Identify the Independent Variable and the Dependent Variable
This assignment requires you to review the five scholarly articles attached to this
assignment and identify the following:
1) Determine whether the article is a research study.
a. Hint:
i. All research studies include a sample of participants, at least one
independent variable and at least one dependent variable, and a
section of the article that reports the results of the study. If any
one of these are not present than it is not a research study.
ii. Research studies tend to have the same predictable format
that includes the following:
1. Introduction
2. Methods
3. Results
4. Discussion
2) If it is a study, identify at least one independent variable and at least one
dependent variable.
a. Hint:
i. The independent variable is the “causal” variable. In other words,
the researchers expect that the independent variable will have some
influence over the level of dependent variable. In this case, the
level of the dependent variable will depend on the level of the
independent variable.
b. Big Hint:
i. When a study is testing the effectiveness of an intervention, the
intervention is always the independent variable.
Helping Homeless Individuals with Co-occurring Disorders — The Four Components
Deaths in the Desert — The Human Rights Crisis
Family-based Crisis Intervention
Depression and Anxiety among Asian Americans
Burnout and Physical Health among Social Workers – A Three-Year Longitudinal Study
Depression and Anxiety among Asian
Americans: The Effects of Social Support and
Strain
Cindy C. Sangalang and Gilbert C. Gee
It is almost taken for granted that social relationships benefit mental health, yet these rela-
tionships may not always be protective. This study examines how the support and strain
s
individuals derive from family and fiiends may be related to depression and anxiety amon
g
Asian Americans. Data come from the 2002-2003 National Latino and Asian American
Study, the first nationally representative study of mental health outcomes among Asian
Americans (rt = 2,066). Results indicate that farrdly support was associated with decreased
odds oí Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria for
both major depressive disorder (MDD) and generalized anxiety disorder (GAD) among
men and women. In addition, family strain was associated with increased odds of GAD
equally among men and women. However, fiiend strain was associated with increased
odds of GAD among women but not men, and faniüy strain was marginally associated
with increased odds of MDD for women but was unrelated for men. The findings affirm
the need to consider social strain along with social support, as well as their sources, with
attention to the potentially stronger effects of strain for women. Implications for social
work practice are discussed.
KEY WORDS; Asian Americans; mental health; social strain; social support; women
C onventional wisdom indicates that
receipt of social support is universally
beneficial. Social support from network
ties is beheved to be a fundamental aspect of psy-
chological well-being and the therapeutic process
(Kawachi & Berkman, 2001); however, social
strain rooted in the same support networks may
contribute to poorer mental health outcomes
(Rook, 1992). Furthermore, research suggests
support and strain may differentially affect men
and women (Umberson, Chen, House, Hopkins,
& Slaten, 1996). Recent research suggests that
social networks and the ways individuals use these
networks may also vary by culture, yet studies on
minority communities, such as Asian Americans,
are limited (H. S. Kim, Sherman, Ko, & Taylor,
2006).
Asian Americans are one of the fastest-growing
minority groups in the United States (U.S.
Census Bureau, 2011). Although prior research
suggests that Asian Americans have lower rates of
psychological disorder and use of mental health
services than other racial and ethnic groups
(Matsuoka, Breaux, & Ryujin, 1997), recent
studies indicate a substantial need for mental
health care among Asian Americans (ManhaU,
Schell, Elliott, Berthold, & Chun, 2005; Mui &
Kang, 2006; Takeuchi et al., 2007). Shame and
stignia associated with mental ulness may discour-
age people from using formal mental health ser-
•vices. This may be particularly true among Asian
Americans, who often rely on famüy and
members of their informal networks for support
of their mental health problems (Leong & Lau,
2001; Spencer & Chen, 2004).
The purpose of this study is to investigate the
effect of social support and strain on mental health
among Asian Americans. This study has several
unique features. First, in contrast to prior studies
that only focus on either support or strain, we
examine both factors simultaneously whüe distin-
guishing between support and strain from friends
and from farrdly. Second, we investigate major
depressive disorder (MDD) and generalized
anxiety disorder (GAD) because these are clinical
outcomes that contribute to considerable disabuity
(World Health Organization, 2001). Third, we
explore possible gender differences in these
doi: 1O.1O93/sw/swrOO5 ® 2012 National Association of Social Workers 49
relations. Finally, we examine these issues among
an understudied population and use a nationally
representative sample.
BACKGROUND
Social Support, Social Strain, and
Well-Being
A large body of hterature has described the salu-
brious effects of social support (Berkman 8c Glass,
2000; House, Landis, & Umberson, 1988).
Berkman and Glass described social support as
emotional, instrumental, tangible, and informa-
tional resources that individuals obtain firom their
network ties. These resources are known t
o
promote mental health by enhancing self-esteem,
strengthening effective coping, and mitigating dis-
tress. In studies on Asian Americans, social
support has been negatively associated with accul-
turative stress and depression (Mui, 2001; Yeh &
Inose, 2003). Social support also buffered the
effect of Stressors on mental and physical health
among diverse Asian American groups (Choi,
1997; Gee et al., 2006).
Other research suggests that Asian cultural
values related to collectivism can limit the health-
ful benefits of social support. In contrast to
Western individualism, a coUectivist orientation
may hinder disclosure of personal problems for
fear of burdening others, disrupting group
harmony, or losing face (B.S.K. Kim, Atkinson, &
Umemoto, 2001; H. S. Kim et al., 2006). Indeed,
some studies have found that compared with
white Americans, Asian Americans appear less
hkely to seek social support in response to stress
(Taylor et al., 2004) or after breast-cancer treat-
ment (WeUisch et al., 1999). H. S. Kim et al.
(2006) found that Asian American students sought
less support firom family and friends and, further,
perceived support to be less helpful in deahng
with stress than white students. Taken together,
the conflicting findings regarding social support’s
effectiveness for Asian Americans demonstrate
a
need for further investigation.
An emerging body of research suggests that the
very relationships that provide support can also
engender strain. Social strain includes conflicts,
feelings of undue obhgation, and demands from
one’s friends and family (Lincoln et al., 2010;
Lincoln, 2000; Mittelmark, 1999; Rook, 1992).
Because greater attention is given to positive
rather than negative components of social interac-
tions, only a handful of studies have simultaneous-
ly examined both social support and social strain
(Lincoln, 2000).
Some studies have found that strain and support
are independently associated with well-being,
such that strain is associated with diminished
mental health while support is associated with
improved mental health (Revenson, Schiaffino,
Majerovitz, & Gibofsky, 1991; Stephens, Kinney,
Norris, & Ritchie, 1987). Other studies have
found that social strain exerts more robust effects
on psychological well-being than social support
(Fiore, Becker, & Coppel, 1983; Rook, 1984).
Although promising, these studies have tended to
focus on specific Stressors (for example, caregiving
to spouses with Alzheimer’s disease), which can
obscure the presence of multiple straining rela-
tionships and contexts (Fiore et al., 1983;
Mittelmark, 1999). Moreover, these studies used
speciahzed, nonrepresentative samples, raising
questions about generalizabOity to other popula-
tions (Monette, Sullivan, & Dejong, 2005).
The coUectivist orientation that characterizes
many Asian cultures can also trigger social strain
rooted in obhgation, expectations, and norms of
reciprocity (B.S.K. Kim et al., 2001). For
example, Asian Americans who are family
oriented may feel burdened with obhgations that
confhct with American norms of individuahsm
(Yee, Huang, & Lew, 1998). Children and parents
of Asian American famihes may have friction over
parental expectations of educational and occupa-
tional achievement (Yee et al., 1998). Individuals
may face pressure to fulfill unspoken expectations
of reciprocity and indebtedness to friends and
other network des, such as the cultural value of
utang na hob (feeling of mutual obligation) among
Füipino Americans (Nadal, 2009). These aspects
of cultural norms that can constrain social relations
may not be captured in existing studies on social
support for Asian Americans.
Social Support and Social Strain from
Family versus Friends
Family members and friends may not present the
same types of support and strain. Family relation-
ships are often of longer duration and can include
legal responsibüities and benefits. Studies have
produced equivocal evidence for family versus
friend support, with some studies showing that
50 Social Work VOLUME 57, NUMBER I JANUARY 2011
famüy support may buffer health more (Procidano
& HeUer, 1983; WeUisch et al., 1999), whereas
other studies have found the convene (Walen &
Lachman, 2000). These mixed findings may be
due, in part, to the sampling of different cultural
populations, in which the bonds of family may be
more or less sahent than the bonds of fdendship.
With regard to Asian Amedcans, scholan have
noted that the family is often the central social
unit, not the individual (H. K. Kim & McKenry,
1998). Indeed, research suggests that many Asians
avoid bdnging shame to their families (B. S. K.
Kim et al., 2001) and have a strong sense of family
obhgation (Fuhgni, 2001). Furthermore, family is
often the fint line in seeking help for mental
health problems (Lin, Inui, Kleinman, &
Womack, 1982). Hence, family members may be
more aware of one’s mental health needs, and
their support may play a greater protective role
than support from one’s fdends. Yet, for these
same reasons, the strain from famuy may be even
more salient than similar stresson coming from
fdends.
Social Support, Social Strain, and
Gender
Gender may also influence how strain and support
are related to mental health. Umbenon et al.
(1996) descdbed the ways in which social relation-
ships may have greater demands and responsibil-
ities for women than for men. One factor relates
to increased exposure to stress due to role strain.
Compared with men, women tend to have add-
itional demands from vadous relationships, par-
ticularly for those who have chüdren, are manried,
or care for Ul family memben (Umbenon et al.,
1996). Another factor involves differential sensitiv-
ity to social strain. Several scholan have suggested
that social relationships are more important for
women than men and that disordered relation-
ships may be particularly harmful for women
(BeUe, 1982; Miller, 1988). Accordingly, this sug-
gests that social strains may place a greater psycho-
logical burden on women than men.
Studies indicate that social support for Asian
Amedcan women is pdmarily family based
(Meemeduma, 1992; WeUisch et al., 1999).
WeUisch et al. found that Asian Amedcan women
survivon of breast cancer relied less on social
support compared to Anglo Amedcan women, in
hne with previous work that suggests Asian
Amedcan women prefer to provide rather than
receive care and are concerned with maintaining
interpenonal harmony. Taken together, the afore-
mentioned hnes of research suggest that social
support may be less protective of mental illness for
women than men and, further, that social strain
may be more strongly related to mental Ulness for
women than for men. Moreover, the effects of
family support and strain should be stronger
among women for these same reasons.
Based on the hterature, we examine the foUow-
ing four hypotheses:
1. Social support is related to lower dsk of de-
pressive disorder and generahzed anxiety
disorder.
2. Social strain is related to higher dsk of de-
pressive disorder and generahzed anxiety
disorder.
3. Support and strain firom family wül be more
strongly related to these mental health pro-
blems than support and strain from fdends.
4. Gender wül moderate these associations,
such that famuy or fdend support wül be
more protective for women and strain wül
be a greater dsk for women than men.
Because depressive disorder and generahzed
anxiety disorder (CAD) often co-occur (Bakish,
1999), we anticipate that the relationship between
both social support and social strain wül have par-
aUel effects across both disorden.
METHOD
Data and Sampling
This study is based on data from the National
Latino and Asian Amedcan Study (NLAAS), a
psychiatdc epidemiologic survey conducted
between 2002 and 2003 across the United States
(Alegda et al., 2004a, 2004b; Heerenga et al.,
2004). Eligible respondents were age 18 yean or
older and were not in the muitary or institutiona-
hzed. The current analysis is restdcted to Asian
Amedcan respondents.
The NLAAS used a three-stage stratified prob-
abüity sampling design. Fint, pdmary stage units
of single counties or groupings of adjacent coun-
ties were devised into strata on the basis of size,
location, and population charactedstics. Second,
within primary stage units, census blocks compds-
ing area segments were stratified by geographic
SANGALANG ANO G E E / Depression and Anxiety among Asian Americans 51
location and the race/ethnicity of household
respondents. High-density supplemental samples
were obtained firom areas with five percent or
greater of targeted ethnic groups. Sampling was
performed within probabilities proportionate to
census blocks for each area segment. Third, sys-
tematic random sampling was used to select
housing units within area segments. Within con-
senting households, eligible main respondents
were randomly selected, and then secondary
respondents from the same household were also
recruited. Interviews were conducted in the
respondents’ choice of Cantonese, English,
Mandarin, Spanish, Tagalog, or Vietnamese using
computer-assisted survey instruments. The re-
sponse rate was 69.3 percent for main respondents
and 73.7 percent for secondary respondents.
Sample weights were developed to account for
the complex sampling design and to allow esti-
mates to be nationally representative (Heerenga
et al., 2004).
The NLAAS is designed to be valid and reliable
for diverse Asian and Latino communities. Briefly,
this involved five steps: (1) identification of con-
structs that are relevant to the target population;
(2) collaboration among a multicultural study
team that included researchers with ethnic back-
grounds similar to those of the target population;
(3) translations and back-translations of research
materials, and by extension, the availability of the
study in sbc languages; (4) use of key-informant
interviews with members of the target population
across several states (and in Puerto Rico) to assess
materials; and (5) pilot testing and revision of the
materials as needed. Further details are available
elsewhere (Alegria et al., 2004a, 2004b).
Participants
The Asian Ametican subsample includes 2,095
respondents. The current analysis is restricted to
individuals with no missing values for variables of
interest (n = 2,066). Weighted sample characteris-
tics are presented in Table 1.
Measures
MDD and GAD. The dependent variables were
based on measures from the World Health
Organization’s expanded version of the
Composite International Diagnostic Interview
(WHO-CIDI) (World Mental Health Survey
Consortium, 2004). Diagnostic outcomes were
derived from algorithms of participant responses
to the WHO-CIDI that were then used to classify
an individual as meeting criteria for MDD or
GAD, respectively, as defined by the Diagnostic
and Statistical Manual of Mental Disorders (4th ed.,
text rev.) (DSM-IV-TR) (American Psychiatric
Association [APA], 2000). These dichotomous
Table 1: Sample Characteristics of Asian
Americans in the National Latino and
Asian American Study, 2002-2003
(n = 2,066)
DSM-IV—TR major depressive
disorder (past 12 months)
DSM-IV—TR generalized anxiety
disorder (past 12 months)
Family support (range: 1—4)
Friend support (range: 1—4)
Family strain (range: 1—4)
Friend strain (range: 1-4)
Gender
Male
Female
Age (range: 18-95 years)
Ethnicity
Chinese
Filipino
Vietnamese
Other Asian
Education
Less than high school
High school graduate
Some college
College graduate
Work status
Employed
Unemployed
Not in the labor force
Marital status
Married
Divorced/separated/widowed
Never married
Nativity status
U.S. born
Foreign born
Region
West
Northeast
Midwest
South
4.6
1.
4
47.4
1
52.5
9
28.51
21.58
12.87
37.04
14.29
17.77
25.07
42.87
63.82
6.4
0
29.78
68.66
8.31
23.03
23.7
76.30
68.
01
15.53
8.56
7.89
2.73
2.66
1.96
1.68
41.27
0.03
0.03
0.02
0.02
0.70
Notes: Data are weighted to reflect population percentages. DSM-IV-TR = Diagnostic
and Statistical Manual of Mental Disorders {4th ed., text rev.) (American Psychiatric
Association, 2000).
52 Social Work VOLUME 57, NUMBER I JANUARY 2012
variables indicated the presence or absence of the
disorder within the past 12 months (0 = absent, 1
= present).
Social Support among Family and Friends.
Social support was measured with a brief six-item
scale previously examined in the NLAAS with
Latinos by Mulvaney-Day, Alegria, and Sribney
(2006). Three questions asked about the firequency
of support (1 = none to 4 = a lot) by three specific
means: (1) talking on the phone or getting to-
gether with relatives, (2) relying on relatives for
help with a serious problem, and (3) relying on
relatives to talk about worries. Family support was
assessed by averaging across these three items
(Cronbach’s alpha = 0.71); higher values indicated
greater social support. The same three questions
were repeated, but with regard to friends, to
create an analogous measure of friend support
(Cronbach’s alpha = 0.77).
Social Strain among Family and Friends. Two
items measured family strain, or the firequency of
respondents’ confiicts and demands with family
members. Respondents were asked two questions:
(1) how often their relatives and children make
too many demands, and (2) how often they argue
with family. Responses ranged from 1 = not at all
to 4 = often. Items were averaged to create an
index in which higher scores reflected greater
strain (Cronbach’s alpha = 0.59). Friend strain was
measured with two similar items (Cronbach’s
alpha = 0.60).
Control Variables. The multivariate analyses
control for the following sociodemographic char-
acteristics: gender, age, education, work status,
marital status, ethnicity, and nativity (immigrant
versus nonimmigrant). These characterisdcs have
all been previously related to psychological well-
being and disorder (Aneshensel, Rutter, &
Lachenbruch, 1991; Dohrenwend et al., 1992;
Mirowsky & Ross, 1992; Peadin & Johnson,
1977; Stronks, Van De Mheen, Van Den Bos, &
Mackenbach, 1997; Takeuchi et al., 2007).
Analysis
We first examined bivariate relations between
variables and then proceeded with multivariate
models using logisdc regression for each depend-
ent variable. First, we examined the associations
between family support and the dependent vari-
able (MDD or GAD within the past 12 months)
and between friend support and the dependent
variable, controlling for covariates. Second, we
examined the associations between faniuy strain
and the dependent variable and between friend
strain and the dependent variable, controlling for
covariates. The final model included family
support, friend support, family strain, friend strain,
and covariates simultaneously. We then examined
the effect of gender on the associations between
support and strain and dependent variables with
interaction terms. These analyses centered con-
tinuous variables at their mean to reduce multi-
coUinearity and to facilitate interpretation (Aiken
& West, 1991). Finally, significant interacdons
were graphed to aid interpretation. All analyses
were weighted to account for complex sampling
design and to make the estimates nationally repre-
sentative. We used the Stata software program,
version 10.0 (StataCorp, 2007).
RESULT
S
Of the respondents, 4.6 percent could be classified
as having MDD and 1.4 percent as having GAD
within the past 12 months (see Table 1).
Respondents as a whole reported moderate levels
of social support; a mean of 2.73 from family and
2.66 from friends suggests that respondents relied
on these people “sometimes.” A relatively lower
level of social strain was reported; a mean of 1.96
from family and 1.68 from friends indicates that
conflicts and demands fix)m these people occurred
“rarely.”
The bivariate associadons between measures of
social support and strain from family and friends
and the odds of meeting criteria for MDD and
GAD within the last year are presented in
Table 2. Unadjusted bivariate analyses showed
that family strain was positively associated with
Table 2: Bivariate Odds Ratios (ORs) of
12-Month Major Depressive Disorder
(MDD) and Generalized Anxiety Disorder
(GAD) (n = 2,066)
IMDDJ [GÀDl
Family support
Friend support
Family strain
Friend strain
• O R S
0.75
1.35
1.83***
1.64
K.95%tCll
0.56, 1.00
0.91, 2.00
1.42,2.37
0.94, 2.88
• P R l
0.55*
1.06
1.90*
1.76
•95yo'[Cj
0.32, 0.94
0.59, 1.89
1.10,3.28
0.94, 3.28
Note: CI = confidence interval.
*p<.05. ***p<.001.
SANGALANG AND GEE / Depression and Anxiety among Asian Americans 53
higher odds of MDD. Specifically, a one-unit in-
crease in family strain resulted in 1.83 greater odds
of MDD (95 percent confidence interval [CI]
[1.42, 2.37]). Unadjusted bivariate analyses also
showed that family support was negatively asso-
ciated with the odds of meeting criteria of GAD
(odds ratio [OR] = 0.55; 95 percent CI [0.32,
0.94]) and family strain was positively associated
with the odds of meeting criteria of GAD (OR =
1.90; 95 percent CI [1.10, 3.28]).
Associations between Support and Strain
and MDD
Models la to 5a in Table 3 show the associations
between support and strain firom family and
friends and MDD, controlling for covariates
(tables omit the covariates for parsimony, but they
are available from the authors). These models
indicated that both famuy support and family
strain were associated with MDD within the last
year. In model la, family support was associated
with decreased odds of MDD (OR = 0.63; 95
percent CI [0.48, 0.83]), whereas in model 3a,
family strain was associated with increased odds of
MDD (OR = 1.63; 95 percent CI [1.28, 2.07]).
We found no significant associations between
friend support and MDD or fiiend strain and
MDD (models 2a and 4a). With the inclusion of
all of the support and strain variables, model 5a
shows a similar pattern of relations, in which
greater family support was associated with reduced
odds of MDD (OR = 0.63; 95 percent CI [0.48,
0.82]) and greater family strain was associated with
greater odds of MDD (OR = 1.15; 95 percent CI
[0.64, 2.05]).
Associations between Support and Strain
and GAD
Models lb to 5b in Table 3 show the associations
between support and strain firom family and
fiiends and GAD, controlling for covariates.
Model lb indicated that increased family support
was protective against GAD (OR = 0.44; 95
percent CI [0.26, 0.74]). In model 3b, a one-unit
increase in family strain was associated with 1.78
higher odds of meeting criteria for GAD (95
percent CI [1.04, 3.05]). Models 2a and 4a show
that neither fiiend support nor friend strain was
associated with GAD. In model 5b, family
support and strain variables exerted similar effects
on GAD with the inclusion of all independent
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54 Social Work VOLUME 57, NUMBER I JANUARY 2012
variables. Specifically, family support was nega-
tively associated with meeting criteria for GAD
(OR = 0.42; 95 percent CI [0.27, 0.65]). Further,
in the presence of famüy support, family strain
continued to be related to higher odds of meeting
criteria for GAD (OR =1.69; 95 percent CI
[1.13,2.51]).
The Moderating Effect of Gender
Our analyses suggested that gender moderated
strain. Specifically, we found a significant inter-
action between gender and friend strain with
GAD {p < .05) and a marginally significant inter-
action between gender and family strain with
MDD (p = .06). The interaction between friend
strain and gender with GAD, wherein friend
strain was associated with increased log odds of
GAD among women but not among men is illu-
strated in Figure 1. Among men, friend strain was
associated with decreased log odds of GAD. In a
similar manner. Figure 2 presents the interaction
between family strain and gender with MDD. For
both genders, family strain was associated with
increased log odds of MDD, but this association
appears attenuated among men compared with
women. Finally, gender did not moderate the
effect of support from family or friends on MDD
or GAD.
Figure 1: Gender Differences in the
Influence of Friend Strain on Generalized
Anxiety Disorder (GAD)
0-
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§
s -s
– 6
•
-7
– 8 –
—
1 2 3
Strain from Friends
MEN
WOMEN
4
Figure 2: Gender Differences in the
Influence of Family Strain on Major
Depressive Disorder (MDD)
0-
-o.s-
– 1 –
-3-
-3.5-
-4-
•
•
1
‘
2 3
Strain from Famiiy
MEN
WOMEN
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4
DISCUSSION
The aims of this study were to examine the main
effects of social support and social strain firom family
and fiiends on mental health variables (MDD and
GAD) and to investigate possible gender differences
in these relationships among a nationally representa-
tive sample of Asian Americans.
Our data showed that support from famüy, but
not friends, was associated with decreased odds of
MDD and GAD, after controlling for sociodemo-
graphic characteristics. Many studies combine
support fi’om family and friends (for example,
Noh & Kaspar, 2003; Taylor et al., 2004; Yang &
Clum, 1995). Our study indicates that it is im-
portant to consider who is providing this support.
Furthermore, strain from family, but not
friends, was related to increased odds of MDD
and GAD. These results are aligned with other
studies that demonstrate greater levels of social
strain are hnked to psychological distress and dis-
order (Revenson et al., 1991; Walen 6¿ Lachman,
2000). In particular, measures of familial strain
related to confiicts and demands such as those
reported presently have also been captured in
earher studies on Asian Americans that examined
issues such as intergenerational confHct and care-
giver burden (Adams, Aranda, Kemp, & Takagi,
2002; Ying& Han, 2007).
SANGALANG AND G E E / Depression and Anxiety among Asian Americans 55
Moreover, this finding demonstrates the con-
tinued influence of family strain after controUing
for receipt of support vadables and other demo-
graphic charactedstics. This suggests that famuy
support and strain are independent constructs that
are not necessadly invenely related (Lincoln et al.,
2010; Rook, 1984). Hence, future studies should
not merely infer strain based on low social
support but rather measure strain and support as
distinct concepts.
Although strain and support from famüy were
associated with GAD and MDD, there were no
such associations for support from fdends. The
prominence of famüy network faetón compared
with fdendship network faetón is consistent with
other research suggesting that for Asian popula-
tions the major social unit is the fanúly (B. S. K.
Kim et al., 2001). Although pdor research indi-
cates that social support may be less effective for
mitigating distress among Asian Amedcans com-
pared with European Amedcans (H. S. Kim et al.,
2006; Taylor et al., 2004), our findings provide
another interpretation of these weaker associa-
tions: Perhaps the effects were attenuated because
past studies did not distinguish between famuy
and fdends. We do not have non-Asian popula-
tions represented in our study, although future re-
search should examine whether some of the
population differences in support could be
explained by the source of support (that is, firom
fdends venus famüy).
The data provided partial support for the hy-
pothesis that the effects of support and strain
vaded by gender. There were no gender differ-
ences for support, but there were for strain. Strain
firom relatives was related to increased dsk of
MDD for women but not for men.
Several interpretations of these findings are pos-
sible. The sahence of social relationships in
women’s lives may contdbute to a greater impact
of social strain for women. If women’s psycho-
logical development is rooted in the quality of
their social relationships, as Miller (1988) sug-
gested, social strain may be more toxic for women
than it is for men.
In addition the findings may be related to one’s
abüity to control his or her strains. Low control
has been linked to the development of depression
and anxiety (APA, 2000; Seligman, 1975).
Women may be more hkely to encounter social
strains that are less controUable in nature due to
gendered expectations about women’s social roles.
For example, women are often expected to be
caregiven and may feel unable to avoid a caregiv-
ing role (Adams et al., 2002). Men, on the other
hand, may not face this type of role strain and
may feel more able to escape from obligations and
responsibüities tied to their social networks.
FinaUy, studies have descdbed gendered expres-
sions of distress, in which men and women may
equaUy expedence distress but express it different-
ly. For example, women are more likely to be
diagnosed with mood disorden, whereas men are
more likely to be diagnosed with alcohol or sub-
stance abuse (Aneshensel et al., 1991). The low
prevalence of alcohol and drug abuse in our
sample did not aUow for compadson across clinic-
al outcomes. Future research should detennine
whether our results are replicable and investigate
the potential mechanisms that may underhe these
potential gender differences.
A caveat, however, is that the interaction of
gender and famüy strain for MDD was only mar-
ginaUy statisticaUy significant. One interpretation is
that this particular result was an artifact of the data
because the interaction was significant at p< .06.
That is, on the basis of a very stdct cdtedon of
alpha, it would be reasonable to argue that men
and women showed simuar associations between
famuy strain and MDD. However, interactions are
often statistically underpowered and the hne
between .05 and .06 arbitrary (Abraham & RusseU,
2008; Aücen & West, 1991; Greenland, 1983).
Hence, it would be prudent to consider these po-
tential gender differences with the undentanding
that future research is required to verify them.
There was also a statistically significant inter-
action between strain firom fdends and gender
with regard to GAD. Strain from fdends was
related to increased dsk of GAD for women, but
unexpectedly, this strain was related to decreased
dsk for men. Hence, the nuU association between
fHend strain and GAD seen in the aggregated ana-
lysis resulted from the trends from women and
men canceUing each other.
It is unclear why men seemed to have lower
dsk of GAD with increasing strain. We speculate
that there may be an omitted vadable related to
how men process questions related to strain. GAD
is often charactedzed by excessive worry
(Borkovec & CosteUo, 1993). Perhaps men who
report strain are simultaneously dismissive of these
56 Social Work VOLUME 57, NUMBER I JANUARY 2012
demands (for example, “my fiiends make too
many demands on me, but that’s them and I
don’t worry about it”). Future research is required
to clarify the veracity of these ideas and mechan-
isms that may underlie our anomalous finding.
In addition to the caveats already mentioned,
several othen should be acknowledged. First, the
low prevalence of MDD, GAD, and strain may
contribute to type II errors—that is, diminished
ability to detect potential relations, such as the as-
sociation between friend support and MDD and
GAD. Furthermore, these lô w rates may be re-
flective of Western diagnostic criteria based on the
DSM—IV—TR, which may have underestimated
the actual prevalence of depression and anxiety
due to cultural bias in instrumentation (Ying,
2002). This may be particularly relevant to the
data in the sample as three-quarters of respondents
are foreign bom.
Second, our measures coUapse across various
types of social support and strain. For example, we
were unable to distinguish between emotional
and instrumental support. An important next step
is to make these finer distinctions in the types of
support and strain Asian Americans encounter.
Indeed, one prior study found that instrumental,
but not emotional, support was related to chronic
physical ülness among Filipino Americans (Gee
et al., 2006).
Third, cross-sectional data cannot confirm the
causal direction of the hypothesized relationships.
For example, the reverse may be true, with indivi-
duals with depression and anxiety encountering
greater strain from their social ties. Longitudinal
data is needed to enhance our understanding of
these relationships.
Fourth, we did not examine additional Stressors,
such as caregiving responsibilities, physical health,
or trauma exposure (Adams et al., 2002; Leong &
Lau, 2001; Patterson & Garwick, 1994). It is im-
portant to note that such variables can mutually
affect and be influenced by social relationships as
well as conditions like depression and anxiety. For
instance, caregiving responsibilities may moderate
family strain (that is, people who must care for
family members may have more depression for a
given level of family strain than people without
such responsibilities). Future studies should
include these and similar factors.
Fifth, although the internal consistency reliabil-
ity of our social support measures are considered
acceptable, the Cronbach’s alpha for the strain
measures could be improved. This is not surpris-
ing given that our strain measures consisted of
only two items, and it is well known that alpha
increases with the number of items in the scale.
To check our findings, we performed additional
analyses that used the individual items in lieu of
the scales (not shown). These analyses are consist-
ent with those reported here, suggesting that our
findings are robust to the specification of the strain
measures. Nonetheless, future studies should
develop more comprehensive measures of strain.
Finally, due to the low prevalence of MDD
and GAD, we did not disaggregate among Asian
ethnic groups. However, a key step for future re-
search would be to examine the diversity within
Asian Americans. For example, the types of social
strains experienced by Vietnamese Americans,
who tend to have low rates of out-marriage and
larger families, may differ from those of Japanese
Aniericans, who tend to have higher rates of out-
marriage and smaller families (Huang, Saenz, &
Aguirre, 1997).
With these caveats recognized, several strengths
of our study deserve mention. Fint, we analyzed
the contributions of social support and strain sim-
ultaneously. Second, we investigated important
and clinically relevant mental disorders using a
highly structured and previously validated instru-
ment. The WHO-CIDI was developed by groups
of experts from across the world, including Asian
and Asian American collaborators, -who sought to
develop a valid and reliable measure of mental dis-
orders applicable across diverse cultures (Kessler &
Ustun, 2006). Third, we examined an understud-
ied but rapidly growing population. Finally, our
data are nationally representative of Asian
Americans living in the United States.
Social Work Implications
Although social workers have generally recog-
nized the positive sides of social relationships, our
study serves as an important reminder not to
assume that individuals always enjoy benefits firom
their networks. Mental health interventions
aimed at enhancing social support among indivi-
duals with depression and anxiety may be more
effective by understanding the quality of a client’s
social relationships. Our findings are consistent
with what practitionen already understand—that
individuals can have both positive and negative
SANGALANG AND G E E / Depression and Anxiety among Asian Americans 57
interactions with members of their social
network. This notion can be commonly taken
for granted, and social workers must be cognizant
of the ways in which clients’ relationships can
both alleviate and cause psychological distress.
Furthermore, greater specificity in our under-
standing and assessment of the positive and nega-
dve aspects of social relationships need to be
developed for both research and practice (Lincoln,
2000).
With regard to cultural considerations for Asian
American clients, a key finding is that social
workers should pay close attention to strain and
support (k>m family members in pardcular. Indeed,
social workers should consider how Asian
American families could be a primary source of
their clients’ troubles. Accordingly, culturally sensi-
tive pracdce could include interventions that focus
not only on individuals, but also on their families.
Potendal differences between men and women
should also be considered. Women may be pardcu-
larly vulnerable to social strain, possibly due to
greater exposure or sensitivity to distress. An im-
portant implication is that social workers should
be attuned to gender differences when identifying
therapeutic approaches. For Asian American
women, understanding their role in relation to
others in the family may be pardcularly important.
In conclusion, social workers must be attuned
to the quality of their chent’s social relationships
and interactions as well as the various flmctions of
their social networks. Although our study focused
on Asian Americans in the United States, future
studies should investigate these same issues of
support and strain among other racial and ethnic
groups. Our findings further support the need to
acknowledge the benefits and costs associated
with social networks, particularly for Asian
Americans.
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Cindy C. Sangalang, MSW, is a PhD candidate.
Department of Social Welfare, School of Public Affairs, and
Gilbert C. Gee, PhD, is associate professor. Department
of Community Health Sciences, School of Public Health,
University of California, Los Angeles. Address correspondence
to Cindy C. Sangalang, 3250 School of Public Affairs, Los
Angeles, CA 90095; e-mail: sangatan@ucla.edu.
The authors thank Todd Franke and the anonymous reviewers
for their comments on the manuscript. This study was sup-
ported by the Council on Social Work Education Minority
fellowship Program. An earlier version of this article was pre-
sented at a meeting of the Society for Social Work and
Research, January 16, 2010, San Francisco.
Original manuscript received December 2, 2008
Finai revision received Juiy 8, 2010
Accepted Juiy 9, 2010
Social Work VOLUME 57, NUMBER I JANUARY 201260
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Burnout and Physical Health among Social
Workers: A Three-Year Longitudinal Study
Hansung Kim, Juyeji, and Dennis Kao
The high risk of burnout in the social work profession is well established, but little is known
about burnout’s impact on the physical health of social workers. This article examines the
relationship between burnout and physical health, using data from a longitudinal study of
social workers. California-registered social workers (N = 406) were surveyed annually over
a three-year period. Using structural equation modeling, the authors conducted a path
analysis to test whether burnout predicted changes in physical health over time. The results
showed that social workers with higher initial levels of burnout later reported more physical
health complaints. Moreover, higher levels of burnout led to a faster rate of deterioration in
physical health over a one-year period.The potential implications for policy and social service
organizations are discussed.
KEYWORDS: bumout; longitudinal data; physical health; social workers
Social workers deliver a broad range of vital
services and, thus, play a critical role in en-
suring the health and well-being of society’s
most vulnerable members. Ho’wever, the high
demand for their services—coupled with increas-
ingly diminishing resources—can present significant
challenges for social workers. According to a recent
national study (Whitaker,Weismiller, & Clark, 2006),
social workers face increasing levels of paperwork
and inadequate supervision. Beset by chronic staff
shortages and turnover, social workers tend to be
overworked and are often asked to take on large cli-
ent caseloads. Given the heavy demands placed on
them, it is not surprising that social workers often
experience psychological distress and, eventually,
high levels of burnout.
Burnout is a prolonged psychological response
to chronic workplace Stressors and is theorized to
include three dimensions: emotional exhaustion,
depersonalization or cynicism, and diminished per-
sonal accomplishment (Maslach, Schaufeli, & Leiter,
2001). Over the past decade, clear empirical evidence
has emerged regarding the prevalence of burnout
in the social work profession. For example, on the
basis of a sample of 751 social workers, Siebert (2005)
found that about three-fourths reported having had
trouble with burnout during their careers. This
high prevalence of burnout among social workers
has been found across the broad range of practice
fields. For example, Oktay (1992) found high lev-
els of emotional exhaustion and depersonalization
among hospital AIDS social workers. Poulin and
Walter (1993a) examined burnout among 1,196
gerontological social -workers and found that about
60 percent of them were experiencing moderate
to high levels of emotional exhaustion. Similarly,
Lloyd and King (2004) reported that Australian
social workers working in mental health settings
exhibited high levels of emotional exhaustion. In
a study of 151 fiontline child protective services
(CPS) workers, Anderson (2000) found that about
62 percent of participants were experiencing high
levels of emotional exhaustion.
Social worker burnout is a serious problem be-
cause it can adversely affect the quality and stability
of social services. The hterature suggests that social
workers experiencing burnout have an increased risk
of psychological distress, such as depression (Evans
et al., 2006; Siebert, 2004; N. Stanley, Manthorpe, &
White,2007), which can ultimately lead to increased
turnover (Kim & Stoner, 2008; Mor Barak, Nissly,
& Levin, 2001). Although a significant number of
research studies have shown the negative effects of
burnout on social workers’practice and performance
outcomes, less is understood about the effects of
burnout on the physical health of social workers.
The role of psychological distress in physical illness
is more established for the general workforce. For
example, in a 20-year follow-up study based on a
U.S. national sample, Ferraro and Nuriddin (2006)
258 ccc Code: oc;” ::ir..;_”_”” _”‘ I Workers
found that high levels of distress raised mortality
risk. Darr and Johns (2008) recently conducted
a meta-analysis to examine the negative effects
of work strain on the psychological and physical
symptoms that often lead to absenteeism at work;
their results suggest that psychological symptoms do
affect physical illness. Extensive research has shown
that job-related Stressors and strain can have adverse
health effects through several potential mechanisms,
such as decreased immunity functioning and poor
health behaviors (Melamed, Shirom,Toker, Berliner,
& Shapira, 2006). For example, Nakamura, Hágase,
Yoshida, and Ogino (1999) found that deperson-
alization (one of the dimensions of burnout) was
associated •with diminished cellular immunity. Other
studies suggest that job Stressors can also lead to
negative health behaviors, such as smoking, alcohol
or substance abuse, and less exercise (Johansson,
Johnson, & Hall, 1991)—all activities known to
have adverse effects on a person’s health (F. Jones
& Bright, 2001).
In the burnout literature, there is substantial
evidence on how burnout can affect the physical
health of a country’s workforce. For example, in a
national study of workers in Finland, Honkonen
et al. (2006) found that physical illness was more
common among workers with burnout, includ-
ing musculoskeletal disorders among women and
cardiovascular diseases among men. In sum, the
research has shown that burnout can negatively
affect overall self-rated health status (Peterson et
al., 2008) and can lead to a broad range of health
problems, including somatic complaints (Soares,
Grossi, of Sundin, 2007); cardiovascular diseases
(Melamed et al., 2006; Toker, Shirom, Shapira, Ber-
liner, & Melamed, 2005); sleep disturbances (Grossi,
Perski, Evengard, Blomkvist, & Orth-Gomer,
2003; Söderström, Ekstedt, Âkerstedt, Nilsson, &
Axelsson, 2004); headaches (T. L. Stanley, 2004);
flu-hke illnesses, common colds, or incidences of
gastroenteritis (Mohren et al, 2003); and illness-
related absences from work (Burke & Mikkelsen,
2006). Furthermore, job stress—which can cause
burnout—is a significant predictor of gastrointes-
tinal problems (EdéU-Gustafson, Kritz, & Bogren,
2002; Sveinsdóttir, Gunnarsdóttir, & Riksdóttir,
2007). Diminishing physical health can lead to lost
workdays, diminished job effectiveness, permanent
disabilities, and increased compensation for sick
leave (Eriksen, Svendsrod, Ursin, & Ursin, 1998;
Schwartz, Stewart, Simon, & Lipton, 1998).
The relationship between burnout and physical
illness has also been found among professionals
who may work in settings similar to those of social
workers. Among Swedish health care •workers, for
example, Peterson et al. (2008) found that burnout
was associated vî ith lower self-rated health status,
sleep disturbance, and neck and back pain.
Despite the high risk of burnout in the social
work profession, little is known about its impact on
the physical health of social workers.To address this
gap in the research, the present study used longitu-
dinal data from a sample of social workers registered
in California to examine the impact of burnout on
their physical health.
METHOD
Data and
Sample
Data were drawn from a longitudinal study examin-
ing the job-related factors associated •with burnout
among social workers. In this study, participants
•were randomly selected from a California registry of
clinical social workers and surveyed three times (ap-
proximately annually) for a three-year period from
2005 to 2007. Information was gathered through
the use of mail questionnaires, which included
both standardized instruments (for example, the
Maslach Burnout Inventory—Human Service Survey
[Maslach & Jackson, 1986]) and sociodemographic
measures. The physical health measures were not
included in the baseline survey (in 2005), but they
were used in the second and third surveys (in 2006
and 2007) .When resources •were available, individu-
als were sent multiple follow-up questionnaires in
an effort to maximize the response rate. The insti-
tutional review boards of the authors’ universities
approved this research.
The current study’s sample included participants
who completed the wave 2 questionnaires, in which
the physical health measure was first collected. Of
the basehne sample (N = 406), about 70 percent
participated in the second wave (n = 285), and
about 36 percent participated in the third wave (n
= 146). Because the study used social workers who
participated in the wave 2 questionnaire (n = 285),
it was important to determine whether the study
sample was similar to the initial sample and •whether
the attrition •was random. As a preliminary analysis,
•we conducted logistic regression models to examine
the relationship among the study variahles (that is,
age, gender, years in the field, income, and initial
level of burnout) and the likelihood of a partici-
among Social Workers: A Three-Year Longitudinal Study 259
pant dropping out at waves 2 or 3 and found no
significant relationships (results not reported here).
It was therefore assumed that the study’s attrition
was random and that our samples were similar across
all three waves.
Measures
Physical Health Complaints. Physical health was
measured using the Physical Health Questionnaire
(PHQ) (Schat, Kelloway, & Desmarais, 2005). For
this analysis, we focused on four types of physical
health problems: sleep disturbances, headaches, re-
spiratory infections, and gastrointestinal infections.
Respondents were asked to respond to 14 questions
regarding the frequency of sleep disturbances (four
items), headaches (three items), respiratory infections
(four items), and gastrointestinal problems (three
items) in the previous six months. Responses •were
made on a seven-point Likert-type scale ranging
from 1 = not at all to 7 = all of the time. Scores for
overall physical health and for each health problem
were computed by averaging the responses, with
higher scores indicating greater severity. Change
scores for each respondent were computed by sub-
tracting his or her wave 2 physical health score from
his or her scores in wave 3. A confirmatory factor
analysis conducted by Schat et al. (2005) empirically
demonstrated the construct validity of the PHQ.
For our sample, we obtained Cronbach’s alphas of
.80 for sleep disturbance, .92 for headaches, .86 for
respiratory infections, and .78 for gastrointestinal
problems at wave 2.
Burnout. Burnout was measured using the
Maslach Burnout Inventory—Human Service Survey
(MBI-HSS), a 22-item scale that conceptualizes
burnout as having three dimensions: emotional
exhaustion, depersonalization or cynicism, and
diminished personal accomplishment (Maslach &
Jackson, 1986; Maslach et al, 2001). Emotional
exhaustion (nine items) is related to the worker’s
feelings of being overextended and depleted of
emotional and physical resources. Depersonaliza-
tion (five items) addresses the worker’s negative or
excessively detached responses to various aspects of
the job. Finally, diminished personal accomplishment
(eight items) reflects the worker’s feelings of incom-
petence and lack of achievement at work (Maslach
& Jackson, 1986). For each item, respondents are
asked to report the extent of their experiences along
a seven-point continuum, ranging from 0 = never to
6 = every day. Although all three burnout dimen-
sions are commonly used together in the literature.
Acker (1999) found that social workers working
with severely mentally ill chents were more likely to
experience emotional exhaustion and depersonaliza-
tion but not diminished personal accomplishment.
A recent study by Kim and Ji (2009) also showed
that burnout among social workers may be largely
explained by emotional exhaustion and deperson-
ahzation. In this study, findings from a longitudinal
factorial invariance test of the MBI-HSS suggested
that personal accomphshment may be associated
not only with burnout, but also with professional
development. Therefore, for the present study, we
only used the 13 items for emotional exhaustion
and depersonahzation to calculate a single burnout
score for each participant, leaving out the personal
accomplishment items. For our sample, we obtained
Cronbach’s alphas of .91 for emotional exhaustion
and .75 for depersonalization.
Control Variables. The analysis also controlled for
other demographic and work-related characteristics
that may affect burnout or physical health, including
a respondent’s age, gender, field tenure, and annual
salary. Gender was coded as follows: Female = 1,
and male = 0. Field tenure refers to the self-reported
number of years a respondent had •worked as a social
•worker. Annual salary •was based on a respondent’s
self-reported income from his or her current job
(at the time of the first survey). Age, field tenure,
and annual salary were all included in the analysis
as continuous variables.
Analysis
The analysis consisted of t̂ wo stages. First, •we ex-
amined the bivariate relationships between burnout
and physical health complaints. Following previous
studies (for example, Lau,Yuen, & Chan, 2005), re-
spondents were evenly divided into three groups on
the basis of their baseline MBI-HSS scores: low [n
= 92), moderate (« = 93), and high (n = 91). One-
way analyses of variance (ANOVAs) were used to
test whether the three burnout groups differed in
their subsequent physical health complaint scores
(measured at wave 2). Second, using structural
equation modeling (SEM), we used path analysis to
test whether basehne levels of burnout predicted
changes in physical health over time with control
variables accounted for. As shown in Figure 1, we
modeled the change in the respondents’ physical
health (from wave 2 to wave 3) as being predicted
by their burnout levels at •wave 1, •while account-
260
Figure 1: A Path Model of Changes in Physical Health Complaints among Social Workers
Burnout
at wave 1
Annual
salary
Physical health
:omplaints at wave 2
Gende
Years in
the field
Change in physical
health complaints
(wave 3-wave 2)
ing for their physical health at wave 2. Baseline
demographic and •work-related characteristics were
also controlled for in the model.
The one-way ANOVAs were conducted using
SPSS 17.0, and the parameters for the path models
were estimated •with Mplus 5.0 software (Muthén
& Muthén, 2007). To estimate the path model
parameters, fuU-information maximum likelihood
estimation (FIML) was used to account for any miss-
ing data (Arbuckle, 1996). FIML allows the estima-
tion to proceed using all available data by breaking
down the likehhood function into components
on the basis of the patterns of missing data. SE
M
approaches using FIML requires data with normal
distribution—absolute values of univariate skewness
index greater than 3.0 and absolute values of uni-
variate kurtosis index greater than 10.0 considered
as problematic (Kline, 1998). For the current study’s
data, univariate skewness values ranged from —1.48
to 0.46, and kurtosis values ranged from -0.94 to
7.01, so practically acceptable distributions were
assumed for all study variables.
Model goodness-of-fit was evaluated on the basis
of several indices; the chi-square statistic divided by
the degrees of freedom (x^/dfj, the comparative fit
index (CFI), and the root mean square error of ap-
proximation (RMSEA). A %-/df value of less than
3 •would indicate a reasonable fit (Kline, 1998). CFI
values can range firom 0 to 1, with a value above
0.90 suggesting an acceptable fit between the model
and the data (Kline, 1998). Finally, an RMSEA of
.05 or less would indicate a good fit (Browne &
Cudeck, 1993).
RESULTS
The characteristics of our sample are summarized
in Table 1. Among the 285 social workers in wave
2, 65 percent were licensed clinical social workers
(LCSWs), whereas 35 percent were associate social
workers (ASWs [that is, registered in the state but
not yet licensed]). Almost half of the sample worked
in the mental health field. At the time of the initial
survey, the mean age of the sample was 46 years.
Participants had worked in the social work field
for an average of 17.4 years and earned an average
annual income of $57,100. For the total sample, the
average physical health complaints score decreased
marginally from 39.6 in wave 2 to 39.5 in wave 3.
The means, standard deviations, and correlation
coefficients for the study variables are presented in
Table 2. Physical health was positively associated
with burnout experience (r = .50) but negatively
.:th among Social Workers: A Three- Year Longitudinal Study 261
Table 1: Description of the Sample
characteristic
Wave(W)
Sample
Gender (%)
Male
Female
License status (%)
Associate social worker
Licensed clinical social worker
Service field (%)”
School social work
Child welfare/family
Healthcare
Mental health
Mean age (in years)
Mean years in the field
Mean annual salary (in thousands of dollars)
Mean level of hurnout
Mean physical health complaints scores'”
Sleep disturbances
Headaches
Gastrointestinal prohlems
Respiratory infections
Overall physical health
Mean change in physical health (W3 – W2)
406 285 146
19.9
80.1
36.7
63.3
6.9
1
7.0
21.7
46.1
45.6 (12.0)
17.1 (10.6)
57.0 (17.0)
31.3 (14.3)
21.7
78.3
35.
4
64.6
6.0
16.5
21.4
48.4
46.0(11.9)
17.4 (10.4)
57.1 (17.1)
29.9 (13.9)
13.3 (4.8)
9.1 (4.6)
10.1 (5.2)
7.1 (3.3)
39.6(13.3)
21.0
79.0
33.6
66.4
7.5
17.1
22.6
47.3
46.1 (11.3)
18.0 (10.0)
59.9 (16.1)
31.1 (14.3)
13.7 (4.5)
8.4 (4.4)
10.0 (5.1)
7.3 (3.3)
39.5 (12.9)
-0.8 (8.7)
Notes: The sample for the present consisted of the 285 social workers who participated in the W2 survey. Where means are reported, standard deviations are included in paren-
theses. Burnout scores were calculated by summing participants’ responses to 13 questions on a seven-point scale (coded as 0 to 6), with total scores ranging from 0 to 78. Scores
for overall physical health complaints were calculated by summing participants’ responses to 14 questions on a seven-point scale (coded as 1 to 7), with total scores ranging from
7 to 98. The scores for each physical health complaint were calculated in a similar manner, but their ranges varied on the basis of the number of items for each subscale: sleep
disturbances (four questions; scores ranged from 4 to 28); headaches (three questions; scores ranged from 3 to 21); gastrointestinal problems (three questions; scores ranged
from 3 to 21); respiratory infections (four questions; scores ranged from 4 to 28).
‘Totals equal more than 100 percent because the participants were allowed to select multiple responses. Participants indicated their areas of praaice by using the categorizations
of service area developed for the NASW Center for Workforce Study (Whitaker, Weismiller, & Clark, 2006).
”Physical health was not assessed at W l .
associated with age (r = —.21) and years in the field
(r = -.25). In addition, burnout was significantly-
correlated with age (r= -.19) and years in the field
(r=-.16).
The one-way ANOVA results (see Table 3)
showed significant relationships between burnout
and overall physical health and between burnout and
each individual health problem. In general, physical
health problems were the least severe among social
workers with low burnout levels and the most
severe among those with high burnout levels. For
overall physical health, the mean score was the lowest
for social workers with low burnout levels (31.7),
gradually increased for the moderate burnout group
(39.7), and was even higher for the high burnout
group (47.8). Similar patterns were also found for
each health problem. Results from Tukey post-hoc
analyses also revealed significant low versus moderate
and moderate versus high group differences: The
high-burnout group was significantly worse than
the moderate group, which, in turn, was significantly
worse than the low group, for overall physical health
and for each individual physical health problem.
The final path model, including only the signifi-
cant parameters, is shown in Figure 2. We initially
estimated all the parameters in our model and found
that neither age nor annual salary significantly in-
fluenced physical health at wave 2 or the change in
physical health from wave 2 to wave 3. To derive
the most parsimonious model, we removed the non-
significant paths, but only if their removal did not
significantly influence the overall model fit (on the
262
Variable
Table 2: Correlation Coefficients, Means, and
Standard Deviations for Observed Variables
4
l.Wage
2. Gender
5.Ag,e
4. Years in the Field
5. Burnout at Wl
6. PHC (W2)
7. Change in PHC (W3 – W2)
M
SD
1.00
-.28*
.23*
.34*
.05
-.09
.13
57.07
17.12
—
1.00
-.23*
-.28
.01
-.17
-.01
0.78
0.41
—
1.00
.70*
-.19*
-.21*
-.03
46.02
11.88
—
1.00
-.16*
-.25*
.05
17.45
10.42
—
1.00
.50*
.05
30.96
14.36
1.00
-.34*
39.59
13.27
l.ÓO
-0.82
8.71
Note: Scores for overall physical health complaints (PHC) were caiculated by summing participants’ responses to 14 questions on a seven-point scale (1 to 7), v^ith totai scores
ranging from 7 to 98. Scores for change in overall PHC were caiculated by subtracting PHC scores at wave 2 from PHC scores at wave 3. A positive change in PHC score indicates
an increase in PHC over time, w = wave,
•p < .05.
basis of nonsignificant chi-square difference tests).
This model trimming process is discussed in greater
detail in KUne (1998).This process led to our final
path model, which was a good fit to the data {“/^/df
= 0.57, RMSEA = .00).This model explained 29
percent of the variance in physical health at •wave
2 and 18 percent of the variance in the change in
physical health fiom wave 2 to wave 3.
The path analysis results showed that burnout was
positively associated with both the initial physical
health complaints (ß = .47) and the change in physi-
cal health complaints from wave 2 to wave 3 (ß =
.29), even after initial physical health was controlled
for. In other words, higher levels of burnout led to
worse physical health. Moreover, social workers
with higher levels of burnout experienced a greater
Table 3: Physical Health Complaints and Burnout among
Social Workers: One-Way Analysis of Variance Results
Physical Health Complaints’
Sleep disturbances
M
SD
Headaches
M
SD
Gastrointestinal problems
M
SD
Respiratory infections
M
SD
Overall physical health
M
SD
Low (n = 92)
11.2
3.9
7.0
3.8
7.9
3.5
5.7
2.3
31.7
9.4
Level of Burnouf
Middle (n = 93)
13.3
4.3
9.3
4.1
10.4
4.9
7.0
3.0
39.7
10.6
High (n = 91)
15.6
5.0
11.1
5.0
12.1
5.9
8.8
3.7
47.8
UA
Hcffe) 1
23.4(2, 273)*
20.9(2, 271)*
“ÜB
17.6(2, 272)*
“A
23.8(2, 273)*
•m
44.1(2,272)*
m
Notes; Scores for overall physical health complaints were calculated by summing participants’ responses to 14 questions on a seven-point scale (coded as 1 to 7), with total
scores ranging from 7 to 98. Scores for each physical health complaint were calculated in a similar manner, but their ranges varied on the basis of the number of items for each
subscale: sleep disturbances (four questions; scores ranged from 4 to 28), headaches (three questions; scores ranged from 3 to 21), gastrointestinal problems (three questions;
scores ranged from 3 to 21), and respiratory infections (four questions; scores ranging from 4 to 28). All Tukey post-hoc tests for low versus middle and middle versus high levels
of burnout were significant at p < .05.
'Assessed at wave 2.
"•Assessed at wave 1.
' p < .01.
.^^.a/j among Social Workers: A Three-Year Longittidinal StuAy 263
Figure 2: Final Model of Changes in Physical Health Complaints among Social Workers
Burnout
at wave 1
Female
(versus male)
.47*
Physical health
complaints at wave 2
– .50*
Change in physical
health complaints
(wave 3—wave 2)
Years in the field
– .14*
Notes: Results are reported as standardized path coefficients (ßs). Model fit: x'(6, N = 285) = 3.44. Comparative fit index = 1.00, root mean square error of appro:
(Pelóse = .94).
•p < .05.
deterioration in physical health over tiine. Female
social workers were less healthy than their male
counterparts (ß = .12). More years in the field was
associated with better initial physical health (ß =
—.14). Additional path analyses (not shô wn) were
conducted for each separate physical health problem
and showed that burnout was associated with signifi-
cant increases in headaches (ß = .23),gastrointestinal
problems (ß = .20), and respiratory infections (ß =
.19) but not •with sleep disturbances.
DISCUSSION
This study revealed that burnout can adversely affect
the physical health of social workers, with higher
levels of burnout leading to more physical health
problems one year after initial assessment. More im-
portant, social •workers with higher levels of burnout
also experienced a greater decHne in overall physical
health over a one-year period. Specifically, •we also
found that social •workers with higher initial levels of
burnout reported more headaches, gastrointestinal
problems, and respiratory infections a year later.
Given the prevalence of burnout in the social
work profession, these findings may have serious
implications for social work practice. Health prob-
lems may negatively affect the relationship between
social ^vorkers and their clients; more specifically,
such problems may hinder them from developing
nurturing alliances •with their chents. In addition,
poorer physical health can lead to diminished job
performance, including absenteeism and turnover
(Darr & Johns, 2008) .Turnover among social work-
ers has been found to negatively affect the quality,
consistency, and stability of services (Mor Barak et
al, 2001).
Although the current study focused on the physi-
cal health symptoms of social workers, the potential
linkages between physical and mental health cannot
be ignored. Schat et al. (2005) found that physical
health symptoms are significantly associated with
psychological health, as measured by the General
Health Questionnaire (GHQ) (Banks et al., 1980).
The GHQ is a widely used measure of mental health
in occupational settings and consists of items relat-
ing to depression and self-confidence (Schat et al,
2005).This further suggests that burnout can result
in poorer occupational •well-being for social workers
in general, thus greatly compromising the quality
of services provided to clients.
Our findings support the need for both burnout
prevention and recovery interventions. To date,
burnout intervention studies have primarily focused
264 V 2011
on preventive efforts. For example. Maslach et al.
(2001) emphasized educational interventions to
enhance the ability of workers to cope with stress.
Similarly, S. H.Jones (2007) argued that social work
education programs should increase awareness of
burnout symptoms and teach students about strat-
egies to prevent burnout, such as communication
techniques and coping skills. Organizations can
take more proactive steps to address the burnout
issue (for example, increasing employee awareness
of burnout, its symptoms, and its effects; developing
preventive strategies).
In particular, managers and supervisors must play
a critical role in supporting their staff and preventing
burnout. Research has shown that supervisor support
and performance feedback are essential to preventing
worker burnout (Bakker, Demerouti, & Euwema,
2005). Supervisors who are open and responsive
to the opinions of fronthne social workers about
their job-specific problems can help those workers
to cope with job demands (Kim & Lee, 2009). In a
similar vein, Himle andjayaratne (1991) found that
instrumental support from a supervisor helped to
buffer the influence of job stress on burnout. Direct
supervisors and managers may play an important
“bridging” role between their staff and agency ad-
ministrators, helping to identify burnout symptoms
among their staff and communicating these difficul-
ties to administrators. Relatedly, effective supervision
has been identified as a key factor in the retention
of social workers, pubHc child welfare workers, and
human service workers in general (Chenot,Benton,
& Kim, 2009; Mor Barak,Travis, Pyun, & Xie, 2009;
Rycraft, 1994).
In addition to supervisor support, support from
coworkers, peers, and spouses have been shown to
be critical in helping to prevent burnout among
social workers. For example, Himle and Jayaratne’s
(1991) study showed that informational support
among coworkers softened the effects of role conflict
and workload on the risk of emotional exhaustion
among social •workers. Davis-Sacks, Jayaratne, and
Chess (1985) found that increased spousal support
may buffer the risk of depersonalization among
female child welfare workers. Future research could
also focus on the potential role of familial and
community support in alleviating burnout among
social workers.
Also critical, but less understood, are burnout
recovery interventions. Social ^vorkers are argu-
ably at a high risk of burnout because of intense
worker—client interactions and unmanageable case-
loads. Therefore, to mitigate any potentially adverse
effects of burnout, recovery interventions would
be necessary to assist social workers •who have or
are experiencing burnout and to help them cope
with their current burnout experiences. Again, ad-
ministrators and supervisors may play an important
role in supporting and empowering social workers
to sustain their commitment to the job. Self-help
groups or social networks may also provide social
workers with spaces in which to share their experi-
ences and support each other. Easily implemented
screening tools and interventions could be devel-
oped and targeted to social workers in settings that
may pose the greatest risk of burnout (for example,
CPS workers, workers serving severely mentally iU
populations) .The feasibihty and cost-effectiveness of
potential burnout recovery programs are important
topics for fiiture research.
Our results also showed that number of years
in the field was negatively associated with physical
health complaints, suggesting that entry-level or
early-career social •workers are particularly at risk.
This is consistent •with earlier studies, which have
shown that human service workers who are begin-
ning their careers are more hkely to experience
burnout (Maslach et al., 2001). Moreover, on the
basis of an extensive review on the burnout litera-
ture, Schaufeli and Enzmann (1998) concluded that
burnout, if not addressed early on, tends to persist.
Similarly, Poulin and Walter (1993b) conducted
a longitudinal survey of 879 social workers and
found that burnout is a stable phenomenon among
professional social workers. Therefore, prevention
and recovery interventions in the early stages of a
social worker’s career (including while he or she is
a student) could help to improve his or her long-
terni health (and, potentially, career) trajectories.
Both baccalaureate- and graduate-level social work
programs—via their curriculums, alumni networks,
and continuing education programs—could assist
students and recent graduates in handhng burnout
early in their careers and, thus, protect their health
in the long term.
Gender emerged as another significant predictor
of physical health complaints, with female social
workers reporting significantly worse physical
health than their male counterparts. This gender
differential is consistent with findings in the lit-
erature (Haug, Mykletun, & Dahl, 2004) and may
have several explanations. For instance, it is possible
•* among Social Workers: A Three-Year Longitudinal Study 265
that women have poorer health and exhibit more
symptoms than do men, resulting in their report-
ing more symptoms (Barsky, Goodson, Lane, &
Cleary, 1988). Another possible explanation is the
higher prevalence of anxiety and depression found
among women, which has been shown to be as-
sociated with increased reporting of physical health
problems (Haug et al.,2004;Wool & Barsky, 1994).
Considering that the majority of social workers are
female, this finding has significant imphcations.
It is interesting to note that age •was found to
be a negative determinant of physical health in the
bivariate analysis but not in the path analysis. Age has
been consistently found to be a negative correlate of
burnout (Brewer & Shapard, 2004), so one possible
explanation for the negative relationship between
age and physical health is that younger (and often
less experienced) workers are more susceptible to
burnout and, thus, exhibit poorer physical health.
For example, in an extensive reviê w of the litera-
ture on burnout and cardiovascular-related events,
Melamed et al. (2006) found that the relative risk
associated with burnout was equal to, and sometimes
even exceeded, the risk associated •with classical risk
factors such as age, smoking, and body mass index.
The present study has several key limitations. First,
the analysis was based on a sample of registered social
workers in California, which may Hmit the gener-
alizability of the findings to social •workers in other
parts of the United States. Nationally representative
studies could further advance our understanding of
the association between burnout and physical health
in social work. Second, our findings may also be
biased due to sample attrition. We tried to address
this concern •with a preliminary attrition analysis,
which determined that the attrition •was unrelated to
our key study variables. In addition, by using FIML
to estimate our models, •we were able to include
information for the entire sample—including those
participants who left the study.Third, we were only
able to follow social workers for three years, collect-
ing information at one-year intervals. It is possible
that three years is not sufficiently long enough a
period to assess changes in workers’ physical health.
Furthermore, the participants’ initial physical health
status was not collected, so information about their
physical health was only available for two time points.
Finally, the current study did not account for a broad
array of additional factors that may affect a person’s
health, such as health behaviors, life events or Stres-
sors, genetic influences, and accidents.
Nonetheless, this study presents compelling
evidence of the significant impact of burnout on
physical health in the social work profession. The
findings also highlight the critical need for social
workers to pay attention to their own occupational
well-being and, more broadly, the need for the
social work profession to focus more resources on
understanding and addressing the impact of burn-
out. To date, our understanding of burnout and its
potential health consequences for social workers
has been hmited. Moreover, there is a tremendous
need for research on effective burnout interventions.
Future research should explore how physical health
may affect the job performance of social •workers,
including their decision making and job turnover.
At the same time, •we need to identify factors that
may ameliorate the adverse effects of burnout on
physical health among social workers.
Finally, this study highlights the critical need for
the social •work profession and all of its stakehold-
ers (for example, members, educational programs,
service agencies) to deal proactively •with burnout.
Social workers are among the ^vorkers most at risk
when it comes to experiencing burnout at some
point in their careers (for example, Priebe, Fakhoury,
Hoffmann, & Powell, 2005; Siebert, 2005). As our
findings suggest, burnout can lead to a worsening
of one’s health over time, which, in turn, can com-
promise the quality of the services one provides
to chents.
According to the NASW (2008) Code of Ethics,
social workers are called on to promote social justice
and social change by addressing social inequality
through the empo^werment of clients, promotion of
cultural diversity, and resistance to social injustice. In
particular, social •workers are committed to address-
ing the needs of vulnerable and underprivileged
children and families. However, in the process,
social workers find themselves at risk in terms of
their health and well-being. If action is not taken to
counteract the prevalence of burnout and its impact
on the psychological and physical well-being of its
members, our profession •wül continue to struggle
to sustain a strong and vibrant pool of social work-
ers. Therefore, it is critical to build healthy working
environments in which the next generation of social
workers can meet the emerging social challenges of
the 21st century.
One such current effort is the Dorothy I. Height
andWhitney M.Young,Jr. SocialWork Reinvestment
Act (H.R. 795 and S. 686), which is comprehensive
266 LY 2OII
federal legislation aimed at promoting recruitment,
retention, research, and reinvestment in the profes-
sion of social work (see NASW, 2009). If passed, it
would help to improve the working conditions of
professional social workers. For example, it ^would
fund demonstration programs on improving the
workplace, addressing, among other conditions, high
caseloads, fair market compensation, social worker
safety, supervision, and working conditions—all of
which are significant factors in burnout and turnover
among social workers (Chenot et al., 2009; Kim &
Stoner, 2008; Mor Barak et al., 2001,2009; Siebert,
2005). If we are unable to find ways to protect the
occupational well-being of the current workforce,
worker shortages wül only become more serious.
Our hope is that this study will help to inform the
development and the enactment of policy measures,
such as the Social Work Reinvestment Act, focused
on securing both federal and state investment in the
social work profession.
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Hansung Kim, PhD, is assistant professor. Department of
Sociology, Hanyang University, 222 Wangsimni-ro, Seongdong-
gu, Seoul 133-191, Korea; e-mail: hsk@hcinyang.ac.kr.Juye
Ji, PhD, is assistant professor. School of Social Work, Syracuse
University, Syracuse, NY. Dennis Kao, PhD, is assistant
professor. College of Social Work, University of Houston. This
research was supported in part by a research award from the
Hamovitch Center for Science in the Human Services, an Albert
and Frances Feldman Endowed Fellowship from the Univer-
sity of Southern California School Social Work, and a faculty
development grant from California State University, FuUerton.
The authors thank all of the social workers who participated in
this longitudinal study for their patience and support. An earlier
version of this article was presented at the Í2th annual confer-
ence of the Society for Social Work and Research, January 19,
2008, Washington, DC.
Original manuscript received January 5, 2009
Final revision received October 13, 2009
Accepted March 25, 2010
268 JLY 2OII
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Family-based Crisis Intervention with Suicidal
Adolescents in the Emergency Room: A Pilot
Study
Elizabeth A. Wharff, Katherine M. Ginnis, and Abigail M. Ross
The prevailing model of care for psychiatric patients in the emergency room (ER) is eval-
uation and disposition, with little or no treatment provided. This article describes the
results of a puot study of a famuy-based crisis intervention (FBCI) for suicidal adolescents
and their families in a large, urban pédiatrie ER. FBCI is an intervention designed to
sufficiently stabilize patients within a single ER visit so that they can return home safely
with their families. Of the 100 suicidal adolescents and their families in the sample, 6
7
met eligibility criteria for FBCI. Demographic and clinical characteristics and disposition
outcomes from the sample were compared with those obtained retrospectively from a
matched comparison group (N= 150). Statistical analyses compared group inpatient ad-
mission rates and disposition outcomes. Patients in the puot cohort were significandy less
likely to be hospitalized than were those in the comparison group (36 percent versus 5
5
percent). Only two ofthe patients in the FBCI cohort were hospitalized immediately after
receiving the intervention during their ER visit. FBCI with suicidal adolescents and their
families during a single ER visit is feasible and safely limits the need for inpatient psychiat-
ric hospitalization, thereby avoiding disruption offamily, academic, and social activities
and increasing use of less intrusive and more cost-effective psychiatric treatment.
KEYWORDS; crisis intervention;family intervention; suicidal adolescents; suicide
As the adolescent suicide rate has been in-
creasing over the last several decades
(Centén for Disease Control and Preven-
tion, 1998, 2007a, 2007b, 2008; Office of Disease
Prevention and Health Promotion, 2000), there
has been a parallel increase (as high as 59 percent)
in pédiatrie emergency room (ER) usage rates by
adolescents in need of mental health evaluations
in the United States (Breslow, Erickson, & Cava-
naugh, 2000; EUison, Hughes, & White, 1989;
Hughes, 1993; Page, 2000; Sills & Bland, 2002;
Stewart, Spicer, & Babl, 2006). Suicidality in ado-
lescents has been the most significant factor in the
majority of ER visits for behavioral health con-
cerns (Stewart et al., 2006) and the most common
presenting problem for adolescents subsequently
admitted to an inpatient psychiatric unit (Brooker,
Ricketts, Bennett, & Lemme, 2007).
Although the number of psychiatric ER visits
has increased substantiaUy (Bruffaerts, Sabbe, &
Demyttenaere, 2004; Hughes, 1993; Larkin,
Claassen, Emond, PeUetier, & Camargo, 2005),
child mental health service avaUabUity has not
kept pace, resulting in longer ER wait times and
stays for patients (American CoUege of Emergency
Physicians, 2008), Ekely contributing to a phe-
nomenon termed psychiatric “boarding” (Man-
sbach, Wharff, Austin, Ginnis, & Woods, 2003)
that has gained notoriety in the popular press
(Holmberg, 2007; Katz, 2006; Kowalczyk, 2007;
Trafford, 2000). Boarding describes a patient who
is in psychiatric crisis and requires inpatient hospi-
talization but for whom there is no available inpa-
tient psychiatric bed (Mansbach et al., 2003). In a
recent survey of ER medical directon, over 7
0
percent reported boarding psychiatric patients as a
routine practice, with nearly 40 percent doing so
a minimum of once a week (American CoUege of
Emergency Physicians, 2008).
In current practice, the standard of care in
emergency psychiatry is evaluation and disposition
with little or no treatment provided at the time of
presentation (Bruffaerts, Sabbe, & Demyttenaere,
2008). Psychiatric ER protocol is a noteworthy
deviation from triage practice in standard emer-
gency care, in which the most acute patients are
doi: 10.1093/SW/SWS017 O 2012 National Association of Social Wo-kers 133
prioritized and receive the most rapid and inten-
sive care. Historically, there has been little focus
on psychiatric treatment within the emergency
setting, often due to time pressures to move pa-
tients through the ER and the prevailing treat-
ment philosophy that psychiatric treatment of
suicidal patients requires admission to a locked in-
patient facility.
A number of studies evaluating specialized in-
terventions occurring within the context of the
ER have yielded significant increases in after-care
treatment compliance among psychiatric patients
(Rotheram-Borus et al., 1996; Spooren, Van
Heeringen, & Jannes, 1998) and reductions in de-
pressive symptomology (R.otheram-Borus, Piacen-
tini, Cantwell, BeUn, & Song, 2000) and suicide
attempts (Huey et al., 2004). None, however, have
piloted or evaluated a single-session intervendon
that occurs exclusively within the ER.
Though limited data on the cost-effectiveness of
alternatives to inpatient hospitalization are avail-
able (Lamb, 2009; Shepperd et al., 2009),
community-based interventions like multisystemic
therapy (MST) show promising results; specifically,
in a randomized controlled trial of 116 adolescents
meeting criteria for inpatient hospitalization re-
ceiving either home-based MST or inpatient
hospitalization, higher levels of patient satisfaction,
improvement in family functioning, and reduc-
tions in externalizing symptoms were reported in
the MST group than in the group receiving
inpatient hospitalization (Henggeler et al., 1999).
Because the ER is frequently a critical point of
contact for suicidal adolescents to receive access to
services, we developed a farrdly-based crisis inter-
vention (FBCI) for use exclusively in the ER,
with the explicit goal of decreasing acute symp-
toms and sending more suicidal adolescents home
safely with their families.
FBCI is based on the assumptions that an inpa-
tient hospitalization is not necessarily the most
helpful level of psychiatric care for adolescents
with suicidal ideation/behavior, that families and
caregivers are able to provide support to an adoles-
cent fanuly member if given both an opportunity
and effecdve tools to use, and that a family that
learns to support an adolescent while he or she is in
crisis wül be empowered to provide ongoing
support once the acute psychiatric crisis subsides.
Based on an integradon of cognidve-behavioral skill
building, psychoeducadon, therapeudc readiness.
and safety planning, FBCI uses nonjudgmental
collaboradon (Madsen, 1999) to stabilize padents
and provide psychiatric intervention in the ER for
both the adolescent and the family, thereby de-
creasing a patient’s level of risk and increasing the
capacity of the family to maintain the patient at
home with appropriate therapeutic supports.
This two-part puot study explored (1) the
safety and feasibility of FBCI in a population of
adolescents presenting with suicidal complaints in
a large urban pédiatrie ER and (2) disposition
outcomes between the pilot sample and a com-
parison sample obtained retrospectively during the
identical calendar period immediately preceding
the FBCI study period. It was hypothesized that
FBCI during an ER visit would prove both feasi-
ble and safe and that rates of inpatient psychiatric
hospitalization in the sample of patients presendng
during the FBCI study period would be lower
than those in the retrospective cohort sample.
METHOD
Study Design
This puot study was conducted in the Boston
Children’s Hospital ER, in which approximately
1,000 patients in psychiatric crisis are seen annually.
Nearly 40 percent of these patients present
•with chief complaints of depression or suicidal
ideation/behavior. During an 18-month period
(January 1, 2001, through June 30, 2002), 100
suicidal adolescents and their families were re-
cruited to participate in the pilot study of FBCI
when presenting to the ER. The sample was ob-
tained consecutively. Padents were excluded
when they met at least one of the following
five criteria: (1) not currently living with a fanuly,
(2) presenting to the ER unaccompanied by a
family member, (3) intoxicated/sedated at the
time of ER presentation, (4) presenting with cog-
nitive limitations that prohibited FBCI participa-
tion (that is, severe psychosis or significant
developmental delay), and (5) presenting during
an overnight shift (11:00 P.M. through 8:00 A.M.,
Monday through Friday) or during weekend
hours (5:00 P.M. Friday through 8:00 A.M.
Monday), because FBCI-trained staff were not
available to administer the intervention during
these ER shifts. Informed consent and assent were
obtained from all patients and families prior to
patients receiving both a standard psychiatric
134 Social Work VOLUME 57, NUMBER 2 APRIL 2012
evaluation and FBCI. After finishing the standard
psychiatric evaluation with the chUd and famUy,
the social worker used her best chnical judgment
to make the decision about whether the patient
could benefit from FBCI. If the evaluating social
worker had any uncertainty about whether the
patient was appropriate for FBCI, a supervisor was
avaUable for consultation.
A pUot design was selected because the entire
ER psychiatry staff was trained in the interven-
tion protocol, rendering random assignment of
famihes to standard or specialized ER care im-
possible. Prior to commencing the study, aU ER
psychiatry social work staff members were trained
in FBCI protocol by the creators of the inter-
vention. FBCI staff were required to attend
weekly meetings to review cases with the crea-
tors of the intervention. Fidelity to the interven-
tion was measured using a checklist requiring
completion of each of the four core essential
components of FBCI. Interrater rehabUity was
established prior to study start. FBCI staff met
weekly during the 18-month pUot study period
to maintain interrater reHabUity. The safety of
FBCI was measured by the number of FBCI
patients who reported incidence of a suicide
attempt or completion during the three-month
foUow-up period. FeasibUity was measured by
our abUity to adequately train ER staff in FBCI
protocol and implement the single-session inter-
vention within the context of a busy ER. Fideh-
ty to the intervention was measured using a
checklist requiring completion of each of the
four core essential components of FBCI. Demo-
graphic and clinical characteristics and disposition
data from the pUot sample were then compared
with data obtained retrospectively from a cohort
of suicidal adolescents presenting consecutively
to the ER during the previous 18-month calen-
dar period (fanuary 1, 1999, through June 30,
2000). The Boston ChUdren’s Hospital institu-
tional review board approved the pUot study.
Recruitment and Consent for the Pilot
Study
AU patients and famUies presenting to the ER
during the study period received standard emer-
gency care, or treatment as usual (TAU). This
process began with a medical examination by an
ER physician. Once medical clearance was ob-
tained and a psychiatric consultation was
requested, participants were approached by a psy-
chiatry research assistant to obtain informed
consent/assent. Once consent was obtained, the
patient and famUy were asked to complete some
brief psychometric measures—the ChUdren’s
Depression Inventory (CDI) (Kovacs, 1982), the
Hopelessness Scale for ChUdren (HSC) (Spirito,
WUhams, Stark, & Hart, 1988) and the FamUy
Adaptability and Cohesion Evaluation Scale
II
(FACES II) (Olson, Portner, & Lavee, 1982)—to
assess depression, hopelessness, and flexibUity of
famUy system, respectively. AU psychometric mea-
sures used have demonstrated strong reliabUity
and vahdity (Kazdin, Rogers, Sc Colbus, 1986;
Kovacs, 1992; Olson et al., 1983). Famihes were
also asked to complete a comprehensive famUy
self-report form, which coUected demographic
and historical information. Patients and families
were not excluded if the famUy or adolescent did
not complete the assessment forms. AU forms
were avaUable in Spanish and English. Interpreters
were avaUable for famUies whose first language
was other than English or Spanish. The Study
Flow is depicted in Figure 1.
Determination of Inclusion for FBCI
On completion of the standard emergency psy-
chiatry evaluation with the adolescent and family,
the evaluating chnician, either a licensed master’s-
or doctoral-level social worker, reviewed the case
with the attending psychiatrist to determine the
appropriate level of psychiatric care. FamUies were
offered FBCI only if the evaluating social worker,
attending psychiatrist, and famUy were in agree-
ment that FBCI might enable the adolescent to
return home safely. The decision to offer FBCI
was based on both the acuity of the adolescent’s
suicidality and the capacity for galvanizing envi-
ronmental supports avaUable to and within the
famUy system. If the evaluating social worker, at-
tending psychiatrist, and famUy concurred that
FBCI might help the adolescent return home
safely with his or her famUy, the social worker
then proceeded with FBCI. Adolescents who
were not offered FBCI were hospitalized at an in-
patient psychiatric facUity.
FBCI
The thoretical underpinnings of this single-session
ER intervention come from cognitive-behavioral,
narrative, and family systems therapies, with an
WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 135
Figure 1: Study Flow Chart
Patient presents to ER with
suicidality and is medically cleared
Exclusion
Criteria:
Acuity of
suicidality
• Study team obtains informed
consent and administers CDI, HSC,
and FACES II
• Clinician performs standard
psychiatric evaluation and
determines FBCI eligibility
Patient is ::iot FBCI
eligible: Disposition of
inpatient tospitalization
(« = 33)
Exclusion Critetia:
• Not currently living
with a family
• Presenting to ER
unaccompanied by a
family member
• Intoxicated/
sedated at the time of
ER presentation
• Severe cognitive
limitations that
prohibited FBCI
participation
• Presenting during an
ovemight/ weekend
shift
Patient is FBCI eligible
(n = 67)
Clinician does FBCI in
ER: Meets with patient
and family both
individually and together
Clinician consults with
attending psychiatrist,
adolescent, and family to
determine whether the
patient can retum home
safely
Patient is hospitalized (n =
2)
Patient returns home safely
(« = 65)
Note: ER = emergency room; CDI = ChildreiTs Depressio • Inventory; HSC = Hopelessness Scale for Children; FACES II = family Adaptability and Cohesion Evaluation Scale II;
FBCI = family.based crisis intervention.
overaU approach of nonjudgmental collaboration,
as described by Madsen (1999;. First, the social
worker holds separate meetings with the adoles-
cent and family to assess the sequence of events
and differing perceptions leading to the suicidal
problem. During these meetings, the social
worker uses a narrative approach to help each
party tell his or her story. The social worker also
explores what each party feels would be necessary
for the adolescent to retum home safely with his
or her family. Next, the social worker meets with
the whole family together, attempting to con-
struct a single, unified perception of the problem
using the same narrative approach. We refer to
unified perception of the problem as the “joint
crisis narrative.” During the meeting, the social
worker assesses family roles and the potential flex-
ibUity and adaptabiUty of the family system, using
cUnical interventions to both facilitate and
improve communication among family members.
The social worker uses cognitive—behavioral ther-
apeutic approaches, including relaxation.
136 Social Work VOLUME 57, NUMBER 2 APRIL 2012
problem-solving, and cognitive reframing tech-
niques to shift negative atttibutions. The social
worker also works with the chud and family to
problem solve around any specific dilemmas as
needed. In the family meeting, the social worker
tties to help the family and adolescent work to-
gether to improve intrafamilial communication, to
safety plan, and to effect additional changes that
will enable the adolescent to feel safe at home.
The goal of FBCI is to effect changes that wOl
reduce the acute symptoms that brought the ado-
lescent to the ER and increase the family’s aware-
ness of the problem and sense of efficacy to help
their chud, thereby avoiding inpatient admissions
and further disruptions of the adolescent’s hfe.
After completing FBCI, the social worker again
consults with the supervising psychiattist to
review the case and obtain consensus that the
patient is able to return home safely. Patients are
discharged home only when the patient, family,
attending psychiattist, and assessing social worker
agree that this is the best disposition for the
adolescent.
Follow-up Assessments
Five follow-up assessments were completed by a
study clinician via telephone at one-day, one-
week, two-week, one-month, and three-month
intervals from the date of the ER visit. Follow-up
assessments served the dual purpose of obtaining
information about the patient’s level of function-
ing and facilitating acquisition of additional sup-
portive services as needed. Follow-up assessments
were completed only for those adolescents and
families who were discharged home after their
ER visit. Data on incidence of subsequent psychi-
attic evaluations and inpatient hospitalizations
were also collected at these five follow-up
intervals.
Retrospective Comparison Group
Demographic and clinical charactetistics and dis-
position outcomes of patients in the pilot sample
were compared retrospectively with adolescents
{N= 150) who presented consecutively to the
same ER with complaints of suicidal behavior/
ideation duting the corresponding 18-month cal-
endar petiod immediately preceding the puot
study petiod Qanuary 1, 1999, through June 30,
2000). Retrospective cohort patients met the
same inclusion and exclusion ctitetia as those in
the pilot sample. Standard psychiattic assessment
information—including demographic informa-
tion. Diagnostic and Statistical Manual of Mental Dis-
orders (4th ed.) {DSM-IV) (Ametican Psychiattic
Association, 1994) diagnoses, and disposition de-
tennination—that pertained to each patient in the
retrospective compatison group was obtained
through a medical record review.
Statistical Analyses
Frequency disttibutions and means were calculat-
ed for demographic data in both the puot and
retrospective cohort compatison samples (see
Table 1). Mean CDI, HSC, and FACES II adapt-
ability and cohesion scores were computed for the
sample using a dichotomous disposition outcome
(inpatient hospitahzation/aU others) as the depen-
dent vatiable (see Table 2). Between-groups dif-
ferences in mean CDI, HSC, and FACES II
scores were examined using independent sample
Í tests (see Table 2).
Chi-square analyses were used to examine dif-
ferences in demographic vatiables and disposition
outcomes between the pilot and retrospective
cohort samples. Disposition outcomes were cate-
gotized by level of support (inpatient, intensive
outpatient, and outpatient services). Analyses of
disposition outcome rates between the pilot and
retrospective cohort samples are reported in
Table 3.
RESULTS
Demographics
The pilot sample included 100 adolescents ages
13 to 18 years presenting to a large urban ER
with symptoms of suicidality. A total of 144 suici-
dal adolescents presented to the ER duting the
FBCI study petiod, 44 of whom were excluded
from participating in the study due to aforemen-
tioned exclusion ctitetia, lack of available research
assistants, or lack of available FBCI-trained staff.
Among the 100 adolescents participating in the
pilot study, 76.0 percent were female. Mean
patient age was 15.6 {SD= 1.5) years. Sixty-five
percent of patients self-identified as white,
1
6
percent self-identified as black, 11 percent self-
identified as Hispanic/Latino, 3 percent self-
identified as biracial, 2 percent self-identified as
Asian, and 3 percent self-identified as being of
another race. Demographic data obtained
WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 137
Table 1: Demographics of Intervention and Comparison Groups
iiteryention'(/V= 100)
Variable
Comparison (/V={150) ¡
Gender
Female
Male
Race/ethnicity
Asian
Black
Hispanic/Latino
White
Biracial
Other
Living arrangement
Parents
Other relative
Foster care
Primary language
English
Spanish
Other
Legal custody
Parents
DSS/DCF
Other relative
Other
Primary DSM-IVxás I diagnosis
Total depressive disorders
Bipolar disorder
Other mood disorders
Anxiety disorders/PTSD
Other’
76
2
4
2
16
1
1
65
3
3
96
4
0
89
7
4
96
1
2
1
76
5
1
8
II
76.0
2
4.0
2.0
16.0
1
1.0
6
5.0
3.0
3.0
96.0
4.0
0.0
89.0
7.0
4.0
96.0
1.0
2.0
1.0
76.0
5.0
1.0
8.0
11.0
1
11
39
4
26
15
97
2
6
139
11
1
138
11
1
140
5
1
0
105
10
2
10
23
74.0
26.0
2.7
1
7.3
11.0
64.7
1.3
4.0
92.7
7.3
0.7
92.0
7.3
0.7
9
3.3
3.3
0.7
0.0
70.0
6.7
1.3
6.6
15.3
Notes: The average age in years was 15.60 (SD=1.4S) for the intervention group and 15.50 {SD=1.47) for the comparison group. DSS = Department of Social Sen/ices; DCF =
Department of Children and Families; DSM-IV= Diagnostic and Statistical Manual of Mental Disorder (4th ed.); PTSD = posttraumatic stress disorder.
‘Includes eating disorder, psychosis, substance abuse behavioral disorders, attention-deficit/hyperactivity disorder, and somatoform disorders.
Table 2: Pilot Sample CDI, FACES II, and
HSC Scores
Total CDI
Patient cohesion
Family cohesion
Patient
adaptability
Family
adaptability
Hopelessness
Inpatient
All others
Inpatient
All others
Inpatient
All others
Inpatienc
All others
Inpatient
All others
Inpatient
All others
34
61
31
59
33
60
32
54
32
58
27
60
31.56
23.26
47.19
47.63
54.73
56.02
38.66
40.56
44.72
44.81
11.15
7.52
9.863
9.83
12.38
12.925
8.596
8.54
9.46
9.07
7.10
6.32
4.36
4.44
<.OO1
.876
.490
.364
.952
.001
Notes: W=100. CDI = Children’s Depression Inventory; HSC = Hopelessness Scale for
Children; FACES II = Family Adaptability and Cohesion Evaluation Scale II.
Table 3: FBCI and Comparison Group
Disposition Outcomes, in Percentages
Disposition
Outcome
Inpatient
Intensive outpatient
Outpatient
Other
FBCI
(/V=100)
35″
21″
43
0
Comparison
(W=150)
55
5
37
3
Note: FBCI = family.based crisis intervention.
“Reduction in hospitaiization rate: p<.0001.
''increase in intensive outpatient referrai: p < .001.
retrospectively from the comparison sample (150
suicidal adolescents presenting consecutively to
the ER during the corresponding previous
18-month calendar period) are presented in
Table 1. Patients in the comparison sample did
not differ significantly in age, race and ethnicity,
138 Social Work VOLUME 57, NUMBER 2 APRJL 2012
living arrangements, primary language, legal
custody status, caregiver relationship status,
primary DSM-IV diagnosis, or reported family
history of depression from their counterparts in
the pilot study. Exclusionary criteria were
matched between samples.
On compledon of the initial psychiatric evalua-
tion, 67 percent of adolescents (n = 67) were eligi-
ble to receive FBCI. The remaining 33 percent
(n = 33) who did not receive FBCI were hospital-
ized due to the acuity of their suicidality. Of the
67 patients who received FBCI, 97.0 percent
{n = 65) were not hospitalized. Only two padents
who received FBCI were hospitalized after their
ER visit. These patients were unable to engage in
safety planning during FBCI and thus required
hospitalization. Statistically significant differences
in depressive symptom severity occurred between
patients who were admitted to an inpatient unit
and those who were not. Mean CDI scores for
34 patients with an inpatient disposition (31.50
[SD = 69.86]) were significantly greater than the
mean CDI scores for 60 patients who did not
(23.26 [5D = 9.83]). CDI scores were not avail-
able for two patients who were ineligible for
FBCI and for three who received the intervention
and were discharged home. Similarly, mean HSC
scores were higher among patients who were hos-
pitalized (n = 27 [p = .001]). HSC scores v/ere not
available for eight patients deemed ineligible for
FBCI and for five patients who received FBCI
and were discharged home.
Neither CDI nor HSC scores differed signifi-
cantly between patients receiving an inpatient
hospitalization and those receiving intensive out-
patient treatment. Differences in patient and
family FACES II cohesion or adaptability subscales
did not approach significance for any disposition
category (see Table 2).
Suicidal adolescents and families who presented
to the ER during the FBCI pilot period v/ere sig-
nificantly less likely to be admitted to an inpatient
psychiatry unit than were members of the
matched sample who presented during the com-
parison period. Sixty-five percent of suicidal pa-
tients presenting during the study period were
discharged home, whereas only 44.7 percent of
the comparison cohort (n = 67) were discharged
home. Adolescents and their families presenting
to the ER during the pilot study period v/ere sig-
nificandy more likely to receive a referral to
intensive outpatient services (acute day treatment
programs and intensive home-based therapies) at
discharge fi’om the ER (21.0 percent [n = 21]
venus 5.3 percent [n = 8], p<.001) than were
their TAU counterparts in the retrospective
cohort (see Table 3).
Of the 65 patients and families who received
foUow-up assessments at five separate intervals as
a component of the intervention protocol, 43
(66.1 percent) were reached at one day, 44 (67.7
percent) were reached at one week, 42 (64.6
percent) were reached at two weeks, 44
(67.7 percent) were reached at one month, and 36
(55.4 percent) were reached at three months. A
total of 55 patients (84.6 percent) were reached at
least once during the foUow-up period. Pearson
chi-square tests revealed no significant differences
between patients reached at foUow-up and those
unable to be reached in age, gender, primary axis I
diagnosis, CDI or HSC scores, or insurance cate-
gories. No patients reported incidence of attempt-
ed or completed suicide during the three-month
foUow-up period.
None of the patients for whom data was
coUected at the one-day foUow-up required an
inpatient hospitalization. At the three-month
foUow-up, seven patients reported requiring an
inpatient hospitalization since the initial ER visit
(12.7 percent), only two (3.6 percent) of whom
were hospitalized because of suicidal complaints.
Other reasons for hospitalization included transi-
tion between partial hospitalization placements,
decompensadon due to schizophrenia, self-injurious
behavior (nonsuicidal), and psychiatric evaluadon
required prior to entering child protecdve custody.
DISCUSSION
Considering the increasing rates and high costs of
adolescent psychiatric hospitalization and an in-
creasingly overburdened health-care system, inves-
tigations evaluating the efficacy of therapeutic
interventions occurring within the ER are essen-
tial. To date, FBCI is the only standardized single-
session crisis intervention for suicidal adolescents
evident in the literature that has been designed for
and pUoted within the ER to demonstrate feasi-
bility, acceptabUity, and significant reductions in
inpatient hospitalization rates relative to a demo-
graphicaUy matched, retrospectively obtained
comparison sample.
WHARPF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 139
Avoidance of inpatient psychiatric admission for
suicidal adolescents has several benefits for the in-
dividual adolescent, the familŷ and the mental
health system. Although the sodetal stigma associ-
ated with mental health problems has been
reduced somewhat, the stereotypical view of ado-
lescent inpatient psychiatric care depicted in
popular literature and films continues to prevail.
An inpatient admission may negatively affect an
individual or family’s beliefs about recovery
(Hellzen & Lilja, 2008), the capacity to be safe in
the world, or the family’s ability to provide a safe
and supportive environment for their chud. Con-
venely, community-based supports may allow a
chud to refrain from developir.g a “dependency
upon the hospital environment or from being
stigmatized” (Shepperd et al, 2009, p. 3). An
ER-based crisis intervention provides the adoles-
cent and family with the message that, despite the
suicidal ideation/behavior with, which they pre-
sented, there are skills that famlies can learn that
will enable the adolescent to alleviate his or her
distress and thus remain at home. The family feels
empowered to be the coordinator of and partici-
pant in their child’s care, comparable to the foun-
dational empowerment model used by the
community intensive therapy team in the United
Kingdom (Darwish, Salmon, Ahi^a, & Steed, 2006).
roCI provides psychoeducation to promote en-
gagement in therapy and (¡mraiy understanding of
treatment. In addition to the tangible parts of the in-
tervention, FBCI provides hope for a family that
arrived at the ER overwheln^ed, anxious, and
worried for a child’s survival. During the study, sev-
eral families expressed relief and gmdtude for the care
that they received in the ER and noted during
follow-ups that family communication and function-
ing in home and school domains had improved.
The absence of significant differences between
family adaptability or cohesion TACES II scores)
and hospitalization in the intervention group was
an unexpected finding. Even the most seemingly
inflexible and uncommunicati’^e families could
engage with a skilled clinician to participate in
psychiatric treatment of their child. Using Parad’s
(1965) crisis theory approach, ve posit that even
the most rigid family system is open to change
during a crisis. FBCI allows cHricians to take ad-
vantage of this opportunity, thereby avoiding un-
necessary psychiatric hospitalization.
The significant increase in referrals for intensive
outpatient treatment in the puot sample indicates
that these adolescents were clearly in need of in-
tensive mental health support; however, FBCI
enabled chnicians to join with families to provide
them with the tools needed to care for their chil-
dren safely at home, allowing this intensive treat-
ment to occur outside the hospital. As previously
noted, FBCI incorporates cognitive therapeutic
techniques to reframe negative attributions. A
recent study of a 12-session cognitive-behavioral
treatment for suicide prevention that also includes
cognitive refcaming as a key component has dem-
onstrated feasibility in a population of suicidal ad-
olescents (Stanley et al., 2009), providing further
empirical support for cognitive-behavioral treat-
ment techniques for suicidahty specifically. FBCI
could be a part of a growing number of more
cost-effective alternatives to inpatient hospitaliza-
tion—such as multisystemic therapy (Henggeler &
Borduin, 1990; Henggeler et al., 1997; Huey
et al., 2004; Schoenwald, Ward, Henggeler, &
Rowland, 2000) and rapid-response outpatient
models (Greenfield, Larson, Hechtman, Rous-
seau, & Platt, 2002)—that have been shown to be
as feasible as inpatient hospitalization for treating
suicidality in adolescents presenting to the ER.
The absence of significant differences in HSC and
CDI scores between those receiving dispositions
of an inpatient hospitalization and intensive out-
patient services within the puot study group indi-
cates that safety can be estabhshed at home for
even severely depressed adolescents.
The follow-up component of the FBCI proto-
col also yielded promising results. Of the 55 pa-
tients (85.9 percent) reached during the
three-month follow-up period, none required an
immediate inpatient hospitalization (within one
week). Remarkably, only two FBCI patients (3.6
percent) reached during the three-month
foUow-up period required an inpatient hospitali-
zation due to suicidal ideation or behavior.
The medical system uses a model of stabihza-
tion in the ER whenever possible and admission
only when necessary. FBCI and other crisis inter-
vention protocols could help the mental health
system move to a similar model in which inpatient
admission is no longer the default position.
Current trends indicate that the majority of ado-
lescents presenting with suicidal ideation/behavior
140 Social Work VOLUME 57, NUMBER 2 APRIL 2012
are admitted to psychiatric inpatient facilities
(Brooker et al., 2007). Inpatient hospitaUzation is
much more costly than other alternatives that
have been shô wn to be as effective in reducing
suicidal ideation/behavior in adolescents (Gould,
Greenberg, Velting, & Shaffer, 2003; Henggeler
et al., 2003).
This change in mindset is critical for the system to
appropriately respond to and care for patients along
the continuum of care. Patients who can go home
with intensive outpatient follô w-up do not board in
the ER, where they •wül receive minimal psychiatric
treatment. Instead, they go home with outpatient
services in place, allowing them to engage in treat-
ment more quickly than they would if they were
sitting in the ER awaiting an inpatient bed.
LIMITATIONS
There were several limitations to this study.
Though random assignment to FBCI or TAU
conditions would have been preferable, FBCI
involved changing clinicians’ practice within the
ER; it was not possible to randomly assign famiUes
to treatment and control groups. The closest avail-
able approximation to a control group was a retro-
spectively obtained sample from the most recent
corresponding 18-month calendar period prior to
cUnician training in FBCI. The retrospective com-
parison component of the study also prohibited
acquisition of data on the frequency of ER visits in
the TAU group; thus, ER recidivism rates could
not be analyzed comparatively between the two
samples. The foUô w-up duration of three months
is also a Umitation. Though alternatives to inpa-
tient hospitalization have been shown to be more
effective in extemaUzing symptom reduction and
improvement in family functioning than inpatient
hospitalization (Henggeler et al., 1999; Schoen-
wald et al., 2000), research indicates that these
gains may be relatively short-lived (Henggeler
et al., 2003). We hypothesize that FBCI may
reduce ER recidivism and hospitaUzation rates.
Studies of pédiatrie emergency psychiatry services
indicate that multiple presentations account for 19
percent to 36 percent of ER visits and that ap-
proximately 50 percent of repeat •visits occur
within one month of the prê vious presentation.
Though data were unavailable on foUow-up hos-
pitalizations for the comparison group, rates of
repeat ER presentations were much lower in the
FBCI sample than in other samples. Currently, we
are conducting a randomized cUnical trial that ex-
amines the efficacy of FBCI, long-term gains, and
effects of FBCI on ER recidî vism rates. Although
we did place foUow-up phone caUs to aU study
participants, no famiUes required assistance in ac-
cessing additional services at any of the foUow-up
time points; however, other services (beyond
those recommended as part of the discharge plan)
were not controUed for in this study. Future
studies should control for additional service use
and variability.
CDI, HSC, and FACES II scores were not col-
lected posttreatment or during foUow-up and,
therefore, could not be analyzed. No psychomet-
ric measures were obtained for the TAU group at
any time point, as there was no practical way to
proceed because of the nature of the population
presenting to the ER and human subjects issues.
In addition, frequency and dose of each of the
four core components of FBCI were not coUected
as part of this study. Future studies exploring the
efficacy and effectiveness of FBCI should incorpo-
rate the frequency and dose of each of these core
components.
CONCLUSIONS
Patients who received FBCI were significantly less
Ukely to be hospitaUzed than were their compari-
son cohort counterparts. Suicidal adolescents pre-
senting in crisis to the ER were able to be sent
home safely with appropriate therapeutic supports.
This puot study demonstrates that a single-visit
model of crisis intervention for suicidal adoles-
cents and their famiUes deUvered in the ER can
sufficiently stabilize an adolescent and family
system, regardless of cohesion and adaptabiUty
levels, to enable a safe discharge home.
It is essential to begin to use a model of crisis
intervention for suicidal adolescents and their
families to provide reUef from their acute symp-
toms with the least amount of family disruption.
Empirical ê vidence has yet to document the supe-
riority of inpatient care in effectively reducing
rates of suicidal ideation, nonlethal attempts, or
completed suicides among adolescents (Gould
et al, 2003). FBCI benefits the adolescent and
family and simultaneously alleviates an overbur-
dened mental health system by limiting use of
scant inpatient resources, keeping them available
for those who truly need them. FBCI is a stan-
dardized protocol that could be used by crisis
WHARFF, GINNIS, AND ROSS / Family-based Crisis Intervention with Suicidal Adolescents in the ER 141
clinicians across contexts to provide this kind of
intervention, and it may be a cost-effective and
advantageous alternative to inpatient hospitaliza-
tion for both patients and providers.
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Elizabeth A. Wharff, PhD, MSW, is director, Katherine
M. Ginnis, MSW, MPH, is associate director, and
Abigail Ross, MSW, MPH, is a research social worker,
Emergency Psychiatry Service, Department of Psychiatry,
Boston Children’s Hospital. Funding for this pilot study was
provided by the George Harrington Trust. The authors are
grateful to the adolescents and their families who participated in
the study and to the ER social workers who piloted family-
based crisis intervention (FBCI) with them, including Ariel
Botta, Elizabeth Colton Notine, Christina Feith, Lara Kay,
Mary Kate Little, and Katie Naftzger. The authors also
thank David DeMaso, chief of psychiatry, and the ER
nursing and physician staff at Boston Children’s Hospital for
their support during the FBCI study period. Address corre-
spondence to Elizabeth A. Wharff, Department of Psychiatry,
Boston Children’s Hospital, Fegan 8, 300 Longwood Avenue,
Boston, MA 02115; e-mail: elizabeth.wharf@childrens.
harvard.edu.
Original manuscript received Aprii 12, 2010
Final revision received August 27, 2010
Accepted September 1, 2010
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Helping Homeless Individuals with
Co-occurring Disorders: The Four Components
An-Pyng Sun
Homeless individuals with co-occurring disorden (CODs) of severe mental illness and sub-
stance use disorder are one of the most vulnerable populations. This article provides practi-
tionen with a framework and strategies for helping this client population. Four components
emerged from a literature review: (1) ensuring an effective transition for individuals with
CODs from an institution (such as a hospital, foster care, prison, or residential program) into
the community, a particularly important component for clients who were previously home-
less, impoverished, or at risk of homelessness; (2) increasing the resources of homeless indi-
viduals with CODs by helping them apply for govemment entitlements or supported
employment (3) linking homeless individuals to supportive housing, including housing fint
options as opposed to only treatment first options, and being flexible in meeting their
housing needs; and (4) engaging homeless individuals in COD treatment, incorporating
modified assertive community treatment, motivational interviewing, cognitive-behavioral
therapy, contingency management, and COD specialized self-help groups.
KEY WORDS; co-occurring disorder; homelessness; mental disorder; substance use disorder; treatment
H elping vulnerable cUent populations has
long been a major mission of the social
work profession (National Association
of Social Workers, 2008). Homeless individuals
with co-occurring disorders (CODs) of severe
mental illness (SMI) and substance use disorder
(SUD) are one of the most vulnerable cHent pop-
ulations. Compared with homeless individuals
without CODs, SMI, or SUD, who often are just
transitionally homeless, individuals with CODs
are more likely to experience chronic homeless-
ness (Caton, Wilkins & Anderson, 2007; Kuhn &
Culhane, 1998). Compared with individuals with
CODs, SMI, or SUD who are not homeless.
Homeless individuals with CODs, SMI, or SUD
are less likely to engage in treatment and to
recover from their diseases. Social workers may
come across chronically homeless clients in
various practice fields. During 2008, among the
642,000 positions held by social workers, 46
percent were in family, school, and chud social
work; 22 percent were in pubhc health and
medical social work; 21 percent were in substance
abuse and mental health social work; and 11
percent were in other types of social work
(Bureau of Labor Statistics, n.d.). Practitioners in
all four fields, though particularly the pubhc
health and medical field and the mental health
and substance abuse field, are hkely to encounter,
directly or indirectly, homeless clients with CODs
and related challenges. It is critical that both social
work students and practitioners be equipped
with knowledge and skills to help this client
population.
This article discusses strategies for helping
homeless individuals with CODs on the basis of a
hterature review. Relevant articles were located
via database searches of PubMed, PsycINFO, and
Social Work Abstracts^ using the key words “home-
less individuals,” “homelessness,” “housing,”
“co-occurring disorders,” “dual diagnosis,”
“mental disorders,” “schizophrenia,” “bipolar,”
“substance abuse,” “substance dependence,” “sub-
stance use disorders,” and “treatment,” plus the
reference hsts of located articles. Because research
on the homeless population with CODs and SMI
using randomized controlled trials (RCTs) is stül
very limited (Caton et al., 2007), all relevant
located studies on the homeless population with
CODs that used various levels of designs— for
example, RCTs; meta-analyses; quasi-experimen-
tal designs; observational studies; quahtative
studies; the ‘consensus of expert clinicians,’ in a
few sources in which research evidence was com-
bined with consistent expert opinion (Burt et al.,
2004; Caton et al., 2007; Center for Substance
doi: 10.1093/sw/swr008 O 2012 National Association of Social Workers 23
Abuse Treatment [CSAT], 2005; Ziedanis et al.,
2005)—were adopted. Rog (cited in Catón et al.,
2007, p. 4-12) stated that although studies may
fall short of the most rigorous standard, “when
[they] produce a consistent pattern of findings,
may also be considered as additional evidence to
determine whether an intervention is considered
evidence based.” Four components emerged from
the review of the study fmdings: (1) ensuring ef-
fective transition, (2) increasing resources via gov-
ernment entitlements and supported employment
(SE), (3) providing linkages to housing, and (4)
offering COD treatment.
COMPONENT 1: ENSURING EFFECTIVE
TRANSITION FROM INSTITUTION TO
COMMUNITY
Reducing the flow of at-risk individuals being re-
leased from institutions (for example, psychiatric
hospitals, substance abuse treatment programs,
correctional facilities, foster care) into the com-
munity without receiving proper transitional ser-
vices is critical to reducing homelessness among
individuals with CODs (Burt et al., 2004). The
literature contains six strategies for niore effective
transitions, with the enhancement of continuity
of care being common feature (Compton et al.,
2003).
Establishing Rules Regarding Discharge
Planning
State and local agencies should establish rules to
ensure a well-executed discharge plan that links
an institution that discharges an individual with
the community that takes in the individual (Burt
et al., 2004). Some states have required discharge
planning as a formal responsibüity of the institu-
tion releasing a person, whereas other states treat
it only as an informal responsibility. The lack of
policies about discharge may contribute to the
deemphasis on discharge planning, precipitating
discontinuity of care (Burt et al., 2004).
Developing a Thorough Discharge Plan
Lauber, Lay, & Rössler (2006) suggested that insti-
tutions develop a discharge plan for a homeless
client with CODs immediately after his or her ad-
mission to an inpatient setting. A thorough dis-
charge plan provides a projected discharge date,
gathers medical records, arranges postrelease
housing, coordinates medical and mental health
care, and brings together other community servic-
es (Caton et al., 2007; Community Shelter Board,
cited in Burt et al., 2004).
Offering Critical Time Intervention
The institutions that release individuals into the
community can offer critical time intervention
(CTI) (Susser et al., 1997), an evidence-based
treatment that goes one step beyond a discharge
plan. During the fint months after discharge,
when a client’s relationship with people in the
community may be frague, CTI strengthens the
client’s adjustment to the community by pairing
the client with a social worker who visits the
client’s community residence, accompanies the
client to appointments, and helps the client
develop relationships with people at the appoint-
ments and provides advice in periods of crisis
(Susser et al., 1997). Susser et al.’s RCT study (N
= 96) found that during the 1.5-year follow-up
period, the mean number of homeless nights was
30 for CTI recipients, whereas it was 91
(p = .003) for usual-service recipients. Later em-
pirical studies also showed that CTI recipients
tend to do better with respect to housing, alcohol
and other drug (AOD) use, and psychiatric symp-
toms (Kasprow & Rosenheck, 2007, a non-
randotnized two-cohort cotnparison study) and
negative psychiatric symptoms (Herman et al.,
2000, a randomized two-group design). Psychiat-
ric symptoms may include positive and negative
symptoms. Positive symptoms may include delu-
sions, hallucinations, grossly disorganized/cataton-
ic behavior, and so on. Negative symptoms may
include affective flattening, alogia, avolition, and
so on. Research shows that CTI not only reduces
recurrent homelessness among people with SMI,
but it is also cost-effective in that it reduces home-
less nights at a lower expense compared with the
usual care approach Qones et al., 2003).
Providing Motivational Interviewing
before Discharging Clients
Research suggests that a motivational interviewing
(MI) session prior to hospital discharge may in-
crease the likehhood of a patient attending an
initial outpatient appointment (CSAT, 2005;
Swanson, Pantalon, & Cohen, 1999). The MI
session addresses the differences between hospital
and outpatient treatment regarding the treatment
goals and methods and engages the client to
24 Social Work VOLUME 57, NUMBER I JANUARY 2012
explore his or her own understanding of his or
her clinical condition and commitment to
treatment.
Engaging Clients Early
Community agencies that accept clients released
from institutions can play a role in promoting an
effective transition. Data indicate that the begin-
ning period of treatment is one of three high-risk
periods for dropout among homeless clients
(Orwin, Garrison-Mogren, Jacobs, & Sonnefeld,
1999). It is risky because the clients need to adjust
to new rules and demands, which may take a toll
on their already fragile survival skills (Lipton,
Siegel, Hannigan, Samuels, & Baker, 2000;
O’Brien, Fahmy, & Singh, 2009; Orwin et al.,
1999). Strategies to reduce early hazards include
reducing waiting time (for being formally accept-
ed or admitted to the treatment program or for
actually starting the treatment), providing orienta-
tion, engaging clients early (to buud a trust rela-
tionship or alliance with chents during the early
stage [for example, when clients initially enter
treatment] and therefore motivate clients to stay in
treatment) (Orwin et al., 1999), and forming a
short-term reentry group that facilitates outpatient
treatment participation and compliance using a
psychoeducational approach (Kamiel-Lauer et al.,
2000 [N= 75]).
Allocating Funds
Providing funds for rent, deposits, and utility pay-
ments to homeless clients with CODs before they
secure employment or government benefits can
help them transition firom institutions to the com-
munity (Foote, Tucker, & MOlspaugh, 2008).
Forchuk et al.’s (2008) randomized study (N =14)
showed that intervention group participants who
received immediate assistance with housing access
and rent on discharges from psychiatric settings
maintained housing after three and six months,
whereas all but one of the control group partici-
pants remained homeless (the exception traded
sex to avoid homelessness).
COMPONENT 2: INCREASING THE RESOURCES
OF HOMELESS INDIVIDUALS WITH CODS
Many homeless individuals with mental disorders
consider their homelessness to be caused by their
lack of income rather than by their psychiatric dis-
ability (Tsemberis & Eisenberg, 2000). Compton
et al. (2003) found that whether individuals with
SMI have “sufficient income for housing” was
one factor predicting homelessness. Linking indi-
viduals to government enddements and connect-
ing them with SE are two strategies to increase
their income.
Applying for Government Entitlements
Many homeless people, although eligible for gov-
ernment entidements, do not receive, apply for,
or maintain such benefits (Long, Rio, & Rosen,
2007; Page & Nooe, 2002; Zuvekas & HiH,
2000). Wechsberg et al. (2003) found that having
an income below $500 in the preceding month
predicted women’s homelessness {p= .014),
whereas receiving welfare income in the preced-
ing month predicted women’s nonhomelessness
(p=.OOl). Some individuals may exit from the
original Temporary Assistance for Needy Families
(TANF) roUs because they were sanctioned;
others may be removed from TANF roUs without
knowing what they needed to do to comply with
the rules (Page & Nooe). Nwakeze, Magura,
Rosenblum, and Joseph (2003) considered the
low use of Medicaid and food stamps by homeless
people puzzMng, because those two government
entitlements are not affected by the Welfare
Reform Act (part of the Personal Responsibility
and Work Opportunity^ Reconciliation Act of
1996 [P.L. 104-193]). They offered three possible
explanations:
1. Homeless individuals have a lower sense of
self-efficacy, which leads to deficient
service-seeking behavior.
2. Agency bureaucracy and staff discrimination
discourage homeless individuals fiom
seeking services.
3. Homeless individuals consider their housing
needs the top priority and Medicaid and
other entidements secondary and do not
pursue the secondary needs.
In addition, lack of verifying identity or other
documentadon and permanent address often pre-
vents homeless individuals from successfully com-
pleting the appHcation process. Furthermore,
many homeless individuals lost their Supplemental
Security Income (SSI) or Social Security Disability
Insurance (SSDI) under the 1997 pohcy change
that eliminated AOD addiction as a legitimate
SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 25
disability. Despite this, statistics showed that only
11 percent of homeless individuals surveyed were
getting SSI and only 8 percent of homeless indi-
viduals were getting SSDI, whereas it is estimated
that 46 percent of homeless individuals had physi-
cal disabüities and 39 percent of homeless individ-
uals had mental health problems (cited in Long
et al., 2007).
Practitioners should be equipped with knowl-
edge of community resources and the skills for
linking a homeless individual with government
entitlements. The Substance Abuse and Mental
Health Services Administration’s SSI/SSDI Out-
reach, Access and Recovery (SOAR) program
provides technical assistance to case managers and
program staff in this regard. Data showed that the
success rate among SSDI/SSI apphcations was
only 10 percent to 15 percent prior to SOAR,
whereas it dramatically increased in states that par-
ticipated in SOAR. For example, the average
success rate in the 32 states involved in SOAR
was about 71 percent during spring and summer
of 2009 (Policy Research Associates, Inc. [PRA],
2009). The application processing times were also
significantly reduced after SOAR implementation.
For example, the processing time was eight
months before SOAR training and 4.5 months
after SOAR training in Oregon (Long et al.,
2007), and the average time to reach a decision
during spring and summer of 2009 was 89 days
among the 32 SOAR-participating states (PRA,
2009). According to the Substance Abuse and
Mental Health Services Administration (2011), 37
states reported SOAR-assisted 8,978 applications
from 2006 to June 2010, with an approval rate of
73 percent and an average time of 91 days from
application submission to approval.
Connecting with Employment
Homeless individuals with SUD consider housing
and employment to be two major factors that
keep them homeless (Governor’s Advisory on the
Homeless, Oklahoma Department of Human
Services, cited in Foote et al., 2008). Caton et al.’s
(2005) study found that being currently employed
at time of homeless shelter admission or having a
previous employment history, even if currently
unemployed, was associated with a shorter dura-
tion of homelessness.
However, individuals with CODs face obstacles
in seeking and maintaining employment. One
hindrance is the fear that employment may jeop-
ardize their government benefits. Studies show
that receipt of SSI/SSDI benefits may discourage
individuals with mental disorders from pursuing
competitive employment (Becker, Whitley,
Bailey, & Drake, 2007 [N= 38]; Rosenheck et al.,
2006 [N= 1,411]). Federal regulations require a
person’s disability status to be reviewed on his or
her return to work; an SSDI recipient’s cash
payment may cease if his or her allowable income
exceeds the substantial gainful activity level for a
particular number of months. Furthermore, indi-
viduals who lose SSDI due to employment may
be at risk of losing other benefits, such as food
stamps, utility supplements, and housing subsidies
(Polack & Warner, cited in Cook, Terrell, &
Jonikas, 2004). Becker et al. (2007) found that
participants seemed to prefer part-time work,
owing not only to its lesser demands, but also to
their perception of its allowing them to maintain
their Social Security and other benefits. It is thus
critical to provide benefits counsehng to chents
with CODs and their families to empower them
to make informed decisions regarding employ-
ment (Biegel, Ronis, & Boyle, 2008). Although
various attempts have been made to address the
issue of SSI and SSDI being disincentives for ben-
efits recipients to pursue better financial security,
the results seem to be disappointing, and more
efforts are needed in this regard (Cook et al.,
2004).
Other barriers to employment are an individu-
als’ COD symptoms, lack of self-efficacy, agency-
level barriers, and society’s biases. Becker et al.
(2007) found that psychiatric illness is the primary
hurdle and that long-term supports and part-time
employment are the major facilitators to work. SE
has been recognized as an evidence-based practice
for linking individuals with mental disorders or
CODs to competitive employment; clinical
studies reporting SE success include Becker et al.
(2001 [N=127]; 2007 [N=38]), Biegel et al.
(2008 [N=194]), and Drake et al. (1999 [N =
152]). SE encourages all individuals, regardless of
whether they have mental disorden or CODs, to
seek competitive employment (that is, work that
pays at least minimum wage and provides a non-
segregated work setting) directly and swiftly. The
eligibility for job placement is an individual’s
choice rather than his or her job readiness or
abstinence from AOD (Becker, Drake, & Naughton,
26 Social Work VOLUME 57, NLIMBER I JANUARY 2012
2005). Studies have found that clients with mental
disorders may achieve more success in obtaining
and maintaining competitive employment if they
are being linked to competitive employment right
from the beginning rather than being linked
to prevocationaJ training and sheltered jobs before
being hnked to competitive jobs (Drake et al.,
1999). One key person in SE is an employment
specialist, who helps clients seek a competitive
job, provides them with individuaHzed and long-
term support after they obtain employment so as
to prolong job tenure, and works coUaboratively
with other team members (Becker et al., 2005).
More SE studies, however, have been done on
individuals with mental disorders than on individ-
uals with CODs (Biegel et al., 2008). Biegel et al’s
study revealed that although the competitive em-
ployment rates of clients with CODs who re-
ceived SE were lower than those in SE chnical
trials, they were nonetheless significantly higher
than the rates of the control groups in those trials.
Furthermore, Biegel et al. found that alcohol use
was not an impediment to the participants’ em-
ployment. Both findings facüitated the inference
that SE can be effective with clients with CODs
(Biegel et al., 2008). Becker et al. (2005) suggested
three guidehnes for applying SE to help individu-
als with CODs:
1. Employment specialists and other team
memben should ensure optimism about a
client’s ability to recover and to work and
instiU hope in the client, as the chent may
have low self-efficacy.
2. Employment speciahsts and other team
members should work together with the
client to create a detailed vocational profile
and include in it the client’s substance abuse
situation. The specialist should unk the
client with a job that supports recovery (for
example, not a bartending job) and design
an individualized treatment plan, so that, for
example, the client and the treatment team
can develop a mutually agreeable money
management plan so that the money earned
from employment wul not be used to pur-
chase AOD.
3. Employment specialists and other team
members should coordinate systems of
mental health treatment, AOD treatment,
and vocational services.
COMPONENT 3: LINKING HOMELESS
INDIVIDUALS WITH CODS TO HOUSING
To successfriUy treat the COD problems of home-
less clients, practitioners must help them obtain
and maintain housing. The literature has consis-
tendy suggested that most homeless clients with
CODs or SUD place housing over other needs,
such as psychiatric and addiction treatments
(Nwakeze et al., 2003; Orwin et al., 1999). Three
strategies to help link COD homeless individuals
to housing were addressed in the hterature.
Providing Effective Outreach
Research and consensus of expert clinicians (Burt
et al., 2004; Murray, O’Donnell, & Speedling,
2005) suggested that effective outreach may
require
• offering “repeated engagements over time”
and “familiarity with the same outreach
worker,” as both enable a relationship that
comprises consistency and trust, elements that
are often missing in a street-dweüing home-
less person’s Ufe;
• organizing various agencies under one central
unit so that the operation can be more effi-
cient and each client’s data can be more
complete;
• ensuring that the outreach team has direct
access to supportive and “low-demanding”
housing and fuU support from the city’s
mental health, AOD treatment, and health
treatment programs, as an outreach would be
fritile if “the other end of the spectrum” is
not ready to provide housing or treatment
when a homeless person is initially reached;
• conducting outreach during the day instead
of only at nighttime, as more resources are
available during the day;
• creating 24-hour homeless hotlines to involve
the entire conimunity to engage homeless in-
dividuals; and
• targeting the areas where chronically home-
less individuals cluster.
Some experts suggest involving trained law en-
forcement officers who understand the philosophy
of the helping professionals, as this may smooth
the outreach work and protect the outreach
workers.
SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 27
Triaging and Linking Clients with Proper
Permanent Housing
Nelson, Aubry, and Lafi:ance’s (2007) review of
16 controlled studies showed that supported and
pemianent housing have a positive effect in com-
bating chronic homelessness among people with
mental disorders. Hurlburt, Wood, and Hough
(1996) found a strong positive relationship
between individuals with CODs, SMI, or SUD
having access to pubhc housing (for example.
Section 8) and their finding steady independent
hving arrangements. Clark and FUch (2003) found
that a comprehensive housing program that
ensures both housing and case management, as
opposed to a program with only case manage-
ment, appean to be more critical to people with
severe psychiatric symptoms and high substance
use than it is to their counterparts with only
medium- or low-level symptoms. For individuals
with only medium- or low-level psychiatric
symptoms and a low level of AOD use, a case
management-only program can do as well as a
comprehensive housing program.
Although offering permanent housing and
support appean to be successful for combating
chronic homelessness, it may be easier for chents
with SMI than for clients with SUD or CODs to
obtain and maintain pubhc housing. Individuals
with SUD or SUD histories may face more diffi-
culty in applying for public housing than do
others because of their AOD problems and the
frequent connection between AOD use and crim-
inal behaviors. Both the official and unofficial
housing pohcies may place individuals with SUD
at a disadvantage (Dickson-Gomez, Convey,
Hilario, Corbett, & Weeks, 2007).
The “one strike, you’re out” policy permits
federal housing authorities to take into account
the AOD and convictions problems of an appli-
cant and his or her family members when deter-
mining eligibility for or eviction from federally
subsidized housing (Dickson-Goniez et al., 2007).
The Quality Housing and Work Responsibihty
Act of 1998 (P.L. 105-276) (QHWRA) also re-
quires Section 8 and pubhc housing agencies to
exclude any applicant who was “evicted from
pubhc, federally assisted, or Section 8 housing
because of drug-related criminal activity,” and
that ban may last for three years after the appli-
cant’s eviction (CSAT, n.d.). Despite the fact that
the QHWRA also indicates that the ban can be
lifted or shortened if the applicant completes a
treatment program, overall the rules are not favor-
able toward individuals with SUD or SUD histo-
ries, and the ultimate ehgibOity decision is up to
the housing authorities. Although some states (for
example, Connecticut) opted out of the “one
strike, you’re out” policy and do not use drug
convictions to deny housing applications, the
routine criminal background checks in apartment
rental applications still put drug usen in a disad-
vantageous position (Dickson-Gomez et al.,
2007).
Unofficial policy may further exacerbate
substance-abusing clients’ housing applications
(Dickson-Gomez et al., 2007). Dickson-Gomez
et al.’s quahtative study revealed that housing
caseworkers can exercise much discretion in the
final say regarding housing apphcations, and they
may favor apphcants without an AOD problem or
history due to their higher hkehhood of maintain-
ing housing tenure. The drug-using participants
in Dickson-Gomez et al.’s study stated that
housing caseworkers often disrespected and
imposed bureaucratic red tape on them. It is thus
critical for practitioners to work closely with
housing authorities to advocate for homeless
chents with CODs. Other barriers may include
fi-equently long waiting hsts and the recent short-
fall of federal funding. For example, the Las Vegas
Housing Authority (LVHA) has currently closed
its housing apphcation process, and it is not ex-
pected to reopen for three or more years when
federal funds become available (personal commu-
nication, LVHA, August 2009).
Considering Housing First as Opposed to
Treatment First Practice
Unlike the traditional treatment fint (TF) ap-
proach, which places homeless clients with CODs
or SUD first in treatment programs before they
are ready for (permanent) housing, the housing
first (HF) approach shifts the paradigm and places
them directly into (permanent) housing without
first requiring treatment or sobriety (Burt et al.,
2004; Pathways to Housing, Inc., New York,
2005). Studies have shown that compared with
TF, HF can not only better retain cHents, but also
results in similar AOD treatment outcomes (Padgett,
Gulcur, & Tsemberis, 2006 [RCT { J V = 2 2 5 } ]
Tsemberis & Eisenberg, 2000 [quasi-experimental
{N= 1,842}] Tsemberis, Gulcur, & Nakae, 2004
28 Social Work VoLinnE 57, NUMBER I JANUARY 2012
[RCT {N=225.}]) Lipton et al. (2000 [quasi-
experimental {N= 2,937}]) also found that indi-
viduals with CODs residing in highly structured
housing programs may have a lower level of resi-
dential stability than their counterparts residing in
housing programs flexible regarding AOD issues.
Homeless individuals who have “faüed” almost all
of the traditional treatment or housing programs
have emphasized the significance of “having
control over their own service uptake” and having
program staffs respect regarding “their right to
move at their own pace” (Burt et al., 2004, p. 27).
They also appreciate programs that respect person-
hood and that stress chent autonomy (for
example, “no curfew”) and privacy (for example,
“a room with a key”) (Lincoln, Plachta-EUiott, &
Espejo, 2009 [qualitative study {N= 16}]).
An HF program is not completely uncondi-
tional; it may impose various minimal demands
on tenants. For example, HF programs sponsored
by the U.S. Department of Housing and Urban
Development prohibit tenants from using illegal
drugs on the premises (Burt et al., 2004). Some
HF programs only require tenants to cotnply with
the conditions specified in their lease. Some
require tenants to participate in a representative
payee program or a money management program
to ascertain tenants’ abuity to pay rent reliably and
to manage their money effectively (Burt et al.,
2004; Tsemberis & Eisenberg, 2000). Some
require clients to meet with program staff at least
twice each month (Tsemberis & Eisenberg, 2000)
and some require tenants to attend sessions focus-
ing on skills development and job seeking and to
not have too many visitors (Pratt, 2008). Some
HF programs may be “applied flexibly to all
tenants” and have pohcies that “housing or servic-
es would not be denied to a person coming off
the streets after many years who feels mistrustful
about agreeing to money management” (Tsembe-
ris & Eisenberg, 2000, p. 489).
Although an HF program does not require
tenants to receive treatment, it is required to
provide treatment. When providing treatment, a
division of labor between property management
and COD treatment is appropriate as it helps to
avoid conflicts of interest with respect to nonpay-
ment and other lease-related issues (Burt et al.,
2004). Second, if most tenants with CODs are
clustered, it may be more effective to bring the
treatments to them instead of referring them out
to the agencies, as “the demand that they deal
directly with service systems may be enough to
prevent them from getting the services they need”
(Burt et al., 2004, p. 30). Third, because tenants
are not required to receive treatments, it is essen-
tial to make treatment attractive to them. A modi-
fied assertive commutiity treatment approach
(introduced in the next section) that emphasizes
consumers’ decision-making power may be useful
in this regard (Tsemberis & Eisenberg, 2000).
Other strategies include making oneself available
to clients, making friendj with clients, and creat-
ing social activities (for example, holding birthday
parties) (Burt et al., 2004). Burt et al. emphasized
that the best referrals actually come frotn tenants
talking about the program to their friends and
neighbors, who then come into the program
themselves.
COMPONENT 4: OFFERING COD TREATMENT
Empirical data are sriU limited regarding effective
techniques that produce change among individu-
als with CODs iBellack, Bennett, Gearon,
Brown, & Yang, 2006; Cleary, Hunt, Matheson,
& Walter, 2009). Nonetheless, the literature
stressed three elements: (1) an integration of psy-
chiatric and AOD treatments, (2) treatment as a
long-term process, and (3) harm reduction
(Bellack et al., 2006). Drake et al. (2001) also sug-
gested four stages: (1) engaging individuals with
CODs by using outreach techniques. Unking
them with practical assistance, and estabUshing a
trusting relationship; (2) motivating them to get
involved in COD treatment and offering individ-
ual counseUng and groups (persuasion); (3) equip-
ping them with the skiUs and support (groups or
family) to manage ulnesses and pursue goals
(active treatment); and (4) preparing them with
relapse prevention skills and support to maintain
treatment progress (relapse prevention). The stages
are not necessarily Unear. A client may enter treat-
ment at an advanced stage or may relapse back to
an earlier stage, or a client may be in different
stages in terms of mental illness and substance
abuse. Different stages should be paired with
stage-specific interventions. The following five
methods help in the implementation of tasks in-
volved in the elements and stages of COD
treatment.
SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 29
Assertive Community Treatment
To engage homeless individuals with CODs, a
more intense and proactive intervention may be
necessary (DiClemente, Nidecker, & BeUack,
2008). Assertive community treatment (ACT)—
an approach that emphasizes outreach, communi-
ty tenure, practical and intensive case manage-
ment, small caseloads (usually a client-worker
ratio of 10 to 1), 24-hour service, and interdisci-
plinary teamwork (Drake et al., 1998)—may fulfill
the goal. ACT is an evidence-based approach
proven by some studies to reduce hospital days
(for example. Bond et al., 1990), increase time in
housing or decrease homeless rates, and improve
psychiatric symptoms (Coldwell & Bender, 2007).
The ACT outcomes findings, however, are not
completely consistent; findings in the United
States are more consistent in generating a positive
effect than are those in the European studies
(Bums, Fioritti, Holloway, Malm, & Rössler,
2001). The inconsistency could be related to dif-
fering operational definitions for the variables
(Coldwell & Bender, 2007), lack of model fidelity,
and “treatment quality” improvement of the
control group (Verhaegh, Bongers, Kroon, &
Garretsen, 2009).
Although ACT has been criticized for being
expensive and lacking a recovery orientation,
recent studies have shown that ACT does not
have to be time unlimited, and some clients can
transition from ACT to less intensive community
mental health services or step-down programs
(Hackman & Stowell, 2009; Rosenheck, Neale, &
Mohamed, 2010). Recent studies also found that
not all clients with CODs need ACT and that
ACT may be necessary only for clients with more
severe problems. For example, Essock et al. (2006
[N= 198]) found that, compared with ACT, clin-
ical case management (a less intensive form than
ACT [for example, with a client-worker ratio
being 25 to 1 instead of 10 to 1]) created similar
treatment outcomes among homeless or unstably
housed clients with CODs. However, Frisman
et al. (2009 [N= 124]) found that ACT appeared
to be more effective than the cHnical case man-
agement approach for clients with CODs and an-
tisocial personality disorder (ASPD), whereas
ACT and the clinical case management approach
created similar treatment outcomes for dually dis-
ordered clients without ASPD. More research is
needed regarding successfully matching clients
with ACT, step-down programs, and regular clin-
ical case management.
Modified Motivational Interviewing/
Motivational Enhancement Therapy
Modvational interviewing (MI)/motivational en-
hancement therapy (MET) produces some evi-
dence of decreasing substance use and psychiatric
symptoms and increasing treatment engagement
during the short term among individuals with
CODs (see Cleary et al.’s, 2009, review of nine
empirical studies, mosdy with a randomized
design). For example, Graeber, Moyers, Griffith,
Guajardo, & Tonigan’s (2003 [A/=30]) RCT
found that, compared with an educational treat-
ment intervention, MI was more likely to reduce
drinking days and increase abstinence rates among
schizophrenic patients with drinking problems.
Santa Ana, Wulfert, and Nietert’s (2007 [N =
101]) RCT revealed that, compared with controls,
clients with CODs receiving group MI attended
more aftercare sessions and drank less. Other
RCTs also suggest that combining MI with
cognitive—behavioral therapy (CBT) and family
intervendon may help clients with CODs of
schizophrenia and substance use disorders (Bar-
rowclough et al., 2001 [N=36]) and that com-
bining MI, contingency management, and social
skills training resulted in better treatment out-
comes than did the control condition (“a suppor-
tive group discussion”) among clients with CODs
(BeUack et al., 2006 [N= 175]).
MI/MET facilitates change and helps a client
move from a more initial stage (for example, pre-
contemplation) to a more advanced stage (for
example, contemplation, determination, action.
CUents compare their baseline AOD use with the
normadve data, develop discrepancies between
where they are and where they want to be,
discuss the role of AOD use as a barrier preventing
them fiom being where they want to be and the
role of quitdng AOD as a facilitator promodng
their well-being, explore ambivalence related to
changing AOD use, tip the decisional balance
toward change, and develop goals and action
plans (Miller & Rollnick, 2002). Individuals with
CODs, particularly those with an SMI, may expe-
rience a lower motivation to change because of
their positive symptoms (for example, delusions,
hallucinations) and negative symptoms (for
example, anergia, avolidon), other cognitive
30 Social Work VOLUME 57, NUMBER I JANUARY 2012
limitations, low self-efficacy, or limited external
resources and support systems (Carey, Pumine,
Maisto, & Carey, 2001; DiClemente et al., 2008;
Horsfall, Cleary, Hunt, & Walter, 2009). Al-
though the research on motivation to change
among individuals with CODs is preliminary
(DiClemente et al., 2008), it suggests that—with
proper cues, guidance, encouragement, and struc-
ture—clients with CODs (including cUents with
schizophrenia) can reflect on the pros and the
cons of their substance-using behavior and be in-
volved in decisional balance and goal setting
(Carey et al., 2001). Research evidence and the
consensus of expert clinicians (for example,
CSAT, 2005; Ziedonis et al., 2005), systemic
reviews of empirical studies (for example, DiCle-
mente et al., 2008; Horsfall et al., 2009), and em-
pirical studies (for example, Carey et al., 2001)
suggest the following strategies to modify MI/
MET to help chents with CODs.
Empathy and an Alliance with the Client.
Clients with CODs, especially those with SMI,
are less able than others to tolerate stress, confron-
tation, and criticism. Practitioners thus need to be
nonjudgmental, friendly, passive, low-key, and
patient (Evans & Sullivan, 2001). Many clients
with CODs also suffer from low self-efficacy (Zie-
donis et al., 2005), which can be helped by con-
veying admiration for clients’ strengths in daily
coping, but this should be done without imposing
too much pressure on them (DiClemente et al.,
2008; Evans & Sullivan, 2001).
Psychoeducation and Counseling on Illness Self-
Management and Psychiatric Medication Compli-
ance. Modified MI/MET should be applied not
only to SUD, but also to SMI problems. Psychiat-
ric medication noncompliance is especially preva-
lent among individuals with CODs with psychosis
(CSAT, 2005). Individuals with schizophrenia and
co-occurring SUD are less hkely to adhere to
medication regimens than are individuals with
only schizophrenia (Ziedonis et al., 2005). Psychi-
atric medication noncomphance has a tremendous
effect on a person’s function and presenting symp-
toms (CSAT, 2005); individuals with psychotic
disorders must take antipsychotic medications to
control their psychotic symptoms (Evans & Sulli-
van, 2001). Clients with CODs need to be moti-
vated to manage their psychiatric disorders
(including medication compliance) and to under-
stand how not doing so may prevent them from
attaining their goals (Drake et al., 2001; Ziedonis
et al., 2005).
Research shows that psychiatric medication
noncompliance may be related to side effects, dis-
trust of the effectiveness of a medication, or denial
of one’s illness and the need to take medications
(Weiss et al., cited in Weiss, 2004). A person who
is active in AOD use may stop taking the medica-
tions for fear of the alcohol—medication interac-
tion (Weiss, 2004; Ziedonis et al., 2005), or the
person may be so disorganized that it becomes
too difficult for him or her to get anything done,
including taking medications (CSAT, n.d.; Evans
& Sullivan, 2001; Ziedonis et al., 2005). Medica-
tion compliance may be facilitated by
• using all appointments to discuss the medica-
tions—the purpose, the expected time coune
and results, side effects, and AOD-psychiatric
medication interaction effects and to promote
hope and realistic expectations to increase
medication adherence;
• simplifying medication regimens (for example,
administering long-acting puls, depot injec-
tions, or once-a-day regimens) and starting
low and going slow in dosing;
• discontinuing medications with side effects
that lead to nonadherence;
• encouraging patients to continue taking anti-
psychotic medications despite their AOD use,
as discontinuing the former may be more
risky than the concurrent use of both; and
• involving significant others in medication
psychoeducation and treatment monitoring
(CSAT, n.d.; Ziedonis et al., 2005).
Harm Reduction and Smaller Goals. Theoreti-
cally, it would be safer to adopt total abstinence
(venus reduced use) as the treatment goal for
clients with CODs, because people with mental
disorders may be more sensitive to the biological
effects of AOD, and AOD even in moderate
amounts may exacerbate psychiatric symptoms
and worsen problems (Evans & Sullivan, 2001;
Mueser et al., cited in Drake, Wallach, & McGov-
em, 2005). In reality, however, clients with
CODs may experience more difficulty in achiev-
ing total abstinence than do clients with SUD
because of their impaired cognitive functions and
other psychiatric symptoms (Carey et al., 2001;
StJN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 31
DiClemente et al., 2008; Horsfall et al., 2009).
Reduced use and harm reduction goals rather
than total abstinence may be more attainable by
individuals with CODs, especially individuals
with SMI (Carey et al., 2001; DiClemente et al.,
2008).
Structure, Concreteness, Repetitiveness, and
Degree of Alertness. Group sessions with a topical
focus are better than process groups; in-session
role playing and in-session homework can also
enhance session structure (Carey et al., 2001;
Evans & Sullivan, 2001). Providing written cues
with respect to daily activity checklists and using
written worksheets to guide each session may be
helpful to individuals with schizophrenia as they
may have difficulty with auditory materials (Carey
et al, 2001; Evans & Sullivan, 2001; Ziedonis
et al., 2005). Information related to CODs and
the link between AOD and negative consequenc-
es needs to be presented to clients repeatedly, and
opportunities need to be offered to practice newly
learned skills over and over (Evans & Suüivan,
2001; Ziedonis et al., 2005). Ziedonis et al.
further suggested adapting interventions according
to a patient’s level of alertness.
Modified CBT
CBT helps a chent identify- his or her internal
triggers (thoughts, feelings, and emotions) and ex-
ternal triggers (events, acti\’ities, and incidents)
and learn skills to effectively deal with those trig-
gers. RCTs have reported efficacy in MI with
CBTs in improving alcohol problems among
chents with CODs of depression and AOD disor-
den (Baker et al., 2010) and in CBTs and CBT
plus contingency management reducing substance
use and posttraumatic stress disorder (PTSD) and
other psychiatric symptoms among clients with
CODs of PTSD and AOD disorder (Hien,
Cohen, Miele, Litt, & Capstick, 2004 [N = 107];
Lester et al, 2007 [N=118]). Cleary et al.’s
(2009) review of another four RCTs revealed that
a combination of MI and CBT over a longer term
improves substance abuse and mental health out-
comes of clients with CODs, including chents
with comorbid schizophrenia and AOD disorden.
Their revie^v further showed inconsistent support
for the application of stand-alone CBT to help in-
dividuals with CODs—a 16- to 20-session round
of CBT targeting clients with bipolar disorder ap-
peared to be effective, whereas a 6- to 12-session
round of CBT working with clients with schizo-
phrenia created no significant difference compared
with a control group.
Research evidence and the consensus of expert
clinicians argue for the following modifications to
CBT to accommodate clients with CODs:
• offering CBT only when chents are stabihzed
(both their SUD and their mental disorders);
• building a working alliance and rapport;
• having clients be active participants, with the
chnician being mainly an educator;
• starting low and going slow, with the chni-
cian undentanding that it takes trust and time
for the clients to change and refraining from
pushing clients too soon to address their in-
grained habits of thoughts;
• using concrete methods (for example, role
playing) and arranging highly structured,
small-group sessions, if a group modality is
adopted;
• helping chents leam specific coping skills to
deal with the combined trials of SUD and
mental disorder;
• accommodating clients’ cognitive limitations
and refraining from addressing too many spe-
cific skills; and
• enhancing clients’ self-efficacy by reinforcing
their early successes (CSAT, 2005; Ziedonis
et al., 2005).
Contingency Management
Contingency management (CM) systematically
reinforces a chent’s desirable behaviors by provid-
ing incentives and discourages the client’s undesir-
able behavion by using disincentives (Petry,
2000). Numerous studies have indicated the posi-
tive effects of CM in reducing the substance use
and other negative behavion of chents with SUD,
at least in the short term (Higgins, Alessi, &
Dantona, 2002; Prendergast, Podus, Finney,
Greenwell, & Roll, 2006). Contingency manage-
ment has also recendy been found to be effica-
cious with chents with CODs (Cleary et al.’s,
2009, review of three RCT studies Prebing
et al., 2005; Ries et al., 2004; Tracy et al., 2007];
Drake, O’Neal, & Wallach’s, 2008, review of five
experimental/quasi-experimental studies [Bellack
et al., 2006; Drebing et al., 2005; Heimus, Saules,
Schoener, & Roll, 2003; Ries et al., 2004;
32 Social Work VOLUME 57, NUMBER I JANUARY 2012
Sigmon et al., 2000]). Drake et al. (2008), citing
Ledgerwood and Petry, stated that “improvements
related to contingency management are probably
unrelated to motivation and other cognitive
factors” (p. 134); they suggested that this may be
an advantage for dual-diagnosis chents.
However, two issues need to be noted. Some
researchen beheve that both a chent’s extrinsic
and intrinsic motivations should be enhanced;
CM often increases only extrinsic motivations,
and the improved behavior may not last long
when the reinforcers stop (Moos, 2007; Prendergast
et al., 2006). For example, Drebing et al.
(2007) found that military veterans with CODs
who receive both vocational rehabUitation and
CM do better in job searching and have a higher
AOD abstinence rate than do those who receive
only vocational rehabilitation. However, the CM
impact on abstinence was not sustained after rein-
forcers stopped. Research suggests combining MI/
MET with CM (BeUack et al, 2006; Drebing
et al., 2007). The second issue is the cost, as CM
necessitates provision of a concrete reward to a
chent each time a desirable behavior is performed.
Strategies targeting this issue are
• considering a prize-based CM (drawing to
determine receiving a prize or not and the
value of a prize), as it is less expensive than a
voucher-based CM;
• seeking donations from community organiza-
tions and companies;
• applying CM only to individuals with severe
impairments (not aU individuals need CM to
change); and
• using nonmonetary rewards.
Although CM is considered highly promising in
helping chents with CODs, research is stiU in the
beginning stage (Cleary et al., 2009; Drake et al.
2008; Drebing et al., 2007).
Dual-Focus Mutual-Aid Groups
Mainstream 12-step group involvement appears to
be associated with better outcomes with respect
to AOD abuse, self-efficacy, motivation, and
coping skills (Kownacki & Shadish, 1999; McKay,
2001), but a mainstream 12-step group may not
be appropriate for individuals with CODs,
because
• it may be prejudicial toward meniben with
CODs because of the stigma attached to
having a mental disorder;
• it may stick to the total abstinence orienta-
tion, \vhich may influence members with
CODs to stop taking prescribed psychiatric
medications, despite this not being the official
position of the Alcohohcs Anonymous or
Narcotics Anonymous organizations; and
• its coUective insights may not necessarily
benefit memben with CODs, as members
with SUD may have very different needs for
recovery than do members with CODs
(CSAT, 2005;Magura, 2008).
A specialized 12-step group allo^vs for open dis-
cussion of not only AOD issues, but also issues
related to mental disorders, psychiatric medica-
tions, medication side effects, psychiatric hospitah-
zations, and other issues regarding which
participants might expedence stigma if discussed
in mainstream 12-step groups (Bogenschutz,
2005). Magura et al. (2003) of specialized 12-step
groups showed that by helping othen, an individ-
ual reinforces self-learning of valued behaviors
and that by sharing recovery experiences, individ-
uals learn from each other. Although few studies
have researched the outcomes of specialized
12-step groups, they suggest that such groups
benefit individuals with CODs more than main-
stream self-help groups do (Bogenschutz, 2007). A
two-year foUow-up study of Double Trouble in
Recovery (DTR), a speciahzed 12-step group
(A/=310), conducted firom 1998 to 2000 by
Magura and coUeagues produced 13 articles.
Based on this 1998-2000 study, Laudet et al.
(2004) reported that continuing DTR attendance
was related to a higher likelihood of abstinence,
and Magura, Laudet, Mahmood, Rosenblum, and
Knight (2002) observed that weekly DTR atten-
dance, not attendance at mainstream self-help
groups, was associated with psychiatric medication
adherence. Magura’s (2008) solo review of this
1998-2000 study suggested DTR’s effectiveness
in four areas: (1) AOD abstinence, (2) psychiatric
medication adherence, (3) self-efficacy for recov-
ery, and (4) quality of Hfe.
Most specialized self-help group studies (for
example, Magura et al.’s, 1998-2000, study) suf-
fered firom a lack of a control group (the same
issue apphes to the studies of mainstream self-help
SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 33
groups). To improve the research design, Magura
et al. (2008) recently conducted a quasi-experi-
mental study and found that a cohort with DTR
exposure had significantly fewer days of AOD use
than did a cohort without DTR exposure, a
finding consistent with the team’s previous find-
ings. Because the speciaUzed 12-step group has a
relatively shorter history, treatment programs
should faciUtate Unkages between their cUents
with CODs and such groups. CUents with CODs
who are in more advanced recovery should also
be encouraged to assume a facilitator’s role; both a
manual and facüitator training are available from
the founden of some dual-focus 12-step self-help
groups (Magura et al., 2003).
CONCLUSION
Helping chronically homeless individuals who are
afflicted with CODs—one major calling for social
workers—involves multiple complex and chal-
lenging tasks. This article suggests four compo-
nents in this regard: (1) ensuring effective
transition of homeless individuals from institutions
into community living; (2) helping them apply
for govemment entitlements and obtain SE; (3)
linking them with supported and supportive
housing, a task that particularly demands practi-
tioners’ creative thinking in the context of the
current economic crisis, which has cut housing re-
sources; and (4) applying and combining modified
ACT, cUnical case management, MI/MET, CBT,
CM, and speciaUzed 12-step groups to maximize
treatment effects. All four components are consis-
tent with social work values; they help social
workers to affirm and empower cUents and link
them with resources.
This article has limitations. The empirical
studies covered here included many more male
than female subjects (for example, about 50
percent to 90 percent of subjects were men,
whereas about 25 percent 😮 60 percent were
women, with a few studies being extreme, includ-
ing 100 percent men, 100 percent women, or
only seven percent women in a veterans study).
Although this reflects the actual gender distribu-
tion in that chronically homeless individuals are
more Ukely to be men, understanding of chroni-
cally homeless women with CODs wül require
more studies with larger samples of women. The
ethnic gap appeared narrower than did the gender
gap. Although a couple of the studies contained
mainly white participants, many had equivalent
portions of white and nonwhite participants, and
in many other studies, African American partici-
pants composed a higher percentage than did
other ethnic groups. This is consistent with statis-
tical data indicating a higher percentage of African
Americans among the homeless population. Also,
the research data covered here were mostly col-
lected from major cities in the United States, with
only Uttle from rural areas; rural homeless individ-
uals may have different needs than do urban
homeless individuals. One other issue is that this
article focuses only on individual homeless clients,
not homeless famiUes, as it targets chronic home-
lessness (or homeless clients with CODs), and
homeless famiUes are less likely than homeless in-
dividuals to be chronically homeless. (Nonethe-
less, 30 percent of the U.S. homeless population
are famuies with chüdren, and practitioners should
prepare themselves to help these famuies.) Finally,
COD treatment methods, although emerging and
promising, are stul in their infancy, and more
studies with rigorous designs are needed.
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An-Pyng Sun, PhD, LCSIV, is professor. School of Social
Work, University of Nevada, Las Vegas, 4505 Maryland
Parkway, Box 455032, Las Vegas, Nevada, 89154-5032;
e-mail: an-pyng.sun@un’lv.edu. An earlier version of this
article was presented at the 2010 annual program meeting of
the Council on Social Work Education, October 14-17,
2010, Portland, Oregon.
Original manuscript received November 24, 2009
Final revision received May 31, 2010
Accepted June 9, 2010
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Deaths in the Desert: The Human Rights Crisis
on the U.S.-Mexico Border
David K. Androffand Kyoko Y. Tavassoli
Many would acknowledge that immigration is a major issue in the United States and that
immigradon reform should be a priority. However, there is Utde attention to the human
rights crisis on the U.S.-Mexican border. As a result of dghtened border security since
1994, it is estimated that over 5,000 migrants have died in the Sonoran desert. The crimi-
nalization of immigradon has resulted in a human rights crisis in three areas: (1) the rise of
deaths and injuries of migrants crossing the border in hanh and remote locations, (2) the
use of mass hearings to prosecute apprehended migrants, and (3) abuses of migrants in
immigration detention. These poUcies and practices have serious repercussions for the af-
fected vulnerable population. Despite recent legisladon designed to discourage undocu-
mented immigration, such as Arizona’s Senate Bul 1070, the deterrence strategy has not
diminished migration—it has only increased the suffering and deaths of migrants. Human-
itarian groups are working to prevent more deaths but also have been targeted for crimi-
naUzation. The profession’s ethics compel social workers to work with humanitarian
organizations to prevent more deaths and to advocate for humane immigration reform.
KEY WORDS: border policy; ethics and values; human rights; immigration; migrants
S panning 120,000 square miles along the
U.S.-Mexico border, the Sonoran desert is
a hanh and brutal environment. Summer
temperatures reach highs above 120°F, and winter
lows faU below 32°F. The lack of natural resources,
such as water and plant life, makes it difficult to
sustain human Ufe. Many travelen are Ul-prepared
for this ferocity and perish. Since 1994, it is esti-
mated that more than 5,000 migrants have died in
the desert attempting to cross into the United
States from Mexico and that one migrant dies
every day (Jimenez, 2009). The U.S. Govemment
AccountabOity Office (GAO) has estimated that
the annual number of migrant deaths has doubled
since 1995, more than 75 percent of which oc-
curred in the Arizonan desert (GAO, 2006).
As federal, state, and local immigration poUcy
and enforcement pattems have increasingly re-
stricted immigration and criminaUzed migrants
(Androff et al., 2011), the humanitarian situation
of migrants crossing the Sonoran desert has deteri-
orated (Rubio-Goldsmith, McCormick, Martinez,
& Duarte, 2007). Despite efforts to prevent immi-
gration into the United States, the dangerous
journey north for migrants condnues to result
in deaths, tremendous health risks, separation
from family memben, and the risk of inhumane
treatment if apprehended and detained. To
address this human rights crisis and prevent further
loss of Ufe, volunteen have organized to provide
humanitarian aid to migrants and have in turn
been criminalized.
Undocumented immigrants represented ap-
proximately 4 percent (11.9 miUion) of the U.S.
population and 5.4 percent (8.3 miUion) of its
workforce in 2008, a dramatic increase from a
total of 3.5 miUion in 1990 (Passel & Cohen,
2009). Seventy-six percent of undocumented im-
migrants are reported to be Hispanic, 59 percent
(7 miUion) of whom are fr̂ om Mexico (Passel &
Cohen, 2009). Although undocumented im-
migrants in the United States come from aU
regions around the globe, Mexico has experi-
enced unique economic and social chaUenges; the
Mexican peso crisis and the North American Free
Trade Agreement have increased poverty and in-
equaUty in Mexico since the mid-1990s (GaUegos,
2004; Lovett, 1996). The growth of the ülegal
drug trade and the Mexican government’s crack-
down has resulted in widespread corruption and
violence (Beer & MitcheU, 2004). Many migrants
cross the Sonoran desert after enduring yean of
poverty, seeking opportunities to provide for their
famiUes (Cleaveland, 2010).
doi: 10.1093/SW/5WS034 O 2012 National Association of Social Workers 165
The criminalization of undocumented immi-
gration has contributed to a climate of discrimina-
tion that negatively affects immigrant communities
in the United States and both documented and
undocumented immigrants. This criminalization
has resulted in human rights violations, including
migrant deaths, processing of apprehended mi-
grants in “mass hearings,” abuses in immigration
detention, and inhumane deportation practices.
This article reviews federal and academic data on
these conditions and data compiled by advocacy
groups. Where possible, data from advocacy
groups have been verified with other sources;
however, often these organizations supply the
only data currently available on conditions like
abuse of migrants in immigration detention. Al-
though such anecdotal evidencs has limitations, it
illustrates the conditions faced by migrants. By
placing the crisis on the border within the context
of human rights and social work ethics, this article
aims to stimulate social workers’ commitment
to social justice by advocating for the welfare of
this vulnerable population and a more inclusive
society.
HUMAN RIGHTS AND SOCIAL WORK ETHICS
Article 13 of the Universal Declaration of Human
Rights holds that everyone has the right to freedom
of movement (United Nations, 1948). The
United Nations (1990) has recognized the needs of
international migrants by adoptkig the International
Convention on the Protection of the Rights of All
Migrant Workers and Members of Their Families,
which emphasizes that migrants are not only
workers, but also human beings with families, and
draws attention to the dehumanization and human
rights violations of migrant workers and their fam-
Uies. Although the United States is currently not a
party to this convention, social workers are ethi-
cally obligated to protect the human rights of mi-
grants and their family members. Elvira Craig de
Suva, former NASW presidents quoting from the
NASW poHcy statement on immigrants and refu-
gees, expressed that “the plight of refugees and im-
migrants [must] be considered on the basis of
human values and needs, rathei than on the basis
on an ideological struggle related to foreign
policy” (NASW, 2006, p. 4). The NASW (2008)
Code of Ethics calls social workers to advocate for
noncitizens regardless of immigration status (see
section 6.04[d], “Social and Political Action”).
CRIMINALIZATION OF MIGRANTS AND
HUMANITARIAN AID WORKERS
As different ethnic groups have immigrated to the
United States, immigrants have been alternately
viewed as public menaces or threats to national
security and subjected to discriminatory policies
(Padüla, Shapiro, Fernandez-Castro, & Faulkner,
2008). This article focuses on the impact of immi-
gration policy on undocumented immigrants;
however, many policies targeting this population
also affect documented immigrants and citizens.
The current trend toward controlling undocu-
mented immigration began in the 1980s when
Congress criminalized the unauthorized hiring of
noncitizen workers and using false documents to
evade employer sanction laws and increased pen-
alties for immigration violations (Chacón, 2009).
Immigrants have also been excluded from social
welfare benefits; in 1996, welfare reform discour-
aged immigrants from accessing benefits, regard-
less of legal status (PadiUa, 1997). Even legal
permanent residents with green cards face restrict-
ed eligibuity for most benefits and are required to
meet a minimum of five years’ residency with
proof of good character (PadiUa, 1997).
State and Local Policies
Border states such as Arizona have become central
batdegrounds in the criminalization of immigra-
tion policies. In 2002, Arizona passed an identity
theft law (Ariz. Rev. Stat. §13-2008, 2002) to
criminalize the use of “fake” identities. In 2004,
Arizona passed Proposition 200 (Arizona Tax-
payer and Citizen Protection Act, 2004) to deny
public benefits to undocumented migrants; pubHc
employees who fail to check the immigration
status of clients are subject to fines or jaü time
(Furman, Langer, Sanchez, & Negi, 2007). In
2005, the Arizona Smuggling Law (Ariz. Rev.
Stat. §13-2319, 2005) made smuggling migrants a
felony. The Maricopa County Attorney’s Office
has prosecuted migrants as coconspirators in their
own trafficking by having consented to be trans-
ported across the border. Recendy, Arizona
passed Senate Bul 1070 (Support Our Law
Enforcement and Safe Neighborhoods Act of
2010), the most restrictive state immigration
166 Social Work VOLUME 57, NUMBER 2 APRIL 2012
poUcy in the United States, which grants local law
enforcement unprecedented latitude to detain
people if there is “reasonable suspicion” that they
may be in the country without documentation.
FoUowing a federal injunction that blocked most
provisions, this law is currentiy under appeal yet
has already contributed to a cUmate of discrimina-
tion against undocumented immigrants.
Federal Apprehensions and Prosecutions
of Migrants
In 2008, the U.S. Department of Homeland
Security (DHS) (2009) apprehended 791,568
foreign nationals in the United States without
documentation, 88 percent of whom were
Mexican nationals. Ninety-one percent of these
apprehensions were made by the U.S. Border
Patrol, primarily along the southwest border. The
Tucson Sector covers 262 mues along Arizona’s
border with Mexico and is the busiest sector in
the country, accounting for almost half of aU ap-
prehensions along the southwestern border (DHS,
2009). During the second Bush administration,
annual federal criminal prosecutions for inimigra-
tion offenses increased by four times; this trend
has continued in the Obama administration
(Transactional Records Access Clearinghouse
[TPJVC], 2009), despite a decUne of federal prose-
cutions between 2004 and 2009 for nonimmigra-
tion crimes such as white collar, civu rights,
environmental, and drug-related crimes. The most
frequent immigration charges are illegal entry or
reentry, accounting for 92 percent of all prosecu-
tions (TRAC, 2009). Of the 94 federal districts,
the five along the U.S.-Mexico border process
75 percent of aU criminal cases p H S (2009).
Fatalities in Border Crossings
Another aspect of the criminalization of immigra-
tion poUcy has been what is caUed the “militariza-
tion” of the border; in the mid-1990s, the United
States implemented a “prevention through deter-
rence” strategy of border enforcement (Cornelius,
2001). This has meant a more than doubling of
the U.S. Border Patrol budget and personnel, a
security wall, and other technologies to deter mi-
gration (ComeUus, 2001; Whitaker, 2009). This
effectively closed the border at urban centers and
created a “funnel effect,” resulting in more cross-
ings in remote areas and an increase in migrant
deaths (Cornelius, 2001; GAO, 2006; Rubio-
Goldsmith et al, 2007). It is difficult to estimate
the extent of migrant deaths in the desert, and
studies have used different methodologies, data
sources, and time frames; estimates in the literature
range between 3,861 and 5,607 deaths from 1994
to 2009, or annual averages of from 356 to 529
Qimenez, 2009). AU figures should be used with
caution; the avaüable data sources—including
county medical examiner records, death certifi-
cates in vital registries, and state fataUty review
programs—aU have Umitations (Bowen & Mar-
shaU, 2008; ComeUus, 2001; GAO, 2006;
Jimenez, 2009; Rubio-Goldsmith et al., 2007;
Sapkota et al., 2006). Medical examinen can orüy
investigate deaths where remains are recovered; as
most of the Sonoran desert is an uninhabited,
remote wüdemess, the discovery of remains is de-
pendent on their identification by U.S. Border
Patrol agents or others, and researchers agree that
not aU remains are recovered (Bowen & MarshaU,
2008; ComeUus, 2001; GAO, 2006; Jimenez,
2009; Rubio-Goldsmith et al., 2007; Sapkota
et al., 2006). In addition to unrecovered bodies in
the desert, studies exclude counts of drowning
victims whose remains are deposited on the
Mexican side of the Rio Grande, of cases in
which a decedent’s country of origin is undeter-
mined, and when it cannot be determined if the
decedent was an “ülegal entry” (GAO, 2006;
Rubio-Goldsmith et al., 2007; Sapkota et al.,
2006). In addition to varying methodologies,
another explanation for the disparity in estimates
may be that, as with other difficult-to-measure
social problems Uke human trafficking, govern-
ment figures tend to minimize estimates, whereas
advocacy groups use higher estimates to draw at-
tention to an issue (Androff, 2011). However, U.S.
government agencies, academic researchers, and
nongovernmental organizations concur that the
death count is in the thousands and that estimates
based on recovered bodies consistently undercount
the actual number of deaths (Bowen & MarshaU,
2008; GAO, 2006; Rubio-Goldsmith et al., 2007;
Sapkota et al., 2006; Whitaker, 2009).
There is also consensus on the increase of
migrant deaths along the border, despite an in-
crease in border security and decreases in estimat-
ed undocumented entries and apprehensions,
which may suggest a decUning trend in undocu-
mented migration due to the recent economic re-
cession (GAO, 2006; Jimenez, 2009). The U.S.
ANDROFF AND TAVASSOLI / The Human Rights Crisis on the U.S.-Mexico Border 167
Border Patrol estimates a 29.1 percent increase in
migrant deaths from 1998 tc 2004 (Jimenez,
2009). The GAO (2006) estimated that deaths
doubled from 1995 to 2005. Rubio-Goldsmith
et al. (2007) found a 20-fold increase in recovered
bodies from 1990 to 2005 in tne Tucson Sector
alone. ComeHus (2001) estimated a 474 percent
increase in deaths along the southwest border
from 1996 to 2000. The number of deaths among
migrants who are women and children has also
increased (Bowen & Marshall, 2008; Jimenez,
2009). Sapkota et al. (2006) found that migrant
deaths are largely preventable. Environmental ex-
posure, the leading cause of deaths of migrants,
has increased even though migrant deaths due to
other causes (such as traffic accidents and homi-
cides) have declined (Rubio-Goldsmith et al.,
2007; Sapkota et al., 2006). Migrants unprepared
for the harsh terrain lack basic food and water to
survive. Any reason for migrants to be left behind
can make them susceptible to death; a blister can
be fatal. Death by exposure is slow and agonizing;
physical detetioration and organ failure are ac-
companied by confusion and disotientation. In
addition to the common tisks of snakebites and
getting lost, ctiminal gangs prey on migrants,
robbing, raping, and killing them.
Responses to the Crisis
Several prevention measures have been imple-
mented, such as pubHc health campaigns to dis-
courage migrants in Mexico, warning signs in the
desert stating the tisk of death and encouraging
migrants to turn back, and search-and-rescue
operations by the U.S. Border Patrol for migrants
in distress (Sapkota et al., 2006; Whitaker, 2009).
However, these efforts have not stopped the
overall increase in the rate of deaths (Guerette,
2007), so Atizona citizens have organized a re-
sponse based on human tights, humanitatianism,
and religious faith. Believing the deaths to be pre-
ventable, the grassroots groups Humane Borders,
Samatitans, and No Más Muettes (NMM) (No
More Deaths) provide rehef by meeting migrants’
basic needs for hydmtion and health. Since 2000,
Humane Borders (n.d.) has managed 100 water
stations with over 200 members and 1,500 volun-
teers. Since 2002, Samatitans (n.d.) has provided
emergency medical aid to hundreds of migrants
through daily patrols. A coalition of interfaith and
community groups formed NMM in 2004 and
has helped over 250,000 migrants through water
stations, desert aid camps, and relief camps for de-
ported migrants who are left on the Mexican side
of the border without resources (NMM, 2008).
However, these groups have also been ctimi-
nalized. In 2005, two NMM volunteers were ar-
rested for transporting a migrant to a hospital
(NMM, n.d.). In 2008, Dan Millis, another vol-
unteer, found the body of a 14-year-old girl from
El Salvador in the desert (NMM, 2010). This girl
and her 10-year-old brother were crossing the
border with a group of migrants when she
became very iU and could not keep up. Urging
her brother to continue with the group to be re-
united with their mother in California, she was
left behind and died of exposure. Two days later,
Millis was issued a Htteting ticket by the U.S. Fish
and Wildlife Service for placing water jugs along
migrant trails, despite having collected five crates
of trash. MOHs refused to pay the $175 fine,
arguing that providing humanitatian aid is not a
crime. In 2010, an appellate court overturned the
conviction (NMM, 2010). In 2009, Walt Staton
was sentenced to 300 hours of community service
for leaving water for migrants (Whitaker, 2009).
In 2009, 13 more NMM volunteers were ticketed
for Htteting; their case has been dropped (NMM,
n.d.). Ctitics contend that providing humanitatian
relief encourages migrants, yet volunteers post
warning signs and disttibute information on the
tisks of death and injury, and such aid has not
been shown to influence migrants’ decisions to
cross the border (Whitaker, 2009).
OPERATION STREAMLINE
Operation Streamline, established in 2005, enforc-
es a federal zero-tolerance border policy by ctimi-
nally prosecuting all people caught crossing the
border without documentation (WUHams, 2008).
To cope with the number of defendants, the
courts have combined initial appearances, arraign-
ments, pleas, and sentencing into a single day and
one “mass heating.” Up to 80 people are chosen
from a larger group of apprehended migrants for
the daily court docket and given less than 30
minutes with an attorney (WOHams, 2008). Ques-
tions are posed to the migrants en masse and
answers, such as pleas, are taken in unison. Most
migrants admit that they are not citizens and plead
guilty to enteting the United States without in-
spection at a port of entry. If they do not have a
168 Social Work VOLUME 57, NUMBER 2 APRIL 2012
criminal history, they are sentenced to time served
and deported; migrants with a history of criminal
or immigration violations face longer detention.
This assembly-line processing of migrants de-
prives them of due process (Chacón, 2009;
Jimenez, 2009; Lydgate, 2010; National Network
for Immigrants and Refugee Rights [NNIRR],
2009; Williams, 2008). Mass hearings diminish the
ability of defense attorneys to provide effective as-
sistance of counsel. Potential defenses like deriva-
tive citizenship, immigration relief, and midgating
information cannot be fully explored, limiting the
ability of counsel to provide advice. Claims of in-
competency due to mental illness, lack of educa-
tion, intoxication (the rate of processing may not
allow time for detoxification), physical iUness, in-
adequate nourishment or sleep, and migrants’
primary language not being English or Spanish go
unaddressed (Williams, 2008). Migrants may not
understand their rights, the pleas they are enter-
ing, or what it means to be charged with a crime
in a federal court of law that jeopardizes their
ability to obtain future legal residency or citizen-
ship. During mass hearings, individuals may be
discouraged from speaking up, and questions
about procedures or plea agreements may remain
unanswered. Streamlining has resulted in sky-
rocketing numbers of cases in border districts;
immigration offenses grew more than 330 percent
from 2002 to 2008. Previously, migrants, especial-
ly fint-time border crossers, were voluntarily
returned to Mexico. Streamlining has diminished
judicial and prosecutorial discretion, and it
diverts resources from the investigation and prose-
cution of trafficking and smuggling cases (Lydgate,
2010).
DETENTION AND DEPORTATION
Immigration detention is the fastest growing form
of incarceration in the United States, and immi-
grants are the fastest growing population in federal
prisons (Lopez & Light, 2009). U.S. Immigration
and Customs Enforcement (ICE) detained a
record 378,582 individuals in 2008, up 22 percent
from 2007. Forty-nine percent of detainees were
Mexican nationals (DHS, 2009). As of 2009, there
were 32,000 people in immigration detention on
any given day in over 300 facilities around the
country, almost four times the 8,279 in 1996
(ICE, 2008). People held in ICE custody for over
72 hours are considered to be in long-term
detention; the average detention is 30 days, al-
though such detentions may last months or years.
Human rights abuses such as physical and verbal
abuse, lack of medical care and legal counsel, and
inhumane conditions have been documented in
long-temi detention (DHS 2006; Phillips, Hagan,
& Rodriguez, 2006; Southwest Institute for Re-
search on Women, 2009). A total of 110 detainees
have died in immigration detention since 2003
(ICE, 2008); research has suggested that some of
these deaths were the preventable result of inade-
quate and substandard medical care (Venters,
Dasch-Goldberg, Rasmussen, & Keller, 2009).
On apprehension, migrants are held for 72
hours or less in service processing centers, await-
ing a court appearance to determine their
status. This short-term custody is unregulated and
lacks oversight (NMM, 2008; NNIRR, 2009).
Between 2006 and 2008, NMM (2008) docu-
mented 345 cases of substantiated human rights
abuses of migrants in short-term custody, such as
the denial of food, water, and medical care; physi-
cal, sexual, and verbal abuse; and the separation of
families, including parents and children. For
example, when held ovemight without food or
water, one woman begged for water for her chil-
dren, ages six and nine; Border Patrol officen
drank in front of them and refused to provide any
water (NMM, 2008). Migrants often receive no
medical attention for injuries suffered prior to or
during apprehension, such as blisters, sunbum,
dehydration, and lacerations (NMM, 2008). Preg-
nant women have been denied medical care, and
othen have had medication confiscated (NMM,
2008). Conditions in short-term custody can be
inhumane, including the denial of bathroom facil-
ities, extreme temperatures in cells, and refusals to
provide blankets to women and children, even
infants (NMM, 2008).
Removal refers to deportation, when people
receive formal deportation orders by a judge, and
repatriation refers to when people are voluntarily
returned to their country of origin. A total of
356,739 people were removed in 2008, over three
times more than the 116,464 removed in 2001
(ICE, 2008). Mexican nationals accounted for 69
percent of all removals in 2008 P H S 2009).
More than 1,000 such “expulsions” occur daily
along the southwest border, at all hours of the day
and night (NMM, 2008). Women and children
are particularly vulnerable to crime at the border
ANDROFF AND TAVASSOLI / The Human Rights Crisis on the U.S.-Mexico Border 169
when repatriated at night. Belongings such as
identification, money, and clozhes are often not
retumed on repatriation (Williams, 2008). Mi-
grants have reported physical aad verbal abuse on
removal; for example, one malí migrant reported
being kicked in the stomach by Border Patrol
agents and denied medical attention (NMM,
2008). At an aid station in Mexico, the Red Cross
recommended surgery for sweUing in his genitals
and blood in his urine, indications of abdominal
or testicular injury (NMM, 2008). U.S. deporta-
don poUcy often leads to the separadon of families
(Hagan, Eschbach, & Rodriguez, 2008). Humani-
tarian volunteen have witnessed the deUberate
separation of hundreds of famuy memben in
custody and their repatriadon to different ports of
• entry, making reunification extremely difficult
(NMM, 2008). In one case, an adult male and his
teenage sister were separated by the Border Patrol;
the man was repatriated but was not given any in-
formation about his sister, v̂ ĥo was likely repatri-
ated somewhere else (NMN4, 2008). A growing
number of people expeUed to Mexico are appre-
hended in the interior of the United States.
Having Uved in the United Ststes for yean, they
speak only or primarily EngUsh, have famiUes and
children who are citizens, and Uttle or no des to
Mexico (NMM, 2008).
IMPLICATIONS FOR SOCIAL WORK PRACTICE
The criminaUzation of immigradon and the
border security poUcy of “pcevention through
deterrence” have increased tlie apprehensions,
prosecutions, détendons, and deportations of mi-
grants. These poUcies have contributed to a crisis
on the U.S.-Mexico border: The deaths of mi-
grants, mass hearings of apprehended migrants,
abuses in detendon, and deportations violate uni-
venal human rights. The chaUenge is how social
worken respond to this crisis; social worken can
take action to promote human rights and social
justice for migrants through direct pracdce, macro
pracdce, and advocacy for poUcy reform.
Social Work Practice with Iramigrant
Populations
Social worken should strive to provide culturaUy
competent services by attending to the stress
of immigration on famiUes (Furman, Negi, &
Cisneros-Howard, 2008; PadMa, 1997). The
specific problems described in this article pertain
primarily to Latino immigrants; however, immi-
grants and refugees of other ethnicities may be
affected by similar human rights violations in their
immigradon joumeys. Although social work prac-
tice with immigrants is not new, the contempo-
rary prominence of immigration and concomitant
anti-immigrant cUmate requires social workers to
attend to these issues in their practice with
renewed emphasis. For social worken engaged in
cUnical practice, this can be accompUshed through
enhanced assessment, treatment planning, and
case management services. As part of a compre-
hensive assessment process, social work practition-
en should explore immigradon history with aU
their cUents. Immigrants and their families may be
suppressing histories of immigration replete with
incidences of trauma and experiences of human
rights violations; practitionen should be cognizant
of such faetón in assessing the effects of these ex-
periences on their cUents. Treatment plans should
be developed with the recognidon that immigra-
tion experiences may affect every facet of immi-
grants’ weU-being, such as housing, education,
health care, and employment. Treatment plans
should also incorporate measures to address the
effects of discriminadon faced by immigrants.
Case management services should include referrals
for EngUsh language services, job-training skills,
employment, and legal aid. Effective social work
pracdce requires practitionen to be educated
about the cunent chaUenges faced by immigrants
and their famiUes.
Direct Practice with Latino Immigrants
There is no greater respect for the dignity and
worth of a penon than to prevent death. Direct
pracddonen can take an active role in supporting
the lifesaving efforts of humanitarian groups
working with migrants on the border—for
example, by volunteering with NMM. In addi-
don to assisting in the basic work of placing water
on migrant trails, social worken can contribute
speciaUzed cUnical sldUs and provide psychosocial
and crisis intervention services to migrants in dis-
tress. Social worken can make donations of
money and goods to these groups. Clinicians can
also provide services to volunteen experiencing
secondary trauma from working with dead and
170 Social Work VOLUME 57, NUMBER 2 APRIL 2012
dying migrants. Direct practitioners can buud col-
laborations with social workers in Mexico to
provide psychosocial services at relief centers along
the border for deported migrants. In their own
communities, direct practitioners can conduct
workshops and trainings on the psychosocial
effects of racism, discrimination, and trauma.
Direct practitioners can influence the immigra-
tion debate by using nondiscriminatory language,
using terms such as “undocumented” rather than
“ülegal,” a term that reinforces a criminal justice
frame. In their own practice, social workers may
be confronted with policies requiring them to
check immigration statuses before delivering ser-
vices. Social workers should challenge policies
that conflict with their ethical values, and they
can partner with and make referrals to legal advo-
cates and immigration lav̂ ryers to protect their
clients’ rights. Social workers should report cases
in which their clients are denied services and care
on the basis of their status; documenting cases
with NASW and civil rights groups can contri-
bute to advocacy efforts. Latino and immigrant
populations already underuse social services
(Furman et al., 2008); direct practitioners should
be sensitive to the risks of service underutilization
and unreported victimization that may result from
increased discrimination. Through case manage-
ment services, referrals to community- and
school-based services may be useful for linking
famihes to services (PadiUa, 1997).
Latino and immigrant families may have rela-
tives who are undocumented or who came into
the United States without documentation; social
workers with Latino and immigrant clients should
conduct assessments with the awareness that their
own clients or their chents’ famuy members may
have suffered physical and psychological trauma
from their immigration experiences. Chencs and
their families may have been vulnerable to human
trafficking and abuse by human smugglers, injuries
or deaths from crossing the border, and abuses
whue in immigration detention. Many families in
the United States do not know what became of
relatives who attempted to cross the border but
did not arrive in the United States; they may have
died in the desert undiscovered, been detained,
had their rights violated, or been deported to
Mexico without resources or connections. Social
workers can attend to the needs of separated
families and work to promote the reunification of
families separated by immigration policies.
Macro Practice and Policy Advocacy for
Immigration Reform
All social workers have an ethical responsibility to
advocate for humane and socially just policies;
social workers can use the NASW (2006) Immigra-
tion Policy Toolkit to do this. In addition, social
workers should write letters to local, state, and na-
tional representatives as weU as to media outlets.
Social worken should work within their local
NASW chapters to promote advocacy, and they
should attend state lobby days. Direct practitionen
can also translate their clients’ experiences into ad-
vocacy by providing testimony to legislative
bodies on the impact of immigration policies.
Macro practitioners can work to organize im-
migrant communities and form coalitions of
stakeholder and aUied groups affected by discrimi-
natory immigration policies, such as memben of
the business community, labor groups, and
church congregations. Engagement with the im-
migration debate and advocacy on behalf of mi-
grants presents opportunities for social work to
recommit to the values of the protection of vul-
nerable populations and social justice (Cleaveland,
2010; Furman et al., 2008).
Social workers should advocate for immigration
policies that embody the values of equahty, fair-
ness, justice, and respect for human relationships
(Padilla et al., 2008); NASW (2006) supports
comprehensive immigration reform and acknowl-
edges that current immigration policy compro-
mises civu rights and social justice. Border security
pohcy should be reformed to prevent the unnec-
essary deaths of migrants. The “prevent through
deterrence” strategy has not reduced migration or
deterred migrants; it has only increased their suf-
fering. With legislation such as Arizona’s SB 1070,
the trend toward punitive immigration policies is
increasing and wül likely produce more of the
same deadly results. Research with migrants has
shown that the primary factors influencing deci-
sions to migrate include the health of the U.S.
economy, the cost of crossing, and personal and
family circumstances (Cleaveland, 2010; Lydgate,
2010). To facilitate relief for migrants and prevent
future deaths, U.S. Border Patrol search-and-
rescue operations should be increased and work in
ANDROFF AND TAVASSOLI / The Human Rights Crisis on the U.S.—Mexico Border 171
concert with humanitarian groups in the provision
of food, water, and medical aid. Operation
StreamUne should be suspended for the harm it
does to the rights of defendants; due process and
the constitutional protection of rights should be
restored. Human rights abuses and inhumane
treatment in iminigration detention should never
be permitted. Regulations and standards for care
of migrants in short-term custody must be
adopted. Removal and deportation practices
should be reformed to respect famuy relationships
and promote family reunification.
Immigration must be decriminalized; immi-
gration violations are technically civu offenses
(Chacón, 2009). Significant reform must include
an increase in the options for legal avenues of im-
migration, legal pemianent residency, and citizen-
ship as well as a reduction in the backlogs and
lengthy delays for appUcants. Current immigration
poUcy marginalizes those migrants quiedy Uving
and working in the United States by criminaUzing
their status. Reform needs to bring them out of
the shadows through a nonexploitative guest
worker poUcy and a system to address current un-
documented immigrants who are without crinunal
backgrounds. Social workers should promote poU-
cies that expand opportunities for migrants, such as
restoration of eUgibüity for a safety net of social
and medical services and the DREAM Act, which
would provide access to higher education for
chüdren of undocumented immigrants. Social
worken should oppose immigration policies that
contribute to discrimination against migrants, such
as the constitutional guarantee of citizenship for
aU bom in the United States and English-only
policies.
Migration is a complex international phenome-
non. Social workers must encourage poUcies that
address the social, poUtical, and economic context
of immigration, such as responsible trade, good
governance and democratization, economic
growth, and social development. With an ethical
imperative to promote social justice and a more in-
clusive society, social workers cannot choose to
remain neutral and aUow the tragedy of migrant
deaths to continue. These deaths must be recog-
nized as an international human rights crisis;
human rights abuses wül continue if there is no
sigmficant reform. Unless something changes,
more men, women, and chüdren wül die in the
desert. These deaths are not inevitable.
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David K. Androff, PhD, MSW, is assistant professor, and
Kyoko Y. Tavassoli, MSW, is a doctoral student. School of
Social Work, Arizona State University, Phoenix. Address
correspondence to David K. Androff, School of Social Work,
Arizona State University, Mail Gode 3920, 411 North
Gentral Avenue, Suite 800, Phoenix, AZ 85004; e-mail:
david.androff@asu.edu.
Original manuscript received Aprii 29. 2010
Final revision received November 16. 2010
Accepted November 19. 2010
ANDROFF AND TAVASSOU / The Human Rights Crisis on the U.S.—Mexico Border 173
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