Handbook of Social Work Practice with Vulnerable and Resilient Populations

CHAPTER 1

Social Work Practice with Vulnerable and Resilient Populations

ALEX GITTERMAN AND LAMBRINE A. SIDERIADIS

Through our teaching and practice experiences, we have become distressed by the increasing degradation and distress faced by large sectors of the client population served by social workers. Students and professionals confront daily the crushing impact of such problems as mental illness, substance abuse, disability and death, teenage pregnancy, and child neglect and physical and sexual abuse. Clients suffer from the debilitating effects of such life circumstances as homelessness, violence, family disintegration, and unemployment. The miseries and human suffering encountered by social workers in the new millennium are different in degree and kind from those encountered in the 1960s, 1970s, 1980s, and 1990s. The dismantling of the welfare state, the consequences of welfare reform, and foreclosures are examples of newly devastating social phenomena.

Social workers in practice today deal with profoundly vulnerable populations, overwhelmed by oppressive lives, and circumstances and events they are powerless to control. The problems are often intractable because they are chronic and persistent, or acute and unexpected. When community and family supports are weak or unavailable and when internal resources are impaired, these populations are very vulnerable to physical, cognitive, emotional, and social deterioration. Yet, in spite of numerous risk factors and vulnerabilities, a surprisingly large number of children, for example, mature into normal, happy adults. Why do some people remain relatively unscathed and somehow, at times, miraculously manage their adversities? Why do some thrive and not simply survive in the face of life’s inhumanities and tragedies? To more fully understand the human experience, this book examines vulnerability and risk factors as well as resilience and protective factors.

Defining and Explaining Life Conditions, Circumstances, and Events

After a brief introduction about the respective population, contributors analyze the definitions of the life condition, circumstance, or event. What are the different political and theoretical definitions and explanations of the condition, circumstance, or event? What are the effects of the definitions and explanations on the larger community, service providers, and service users? With certain personality conditions such as chronic depression, schizophrenia, and borderline personality, and with certain addictions such as alcoholism, growing evidence suggests potent predisposing genetic, biochemical factors. Researchers’ studies have, for example, analyzed the life careers of identical twins separated at birth and have used other tracking designs to find significant genetic linkages to alcoholism (Cloninger, 1983, 1987; Doweiko, 2006; Palmer et al., 2012), bi-polar disorder (Gallitano, Tillman, Dinu, & Geller, 2012), depression (Pirooznia, Seifuddin, Judy, Mahon, Potash, & Zandi 2012), and schizophrenia (Gejman, Sanders, & Duan, 2010).

These conditions have in common certain genetic and neurochemical predispositions. With alcoholism, for example, serotonin and dopamine, major neurotransmitters used by the central nervous system, have been associated with depression. Research suggests that chronic alcohol use decreases the number of dopamine receptors in the brain and reduces serotonin turnover. Decreased levels of dopamine and serotonin have been linked to depression and increased risk of violent behaviors, such as suicide, among chronic alcohol users (Doweiko, 2006). The brain also manufactures natural substances that have painkilling properties. Kosten and George (2002) suggest that narcotic analgesics mimic the action of these natural substances resulting in a sensation of drug induced euphoria when the user is not experiencing pain. Thus, neurochemical imbalances appear to be associated with various life conditions.

With AIDS, our vulnerability to parasitic relations with microorganisms from within and without is ominous. AIDS continues to be one of the leading causes of death among all Americans aged 25 to 44. The biological reality of AIDS demonstrates how defenseless our immune systems can be to parasitic and toxic environments. With other life conditions such as anorexia and bulimia, the genetic linkages have not yet been discovered. Thus far, personality and family dynamic explanations are most frequently offered to explain these conditions. We should not, however, be surprised if in the near future genetic and biochemical predisposing conditions are discovered. With obesity, however, there is clear evidence of genetic influence (Garaulet, Ordovas, & Madrid, 2010; Spruijt-Metz, 2011).

Chronic physical illnesses and disabilities and learning and developmental disabilities reflect problematic physiological and neurological functions. Developmental disability often has genetic determinants (Butler & Meany, 2005). Similarly, possible genetic bases for the condition of Alzheimer’s disease (Kuller & Lopez, 2011) and cancer have also been identified (Hall, 2012). Even though many of the presented life conditions have genetic determinants, they may not be inherited. Certain toxic environmental agents can damage and disrupt normal genetic processes. A mother abusing alcohol, for example, may give birth to an infant with fetal alcohol syndrome, which is often characterized by developmental disability, facial deformity, etc. Radiation can cause infertility and birth defects (Cwikel, Gidron, & Quastel, 2010; Sabin et al., 2012). Whatever the cause, physiological and cognitive impairments severely curtail human activities. People with these life conditions often suffer for protracted and indefinite time periods. Their neurological and physiological disabilities create limitations and burdens of varying severity.

Genetics, biochemistry, neurological loading, and predisposition to a condition do not imply, however, that a person will necessarily acquire the condition or, if the person does acquire it, be debilitated by the condition. The resources and the limitations in the person’s environment, i.e., family, relatives, friends, workmates, neighbors, community, organizations, and spiritual life, all transact with individual constitutional resources and limits. On one end of the continuum, high genetic and organic loading may push certain people toward alcoholism, depression, borderline personality, or schizophrenia regardless of how protective and supportive the environment (although a supportive environment can certainly cushion its consequences). Similarly, a youngster born developmentally disabled or severely physically disabled has to function within the constraints of these neurophysiological impairments. Although supportive environments can provide essential instrumental and expressive resources, they cannot eliminate the disability itself. On the other end of the continuum, severely impoverished and invalidating environments may push certain people toward alcoholism or depression no matter how well they are constitutionally endowed. A youngster repeatedly exposed to malnourishment and physical and emotional abuse may succumb to these harsh environmental assaults with alcoholism or depression despite limited, or even no, genetic predisposition. Studies of psychiatric epidemiology have demonstrated that the lower the social class, the higher the rates of mental illness and the greater the severity of the mental illness (Mauksch, Reitz, Tucker, Hurd, Russo, & Katon, 2007; Sheperis & Sheperis, 2012).

Family, community, and society dysfunctions provide the most frequent theoretical explanations for the distressing life circumstances and events presented in this book. Unplanned pregnancies, for example, are associated with poverty, repeated academic failures, and pervasive lack of opportunities with consequent hopelessness and despair. Community and family norms reinforce or mitigate the personal impact of poverty. In intimate partner violence, the female as victim of her male partner is the principal problem. A pattern of control over the female maintained by physical, emotional, and sexual abuse is associated with violence and battering. On a more general level, sexism and sex-role socialization surely contribute to, if not induce, intimate partner violence. Boys observing their fathers abuse their mothers are more likely than otherwise to be violent toward their own wives (McClennan, 2010). Clearly, intimate partner violence is learned behavior that has to be unlearned.

No citizen, regardless of class or social status, is safe from crime. Women, children, and the elderly, especially those living in poor communities, are at highest risk of victimization by crime. They simply are easier prey! Perpetrators tend to be caught in a cycle of family poverty, illiteracy, drugs, racism, child abuse, and family violence. When they are incarcerated, they usually return to their community further damaged, hardened, and embittered. They often become socialized to a lifetime of crime and intermittent incarceration. In poor communities, both the victim and the perpetrator are trapped in the mire of despair. Similarly, the elimination of low-income housing, underemployment and unemployment, sharply curtailed and disappearing benefit programs, lack of health insurance, foreclosures, and deinstitutionalization have all conspired to create homelessness and an unconscionably large number of adults and children deprived of the basic human need for shelter.

The life event of being born black in the United States creates a trajectory with profound impact on education, employment, housing, health, and family life. For example, black Americans suffer higher death rates from most major causes. They receive less and poorer health care and die four to five years earlier than white Americans (National Vital Statistics, 2010). Moreover, major changes have taken place in the composition of black American families over the last several decades. In the 1950s, 78 percent of black families were composed of couples, compared with only 35 percent in 2010. During the same period, the presence of couples in white families witnessed a smaller decline, from 88 percent to 75 percent (U.S. Census Bureau, 2012).

When people find themselves in distressing life circumstances and dealing with stressful or traumatic life events, some become helpless, hopeless victims. They live on the margin struggling for day-to-day survival. Others somehow miraculously and astonishingly manage deeply adverse situations as survivors, not as victims. Various theories attempt to explain what differentiates a victim from a survivor. Unfortunately, most of our theories have focused on the deficits and negative aspects of individual and family life. Since many of our theoretical approaches are based on people who do not rebound well from life’s miseries, we know much less about those who do and how they do it. Rutter (1971) eloquently captures this pattern:

There is a most regrettable tendency to focus gloomily on the ills of mankind and on all that can and does go wrong. It is quite exceptional for anyone to study the development of those important individuals who overcome adversity, who survive stress and rise above disadvantage. (p. 7)

By developing knowledge about the positive as well as the negative poles of people’s lives, social workers are more likely to formulate balanced assessments and responsive interventions. For example, children dealing with parental alcoholism or divorce must find ways to disengage and to develop psychological distance from daily conflicts and hassles. Adaptive distancing requires the ability to disengage internally while pursuing and sustaining external connections (Berlin & Davis, 1989).

Many theoretical explanations pathologize the black family. By evaluating and judging from the outside, however, we miss the resourceful survival adaptations, such as: They 1) may be comprised of several households; 2) have a multiple parenting and inter familial consensual adoptions; 3) are child-centered; 4) have a close network of relationships between families not necessarily related by blood; and 5) have flexible and interchangeable role definitions and performance (Fine & Schwebel, 1991, p. 34). These features provide the kinds of conditions that nurture the development of protective factors that also promote resilience. That many poor families of color survive extreme poverty, racism, and oppression is a tribute to their resilience in overcoming overwhelming odds.

While various theories attempt to explain what differentiates a victim from a survivor, no single theory is apparently capable of providing a comprehensive explanation. We do know, however, that people’s social functioning and adaptations reflect the interplay and degree of congruence and compatibility between body, mind, and environment. Sometimes people’s exchanges with their environments are mutually fulfilling. The congruence and compatibility between people and their environments provide the context for realization of potential. Other times, these exchanges can lead to isolation and alienation. A poor fit limits realization of potential. How people perceive their constitutional and environmental resources and limitations, their personal attributions and social constructions, also has a profound impact. Thus, two people with similar constitutional and environmental attributes may perceive subjectively their personal and environmental resources quite differently and consequently function at differing levels. And, finally, there is the simple element of chance—good fortune and misfortune. Although our efforts to be scientific may cause us to shy away from the idea of chance, it may well enhance our understanding and feeling for the human experience.

Demographic Patterns

Each contributing author in this text presents available demographic data about the particular life condition, circumstance or event. Webster’s dictionary defines vulnerability as capable of being wounded; open to attack or damage. Research into physical or emotional wounding consistently identifies two associated risk factors for physical and emotional deterioration: prolonged stress and cumulative stress. And among many factors, chronic poverty is the major force responsible for both prolonged and cumulative stress.

According to the United States Census Bureau October (2011), the poverty rate in the United States increased from 12.2 percent in 2000 to 15.3 percent in 2010, representing the highest level since 1993. Accordingly, 46.2 million people lived in poverty in 2010 (income below their respective poverty thresholds). Although the child poverty rate has fluctuated over the past ten years, the percentage of poor children under the age of 18 years has risen from 16.9 percent in 2001 to 21.6 percent in 2010. Currently, one out of five of the nation’s children is living in poverty with 1.1 million children added to the poverty population since 2009. Poverty creates chronic disadvantages and problems for children. Poor children have higher rates of infant mortality, have higher rates of physical and mental health problems, complete fewer years of education, and are more likely to be underemployed or unemployed as adults (Wagmiller, Lennon, Kuang, Alberti, & Aber, 2006).

A strong correlation between poverty and family structure is evident. Since 2000 we have witnessed dramatic changes in family structure and living arrangements that impact access to economic resources and social support systems. In 2010 for the first time since data began to be collected and analyzed in 1940, two-parent families represented less than half of all households (48 percent), down from 52 percent in 2000 and 55 percent in 1990. Conversely, the number of female and male householders with no spouses both increased since 2000. Single-mother households rose by 11 percent in 2010, with 8.3 million families maintained by a single female, while single father households increased by 27 percent, representing 2.8 million households. In the last decade the number of nonfamily households, defined as a householder living alone or with nonrelatives only increased twice as fast (16 percent) as family households (8 percent). In 2010, 17.2 million women lived alone, compared to 14.6 million in 1996, while 13.9 million men lived alone, compared to 10.3 million in 1996.

The number of children living in single-parent homes has also steadily risen. Twenty-six percent of children lived with only one parent in 2010, as compared with only 12 percent in 1970. Of the approximately 75 million children under the age of 18 years in the United States, 69 percent lived with both parents in 2010, compared with 85 percent in 1970. Black and Hispanic children are less likely to be raised in a two-parent household than white children. In 2010, 75 percent of white children lived with two married parents, while only 35 percent of black children and 61 percent of Hispanic children resided with their married parents (Federal Interagency Forum on Child and Family Statistics, 2011).

Children living in single-mother families are more likely to live in poverty than children in two-parent families. In 2009 the poverty rate for related children living in female head of household families was four times greater (44 percent) than the poverty rate for children living in married couple households (11 percent). In 2010 the median income of married couple households is more than triple that of female households and more than double of male households. Table 1.1 presents the actual median family income among families with children under age 18 by family type (U.S. Census Bureau, September, 2011). The dramatic increase in single-family, female households forebodes a worsening economic trend for our nation’s children.

TABLE 1.1 Median Family Incomes Among Families with Children Under Age 18, by Family Type

Source: United States Census Bureau 2011

Black children have a significantly lesser chance of being raised in a two-parent household than do white children. In 2010 only 35 percent of black children lived with two parents as compared with 75 percent of white children. As table 1.2 indicates single mothers raise almost half of black children under age 18 (U.S. Census Bureau, 2012).

TABLE 1.2 Family Structure and Living Arrangements: Percentage of Children Under Age 18, by Race and Hispanic Origin, Selected Years 1990–2010*

*Table adapted and presented in summary form. Persons of Hispanic origin may be of any race.

The U.S. Census Bureau reported in 2010 that Hispanic persons of any race comprised 16 percent of the total population of 308.7 million people (table 1.3). While comprising only 16 percent of the country’s population, Hispanic persons of any race represent 25.3 percent of the nation’s poor. In 1995 the median household income of Hispanic residents fell 5.1 percent while it rose for all other ethnic and racial groups. Goldberg (1997) noted, For the first time, the poverty rate among Hispanic residents of the U.S. has surpassed that of blacks.

TABLE 1.3 Resident 2010 Population of the United States: By Race and Hispanic Origin (Numbers in Millions)

Source: United States Census Bureau 2011

Language and education appear to account for the growing ethnic and racial disparity. In 2008, Hispanics were nearly four times more likely to drop out of high school (18.3 percent) than whites (4.8 percent), while the dropout rate for black persons was more than twice that of white persons (9.9 percent). High school completion rates also vary between race and ethnic groups. In 2008, 94.2 percent of white persons completed high school as compared to 75.5 percent of Hispanic persons and 86.9 percent of black persons (National Center for Education Statistics, 2010). Hispanic persons continue to be the fastest growing ethnic group in the United States. The Hispanic population grew by 43 percent between 2000 and 2010, representing four times the growth rate of the total population (U.S. Census Bureau, May, 2011). By the year 2050, the Hispanic population is expected to increase to 30.2 percent of the total projected population. These data suggest that in the decades to come the Hispanic population will account for an increasing proportion of the poor in this country because they are insufficiently prepared to compete in a highly technical society.

Societal Context

After a discussion of the definitions and demographics of the distressing life condition, circumstance, or event, the authors examine how social structures and institutions cushion or cause the problems in question. When social structures and institutions provide essential resources and supports, they are critical buffers, helping people cope with life transitions, environments, and interpersonal stressors (Gitterman & Germain, 2008). By providing emotional, instrumental, informational, and appraisal supports, society structures influence the worldviews and self-concepts of people and fortify them against physiological, psychological, and social harm (Cohen, Underwood, & Gottlieb, 2000; Gottlieb, 1988a, 1988b). In contrast, when these resources and supports are unavailable or insufficient, people are apt to feel helpless and lack self-confidence and skill in interpersonal and environmental coping.

In the United States, the rich continue to become richer; the poor become poorer. In essence, the gap between the poor and the wealthy, the unskilled and the skilled has been widening for decades.¹ In terms of annual income, the disparity between the top 1 percent of Americans and the rest of the population is vast. In 2012, the average annual income of the top 1 percent of the population is $717,000 compared to the average annual income of $51,000 for 99 percent of Americans. In terms of accumulated wealth and other assets, inequality is even more pronounced. The net value of the top 1 percent is about $8.4 million, or 70 times the worth of the lower classes (Dunn, 2012). Warren Buffett put the matter correctly when he said, There’s been class warfare going on for the last 20 years and my class has won (Stiglitz, 2012). For example, the six heirs to the Walton Empire are worth $90 billion, which is equivalent to the entire wealth of the bottom 30 percent of Americans.

The United States is facing its worst economic crisis in 70 years, resulting in hardships for all Americans and particularly for black and Hispanic workers. In 2009, the Economic Policy Institute estimated that 8 million jobs (5.9 percent of all jobs) had been lost and 16 million people were unemployed. However, the crisis in the U.S. economy has not affected all groups equally. In 2010, the nationwide black unemployment rate stood at 15.9 percent, twice that of white Americans, and in several of the country’s large metropolitan areas, the black unemployment rate was significantly higher (Austin, 2011). Moreover, a large and growing number of young black males are hopelessly locked into a life of unemployment. The dramatic economic changes intensified by our country’s long history of racism and discrimination have left the black family extremely vulnerable. In addition, the Great Recession has resulted in severe job losses in construction, manufacturing, and retail that disproportionately affect young black men and women. In 2010, 32.5 percent of young black males aged 16 to 24 were unemployed, more than twice the rate for the white males of that age group (15.2 percent). Similarly, the unemployment rate of young Hispanic males was 24.2 percent (Edwards & Hertel-Fernandez, 2010). Whereas the previously slave-exploited agricultural economy required relatively unskilled labor, our increasingly automated and service economy requires skilled labor. Wilhelm and Powell (1964) suggest that our economy no longer needs the unskilled black male:

He is not so much unwanted as unnecessary; not so much abused as ignored.

The dominant whites no longer need to exploit him. If he disappears tomorrow he would hardly be missed. As automation proceeds it is easier and easier to disregard him … thus, he moves to the automated urbanity of nobidiness. (p. 4)

Lack of employment opportunities institutionalizes poverty and its varied consequences.

Not only have workers lost jobs, but their real wages have also declined and the income disparity among races and ethnicities continues. The United States Bureau of Labor Statistics (2010) reports that the median weekly earnings for white men and women exceed earnings of blacks and Hispanics in every age range. As indicated in table 1.4, weekly earnings for black men working full time were $668 or 75 percent of the median earnings for white men ($891). Similarly, black women earned 87.9 percent ($616) of the earnings of white women ($701). However, Hispanic men and women both earned less than blacks and whites, $600 and $525, respectively, and older Hispanic men (ages 55 and over) make only 58 percent ($624) of the weekly earnings of white men ($1,020).

TABLE 1.4 Median Usual Weekly Earnings of Full-Time Workers by Age, Race, Ethnicity, and Sex (Second Quarter 2012 Averages, Not Seasonally Adjusted)

Source: U.S. Bureau of Labor Statistics 2012

Broad changes in the economy have further victimized the poor. Globalization and the economic recession have negatively impacted the demand for low-skilled workers. Over the last two decades blue-collar and lower-income workers’ wages have eroded as manufacturing plants close and jobs are outsourced to other countries. The loss of blue-collar and lower-income jobs has created severe economic hardships. In 2009 white-collar unemployment was 6.8 percent, while the rate of blue-collar unemployment was 50 percent higher than the national average (Economic Policy Institute, 2009). At the same time, service industries have grown rapidly and created millions of new jobs, requiring new and advanced technical skills not possessed by many in the manufacturing industry. Blue-collar and lower-income workers are less marketable and have difficulty competing in an information- and technologically driven economy (Sum & Khatiwada, 2010).

Education plays a key role in increasing the likelihood of employment and higher wages. At nearly every level of education, blacks and Hispanics are less likely to be employed than whites. Median weekly earnings also vary across race and ethnicity. In 2010, the median weekly earnings of white, black, and Hispanic men, 25 years or older, without a high school diploma, were generally equally distributed, with wages for whites ($488) slightly higher than those of blacks ($466) and Hispanics ($443). In contrast, black men, 25 years or older, with a bachelor’s degree or higher made 75 percent ($1,010) of the weekly wages of white men ($1,354) with equal educational levels, while Hispanic men made 79 percent of the earnings of white men ($1,065). Black and Hispanic women with a college degree or higher fared significantly worse. Black women earned 66 percent of weekly earnings ($889) compared to white males with equivalent education, and Hispanic women earned (63 percent) of the earnings of their white male counterparts (U.S. Bureau of Labor Statistics, 2010).

The environment of poor people is particularly harsh. Because of their economic position, they are unable to command needed goods and services. Good education, preventive health care, jobs, housing, safe communities, neighborhood amenities, and geographic and social mobility are unavailable or extremely limited for the poor. They are not able to compete for societal resources and their leverage on social institutions is extremely limited. A devastating cycle of physical, psychological, and social consequences follows. And with the government reducing its role in providing a safety net, the plight of poor, particularly poor children, can only worsen.

In 1996, President Clinton signed into law the welfare reform act—the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). This federal law imposed work requirements and a sixty-month lifetime time limit, promising to end welfare as we know it. The new law’s manifest purpose was to end public assistance recipients’ dependence on the government and create economic independence and self-reliance by limiting benefits to a maximum of five years and by providing job training and employment opportunities.² Some believe that the new legislation’s latent and real purpose was to punish poor women for having children they shouldn’t have had—through stigma, economic deprivation, work requirements, and lack of provision of child care.

The campaign to gain the public’s approval and to pressure the president to sign PRWORA into law conveniently ignored the fact that in 1995 approximately two-thirds of the recipients receiving Aid to Families with Dependent Children (AFDC) were children and only one-third were adults (U.S. House of Representatives, 1996). In 1996 TANF (Temporary Assistance for Needy Families) replaced AFDC, ushering in a dramatic 50 percent drop in the number of participating families from 3.9 million families in 1997 to 1.95 million families in 2011. Congress enacted changes to TANF in the Deficit Reduction Act of 2005 (DRA) that further increased the work requirements of recipients. The three states with the largest number of TANF recipients live in California, (30 percent), in New York, 8 percent, and in Ohio, 5 percent (Loprest, 2012).

On the surface, TANF appears to have achieved its goal of reducing long-term welfare dependency, lowering by 50 percent the number of individuals and families receiving welfare. Since its inception, nearly two-thirds of recipients have obtained employment after exiting welfare (Gyamfi, Brooks-Gunn, & Jackson, 2005). Yet these data are misleading. More than 50 percent of those who exit welfare continue to remain poor (Danzinger, 2001). One-half to one-third of TANF leavers experience a decrease in income and quality of life. The majority of women (78 percent) who secure employment enter into four low-wage occupations: (1) service, (2) clerical administrative support, (3) sales, and (4) as laborers, operators, and fabricators that offer fewer opportunities to advance (Peterson, Song, & Jones-DeWeever, 2002). Working mothers encounter a lower income as they move into dead-end occupations and struggle to make ends meet to support themselves and their children (Danzinger, Heflin, & Corcoran, 2002; Dunlap, Golub, & Johnson, 2003). Many recipients lose other benefits such as Medicaid, food stamps, and child care subsidies that further erode their well-being. Morgan, Acker, and Weight (2010) surveyed 900 mostly single, white women who were ineligible or exited from welfare rolls in 1998 and found that over half (55 percent) took jobs at or below the poverty level and half of these women continued to earn wages below the poverty level two years later.

Although TANF represents the only federal means-tested cash safety net for poor families with children, it is estimated that 20 percent to 25 percent of eligible single mothers remain disconnected; that is, they receive no public assistance and have little or no connection to the labor market (Loprest, 2011). In fact, the number of eligible families who apply for assistance has steadily decreased, with only 36 percent of families participating in 2007 compared to 79 percent family participation in 1996. Confusion about eligibility and difficulty with enrollment are two contributing factors that impact participation in TANF.

In the years since TANF was enacted, the demographic characteristics of adult recipients have remained relatively the same. A comparison of characteristics of adult recipients between 1997 and 2009 suggests that the majority of recipients are single (70 percent), female (86 percent), between the ages of 20 and 39 years of age (76 percent), unemployed (47 percent), with 12 or more years of education (58 percent). Fifty-one percent of recipients had one child and 47 percent had two or more children receiving TANF assistance. The percentage of white adults remained the same (35 percent) and slightly outnumbered other racial and ethnic groups, while the percentage of blacks dropped from 37 percent to 34 percent from 1997 to 2009, and the number of Hispanics grew from 20 percent to 24 percent. Yet in over 50 percent of the TANF cases, adults living in households with children are not receiving assistance because they are ineligible or they are not the child’s parent (Loprest, 2012).

Although the majority of adult public assistance recipients are white, the United States Department of Health and Human Services (2012) suggests in 2009 blacks families accounted for 33.3 percent of TANF recipients, compared to 31.2 percent for white families, and the rate of Hispanic families enrolled in TANF increased from 25 percent in 2000 to 28.8 percent in 2009. Indeed, 33.5 percent of recipient children were of Hispanic origin, compared with 31.1 percent for black children and 26.1 percent for white children.

Finding suitable child care is a problem for most families and significantly more so for larger single-parent poor minority families. Poor children are less likely to enter kindergarten with prior early childhood program experience than children living in families above the poverty line. In 2007, 41 percent of children whose family income was below the poverty line were enrolled in an early childhood program, as compared with 65 percent of children living in families whose income was above the poverty line. Hispanic children were the least likely (39 percent) to attend an early childhood program, compared with 65 percent of black children and 58 percent of white children (Federal Interagency Forum on Child and Family Statistics, 2011). For Hispanic mothers, the cultural expectation is that the woman’s primary role is to stay home and raise her children. Day care centers are often deeply distrusted. In a New York State survey, 75 percent of Hispanic mothers feared that their children would be mistreated in day care compared with 45 percent of non-Hispanic mothers (Swarns, 1998).

Poor and low-income neighborhoods are another barrier that hinders employment due to lack of access to public transportation and mobility (Smiley, 2001). Minority families are more likely than white families to live in inner-city, high-crime, and job-scarce communities. While 71 percent percent of black families and 63 percent of Hispanic families receiving public assistance lived in large urban inner cities, only 31 percent of white welfare families did so. As DeParle (1998) poignantly states, Race is intertwined with place (p. A12). Race is also intertwined with job discrimination.

Vulnerabilities and Risk Factors

Anthony (1987) analogizes vulnerability and risk to three dolls made of glass, plastic, and steel. Each doll is exposed to a common risk, the blow of a hammer. The glass doll completely shatters, the plastic doll carries a permanent dent, and the steel doll gives out a fine metallic sound. If the environment buffers the hammer’s blow by interposing some type of ‘umbrella’ between the external attack and the recipient, the outcome for the three dolls will be different (Anthony, 1987, p. 10). Each contributor identifies the major vulnerabilities and risk factors for people finding themselves with the life’s condition, circumstance, and event presented in this book.

As stated earlier, chronic poverty is the major force responsible for both prolonged and cumulative stress; consequently, it is the most potent risk indicator for many of the distressing life circumstances and events. Poor people are simply most likely to become unhealthy, single parents, homeless, crime victims, abused and violated, imprisoned, pregnant in adolescence, jobless, etc. And among the poor, people of color are at highest risk. Two examples follow.

Generally, people who live in societies with large income and wealth disparities are less healthy than those who live in societies characterized by a small disparity in income and wealth. In a society like the United States where differences in income and wealth are extremely large, your chances of escaping chronic illness and reaching a ripe old age are significantly worse than if you live in place where differences are not as large (Sweden, for example) (Larder, 1998). The association between family income and health is clearly evident in the health of the country’s children.

Family income directly affects the health of children. Studies indicate that children from low-socioeconomic families have poorer health outcomes (Evans, 2003; Poulton et al., 2002). In 2003, the health status of 16 percent of children under 17 was less than optimal (neither very good nor excellent). Depending on the state, children living in poor families in the United States (below 100 percent of the federal poverty level) were over six times as likely to be in less than optimal health (Commission to Build a Healthier America, 2008).

A significant factor accounting for this disparity is that poorer children simply receive poorer medical care. A significant number of poor children are not covered by health insurance. In 2009, 10 percent or 7.5 million of our nation’s children were without health insurance (Federal Interagency Forum on Child and Family Statistics, 2011). Most of these children live below the poverty line. Without health insurance, poor children receive less preventive, as well as restorative medical care. For example, fewer than half of uninsured children, 45 percent, visit their doctors on a regular basis, as compared to 95 percent of publicly and privately insured children who receive regular medical care by their doctors. In addition, 44 percent of parents of uninsured children report that they have had to delay medical procedures for their children (U.S. Department of Health and Human Services, 2011).

White persons are expected to live more than four years longer than black persons. The life expectancy for a white person is 78.8 years, while a black person is expected to live to the age of 74.4 years (National Vital Statistics Report, 2012). The differentials in white and black mortality rates begin at the outset of life and persist throughout the life span. In 2009, the black infant mortality rate was 13.4 infant deaths per 1,000 live births, compared with 5.6 infant deaths per 1,000 live births for white infants. Black infants die at a rate almost two and a half times higher than white infants (Federal Interagency Forum on Child and Family Statistics, 2011). Child mortality rates also illustrate the inequity among race and ethnicity. As table 1.5 demonstrates, in 2009, there were 25 deaths per 100,000 white children ages 1 to 4 years as compared with 42.2 deaths per 100,000 black children of the same age (nearly than twice as many). Among children 5 to 14 years of age, there were 12.4 deaths per 100,000 white children as compared with 20.5 deaths per 100,000 black children. As table 1.5 shows, the Asian and Pacific Islander mortality rate is the lowest for all age children (National Vital Statistics Report, 2012).

TABLE 1.5 Child Mortality Rates by Age, Race, and Hispanic Origin, Selected Years

*Persons of Hispanic origin may be of any race. Each race category includes Hispanics of that race.

**and Pacific Islander

Black children and adults also suffer higher death rates than whites from most major health-related causes; the gap between black persons and white persons continues to widen in the incidence of asthma, diabetes, tuberculosis, several forms of cancer, and major infectious diseases. Several examples illustrate this racial health disparity. The asthma death rate between 2007 and 2009 was higher for blacks than whites for every age group, except persons aged 75 years and over. In fact, the asthma rate for black children under 14 years of age, was almost eight times greater than for white children of that age. In another example, the rate of diagnosed diabetes for blacks (12.6 percent) aged 20 years or older, was nearly twice that of whites (7.1 percent), while the risk of developing diabetes was 77 percent higher for blacks when compared to whites. In relation to tuberculosis, in 2010 the rate of tuberculosis disease was disproportionately higher in blacks than whites. Black persons were seven times more likely to contract the disease than whites. Similarly, for coronary heart disease, prevalence data indicate a national overall decline from 2006 to 2010. However, heart disease rates for black men and women rose by 1.6 percent over that time (Centers for Disease Control and Prevention [CDC], 2011). Finally, for every 100,000 live births in 2003, the white maternal mortality rate was 8.7, as compared with a rate of 30.5 for black mothers (Hoyert, 2007).

Cancer incidence and death rates in the United States continue the decline first noted in 1990. However, the overall cancer incidence and death rates for black men and women were greater than all other racial and ethnic groups, with the death rate of black men 15 percent higher than that of white men. In 2009 blacks had a higher proportion of cancer incidence per year (489.5 for blacks, 471.7 for whites per 100,000 men and women) and more deaths from cancer (216.4 for blacks, 177.6 for whites per 100,000) (National Cancer Institute, 2012). The Center to Reduce Cancer Health Disparities (2008) suggests that black women are more likely than white women to die from breast cancer even though the incidence of breast cancer in white women is nearly twice as great. Comparable disparities apply to other types of cancers. For black men, the incidence of prostate cancer (255.5 per 100,000), the most common type of cancer for men, far surpasses the incidence for white men (161.4 per 100,000), and the death rate for blacks (62.3 per 100,000) resulting from prostate cancer is more than double that of white men (25.6 per 100,000). Similarly, incidence and death rates for lung cancer and colorectal cancers, the second and third most common cancers in men, are greater in blacks than in whites; of 100,000 men and women, the death rates for lung cancer for black persons (62) and colorectal cancer (27) exceeds that of whites for lung cancer (55), and colorectal cancer (19). Cancer health disparities may be attributed to numerous factors, including low socioeconomic status, lack of health care coverage, lower levels of education, obesity, insufficient physical activity, and an unhealthy diet,

The Centers for Disease Control and Prevention (2012) estimate that 1.1 million people in the United States are living with HIV, and approximately 50,000 new cases are diagnosed yearly. The introduction of antiretroviral therapy in the mid-1990s significantly extended the lives of people living with HIV and dramatically decreased the number of AIDS deaths. Yet, nearly 18,000 people with AIDS die each year in the United States. In 2009 the greatest incidence of new HIV infections (61 percent) occurred among men who have sex with men (MSM) of all races and ethnicities. MSM represent only 2 percent of the country’s population but disproportionately account for 61 percent of all new HIV infections and more than half of all people living with HIV. Heterosexuals accounted for 27 percent of newly diagnosed cases, with black heterosexual women most heavily affected. Injection drug users constitute 9 percent of new HIV infections and 27 percent of people currently living with HIV. Among injection drug users, blacks have a higher incidence of new HIV infections. Indeed, black Americans, only 14 percent of the nation’s population, comprise nearly half (44 percent) of new infections and people living with HIV (44 percent). More alarming is a 48 percent increase of HIV among young black men who have sex with men. The second largest group, Hispanics, account for 20 percent of new infections and 19 percent of people living with HIV.

The racial and ethnic health inequity that results in higher incidence of HIV in blacks and Hispanics is attributed to multiple complex socioeconomic and environmental factors. Poverty may impact access to appropriate health care for HIV testing and medications that can manage infection and prevent transmission. Lack of appropriate health care increases the rate of undiagnosed or untreated HIV and may result in increased risk of acquiring or transmitting HIV. Similarly, the prevalence of HIV in communities can increase risk of transmission. Finally, stigma related to HIV and the perceived discrimination may discourage people from obtaining medical services to test, prevent, or treat HIV infections (CDC, 2012).

Poverty breeds violence. Neighborhoods that have a large number of reported child abuse cases tend to be impoverished, with substandard housing and a low level of neighborhood interaction. Child abuse and neglect have been associated with lower socioeconomic status, unemployment, lack of education, childbearing at an early age, alcohol and drug abuse, and spousal violence (Aron, et al., 2010; Slack, Holl, McDaniel, Yoo, & Bolger, 2012).

Violence is endemic and epidemic in our society. The country’s poor youth are the primary victims of violent crimes. According to Truman, (2011), youth between the ages of 12 and 17 had the highest rates of violent crime victimization (50.5 per 1,000) in 2010. This age group was nearly three times as likely as those ages 25 to 34 (18.8), four times as likely as those ages 35 to 49 (12.6), and over twenty times as likely as those ages 65 or older (2.4) to experience violent crimes. Youth in households with annual incomes of less than $15,000 were much more vulnerable to violent crimes than youth in higher-income households. Per thousand, 170.4 persons in the poorest households were victims of crimes of violence as compared with 119.3 persons in households with annual incomes of more than $75,000.

Although the homicide rate has been continually declining for several years, the number of homicides committed annually is much higher in the United States in comparison to other industrial democratic societies. In 2009, for every 100,000 people living in the United States, 4.4 persons were murdered. In contrast to other nations, the U.S. homicide rate was over twice that of Canada (1.8) and nearly four times higher than industrialized countries in Europe, such as France (1.1), Germany (0.9), and Great Britain (1.2) (United Nations, 2011). While the mass media and public perception frequently equate violence with minorities living in the urban inner cities of the Northeast, Southern states experience a higher homicide rate. In fact, the South has almost double the murder rate of the Northeast. This regional difference has been traced back to the nineteenth century. For example, from 1880 to 1886, the murder rate in South Carolina (then a primarily agricultural state) was four times higher than that of Massachusetts (then the most urban, industrial state). In 1996, the murder rate in South Carolina was 9 per 100,000 people as compared with 2.6 per 100,000 people in Massachusetts. Currently, the former slaveholding states of the old Confederacy all rank in the top 20 states for murder, led by Louisiana with a rate of 17.5 murders per 100,000 people in 1996 (Butterfield, 1998a, p. 1).

The American tradition of violence has its roots in the Southern code of honor. It evolved from a rich and proud culture that prospered in the antebellum rural South. Southern upper-class gentlemen were compelled to defend their personal and familial honor, risking injury and life itself for the sake of reputation and manliness. Gradually, the African American slave society adapted the Southern code of honor. Since African American slaves and their descendants could not trust or turn to the law and its white institutions, disputes were personally and often physically settled. This traditional code of honor has been transformed into modern inner-city street culture: Don’t step on my reputation. My name is all I got, so I got to keep it. As guns and semiautomatics have become available to younger and more neglected and desperate children, the rituals of insult and vengeance represent a lethal anachronism (Butterfield, 1996). And true to the Southern tradition of defending honor and proving manliness, most murders are not committed in pursuit of a crime, but rather as an outcome of personal differences, such as lovers’ quarrels or bar or neighborhood brawls (Butterfield, 1998a).

The cumulative impact of the exposure to violence is devastating. Exposure to violence has been associated with feelings of depression and anxiety, higher levels of antisocial and aggressive activities, lower school attainment, and increasing risk taking (Marans, Berkman, & Cohen, 1996, p. 106). An increasing number of inner-city children, for example, suffer from low self-esteem and a posttraumatic stress syndrome similar to that seen in Vietnam veterans (Lee, 1989). These children have been exposed to violent attacks on and murders of their parents, friends, relatives, and neighbors. They are further traumatized by domestic violence and child abuse. These experiences have long-lasting physical, psychological, and social effects.

In 2010 serious violent victimization rates for blacks (20.8 per 1,000) age 12 and over, and Hispanics (15.6 per 1,000) were higher than for whites (13.6 per 1,000). For example, black youth are 17 times more likely than whites to be victims of death by homicide. In 2009, among 15- to 19-year-olds, the homicide rate for white males of this age group was 2.9 deaths per 100,000, while the homicide rate for blacks was 50.5 deaths per 100,000 resident populations. Similarly, death by firearms was five times greater among black males (52.4 per 100,000) than white males (10.3 per 100,000). Conversely, as seen in table 1.6, more whites males (20.4 per 100,000) die from injuries sustained in motor vehicle accidents than black males (13.3 per 100,000) (Federal Interagency Forum on Child and Family Statistics, 2011).

TABLE 1.6 Mortality Rates Among 15- to 19-Year-Old Males, by Gender, Race,*

*Persons of Hispanic origin may be of any race. Each race category includes Hispanics of that race.

Resiliencies and Protective Factors

A surprisingly large number of people mature into normal, happy adults in spite of various vulnerabilities and risk factors. Why do some people collapse under certain life conditions and circumstances while others remain relatively unscathed? What accounts for the remarkable individual variations in people’s responses to adversity and trauma? How do people adapt, cope, and meet the challenges of physical and mental impairments, severe losses, chronic discrimination, and oppression? Why do some people thrive and not simply survive in the face of life’s inhumanities and tragedies?

What accounts for their resilience? Webster’s defines resilience as the tendency to rebound or recoil, to return to prior state, to spring back. Protective factors are biological, psychological, and/or environmental processes that contribute to preventing a stressor, or that lessen its impact or ameliorate it more quickly. The process of rebounding and returning to prior state does not suggest that one is incapable of being wounded or injured. Rather, in the face of adversity a person can bend, lose some of his or her power and capability, yet recover and return to prior level of adaptation.

Although, as mentioned earlier, most investigations to date have focused on the negative rather than the positive aspects of people’s responses to life’s miseries, some research into children living in highly stressed, trauma-inducing environments has helped to inform us about the protective factors that children use to negotiate high-risk situations. The protective factors are related temperament, family patterns, external supports, and environmental resources (Basic Behavioral Science Task Force, 1996).

Temperament includes such factors as: (1) activity level, (2) coping skills, (3) self-esteem, and (4) attributions. Children with easy temperaments and lower activity levels are more likely to be accepted and nurtured by parents and others. In comparison, unfriendly and overactive children often encounter much greater rejection, anger, and abuse. Adequate coping skills empower children to physically remove or emotionally distance themselves, thereby reducing their exposure to family discord. Children’s concepts and feelings about themselves and their social environments play an important role in their ability to deal with life’s challenges. Self-esteem is a dynamic, complex concept as individuals have not one but several views of themselves encompassing many domains of life, such as scholastic ability, physical appearance and romantic appeal, job competence, and adequacy as provider (Basic Behavioral Science Task Force, 1996, p. 726). Finally, children’s attribution of responsibility for exposure to trauma-inducing environments also plays an important role. Generally, a self-condemning attribution style has a strong negative impact. People’s subjective realities, i.e., their perceptions of their inner and external resources, their attributions, and social constructions, are essential to professional understanding.

Family patterns represent a second protective factor. In family illness studies, one good parent–child relationship served as a protective factor in cushioning dysfunctional family processes, as well as in increasing the child’s self-esteem. The relationship also reduced psychiatric risk. The presence of a caring adult, such as a grandparent, led to similar outcomes.

Third, external support from a neighbor, parents of peers, a teacher, clergy, or a social worker is a significant cushioning and protective factor. The importance of social support has been widely documented. Supportive social networks are important sources of positive self-concept and also help shape one’s worldview (Miller & Turnbull, 1986).

Last, the broader environment and the opportunity structure create the conditions for all other factors. When social structures and institutions act as buffers, they enhance people’s abilities to cope with life’s transitions and stressors; when environmental resources are unavailable, or insufficient, people are more apt to feel hopeless and are less able to cope.

Many vulnerability or protective processes often concern key turning points in people’s lives rather than long-standing attributes. The direction of a trajectory for the future is often determined by what happens at a critical point. The decision to remain in school, for example, represents a critical turning point, often leading to more positive trajectories than dropping out of school. In contrast, the birth of an unwanted child to a well-functioning teenager, who is then rejected by family, creates a negative trajectory (Rutter, 1987).

Planning in making choices looms as a critical factor in turning-point decisions. Exercising foresight and taking active steps to cope with environmental challenges are critical factors. In a follow-up study of girls reared in institutional care, Rutter (1987) found that if they did not marry for a negative reason, such as to escape from an intolerable situation or because of unwanted pregnancy, and exercised planning in their choice of a partner, they were less likely to marry a man who was a criminal or had a mental disorder. The importance of planning as a protective factor also emerges in areas of school and work (Rutter, 1987).

And then there is always the simple element of chance or God’s will: good fortune and misfortune. Although our efforts to be scientific may cause us to shy away from the idea of chance or spiritual beliefs, they may well enhance our understanding of and feeling for the human experience. For example, survivors of the Holocaust know that they survived because they happened to be at the right place, at the right time. For another example, people involved with Alcoholics Anonymous commit to and align themselves with a spiritual force larger than themselves.

Two factors in addition to planning in making choices and chance or God’s will are worth noting. One factor is humor. Laughter is essential to life. Laughter deflects, unmasks, and frees us from unreal, pretentious, and imprisoning beliefs or perceptions (Siporin, 1984, p. 460). To be able to laugh in the face of adversity and suffering releases tension, provides hope, and takes sadness and makes it sing. Eli Wiesel poignantly noted (as quoted in Baures, 1994):

The truth comes into this world with two faces. One is sad with suffering, and the other laughs; but it is the same face, laughing or weeping. When people are already in despair, maybe the laughing face is better for them; and when they feel too good and are sure of being safe, maybe the weeping face is better for them to see. (p. 31)

And finally, through the processes of helping and giving to others, people help and heal themselves. Frankl (1963), a survivor of the Holocaust, eloquently describes that one finds meaning in life—finds meaning in suffering—not through the pursuit of self-gratification, but primarily through the processes of helping and giving to others. Essentially, when people lend their strength to others, they strengthen themselves.

Programs and Social Work Contributions

Each contributor examines programs and social work contributions in dealing with the population’s life stressors. Managed care has transformed health and mental health services in the United States. Managed care has had a profound impact on almost all social work programs. Spurred by rising health costs and mental health costs, managed care evolved to contain costs and as an alternative to fee-for-service. This change in philosophy, organization, and delivery of health and mental health services has had a profound impact on the quality of services people receive as well as funding of social service agencies and departments.

Managed care’s main objective is cost containment. This is accomplished either by placing limits on patient services (e.g., number of days in the hospital, visits to medical and mental health practitioners, total dollar expenditures per year and per lifetime) and/or by increasing copayments and deductibles. Managed care’s dual emphases on minimizing costs and maximizing profit impose corporate values and ideology on health and social welfare agencies. These values and ideology differ radically from social welfare’s commitment to human rights and the provision of safety nets and buffers to our capitalist economic system (Schamess, 1998, p. 24). In health care, for example, social work departments have been decentralized, supervisory positions eliminated, and social work practitioners integrated into service teams. Consequently, social work directors are yielding some of their administrative responsibilities and searching for ways to survive. The diminished administrative structure limits staff opportunities for promotion and leaves them isolated and vulnerable in ongoing turf battles with nurses and other professionals. Furthermore, staff isolation and vulnerability inhibit their ability to advocate for quality patient care.

Mental health services were also transformed from a purely professional undertaking to a business providing professional services (Lens, 2002, p. 27, citing Abraham & Weiler, 1994, p. 395). The change from professionals to business administrators making crucial therapeutic decisions reshaped professional practice and limited the focus and scope of services to clients (Acker, 2010; Bennett, Naylor, Perri, Shirilla, & Kilbane, 2008; Kerson, 2009). Brief, goal-directed therapy approaches (solution-focused and cognitive behavioral) that focus on acute symptom relief have been defined as the preferred modes of treatment (Cohen, 2003). The emphasis on short-term symptom reduction too often neglects the underlying life stressors that often create the symptoms, or, at the very least, exacerbate them.

Since each author examines the specific programs, services, and modalities and, where relevant, the impact of managed care, our discussion is limited to selected ideas about primary prevention programs. What do we do with our knowledge about populations vulnerable and resilient to various pernicious life conditions, circumstances, and events? Primary prevention, a public health concept, aims to anticipate and forestall some undesirable event or condition that might otherwise occur and spread (Gitterman, 1988; Leighton, 2000). Primary prevention has two distinct strategies: (1) specific protection, an explicit intervention for disease prevention in which a population at risk is identified and something is done with the population to strengthen its resistance and resilience; and (2) health promotion, an intervention for improving the quality of life and raising the general health/mental health level of a population. Social workers also have inherited from their past a third prevention strategy, environmental change, i.e., doing something about the social conditions that play host to and foster the problems.

In times like the present, this tradition, if not ignored, is certainly neglected. Funding, and consequently, professional interests are both primarily engaged in the specific protection aspect of prevention. This direction can be a problem. By emphasizing specific protection, our efforts may be promising much more than they can deliver. Childhood poverty, for example, is deeply embedded in our social structure. The decline in actual earnings, decrease in public entitlements, and increase in single parenting and numerous social problems all conspire to enlarge the dimensions of childhood poverty. These children’s problems are becoming more desperate, intractable, and dangerous. In this context, the premise of specific protection prevention, i.e., intervening before a problem has struck, must be reexamined. If we identify poverty and racism as the major problems, prevention of social ills becomes elusive, if not illusionary.

Intimate partner and child abuse prevention programs, for another example, are being implemented within the context of a violent society. Our society promotes and tolerates violence and few prevention programs deal with the cultural propensity toward violence. Programs that teach selected adolescents to avoid pregnancy by saying no or advise parents who may potentially abuse their child to manage their angry feelings, however useful and pertinent, cannot deal with the multidimensional pathways to social problems. In fact, most new immigrant groups have shown high rates of social pathology, but as they achieved economic security, the social pathology rates declined. These social pathologies are analogous to a high fever: in such an analogy, specific protection interventions may momentarily reduce the fever,