response rather than the etiology of
the disorder itself. While the theory does illustrate the effects of trauma/PTSD, this theory
may be more useful in conjunction with other theories, therefore utilizing a more eclectic
theoretical framework.

NEUROBIOLOGY
The last theoretical lens that will be used to explain the trauma/PTSD is through a
neurobiological framework. The role trauma plays in the brain and body is intricate and
complex. Therefore, amongst the varying neurobiological systems, a brief description of
the normal stress response will be provided followed by a discussion of the differences
seen in individuals who have suffered trauma/PTSD.

The amygdala may have one of the most critical roles in the stress response as it can be
seen as a gateway where sensory input is initially screened. As part of the brain’s limbic
system, the amygdala’s primary responsibility is to appraise safety and be attuned to
danger (Cozolino, 2002).The amygdala has two paths through which sensory input can
be simultaneously received (Cozolino, 2002).

In the first, a more primal response, sensory information is taken in through the thalamus
and is passed straight to the amygdala. This is the quickest path to activating the fight or
flight response. The information is then passed from the amygdala to the hippocampus
and then to the prefrontal cortex (Cozolino, 2002; Cohen, Perel, DeBellis, Friedman, &
Putnam, 2002). However, as humans have evolved, the brain has developed another
pathway. While slower on route to its final destination (the amygdala), this pathway
allows individuals to first interpret the sensory stimuli and cognitively process whether
it is dangerous or not. This path takes in information from the thalamus, directs it to the
prefrontal-cortex (which is in the left hemisphere of the brain), then to the hippocampus
(which is responsible for integration of conscious forms of memory), and finally to the
amygdala (Cozolino, 2002).
19

This process is, however, quite different in an individual who is experiencing trauma.
During a traumatic event, the individual is inputting this sensory information through
the thalamus and simultaneously sending the information down its circuits. However,
during a trauma, it seems as if the hippocampus, where the memory would be stored,
shuts down and the memory is stored in sub-cortical regions of the brain which are
accessible by the amygdala (Applegate & Shapiro, 2005). The amygdala appears to
overreact to the sensory input, which may possibly be the source of the intrusive
symptoms of PTSD, as well as the extreme fear that is seen in trauma survivors. This
understanding of the way information is processed during a trauma is extremely useful
in understanding how traumatic memories are stored and consequently many of the
symptoms of trauma/PTSD survivors.

The hippocampus primarily stores what is referred to as explicit memory (Cozolino,


2002). Explicit memory is a form of conscious memory from which semantic, sensory, and
motor forms of memory are learned and can be pulled into consciousness. This form of
memory is what helps us contextualize our experiences and remember them in a certain
time and place. Implicit memory, which is stored in the subcortical regions of our brain
and is implicated with the amygdala, is memory that involves unconscious learning (i.e.
emotional responses, patterns of behavior, automatic skills) (Cozolino, 2002). What
becomes problematic for the traumatized individual is the ways in which these memories,
or lack thereof, are stored.

Implicit memories are stored in the right hemisphere of the brain, which is online at
birth, dominant for the first three years of life, and is sensitized to facial expressions.
The left brain stores explicit memories, but does not come online until around age four
(Cozolino, 2002). This is useful in understanding the ways in which early childhood
traumas may be consciously “forgotten.” For example, a child sexually abused at
the age of two may not have any explicit memory recall of the event, as the left
hemisphere is not online at this age. However, the right hemisphere is online and is
20

where implicit memories from this childhood abuse (i.e. fear, anger, immobility) are
stored. Even with older children, adolescents, and adults (whose left hemispheres are
online), accessing explicit memories may still be difficult due to the hippocampus’
inability to effectively process information during a trauma. The implicit memories,
however, will still be there.

This explains the inability to recall certain aspects of a trauma among individuals diagnosed
with PTSD. It can further help explain symptoms of re-experiencing, and in particular
flashbacks, re-enactment, and intrusive thoughts, images, or perceptions. Because the
hippocampus was unable to appropriately store the memory of the trauma, traumatized
individuals often have no context in which to place the trauma (Cozolino, 2002). Thus, they
experience the trauma in the present, often in the form of flashbacks, intrusive thoughts,
or re-enactment. These memories of the trauma are often fragmented (due to the poor
processing of the hippocampus) and are mostly comprised of implicit memories (i.e. an
angry face, the feeling of being slapped, the fear accompanied by lack of control).

Even if fragmented memories are able to be retrieved, traumatized individuals often


will have difficulty verbalizing the trauma. This is due not only to the more primitive
information processing track that is utilized during a trauma (from the thalamus to the
amygdala), but also possibly to a decrease in blood flow to Broca’s Area, an area of the
left cortex where verbal expression is controlled. This may result in what is referred to as
speechless terror, and will likewise impact the brain’s ability to explicitly store verbal
conscious memory of the trauma as the trauma is processed through the alternative
sensory input circuit (Cozolino, 2002).

Another neurobiological system to examine is that of the neurotransmitter responsible


for attention and focus—norepinephrine (NE) (Cohen et al., 2002). One of the most
important roles of NE is its involvement with the fight-or-flight response. When an
individual encounters a stressful situation, a surge of NE is released. The locus ceruleus
21

(LC), the primary production area of NE, responds to the stressor by increasing levels of
NE which are sent to the amygdala. Thus, the NE serves to heighten the functioning of
the amygdala, thereby reinforcing the encoding of implicit memory. With traumatized
individuals, this mechanism is particularly salient when considering the consequences
of intensified implicit memories and fragmented, or lack of, clear explicit memories
(Cozolino, 2002; Cohen et al., 2002). This may speak to the exaggerated re-experiencing
symptoms of the trauma response.

A different neurobiological system that plays a role in the stress response is that of
the Hypothalamic-Pituitary-Adrenal (HPA) axis. As a part of the sympathetic nervous
system’s normal stress response, the amygdala activates the paraventricular nucleus in
the hypothalamus (Cohen et al., 2002). Corticotropin-release hormone is expelled and
received by the pituitary gland, which then releases corticotropin (ACTH). ACTH is then
collected by the adrenal cortex which releases cortisol into the body (Cohen et al., 2002).
As cortisol increases, various other organs in the HPA axis adjust accordingly, and the
individual can return to a homeostatic state. However, in an individual who has been
traumatized, the individual’s body remains on high alert, and cortisol levels remain high.
High levels of cortisol can, in turn, be toxic to the hippocampus, resulting in decreased
hippocampal volume (Cohen et al., 2002; Bremner, Randall, Scott, & Bronen, 1995).
This may be especially true and should be kept in mind when working with traumatized
children (Cohen et al., 2002).

Continued stimulation of the HPA axis by the amygdala and the sustained response of
the sympathetic nervous system to a trauma will keep the individual in a heightened
state of alert (Cohen et al., 2002; Cozolino, 2002). Exaggerated startle response,
irritability, and other symptoms within the hyperarousal cluster of PTSD may be a result
of this dysregulation (Cozolino, 2002). Additionally, excessive amounts of dopamine in
the medial prefrontal cortex may likewise account for some of the trauma symptoms of
hyperarousal such as hypervigilance or paranoia (Cohen et al., 2002).
22

Lastly, Cohen et al. (2002) also discuss two other reactions to the stress response that
differ in individuals suffering from trauma/PTSD. While the role of Serotonin is unclear,
it appears that low levels have been found to be associated with consequences of
trauma such as suicidality, depression, and aggression. On the other hand, high levels of
endorphins, which are released as a part of the normal stress response, may contribute
to the psychic numbing and avoidance symptoms experienced by survivors of trauma.
However, this connection remains unclear (Cohen et al., 2002).

CULTURAL DIVERSITY CONSIDERATIONS


An exhaustive discussion of cultural and diversity factors implicated in PTSD/trauma
survivors is beyond the scope of this paper; however, issues to keep in mind when
working with these individuals will briefly be presented here. While trauma is a universal
phenomenon, the ways in which a culture classifies, perceives, interprets, and responds
to threatening events may differ (Chemtob, 1996). It is important to keep in mind that
trauma is ultimately a subjective experience, and different individuals may appraise the
distressing experience according to their cultural context (Young, 1994).

In a study done by Santos et al. (2008), it was found that non-white traumatic-
injury survivors (i.e. American-Indian, African-American, and Hispanic) were more
likely to show higher rates of early posttraumatic stress symptoms than white
traumatic-injury survivors. Ruef, Litz, and Schlenger (2000) examined possible cultural
factors to influence higher rates of combat-related PTSD in Vietnam War veterans.
It was hypothesized that possible differences in emotional processing (i.e. difficulty
expressing traumatic experience) and coping skills for traumatic events (particularly
in combat-related scenarios) may assist in explaining elevated rates of PTSD in
the Hispanic population. Additionally, Ruef et al. (2000) postulate that possible
intergenerational transmission of learned helplessness due to a sociocultural norm
of fatalistic coping mechanisms may be seen in a Hispanic population, as well as in
other ethnic minority groups who share similar cultural coping styles. While this is just
23

one example of how culture may influence the trauma response, this emphasizes the
importance of cultural competence among crisis responders.

In a world where cultures are increasingly coming into contact with one another, where
integration of multiple cultures is becoming a norm, it is important to understand
differences in response to trauma as well as to acknowledge the stress that may
accompany these cultural melting pots and thus an individual’s ability to cope with the
impact a trauma may present (Chemtob, 1996). In addition to cultural competency,
understanding factors that may put certain ethnic/racial/cultural groups at risk is
essential. Ford (2008) discusses the ways in which identification or classification
with a particular cultural/racial group may put an individual at risk for trauma/PTSD.
He highlights the ways in which racism toward a particular group may increase the
likelihood of this group’s exposure to trauma and development of PTSD. Further, Ford
argues not only how racism acts as a stressor that may predispose certain groups to
trauma exposure, but how racism itself may be a psychological trauma.

While it appears that more research needs to be done in this area before stronger
conclusions can be made between trauma and culture, it is clear that there is a
relationship between the two. Cultural competence and understanding of greater
macro-level forces that may be at work within particular groups, therefore, is critical in
dealing with survivors of trauma/PTSD. One of the most important steps to achieving
this awareness is for clinicians treating crisis situations to be familiar with their own
cultural identity and how it may impact treatment (Young, 1994). It is with hope
that by taking culture into consideration that effective treatments for this vulnerable
population will flourish.

TREATMENT
There are several evidence-based interventions that address trauma; however, not all
treatments are utilized with both adults and children. Two evidenced-based approaches
24

that are used to treat trauma are Prolonged Exposure Therapy for Posttraumatic Stress
Disorder (PE), which is designed for use with adults (National Registry for Evidence-
Based Programs and Practices (NREPP, 2007), and Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT), designed for use with children/adolescents (NREPP, 2008). For
purposes of this paper, only TF-CBT will be discussed here in that it most closely aligns
with the theoretical perspectives presented.

TF-CBT is a child-focused evidence-based practice that utilizes cognitive behavioral


theories of practice and addresses neurobiological complications that are seen in
survivors of trauma. This intervention is designed to treat trauma/PTSD as well as
emotional and behavioral problems that often arise in children who have experienced a
trauma (NREPP, 2008). One of the core components of this practice is its adaptable use
among varying cultures, as the authors of the treatment recognize the influence culture
has on the trauma response.

Treatment components can be summarized through the acronym PRACTICE (Cohen et


al., 2006; Cohen & Mannarino, 2008). Psychoeducation is used to assist the parent
and the child/adolescent in understanding the impact of trauma and the symptoms
the child/adolescent may be experiencing. Additionally TF-CBT utilizes a Parenting
Component, in which parents of the traumatized child/adolescent receive paralleled
sessions to assist in developing parenting skills and to allow the parent(s) to process
the trauma of their child. As has been discussed previously, negative appraisals
surrounding symptoms of trauma can exacerbate/reinforce the persistence of PTSD
(Ehlers & Clark, 2000). Thus, both these components may serve to ease anxiety and
reframe negative appraisals.

Relaxation Skills are taught to addresses many of the physiological symptoms that
accompany trauma/PTSD (i.e. hyperarousal). Parents are additionally taught skills to aid
in their own self-care. Cohen et al. (2002) suggest relaxation techniques be used to assist
25

children/adolescents in coping with many of the effects of heightened norepinephrine


levels (i.e. flashbacks, hyperarousal). Affect Expression and Modulation Skills sequentially
follows presenting skills that assist children in their ability to effectively express and
modulate their emotions. Cohen et al. (2002) discuss a lack of connection between the
right and left hemispheres in traumatized individuals. This may result in an inability to
link feelings with verbalizations or manifest as a restricted range of affect, as is seen in
survivors of trauma.

Cognitive Coping and Processing (Part I) is the portion of treatment that assists children
in recognizing the connection between thoughts, emotions and behaviors; combining
tenants from both cognitive and behavioral theory. Once this is done, the child can begin
the Trauma Narrative (Cohen et al., 2006). Applegate & Shapiro (2005) emphasize, from
a neurobiological perspective, the importance narratives serve in connecting neural
networks from implicit memory with explicit memory. By repeatedly discussing the
traumatic event, the idea is that the child will become more comfortable thinking about
the event, thus gradually reducing or diminishing symptoms of PTSD brought about
by this lack of neural connection (Cohen et al., 2006; Applegate & Shapiro, 2005). The
second part of the Trauma narrative is Cognitive Coping and Processing (Part II) in which
the therapist begins to discuss with the child the feelings and emotions surrounding
the traumatic experience, identifying cognitive distortions and assisting the client in
reframing these negative appraisals.

In Vivo Mastery is the next component that works further with the child to master
traumatic memories and cope with the symptoms they may be experiencing. This takes
a behavioral approach, and is particularly useful in dealing with trauma/PTSD symptoms
of avoidance. Co-Joint Sessions are the next step in allowing the child to integrate the
trauma further through sharing the narrative with his/her parent(s). Lastly, Enhancing
Future Safety and Development assists the child/adolescent in any specific skills still
needed by the child and/or family members (i.e. for a child who has been sexually
26

abused, this treatment component may include creating a safety plan) (Cohen et al.,
2006). This brief description delineates the techniques used to treat trauma through a
behavioral, cognitive, and neurobiological lens.

CONCLUSION
The impact of trauma is complex and multifaceted. This paper has presented a brief
description of trauma and the trauma response, as well as three theoretical lenses
through which trauma and PTSD can be explained. While these theoretical frameworks
are useful, they are, alone, unable to account completely for all the manifestations of
the trauma response. Using an eclectic approach when working with survivors of trauma
may be most effective. Additionally, cultural competence among clinicians is essential in
understanding the greater forces that may be at hand when working with traumatized
individuals. Lastly, choosing a treatment modality that will specifically address the needs
of this population is vital to successful recovery. It is through theory, however, that one
can first begin to understand the manifestations of trauma as well as the foundation
upon which treatment is guided.
27
28

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Review of Three Approaches to Play Therapy:
Child-Centered Play Therapy, Filial Therapy,
and Sandplay Therapy

DEBORAH BAUMAN
Directed Research in Social Work
Professor Eugenia Weiss
31

INTRODUCTION TO PLAY THERAPY


Play is the universal language of children and the principal activity of childhood (Landreth,
2002). The value of play for healthy cognitive development, language development, social
competence and physical development is widely recognized (Reddy, Files-Hall & Schaefer,
2005). Piaget posited that play helps connect concrete experience and abstract thinking; it is
therefore the symbolic aspect of play that is critical to a child’s development (Schaefer, 1993).
Through play, children can master feelings, thoughts and experiences through symbolic
representation that may be difficult to manage or directly express in reality (Landreth, 2002).
Because children are not developmentally equipped to adequately express themselves
verbally, a therapist can use play with children experiencing psychosocial problems or serious
mental disorders because it is their natural means of self-expression (Landreth, 2002). In
the presence of an empathic adult or therapist, children will express their feelings and needs
through play materials of their choosing (Schaefer, 1993).

“Play therapy” is a general term that refers to a range of therapeutic interventions


that vary greatly regarding elements, such as use of direction by the therapist,
interpretation and involvement with members of the family (Johnson, Bruhn, Winek,
Krepps, & Wiley, 1999). The common aspects of these approaches are the view
of play as the child’s medium of communication and the use of play materials in
treatment. For clarification, The Association for Play Therapy (2001) defined play
therapy as “the systematic use of a theoretical model to establish an interpersonal
process wherein trained play therapists use the therapeutic powers of play to help
clients prevent or resolve psychosocial difficulties and achieve optimal growth
and development” (p. 20). Uses of play therapy are broad: it can be used to
aid in diagnosis of a child, build a therapeutic relationship, reduce maladaptive
defenses, assist children to verbalize difficult feelings, facilitate the expression of
unconscious material and relieve associated tension, and discover interests that can
be transferred to daily life (Gil, 2002). Play therapy has a variety of curative powers,
including increasing the child’s potential for self-expression and communication,
32

problem-solving, discharge or abreaction of emotion, working through difficult or


painful life experiences, and enhancing relationships (Schaefer, 1993).

A wide range of theories serve as a foundation for play therapy; these theories shape
different approaches to play therapy, and the field at large. Leading schools of play
therapy are client-centered, cognitive-behavioral, family, and psychodynamic; each places
different emphases on the curative powers of play (Reddy, Files-Hall, & Schaefer, 2005).
There is also a prescriptive school of play therapy that promotes the view that play
therapists should apply play therapy approaches differentially to fit the needs of clients
(Reddy et al., 2005). Although there is a paucity of research supporting the efficacy of
one model over another (James, 1997), a meta-analysis by Ray, Bratton, Rhine and Jones
(2001) on the efficacy of play therapy concluded that this intervention was effective
across theoretical schools of thought. For the purposes of the present paper, this writer
will explore three theoretical approaches to play therapy: Child-Centered Play Therapy,
Filial Therapy, and Sandplay Therapy.

APPLICATIONS
Play therapy can be used to treat a broad range of presenting problems (Gil, 2002).
Play therapy has been shown to have positive treatment outcomes with children
across all diagnostic categories, except “the completely autistic and the out-of-contact
schizophrenic” (Landreth, 2002, p. 45). Examples of children’s presenting problems
for which there is empirical support for the intervention of play therapy include: hair
pulling, selective mutism, conduct disorder, aggressive and oppositional behavior,
ADHD, adjustment problems for children of divorce, abuse and neglect, sexual abuse,
child witnesses of domestic violence, separation anxiety, depression, psychosomatic
difficulties, maladaptive school behavior, bereavement, adjustment problems related
to chronic illness, developmental delays, reading difficulties, speech and language
problems, posttraumatic stress disorder, and adjustment related to multicultural
difference (Ray et al., 2001; Landreth, 2002). Play therapy is a flexible intervention; the
33

most comprehensive meta-analysis to date by Ray et al. (2001) found that play therapy
appears effective across modality (individual and group), age, gender, and settings. Play
therapy is appropriate with children between the ages of three and ten, but can also
be useful with preadolescents and early adolescents, especially if play materials are
developmentally appropriate (James, 1997).

RESEARCH ON THE EFFICACY OF PLAY THERAPY


There is a strong need to prove the usefulness of play therapy if it is to be accepted
widely. In the current climate of managed care, play therapists are pressured to
provide empirical support for the effectiveness of this intervention (Reddy et al., 2005).
Practitioners are asked by the legal system, third-party payors, school administrators and
parents who have to approve their child’s form of therapy to provide evidence of the
effectiveness of play therapy (Ray et al., 2001).

Despite the strong theoretical underpinning of play therapy, some critics have
challenged its efficacy, charging that the field lacks sound scientific research (Reddy
et al., 2005; Ray et al., 2001). The criticism has been based on the paucity of rigorous
research designs and methods in studies to evaluate its clinical utility (Reddy et al.,
2005). The research that does exist lacks control groups and has been primarily based
on narrative case studies with limited or no generalizability, and process and outcome
research (Bratton & Ray, 2000; Carroll, 2000). However, more recently, well-designed
controlled experimental studies have been undertaken. Two meta-analytic studies have
evaluated play therapy for its effectiveness with children (LeBlanc & Ritchie, 1999; Ray
et al., 2001). Taken together, the two meta-analyses reveal that play therapy treatments
have moderate-to-large positive effects (.66 to .80) as measured at outcome.
Interestingly, both studies showed increased positive effects with the added factors of
parental involvement in therapy and duration of sessions (Ray et al., 2001). In spite of
the strength of these meta-analyses in answering the charges of critics and providing
evidence for its effectiveness, the authors note that most play therapy research
34

continues to use small sample sizes, and thus have limited generalizability (Ray et
al., 2001). Some researchers recommend that because play-based techniques are
geared towards emotions and symbolic expression, which are generally incompatible
with scientific methods, future study designs should incorporate both processes and
outcomes (Campbell, 2004; Carroll, 2000). However, Reddy et al. (2005) recommend
further rigorous experimental studies assessing outcomes of play interventions, and
present guidelines for future outcome evaluation that include behavior scales, direct
observation, and the use of assessment instruments during play.

CHILD-CENTERED PLAY THERAPY


Child-centered play therapy (CCPT) follows the theoretical model of client-centered
therapy developed by Carl Rogers (Landreth & Sweeney, 1997). Virginia Axline adapted
Carl Rogers’ theory of personality structure and philosophy to working with children
(Gil, 2002). CCPT is based on three central constructs: the person, the phenomenal field,
and the self, with a focus on self-concept (Landreth & Sweeney, 1997). To elaborate,
child-centered play therapists place their focus on the whole child rather than on the
presenting problem. It is not always even necessary for the therapist to know about the
background of the child’s maladjustment. The phenomenal field is the child’s internal
frame of reference; the therapist must appreciate the child’s perception of reality if his
behaviors are to be understood (Landreth & Sweeney, 1997). Maladjustment is viewed
as resulting from a discrepancy between the child’s outer experience and his inner self-
concept (Landreth, 2002). Additionally, child-centered play therapists help children access
their natural striving towards growth and development through their unconditional
acceptance of who the child is (Axline, 1974). This attitude of permissiveness helps a
child attain self-actualization, become less defensive, and develop confidence and self-
direction (Gil, 2002).

Axline set forth eight basic principles of CCPT in which the therapist has a warm,
caring relationship with the child; accepts the child for who he is; creates a sense of
35

permissiveness in the relationship that frees the child; recognizes and reflects the child’s
feelings; maintains respect for the child; follows the child’s lead in play and conversation;
does not hurry the process of therapy; and sets appropriate limits for the child (Axline,
1974). The last principle is critical because CCPT does not endorse a completely
permissive relationship; limits provide safety for the child, physically and psychologically,
and anchor the session to reality (Axline, 1974). To promote the child’s full self-
expression in a safe environment, Axline recommended that the therapist select toys and
materials that promote a wide range of feelings and activities (Axline, 1974; Landreth &
Sweeney, 1997).

APPLICATIONS
CCPT is mostly used with children under age ten; however, positive results have been
demonstrated with ten- to fourteen-year-old children, with play materials adapted for
developmental appropriateness. CCPT is especially well suited for children from different
socioeconomic classes and ethnic backgrounds, since the child can freely communicate
through play; indeed, play materials can be culturally adapted to the child (Landreth &
Sweeney, 1997). CCPT has been used to treat a wide spectrum of childhood problems
(Johnson et al., 1999), including separation anxiety and speech disturbance in preschool
children, adjustment problems of children of alcoholics, and mental retardation (Johnson
et al., 1999). Based on this writer’s research, other examples of presenting problems for
which CCPT has been applied include the self-esteem, locus of control and anxiety level
of at-risk children (Post, 1999); sexually abused children (Scott, Starling, Burlingame,
Porter, & Lilly (2003); low self-confidence of African American boys at the elementary
school level (Baggerly & Parker, 2005); and child witnesses of domestic violence (Kot,
Landreth, & Giordano, 1998).

To elaborate on the application of CCPT to treat children who have witnessed domestic
violence, Kot et al. (1998) describe the use of intensive play therapy with a child-centered
approach to treat children who have been exposed to domestic violence. Research
36

has shown that children who witness domestic violence experience more internalizing
and externalizing behavior problems, increased academic problems, and interpersonal
conflicts (Kot et al., 1998). CCPT is a useful intervention for these traumatized children to
prevent maladjustment by affording them a safe environment with a supportive therapist
to disclose what they have witnessed (Kot et al., 1998). Through the child-centered
techniques, children engage in a self-curative process to replay stressful events that have
rendered them helpless, thus increasing their sense of control and assisting them to learn
coping skills (Kot et al., 1998; Schaefer, 1993). The authors used intensive sessions due
to the relatively short duration a child might stay at a domestic violence shelter. Results
of the authors’ study demonstrated the effectiveness of CCPT with this population.
Children in the experimental group showed statistically significant improvement in their
self-concept, reduction in externalizing and total behavior problems, and an increase in
play behaviors of physical proximity and positive play themes, as assessed using valid and
reliable measures (Kot et al., 1998).

RESEARCH ON THE EFFICACY OF CHILD-CENTERED PLAY THERAPY


A literature search using search terms that included “child-centered play therapy,”
“evidence,” and “efficacy” with different databases (Google Scholar, PsycArticles,
ProQuest) yielded limited results, with the exception of the two most recent and
comprehensive meta-analyses by Ray et al. (2001), and LeBlanc and Ritchie (1999).
Reflecting the state of research on play therapy, most of the articles the search produced
used case studies only, although some more recent studies were conducted with
experimental designs. Although these controlled studies offer empirical support for the
use of child-centered therapy, they are geared for particular populations and problems
only and generally have small sample sizes. It is therefore necessary to turn to the meta-
analyses to form sound conclusions.

The meta-analysis by LeBlanc & Ritchie (1999) of 42 experimental studies evaluated


characteristics or predictors of treatment that correlated to outcome success, but
37

did not analyze different theoretical approaches as predictors of treatment outcome.


Therefore, although the authors (1999) found that play therapy is an effective treatment
modality for children, it is not possible to reach conclusions about the particular efficacy
of CCPT from their meta-analysis. The meta-analysis by Ray et al. (2001) coded 74 out
of 94 studies as using a humanistic/non-directive theoretical model, 12 as behavioral/
directive, and included eight that could not be coded. The humanistic/non-directive
category demonstrated a larger effect size (.93) than the behavioral/directive category
(.73), producing a statistically significant difference. Although the authors (2001) do not
regard this difference as significant due to the low number of studies in the behavioral
category, the large effect range for the humanistic/non-directive category certainly
provides strong empirical support for the use of non-directive CCPT to treat a broad
range of presenting problems. Although a more detailed analysis of the precise nature
of the approaches in the humanistic/non-directive category is beyond the scope of the
present discussion, the meta-analysis overall provides strong empirical support for the
use of child-centered techniques.

FILIAL THERAPY
Filial therapy (FT) was developed by Bernard and Louise Guerney in the 1960s as a
way to reduce children’s psychosocial problems, improve parenting skills, strengthen
parent-child and family relationships, and address family conflicts (VanFleet, Ryan
& Smith, 2005). FT can be considered a hybrid form of CCPT in that parents or
other main caregivers are trained by a therapist to conduct non-directive play
sessions with their own children (Johnson et al., 1999). Parents therefore become
the primary agents of change for their children (Guerney, 2001). A rationale for FT
is the fact that as the parent-child relationship is almost always the most important
in a child’s life, the child’s experience of self-expression and acceptance in the
parent-child matrix should in theory produce a stronger effect than with a therapist
(Guerney, 2000).
38

To train parents, filial therapists use psychoeducation to impart skills and attitudes
that can help resolve the child’s problems and improve family relationships. The model
supports the view that parents have the resources to bring about change, a message that
offers hope and deflects the focus away from pathology and possible etiology (VanFleet
et al., 2005). Parents receive training through a combination of didactic instruction,
watching videotapes, role-playing, and supervision (Tew, Landreth, Joiner & Solt, 2002).
After the practice sessions, parents begin to carry out sessions with their children. Parents
are taught to relate more positively to their children, correcting cycles in which parent
and child misunderstand the others’ feelings or behaviors (Guerney, 2000). This approach
strengthens the parent-child bond, which in turn fosters the child’s healthy development
(VanFleet et al., 2005). As stated by Guerney (2000), another goal of FT it to help
strengthen family relationships; FT helps families achieve the characteristics of close
families (as cited in Sinnette and De Frain, 1985).

Because FT blends play therapy with family therapy, it is important that the therapist
has training in each approach. Although the child-centered play sessions are eventually
conducted by the parents, the therapist must oversee the process to bring about
successful treatment for both the child and parents, and be sensitive to the family’s needs
(VanFleet et al., 2005).

APPLICATIONS OF FILIAL THERAPY


The strength of filial therapy as a preventive and clinical intervention has been evidenced
with a wide range of child or family problems, including oppositional defiant disorder,
attention deficit disorder, chronic medical illness, child or family trauma, adolescent parents,
single parents, domestic violence, attachment disruptions, family reunification, kinship
and foster care, and adoption (VanFleet et al., 2005). Furthermore, VanFleet et al. (2005)
state that filial therapy has been adapted to a variety of settings, including clinical practice
and schools, and with multicultural populations (as cited in VanFleet & Guerney, 2003).
Guerney (2001) points out that FT is not intended to be applied for children with organic
39

problems such as autism, but only for behavioral or emotional problems. Furthermore, FT is
not considered effective with parents with serious mental disorders, who would not have
the capacity to train and conduct play sessions (Guerney, 2001).

Specifically, filial therapy has been used as an intervention for parents and families of
chronically ill children. As stated by Tew et al. (2002), there is substantial evidence that
chronic illnesses can lead to psychological maladjustment in children as these ongoing
conditions place great psychosocial stress on both children and parents (as cited in
VanFleet, 1992). Filial therapy is well-suited to the needs of this population as this
treatment helps strengthen parent-child bonds and increases family cohesiveness, thus
increasing coping ability of all members (Tew et al., 2002). Chronically ill children use the
treatment to communicate fears and feelings associated with their illness through play, thus
reducing emotional and behavioral problems. Parents learn to increase acceptance of their
children and to reduce their level of stress. The effectiveness of this intervention for parents
and families of chronically ill children was demonstrated in the controlled study conducted
by Tew et al. (2002) that showed greater parental acceptance of the child, decreased
parental stress, and reduced child problem behaviors in the group receiving filial therapy;
however, the authors note the need for follow-up studies.

RESEARCH ON THE EFFICACY OF FILIAL THERAPY


In the meta-analysis conducted by Ray et al. (2001), out of 94 studies reviewed, 28
focused on the effectiveness of filial therapy. The evaluation revealed that filial therapy
was an effective intervention for children’s difficulties, with large effect sizes compared
to nontreatment groups that performed at 1.06 standard deviations above nontreatment
groups (Ray et al., 2001). In fact, the authors (2001) state that the parental involvement
utilized in filial therapy “significantly increased the effectiveness of play therapy” (p.
94). Consistent with the findings of the meta-analysis, a critical review of the empirical
support of filial therapy over the past 45 years revealed consistent positive outcomes to
treat a wide range of presenting problems (VanFleet et al., 2005). Numerous controlled
40

studies have shown filial therapy’s efficacy in alleviating children’s presenting and
behavioral problems, increasing parental acceptance and skills, and lowering parents’
level of stress (VanFleet, 2006). Furthermore, follow-up studies have demonstrated that
therapeutic gains are sustained three and five years post-treatment (VanFleet, 2006).

SANDPLAY THERAPY
Sandplay is an expressive arts play therapy technique that blends a client-centered
approach with a Jungian focus on archetypal and symbolic meanings (Hunter, 2006). Of the
expressive arts techniques, sandplay has been described as especially engaging for children,
who enjoy making images in the sand or miniature worlds with small objects (Zinni, 1997).
Although sandplay is sometimes placed under the rubric of a psychodynamic theoretical
approach in that sandplay affords access to the child’s unconscious (Zinni, 1997), it is often
subsumed under Jungian play therapy (Zinni, 1997). It is, however, of note that Zinni (1997)
stresses that sandplay has become widely accepted in clinical practice, and is not currently
viewed as “an esoteric Jungian tool” (p. 658).

Dora Kalff, a student of Carl Jung’s, further developed Margaret Lowenfeld’s technique
from the 1920s in which children created “worlds” in sandtrays, and devised the current
version of sandplay therapy (Hunter, 2006). Kalff refocused the method to incorporate
Jung’s belief that the psyche holds the collective unconscious, and developed Jung’s
active imagination technique into a concrete use of sandplay (De Domenico, 1994).
She encouraged therapists to have a knowledge of symbols and myths to interpret the
child’s expression in the “free and sheltered space” (Kalff, 1980, p. 32). In sandtray work,
children use a tray that is filled halfway with wet or dry sand, water, and optionally with
a collection of miniature and natural objects to create a scene or design in the confines
of a larger container that is termed “temenos” (De Domenico, 1994). Kalff recommended
having numerous toy figures available to the child to bring out the inner expression of
self. Through sandplay work, the child can activate the healing power of symbols (De
Demenico, 1994).
41

To elaborate on the Jungian perspective, Jungian play therapists believe the individual
psyche has the capacity to heal itself in a safe and protected environment in the context
of a supportive transference relationship (De Domenico, 1994; James, 1997). The
content of play, reflecting the client’s inner world, reveals impulses toward growth of
the personality. The scenes and designs in the sand reveal the unconscious conflicts of
the child; sandplay promotes healing and integration by reorganizing contents of the
unconscious that have been expressed symbolically (Green, 2009). The Jungian sandplay
therapist must be familiar with archetypes, cultural and religious traditions. She strives to
recognize these aspects of the collective unconscious manifested in the child’s play that
can teach “the meaning-making matrices of their ancestors” (De Domenico, 1994). The
Jungian sandplay therapist also needs to be attentive to motifs and themes in the child’s
sand tray that express cycles of creation and destruction inherent in the life cycle (Hunter,
2006). As in client-centered non-directive play therapy, the therapist must refrain from
judgment, interference, or giving directions (Hunter, 1994).

APPLICATIONS
Sandplay can be flexibly adapted to different settings and used to treat a wide range
of presenting problems and disorders, including adjustment disorders, learning and
communication deficits, anxiety, depression, bereavement and loss, trauma and abuse,
posttraumatic stress, developmental delays, mood disorders, and borderline and
psychotic states (Hunter, 2006; Carey, 2006). It can be used effectively for culturally
diverse children, as this metaphorical form crosses barriers; miniature figures used
from the child’s culture can promote a sense of belonging (Hunter, 2006). Sandplay
can also be used as a long- or short-term model, and can succeed as a treatment with
individuals or groups.

A specific application of sandplay that has been described by authors Green and
Connolly (2009) in a case study is Jungian family sandplay (JFS) with bereaved children.
The rationale for treatment is that children under the age of ten who experience loss may
42

experience psychosocial problems as they may not be developmentally able to process


grief as well as an older adolescent or adult (Green, 2009). Although the authors (2009)
note the paucity of empirical support for play therapy with bereaved children, case
studies provide anecdotal support at least that sand therapy may help reduce symptoms
associated with grief such as irritability, social withdrawal, insomnia, and guilt (as cited
in Carey, 1991). Through sandplay, children can express loss, say goodbye to loved ones,
and reintegrate the loss while remaining anchored (Green, 2009). Because the child
experiences loss in the context of family, Green and Connolly (2009) suggest including
family members in treatment following several individual play sessions with the child to
better meet the needs of the bereaved child (Green & Connolly, 2009). Using a family-
systems lens, the authors (2009) share a case study of a six-year-old boy whose father
had suddenly died from a drug overdose who undergoes JFS with his mother. Through
JFS, the mother became more emotionally available to the son, and the sandplay enabled
the boy to symbolically express grief in a way that was developmentally appropriate. The
authors (2009) emphasize that they are not recommending JFS as a treatment of choice
for grieving children, but rather as a powerful tool and option in treatment planning.

RESEARCH ON THE EFFICACY OF SANDPLAY THERAPY


A literature search on the evidence for the effectiveness of sandplay therapy that
employed different terms and databases (Google Scholar, PsychArticles, ProQuest)
yielded little-to-no results. The scarcity of empirical support for this modality was noted
by Campbell (2004), who confirms, “few studies have attempted to provide scientific
validation for this technique” (p. 7). Demonstrating this point, in the meta-analysis
conducted by Ray et al. (2001), only one study out of 94 utilized sandplay as an
intervention (Ney, Palveskey, and Markely, 1971), meeting criteria for a rigorous research
design that warranted inclusion in the evaluation. Furthermore, this sandplay study had
a sample size of only 20 participants, limiting its generalizability. However, countering
the bias towards evidence-based interventions, Campbell (2004) asserts that the many
case studies that show positive outcomes of sandplay therapy should nevertheless be
43

considered “valid clinical evidence” (p. 8). The author (2004) suggests that the lack of
scientific validation for sandplay therapy may instead reflect limits in methodology, rather
than treatment ineffectiveness.

CONCLUSION
The three play therapy techniques discussed in this paper are all respected and much
utilized methods of carrying out therapy with a child. Although the three forms of play
therapy share some key underlying principles, they differ in the manner in which therapy
is conducted, the role of the therapist, the use of play materials (although they are
the same in child-centered and filial therapy), and the emphases of treatment. CCPT
emphasizes that the child’s use of toys is his form of communication and release, and
that interpretation is not necessary to resolve difficulties (Schaefer & O’Connor, 1983). FT
is a hybrid of CCPT and family therapy in that parents are the primary providers of child-
centered play therapy for their own children; this modality further places a greater focus
on the family system than CCPT (Guerney, 2003). The emphasis in FT is more on directly
strengthening the bond between parents and children than in CCPT, although gains in
the parent-child relationship can be made using CCPT with an individual child. In FT, the
therapist must play a more supervisory role, in addition to that of therapist, compared to
CCPT. In contrast to the humanistic schools of thought of child-centered and FT grounded
in Rogers’ client-centered therapy, Jungian sandplay is a more psychodynamic approach
in that there is a greater focus on the revelation of unconscious content through the
world the child creates in the sand (Green, 2009). However, CCPT, FT, and Jungian
sandplay therapy share Rogers’ philosophy that the child has an innate capacity for
growth and self-healing (Hunter, 2006). Jungian sandplay additionally emphasizes the
transpersonal healing power of symbols as revealed through sandplay.

All three techniques share basic principles of play therapy, namely that the child is
not a miniature adult (Landreth, 2002), that the best way to connect with a child is
through play and the use of play media, that play serves a function for the child of
44

communication and self-expression, and that the child uses play to work through and
resolve problems (Schaefer & O’Connor, 1983). Furthermore, all three approaches
place a central value on the importance of the child’s relationship with an empathetic
therapist whose sensitive understanding and acceptance fosters the child’s process of
self-realization (Axline, 1974; Landreth, 2002; Hunter, 2006). Encapsulating the child’s
response to the healing experience of play therapy, Axline (1974) quotes a child in play
therapy, who says of the therapist’s work, “I mean I wouldn’t know how to do what she
does. I don’t even know what she does. She doesn’t seem to do anything. Only all of a
sudden, I’m free. Inside me, I’m free” (p. 19). This child’s words stand as a testimony to
the power of play therapy.
45
46

REFERENCES

Association for Play Therapy. (2001, June). Play therapy. Association for Play Therapy
Newsletter, 20, 20.
Axline, V. (1974). Play therapy. New York: Random House Publishing Group.
Baggerly, J. & Parker, M. (2005). Child-centered group play therapy with African American boys at
the elementary school level. Journal of Counseling & Development, 83(4), 387-396.
Bratton, S., and Ray, D. (2000). What the research shows about play therapy. International
Journal of Play Therapy, 9(1), 47-88.
Campbell, M. (2004). Value of sandplay as a therapeutic tool for school guidance counsellors.
Australian Journal of Guidance and Counseling, 14(2), 211-232.
Carey, L. (2006). Short-term family sandplay therapy. In H.G. Kaduson & C.W. Schaefer (Eds.),
Short-term play therapy for children, 2nd Ed. (pp. 202-216). New York, N.Y.:
The Guilford Press.
Carroll,J. (2000). Evaluation of therapeutic play: A challenge for research. Child & Family
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De Domenico, G. (1994). Jungian play therapy techniques. In K.J. O’Connor & C.W. Schaefer
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Gil, E. (2002). Play therapy with abused children. In F.W. Kaslow, R.F. Massey and S.D. Massey
(Eds.) Comprehensive handbook of psychotherapy, volume 3: Interpersonal,
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Guerney, L., (2000a). Filial therapy into the 21st century. International Journal of Play Therapy,
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Guerney, L. (2001b). Filial play therapy. In C.E. Schaefer (Ed.) Foundations of play therapy
(pp. 99-142). Hoboken, N.J.: John Wiley & Sons, Inc.
Hunter, L. (2006). Group sandtray play therapy. In H.G. Kaduson & C.W. Schaefer (Eds.),
Short-term play therapy for children, 2nd Ed. (pp. 273-304). New York, N.Y.:
The Guilford Press.
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James, O. (1997). Play therapy: A comprehensive guide. Northvale, N.J.: Jason Aronson, Inc.
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Kalff, D.M. (1980). Sandplay: A psychotherapeutic approach to the psyche. Santa Monica,
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Kot, S., Landreth, G., & Giordano, M. (1998). Intensive child-centered play therapy with child
witnesses of domestic violence. International Journal of Play Therapy, 7(2), 17-36.
Landreth, G.L. (2002). Play therapy: The art of the relationship. New York, N.Y.: Brunner-
Routledge.
Landreth, G.L. & Sweeney, D.S. (1997). Child-centered play therapy. In K. O’Connor & L.M.
Braverman (Eds.), Play therapy theory and practice: A comparative presentation
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LeBlanc, M. & Ritchie, M. (1999). Predictors of play therapy outcomes. International Journal
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Ney, P., Palvesky, A. & Markely, J. (1971). Relative effectiveness of operant conditioning and
play therapy in childhood schizophrenia. Journal of Autism and Childhood
Schizophrenia, 1, 337-349.
Post, P. (1998). Impact of child-centered play therapy on the self-esteem, locus of control, and
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Ray, D., Bratton, S., Rhine, T., & Jones, L. (2001). The effectiveness of play therapy:
Responding to the critics. International Journal of Play Therapy, 10(1), 85-108.
Reddy, L.A., Files-Hall, T.M., & Schaefer, C.E. (Eds.) (2005). Empirically-based play
interventions for children. Washington, D.C.: American Psychological Association
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Schaefer, C. & O’Connor, K. (Eds). (1983). Handbook of play therapy: Volume one.
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Scott, T., Burlingame, G., Starling, M., Porter, C. & Lilly, J.P. (2003). Effects of individual
client-centered play therapy on sexually abused children’s mood, self-concept, and
social competence. International Journal of Play Therapy, 12(1), 7-30.
VanFleet, R. (2006). Short-term play therapy for adoptive families: Facilitating adjustment and
attachment with filial therapy. In H.G. Kaduson & C.W. Schaefer (Eds.), Short-term
play therapy for children, 2nd Ed., 145-168. New York: The Guilford Press.
VanFleet, R., Ryan, S.D., & Smith, S.K. (2005). Filial therapy: A critical review. In L.A. Reddy,
T.M. Files-Hall, and C.E. Schaefer (Eds.) Empirically based play interventions
for children (pp. 241-264). Washington, D.C.: American Psychological Association.
Zinni, V.R. (1997). Differential aspects of sandplay with 10- and 11-year-old children. Child
Abuse & Neglect, 21(7), 657-668.

SECONDARY SOURCES
Carey, L. (1991). Family sandplay therapy. The Arts in Psychotherapy, 18, 231-139.
Stinnett, Nick; DeFrain, John (1989). The healthy family: Is it possible? In Fine, Marvin J.,
(Ed.), The second handbook on parent education: Contemporary perspectives
(pp. 53-71). Academic Press, Inc., New York, U.S.A. (1989)
VanFleet, R. (1992). Using filial therapy to strengthen families with chronically ill children. In
L. Vandecreek, S. Knapp, & T.L. Jackson (Eds.). Innovations in clinical practice:
A source book (pp. 87-97). Sarasota, FL: Professional Resource Press.
VanFleet, R. & Guerney, L. (2003). Casebook of filial therapy. Boiling Springs, PA:
Play Therapy Press.
49
Evaluation Research Design
in the Immigrants’ Rights Project

ERIN DOWLER
Evaluation of Research: Community Organization, Planning and Administration
Professor Jacquelyn McCroskey
51

INTRODUCTION AND BACKGROUND


Public Counsel was founded by the Beverly Hills Bar Association in 1970. Initially called
the Beverly Hills Bar Association Law Foundation, it was the first bar-sponsored public
interest law firm in the country. In 1977, the Los Angeles County Bar Association joined
the Beverly Hills Bar Association as a sponsor of the Law Foundation. This joint endeavor
resulted not only in a name change to Public Counsel, but also in an expansion of the
organization’s purposes and goals. Direct involvement in public interest litigation was
coupled with a mandate to mobilize and coordinate pro bono efforts of the Los Angeles
legal community to serve the poor.

The mission is stated as follows: “Founded in 1970, Public Counsel is dedicated to


advancing equal justice under law by delivering pro bono legal services to indigent and
underrepresented children and adults, ensuring that community-based organizations
serving this population have legal support, mobilizing the volunteer resources of the
private bar, and providing technical assistance to pro bono attorneys and projects
throughout California.” The goals are: “to generate increased involvement of the Los
Angeles legal community in pro bono activity, to marshal a variety of volunteer resources
from outside the legal community, to undertake direct representation as co-counsel or
amicus in selected impact matters, to enhance the delivery of legal services through
involvement in public policy discussions and community education, and to improve and
secure Public Counsel’s ability to deliver legal services through cultivation of community
resources and leaders” (Public Counsel, 2009).

“There are 33 attorneys along with over 3,600 volunteer lawyers, law students and legal
professionals that assist over 26,000 low-income children, youth, adults and families,
as well as eligible community organizations each year” (www.publiccounsel.org). Public
Counsel maintains very limited data on client demographics. The available data is broken
down into four categories of ethnicity (White, Black, Asian, and Native American), gender,
and number of clients served, broken down by fiscal year. The limiting categories are
52

confusing and create dilemmas for the purpose of this paper because a majority of clients
are Latino, thus rendering the data irrelevant. The clients served at Public Counsel are
both male and female, generally between the ages of 1 and 72 years old, are of many
different ethnicities, and come from many different countries. Although the clients are
of various ethnic backgrounds, those served are often of Mexican and Central American,
African, or Southeast Asian descent, and of lower socioeconomic status.

Within Public Counsel there are a number of programs: Immigrants’ Rights Project,
Homelessness Prevention Project, Early Care and Education Law Project, Consumer Law
Project, Community Development Project, Appellate Law Project, and Childrens’ Rights
Project (CRP). The program to be evaluated is the Immigrants’ Rights Project (IRP), which
provides legal representation to individuals seeking asylum, relief under the Victims of
Trafficking and Violence Protection Act of 2000 (VTVPA), Special Immigrant Juvenile
Status (SIJS), relief under the Violence Against Women Act (VAWA), and representation
in unusual immigration cases involving compelling humanitarian or public policy issues
(Public Counsel). IRP frequently works with the Childrens’ Rights Project to assist with
special immigrant juvenile status (SIJS) in situations of neglect, abuse, or guardian
absence (Public Counsel).

PROBLEM, PROPOSED INTERVENTION, AND LOGIC MODEL


The Southern California area consists of the following counties: Imperial, Los Angeles,
Orange, Riverside, San Bernardino, and Ventura. The sociodemographic profile of this
region which is served by Public Counsel is a population of 18.5 million as of 2006
(U.S. Census Bureau, as cited by SCAG), consisting of 44% Latino, 39% non-Hispanic
White, 12% Asian, and 7% African American (SCAG, 2009). In 2006, it was estimated
that approximately 31% of this region’s total population were foreign-born (SCAG).
Pew Hispanic Center (2005) estimates that there are close to 1.5 million unauthorized
immigrants in this region as of 2004 (Southern California Association of Governments).
The goal of IRP, that is relevant to this evaluation as stated by Public Counsel and
53

summarized by the attorneys, is the delivery of quality legal services to achieve the best
possible outcome for each client. In discussions on how to achieve the best possible legal
outcome for each client two additional goals were discovered: first, achieve attorney
satisfaction by alleviating the attorneys’ heavy workloads due to case management of
clients’ needs outside of the legal realm and second, long term client empowerment.

The main objectives to achieve these goals are: support clients through phone calls and
in-person meetings, provide referrals, link clients with a community they identify with,
advocate for larger policy changes that impact clients, set mutually agreed upon goals,
and broker with hard-to-reach systems and educate their key stakeholders about barriers
to clients’ access of systems.

The variables relevant to Public Counsel and the Immigrants’ Rights Project are the
lack of free or low-cost services for low-income individuals, the fact that families are
often ineligible for public benefits, and confusion on behalf of public service providers
regarding the benefits IRP clients are eligible for. Furthermore, these variables, as an
aspect of immigration status in the United States, are also barriers in formulating,
testing, and implementing this proposed evaluation model. Location is also an obstacle.
In the Southern California region there are high population cities such as San Diego
and Los Angeles, where social services are more accessible. Other areas are rural or
desert area where social services are limited, but housing is inexpensive for many of
the clients served.

Although Public Counsel has been in existence for almost 40 years, IRP has been around
for about 18 years. The social work model that is used in CRP began about 20 years ago,
but the use of this social worker-attorney model would be a new program for IRP. Over
the past 20 years, the social work-attorney approach has been modified as needed, but
there has never been an official needs assessment or program evaluation committed to
the social work-attorney partnership. Because of the nature of the unique approach and
54

the lack of data that supports such a relationship, a review of the literature for a lack
of timely services and case management within a legal setting turned up virtually little
research or data.

In order to gain access to recent literature on a social work model in a legal setting,
an evidence-based search was conducted on the following databases: Google Scholar,
Social Work Abstracts, Social Service Abstracts, ProQuest, PsychINFO, and Academic
OneFile. Although articles, dissertations, and books were found when searching using
the terms “social work AND legal setting”, “social work AND law”, and “social work
AND attorneys”, there appeared to be no research that specifically looks at a social work
model of case management in a pro bono legal setting like Public Counsel.

In order to justify the need for case management of clients in IRP, a second search was
conducted around the bio-psycho-social needs of immigrant populations coping with
side effects from physical and psychological torture and abuse, slavery, sexual assault,
rape, domestic violence, neglect, or human trafficking. The databases searched were
Google Scholar, Social Work Abstracts, Social Service Abstracts, ProQuest, PsychINFO, and
Academic OneFile using keywords such as “refugees”, “asylees”, “human trafficking”,
“immigrants AND domestic violence”, “immigrants AND social work”, “refugees AND
social work”, “trafficking victims AND social work”, “sexual assault AND social work”,
and “asylum AND social work” among others. These search terms are by no means
conclusive.

In reviewing the literature about the experiences of immigrants and the prevalence of
traumatic stress (both voluntary and involuntary) in individuals adjusting to life in a new
country, it is clear the immigration process is filled with obstacles from learning a new
language (Segal & Mayadas, 2005) to falling prey to employers ready to take advantage
of those not familiar with the host culture, observed through personal experience. Fyvie
et al (2003, as cited in Phillimore & Goodson, 2008) describes that the integration of
55

refugees necessitates education and training in health, the labor area, and housing
as key areas of focus before integration can begin. Moving to a new country means
leaving behind family, friends, possessions, and status in a society, which impacts all
immigrants in one way or another (Potocky-Tripodi, 2002). This fact further complicates
individuals’ abilities to cope with physical, mental, and emotional health issues, especially
as individuals who are at risk for oppression and race-based discrimination (Segal &
Mayadas; Potocky-Tripodi).

Traumatic experiences also impact immigrants’ ability to adjust to their new life or to
access resources. Posttraumatic stress disorder (PTSD) frequently accompanies voluntary
immigrants and very often accompanies involuntary immigrants (Potocky-Tripodi). Many
survivors of traumatic experiences, such as domestic violence and torture survivors,
frequently experience PTSD (Balgopal, 2000; Carlson, McNutt, Choi, & Rose, 2002).
Victims of such violence often have low levels of functioning and lack access to resources
(Busch & Valentine, 2000). Victims also are believed to have low self-efficacy, which
means they do not feel they have the ability to control their situation. In the case of
domestic violence, victims most often doubt their ability to start life over in the case of
leaving a perpetrator, thus feeling safer staying with the batterer (Busch & Valentine,
2000).  Self-efficacy issues relate to a sense of power or lack of it (Potocky-Tripodi; Busch
& Valentine), a significant factor among immigrants trying to start a new life.

Before delving into interventions and assistance for clients, it is important to establish
a rapport. As with any client, this is important in order to distinguish whether any
challenges the client faces are emitted from individual issues or if they are effects
from organizational or societal problems (Segal & Mayadas). As is the case in IRP, such
differentiations are often key to winning cases, as well as providing competent social
work services. Immigrants that seek legal services from Public Counsel-IRP frequently
struggle with language barriers, employment, and culture shock in addition to PTSD
as a result of traumatic violence, life-long instability, or sexual violence.
56

The proposal to build a multidisciplinary case management approach for IRP is based
on the existing model in use by CRP social workers and attorneys. The proposed
program will address the identified problems of the present role attorneys play: the time
consuming role of stabilizing and supporting clients in order to build successful cases,
providing competent referrals for multiple needs, and advocating on behalf of the client.
The proposed case management approach would allow attorneys to focus their time
on the legal work, which personal interviews conducted as part of a needs assessment
revealed is a major source of stress and strain (K. Werth, personal communication,
September 25, 2009). Therefore, the intended audience for the proposed program
and evaluation is the attorneys of IRP. The case management would take place within
the office building of Public Counsel with clients being referred to a social worker as
necessary.

The social work approach to case management has proven beneficial to both attorneys
and social workers in CRP because the social workers have been able to address client
needs so clients are able to function from day to day. For example, once clients begin
receiving therapy, they begin consistently showing up for work, and, finally achieving
permanent housing, they are able to meet their legal obligations such as coming to
scheduled appointments and hearings, helping to build their case (J. London, personal
communication, October 2, 2009; K. Jackson, personal communication, date unknown;
B. Tsoulos, personal communication, October 9, 2009). The importance of a social
worker-attorney program for the agency, funders, and stakeholders is based on the
reputation and success of CRP using such a social work case management model for
about 20 years.

This program is relevant to society, the field of social work, and Public Counsel because
the social work role uses interventions that help clients to obtain a level of functioning
where they can contribute to society. It is evident in United States immigration policies
that society expects individuals to be productive and contribute to society. This is clear in
57

the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996
where affidavits of support are required for an immigrant’s application for permanent
status, providing proof that a sponsor can, and will, financially support the applicant (U.S.
Citizenship and Immigration Services). U.S. Citizenship and Immigration Services (USCIS)
also require proof of good moral character, proof of a residence, and English language
abilities (USCIS) when applying for naturalization. Miriam Potocky-Tripodi summarizes
that non-U.S. born individuals have higher unemployment and poverty rates, as well as
a lower salary and a lower rate of home ownership (2002), making it challenging for
individuals to meet the stringent requirements of USCIS.

The program is also relevant to social work. Social work’s approach of viewing
strengths and weaknesses in the environment of the individual (M. Ziegler, personal
communication, October 2, 2009) is uniquely suited to address obstacles by empowering
clients, gaining access to resources and skills, and advocating on behalf of clients.
According to NASW Code of Ethics, social work’s commitment to service and social
justice (NASW) would serve the needs of the immigration population as discussed above.

Based on the needs of IRP’s client population, the clients clearly are underrepresented
and indigent with regard to the high rates of poverty, evidenced by the lack of services
available to clients to meet these needs, based on professional experience.
Based on this knowledge about challenges immigrants face, coupled with traumatic
experiences, it is clear that clients in the Immigrants’ Rights Project would benefit
from referrals and being linked up with services. Often times, the IRP attorney is
the only person in the client’s life who provides assistance, and confusion often
ensues about the attorney’s role in providing legal services versus personal support.
This places a burden on the attorneys who frequently find they spend more time
emotionally supporting their clients. Based on these findings, that clients seeking legal
representation frequently need additional support, the social work case management
model is the best intervention to start with for this pilot program. A logic model
58

displays the proposed outline for IRP, addressing the goals, inputs, activities, outputs,
and outcomes, including the measures.

The logic model displays a series of six interventions (the independent variables) that
are intended to produce five outcomes (the dependent variables). As mentioned earlier
in the literature review, no literature was found that supports or rejects a social work
case management model in a legal setting. However, the activities of supporting clients
through phone calls and in-person meetings, as well as provide referrals that meet client
needs can serve to improve social functioning (Hepworth et al, 2006). It is expected
that improved social functioning will positively influence the outcomes of improved
living conditions and client empowerment. Empowerment can also be encouraged
through aspects of the Lum model (1996) including: mutual goal setting, identifying
and recognizing strengths, and brokering with systems that are often out of reach for
disempowered individuals. The final activity, advocating for policy changes that impact
clients is also one of the key purposes of social work, according to the Council on
Social Work Education (CSWE, 2002, as cited in Hepworth et al). Policy changes help
to decrease the number of obstacles for clients, as do all of the independent variables.
Although the long term goal of empowering the client is difficult to measure, Grinnell,
Gabor, and Unrau (2010) note that this type of performance data is important because
only monitoring the number of clients served, as opposed to the changes that should
occur (increased empowerment), workers may no longer focus on the client outcome
but on how many clients are served. Therefore, it will be important in this program to
continue to monitor ways in which clients are empowered. This example demonstrates
the importance of the relationship between the proposed activities and the expected
outcomes. All of the interventions are designed to improve attorney satisfaction.

RESEARCH QUESTIONS
The research questions that will address the program outcomes are: Will supporting
the client, providing referrals, mutual goal setting, identifying and recognizing client
59

strengths, and brokering with hard to reach systems help to improve client living
conditions, decrease the number of obstacles for the client, obtain the best possible legal
outcome, and empower the client? Will all of the program activities serve to support the
client at a level that attorneys are satisfied with the provision of social work support?
Will advocating for policy changes that impact the clients decrease the number of
obstacles facing the client?

RESEARCH DESIGN
The proposed evaluation methods are based on the social work case management
model outcomes. Because there is little to no existing data on this case management
model as previously discussed, an internal monitoring approach combined with the use
of an ongoing needs and strengths assessment will help focus on quality improvement
(Grinnell, Gabor, & Unrau, 2010) with respect to the attorney workloads and their
ability to focus on the legal work. The methods can be integrated into the evaluation,
which would help provide immediate feedback (Grinnell, Gabor, & Unrau). Currently, the
existing model in CRP requires tracking of clients by the attorneys, but not the social
workers. The needs and strengths assessment plan will identify the needs and strengths
of IRP, as well as the clients for the first year or two of the program. This will help to
determine the best case management services that can be provided to help the clients,
thus meeting the attorney needs of timely and reliable case management services to
enhance the legal aspect of the case.

The proposed data collection methods are subject to change. Recent data identifies the
need for more social services with regard to the income generated by U.S. born versus
non-U.S. born individuals living in the United States (Fortuny & Passel, 2007). Data is
very difficult to obtain for asylees and recipients of various visas and forms of relief that
IRP services. Therefore, a great need exists for more data collection on behalf of Public
Counsel with regard to how many clients are seen, what services and forms of relief
clients receive, and long-term client well being. Data collection on client information
60

should not pose much resistance with clients because the collection could coincide
with attorney-client appointments; however, there is possibility for internal challenges
regarding time constraints. There does not appear to be a system in place that can collect
and manage this type of data for the purpose of generating reports.

The remaining data to be collected using mixed methods focuses on the outcomes. Ordinal
quantitative methods will be used in surveys to measure attorney satisfaction and client
report of living conditions. Tracking ongoing attorney satisfaction will occur on a bi-monthly
basis, in the form of a non-standardized needs assessment questionnaire (Grinnell, Gabor,
& Unrau). In order to monitor the satisfaction of the attorneys and whether or not their
needs are being met, regular surveys, followed by semi-regular interviews, and bi-annual
focus groups would be excellent ways to find out if the proposed program is meeting
the needs of the main audience, the attorneys. Using interviews is beneficial when little
is known about the problem area (Grinnell, Gabor, & Unrau). The client living conditions
survey will be administered every three months for the first year they are a client. After this,
the survey will be administered bi-annually. Key informants to be identified could also play
a role in the strengths and needs assessment, as well as during the ongoing collection of
data for the evaluation (Grinnell, Gabor, & Unrau).

The self-report of the number of obstacles for the client will use qualitative methods in order
for the client to indicate through interview what obstacles exist, if any. This will take place at
the same time the living conditions survey is administered. Whether or not the best possible
legal outcome is achieved will be assessed as necessary through qualitative methods of
attorney interview and case review. Case review is currently conducted every week at Public
Counsel. The minimum data collection will be conducted bi-annually. Client empowerment
will be measured bi-annually using quantitative methods from the Rogers, et al (1997)
empowerment scale description. Additional data will need to be tracked to maintain basic
client information. There could be cooperation in finding new information technology
software to manage this data, as it is important for future funding.
61

Data collection instruments for collecting data via technology (i.e., computer) could be
a simple task of entering data in Microsoft Excel or a similar database. However, the
more sophisticated data base the better because it is important to centralize the data for
future program growth.

SAMPLING STRATEGY
Due to the lack of current data on clients, it is unclear what the sample size will be. It
would be unethical to withhold services from clients who express any sort of need for
assistance in an area of their life, or if the attorney has concern for a client’s well being.
Therefore, all clients will be assisted as necessary.

INFORMED CONSENT, ANONYMITY, CONFIDENTIALITY


The procedures for obtaining informed consent and confidentiality will occur when the
client agrees to accept legal services from Public Counsel. An additional intake form will
explain the range of case management services provided and that the data collected
will track progress, as defined in the outcomes of this program. The program is unable to
maintain anonymity due to the nature of the setting in Public Counsel and the legal and
social work services provided.

ANALYSIS PLAN
The plan for data analysis is to create new data because there is little available data from
Public Counsel. While the attorneys are the main audience for the program evaluation, it
is important to collect data on clients in the form of quantitative data, in order to measure
such things as the number of families living at or below the poverty line, who is receiving
services, and client presence at required appointments.

The dependent variables are attorney satisfaction, living conditions of the client, legal
outcome achieved, number of obstacles for client, and client empowerment. The
independent variables are support clients through phone calls and in-person meetings,
62

provide referrals, link clients with a community they identify with, advocate for larger policy
changes that impact clients, set mutually agreed upon goals, and broker with hard to reach
systems and educate their key stakeholders about barriers to clients’ access of systems.

In assessing the tool to measure empowerment, a test and retest will eventually be
conducted after the pilot program to ensure stability of the empowerment instrument.
The test and retest will use 10% of the sample at baseline once a baseline has been
established through the pilot. A possible sample survey for satisfaction will be the basis
for measuring the satisfaction of attorneys regarding the social work services provided
(Larsen et al, 1979), as well as client satisfaction with their living conditions.

Change will be measured through an increase or decrease in attorney satisfaction,


increase or decrease in the living conditions of the client, increase or decrease in the
number of obstacles facing the client, whether or not the best possible legal outcome is
achieved or being achieved, and an increase or decrease in client empowerment. A one-
way MANOVA is the presumed method of data analysis for the quantitative measures
because the program is looking for improvement in more than two dependent variables.
The qualitative measures should have an underlying theme of client independence and
improved quality of life. The attorneys should also show an improvement in overall
satisfaction of social work case management services being provided.

Finally, disseminating and communicating the information from the evaluation will occur
in a presentation during a meeting to discuss the findings. The presentation will focus on
graphs to display the collected data and other relevant information, which will help to
present the evaluation process in a clear manner. The presentation must also remain on
point and fairly brief to accommodate busy work schedules.

Based on the gathering of information to create the problem identification and needs
assessment, it is clear that the program evaluation will be modified as it is used.
63

Although the dilemma of not already having a case management model in place is
clear, the data to support having such a model is not currently available due to the non-
traditional social work setting. Ongoing data collection is necessary while the program is
implemented and the evaluation is conducted.

RELEVANCE TO MACRO PRACTICE


This social work case management model is relevant to a number of areas. The model
is relevant to Public Counsel, the community, and other practitioners working in
multidisciplinary settings. First, the model has tremendous relevance to Public Counsel
because only one project currently has full time social workers who provide case
management services. The proposed evaluation model would not only provide consistent
services to another department, but the data collected could provide much needed
evidence to gain more funding for IRP, as well as justification for replicating this model in
other projects within Public Counsel or other law centers. For example, the Homelessness
Prevention Project also has clients that are in need of support that the attorneys cannot
provide. The data collected could potentially help Public Counsel to strategically influence
policy at state and federal levels.

The model is also relevant to the community because the case management provides
services and referrals that address root causes of poverty (Huston & Bentley, 2010).
Mediators of poverty are the same factors that immigrants deal with when arriving to
a new country and throughout their lifetime: education, children, housing, family, and
material resources (Huston & Bentley).

Finally, this model is relevant to macro practitioners because the program addresses the
interrelationship between micro and macro practice (Netting, Kettner, & McMurty, 2008).
Other macro practitioners that work in interdisciplinary settings will find that there is a
great opportunity to reach out to clients that come to an organization for one type of
service. These services could be other law centers, medical clinics, or community centers.
64

This model compliments the idea of beneficence that Jansson (2008, as cited in Netting,
Kettner, & McMurtry) illustrates in an example of an attorney who works on divorce cases
but does not consider how this financially impacts the divorcee. Macro practitioners
should consider the multiple needs of individuals and communities (Netting, Kettner, &
McMurtry), which this proposed model addresses.

FEEDBACK ON PROPOSED EVALUATION


Feedback is a key piece of program evaluation (Grinnell, Gabor, & Unrau, 2010). It has
been a challenge to obtain inter-agency feedback for this proposal. The goal is to present
this proposal for feedback in the spring semester of 2010 to the attorneys in IRP. Time
constraints have made it difficult to obtain such feedback. When conducting a needs
assessment earlier in the semester, the main focus for the social work internship was to
provide case management for the clients as outlined by the attorneys based on need. The
goal was to design this proposal and present it once the attorneys became familiar with
the role of a social work intern.

However, feedback during the needs assessment conducted in late September and
early October revealed that case management services provided by a social work
intern provided immediate attorney gratification and relief. The relief was in the form of
reducing client phone calls to the attorney and reducing attorney concern for not having
the capacity to assist the client outside the legal service realm. This information was key
feedback in developing the program activities and outcomes, as well as the evaluation.
In addition, feedback from Beth Tsoulos, the field instructor at Public Counsel, has been
critical. She has been able to testify how her role as a social worker has influenced the
legal process for the attorneys, as well as revealed other issues that might impact the
client’s quality of life and the progression of the case. Feedback from the supervisor
supported the key components of this program development and evaluation through
first-hand experience.
65

AGENCY EXPERIENCES WITH THE EVALUATION PROPOSAL


Meetings with agency employees consisted of consultation with the field supervisor and
all of the attorneys in IRP. Meetings with the field supervisor, Beth Tsoulos, took place
during weekly supervision. The role of a social worker in an interdisciplinary setting was
discussed, as well as how to address differences in opinion between social workers and
attorneys. Beth has overwhelmingly supported the evaluation because it would not only
benefit IRP, but also CRP, which currently does not collect data or track clients. These
meetings have made it clear that the program and evaluation would fulfill a tremendous
need for additional support and data for Public Counsel.

Meetings with the attorneys have provided evidence that the attorneys feel overwhelmed
by client needs. It has also been emotionally draining for some attorneys who struggle to
avert clients’ needs for follow up services in order to focus on time-sensitive tasks related
to the legal case. In some meetings, attorneys clearly express their knowledge about
what their clients needs are. This point is particularly important because although the
attorneys know their clients very well and the obstacles they face, they do not have the
time to conduct a bio-psycho-social assessment to ensure that the full picture is taken
into account.

I truly believe this model program has the potential to effectively meet the needs of the
agency and community. As an intern, I currently provide many of the case management
services that the clients and attorneys need. This experience has been a major part of
the rationalization for the program outline and evaluation proposal. Most certainly
approaches to the model will be modified once the program is put in place and has
received initial survey feedback from the attorneys and the clients.
66

REFERENCES

Balgopal, L. R. (2000). Social work practice with immigrants and refugees: An overview.
In L. R. Balgopal (ed) Social work practice with immigrants and refugees
(pp. 1-29). New York: Columbia University Press.
Busch, N. & Valentine, D. (2000). Empowerment practice: A focus on battered women.
Affilia, 15(1), 82-95.
Carlson, B. E., McNutt, L., Choi, D. Y., & Rose, I. M. (2002). Intimate partner abuse and mental
health: The role of social support and other protective factors. Violence Against
Women, 8(6), 720-745.
Electronic reference formats recommended by the American Psychological Association. Retrieved
October 13, 2009, from www.publiccounsel.org.
Fortuny, K., & Passel, J., (2007). The characteristics of unauthorized immigrants in California, Los
Angeles County, and the United States, the Urban Institute. Retrieved October 13,
2009, from www.scag.ca.gov/sotr.
Golding, J.M. (1999). Intimate partner violence as a risk factor for mental disorders: A meta
analysis. Journal of Family Violence, 14(2), 99-123.
Grinnell, R.M. Jr., Gabor, P.A., Unrau, Y.A. (2010). Program evaluation for social workers:
Foundations of evidence-based programs (5th ed.). New York: Oxford
University Press.
Huston, A. & Bentley, A. (2010). Human development in societal context. Annual Review of
Psychology, 61, 411-437.
Kasturirangan, A. (2008). Empowerment and programs designed to address domestic violence.
Violence Against Women, 14(12) 1465-1475.
Khamphakdy-Brown, S., Jones, L., Nilsson, J., Russell, E., and Klevens, C. (2006). The
empowerment program: An application of an outreach program for refugee and
immigrant women. Journal of Mental Health Counseling, 28(28), 38-47.
Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/
patient satisfaction: Development of a general scale. Evaluation and Program
Planning, 2, 197-207.
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Lum, D. (1996). Social work practice and people of color (3rd ed.). Pacific Grove, CA: Thomson
Brooks/Cole.
National Association of Social Workers. (approved 1996, revised 2008). Code of ethics of the
National Association of Social Workers. Retrieved on October 13, 2009, from
www.socialworkers.org/pubs/code/code.asp
Netting, E.F., Kettner, P.M., & McMurtry, S.L. (2008). Social work macro practice. Boston:
Pearson Allyn and Bacon.
Phillimore, J. & Godson, L. (2008). Making a place in the global city: The relevance of indicators of
integration. Journal of Refugee Studies, 21(3), 305-325.
Pitocky-Tripodi, M. (2002). Best practices for social work with refugees and immigrants.
New York: Columbia University Press.
Public Counsel. (2009). General information packet.
Segal, U. & Mayadas, N. (2005). Assessment of issues facing immigrant and refugee families.
Child Welfare, 84(5), 563-583.
Southern California Association of Governments. (2007). The state of the region reports.
Retrieved on October 13, 2009 from www.scag.ca.gov/sotr/
United States Citizenship and Immigration Services (2009). Legislative history from 1981-1996.
Retrieved on October 14, 2009 from www.uscis.gov/files/nativedocuments/
Legislation%20from%201981-1996.pdf.
Conceptualizing Pedophilia through Theory,
Neurobiology, and Culture

JENNIFER GEBAUER
Human Development and Mental Health
Professor Doni Whitsett
69

Pedophilia is a complex mental health issue that has been significantly ignored
within the mental health community. Pedophilia may be defined as an adult sexually
assaulting a prepubescent child (i.e. any form of genital contact or attempt to elicit
sexual excitement from a child) (Rice, Harris, Lang & Chaplin, 2008). Currently,
society’s preference for managing pedophiles is permanent incarceration. As this
is not a viable or ethical option, significant time and attention has been spent
developing interventions aimed at reducing relapse and recidivism; however,
the etiological cause of pedophilia has not been fully understood, creating the
appearance that pedophilia is untreatable (Rice, Harris, Lang, & Chaplin, 2008). A
question must be posed. How will pedophilia be effectively treated if the origin of the
behavior is unknown?

This paper attempts to provide a biopsychosocial perspective on an individual with


pedophilia through the lenses of Attachment Theory and Self-Psychology. These
theories were chosen to explain pedophilia as they address the preoccupied and
fearful attachment patterns that fuel sexual deviancy in child molesters (Wood & Riggs,
2009). Also, they explain the underlying shame exhibited by a significant population of
pedophiles (Sawle & Colwell, 2001). Neurological factors will also be explored, and a
discussion of diversity issues will be provided, as the focus of this paper is on the adult
male pedophile. Finally, a treatment plan will be proposed aimed at addressing the
theoretical and neurobiological underpinnings of pedophilia.

ATTACHMENT THEORY
According to Bowlby (1969), the capacity of an infant to develop a close relationship
with a primary caregiver occurs because of the attachment system (1969). The purpose
of this system is to regulate behaviors (i.e. smiling, cooing) that will assist the infant in
maintaining closeness to a primary caregiver for protection (Ward, Hudson, & Marshall,
1996). The dyadic relationship that occurs between the child and the primary caregiver
typically lays the foundation for future relationships and impacts the way in which a
70

child is able to experience intimacy as an adult. If a disruption in the attachment process


occurs, it can result in insecure attachment, a lack of self-confidence and identity, and the
inability to develop intimate relationships.

Attachment Theory, originally developed by John Bowlby, assists in understanding


the complex issue of pedophilia as it explains the intimacy and empathy deficits
exhibited by sex offenders. This theory also provides a foundation for understanding the
affect misattunement displayed by pedophiles (McCormack, Hudson, & Ward, 2002;
Ward, Hudson & Marshall, 1996). In order to understand how Attachment Theory
conceptualizes pedophilia, the following topics will be addressed: internal working
models of attachment, a safe haven and a secure base, attachment styles, adult
attachment, and the misattunement of the pedophile.

INTERNAL WORKING MODELS OF ATTACHMENT


A primary concept in attachment theory is that the infant is an initiator in developing a
relationship with the primary caregiver. An infant is not born a “tabula rasa”, but rather,
he is equipped with “behavioral systems” that assist in attaining the attachment goals
(Bowlby, 1969). Behaviors including babbling, smiling, crawling, and walking are all
attempts to obtain positive reciprocal interactions from the attachment figure. If these
behaviors are reciprocated, they lead to a sense of security. However, if these positive
feelings are not returned the negative emotional states such as anxiety, anger, or sorrow
develop. Through these positive and negative interactions with the primary caregiver, the
infant develops feelings about himself, others and the world, also known as an internal
working model of attachment.

In the case of pedophilia, if the parent rejects the infant’s attempts for comfort or
exploration, the child may develop an internal working model of being unworthy
or incompetent (Bretherton, 1992). While such negative interactions do not cause
pedophilia, they lay the groundwork for the development of persistent low self-
71

esteem, feelings of worthlessness and insecurity, which are three factors closely
associated with pedophilia (Ward, Hudson, & Marshall, 1996; Kear-Colwell &
Boer, 2000; Sawle & Colwell, 2001). The early infant and childhood internal
working models typically persist throughout life because individuals typically enter
relationships that confirm the negative beliefs and cognitive distortions about
the self and others (Wood & Riggs, 2009). Consequently, this creates a life-long
pattern for the potential pedophile as his persistent low self-esteem and feelings of
worthlessness are continuously confirmed through relationships. Furthermore, the
disappointment of experiencing negative interactions results in a failure to develop
the social skills and self-assurance necessary to achieve intimacy with adults (Ward,
Hudson, & Marshall, 1996).

A SAFE HAVEN AND SECURE BASE


Two essential components in the application of Attachment Theory to pedophilia are
the concepts of developing a secure base and having a safe haven. A secure base is
essentially finding a sense of security with a primary caregiver so the infant or child
can explore the world and then return for safekeeping. The concept of a secure base
continues throughout life and is utilized during stressful experiences (e.g. a stressed
social work graduate student will seek comfort from her husband). Similarly, a safe
haven is also created through the dyadic relationship of the primary caregiver and infant.
The comfort and security provided to the infant from the primary caregiver soothes the
infant’s emotions and the infant is eventually able to develop self-soothing capabilities
(Bowlby, 1969).

It is through the development of the secure base and safe haven from which affect
regulation begins. Consequently, if a child does not have a safe haven or a secure
base from which to explore, the individual will have difficulty coping with stressful and
anxious situations in adulthood. In the case of a pedophile, it is theorized that intimacy
and security needs are displaced onto children as he does not possess the self-soothing
72

skills required to maintain affect regulation. Nor does he possess the confidence or
social skills required to seek safety through an appropriate secure base, such as an
adult romantic partner. This displacement likely occurs when stressful relationship
situations arise for the potential pedophile, such as rejection or separation (Sawle &
Colwell, 2001).

ATTACHMENT STYLES
Internal working models, a safe haven, and a secure base have a direct impact on the
development of an attachment style and the ability to create healthy adult relationships.
According to Mary Ainsworth, there are three primary forms of attachment for infants:
secure, anxious/ambivalent, and avoidant (Bowlby, 1969). The latter two forms of
attachment are also known as insecure attachment patterns, which are associated with
pedophilia (Ward, Hudson, & Marshall, 1996). Secure attachment is the ideal attachment
style as it is formed when a parent responds lovingly and affectionately to his or her
child. Adults who are securely attached feel valued by others, which creates resiliency
(Sawle & Colwell, 2001).

However, an individual who develops insecure attachment patterns likely did not have
his emotional needs consistently met or he experienced continuous rejection. According
to Ward, Hudson and Marshall (1996), insecure attachment is linked to the onset of
intimacy deficits and developing pedophilic behaviors. Anxious/ambivalent attachment is
a form of insecure attachment, and it develops when the caregiver does not consistently
respond to the infant. This can result in attention-seeking behaviors, impulsiveness,
and a sense of helplessness (McCormack, Hudson, & Ward, 2002). Anxious /ambivalent
attachment is most commonly associated with pedophilia (Bartholomew, 1990). Avoidant
attachment is developed when the caregiver is unresponsive to the child. Avoidant
attachment, which results in a lack of empathy and antisocial behavior, is typically
associated with rapists.
73

Clearly, the early interactions experienced by the infant, such as a stressed mother
who cannot consistently meet the emotional and security needs of an infant, creates a
vulnerability in insecurely attached children. The vulnerability may then be exacerbated
by environmental stressors, such as physical abuse, neglect or sexual abuse, further
worsening a child’s ability to develop a healthy level of self-esteem and affect regulation.
According to Wood and Riggs (2009), many offenders who develop insecure attachment
patterns had abusive or neglectful childhoods. In fact, 43% of male pedophiles reported
they had experienced sexual relations with an adult prior to age 14 (Sawle & Colwell,
2001). While abuse is not required for the development of pedophilia, it must be
considered as one predisposing factor to insecure attachment and the progression of
pedophilic behaviors.

ADULT ATTACHMENTS
The attachment styles of children and adults are essentially the same with regards to
maintaining a secure base and having a safe haven, which is typically attained by a
child from his caregiver and by an adult from his romantic partner. However, the primary
difference between childhood attachment and adult attachment is the sexual mating
system (Woods & Riggs, 2009). Consequently, insecurely attached adults, also known as
fearful, preoccupied, or dismissive, do not know how to meet their relational desires or
engage intimately with others.

Due to the misconstrued internal working models of attachment, the potential pedophile
seeks intimacy and security needs through sex. The search to fulfill his needs becomes
dangerous when the individual does not want to be rejected and he seeks sexual
relationships with children. This is known as fearful attachment. The search to meet such
needs becomes similarly dangerous when the potential pedophile is skeptical of the value
of close relationships and becomes hostile. This attachment form is known as dismissive.
Finally, the search to meet such needs becomes dangerous when the potential pedophile
becomes preoccupied with sex. This attachment schema is known as preoccupation
74

(Bartholomew, 1990). Individuals who possess these forms of attachment patterns have
intimacy desires, but do not have the interpersonal skills, the emotional-wellbeing or the
empathy required to develop a romantic relationship with a peer (Sawle & Colwell, 2001).
In lieu of seeking adults to meet emotional needs, the insecurely attached pedophile seeks
children to avoid true “emotional involvement” (Bartholomew, 1990).

While there are three forms of pedophilic behaviors, the primary attachment pattern
exhibited by child molesters is preoccupied (anxious-ambivalent). According to Lyn &
Burton (2004), pedophiles are more frequently anxious-ambivalently attached as the
onset of pedophilic behavior occurs as a result of a hyper-activation of the attachment
system (rejection, grief and loss, relationship-issues). As a result, the potential pedophile
feels significant anxiety during a stressful situation and does not possess an appropriate
secure base. Consequently, out of the anxiety that is created, they seek to fulfill their
needs and decrease their relational anxiety through sexual interactions with individuals
who will not reject them (e.g. children). As a result, it is hypothesized that anxious-
ambivalent attachment is a predictor to the development of pedophilia.

MISATTUNEMENT AND THE PEDOPHILE


According to Attachment Theory, the core of healthy functioning is the ability to regulate
one’s affect. Conversely, the core of pathology is affect misattunement. Affect regulation
begins in infancy when the primary caregiver resonates, responds and reflects the child’s
emotions. An example of affect attunement is the mother responding to an infant’s
laugh, with a reciprocal smile. When affect misattunement occurs (i.e. a mother responds
to a smiling baby with anger and frustration), the child does not know how to regulate
his own affect. Affect regulation requires two abilities in both childhood and adulthood:
the capacity to self-soothe and the capability to seek others for emotional support.
Unfortunately, the “misattuned” pedophile, does not know how to self-soothe nor does
he possess the confidence to seek outside assistance. The affect misattunement is so
severe that many times a normal behavior, such as a child walking around the house
75

in her pajamas, may be misinterpreted as a sexual advance. Therefore, due to a lack of


affect regulation, pedophiles do not typically have the ability to accurately perceive victim
affliction and respond with empathy (Schwartz, 1997).

Attachment theory assists in explaining how early infant and childhood interactions
are predisposing factors to the development of pedophilia, specifically with regards to
attachment styles, a lack of empathy, and affect misattunement. However, a question
persists. If pedophilia is caused, in part, because of insecure attachments, why don’t all
insecurely attached adults develop pedophilia? This question may be further explained
through Self-Psychology.

SELF-PSYCHOLOGY
Attachment Theory provides a strong theoretical foundation for understanding the
pedophilic psyche and its inception in infancy. However, Kohut’s theory of Self-Psychology
is a fluid model of development that assists in conceptualizing pedophilia from early
infancy and childhood (grandiose and idealizing poles) through adolescence and
adulthood (twinship pole). Kohut’s model specifically addresses the theoretical gap
between infancy affect misattunement and the development of pedophilia in adulthood
through the concept of twinship. In order to fully conceptualize pedophilia through
Kohut’s theory of Self-Psychology, a brief overview of the model will be provided followed
by the conceptualization of the development of pedophilia through the grandiose pole,
the idealizing pole and the twinship pole. Finally, the pathological manifestation of
pedophilia will be discussed.

KOHUT’S MODEL OF SELF-PSYCHOLOGY


Within Kohut’s theory, a child possesses healthy narcissistic needs that must be met,
including validation, reinforcement of self-esteem and communion (Goldberg, 1985). In
order to meet these needs and achieve the consolidation of the self, the child must walk
three pathways of development, which Kohut deemed the grandiose pole, the idealizing
76

pole and the twinship pole. The child’s needs received through each pole must basically
be met. Otherwise, the child will experience a sense of shame that is theorized to be a
primary factor in the development of pedophilia, which will later be addressed.

Relationships are a key concept within Kohut’s theory as the child’s identity is essentially
developed through selfobjects (Kohut & Ornstein, 1991). Selfobjects may be defined as
the persons or things that are experienced as part of the self. They are also the parts of
the primary caregiver that the child internalizes in order to develop a unique self. The
internalization of selfobjects results in a cohesive self. However, if selfobjects are not
internalized, the result is fragmentation and a continuous hunger for selfobjects. For the
pedophile, children serve as the selfobjects for which they hunger. Thus, pedophilia serves
to stabilize the fragmenting self as a result of not internalizing the needed selfobjects.

GRANDIOSE POLE
In Kohut’s model, the grandiose pole represents the “ambitions, goals and ideals” that
comprise the self (Goldberg, 1988). A child has these inborn talents and potentialities;
however, it is the responsibility of the primary caretaker to respond to the child’s needs and
mirror him so his talents, goals and ideals are self-actualized. Thus, mirroring develops into
self-esteem and assertiveness, which results in ambitions, power and success as an adult.

However, in the case of a pedophile, it is theorized that within the grandiose pole he was
not mirrored properly. The child desired to feel special, but he did not feel the beauty
and splendor within because his essential goodness was not reciprocally mirrored;
consequently, he began to lose the possibility of developing a true self or an independent
center of initiative. The child then developed a sense of shame for not having his
goodness mirrored back to him. Therefore, the potential pedophile is unable to develop
a healthy level of self-esteem and he loses the ability to develop ambitions, power and
success in terms of having healthy relationships. The pedophile begins a journey to have
selfobjects reflect back to him his goodness and grandiosity. As his peers will not reflect
77

his goals, ideals and ambitions due to the shame he exudes, it is theorized the pedophile
seeks children to reflect back to him his goodness.

IDEALIZING POLE
The second pole identified in Kohut’s model is the idealizing pole (Goldberg, 1998).
The purpose of attaining and maintaining an idealized selfobject is to receive soothing
and achieve affect regulation. Through an idealized parent imago the child is soothed
and feels safe. Once the child develops the capacity to self-soothe, he becomes a
cohesive and stable self worthy of admiration and respect. In the case of a pedophile,
it is theorized that the child did not see the strength and wonder outside of himself. He
did not have someone strong, calm, and wonderful to idealize and merge with to fulfill
his safety needs. His primary caregiver was not psychologically or physically present
consistently for him to take in the selfobject and feel safe and strong. This likely affected
his ability to develop affect attunement because his feelings of meekness were not
counteracted by the caregiver’s presence.

When a child does not have an idealized parent imago, he begins to lose the ability to
develop tension regulation and self-soothing, which also inhibits his development into
an individual worthy of respect and admiration. It is hypothesized that the potential
pedophilic child experienced transmuting internalization, but in unmanageable doses. The
primary caregiver or selfobject continuously disappointed the child leading him to self-
soothe and manage his emotional needs in a dysfunctional way, which results in anger
and aggression. According to Goldberg (1988), aggression is a symptom derived from an
un-empathetic environment. The potential pedophilic child begins to experience a sense
of narcissistic rage as a result of his interpersonal connectedness needs not being met;
however, this rage remains in the preconscious. Thus, the child develops into the “tragic
man” as the potential pedophile feels empty, lacks emotional connection and is void of
ideals and heroes.
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As an adult, affect misattunement will make the potential pedophile’s relationships


superficial and essentially unsatisfying, leading him to search for fulfillment through
children (Goldberg, 1985). Consequently, children become the selfobjects that the
pedophile attempts to internalize so he in turn, feels powerful and omnipotent, masking
his insecurity, fear, and shame. Thus, the pedophile begins to use children as selfobjects
to regulate his affect from the anxiety he frequently experiences. He also uses children
as selfobjects as a means of externalizing his narcissistic rage. Finally, the pedophile uses
children to fulfill his needs of being respected and admired. He may falsely achieve these
needs through children.

TWINSHIP POLE
In Kohut’s model of Self-Psychology, the twinship pole is the third pole of the tri-polar
self, required to achieve identity cohesion. The basic premise of the twinship pole is
individuals feel an essential likeness, belonging and security with peers. Twinship is
typically achieved in the latency stage when the individual discovers his own goals and
ideals, which are recognized and appreciated by his peers (Banai, Shaver, & Mikulincer,
2005). However, in the case of a pedophile, he cannot experience true twinship among
his peers because he lacks the self-esteem and self-soothing capabilities to develop
genuine relationships. Furthermore, he feels a deep sense of shame that inhibits his
ability to be genuine with others.

As a result of the inability to achieve true twinship, the pedophile seeks children because
he does not feel worthwhile or confident among his peers. It is theorized that the
relationship with children assists the pedophile in gaining a sense of control over the
feelings of shame and powerlessness he likely experienced as a child at the hands of an
adult (Finkelhor & Araji, 1986; Schwartz, 1997). Consequently, the cognitive distortions
many pedophiles exhibit is merely a defense mechanism employed to cover the shame
and justify prepubescent sexual advances.
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PATHOLOGICAL PEDOPHILIA MANIFESTATION


It is hypothesized that pedophiles have developed a primary disorder of the self, as
they have given up hope that they will ever receive empathy or that their archaic needs
to internalize an idealized object will ever be met. According to Goldberg (1998), un-
integrated lust and aggression are products of a pathological breakdown of the self.
Consequently, it is believed that pedophiles experience a fragmentation and breakdown
of the self that develops into narcissistic behaviors. These narcissistic behaviors are
manifested through using children as a way of fulfilling their need to be in control, being
perceived as admirable, and achieving a likeness they cannot obtain through peers
(Banai, Shaver, & Mikulincer, 2005, p. 226).

The end result of the aforementioned difficulties in meeting the needs of the grandiose pole,
idealizing pole, and twinship pole is a chronic, archaic yearning for selfobjects. The pedophile
seeks to fulfill these selfobject needs through children. While non-offending individuals have
likely not fulfilled all their selfobject needs, it is theorized that in the case of a pedophile,
the extent to which their selfobject needs have not been met is severe. This has resulted
in the pathological development of pedophilia. However, while Self-Psychology provides a
developmental perspective, there is a neurobiological basis that must be addressed.

NEUROBIOLOGY OF PEDOPHILIA
Neurobiology is complementary to Self-Psychology and Attachment Theory because
it scientifically supports some of the presuppositions of the behavioral theories and
their application to pedophilia. Significant research conducted on the biological and
neurological differences of pedophiles and non-offenders is significant. According to Rice,
Harris, Lang & Chaplin (2008), “Neuro-developmental disruption forms an important
cause of pedophilia. Men with pedophilia have lower IQ scores, have a childhood head
injury, have elementary school academic problems. . .all indirect indicators of neuro-
developmental perturbation” (p. 409).
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Furthermore, an interference of brain development has been linked to insecure attachment


and cognitive distortions about the self, others, and the world (Wood & Riggs, 2009).
Therefore, an application of neurobiology to pedophilia will be conducted to further
explain this disorder that is misunderstood. The neurobiological research about the
following brain areas and their impact on pedophilia will be discussed: amygdala, the
temporal lobes and the frontal lobe and the orbitofrontal cortex.

AMYGDALA
The amygdala plays a significant role in the development of pedophilia. The amygdala is
the “central neural hub” of emotional experience as it is a vital part of the limbic system
(Cozolino, 2002). The amygdala also contains the implicit attachment schemas developed
in infancy and childhood. Consequently, it has the potential to be a significant factor in
the development of pedophilic thoughts and urges.

A study was conducted by Schilz, Witzel, Northoff, Zierhut, Gubka, Fellmann, Kaufmann,
Tempelmann, Wiebking, & Bogerts (2007) that postulated there was a relationship
between amygdalar impairment and pedophilic offenses. The authors found that
pedophile perpetrators had considerably smaller amygdala volume on the right side of
the brain. Consequently, the right side of the amygdala affects sexual functioning more
than the left (Cozolino, 2002). The study also found that there was gray matter in the
amygdala, which could likely have an effect on sexual development. As a result, the
authors hypothesized that developmental or environmental disturbances occurred at
critical periods in the pedophiles’ lives

While scientific research has shown a correlation between pedophilic desires and
amygdala volume and gray matter, it can be further theorized that the early infant and
childhood interactions of attachment have become implicit memories. As a result, they
serve as unconscious roadmaps to emotional dysfunction and misattunement.
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TEMPORAL LOBES
The reduced volume of the amygdala is a significant predisposing factor to the
development of pedophilic desires; however, the temporal lobes also appear to affect the
development of pedophilic sexual attraction. According to Suchy, Whittaker, Strassberg &
Eastvold (2008), sexual attraction to children is mediated by temporal lobe irregularities.
Temporal lobes are the center of the social brain as they process information from
different senses and integrate the information with affective information obtained from
the amygdala (Cozolino, 2002). Temporal lobes are also associated with auditory, visual
and sensory skills. As such, research has shown that pedophiles have exhibited deficits
in semantic knowledge and verbal learning (Suchy, Whittaker, Strassberg, & Eastvold,
2008). Evidently, there appears to be a significant correlation between damage to social
brain structures, such as the temporal lobes and amygdala, and sexual dysfunction or
pedophilic sexual attraction.

THE FRONTAL LOBE AND THE ORBITOFRONTAL CORTEX


While the aforementioned brain structures may contribute to the development
of pedophilic sexual attraction, damage to such structures does not explain why
an individual would act on impulses. However, this question may be answered by
examining frontal lobe impairment and its impact on pedophilia. The frontal lobe
is the executive of the brain and it affects an individual’s ability to maintain self-
control, control impulses, and make shifts in attention (Cozolino, 2002). Stone and
Thompson (2001) conducted a study on the frontal lobe of pedophiles and rapists
and found significant impairment in the majority of sex offenders. As a result,
damage to the executive functioning system of the brain would inhibit a pedophile’s
ability to control his impulses. Furthermore, as the orbitofrontal cortex is located
in the frontal lobes, damage to this brain structure could also result in increased
impulsiveness, sexual disinhibition and inappropriate social behavior (Cozolino,
2002, p. 138). While this does not absolve pedophiles from responsibility, it does
provide an understanding of the behaviors. As neurobiology provides a biological
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understanding to pedophilia, it does not explain the social and demographic factors
that may impact pedophilic behavior.

DIVERSITY ISSUES
Neurobiology affects the way in which the brain functions and experiences attraction;
however, there are numerous other biological, social, and environmental factors that may
influence an individual’s development of pedophilia. Specific diversity issues, such as gender
and ethnicity have been identified in literature as impacting the motivation of pedophilic
desires (Gannon & Rose, 2008). Consequently, these diversity issues will be addressed.

GENDER
Within the context of sexual offenses, men are stereotypically viewed as the offenders
and women are perceived as the victims (Gannon & Rose, 2008). Statistics confirm
the stereotype as 89.3% of pedophiles are male and 10.7% are female (Peter, 2009).
Nevertheless, it has been hypothesized that the statistics of female perpetrators are
drastically underreported because women are socially viewed as more nurturing and
caring. As a result, benign behaviors women exhibit toward children may be sexual in
nature (i.e. bathing a child in a sexual way).

Since research has focused on men as sexual offenders, there is little information
available regarding the motivational differences between men and women. However,
statistics measuring female offenses and traumatic histories shed a different light on
female sexual offenders. Approximately 80% of women charged with sexual assault had
been historically sexually abused (Lewis & Stanley, 2000). Also, 95% of female offenders
were victims of either physical or sexual abuse (Schwartz, 1995). These statistics are
drastically different than the 43% of male pedophiles who reported sexual abuse (Sawle
& Colwell, 2001). Consequently, the motivating factors in male and female pedophilic
offenses appear to differ.
83

ETHNICITY AND CULTURE


In addition to gender factors, ethnic and cultural factors must also be considered in
conceptualizing the motivations for pedophilia. Few studies have focused on the ethnic
differences of sexual offenders and pedophiles; however, Ward, Hudson & Marshall
(1996) purport that social and cultural factors likely have a “major influence” on an
individual’s ability to form intimate relationships, thus affecting their sexual attractions
and behaviors. A national study conducted on the recidivism of child molesters found that
pedophiles were predominantly non-Hispanic Caucasian males age 30 or older (Langan,
Schmitt, Durose, 2003). Furthermore, 20% of pedophiles were black men, and 3% were
Hispanic (Langan, Schmitt, Durose, 2003). The predominance of Caucasian pedophiles
could be a result of American individualistic culture.

In addition, two ethnicities were identified by Schwartz (1997) as requiring additional


attention for understanding pedophilic motivations: Hispanic and American Indian.
According to Schwartz (1997) the “machisimo” attitude exhibited in Mexican culture
is associated with sex offending. More specifically, within Hispanic culture there is
a concept called “obediencia afiliativa,” which means filial obedience. This concept
has been known to be used by fathers to coerce younger family members into sexual
relationships. Also, within the American Indian population Schwartz (1997) theorized that
sexual offending may be a displacement of violence and anger as a result of poverty and
dependency on the federal government.

While only two primary ethnicities were addressed, it appears evident that ethnic and
cultural factors impact the perception and motivation of pedophilia. Within American
society the minority is frequently overlooked. Overlooking such factors and their
association with pedophilia, only places more children in harm’s way. It is essential
that research conducted and interventions developed for pedophiles are inclusive of
diversity factors.
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TREATMENT
Currently, within the sex offender treatment field 80% of programs focus on cognitive-
behavioral treatments and relapse prevention. These interventions are aimed at reducing
the possibility of recidivism (Saleh & Guidrey, 2003). However, these interventions are a one-
size-fits-all model, which is not conducive to the treatment of all sex offenders, specifically
pedophiles from diverse backgrounds. Furthermore, these interventions do not address the
affect misattunement and insecure attachment styles pedophiles have developed (Hudson,
Ward, Marshall, 1996). As a result, the following treatment plan is aimed to address the
specific needs of pedophiles deriving from Attachment Theory, Self-Psychology, neurobiology
and diversity issues. The following generalized treatment approaches will be addressed:
initial referrals, beginning stage of therapy and the middle stage intervention. Finally, adjunct
therapies will be discussed as enhancements to the treatment plan.

REFERRALS
Upon receiving an individual with pedophilia, two referrals will be made in order to
provide holistic treatment. Due to the correlation between neurological development
and pedophilia, the individual will first be referred for cognitive and psychological
testing. The second referral will be made to a psychiatrist for psychopharmacological
treatment. Research has shown that anti-androgens and serotonin reuptake
inhibitors are helpful in controlling aggressive sexual deviancy (Schwartz, 1995).

BEGINNING STAGES OF THERAPY


The beginning stage of therapy is important as trust and the therapeutic alliance is
developing. Due to the insecure attachments and narcissistic injuries pedophiles may
have experienced in infancy and childhood, the beginning stage of therapy is crucial for
the successful treatment of the pedophile. Developing rapport and a therapeutic alliance
is necessary in order to reach the affective internal working model of the client. The
beginning stages of therapy should not be rushed as the therapeutic relationship can
serve as a “template” for the development of secure attachment (Kear-Colwell & Boer,
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2000). The therapist may serve as the secure base for the client as the client may begin
to feel safe to explore his emotions and affective states.

In addition to serving as a secure base and the therapeutic alliance serving as a template
for new attachments, the therapist may also serve as mirroring, soothing, and twinship
selfobjects. Mirroring in the beginning stages of therapy can build rapport if the therapist
is able to validate and reflect back to the individual his feelings and emotions. The
therapist may also provide empathetic attunement, which is crucial when treating the
pedophile because of his narcissistic wounds. Finally, minimal and carefully selected self-
disclosure may also be done in order to create a sense of twinship. Twinship needs are
essential as pedophiles have a tendency to seek children for emotional needs because
they do not feel worthy among their peers.

MIDDLE STAGE OF TREATMENT: THE ROCKWOOD PROGRAM


In addition to individual therapy, the client will be placed in group therapy during
the middle stage of treatment. The rationale for group therapy is because sexual
deviancy is similar to the psyche of an individual with an addiction, specifically with
regards to “denial, guilt and secrecy” (Schwartz, 1995). These are the characteristics
that make therapy with pedophiles particularly difficult. According to Schwartz,
“Because these offenders often lie, minimize, and rationalize their behavior, it is quite
a task for a lone therapist to muster the strength or the evidence to confront their
defenses. Group members are able to recognize their own patterns and may provide
confrontation, which is more effective than the tactics of the therapist” (p. 451).

Therefore, in lieu of traditional treatments, the Rockwood Program is proposed as it


focuses on the expression of emotion and the development of affect regulation in
a group setting (Marshall, Marshall, Serran & O’Brien, 2008). The program includes
various topics aimed at treating pedophilia from a holistic perspective. Group topics
include the following: creating an autobiography, accepting responsibility, creating an
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offense pathway, developing coping skills and self-management skills and processing
relationship and sexual issues.

TREATMENT ADJUNCTS
While the Rockwood Program is proposed as the primary treatment in addition to
individual therapy, adjunct treatments will also be recommended to prevent relapse.
These treatments include CBT, as it addresses the cognitive distortions that many
pedophiles possess. Furthermore, CBT has been effective in reducing trauma symptoms
for the pedophile sexually abused as a child (Burton, 2008). Finally, behavioral
techniques may be used to “alter sexual arousal” (Schwartz, 1995). While these
techniques have proven beneficial in reducing recidivism, they do not address the
primary cause of pedophilia.

CONCLUSION
Child molesters have a deep-rooted fear of intimacy and close relationships, likely
stemming from early infant and childhood interactions (Sawle & Colwell, 2001; Ward,
Hudson, & Marshall, 1996). Pedophiles have the right to effective treatment for the
promotion of their own recovery and also for the benefit of their otherwise potential
victims (Ricci, 2004). In order to utilize an effective treatment for pedophilia, a strong
theoretical foundation for pedophilia must be conceptualized. Therefore, this paper
employed the use of Attachment theory to explain the misattuned pedophile. Self-
Psychology described sexual deviancy as unintegrated lust and aggression as a result
of the pathological breakdown of the self (Goldberg, 1998). In addition, neurobiology
explained why pedophiles may act on their sexually deviant impulses. Diversity issues
such as gender and ethnicity were also discussed within the context of their impact on
motivation. Consequently, a holistic perspective of the pedophile was conceptualized.
The NASW Code of Ethics states that the advancement of the most effective practices,
obtained through relevant theoretical application, is essential to maintain the dignity
and worth of the person being treated. While the crimes pedophiles commit do not
87

require approval, the individuals as humans deserve respect and the best attempts to
create environments in which recovery is fostered.
88

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Cross-Cultural Skills Building Training
Program for the Program for Torture Victims
Clinical Staff

LORENE GINGERICH
Evaluation of Research: Community Organization, Planning and Administration
Professor Jacquelyn McCroskey
93

INTRODUCTION AND BACKGROUND


Program for Torture Victims (PTV) is a non-profit organization in Los Angeles with the
mission of providing services “to alleviate the health consequences and suffering of state
sponsored torture by providing medical, psychological and case management services
to survivors of torture” (Program for Torture Victims, n.d.). PTV is the oldest torture
treatment program in the U.S., and the specific services PTV offers to accomplish its
mission are psychological evaluation and counseling, medical evaluation and treatment,
forensic services (including forensic medical and psychological evaluations and expert
witness testimony in federal immigration court), case management and support groups.
The agency does not limit its services to the refugee community, but also works closely
with the community to do training, public education, advocacy and legislative work
(Program for Torture Victims [PTV], 2009).

In order to provide specialized services, PTV has an extremely knowledgeable and skilled
staff. Dr. Jose Quiroga of Chile and Ana Deutsch of Argentina are torture survivors
who co-founded PTV in 1980 (Lopez, 2006). Both Dr. Quiroga and Ana Deutsch have
pioneered the treatment of torture survivors in the United States and remain as active
staff in the agency (Dr. Quiroga, Medical Director and Ana Deutsch, Clinical Director).
PTV is unique in the national community of torture treatment centers because it was the
first program of its kind in the United States, and all services are free of charge to eligible
clients, persons who have experienced state sponsored torture living in the greater Los
Angeles area. PTV is almost the only agency in the nation to provide in-house medical,
psychological and case management services, facilitating its ability to provide integrated
interdisciplinary care and longer term services to survivors.

PTV is unique in its geographical location because it is the only torture treatment
program in the greater Los Angeles region. PTV serves clients from five counties,
including Los Angeles, Orange, San Bernardino, Ventura and Riverside. Being the only
torture treatment program in greater Los Angeles, PTV has served approximately one
94

thousand clients since 2000 (PTV, 2009). PTV provides services to survivors of state-
sponsored torture who come to the U.S. seeking asylum from over 65 countries. To name
a few, PTV serves clients from Africa, Asia, the former Soviet Union, the Middle East and
Latin America. However, the demographic population at PTV is constantly changing,
along with the world’s political, social and economic dynamic.

PROGRAM EVALUATION
To respond to the constantly changing environment in the world and to diverse clients
PTV serves, PTV gives regular training on cross-cultural skills building in order to promote
continuing efforts for cultural awareness among all community providers. Then, the
program to be evaluated is the existing cross-cultural skills building training PTV staff
gives to the community that will be regularly incorporated into in-house staff training.
In-house cross-cultural discussions occur regularly during weekly PTV staff meetings,
but there is no formal training program or tracking mechanism. PTV does however have
a format for training. PTV staff gives training to the Department of Homeland Security
Los Angeles Asylum Office, immigration judges, lawyers, local physicians, mental health
providers, social service agencies, institutions of higher education, and community
groups. Community training is provided by PTV staff members as advocacy and public
education on the unique cultural practices and worldviews of refugees, especially PTV
clients (American Psychology Association, 2003).

The PTV clinical staff has created several different training formats, handouts
and PowerPoint presentations for this community training. The most recent and
comprehensive training was created in 2007 called “Building Cross-Cultural Clinical
Skills in Providing Mental Health Services to Refugee Survivors of Torture” (Berthold &
Durocher, 2007). The goal of this training is to provide a cross-cultural skills building
training to professionals in the community to help them become more aware of cultural
differences and how these differences may impact their professional practice. The training
objectives are to increase the attendees’ knowledge of cultural diversity by providing
95

definitions, statistics and the range of experiences and challenges refugee populations
experience in relation to mental health in Los Angeles County. The training extensively
reviews the approaches and considerations practitioners must exercise when working
with refugees including the following: three phases of traumatization, rape, assessment
and interviewing techniques, diagnostic and treatment considerations, burn out, counter
transference, vicarious traumatization and outreach approaches.

Healy (2008) suggests that learning about cultures to improve services is not sufficient,
but that further attention is needed in cultural competence practice to increase
knowledge on international populations within nations and knowledge on the oppressive
forces that cause PTV clients to flee from their countries. Then, focusing on cultural
competency can expand PTV’s training program.

In order to expand the training program to focus on cultural competency, a definition


for cultural competency must be established. There are varying definitions of cultural
competency (Lo & Fung, 2003; Alvarez & Chen, 2008; D.W. Sue & Torino, 2005; S.
Sue, 1998) but the overall goal of cultural competency is to work for social justice and
empowerment of clients through learning about cultures, skills or interventions and the
process involved (Gutierrez, Fredricken & Soifer, 1999; Sue, Zane, Hall & Berger, 2009).
Falicov (1995) and Sue et al. (2009) explain that it is difficult to integrate changed
attitudes and behaviors, competency skills and knowledge into practice. Therefore, the
training needs to incorporate education on specific cultural backgrounds (ethnic and
religious) and provide tools for incorporating this knowledge into practice.

PTV clinical and medical staff members have competency skills in their practice because
of their extensive work and experiences with international populations. According to
Client Outcome Study from 2000-2008 (Program for Torture Victims, 2009), many of the
torture survivors seeking PTV services have experienced multiple traumas and without
treatment may experience relapses in symptoms such as pain (somatic complaints),
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anxiety, depression, and withdrawal from normal activities and absence from work.
Many have also fled to the US without their normal social networks and support and
find it difficult to establish relationships with community organizations and resources.
It is crucial for the case manager and clinical staff to work with the client to identify
communities in Los Angeles with connections to their religious, ethnic or refugee groups
to extend their social network. Lastly, the Client Outcome Study demonstrates that clients
have benefited from PTV staff members’ cultural sensitivity and flexible approach to
services (Program for Torture Victims, 2009).

Since treatment of torture victims requires flexibility and a heightened cultural awareness,
there is a great need for the clinical and medical staff to be even more culturally
competent. There are numerous cultural backgrounds and unique worldviews that
practitioners have not worked with and do not have cultural competency skills for their
practice. As conflicts and wars continue to break out around the world there is a growing
need for PTV staff to continue improving their knowledge of cultures.

The current cross-cultural clinical skills training uses a skills and cultural adaptation
model focusing on skills or strategies learned in working with culturally diverse clients
and provides training in developing psycho-therapeutic competencies (Whaley & Davis,
2007; Sue et al., 2009). In order to expand the current training for PTV staff members,
PTV needs to expand its delivery method to include translating materials, provide more
education on culturally appropriate respect, and provide interventions in cultural contexts
(Sue et al., 2009). For example, PTV does not have agency materials translated into
other languages and relies on interpreters to translate the material. This is problematic
because often the meaning of the question or original material can get lost in translation
(M. Berthold, personal communication, September 30, 2009). PTV staff has knowledge
and experiences with many cultures but it would enrich the agency’s services to do
more staff training on culturally appropriate respect (formal language, greetings, titles,
communication, cultural standards and practices). Finally, providing interventions in
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a cultural context is difficult because of institutional and Western cultural constraints


(Sue et al., 2009). For example, clinical and medical staff must provide evaluations
and testimony for federal court that is in the context of Western therapy and medical
language. Interventions like cultural ceremonies, such as pouring libations for ancestors
or lighting candles, are not interventions that are legitimized in court (Sue et al., 2009).
Therefore there is a tendency for staff to practice with cultural awareness while still
providing “traditional Western” therapy.

Expanding training in cultural competency to include skills building and culturally


adaptive interventions will enable PTV staff to provide even more valuable and needed
services to its clients. The information PTV learns from training its own staff members can
inform new training given to other service providers on culturally appropriate techniques
and interventions for practice.

PROBLEM IDENTIFICATION
Torture is a social problem in countries around the world, including the United States.
In 2000, it was reported that 150 nations practiced torture or maltreatment (Amnesty
International, 2000). Despite the increased visibility and prevalence of torture, there
remains relatively little scientific data on the effects and treatment of torture (Quiroga
& Jaranson, 2005). Then, in order to demonstrate the medical and psychological impact
torture has on individuals, it is important to establish a definition of torture.

Torture is defined by many entities in different ways. Amnesty International was the first
organization in 1973 to give a broad definition of torture from a political and operational
point of view and later in 1975 the World Medical Association (WMA) adopted a similar
definition (Quiroga & Jaranson, 2005). Both definitions of torture include the deliberate
or systematic infliction of mental or physical pain by force of another person in order to
gain information, a confession or for any other reason (Amnesty International, 1975;
Amnesty International, 1994). These definitions from Amnesty International and WMA
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were used from 1973-1984 until the United Nations (UN) Convention against Torture
and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) (Office of the
United Nations High Commission for Human Rights, 2007). In 1984 CAT adopted the
definition for torture as:

…any act by which severe pain or suffering, whether physical or mental, is


intentionally inflicted on a person for such purpose as obtaining from him or a
third person information or a confession, punishing him for an act he or a third
person has committed, or is suspected of having committed, or intimidating or
coercing him or a third person, or for any reason based on discrimination of any
kind, when such pain or suffering is inflicted by, or at the instigation of, or with the
consent or acquiescence of, a public official or other person acting in an official
capacity.

This definition from CAT is the official definition for torture that was adopted and ratified
by 210 countries on April 23, 2004 (Quiroga & Jaranson, 2005). The purpose for ratifying
and adopting a definition for torture was not to group, label or pigeonhole individuals
but as an accountability measure for those who participate in torture. Then, the official
definition of torture fails to capture who experiences torture because torture survivors
do not have a specific profile. They are men, women, children, rich, poor, educated,
uneducated, farmers and businesspeople (Fabri, 2001). For this paper the official CAT
definition for torture will be used as any kind of physical or mental pain or suffering
experienced by individual for the purpose of information or based on discrimination by a
public official or third party acting on behalf of the official.

Following the ratification of CAT and the total number of refugees in the world reaching
nearly 16 million (U.S. Department of State, 2009) there was increased demand for the
U.S. and other nations to respond to unsettled refugee populations. In response to the
growing number of refugees in the world, U.S. Congress passed the Torture Victims
99

Relief Act of 1998 (TVRA), that recognized there was a significant number of refugees,
asylees, and asylum seekers entering the United States who have suffered torture (U.S.
Department of Health & Human Services, 2009). TVRA was a monumental act passed by
Congress because despite scarce research on torture victims among refugee populations
(Quiroga & Jaranson, 2005), the legislation provided funding to treatment centers for
treatment programs and services. Before TVRA torture treatment programs had little to
no funding for services and the majority of centers were volunteer based. PTV received
the first cycle of TVRA funding in 2000 and continues to rely heavily (64% of its overall
funding) on this federal grant.

However, one year after dispersing federal funds to eligible torture treatment centers,
the terrorist’s attacks on September 11, 2001 posed new threats to immigrant
populations, affected US policy on security and increased the need for services in
the refugee populations. New US policies like the USA PATRIOT Act (Uniting and
Strengthening America by Providing Appropriate Tools Required to Intercept and
Obstruct Terrorism) were meant to increase US security. However, it posed new
threats to immigrants because it was applied retroactively calling for deportation of
immigrants known to support terrorist organizations (Matthews, 2002). The Patriot
Act increased the need for services because it increased the number of detentions and
deportations in the immigrant and refugee populations (Healy, 2008). Despite PTV
receiving federal funding for medical and clinical torture treatment services, during
the eight years following 9/11 the agency has found itself providing more and more
forensic services to refugees who have been detained and even tortured under this
new US policy.

LITERATURE REVIEW FOR PROPOSED INTERVENTION


According to the U.S. Refugee Admissions Program (USRAP) report of the 48,217
refugees admitted into the U.S. in 2007, 6,699 (13.89%) resettled in California
(Quiroga & Jaranson, 2005; U.S. Department of State, 2009). California had the
100

highest number of refugee arrivals of any state in the U.S, with Florida (2,619) and
New York (2,978) following California. Additionally, of the 6,699 refugees who
resettled in California, 4,645 (69%) resettled in the five counties that PTV serves
(California Department of State Office of Admissions Refugee Processing Center,
2009). The Los Angeles Federal Immigration Court had the highest number (4,064) of
asylum applicants in all of California’s counties (Program for Torture Victims, 2009).
Therefore, the treatment of torture survivors is relevant to the greater Los Angeles area
because a majority of the refugees entering the US have resettled in California, but in
particular within the communities and neighborhoods that Program for Torture Victims
(PTV) serves.

According to the Los Angeles County Census (2000) the demographics for Los Angeles
County foreign-born populations included people from Asia (29.6%), Africa (1.2%),
Oceania (.4%), Latin America (62.1%) and Mexico (44.2%). Similarly, statistics from the
Client Outcome Study 2006-2007 indicated that PTV serves clients from Africa (52%),
Asia (27%), the former Soviet Union (15%), the Middle East (4%) and Latin America
(2%). There are many similarities and differences in the percentages of Los Angeles
County and the populations PTV serves. The first noticeable difference in statistical data
can be contributed to the census information from 2000 and PTV data collection from
2006-2007. Also, one must take into account that differences in data can be attributed
to the changes occurring politically, socially and economically from 2000-2007. Despite
the differences in statistics or demographics, the overall impact of these statistics
demonstrates that Los Angeles is serving significant numbers of immigrants entering this
country, with the majority of these refugees resettling in communities PTV serves.

Likewise, client statistics from 2006-2007 indicate that on average PTV serves nearly 300
clients per year (including approximately 90-100 new clients). Typically the population of
clients is evenly split between males and females. The age range of clients who entered
PTV in 2007 is between the ages of 5-66, where the average age is 37.6 (Program
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for Torture Victims, 2009). Since 2000, PTV has served approximately one thousand
individuals seeking asylum in the U.S. with psychological, medical, case management and
legal services.

In order to demonstrate the full spectrum of services PTV provides, one must understand
US policy and what the process for seeking asylum may look like. The US policy on
asylum states that individuals from any country may seek protection from prosecution or
fear of prosecution on the basis of race, religion, nationality, membership in a particular
social group, or political opinion (U.S. Citizenship & Immigration Services, 2009). After
the PATRIOT Act (2001) gaining asylum in the U.S. has become an even more difficult,
long and traumatizing process (Program for Torture Victims, 2009). In order to gain
asylum one must file a Form I-589, Application for Asylum and for Withholding of
Removal within a year of arriving to the U.S., interview with a Department of Homeland
Security (DHS) Los Angeles Asylum Officer who can grant you asylum or Notice to Appear
is issued and the case is referred to a Federal Immigration Judge (IJ) (U.S. Citizenship
& Immigration Services, 2009). If an asylum case is sent to the Los Angeles Federal
Immigration Court most asylum seekers are assigned an attorney, who then refers clients
to PTV. The medical and clinical team conducts forensic assessments, writes affidavits
for asylum interviews with DHS Asylum officers and immigration court proceedings, and
serves as expert witnesses in immigration court as needed. PTV aims to ensure that
asylum-seekers do not continue to fall through the cracks in policies, social services
(Sakamoto, 2007) and do not have to continue to fight the risks of homelessness, hunger
and health (mental and physical health) problems (Jones, 2001; Lacroix, 2006; Program
for Torture Victims, 2009).

The staff at PTV is trained to provide services that aim at decreasing the risk of these
social and health problems. A majority of staff members have been with the agency for
6 or more years, but bring with them many years of knowledge and experience working
with torture survivors. The treatment team consists of two physicians (internal medicine
102

and gynecologist), two clinical psychologists, two therapists, one MFT, one MSW, case
management and a team of interpreters.

The PTV clinical staff and team of interpreters speak the following languages: Amharic,
Arabic, Armenian, Farsi, Punjabi, Russian, Tigrinya and Urdu. The interpreters are used for
cultural consultation, but they are not experts in every dialect of their language nor have
they shared the same cultural experiences as the clients.

Case management assists clients integrate into Southern California’s society and
culture (Program for Torture Victims, 2009). According to social work literature more
attention is needed in the integration of immigrant, refugee and asylum-seeking
populations into the host society (Balgopal, 2000; Lacroix, 2006; Nash et al., 2006).
It is important to note integration as a strength at PTV, while continuing to promote
that effort is made by PTV staff to establish culturally appropriate integration and
intervention principles.

The medical and clinical staff members (therapists, interpreters, and case manager) are
sensitive to the clients through utilizing principles of trauma theory and working cross-
culturally to ease any hesitation or unfamiliarity clients may have to the Western practice of
medicine and therapy services (American Psychology Association, 2003; Kinzie, 2001; Briere
& Scott, 2006). More than three fourths of the world’s population lives in non-Western
cultures and 90% are unfamiliar with Western psychotherapeutic constructions (Berthold &
Durocher, 2003). PTV clinicians explained their approach as using the person in environment
(Zastrow & Kirst-Ashman, 2007; Greene, 1999), cross-cultural principles, and culturally
appropriate interventions that can look radically different for each client depending on the
therapeutic relationship and the way the therapist implements these principles (M. Berthold,
personal communication, October 7, 2009). For this reason, additional training is essential
to PTV’s clinical staff members in order to ensure that clinicians are continuing to learn from
one another and share information about interventions, therapeutic relationships and cultural
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practices. The following section will identify a model for implementing a cross-cultural skills
building training program for PTV clinical staff.

LOGIC MODEL
A logic model is a useful framework for examining outcomes (United Way, 1996).
A logic model includes identifying inputs, activities, and outputs or outcomes to be
achieved. Based on the logic model for the proposed cross-cultural skills building training
(Appendix A), the input for the training program is PTV clinical staff will incorporate
the cross-cultural skills building training into their clinical staff meetings. Clinical staff
meetings occur every Thursday of the month. The training program will build on the
current training curriculum (Building Cross-Cultural Clinical Skills in Providing Mental
Health Services to Refugee Survivors of Torture, Berthold & Durocher, 2007) and other
agency training materials.

For the purposes of this training program, the activities will including incorporating
the cross cultural skills training once a month, on the last Thursday of the month, into
the clinical staff meetings. The format for the training program is that each month one
member of the 6 person clinical staff will be identified to present at the staff meeting
on the last Thursday of the month. There will be 6 trainings in total, over 6 months.
The clinical staff member selected to present will prepare a 30-minute presentation
on particular variations in clients’ customs, backgrounds, clinical approaches and
personal experiences. These presentations should include case vignettes or handouts
on the material being presented. Then, the second activity is to have tangible learning
devices so that a resource guide can be created, compiling all the handouts or case
vignettes from the presentations. The resource guide is meant to be useful for agency
staff members as well as a resource for future community trainings. The third activity
is to create a form for case management to complete at intake. The form would be
in addition to all other intake materials and would contain questions that are more
culturally competent. These questions would be drawn from Kleinman’s Questions
104

(1978). The purpose of creating and adding this form to the intake packet is to elicit
clients’ beliefs about illnesses in a respectful and culturally competent manner (Pilcher
et al., 2008). The fourth activity is to translate agency forms. Translating agency forms
is essential in building cultural competency because it ensures that clients are able
to read and understand the materials they are signing. Likewise, clients with limited
English proficiency “have difficulty entering, continuing and benefiting from services”
(Sue et al., 2009, p. 534). The final activity includes monitoring data collected from the
Client Outcome Study (PTV research project). The activity will be to monitor clients’
responses, at one-year follow up, on what worked and what did not work with the
services as well as attitudes and behaviors of PTV clinical staff. The follow-up interview
will be a self-report by clients’ and will include questions on the client’s perception of
cultural competency within PTV staff and services.

The output from the training will be an established cross-cultural skills building program
that includes translated agency materials, a new form at intake, and 6 sessions of
training that produce resources (case vignettes, information on clinical approaches, and
presentation handouts) for an agency resource guide.

Finally, the outcomes of the training program are broken into initial, intermediate, and
long-term outcomes. The initial outcome is to increase the PTV clinical staff’s knowledge
of cultural diversity measured through a Self-Assessment Checklist (Goode, 2004). The
intermediate outcome is that PTV staff are more confident to use the knowledge from
the training to interact with clients outside of their clinical expertise measured through
the Clinical Cultural Competency Questionnaire (Like, 2001). The long-term outcomes are
to improve client functioning as measured through self-report in the one-year follow-up
interview and integration of specialized cultural competency training measured by staff
being able to train others.
105

RESEARCH QUESTIONS
This program evaluation will test four research questions to address all of the outcomes
in the logic model. The four research questions include:

Research Question 1:
What will PTV clinical staff gain from the cross-cultural skills building training?

Research Question 2:
How does the training impact PTV clinical staff members’ ability to interact with clients in
the clinical setting?

Research Question 3:
What impact will the training have on client functioning?

Research Question 4:
What new information will PTV staff be able to integrate into the existing community
cross-cultural skills building training?

RESEARCH DESIGN
Because the demographic population at PTV is constantly changing, it is important that
PTV staff are continuously learning about cultural customs, background, client traditions
and practices (religious, cultural, communal). The goal of this training program is to
provide cross-cultural skills building training to PTV clinical staff (6) who participate in
weekly staff meetings to help these clinicians become more aware of cultural differences
and how these differences may impact their professional practice. In order to achieve
the goal of this program, the objectives are to increase PTV clinical staff knowledge of
cultural diversity and differences and increase client functioning.
106

SAMPLING STRATEGY
The study will focus on 6 PTV clinical staff participating in the training program as well as
clients who participate in the intake process for PTV services during the 6-month training
program. The sample of 6 PTV clinical staff members will include one case manager,
one physician, and four psychologists/therapists. The sample of clients will include those
participating in the intake process for PTV services during the 6-month training program in
order to track the level of services clinicians provide after receiving the training until one-
year follow up. Not all clients who participate in the intake process continue to receive
services from PTV, but it is important to track those that answered Kleinman’s Questions
to evaluate whether or not the questions are perceived as more/less culturally appropriate
than the previous “Western-framed” intake questions. Since neither the staff nor the
clients will be recruited for the program, recruitment time will not be needed.

INFORMED CONSENT AND ANONYMITY


Since the program being evaluated is for training purposes an informed consent will
be given to PTV staff members at the beginning of the training program to ensure that
each staff member agrees to participate and is not being forced to participate because
it takes place during their weekly meeting. In the informed consent form it will explain
that all the information gathered from self-assessments and evaluation questionnaires
will be anonymous. To ensure anonymity each staff member will be given a number and
the only person that will know this information will be the Principal Investigator (Lorene
Gingerich). The instruments will be kept in a secure location in PTV’s office. Since the
findings of this study are for the benefit of the agency and not for publishing purposes,
the information will only be shared with PTV administrators and PTV staff members.

However, for the purposes of the one-year follow-up interview, there is an existing
participant consent form that is explained and administered at intake. Therefore, all
the clients that are of interest to this study (those participating in the intake process
during the 6-months of training) will have already completed the informed consent at
107

intake. Also at intake clients are given a client number that is used to label their file
and on every sheet that put into their client file. Therefore, the Client Outcome Study is
anonymous and no PTV staff will know the clients identity (except the two staff members
assisting with the study). During the one year follow-up interview clients will be asked
questions about their satisfaction with PTV services and clinicians’ knowledge regarding
cultural practices or norms. This information will be collected and reviewed by a PTV
non-staff member (MSW intern) in order to ensure client confidentiality and prevent any
conflicts between clinicians and client.

Also, because the interviews will take place one year following intake, the participants
will be asked to provide contact information (phone or email address) so that the
researchers can contact the participants for the follow-up interview. No other information
that may identify the individual’s identity will be collected during the research study.

ANALYSIS PLAN
Data collection will consist of the intake form with Kleinman’s Questions, one initial post-
training self-assessment by clinical staff, an intermediate questionnaire, one long-term
post-training interview of clients to assess staff knowledge and confidence and client
functioning, and the other long-term data collection will measure the ability of staff to
train others.

The first cultural competency building technique will take place in the intake process. The
intake process consists of the case manager collecting information about demographics and
the presenting problem as well as consent to services. The primary complaint/presenting
problem tool is based on Western practice of medicine and therapy (American Psychology
Association, 2003; Kinzie, 2001; Briere & Scott, 2006). Therefore, research suggests
integrating Kleinman’s Questions into health and social services to elicit clients’ beliefs
about illnesses in a respectful and culturally competent manner (Pilcher et al., 2008).
Following the cross-cultural skills building training of PTV clinical staff there will be an
108

initial post-training self-assessment administered to clinical staff. The self-assessment


tool will be administered (in paper form) one week after the sixth presentation in the
Thursday clinical staff meeting. The clinicians will be given one week to complete the
self-assessment, which will be collected in the following week’s staff meeting. The self-
assessment tool will be a modified version of Goode’s (2004) Self Assessment Checklist.
The Self Assessment Checklist asks statements about physical environment, materials
and resources, communication styles and values and attitudes. This tool will measure
how or if the training increased the PTV clinical staff’s knowledge of cultural diversity in
these areas.

The intermediate questionnaire will be administered 3 months after the training to assess
if PTV staff are more confident in using the knowledge from the training to interact with
clients outside of their clinical expertise. The self-assessment tool will be the Clinical
Cultural Competency Questionnaire modeled after the Like (2001) instrument. The
questionnaire will be in a Likert format and will measure the knowledge clinicians gained
from the training and the confidence and ability to use their knowledge in practice. The
questionnaires will also be administered in the clinical staff meeting 3 months post-
training. There is little concern for staff turnover since PTV’s clinical staff members have
been with the agency for nearly 11 years (with the exception of the case manager who
has been with the agency for 6 years). Like the initial self-assessment tool the clinicians
will be given one week to complete the questionnaire and it will be collected in the
following week’s staff meeting.

The long-term outcome is to assess client functioning at the one-year follow up interview
measured by self-report. The data will be collected in coordination with PTV’s existing
Client Outcome Study where clients who participated in the intake process for PTV
services have already consented for the interview. The goal will be to target individuals
who participated in the intake process during the 6-month training program to track the
level of services clinicians provide after receiving the training. As mentioned above, not
109

all clients who participate in the intake process continue to receive services from PTV,
but it will be important to follow-up with clients to evaluate whether or not Kleinman’s
Questions are perceived as more or less culturally appropriate than the previous
“Western framed” intake questions. Currently in Part III of the Client Outcome Study
there are eight open-ended questions about clients’ experiences with PTV services,
including case management, therapy and medical services. Then, questions will be
included regarding client satisfaction with PTV cultural competency services (translated
materials and interpreters) and clinicians’ knowledge regarding cultural practices or
norms. The data will be analyzed by identifying themes from the information clients
provide. The themes this study will be interested in are clients identifying their experience
with services, specifically if services were delivered in a way that the client liked or was
familiar with or if the client identifies any areas of discomfort or challenges.

Finally, staff being able to train others will measure the integration of the cross-cultural
skills building training. This outcome does not have an established measure, therefore it
will be evaluated after the next community training. The basis of the evaluation will be
assessing whether or not PTV was able to integrate case vignettes or handouts, practices,
skills and knowledge learned from the in-house cross-cultural skills building training.

RELEVANCE TO SOCIAL WORK MACRO PRACTICE


The relevance of this study to the agency is that it provides a way for the clinical staff
to use the current training they provide out in the community and use the curriculum
in-house to build a deeper understanding and knowledge about cultural backgrounds
outside of their clinical expertise. Since most of the clinical staff is part-time many do not
come in contact with other clinicians’ clients. Although PTV clinical staff strive to provide
culturally appropriate interventions to their clients, they do not have knowledge and
awareness of all cultural factors that may arise in the clinical setting. Therefore, this study
is relevant to PTV because it provides a mechanism for staff to expand their knowledge
for the benefit of the clients.
110

The program is also relevant to the community because the long-term outcome is to
provide more culturally competent training to professionals in the community, with
additional examples and practices tips (case vignettes and personal experience). The
program will help professionals in the community become more aware of cultural
differences and how these differences may impact their professional practice.

The limitations to this study will be ensuring that clinical staff members attend the
meeting and are prepared to present. Getting buy-in from staff will not be difficult.
However, clinicians often have client emergencies or get called to court on days when
there are staff meetings. So one limitation will be coordinating availability amongst the
clinical staff members. Likewise, if a staff member misses a meeting/presentation it may
skew the self-assessment and evaluation of knowledge attained from the program. The
second limitation to the study is tracking clients for the one-year follow-up interview.
The MSW research assistant currently conducting Year 10 of the Client Outcome Study
struggles with contacting and scheduling clients for interviews. Additionally, this study
will include all clients who completed the intake process for the 6-months during the
training program. It may be particularly difficult to track clients who may not have
returned after intake to receive services. Similarly, the population PTV serves is difficult to
track given that most do not have legal status.

FEEDBACK ON PROGRAM EVALUATION


Dr. Quiroga is one of the founders of PTV and provides in-house medical care. Dr.
Quiroga as the only medical team member at the agency and provides medical care
to all PTC clients (if needed). Dr. Quiroga works with the case manager, clinicians
and translators to provide the best care for his clients. In speaking to Dr. Quiroga, he
expressed the need for more translators and more translated medical information.
Because medicine is practiced and perceived differently in every culture, Dr. Quiroga
was involved with giving feedback and input in this program evaluation. Likewise,
Dr. Quiroga is often the representative that goes to the Department of Homeland
111

Security, LAFLA and Public Counsel to give trainings. Therefore, he was receptive to
integrating more case examples and additional information from other clinicians into
the training curriculum.

Another, key informant was Dr. Megan Berthold the Director of Research and part-time
therapist (LCSW) at PTV. Dr. Berthold is one of the clinicians that created the most recent
and comprehensive training at PTV called “Building Cross-Cultural Clinical Skills in
Providing Mental Health Services to Refugee Survivors of Torture” (Berthold & Durocher,
2007). Dr. Berthold was actively involved in the research (on torture and cross cultural
training) and evaluation of this study’s training program for PTV. Dr. Berthold is also the
Principal Investigator (PI) for the ongoing Client Outcome Study at PTV. Therefore, Dr.
Berthold gave her opinion on the feasibility of adding questions about client satisfaction
with PTV’s cultural competency services (translated materials and interpreters) and
clinicians’ knowledge regarding cultural practices or norms. In fact, Dr. Berthold
expressed interest in incorporating knowledge found in this study into the PTV research
study and training curriculum.

Finally, Dr. Jene Moio is a MSW and pro bono research analyst from UCLA, who has been
working with the agency for over 6 years. Dr. Moio began her work with PTV as a part of
her dissertation. Through her work at PTV Dr. Moio has become an expert in the effects
of torture on women. Dr. Moio was a key informant to the issue of cultural competency
because she was available for consultation on her findings about women and different
cultural experiences.

AGENCY EXPERIENCES WITH RESEARCH EXERCISE


During meetings (beginning in September), clinical staff expressed a need for more
organized information sharing. This program was a direct response to this need.
After building this program model, meetings were conducted with agency staff
about implementing a cultural-competency training program. The clinical staff and
112

administration were very supportive of the concept. Then, the design of this study could
work effectively at PTV because the program would be built into existing staff meetings
and agency evaluation methods. Although the clinicians will be asked to prepare a
presentation and complete two self-assessments, there is a general sense of buy-in and
enthusiasm about the program. As mentioned above, PTV staff members have been with
the agency for a very long time and encourage continuous learning.
113

APPENDIX A
PROGRAM LOGIC MODEL
Program: Cross-Cultural Skills Building: To provide integrated cross-cultural skills building training
during monthly PTV staff meetings.

INPUT
Agency clinical staff has monthly (6 total) cross-cultural skills building training sessions: current training curriculum and
other training materials.

a
ACTIVITIES
One clinical staff pres- Resource guide: Create form for case Translate agency forms During Client
ents monthly for 30 compile handouts or manager and clinicians Outcome study
minutes on variations case vignettes from (with Kleinman’s (agency research
in clients’ customs, presentations and Questions) and add project) interview
background, clinical potentially use for forms in resource clients during
approaches that community training. guide. 1-year follow-up
worked and did not on what worked
work, personal experi- and what did not
ences, case studies or work, including
compiled vignettes. Kleinman’s
Questions and
self-report by
clients.
a

OUTPUT
Training program: including 6 sessions, resource guide, resources (case vignettes, new clinical approaches form, presenta-
tion handouts) available.
a

OUTCOMES
INITIAL INTERMEDIATE LONG-TERM
Increase clinical staff’s knowledge of Staff are more confident in using Improve client Integration
cultural diversity measured through knowledge and interacting with clients functioning as of specialized
self-assessment (Goode, 2004). outside of their clinical expertise. measured by cross-cultural
self-report in skills training
1-year follow-up measured by
interview PTV staff being
able to train
other community
members.
114

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Successful Aging and Its Implications for
Chinese Communities

SARAH JACOBUS
Directed Research in Social Work
Professor Iris Chi
119

Ideas about what constitutes a positive experience of old age can be traced back to
a treatise by the Roman philosopher Cicero, who maintained that later life could be
a period of great vitality and engagement (Baltes & Baltes, 1990). Until the last few
decades, however, the prevailing Western theoretical paradigm depicted the aging
process in terms of physical decline and social withdrawal. In a departure from this
gloomy representation, social gerontologists have begun to redefine what it means to
grow old, conceptualizing old age as a stage of life in which good health, psychological
growth and contributions to society are active possibilities (Holstein & Minkler, 2003;
Minkler & Fadem, 2002; Rowe & Kahn, 1997).

The concept of successful aging, as this collection of theories and definitions is most
commonly known, is informed by the notion of “adding life to years, not merely years
to life” (Minkler & Fadem, 2002, p. 229). Approaches to successful aging vary. Some are
outcome-oriented, focused on a minimal decrease in physical functioning, sustaining
the physical and psychological capacities of middle age, and possessing a sense of life
satisfaction and well-being (Havighurst, 1961). The notion of remaining productive in
later life, whether by paid or unpaid services and contributions, falls within this category
of outcomes of successful aging (Bass & Caro, 2001). The work of German psychologists
Baltes and Baltes (1993) explores psychological resources inherent in successful
aging. Their concept of selective optimization and compensation emphasizes effective
adaptation to age limitations and sustaining a sense of self-efficacy by adjusting goals to
match actual capacities, or doing the best with what you have.

In the late 80s, under the auspices of the MacArthur Foundation Study of Successful
Aging, John Rowe and Robert Kahn began formulating what has become the leading
theoretical paradigm in gerontology and geriatrics and the most widely used concept
in biomedical research (Holstein & Minkler, 2003). Rowe and Kahn posited that much
of what researchers had traditionally viewed as effects of aging were in fact effects of
disease, maintaining that certain functional decreases were the result of external factors
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such as diet and exercise and not necessarily age-determined. They drew a distinction
between “usual” aging, experiencing the normal physical, social and cognitive losses
of aging, and “successful” aging. It was possible, they argued, to reach old age free
of disease, functional decline and cognitive loss (Holstein & Minkler, 2003; Hooyman
& Kiyak, 2008; Knight & Ricciardelli, 2003; Minkler & Fadem, 2002; Phelan, Anderson,
LaCroix, & Larson, 2004; Rowe & Kahn, 1987, 1997) .

Rowe and Kahn expanded their definition in a 1997 article and their mass-market book
Successful Aging the following year to encompass a multi-dimensional framework with
three major components: a low probability of disease and disease and disease-related
disability, high cognitive functioning, and active social engagement. Their model stresses
the importance of individual lifestyle choices—such as proper nutrition, physical exercise,
and community involvement through volunteer activities—that promote health, prevent
disease and foster continued involvement in social networks (Holstein & Minkler, 2003;
Hooyman & Kiyak, 2008; Rowe & Kahn, 1997).

A positive vision of old age, to be sure, but how realistic are these criteria for the majority
of older adults? In one of few studies of successful aging in China, a sample of Shanghai
adults, age 65 and older, completed the Shanghai Successful Aging Project Questionnaire.
Using a three-pronged definition of successful aging that closely paralleled Rowe and
Kahn’s, the study sought to compare rates of successful aging in Shanghai with those
found in Western studies. The project used international measurement instruments to
facilitate the comparison. Results of the Shanghai study showed less than half, 46.2%, of
the participants overall who met the three Rowe and Kahn criteria for successful aging.
The percentage may sound low, but the results are similar to research findings from the
West (Li, Wu, Zhang, Xue, He, Xiao, Jeste & Zhang, 2006).

In fact, a study from Alameda County, California, a major urban area that includes the cities
of Berkeley and Oakland, found only 18.8% of respondents ages 65 to 99 to be aging
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successfully according to Rowe and Kahn. However, 50.3% of these same individuals rated
themselves as aging successfully. 36.8% of the participants classified as aging successfully
by Rowe and Kahn’s standards did not rate themselves as aging successfully. Inversely,
out of the participants classified as not aging successfully, 47.3% believed that they were
(Strawbridge, Wallhagen, & Cohen, 2006)! This disparity between older adults’ perceptions
of their own aging process and researchers’ definitions underscores one of the most
frequent criticisms of Rowe and Kahn’s theoretical framework: that it fails to recognize the
impact of a diverse range of experiences, values and cultural orientations on the meaning
of aging well (Holstein & Minkler, 2003; Hooyman & Kiyak, 2008; Knight & Ricciardelli,
2003; Torres, 2003). Critics argue that there is no universal idea of what constitutes
success, or even good health (Torres). Standards vary by age group and even between
individuals. Portraying healthy aging mainly in terms of physical function and absence of
disease provides a limited picture, excluding the concept of well-being (Strawbridge et al.,
2006). In a study of China’s “oldest old,” for example, 60% of respondents in their 80s
describe themselves as being in “good health,” despite chronic conditions and functional
limitations (Wu & Schimmele, 2006).

By making successful aging a matter of individual choices and behaviors, Rowe and Kahn
disregard socioeconomic and environmental factors that limit elders’ access to the tools
of self-care. For instance, a daily regimen of physical exercise and the expense of organic
veggies is likely to be out of the realm of possibility for a 65-year old woman who cannot
yet afford to retire and comes home from work after dark to an unsafe neighborhood
(Cardona, 2008; Holstein & Minkler, 2003; Hooyman & Kiyak, 2008; Liang, Liu, & Gu,
2001; Minkler & Fadem, 2002). Making individuals primarily accountable for maintaining
health also absolves the government of its responsibility to provide health and social
welfare resources at a time when programs are jeopardized by funding cutbacks and the
economic downturn (Cardona; Scannell, 2006).
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Critics charge that this framework presumes that successful coping in later life requires
sustaining youthfulness, postponing the characteristics of normal aging. A measure of
health maintenance, then, becomes the capacity to retain a youthful, or middle-aged,
appearance (Cardona, 2008; Holstein & Minkler, 2003; Hooyman & Kiyak, 2008).
Another analysis contends that by resorting to the either/or language of successful and
unsuccessful, the inability to adhere to the successful aging model implies personal
failure, thus further devaluing those who are already marginalized in society, including
older women and racial minorities. A physical impairment or disability also makes an
older adult ineligible for successful aging status, according to Rowe and Kahn (Holstein &
Minkler, 2003; Minkler & Fadem, 2002). But would we really think of renowned physicist
Stephen Hawking, who suffers from ALS—Lou Gehrig’s disease—or violinist Itzhak
Perlman, taking the stage in a wheelchair, as failing the test of successful aging?

Perhaps most important for consideration in the context of Chinese communities is the
claim that Rowe and Kahn’s successful aging model is culture-specific, shaped by values
that are not only Western, but distinctly American in character. The very language of this
paradigm reflects a competitive society that prizes external appearances of success and
values individual achievements and initiative (Holstein & Minkler, 2003; Torres, 1999).
For older adults in this culture, success is measured by degrees of self-sufficiency and
independence, how well they can function on their own. One California geriatrician goes
so far as to assert, not completely in jest, that dependence and being a “burden” on
others is so great an affront to the national mythology celebrating personal freedom and
autonomy as to be “un-American” (Scannell, p. 1416)! For Chinese elders, the concept
of self-sufficiency is something of a mystery. Why would anyone with a family willing to
meet their needs want to be self-sufficient in old age (Torres, 2002)?

Even in the face of modernization and rising Western influence in China, the importance
of the group continues to take precedence over that of the individual. This emphasis on
the collective is especially prevalent among the current generation of Chinese elders,
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most of whom came of age in the 40s and 50s. In keeping with the traditional cultural
value of social harmony, Chinese elders tend to be more concerned with how they are
viewed by others, setting greater store by being tolerant and agreeable. Contribution
to group well-being is a measure of individual self-worth (Mjelde-Mossey & Chi, 2005;
Torres, 1999, 2002; Wu, Yue, Silverstein, Axelrod, Shou, & Song, 2005).

In individualistic American culture, on the other hand, elders think of successful aging
in terms of their personal outlook on the world, stressing optimism, motivation and
enthusiasm (Cardona, 2008; Torres). Rowe and Kahn’s emphasis on productive activities
in later life strongly reflects mainstream Western culture. Chinese culture affords
permission for elders to slow down and take a more contemplative view of life, freed
from the pressures of productive labor (Hooyman & Kiyak, 2008).

The family remains the primary unit of social and economic support for elders in China.
The concept of filial piety, reinforced by law requiring adult children to support and
assist their parents, tends to carry more symbolic than actual importance for the younger
generation of Chinese, especially in urban areas. The easing of official policies regarding
family responsibility for elder care has made placing elders in homes for the aged more
socially acceptable in China’s large cities. Still, the expectation that children will care for
aging parents persists in Chinese society (Joseph & Phillips, 1999; Leung, 2001; Yi, 2007).
A majority of older adults receive regular financial assistance from their adult children,
the inverse of the pattern in the U.S., where not only cultural values but public policy as
well promote greater independence from family support among elders (Wu et al., 2005).

The traditional three-generation extended family household may be giving way to a


more diverse range of living arrangements in both rural and urban China, spurred by a
migrating labor force, reduced fertility rates and modernization. But the proportion of
Chinese elders who live with their children remains considerably higher than in the West
(Silverstein, Cong, & Li, 2006). Western culture prioritizes living independently as long as
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possible and tends to equate dependence with lack of dignity (Scannell, 2006). However,
research shows that for Chinese elders who adhere to more traditional values, living with
adult children creates a greater sense of life satisfaction and purpose and is an important
reflection of successful aging (Silverstein et al., 2006). For adult children as well, parents
in co-residence are more likely to be seen as a resource than a burden, providing
assistance with childcare and household chores (Leung, 2001).

Studies reveal other differences in cultural-value orientation that raise questions about
the suitability of the successful aging framework for Chinese elders. Rowe and Kahn’s
model places heavy emphasis on volunteer activities in the community as a condition
for successful aging. This concept is comfortably aligned with Western culture, where
diverse social networks of family, friends, neighbors and organizations are normative. For
Chinese elders, social activity is overwhelmingly centered around home and family. Group
participation, even social interaction, outside the family structure is an unfamiliar practice
(Cheng, Lee, Chan, Leung, & Lee, 2009; Wu et al., 2005). Even in urban Hong Kong, a
movement among policymakers to encourage elders to engage in volunteer activities has
been slow to catch on (Mjelde-Mossey & Chi, 2005).

China’s tradition of respect for elders has perhaps been eroded by the rapidly changing
economy and social structure. Yet Chinese reverence for elders’ knowledge and wisdom
still stands in sharp contrast to the negative attitudes and discrimination toward
older adults of American society (Wu et al., 2005). Aging in the West is cause for
anxiety, managed by the attempt to forestall the inevitable declines, and even physical
appearance, of aging (Andrews, 1999; Cardona, 2008; Holstein & Minkler, 2003). Mass
marketing in the U.S. proclaims that “80 is the new 60!” and “Today’s old is tomorrow’s
young!” (Scannell, 2006, p. 1416) In Chinese culture, old age is not a stage of life to be
feared or avoided, but it is accepted with all of its challenges (Torres, 2003).
125
126

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Social Work and the Patient-Centered
Medical Home

CAROLINA RODRIGUEZ
Social Policy: Health Care
Professor Maryalice Jordan-Marsh
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CASE STUDY
Ms. Betsy Smith, a pseudonym used to protect her anonymity, is a 55-year-old, widowed,
retired African-American female, diagnosed with B-cell non-Hodgkin’s lymphoma (NHL)
with secondary involvement of the pancreas. Ms. Smith was diagnosed in March of 2006
when she was hospitalized for obstructive jaundice. She has a past medical history of
hypothyroidism, hypertension, obstructive jaundice, and congenital blindness. At the time
of diagnosis she was living in Cleveland, Ohio. A year after her diagnosis, her husband of
28 years died.

A few months after Ms. Smith’s diagnosis, she was treated with chemotherapy at a public
community hospital in Cleveland. Her two adult sons and seven grandchildren lived in
the same community, where they were born and raised. After three months of treatment
with chemotherapy, Ms. Smith developed severe side effects from the chemotherapy
agents. She felt this issue was inadequately addressed, possibly because of her race.
Distressed and fearful, she consulted with her younger brother living in California. Her
brother recommended that she move in with him and his family in order to receive better
treatment and care.

In 2007, Ms. Smith arrived at the Ontario International Airport to live with her brother,
sister-in-law, and two school-aged grandchildren in Victorville, California. According to
the U.S. Census Bureau in 2007, Victorville has experienced a population growth of 9.5
percent in recent years. Victorville is north of the San Bernardino Mountains, northeast of
Los Angeles, west of Highway 395, and at the edge of the Mojave Desert.

Shortly after getting settled, Ms. Smith was referred to a major cancer center
approximately 45 miles away. She received chemotherapy treatment for six months, but
had to stop treatment due to a weeklong hospitalization for obstructive jaundice. After
being discharged from the cancer center, she was told that the cancer center was out
of her network, and that therefore she would have to find a new oncologist to treat her
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NHL. In 2009, she came to a major university hospital and found a young oncologist
willing to treat her cancer. Ms. Smith travels approximately 89 miles to the clinic for
maintenance treatments, which are scheduled once a week for four weeks. The need for
treatment will be revisited based on the results of her diagnostic scans.

HEALTH DISPARITIES AMONG MINORITY WOMEN


The issues in this case highlight the disparities that many minority women face when
accessing cancer screening and high-quality treatment and follow-up care (Kim et al.,
2008). In addition to Ms. Smith experiencing perceived racial- or ethnic-based medical
discrimination, she lacks access to a usual source of medical care, such as a primary
care physician who could coordinate her care across multiple settings (Crawley, Ahn, &
Winkleby, 2008).

HEALTH CARE DISPARITIES AMONG MINORITY WOMEN WITH CANCER


According to a recent longitudinal research study conducted by Penner et al. (2009) on
experiences of black patients, subtle and unintentional racial biases of white physicians
lead to low utilization of services, feelings of mistrust, and a sense of wariness that affects
patient-physician communication. This can contribute to poor adherence to treatment and
ultimately poor health outcomes for members of the African-American community.

The United States (U.S.) Department of Health and Human Services’ National Healthcare
Disparities Report (2007) reported that cancer is the second most common cause of
death in the U.S., causing 559,650 deaths in 2007. The report pointed out the cost
of cancer was estimated at $206 billion in 2006 with $78 billion in direct costs. In
California, the California Cancer Registry, California Department of Public Health, Cancer
Facts and Figures report (2009) indicated that over 1,168,500 people have a history of
cancer, that about 140,815 will be diagnosed with cancer in 2009, and that 54,600 will
die of the disease. At the same time, 89,513 Californians who get cancer in 2009 will
survive five years after diagnosis.
133

The risk of developing cancer and receiving low quality of care varies by race and
ethnicity. African-American women are the most likely to die from cancer even though
non-Latina white females are the most likely to be diagnosed with cancer. According to
the National Healthcare Disparities Report (2007), African Americans receive a poorer
quality of care and have worse access to care than non-Latino whites. In particular,
African Americans have worse care when examining patient centeredness, a core
component of quality of care, as compared to white non-Latinos. African Americans also
suffer from poorer chronic disease management when compared to white non-Latinos.

PUBLIC POLICY FOCUS


This macro-level policy advocacy paper will focus on a public proposal to promote the role
of social workers in Patient-Centered Medical Homes (PCMH) by placing this proposal on
the policy advocacy agenda of the National Association of Social Workers. This proposal will
impact health care consumers—particularly minorities—diagnosed with chronic diseases
such as cancer.

AUDIENCE
According to Coffman’s (2007) evaluation approach based on the theory of change
expected to occur through advocacy, this policy advocacy affiliation will be with specific
constituencies in a public university­‑affiliated health care system setting. As a second-year
master of social work intern at the Simms/Mann University of California, Los Angeles Center
(UCLA) for Integrative Oncology, this advocate will inform and educate oncology social
workers, medical social workers, and graduate students in the school of social policy.

CONTEXTUAL FACTORS
The passage of comprehensive health care reform is one of the most significant changes
undergoing health care in the United States for decades. While the government has not
yet adopted or voted on a health care reform plan, the current social and political climate
provides opportunities for social workers and nurses to align with U.S. residents as well
134

as physicians to improve the quality of health care for all U.S. residents (DeAngelis,
2009). Furthermore, health care professional associations are positioning themselves
using issues competition, as outlined by Coffman (2007), in order to propose solutions
that advocate for and support patient care in both behavioral models of primary care and
in the available funding to support that care (DeAngelis).

INPUTS
PREPARATION AND PLANNING
The National Association of Social Workers is promoting the care model for transitions of
care for older adults during transitions from one health care delivery system to another
(NASW, 2009). A practice update developed by NASW (2009) examined the need for
social work interventions during transitions of care and found that psychosocial factors
can play a significant role in rehospitalizations of older adults, leading to problematic
care transitions. In addition to highlighting the potential benefits of having social workers
manage transitions of care in the hospital and/or community, it exemplified the financial
impacts and savings that social work interventions can contribute within the medical
community and health care delivery systems.

Volland, Berkman, Phillips, and Stein (2003) examined the changing role of social workers
in health care settings and found five trends that are associated and consistent with a
patient-centered medical model. Trend one is the shift to social workers practicing in a
multidisciplinary structure. Trend two is the knowledge of social workers of resources
regarding navigating health care systems and working with population and/or disease-
specific programs. Trend three is the strong foundation social workers are acquiring on case
management and networking. Trend four is the use of evidence-based research to develop
effective and therapeutic intervention for consumers and the continuous collection of data
for evaluation of patient and systems outcome. Lastly, trend five describes the ability of
social workers to design programs, using data to increase the quality of care using cost
effective strategies and innovations adopted from national models of care.
135

ORGANIZATIONAL CAPACITY BUILDING


The Simms/Mann UCLA Center for Integrative Oncology is a national model for providing
patient care for individuals and families touched by cancer. Built on a foundation of academic
research and advanced treatment approaches, the Center offers educational and support
services that integrate psychological, nutritional, spiritual and complementary approaches
to healing (personal communication, September 15, 2009). As such, the Center can provide
information, knowledge, and wisdom to organize the operational supports this advocate will
need to improve cancer care services for minority women (Coffman, 2007).

GOAL SETTING
SMART GOAL
To develop a strategic plan for program development, objectives, and activities related to
promoting and securing the role of social workers in the Patient-Centered Medical Home.
The goal is to present this plan by March 2010 and place it on the agenda of the NASW
California Political Action Committee (CALPACE) annual meeting scheduled for May 2010.

LANDSCAPE MAPPING
Similarly, California Healthline in 2007 reported on a project led by nurses under
the direction of physicians to develop innovative, patient-centered personal health
information and decision support tools that will promote patient-provider communication
and potentially increase patient satisfaction regarding their health care decisions and
experiences. The team at the Carol Franc Buck Breast Care Center at the University of
California, San Francisco is playing a key role in helping consumers use information
technology to better meet their health care needs in an integrated fashion—one of the
key tenets of the patient-centered medical home model proposed by physicians.

Professional nursing organizations are developing models of care that are patient-
centered, efficient, safer, and potentially cost effective. Coffman (2007) suggested
that in the preparation and planning phase of advocacy, advocates should engage in
136

“Landscape Mapping” in order to assess and collect information to analyze competing


options using a value-based criteria (Jansson, 2008). Social workers and nurses can form
an alliance to promote their role and participation in a patient-centered medical home
in order to increase the quality of care for all consumers, paying special attention to
vulnerable populations such as minority women diagnosed with cancer.

Robbins and Birmingham (2005) argued that standards of care in care coordination and
case management are not profession-specific but rather serve as a standard of practice
and a set of guidelines describing the rules, actions, or conditions that direct patient care
for providing high-quality care, and in turn for evaluating care. Historically and presently,
both nurses and social workers function in the roles of case managers and coordinators
employing similar interventions and responsibilities. However, each profession contributes
a specific process that is unique and essential to obtaining successful outcomes for
consumers and the health care system. Hence, promoting and facilitating professional
relationships in a complex and medical-oriented system requires coalition building and
bridging alliances to strengthen the image, uniqueness, and practices of both nurses and
social workers.

SMART GOAL
By May 2010, nursing organizations and nurse researchers and leaders from universities and
community agencies will be educated and engaged in discussions focused on supporting the
collaboration of nurses and social workers in patient-centered medical homes.

METHOD OF DATA COLLECTION


To defend this policy proposal, the social-network analysis method for advocacy
evaluation will be utilized for data collection (Dorfman et al., 2009). According to
Dorfman, the social-network analysis is an innovative method that explores the
connections or relationships that make up the system, examining the relationships
among groups using mathematical algorithms.
137

ACTIVITIES AND TACTICS MATRIX


Table 1 summarizes activities and tactics for policy and politics and communications
and outreach using the Advocacy and Policy Change Composite Logic Model (Coffman,
2007). Rating Scale: 0-10 with “0” being “Not Likely or Low and Negative” and “10”
being “Likely or High and Positive.”

U.S. politicians are currently exploring ways to finance and sustain a health care reform
plan that will provide medical and mental health care to all Americans in a way that
will not offset or increase the federal deficit. To do this, infrastructure changes will need
to be put in place to ensure that health care will be delivered to medically underserved
or vulnerable populations by having a health care workforce that is able to meet the
demands of this plan (Sherman, Moscou, & Dang-Vu, 2009). External forces, such
as court rulings, flows of revenue, and potential sanctions that health insurance and
pharmaceutical companies will impose will drive the enactment of a health care reform
plan (Jansson, 2009). On the other hand, internal organizations such as the American
Academy of Family Physicians, the American Academy of Pediatrics, and the American
College of Physicians are supporting the patient-centered medical home primary care
model of care, based on empirical evidence stating that the ability of medical centers
and health professionals to advance societal health and improve patients’ health across
the continuum of care will be improved by the utilization of a multidisciplinary team
approach to delivery of primary health care (Rosenthal, 2008).

ASSETS AND LIABILITIES AT THE ORGANIZATIONAL LEVEL


The case study presented in this proposal identifies assets and liabilities within the
Simms/Mann UCLA Center for Integrative Oncology. According to Jansson (2009), it is
sometimes useful to outline assets and liabilities in order to understand the strengths
and weaknesses of the organization and system. Assets and strengths are summarized in
Table 2 (Jansson, 2009).
138

IMPLEMENTATION ISSUES AND PROBLEMS


BENCHMARK: ADVOCACY CAPACITY
The National Social Work Association will review and recommend for action the
adoption of the role of social workers in patient-centered medical home models. They
will also participate in demonstration and pilot projects to demonstrate the quality and
effectiveness of social workers working with a multidisciplinary team.

BENCHMARK: POLICY
The National Social Work Association will increase its constituency base growth by
aligning with national and state-wide advocacy coalitions to support the implementation
of the role of social workers and nurses in patient-centered medical homes.

CHALLENGES TO IMPLEMENTATION
One of the main challenges for social workers in gaining visibility and credibility for
generating support and a role in patient-centered medical home models will be the lack
of a body of knowledge that social workers currently have on this model of care. Based
on a literature search for social work and patient-centered medical homes, there were no
social work research studies to date or commentaries, issue reports, or briefs written by
social workers.

The psychology and nursing literature on PCMH promotes the roles of these respective
professions in this debate. They are participating in demonstration and pilot projects
to provide evidence of the value of using psychologists or nurses to assist primary
care providers in building a patient-centered medical home that incorporates and
provides patients with the integrated health care they deserve in a comprehensive and
compassionate manner (McDaniel & Fogarty, 2009).

STRATEGIES TO MINIMIZE PROBLEMS


One of the cornerstones on which social work was built is the desire and commitment to
139

make a difference for all members of society, especially vulnerable populations. To this end,
one means NASW utilizes is advocacy to increase the quality of life of consumers by serving
as safety net providers and decreasing health care disparities through the use of policy
advocacy, research, coalition building, and maintaining hope (Clark, 2009). In the past,
NASW has championed legislation that has changed the quality of life and opportunities
for disenfranchised populations such as foster children and families, homeless persons,
persistently and mentally ill persons, low-income children and families, and older adults.
These successes speak to the capacity and potential social workers employ when they join
forces to build support on social issues deemed urgent, critical, and timely.

The PCMH model is still evolving today with new additions, developments, and
improvements of core principles, based on a patient-beneficial health care system that
will ultimately lead to the future reduction or elimination of barriers to care for chronic
conditions (Carney et al., 2009). Based upon these ideas and policy proposals, research
and policy advocacy around integrating the role of social work and nursing around the
development of the PCMH model will promote standards of practice that will ensure
that the physical, mental, and social well-being of the underserved patient in a family-
centered approach is met.

CONCLUSION
This advocacy proposal presents an opportunity for social workers’ involvement in health
care reform and coalition building. Social work can accomplish this by aligning and
collaborating with professional nursing organizations to become part of the development
of patient-centered approaches to improving the quality of care for consumers and
reducing disparities in health care. Ultimately, the perceptions and experiences of
consumers about the value of health care for themselves and their family members are
one of the primary determinants of utilization. Integrating the role of professional social
workers and nurses in the PCMH will empower consumers, especially minority women
with cancer, with hope for better health and well-being.
140

TABLE 1

ADVOCACY AND POLICY CHANGE COMPOSITE LOGIC MODEL

ACTIVITY/TACTIC CAPITAL REQUIRED TIME REQUIRED FEASIBILITY TOTAL


Policy and political Human: Meeting heavy: Having systems, 16 hours
tactics: Charisma, knowledge, 4 hours expertise, and time
Relationship building skills, attitude, and in place to conduct
with professional ability to be transpar- activities:
social work and nurs- ent 5 hours
ing organizations
Social:
Connect with agen-
cies, decision makers,
academicians, ability
to market/package
proposal, influence

Economic:
Paying for innovative
tools/applications:
7 hours
Communication and Sociotechnical to use Sending emails, creat- Consensus: 11 hours
outreach: networking tools: ing website, utilizing Not a priority for the
Coalition and 8 hours social networking agency: 1 hour
network building applications, calling,
writing, and joining
an organization’s
advocacy efforts: 2
hours
141

TABLE 2

EVALUATING THE CONTEXT

EXTERNAL ASSETS LIABILITIES


1. Public health insurance 1. Weak health care infrastructure in place
(Medicare and MediCal)
2. Lack of monitoring and health care out-
2. Public university-affiliated health care system comes by the public system

3. Evidence-based research 3. Lack of continuity of care with public health


care plans

4. Lack of interoperable computerized records

5. Lack of integrated systems of care

6. Lack of electronic portals


INTERNAL ASSETS LIABILITIES
Ms. Smith saw flyers/pamphlet about Simms/ Ms. Smith’s oncologist did not refer her case
Mann services and self-referred. to social work.

Simms/Mann provides psychological, emo- The Center can only provide oncology related
tional, and integrative services that combine services and resources.
integrative and conventional treatments.
Oncologist does not discuss advance care
Simms/Mann provided social work intervention planning.
services on site.
Lack of integrated system of care.
Simms/Mann social work intern was knowl-
edgeable in case advocacy. Lack of coordination between primary care and
specialty care.
142

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findings from preparing the personal physician for practice. Journal of Family
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Clark, E.J. (2009). A broader vision for the social work profession. National Association of Social
Workers. Retrieved December 2, 2009, from www.naswdc.org/nasw/vision.asp.
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Exchange, 13(1), 1-16.
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screening behaviors of racial and ethnic and minority adults. Cancer Epidemiology,
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A resource guide for developing a course on advocacy for public health.
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Association of Social Workers. Retrieved December 3, 2009, from socialworkers.org.
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Thomsson Brooks/Cole.
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Tasks, skills, and actions. Hoboken, New Jersey: John Wiley & Sons, 60-103.
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Tasks, skills, and actions. Hoboken, New Jersey: John Wiley & Sons, 103-153.
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McDaniel S. H., & Fogarty, C. T. (2009). What primary care psychology has to offer the patient-
centered medical home. Professional Psychology: Research and Practice, 40(5), 483-
492.
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S. L. (2009). The experience of discrimination and Black-White health disparities in
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roles in case management. Applying the three R’s. Lippincott’s Case Management,
10 (3), 120-127.
Rosenthal, T. C. (2008). The medical home: Growing evidence to support a new approach to
primary care. Journal of the American Board of Family Medicine, 21(5), 427-440.
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Journal of Health Care for the Poor and Underserved, 20(4), 944-950.
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Head Start and DCFS

HEATHER STEPHENS
Social Work in Public Child Welfare Settings
Professor Jacquelyn McCroskey
145

Through thorough observation of cases at the Department of Children and Family


Services (DCFS) in Los Angeles from 2008 to 2009, it has been noted that there is
a dearth of resources for homeless preschool-aged children in terms of education.
Therefore, the following paper will examine the effectiveness of Head Start-type
preschool programs for homeless preschool-aged youth. The research will focus
particularly on the urban setting of Los Angeles, since very few, if any, Head Start
research studies have been conducted in such a setting, as they usually take place in
rural settings (Currie & Thomas, 1995; Reynolds, Temple, Robertson, & Mann, 2001). First,
the practice arena will be discussed, followed by a review of the literature, a discussion
of competing perspectives and opinions of experts, an assessment of how these issues
affect child welfare practice, the contribution to disproportionality, and the writer’s
perspective on the best practice.

PRACTICE ARENA
The following research hopes to acknowledge a controversial issue within the
Department of Children and Family Services (DCFS). DCFS offers a multitude of services
ranging from reducing the recurrence of child abuse and neglect to offering education
services to families in and around the Los Angeles area.

Head Start is a federally funded grant program that aims to improve the learning, social
skills, and health of poor children in order to bring them up to par with their peers (Currie
& Thomas, 1995; Lee, Gunn, Schnur, & Liaw, 1989). It has been referred to as one of
the only long-term legacies of late President Johnson’s War on Poverty (Lee et al., 1989;
Jansson, 2008). The goal of such a program was that the plan would help disadvantaged
children break free from the cycle of poverty (Lee et al., 1989) and it places an emphasis
on the whole child (Cole & Washington, 1986). Even more recently, both former
Presidents Bush, Sr., and Clinton pledged to allocate funding so all eligible children
would have access to services. Unfortunately in 1995, only 28% of eligible three- to five-
year-olds were served (Currie & Thomas, 1995). Therefore, resources are still needed.
146

In order to examine the gaps within DCFS, an assets mapping and needs assessment
was conducted. Asset mapping and needs assessment is carried out in order to
provide information about the incidence of issues that are not addressed within an
agency and provides data to be used by them in advocating for their work (Netting,
Kettner, & McMurtry, 2008). When examining reports conducted by different DCFS
agencies, there is no mention of preschool issues within the community. However, in
examining the DCFS SPA 4 scorecard it was found that out of 43,623 youths three- to
five-years-of-age in the region, only 17,099 were in preschool (CPC, 2007). Therefore,
only 39% of youths were enrolled in preschool in 2006-2007. Even more, Hottenroth,
Strum, Woods, and Picone (2009) note that only 20% of children within child
protective services are enrolled in early childhood education. Also, the need for such a
program can be noted by the broader finding that only 15% of homeless preschoolers
in the United States are enrolled in preschool (USDOE, 2002). Therefore, with so few
children in preschool services, the assets mapping and needs assessment of DCFS
found that such services are needed.

REVIEW OF THE LITERATURE


This specific population has been targeted due to the transient nature of the homeless
population and the difficulty of meeting their educational needs. Many preschool-aged
homeless youth are overlooked due to the enrollment barriers they face, such as lacking
a stable address (LAHSA, 2008). Even programs such as Head Start, which are designed
to address this poverty-stricken population, require an address to enroll (NHSA, 2008).
Also, it has been found that in order for poor children to succeed academically, they
need to be involved in education early (Prince, Hare, & Howard, 2001). Thus, the need for
effective interventions for homeless preschool youth is even more important.

When examining the literature it is noted that where one lives determines their economic
success, but it should not establish it (Dreier, Mollenkopf, & Swanstrom, 2001) and
this is the case in this situation as well. According to Salcido (2005) and Rafferty and
147

Shinn (1991), there has been little research conducted on community collaborations for
homeless youth. Hottenroth et al. (2009) have started community collaborations with
Head Start that address such populations; however they do not further allocate services
to the homeless.

Even more, the exact number of homeless youth in the United States is unknown (Zastrow
& Kirst-Ashman, 2007), but the United States is still recognized as the nation with the
highest rate of child poverty (Karger & Stoesz, 2006). Further, it is estimated that over
42% of the homeless in the United States are under the age of five (LAHSC, 2008).

Children are one of the fastest growing and one of the most vulnerable homeless
populations (Dryness, Spoto, & Tompson, 2004). This means that something needs to be
done now, while they are still young, in order to help them. According to Lynch (2007)
and Reynolds et al. (2001), offering a high-quality preschool program to homeless
youth will benefit the state in the end. For example, one of the main attractions of
preschool is that it reduces the amount of people in the criminal system or the amount
of people experiencing labor force difficulties later on in life, saving the government
money in the end (Temple & Reynolds, 2007; Venkatesh, 1999). Also, for every dollar
spent on early child education, seven dollars is saved in the long run (Prince, Hare,
& Howard, 2001). Research has shown that when high-quality care is given before
kindergarten, there is less need for specialized education services later on in K-12
(Lynch, 2007). This is important to note as Hottenroth et al. (2009) found that half of
the children in DCFS caseloads have some type of learning delay or disability. Even
more, it has been noted that those born into poverty have greater economic and
educational attainment when they attend preschool compared to those that do not
(Halle et al., 2009; Schweinhart & Weikart, 1997). Also, in a study conducted by Levin,
Belfield, Muennig, & Rouse (2007), of 100 high school dropouts, it was found that if
they had gone to preschool, 19 more of them would have graduated. That is 20% fewer
people dropping out if they had attended preschool. Lastly, poverty has been noted
148

to be one of the leading causes of dropping out of school (Bassuk et al., 1997), thus
services need to take this into consideration.

Further, preschool is an important aspect of one’s development, especially when looking


at it from a theoretical standpoint. For example, Vygotsky, Cole, John-Steiner, Scribner,
and Souberman (1978) noted that learning is achieved when one is involved in activities
with others, as they are able to negotiate different meanings with these persons in
their environment. They are able to reach goals by interacting with peers and their
instructors (Vygotsky et al., 1997). Thus, if these homeless youth do not have access to
such interactions at a young age, it is quite possible that they will be at a disadvantage
in terms of cognitive development when compared to their peers that did attend
preschool. Further, since they do not have this early learning experience, their language
development may be at a disadvantage.

Head Start research has also shown that it is important to take into consideration
that it does serve the poorest of the poor and the least advantaged of children (Currie
& Thomas, 1995; Lee et al., 1989; Nicholas et al., 2003). For example, it was noted
by Nicholas et al. (2003) and Meisels and Atkins-Burnett (2004) that the Head Start
population is composed mainly of those children whose families come from incomes
below the national poverty line. Therefore, such research findings might elicit results
that are not ideal or representative of the entire population. Lee et al. (1989) found that
Head Start was one of the only preschool options available to poor families, and current
research at DCFS has shown that this is still the case (B. Mistrano*, LCSW, personal
communication, November 20, 2008). On the other hand, when well implemented, Head
Start-type programs can reverse negative development for many of low-income youth
(Knitzer, 2007) and reduce crime rates (Temple & Reynolds, 2007). Therefore, this just
shows the importance of Head Start programs for such a disadvantaged population.
149

In one study of 139 homeless children of varied ages, it was noted that they scored
near or at the mentally retarded range three times more than those children that were
not homeless (Douglass, 1996). Bassuk et al. (1997) and Hottenroth et al. (2009) also
noted that homeless preschool children and children from protective services have more
developmental delays. However, when examining a different study that was conducted
on 213 homeless preschool children, their scores differed very little from the general
population (Douglass, 1996). Douglass (1996) then looked at literature that compared
children of low-income families to homeless children and found no real differences. The
one main difference that was found in this study was that regardless of having a home
or not, if they were in an early childhood education program they scored better than all
children not in such programs (Douglass, 1996). Even though research findings vary, it is
still apparent that preschool access is imperative to all children’s development, especially
the homeless.

Upon entering preschool, it was found that homeless preschool children have more
health problems and emotional and behavioral difficulties than those with homes
(Bassuk et al., 1997; Spernak, Schottenbauer, Ramey, & Ramey, 2006). This has been
found to be attributed to lack of sleep and discomfort (Spernak et al., 2006), which
correlates with the difficulty of restful sleep due to being homeless. Also, it has been
linked with the stress and anxiety that results from constant moving around and
relocation (Stoneman, Brody, Churchill, & Winn, 1999). Homeless children in poor
health are then at an even greater risk of low academic achievement and failing in
school (Spernak et al., 2006). Even worse, it was found that the housing status effect
on children increases with age (Bassuk et al., 1997).

Going further, homeless people do not necessarily share the same experiences. For
example, children who are constantly moving around experience similar anxiety as those
children who are homeless. Anxiety has been known to cause psychological effects, poor
affect, and suppressed cognitive functioning (Stoneman et al., 1999). Further, Hausman
150

and Hammnen (1993) noted that the experience of a homeless person is vastly different
if living in a residential facility compared to an emergency shelter or a hotel or motel.
Each particular environment provides a different environmental constraint (Hausman &
Hammnen, 1993). Douglass (1996) even found that those in low-income housing are
often referred to as homeless, so this may skew data as well. Another issue presented
by the research is that since there are so many different classifications of homeless, it
becomes a problem when all homeless are treated as a homogenous group (Cole &
Washington, 1986).

COMPETING PERSPECTIVES AND OPINIONS OF EXPERTS


In personal communication with Peter Storm*, who specializes in DCFS educational
programs, it was stated that in all of Los Angeles, only 34% of three- to four-year-
olds are in preschool (personal communication, February 9, 2009). This statistic raises
questions. When asked if he thought access to preschool for homeless clients at DCFS
was a problem, Peter Storm* stated, “It is definitely a problem and DCFS has yet to
address it” (personal communication, February 9, 2009).

More recently, Hottenroth et al. (2009) began to address the disparity in access to Head
Start services for DCFS clients, but more needs to be done in order to assure that all
clients have the chance to use such resources. More specifically, Hottenroth et al. (2009)
identified190 children within DCFS caseloads in the El Monte, California area as being
eligible for free preschool; out of that, 58 applications were sent in for services and 15
were accepted. If the overall population is having difficulty attending preschool, how can
one expect the homeless population within DCFS to be any different?

Going further, when contacting Los Angeles Unified School District (LAUSD) educational
services worker, Veronica Girgin*, it was found that their records showed only 24 homeless
children enrolled in preschool classes in all of Los Angeles (personal communication,
February 9, 2009). These numbers are very low, and one wonders why so many of these
151

homeless youth are not being assisted by Head Start through referrals by DCFS. Even more,
why do schools have a record of so few homeless youths?

Also, guest lecturer, Lilia Guirguis, the director of Magnolia Place Community Initiative,
stated that one of their four goals to address within the community was to have their
children ready for kindergarten (personal communication, November 24, 2009). Just in
their 500-block service area alone they have 10,000 zero- to five-year-old children (L.
Guirguis, personal communication). Therefore, even community partners outside of DCFS
are identifying this as a service area that needs help.

However, guest lecturer Jack Coven* from Head Start stated that the homeless
population has priority access to services within Head Start (personal communication,
October 13, 2009). When communicating with DCFS social worker, Monica Sanchez*
(personal communication, February 11, 2009), she was under the impression that her
homeless clients had to reapply to Head Start each time they moved. Further, DCFS social
worker Monica Sanchez* stated she did not feel access to preschool was a problem
within DCFS (personal communication, February 11, 2009). She acknowledged she knew
preschool was optional, and for her clients who were homeless this was not her top
concern. Thus, there are differing opinions when it comes to the experts and workers in
the field.

From firsthand experience interning at DCFS, I did not find that my clients had priority
access. My two clients were homeless, moving around from relative to relative. They
never had a chance to start Head Start as they were on the waiting list and constantly
moving, which forced them to have to be placed on another waiting list. No one ever
said they should be granted priority access to preschool services.

ASSESSMENT OF THE EFFECTS ON CHILD WELFARE PRACTICE


From working firsthand with social workers at DCFS and communicating with
152

professionals in the field, it is clear why there is confusion on which information is


accurate in regards to homeless preschool youth. According to DCFS staff member,
Barbara Mistrano*, many of the social workers have to spend a lot of time planning
what to do with such clients, and a majority of them still believe that their homeless
preschool youth either do not qualify for services or they have to be placed on a waiting
list like the rest of the clients (personal communication, February 11, 2009). Thus, this
issue deeply affects the practice of working with such clientele. Therefore, much more
outreach and training needs to be done in order to further educate the case workers
about where to refer their clients. Further, when communicating with some Head Start
offices directly, they too confirmed that one needs an address to even be placed on the
waiting lists (personal communication, February 9, 2009); thus, such regulations need
to be further clarified.

Once a collaboration between DCFS and Head Start was made, problems would continue
to arise. For example, Hottenroth et al. (2009) note that there are approximately 15,000
youths aged zero to five in and out of foster care, which means there are not enough
homeless preschool programs for all of them to attend. In the future, more preschool
programs may need to be created to further address this issue.

With all of the confusion and challenges, there are many pros that would come from
such collaboration. For example, once the social workers were updated on how to deal
with this population, they would have acquired more knowledge, which would help them
to address community problems. Also, this new collaboration between DCFS and Head
Start would bring about a more innovative multidisciplinary approach that could only
assist DCFS in the long run.

DISPROPORTIONALITY
In terms of cultural diversity, DCFS sees a wide array of ethnic backgrounds (CPC, 2007).
Interestingly, most of the research conducted on homeless preschool youth has focused
153

on African-American children (Currie & Thomas, 1995). Thus some of the findings may
not be as applicable to the population of Los Angeles. Also, according to Hausman and
Hammnen (1993), the cultures of homeless people are different. For example, each
homeless family is homeless for different reasons and will have varied experiences while
being homeless. Thus, each homeless family has a different homeless culture. Therefore,
when assessing the needs and the culture of the homeless, preschool-aged DCFS clients,
their individual backgrounds need to be considered. For example, some of these children
may be living with relatives while some may be living in cars, causing their specific
education needs to vary. This background needs to be taken into consideration when
creating such programs.

BEST PRACTICE
I personally believe that all children, regardless of economic standing, should have
access to the best preschool available. Even more, research is showing that what
children learn before the age of five is of utmost importance and shapes them for the
rest of their lives. Therefore, something needs to be done soon to further acknowledge
the lack of access. With this being said, I feel that DCFS is behind in recognizing the
need for such services. Also, there is a barrier in communication between Head Start
and DCFS, as both organizations show confusion about their roles in addressing the
homeless preschool-aged population. Therefore, I feel when it comes to best practice,
DCFS should have priority in placing children at Head Start for preschool services, and
more collaboration needs to be done.

*Some names have been changed to protect privacy.


154

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LAHSA (2008). Los Angeles Homeless Services Authority. Retrieved October, 24 2008,
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Policy Analysis of the Gang Violence and
Juvenile Crime Prevention Act

IMAN A. TURNER
Policy and Practice in Social Service Organizations
Professor Heather Moore
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INTRODUCTION
Since the 1970s, there has been a sharp rise in the number of juvenile offenders being
transferred to adult courts. This increase in transferred youths was a response to the
increase of juvenile crimes in the 1970s and 1980s. The main social welfare issue
that prompted this increase in juvenile transfers was the concern for public safety and
serving justice to the victims by holding these juvenile offenders just as accountable for
their actions as their adult counterparts (Backstrom, Walker, 2005). In California alone
it was estimated that 6,629 youths were charged as adult offenders from 1989-2003
(Fagan, 2008). Another survey indicated that twenty-five percent of all juvenile cases
are transferred to adult courts (Fagan, 2008). Although the magnitude of this issue
continues to be quite pervasive within the legal field, whether the effect of transferring
youths to adult courts is more beneficial or detrimental for society as a whole continues
to be debated.

Since this peak in juvenile crime, various data have been presented by scholars and
professionals illustrating either the strengths or weaknesses of the policies that allow
juvenile courts to transfer youths to adult courts. However, the larger policy question that
will be analyzed in this paper is whether juvenile offenders should be tried as adults in
the courts. And if so, at what age is this appropriate? By looking at this social welfare
issue from a macro point of view, we are able to first determine whether this policy holds
any validity before delving into how to improve or alter a policy that may in essence call
for complete removal.

POLICY ANALYSIS
The policy that has had a significant impact on the transferring of juvenile offenders to
adult courts is the Gang Violence and Juvenile Crime Prevention Act of 1998 (Hannan,
2008). The implementation of this law was to address the increasing severity of crimes
committed by juvenile offenders. In 1996 the United States Department of Justice
reported that the rate at which juvenile offenders were being arrested for serious crimes
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increased by 46 percent from 1983 to 1992, while murders committed by juvenile


offenders more than doubled during this same time period (Ezell, 2007). These alarming
statistics made it apparent that something needed to be done about the growing
problem of young offenders.

Although juvenile courts have always had the jurisdiction to waive their rights in presiding
over a “violent or serious” juvenile case, the Gang Violence and Prevention Act further
expanded this right. This act redefined which crimes were considered violent or serious,
which ultimately led to longer prison sentences and an increase in the number of juvenile
offenders being susceptible to the Three Strikes law.

Prior to the Gang Violence and Juvenile Crime Prevention Act, juvenile offenders 14 or
older could be tried as adults for certain offenses. However, in order for a transfer to take
place the prosecutor had to file a petition with the juvenile court requesting the juvenile
be transferred to adult court for prosecution. After this petition was submitted to the
juvenile courts, a hearing was held to determine whether the minor should be transferred.
If the individual in question already had a prior violent or serious criminal offense their
case would automatically be transferred to the adult court system (Hannan, 2008).

After the implementation of the Gang Violence and Prevention Act, juvenile offenders 14 or
older who were charged with committing certain types of murder or serious sex crimes were
no longer eligible to have their case presided over by the juvenile courts. This act also allowed
prosecutors to directly file adult charges against minors, without the juvenile courts waiving
their jurisdiction or conducting a hearing on whether the youth’s case should be transferred to
adult court (Hannan, 2008). This act also eradicated the jurisdiction of probation departments
to determine whether juvenile offenders arrested for a serious or violent crime should be
released or detained until their case could be brought before a judge; under this act the
detention of these juveniles is required.
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On the surface the goals of this policy seem to be legitimate and well-founded. However,
when analyzing this policy from a systematic approach, it appears to be riddled with
flaws and loopholes. Research illustrates that juvenile crime rates have not declined since
the implementation of this policy. Many of these juvenile offenders end up worse after
they are incarcerated in adult prisons and are more likely to reoffend once released back
into the community (Burrow, 2008).

Despite the overwhelming evidence suggesting this policy is not positively affecting the
community or decreasing the number of crimes committed by these minors, this system
of transferring youths continues to be quite prevalent within the juvenile system. Rather
than benefiting the community, as the Gang Violence and Prevention Act proposed to do,
it is actually causing a fiscal deficit for the community. Prior to the implementation of this
act it was estimated that the annual operating costs for counties to house these juvenile
offenders prior to being transferred to adult court could range from tens of millions of
dollars to more than $100 million, with one-time construction costs of $200 million to
$300 million. Given the free discretion at which this policy is currently being used by
prosecutors and the courts, these fiscal estimates have most likely substantially increased
(Burrow, 2008).

POLICY IMPACT ON THE COMMUNITY


The implications of this policy on the Crenshaw community are quite significant. Studies
have illustrated that poverty and dropout rates have been directly linked with crime rates.
Many of the individuals living in the Crenshaw community are living below poverty levels.
This policy has also had a significant impact on African American and Hispanic males.
Research indicates that 95% of the cases that have been waived by juvenile courts
involved members of a minority background (Macallair, Males, 2000). The Crenshaw
population is 73.34% African American and 16.89% Latino. Minority youths are 2.7 times
more likely to be arrested for a violent felony and 3.1 times more likely to have their case
transferred to adult courts than their white counterparts (Macallair, Males, 2000).
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Due to the fact that youths residing in the Crenshaw area are more likely to be subjected
to the adult legal system, there is also a stigma associated with these youths and the
general idea that many of them are “unredeemable,” which creates a bias that has the
ability to spill over into the courts. They are more likely to receive longer sentences and
like many youths from disadvantaged backgrounds are not provided the psychological
support that they may require.

The resolution of this policy will have a significant effect on youths in the Crenshaw
community because many of them are more susceptible to falling victim to this system of
transference. By restructuring the implications of this policy many of these youths will be
provided other services and options to fulfill the consequences of the crimes they have
committed and be successfully rehabilitated back into the community.

POLICY QUESTION
The policies put in place through the Gang Violence and Juvenile Crime Prevention Act
have shaped the way in which many juvenile offenders are processed within the legal
system. This act has caused a sharp divide between those who support and those who
oppose the changes implemented through this act. A key policy question being presented
to these opposing sides is, “At what point should juvenile offenders be tried as adults?
Or should they?”

On one side of the debate you have the individuals who support the policy of transferring
juvenile offenders to adult courts for crimes that are considered heinous. From this
perspective it is argued that juvenile offenders should be held accountable for their
actions and be adequately punished regardless of their age. These supporters argue that
in analyzing whether juveniles should be processed in adult court it is imperative to take
into account the larger issue at hand. The very essence of the legal system is to provide
justice to individuals and communities who have been victimized, regardless of the age,
gender, or ethnicity of these individuals or groups.
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These supporters also argue that age alone should not be a mitigating factor in deciding
whether a minor should be sentenced in a juvenile or adult court. Many supporters have
argued “the primary factors affecting a juvenile’s sentence should be the seriousness
of the crime and the protection of the community from harm, and accountability to the
victim and the public for the juvenile’s behavior” (Backstrom, Walker, 2005). Another
argument that has been discussed by those who support the transferring of juvenile
offenders to adult court is the idea that probation, which is often the sanction issued to
youths in a juvenile system, is not an extreme enough punishment for serious, violent, or
repeat juvenile offenders.

On the opposing side of this debate are individuals who do not think the policy of
transferring juveniles to adult courts poses any direct benefit for these youths or for
society as a whole. The juvenile system was established based the assumption that
these youths were less capable of understanding the severity of their crimes and were
more likely than adults to be driven by emotions and peer pressure but were also more
open to rehabilitation (Park, 2008). This side of the debate emphasizes the fact that
transferred youths are typically subjected to longer waiting periods before their cases are
adjudicated or reach a guilty or innocent verdict. The argument from this opposing side is
that detaining these youths for extended periods of time before reaching verdicts makes
them more susceptible to developing psychiatric problems and suicidal behaviors (Abram,
McClelland, Simon, Teplin, Voss, Washburn 2008).

One study that took place in Illinois found that 65% of transferred youths had or
developed some type of a psychiatric problem prior to or while in prison. This same
study found that only 34% of adult inmates were found to be suffering from similar
psychological problems (Abram, McClelland, Simon, Teplin, Voss, Washburn 2008).
Despite the high rates of psychiatric problems found in these youths, studies have
indicated that only a small portion of them are offered psychiatric services prior to being
sentenced in adult court or after being sent to prison (Abram, McClelland, Simon, Teplin,
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Voss, Washburn 2008). This opposing side argues that one of the major problems with
the lack of psychiatric support offered to these youths is that the majority of these youths
will eventually be released back into the general public, in a worse state than they were
in prior to being transferred to an adult facility (Abram, McClelland, Simon, Teplin, Voss,
Washburn 2008). Research also indicates that transferred youths are more likely to
reoffend earlier and be involved in violent crimes in comparison to youths who remained
in the juvenile justice system, which ultimately contradicts the very essence of the legal
system (Abram, McClelland, Simon, Teplin, Voss, Washburn 2008).

This side of the debate also argues that the juvenile court’s option to waive their
jurisdiction over a case was previously deemed unconstitutional under the Kent v.
United States Supreme Court case. The implementation of this case required a full
investigation be conducted prior to allowing juvenile courts to waive their rights over
he case in question. However, waivers that are considered “statutory or mandatory”
are automatically transferred to adult court without a prior hearing (Park, 2008).

RECOMMENDATIONS AND CONCLUSIONS


In analyzing the policy question “When should juvenile offenders be tried as adults
in the court? Or should they?” it is important to look at the implications and efficacy
of this policy. The expansion of the practice of transferring youths to adult courts took
place during a time when the rate of serious and violent crimes committed by juvenile
offenders was at its peak. The initial goal of this policy was to increase public safety by
taking these dangerous offenders off the streets. However, an overwhelming amount of
research surrounding the transferring of juvenile offenders to adult courts indicates that
this process has not increased public safety and in many ways has been more detrimental
to both the juvenile offenders and the community this policy was established to protect.

The Gang Violence and Juvenile Crime Prevention Act became a law in 2000, and since
its implementation the goals of this policy still remain unaccomplished. After nine years
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of failing to meet its policy goals, it seems rational to reanalyze this policy and question
the purpose of its implementation. There have been no significant achievements since
this policy was put in place, and in many ways it has only exacerbated the problem by
increasing the likelihood of juveniles to reoffend. Many of the juveniles who do not
reoffend once released back into the general public are psychologically impaired from the
victimization they were forced to endure while incarcerated with adult inmates.

The purpose of this policy is to teach these juvenile offenders a lesson and provide justice
to the victims of their crimes. Those who are considered “redeemable” are rehabilitated
and released back into the community, but as Judge Skelly Wright states, “a child is
unlikely to succeed in the long, difficult process of rehabilitation when his teachers during
his confinement are adult criminals” (Park, p. 809).

I do not doubt that at one point the intention of this policy may have been to create a
safer society overall, but at this point it seems as though this policy is taking on a “Band-
Aid” effect. Transferring these youths to adult courts is a quick fix or cover up for the
problem at hand. Although the problem remains, by transferring an increasing number of
youths to adult courts, it makes it appear as though this policy is successfully removing
dangerous offenders from the society they threaten.

There are various avenues that can be taken to address the issue of public safety and
the possible threats certain juvenile offenders may pose. Regardless of what avenue of
change is taken, one of the first steps is to do away with this “Band-Aid” effect that
has a tendency to conceal the root of the problem. Transferring youths to adult courts is
not decreasing the crime rate or increasing the likelihood that they will be rehabilitated,
so why does this policy continue to exist? This is the core question that needs to be
addressed to bring about a positive change in the rehabilitation of these young offenders
and ultimately the safety of society as a whole.
166

Rather than transferring these youths to adult courts, perhaps the expansion of the
juvenile courts’ jurisdiction to preside over serious or violent crime offenders would be
more appropriate. I firmly believe these youths should be held accountable for their
actions, but ultimately the aim should be rehabilitation not punishment. It is imperative
to look at each case on an individual basis and understand the history of the individual in
question and why he or she is engaging in this type of behavior. Trying to get to the root
of the problem and understand why the crime was committed in the first place is crucial
for understanding how to establish a successful policy for change.
167
168

REFERENCES

Abram, K., McClelland, G. Simon, C., Teplin, L., Voss, L., Washburn, J. (2008).
Psychiatric disorders among detained youths: A comparison of youths processed
in juvenile court and adult criminal court. Psychiatric Services, 59(9), pp. 965-973.
Retrieved from ps.psychiatryonline.org.
Backstrom, J., Walker, G. (2005). The role of the prosecutor in juvenile justice:
Advocacy in the courtroom and leadership in the community. pp. 964-987
Burrow, J. (2008). Reverse waiver and the effects of legal, statutory, and secondary legal
factors on sentencing outcomes for juvenile offenders. Crime & Delinquency,
54, pp. 34-64.
Ezell, M. (2007). The effect of criminal history variables on the process of desistance In
adulthood among serious youthful offenders. Journal of Contemporary
Criminal Justice, 23(1), pp. 28-49.
Fagan, J. (2008) Juvenile crime and criminal justice: Resolving border disputes.
The Future of Children, 18(2), Juvenile Justice, pp. 81-118.
Hannan, W. (2008). Judicial waiver as the only equitable method to transfer juvenile
offenders to criminal court. Notre Dame Journal of Law, Ethics & Public Policy,
22, pp. 192-223.
Macallair, D., Males, M., (2000) The color of justice: An analysis of juvenile adult
court transfer in California. Building blocks for youth, for fair and effective
youth justice system, pp.1-11
Park, J. (2008). Balancing rehabilitation and punishment: A legislative solution for
unconstitutional juvenile waiver policies. A Legislative Solution for Juvenile
Waiver Policies, 76(3), pp.786-818.
Woo, B. (2007). Cudgel or carrot: How Roper v. Simmons will affect plea bargaining in
the juvenile system. Pepperdine Dispute Resolution Law Journal,
7(3), pp.475-498.
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Childhood Obesity in America

KRYSTAL WANG
Advanced Theories and Clinical Interventions in Health Care
Professor Julie Cederbaum
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THE EPIDEMIC IN THE UNITED STATES


As a leading nation of the world, the United States is one of the wealthiest and most
progressive countries, with innovative technological advancement that continues to
improve the health and well-being of Americans. Despite its level of social and economic
development, obesity has become a growing health problem that plagues the lives of
many in the U.S. Obesity is not a recent phenomenon in the U.S. but has been prevalent
since industrialization (Edmund, 2006). From the Industrial Revolution to the present
day, the quality of life of individuals has drastically increased due to economic growth,
urbanization, and globalization.

The classification of obesity is commonly measured by using the body mass index (BMI).
The BMI is a mathematical calculation that is based on an individual’s height and weight
(BMI = kg/m2). According to the World Health Organization Report (2009), an individual
is categorized as “obese” with a BMI of 30 or greater. During the past few decades,
there has been a dramatic increase in obesity in the United States. In 2003, the United
States was ranked the most overweight country in the world, with approximately 30.6
percent of Americans suffering from obesity (Streib, 2007). By 2007, the United States
ranked ninth with 74.1 percent of individuals aged 15 and over considered overweight,
with a BMI of over 25 (Streib, 2007). Even though the United States is no longer the
“fattest country,” the nation’s waistline is not shrinking; instead it continues to grow at a
steady pace. In 2008, 26.1 percent of U.S. adults were obese, compared to 25.6 percent
in 2007 (Hitti, 2009). According to a 2009 Centers for Disease Control and Prevention
(CDC) report, obesity in adults has increased by 60 percent within the past twenty years,
while obesity in children has tripled in the past thirty years.

OBESITY AND CHILDREN


The real threat from obesity does not come from being overweight or having excessive
body fat, but from the numerous health problems associated with obesity. The National
Health and Nutrition Examination Survey (NHANES) showed the prevalence of obesity for
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children between ages two and five increased from five percent to 12.4 percent between
the period of 1976-1980 and 2003-2006 (Overweight and Obesity, 2009). Meanwhile,
obesity in children aged six to11 increased from 6.5 percent to 17 percent; for those
aged 12 to 19, prevalence increased from five percent to 17.6 percent (CDC, 2009).
Since 1980, childhood obesity has tripled, with approximately nine million children ages
six to nine (16 percent) classified as overweight or obese (CDC, 2009). Obesity has
become an epidemic not only in the United States, but in the global community as well,
with an estimated 22 million children under five years old, overweight, or obese (World
Health Organization, 2009). Children who suffer from obesity will most likely stay obese
into adulthood and develop non-communicable diseases (NCGs), such as cardiovascular
diseases and diabetes at an earlier age.

Given the facts and data presented, childhood obesity can no longer be viewed as an
individual and/or a family problem, but rather as a national health crisis that could
plague the U.S. into the future. This paper will primarily focus on the correlation between
childhood obesity and low-income families with limited or no access to health and
wellness services.

CONTRIBUTING FACTORS TO CHILDHOOD OBESITY


Childhood obesity is a major health problem that causes short- and long-term physical,
psychological, and emotional harm to children. Childhood obesity increases morbidity
and mortality, due to the various risks and development of chronic illnesses, such as
cardiovascular diseases. In addition, children with obesity are at risk for associated adult
health problems, including heart disease, type 2 diabetes, stroke, and osteoarthritis (CDC,
2009).

For many years, the contributing causes of obesity were overconsumption of calories
and inactivity (CDC, 2009). As a result, parents and children were blamed for obesity
due to lack of impulse control. However, the causes of obesity are enmeshed with
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various components, such as genetic, biological, environmental, behavioral, and cultural


factors. Research has indicated that children whose parents are obese will have a
higher chance of becoming overweight or obese themselves; a family history of obesity
can increase a person’s chances of becoming obese by about 25 to 30 percent (CDC,
2006). While heredity does not mean a child is destined to be obese, by managing the
amount of body mass and fat distribution, childhood obesity can be prevented. Though
genetic predispositions, metabolic determinants, and lifestyle choices are major factors
contributing to obesity, socioeconomic status (SES) plays a crucial role.

LOW SOCIOECONOMIC STATUS MINORITY FAMILIES


Like many health disparities in the United States, childhood obesity is linked to
inequalities in education and income that are most prevalent in low SES minority
families. According to Drewnowksi and Specter (2004), the prevalence of obesity falls
disproportionately upon individuals and families with limited resources as well as upon
racial or ethnic minorities. Drewnowski and Rolls hypothesize that obesity is mainly
attributed to higher-energy dense foods consumed by low-income consumers (as cited
in Townsend, 2006). Higher-energy dense food is defined by the number of calories
in a food’s given weight, which can be calculated using a formula (Energy Density =
calories per serving / weight of serving in grams) (Drewnowksi & Specter, 2004). Thus,
higher-energy dense foods consist of high calories, more fat content, and less water.
Foods with high moisture content, such as fruits and vegetables, allow individuals to
feel fuller, despite having fewer calories (Drewnowksi & Specter, 2004). However, prices
and incomes affect individual food choices and the quality of the food. Thus, families
with lower SES tend to have diets with less nutrition than wealthier households. On
average, low-income households do not meet federal recommendations for consumption
of fruits, vegetables, low-fat dairy products, and whole grains (Stewart & Blisard, 2008).
In addition, households with income below 130 percent of the poverty line not only
spend less on fruits and vegetables, but are also unlikely to increase their spending on
these items if they receive additional income (Blisard et al., 2004). Steward & Blisard
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(2008) show the total weekly food spending of low-income households (LI), middle-
income households (MI), and high-income households (HI) in 2003. Their data shows
low-income households spend less than middle-income households on food: $33.90
per person compared with $44.39 per person (Steward & Blisard, 2008). Similarly,
a smaller percentage of low-income households reported spending money on seven
common foods, including beef (55 percent of low-income households, compared with 59
percent of middle-income and 61 percent of high-income households) and vegetables
(77 percent of low-income households, compared with 83 percent of middle-income
and 86 percent of high-income households) (Steward & Blisard, 2008). The data suggest
that not only are low-income households spending less on food, but they also consume
low-quality, non-healthy food. Food that includes oil, fat, sugar, and refined grains can
be produced at a minimal cost compared to fresh fruits and vegetables. As a result, high
density products are cheaper and more economically friendly for low-income consumers.

Similarly, analysis suggests that childhood obesity is higher among lower socioeconomic
families due to food insecurity. The U.S. Department of Agriculture (USDA) defines food
insecurity as “limited or uncertain availability of nutritionally adequate and safe foods
or limited or uncertain ability to acquire acceptable foods in socially acceptable ways (as
cited in Alaimo, Olso, & Frongillo, 1161 and 2001). Families facing food insecurity may
be categorized under low food security or very low food security (Food Security in the
United States, 2009). Households with low food security may experience some cutbacks
in quality, variety, or desirability in their diets. However, there is little or no evidence of
reduced food intake. On the other hand, the eating patterns of households with very
low food security are severely disrupted due to the reduction of food intake as a result
of limited financial resources (USDA, 2009). In 2008, 85.4 percent of U.S. households
reported that they were food secure throughout the year (Nord, Andrews, & Carlson,
2009). Despite the data and figures, in 2008 the USDA reported that 14.6 percent (17
million) households were food insecure compared to 12 percent of U.S. households in
1995 (Nord, Andrews, & Carlson, 2009 & Alaimo, Olso, & Frongillo, 2001). Similarly, food
175

insecurity was more than four times as prevalent in households with annual incomes
below 185 percent of the poverty line in 2008 (Nord, Andrews, & Carlson, 2009). As
a result, there is a correlation between food insecurity and poverty due to financial
constraints and minimal access to community resources.

The concept of food insecurity encompasses inadequate quantities and quality of


nutrients available in the household. Thus, low-income consumers and families are
unable to purchase necessary food and ingredients to maintain a nutritious diet. As a
result, low-income consumers decide to spend money on less expensive, high-energy
foods, because they are filling. Inexpensive, high-energy foods are not only cost-effective
for low-income and food-insecure families but are able to satisfy their immediate
hunger needs, since they are able to consume large quantities at an inexpensive price.
The consumption of starches, salt, sugar, and fats is extremely unhealthy for infants and
children. According to Cook and Frank (2008), for children with smaller stomach capacity,
excessive eating and overindulgence in poor, low-cost foods (such as sweetened liquids
and french fries) leads to obesity, nutritional short stature, and iron deficiency anemia.
Food insecurity not only influences one’s health and development, but creates stressors
within the family, such as illnesses related to childhood obesity, impaired cognitive skills,
and depressive symptoms. Food insecurity not only harms children during developmental
stages and life cycle, but also exposes them to physical, psychological, and emotional
damage. Recognizing the correlation between childhood obesity, poverty, and food
insecurity, the U.S. government has implemented policies and established programs in
hopes of alleviating the problem.

POLICIES, INTERVENTIONS, AND CHILDREN’S HEALTH


SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
Since the passage of the Personal Responsibility and Work Opportunity Reconciliation
Act (PRWORA) in 1996, the U.S. government has made significant changes in policy
creation and practices to help low-income families, such as Temporary Assistance to
176

Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) (historically
known as the Food Stamp Program). Despite the federal food assistance programs, some
research supposed that programs like the Food Stamp Program may have played a role in
the childhood obesity-food insecurity paradox. For many years, the Food Stamp Program
has been criticized for providing food stamp recipients with low-nutrient, high-energy
dense food products (Townsend, 2006). Even though the intentions of the program were
positive (providing for the nutritional needs of low-income families), the quality of food
was often poor. Oftentimes, the Food Stamp Program required individuals to select food
from an inclusion list (that designates the food types and the brands that are available
for purchase). Similarly, fresh fruits and vegetables were not an option for food stamp
recipients (Townsend, 2006). Therefore, low-income families under the Food Stamp Program
were given low-quality food (limited to only certain types of foods). Since the establishment
of the Food Stamp Program in 1939, it evolved into a $20 billion food intervention.

In October 1, 2008, SNAP became the new federal food stamp program; it meets the
nutritional needs of over 32 million people each month (approximately 10 percent of
the U.S.’s population) (SNAP, 2009). Other than the name change, SNAP recipients
witnessed an increase in minimum monthly benefit (from $10 to $14); retirement and
education accounts were no longer considered as countable resources; and all dependent
care costs (child care, elder care, and/or disabled household members) were taken
into consideration when determining eligibility and benefit amount (SNAP, 2009). In
comparison to the Food Stamp Program, SNAP provides a greater range of food selection
for low-income families. SNAP benefits can be used to purchase fresh produce, meats,
fish, poultry, and dairy products from authorized vendors. Families can also use their
SNAP benefit on seeds and plants to grow food, as long as it is for household use and
consumption. In addition, special programs from individual states authorize restaurants,
nutritional and weight-loss systems (Ensure, Slim Fast, and Nutrisystem), and delivery
services (such as Meals on Wheels program) to accept SNAP benefits from qualified
elderly, disabled, and homeless individuals (SNAP, 2009).
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THINK GLOBALLY, ACT LOCALLY


SOCIAL WORKERS’ ROLES IN CHILDHOOD OBESITY PREVENTION AND INTERVENTION
Unlike adults, it is essential for children to acquire appropriate nutrients crucial to
their growth and development. By consuming adequate calories for daily activities,
growth, and metabolism, children are able to reach to their full potential. However,
overconsumption, inactivity, and excessive body fat creation puts the child at risk for
obesity, which leads to multiple health problems throughout their lives. Looking at it
from a multidimensional perspective, environmental conditions, biological factors, and
psychological schemas must be taken into account. Thus, childhood obesity prevention
and intervention are best conceptualized collectively rather than individually.

According to Erik Erikson’s Stages of Development, the family environment is


childrens’ first experience as part of the social world, in which they develop a sense
of self through their caretakers (Zastrow & Kirst-Ashman, 2007). The early years
of development are critical periods for the family in providing appropriate care
and meeting children’s essential needs. As a result, the family is responsible for
basic development and socialization of a child’s learning and behavior. For children
residing in a chaotic family dynamic (who are exposed to multiple stressors that
threaten their homeostasis) are at greater risk of developing childhood obesity.
Stressors include: physical stressors (trauma), physiologic stressors (hemorrhagic
shock), social stressors (personal conflicts and lifestyle changes), psychological or
emotional stressors (anxiety and fear) (Torres & Nowson, 2007). Lacking family
resilience, children in distressed households may develop maladaptive coping skills
and associate food consumption with emotional survival and comfort. According to
Gibson (2006), depressive symptoms were associated with increased consumption
of sweets and disordered eating patterns, such as skipping meals among depressed
school children. Thus, children in distraught households become stressed emotional
eaters as a result of maladaptive coping skills and develop learned behaviors
through observation and socialization in their families and communities. In addition,
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parents influence children’s eating patterns through food availability and food
micro-managers, such as regulating what the child eats and how much.

Research has shown that the probability of being obese is associated with the layout
of the community. Families residing in safe communities, with low prevalence of crime,
not only have greater access to fruits and vegetables, but are physically healthier.
Individuals who live in high crime rate and high illegal substance communities have
poorer health conditions due to limited access to open space as well as limited fresh
produce (Committee on Environmental Health, 2009). The dominant factors that shape
health and health disparities among low-income populations and communities are the
disproportionate social and economic determinants that negatively affect the health
outcomes of individuals, in terms of prognosis and treatment. To improve health status
and equity among all communities, appropriate prevention and interventions are
necessary to address and combat childhood obesity.

As childhood obesity continues to rise among low-income households, the U.S. witnessed an
increase in public health strategies, campaigns, and programs within the past few decades.
Through community-, school-, and family-based interventions, health care professionals
are promoting healthy food selections and physical activity. As with most federally funded
programs, low-income households and communities are the primary targeted population
for childhood obesity prevention and reduction. Therefore, it is important for health care
professionals to address childhood obesity through a community approach. Though family
interventions are equally important, it is essential for health care professionals to advocate
and address childhood obesity on all three levels of practice (micro, mezzo, and macro),
as they work with individuals, families, groups, organizations, and communities. Through
community-based interventions and public education, health care professionals are able
to highlight environmental changes that would improve health outcomes in high-risk
communities. Successful prevention and intervention programs should emphasize educational
collaboration and involvement among parents, schools, and health care providers.
179

As health care professionals, social workers are able take a familial and environmental
approach to the treatment of obese children. The environments for children should
include, but should not be limited to, the home, child care settings, schools, communities,
recreational facilities, and infrastructure. Thus, health care professionals in inpatient-,
outpatient-, community-, and school-based agencies, need to be active participants and
advocates in health promotion and education, as well as in program implementation and
evaluation. For instance, health care professionals working within the family system can
influence behavioral changes by providing families the necessary nutritional education
and skills. According to Golan & Weizman (2001), nutritional education is essential to all
weight-loss and healthy-food-choice programs. Therefore, health care professionals can
educate families on the health benefits of healthy food choices and facilitate healthy-
eating practices, such as reading food labels, preparing healthy, balanced meals, and
physical activity. Through collaboration between health care professionals and families,
behavioral changes can lead to increased self-efficacy. By helping families find solutions
and treatments that are specifically tailored to their goals, parents and children will
believe that they are capable of performing changes and will not be hesitant about their
abilities when faced with obstacles in the future. In addition, health care professionals
can advocate for childhood obesity prevention and interventions on a macro-level
practice through policy reformation and program evaluations. Through program analysis
and evaluation, health care professionals can adequately determine whether or not
federally, state, and/or privately funded programs are effectively addressing childhood
obesity. Likewise, health care professionals are experts on community resources, and
advocates for school-based nutrition programs and community safety and physical
health promotions.

CHALLENGES AHEAD
Over the last decade, many states have enacted legislation in support of school and
community-based programs and have shown positive results in preventing and reducing
obesity among children. School-based programs and efforts have focused on improving
180

the quality of food, including: regulating the quality of foods sold in school cafeterias and
vending machines and providing free or reduced-cost breakfast for students (Levi, Vinter,
Richardson, St. Laurent, & Segal, 2009). The Maryland Meals for Achievement (MMFA) is
a pilot program that offers breakfast to every student regardless of their family income;
the results show a decrease in tardiness by eight percent and of suspensions by 36
percent (Levi et al., 2009).

Despite the positive outcomes and efforts in preventing and reducing the childhood
obesity epidemic, obesity rates will most likely continue to increase at a substantial
rate due to the economic downturn. The USDA projected a five percent increase in food
prices in 2009, making nutritious foods increasingly out of reach for not only low-income
families, but middle-income families as well (Levi et al., 2009). Between December
2007 and May 2009, the unemployment rate increased from 4.9 percent to 9.4 percent.
As of November, 2009, the unemployment rate in the U.S. was approximately 10
percent (Labor Force Statistics, 2009). Due to the economic recession, many children
are no longer able to receive health and wellness services as a result of parents losing
employer-sponsored health insurance. As the unemployment rate continues to rise,
more Americans will be living in poverty, which could have significant implications for
the obesity rate. Thus, healthy eating and food selection will become less of a priority in
comparison to housing.

While the majority of restaurants are struggling to survive, the fast food industry
continues to thrive during the recession. Owners of fast food chain restaurants, such
as Kentucky Fried Chicken and Taco Bell, reported worldwide sales growth of seven
percent in 2008. Similarly, McDonald’s sales in the U.S. grew 4.5 percent in November
2008, and global sales were up 7.7 percent (Levi et al., 2008). Unable to afford fresh
produce, middle-income and low-income families often have to look to less expensive
food options, which are often high in calories and fat. In addition, health and wellness
programs (school- and community-based) have been eliminated or have witnessed a
181

reduction in federal and state funds. The current economic conditions have pushed more
Americans to seek help from federal and state safety net programs, including SNAP
and Medicaid. Even if Americans’ increased dependency on federal and state assistance
programs results in further challenges and burdens, opportunities are available to the
public despite the economic downturn.

Although the current economy has had a deleterious impact on the health and well-
being of many Americans, there are still opportunities for positive change in preventing
childhood obesity. On February 14, 2009, Congress passed the American Recovery and
Reinvestment Act (ARRA), an economic stimulus package that included $1 billion to
support evidence-based clinical and community-based prevention (State and Territory
Summaries, 2009). Through the ARRA, states are able to use the funding to create
safe community places for physical activity, accessible means of transportation, school
renovations, and program expansions. As childhood obesity continues to be a serious
problem in the U.S., health care professionals must be aware that many programs are
not adequately funded by the states. Thus, it is important for health care professionals
to be aware of the available policies, programs, and community resources, so that they
can become better advocates for reducing childhood obesity. In addition, health care
professionals must collaborate with other professionals, including pediatricians, health
care providers, program analysts, and researchers to make childhood obesity a higher
priority in health reform.
182

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