Using Exercise to Combat Depression

January/February 2012 Issue

Using Exercise to Combat Depression
By Joelle Ruben, MSW, LSW
Social Work Today
Vol. 12 No. 1 P. 22

A growing body of research shows that exercise can be an effective adjunct treatment for depression.

As a social work student, Amy Park (a pseudonym) often brought gym clothes to her field placement so she could get in a run before heading home. This tactic may sound familiar to many individuals seeking to fit exercise into their overscheduled lives. Park, however, had additional motivation for completing regular workouts: keeping her depression in check.

Diagnosed with severe depression in her late teens, Park remembers thinking that something as simple as running or lifting weights would not lessen her daily challenges with the condition. “In my mind, there was such a thing as being too depressed for exercise since very basic things at that time, like eating and bathing, were a real struggle,” she says. But after using a behavioral activation workbook to track the level of satisfaction she felt from daily activities, Park discovered she consistently felt better after working out.

Nearly a decade later, she continues to view exercise as an integral part of her treatment strategy. But Park cautions that people should not view physical activity as a panacea. “Personally, I find it most helpful as a temporary mood boost that gives me the short-term motivation to engage in productive activities that help me get unstuck and move toward things I value,” she says.

A Widespread Issue
Depression, in its multiple forms, affects millions of adults in the United States each year. According to the Substance Abuse and Mental Health Services Administration, 14.3 million adults reported at least one major depressive episode in 2008 that affected their ability to work, sleep, eat, or enjoy once-pleasurable activities.

In 2005, the Archives of General Psychiatry reported that in any given year, approximately 5.7 million adults experience bipolar disorder in which they fluctuate between mania and depression. Dysthymic disorder, a chronic, milder form of depression, affects around 3.3 million adults annually.

These numbers do not account for individuals experiencing symptoms related to postpartum depression, seasonal affective disorder, or more moderate forms of depression. Many people also experience the lethargy, lack of interest in daily activities, and sadness associated with depression without receiving a formal diagnosis.

Conversely, some practitioners report an increasing trend of self-diagnosis among clients before they can be formally evaluated. “Most people who come in to see me identify themselves as depressed even if they don’t meet all of the criteria of depression,” says Amy Chmielinski, LPC, of Jewish Family Service of Metropolitan Detroit. “It’s just a commonly known disorder, and most people have a layperson’s knowledge of it.”

While the statistics are imperfect, they begin to convey the scope of depression and its impact on society. They also set the stage for exercise as an accessible and cost-effective tool that social workers can leverage to help clients battle their symptoms.

The Exercise-Depression Connection
Since the early 1900s, researchers have published more than 100 studies examining the relationship between exercise and depression or anxiety. National attention increased in 1999 when the Centers for Disease Control and Prevention reviewed the literature examining the impact of exercise on mental health. The report concluded that physical activity appeared to relieve symptoms of depression and anxiety while boosting mood. It also called for further clinical research to examine the role of exercise in preventing depression.

Following this somewhat weak endorsement, Daniel Landers, PhD, a professor emeritus from the department of kinesiology at Arizona State University, compared five meta-analytic reviews of the exercise-depression research. His analysis showed a consistent relationship between exercise and moderate reductions in depression across subjects’ age, gender, and depression type. According to Landers (1999), symptoms subsided regardless of the frequency of physical activity, with antidepressant effects beginning as early as the first session.

The literature has also revealed similarities in symptom reduction for multiple types of exercise. Most research has focused on common physical activities such as running, walking, and strength training, but relaxation-focused activities such as yoga and breathing exercises are increasingly being studied.

Perhaps one of the more heated areas of debate is whether exercise should replace, rather than supplement, common approaches for treating depression. James Blumenthal, PhD, who teaches psychology and neuroscience at Duke University, has taken particular interest in studying whether physical activity can prove as effective as antidepressant medications in managing depression.

In 2007, Blumenthal and his research team published results from a study in which they randomly assigned participants to one of four treatment approaches: home-based exercise, group exercise, antidepressant medication, or a placebo. All 202 participants had been diagnosed with major depressive disorder and had completed their respective treatments for 16 weeks. While all three treatment options proved more effective than the placebo, remission rates among the home-based and group exercise cohorts were not statistically different from remission rates among the group taking antidepressants (Blumenthal et al., 2007). This study reaffirmed the results of earlier research involving 156 adults aged 50 or older with major depressive disorder (Blumenthal et al., 1999).

From a practitioner perspective, Chmielinski emphasizes the importance of consulting with a client’s physician or psychiatrist regarding a possible medication change, regardless of findings such as Blumenthal’s. ”I wouldn’t recommend a client start or stop a medication outside of the context of the physician’s direction,” she says.

Chmielinski adds that social workers have an ongoing responsibility to assess the impact of medication changes even after clients have been medically cleared to stop taking antidepressants. “What I would say to some clients is if they’re serious about incorporating exercise and other coping techniques rather than medicating, that’s something we can closely monitor for two or three months.”

Identifying the Cause
Despite growing clinical evidence suggesting that exercise can reduce symptoms of depression, scientists still struggle to determine what causes these changes in humans.

“One of the things I get asked most often is, ‘What is the mechanism by which exercise affects depression?’” says Lynette Craft, PhD, an assistant professor of preventive medicine at Northwestern University. “The short answer is that we don’t really know exactly how exercise works.”

Several hypotheses have emerged. One of the most common theories focuses on serotonin, a neurotransmitter responsible for sending impulses across the brain. Researchers have established that individuals experiencing depression tend to have lower levels of serotonin in their blood. The same is true for the neurotransmitter norepinephrine. Many antidepressant medications, such as Prozac, Zoloft, Effexor, and Cymbalta, seek to increase the amount of these neurotransmitters outside human cells with the aim of better regulating outcomes such as mood and sleep.

But Craft, a trained kinesiologist, cautions that the scientific research in humans is not far enough along to reveal the true effects of either neurotransmitter, let alone the impact that exercise can play on their levels in the human brain. “We don’t have good, noninvasive ways of measuring serotonin or norepinephrine in the brain,” she says. “With improved neuroimaging technology, we hope to get a better sense of what is occurring in the brain following exercise.”

The National Institute of Mental Health (NIMH) has also explored the neurological connection in animals between physical activity and psychosocial stress, which can lead to behavior mimicking depression. In 2010, NIMH research showed that laboratory mice living in environments that allowed for exercise and exploration responded better to bullying from other mice than rodents living in more basic settings (Schloesser, Lehmann, Martinowich, Manji, & Herkenham, 2010).

A later study re-creating this experiment found that mice living in enriched environments also contained signs of increased neuron activity in a portion of the brain known as the infralimbic cortex. According to the NIMH report, the inframlimbic cortex is responsible for activating nearby parts of the brain and may contribute to how animals, and potentially humans, respond to fear and stress (Lehmann & Herkenham, 2011).

Psychological Impact
While scientists continue examining the biological and chemical effects of exercise on depression, it is also important for social workers to consider its potential psychological effects.

Michael Otto, PhD, a psychology professor at Boston University, believes that more emphasis should be placed on the nearly immediate impact of exercise on mood. He claims that most mood benefits occur within five minutes of exercise, although they can be delayed for up to 30 minutes following more intense activity.

Reaping these mood benefits often involves overcoming serious obstacles to working out. “When you’re depressed or anxious, exercise is not the natural option. Both [disorders] encourage you to do less, whereas exercise encourages you to do more,” Otto says. “The most helpful thing we can teach people at the outset is that we don’t want you to dig deep for motivation. We want to you to use all the available elements to make exercise come naturally.”

Otto, who specializes in the cognitive-behavioral treatment of mood and anxiety disorders, advises social workers to suggest incremental changes to clients’ exercise habits to make them seem more manageable. Examples include placing a pair of tennis shoes by the front door or ending workouts on a positive note to instill a happy association with physical activity. More recommendations are included in Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being, a book authored by Otto and colleague Jasper Smits, PhD.

In keeping with Otto’s emphasis on positivity, laughter yoga has emerged as a growing exercise practice promoting the physical and psychological benefits of laughter. While some laughter-based activities involve a lot of movement, programs can be adjusted to accommodate those with physical or cognitive limitations.

“You meet people where they are,” says Lainie Diamond, a certified laughter yoga instructor who teaches two free classes per week at the Houston Public Library. “It is absolutely for everybody.”

Diamond adds that individuals do not need to be in a good mood or even have a sense of humor to benefit from the practice. Indeed, one of the key laughter yoga mantras is to “fake it until you make it,” referring to the real laughter that often emerges from an initially forced response.

Meeting an exercise goal can also affect clients’ sense of accomplishment and fulfillment, potentially leading to an improved psychological state. This argument resonates strongly with Park, who claims that exercise helped shift her focus to a specific goal and its outcome rather than how she was feeling that day. “Exercise is one of those things that can very easily give you a sense of mastery of your environment, which can easily carry over into other aspects of your life,” she says.

The Social Work Role
With so many questions about exercise and depression unanswered, it may seem difficult for social workers to find their role in the equation. But according to Chmielinski, who sees many of her clients on a weekly basis, social workers and therapists are in an ideal position to promote change because of the continuity of their relationship and therapeutic rapport. “How often do you see your doctor every week?” she asks.

Common social work approaches, such as the person-in-environment theory, also come into play. Camielle Call, LCSW, who runs a private consultation practice in Sitka, AK, recalls working with a client who reported decreased enjoyment in daily activities. Although the symptoms appeared to be triggered by southeast Alaska’s continuous cloud cover, Call says the client ultimately benefited from living in a community where she saw people exercising outside. “Seeing people maintaining their physical health by walking with friends, being active with their children, or walking their dogs helped her mindset get to a place where she could say, ‘That’s what I can do to help myself get better.’ She wanted to be a part of that healthy environment,” Call says.

Social workers can also use a strengths-based approach to help clients overcome resistance to physical activity. Call describes another client whose extended family made him feel uncomfortable seeking help for his chronic depressive episodes. Call focused on the client’s strengths as a father to create a treatment plan that included family-building activities based around exercise.

Otto encourages social workers to remember the “doing parts of therapy,” such as developing workout recommendations for clients medically cleared to exercise. Taking this step, however, does not have to include a trip to the gym. For example, practitioners can learn the rated perceived exertion scale (a simple scale used by coaches to rate athletes’ exercise) to help clients measure the intensity of their workouts. Pedometers are another simple way to make people more aware of their daily behaviors.

Additionally, social workers can identify and provide resources to help clients incorporate physical activity into their lives. Donna Ulteig, LCSW, of Psychiatric Services SC in Madison, WI, remembers a client who experienced pain as she exercised. Ulteig responded to this challenge by identifying a nearby exercise class held in a warm-water pool and helping her client find a swimsuit.

Ulteig notes the importance of alternative reward systems for clients who may need additional encouragement. Rewards can be self-induced, such as a person allowing himself or herself to make a small purchase after a workout. Alternatively, social workers can identify external motivators such as friends or family members who can craft customized ideas for positive reinforcement. Ideas include family or friends going to a movie the client wants to see or offering to cook dinner if he or she completes a workout.

As for Park, who recently received her master’s degree in social work, she wishes her own therapist had provided tips to keep her motivated. She sees the benefit in guiding clients through their feelings as they experience both the sense of improvement and plateau often associated with exercise.

Park adds that guiding clients through their emotional response to exercise helps the social worker ensure they are supporting but not forcing the treatment. Ultimately, the decision to incorporate physical activity into a broader treatment plan should remain in clients’ hands.

The Top 5 Social Justice Issues Facing Social Workers Today

The Top 5 Social Justice Issues Facing Social Workers Today
Social Work Today
Celebrating Diversity By Lorraine Gutiérrez, PhD, LMSW

Our commitment to social justice and antioppressive work brought me into social work and keeps me here. Growing up in the late 1960s and early 1970s, the power of the people to transform society and work toward greater gender, racial, and ethnic equality was clear. During my undergraduate years, I learned that social workers active in the progressive movement were at the forefront of policies that reduced working hours, restricted child labor, and created public health clinics to improve conditions for low-income families. These models for how we can change our society shaped my involvement in organizations to end violence against women and work toward the empowerment of diverse groups.

My path as a social worker is not unique. Regardless of our setting, all social workers are engaged in work related to oppression and social injustice. We are more aware than most people of the challenges faced by children and families living in poverty, the inadequacy of our “safety net” of human services, the disproportionate incarceration of men of color, and the challenges experienced by those living with disabilities. We do this work while living and working in a society where groups have mobilized to restrict or eliminate existing rights such as public education for immigrants and the children of immigrants, domestic partnerships for gay men and lesbians, and access to reproductive healthcare for adolescent women. Surviving and thriving as a social worker requires that we have a true appreciation for human diversity and understand how social identities affect access to resources.

Throughout our history, social workers have been agents of both liberation and oppression. During the same era that we founded social settlements, we were involved in the incarceration of Native American children in boarding schools. While we were actively involved in crafting the Social Security Act, we participated in the deportation of Mexican American families who were “public charges.” While we participated in civil rights movements in the 1950s and 1960s, we referred many women of color to doctors who sterilized them against their knowledge. Our approach to diversity within our communities will influence whether we work toward social exclusion or inclusion. Will we work toward the rejection, tolerance, acceptance, or celebration of the different groups that make up our communities?

If we are to work toward social justice, we need to engage in the work involved in celebrating difference and diversity. I use the word celebrate based on its original meanings, which refers to honor, respect, or recognize. We must move beyond tolerating or accepting those who are different from ourselves to a position of cultural humility that requires us to question our own background and experiences to work in partnership with others. When working from this perspective, we, as social workers, must be engaged in ongoing self-assessment and awareness of how power differences affect our ability to be genuinely helpful. This process is an essential element of social justice work.

Celebrating diversity means working as an ally and advocating for marginalized and oppressed groups. We are allies to others when we can recognize and use the sources of our privilege to advance the rights of those who do not share our own identities or backgrounds. We need to ask ourselves how we can use the knowledge we have of unjust practices toward individuals and groups in society to work toward changes to improve their situation. Our knowledge and experience can be used to join with others and create new movements to reduce poverty, improve access to healthcare, support families, and eliminate discrimination on the basis of our social identities.

The United States is becoming an increasingly multiracial, multicultural, and multiethnic society. At the same time, conditions of economic inequality by gender and race have not improved. These trends in the substance and structure of society challenge our profession to evaluate how we address these demographic shifts. It is our responsibility as social workers to strategically use our position and privilege to work toward greater equality. There is no other ethical choice.

Child Welfare
By Judith M. Schagrin, LCSW-C

Social justice means all citizens are entitled to the same rights and services. I am deeply concerned that we continue to fail the children who are abused, neglected, and just plain unwanted. Foster children, who depend on society’s largesse for their very existence, go largely unseen. Because these are children, they don’t fund any political campaigns, lobby any elected representatives for an opportunity to be heard, or organize any marches to advocate for better services. They have no voice if we don’t speak for them.

It’s not that we haven’t tried to organize a functional child welfare system. Since the start of our modern-day foster care system in the mid-1880s, when Charles Loring Brace started the Orphan Train Movement to resettle orphaned children from New York City to states in the Midwest and beyond, there have been numerous efforts to get it right. We have strategically planned, privatized, transformed systems, thought outside the box, been accountable, computerized, wrapped around, and done more with less. But as a national priority, the nation’s child welfare system is nearly an afterthought. Without the occasional sensationalized child death, I suspect these families would fall off the radar altogether. Unfortunately, the story they have to tell often isn’t pretty, revealing a troubling underbelly of our society. Some prefer to keep these images far away, finding comfort in denial.

While we are a country of people who profess to love their children, there were 3 million reports of child maltreatment in 2004. Experts believe this represents only one third of actual incidents. More than 800,000 reports were found indicating a rate of 2.9 per 1,000 children. That’s not surprising, considering how staunchly we defend our right to physically discipline our children. As long as no injuries result, parents may hit their children with impunity.

Four children die from maltreatment every day, a number largely undercounted. Neglect, often associated with poverty, leads to slightly more child deaths each year than abuse. According to the 2005 census, 17.6% of children under the age of 18 live in poverty; the federal poverty level is $20,000 per year for a family of four. Of children in female-headed households, an appalling 42% exist under the poverty line.

Three years ago, news that Maryland could no longer afford our zoo’s elephants generated far more outrage than our child welfare hiring freeze. The freeze lasted three long years, leaving children’s needs overlooked and ignored. We are a wealthy country not just in money but in talent and brains. Surely we can muster the will to develop and support a top-notch child welfare system? What will it take for our children’s needs to grab the public’s attention with the same fervor as our zoo’s elephants?

As for solutions, let’s create the public will to do it better. Let’s reinstate the White House Children’s Conference—derailed by President Reagan in 1980—and bring together national experts from around the country. Lobby hard for loan forgiveness for social workers willing to specialize in child welfare. Enlarge the sphere of influence for social workers by running for a local, state, or federal office—or electing a colleague.

Our children have only a handful of years to be children, only a brief period to build the foundation for a productive and satisfying adulthood. It’s time we got it right—the children can’t wait.

— Judith M. Schagrin, LCSW-C, is the assistant director for Children’s Services at the Baltimore County Department of Social Services. She was named the 2004 Social Worker of the Year by the National Association of Social Workers.

Healthcare Reform
By Libby Gordon, MSW

I live in the healthiest state in the nation. This is according to America’s Health Rankings, issued yearly by UnitedHealth Group. I must admit, I felt pretty good about this, as I traveled to and from the gym, ate my yogurt and veggies, and took the stairs at work. This blissful denial lasted all of one day. The next day, while attending a health disparity task force meeting, I was brought back to reality: You can live in the healthiest state in the country and still be surrounded by desperate need. No statement drove this home so effectively as the African American public health worker who stood up and proclaimed, “My zip code is dying. Why, in a nation of so much, is my zip code dying?”

Why are 46.6 million people without health insurance (383,000 right here in my healthy state)? Why is employee-sponsored health insurance disappearing? Why are the numbers of uninsured African Americans, Hispanics, and immigrants so disproportionate to that of Caucasians? Why is the number of uninsured children—8.3 million—again on the rise, when it had been dropping steadily since 1998? And why aren’t more people as outraged as the public health worker who burst my bubble of denial?

Although these are questions without simple answers, social workers have a tradition of striving for solutions. To begin, we must understand who are most affected by the disparity in health insurance coverage. The Kaiser Commission on Medicaid and the Uninsured (KCMU) reported that families with incomes 200% below the poverty level run the highest risk of being uninsured. Contrary to public perception, however, 81% of the uninsured are in families where at least one adult is working. Also at high risk of being uninsured are minorities and immigrants. According to the Center on Budget and Policy Priorities (CBPP), African Americans (19.6% uninsured) and Hispanics (32.7%) are much more likely to lack insurance than Caucasians (11.3%). Meanwhile, 43.6% of noncitizen immigrants are without insurance. Lastly, 8.3 million children (11.2%) are presently uninsured, and their future looks grim. In Fiscal Year 2007, which began October 1, 2006, the children’s health insurance programs—which are block grants, not entitlement programs—face federal funding shortfalls in 17 states. This amounts to an estimated $800 million and equals the cost of covering 530,000 low-income children.

The recent escalation in the number of uninsured individuals is largely attributed to a continuing decline in employee-sponsored insurance (ESI). Even when employers do offer insurance, employees frequently cannot afford the skyrocketing premiums. A recent report from KCMU found that between 2001 and 2005, ESI premiums increased by no less than 9% per year. Meanwhile, employees’ earning grew by only 2.2% to 4%, making it difficult to keep pace with insurance payments.

The consequences for those who cannot afford or are not offered health insurance are life-altering. KCMU has found that they are less likely to receive preventive care, such as mammograms, and are more likely to be hospitalized for avoidable conditions. These misguided attempts to contain costs by denying treatment of minor conditions often result in the development of problems that are both more expensive and more serious. Those without insurance are likely to have problems paying medical bills—nearly one quarter are contacted by collection agencies. Most importantly, the Institute of Medicine estimates that 18,000 Americans die prematurely each year because they lack health insurance. If the uninsured were to gain continuous health coverage, mortality rates could be reduced by 5% to 15%.

These inequalities are not inevitable. Solutions do exist and can be created with an eye to both effectiveness and cost containment. Policies can be implemented to locate and enroll individuals who are eligible for public programs, while eligibility for these programs can also be expanded to cast a wider net. ESI premiums can be lowered, and employers with a certain number of employees can be required to pay a set percentage of their payroll on health benefits. Affordable health insurance plans can also be made available to small employers. Children’s health insurance can become an entitlement program, providing coverage to any who are in need.

It was not hyperbole for the public health worker to say her zip code is dying. Chances are, some of those 18,000 people who died prematurely—the minorities, the poor, the children—were her neighbors. So long as some zip codes remain endangered, social workers have a mission: to see the whole picture, the one that rankings do not show, and to advocate for those in need. Perhaps, then someday the health rankings will be a cause for all zip codes to celebrate.

Poverty and Economic Injustice
By Mimi Abramovitz, MSW, DSW

“True compassion is more than flinging a coin to a beggar. It comes to see that an edifice which produces beggars needs restructuring.”
— Martin Luther King, April 4, 1967, New York City1

The Bible says the poor will always be with us, but it does not say why. Since then, some observers have blamed the victim, choosing to punish the “undeserving” and offer a meager safety net to the “deserving” poor. In contrast, social workers believe poverty has many complex causes, including low wages, a lack of jobs, racism, sexism, and other forces beyond individual control. We favor helping rather than punishing people and changing rather than protecting a problematic status quo.

However, for the past 30 years, the fight against poverty and injustice has been an uphill battle. Indeed, major economic dislocations and victim-blaming public policies have taken their toll on the capacity of the three traditional sources of income—marriage, markets, and the state—to protect people from poverty even when they work hard and play by the rules.2 Instead of cushioning the blows of the sagging economy as they once did, today’s leaders confront wage stagnation and slow job growth with tax cuts for the rich, spending cuts for the poor, and a war in Iraq. The results include mounting rates of poverty, hardship, and social problems—all of which fall into social work’s domain.

Mounting Poverty
In 2005, 12.6% of the population (or 37 million people) were poor—up from its all-time low of 11.3% in 2000 and higher than in 1979.3 Even the higher African American (24.9%) and Latino (21.8%) rates and the lower Caucasian (8.3%) rates rose above their all-time 2000 lows.4 Meanwhile, the American Dream—the promise that work pays—faded for the working and middle class. In 2004, 7.8 million people aged 16 or older spent at least 27 weeks either working or looking for a job but earned below–poverty-level wages in companies that provided few basic benefits such as healthcare or parental leave. More than 58% of these “working poor” women and men were on the job full-time and 90% worked at some time during the year—twice as many African Americans and Latinos as Caucasians.5 Thanks to tax cuts and corporate welfare, inequality also reached new highs. In 2005, the top 20% of households accounted for a record 50.4% of the national income, up from 49.8% in 2000 and 43.2% in 1970. In contrast, the bottom fifth’s share fell from 4.4% in 1970 to 3.6% in 2000 to 3.4% in 2005.6

Mounting Hardship
Poverty, in turn, takes its toll on people’s lives. In 2004, 40% of poor and 14% of nonpoor families faced food, health, or housing insecurity, considerably more families of color than Caucasian families.7 The situation has worsened over time. From 1987 to 2005, the number of people lacking food security rose from 31 to 35 million; those without health insured soared from 31 to 46.5 million while the number of households paying more that 30% of their income for rent jumped from 31% (1978) to 49% (2005).8-10 These losses were further compounded by a lack of social investment in low-income communities exposing people to: crumbling neighborhood infrastructures (e.g., abandoned housing, poor schools, lack of services, unemployment); interpersonal violence (e.g., battering, rape, child abuse); and community violence (e.g., gang fights, drive-by shootings, surveillance, police brutality, sexism, and racism).

Mounting Social Problems
Social workers know firsthand that people confronted with chronic deprivation and/or harsh living conditions often feel unsafe, insecure, and powerless. We also know that people cope with the desperate condition by harming themselves (e.g., self-medication, dropping out of school, unsafe sex, ineffective parenting, inability to hold a job, lack of self-care, and suicide) and/or others (e.g., crime, assault, battering, rape, homicide). Social workers have the know-how and the professional obligation to help people undo negative coping and promote positive coping—both self-advocacy (e.g., seeking needed social, health, and financial assistance) or social advocacy (e.g., community activism).

Given social work’s location between the client and society, we can either leave solving poverty to the economists or join the fight for economic justice. A growing consensus holds that exposure to economic hardship and adverse conditions often precedes the rise of individual and social problems rather than the other way around, as previously presumed.11 This conclusion translates into a mandate for prevention and social change. Some fear that making individual and social change a fundamental part of our work politicizes a previously objective and unpolitical profession. Yet, to argue for neutrality itself becomes a political stance—one that tolerates government neglect, compromises our profession’s ethics, and otherwise favors the status quo by letting it stand unchallenged. Since social work cannot avoid the political, it is far better to address these issues explicitly than to pretend they do not exist. The middle ground, if one ever existed, has fast receded. We must decide which side we are on. In the words of Martin Luther King, Jr., “Our lives begin to end the day we become silent about things that matter.”

Affordable Housing
By Frederic G. Reamer, PhD

Recently, I attended a meeting at the National Association of Social Workers’ (NASW) headquarters in Washington, D.C. NASW’s offices are located a stone’s throw from the U.S. Capitol, one of the most architecturally impressive and symbolically important buildings in the world. During my walk, I was overwhelmed by the majesty of the scenery but sadly, and ironically, I was also overwhelmed by the number of (apparently) homeless people I passed during my walk from the Capitol to NASW, men and women sleeping in broad daylight on concrete slabs and park benches. The juxtaposition—the contrast between the stately halls of Congress and the stark evidence of America’s poverty and affordable housing crisis—was one of the most stunning I have ever encountered.

Understandably, social workers concerned about affordable housing have focused primarily on the nagging problem of homelessness, particularly among people struggling with mental illness, addictions, and persistent poverty. However, the troubling problem of homelessness is merely symptomatic of a broader crisis of affordable housing, one that has profound implications for social workers’ clients.

Housing costs are staggering in many American communities. The National Coalition for the Homeless reports that approximately 3.5 million people—1.35 million of them children—are likely to experience homelessness in a given year. According to Harvard University’s Joint Center for Housing Studies, nearly one in three American households currently spend more than 30% of income on housing, and more than one in eight spend upwards of 50%. Approximately 2.5 million households live in crowded or structurally inadequate housing units.

It is essential for social workers to understand the magnitude and nature of this country’s affordable housing crisis and its implications for practice. The principal causes of the contemporary affordable housing crisis are complex. The demand for affordable housing is affected by increases in poverty and growth in the number of U.S. households. In addition to ordinary population increases, growth in the number of people needing housing also results from declining marriage rates and an increase in the average age at which people first marry, which postpone the combining of households.

Coinciding with increasing demands for affordable housing are threats to the nation’s supply. Declining and expiring federal housing subsidies, disappearing tax incentives to invest in and build low-income housing, restrictive and exclusionary zoning practices, demolition and abandonment of older housing stock, and gentrification join to reduce the number of affordable housing units in many communities. Consistent with one of the most basic laws of economics, increasing demand combined with diminishing supply can lead to skyrocketing costs.

To be effective advocates for clients and informed participants in the public policy arena, social workers must have a firm grasp of possible solutions. Social workers should seek to preserve the existing stock of affordable housing by pushing for programs that rehabilitate low- and moderate-income housing and advocating for preservation of existing subsidies for low- and moderate-income housing.

Also, social workers should seek to expand the supply of affordable housing through tax incentives that underwrite subsidized mortgages for builders, progressive and enlightened zoning practices that promote the “fair share” development of affordable housing across communities, and creation of housing trust funds fed by a renewable stream of income (for example, via real estate transfer taxes, interest on real estate escrow accounts, interest from government loans, and developer fees).

Social workers have an enduring tradition of concern about individuals’ most basic needs, including housing. One of the profession’s principal trademarks is its simultaneous concern with individual well-being and related public policy issues. Certainly, social workers must be concerned about the basic housing and shelter needs of individual clients. At the same time, however, social workers must be engaged actively in the advocacy, public debate, and policy formation that are so essential to the provision of safe and affordable housing. To do otherwise would be to stray from social work’s time-honored mission.

10 Dedicated and Deserving Social Workers

10 Dedicated and Deserving Social Workers
By Lindsey Getz
Since National Professional Social Work Month will be observed in March, we devote this space to some of the wonderful and committed social workers in the field. With the second annual “10 Dedicated and Deserving Social Workers” recognition, we asked you, our readers, to nominate your colleagues, coworkers, and mentors by writing essays about the people you believe should be recognized. So many of you deserve recognition, but 10 finalists were selected, and we are honored to share their stories with you here.
Stacey Krueger Barton, MSW, LCSW
Clinical Social Worker at Washington University School of Medicine in St. Louis
Prior to working in the Washington University School of Medicine Movement Disorders Center, Stacey Krueger Barton spent almost 10 years working in hospice. She says that background prepared her for working with patients with Huntington’s disease, a progressive and incurable movement disorder that often strikes people in the prime of their life, destroying their ability to move, talk, and reason and eventually leading to their death. Barton was hand-picked for her current position by its former holder—someone who was told she could find her own replacement and knew Barton was the perfect fit.
“Once I learned more about the position, I knew she had pegged me well,” says Barton. “About 60% of my time is clinical, and the rest is doing research.”
Barton’s responsibilities include counseling patients, helping them and their families adjust to future changes related to Huntington’s disease, and heading up numerous research projects for the disease. Patients have a 50% chance of transferring the gene that causes Huntington’s disease to their offspring, so Barton says it’s quite common for her to work with more than one family member. But she says it’s a “family disease” whether the gene has been passed or not.
“The patient’s actions have a ripple effect on the whole family,” she explains. “The disease causes cognitive and psychiatric changes that are tough to deal with. For example, sometimes Huntington’s patients do things that cause them to get in trouble with law enforcement, and that’s an area where we have to intervene.”
While these difficult cases can take a toll on health professionals, Barton says her training helps her deal with the weight of her work. “I learned to measure my goals differently,” she explains. “My goal in hospice wasn’t that the patient would live—it was that they have a good death and that the family was prepared. Maybe I helped get them on Social Security or ensured the patient had good care in their final days.”
In addition to setting realistic goals, Barton says she’s also learned to create boundaries that she keeps in the forefront of her mind at all times. “That’s something else I learned in hospice,” she says. “I became good at letting go of the person I just left prior to walking into the next house. And at the end of the day, I have to let go of that last patient so I can be present for my own family. It can be challenging, and when I mentor students, I try to discuss this with them because I think letting go of patients is something social workers struggle with.
“As engaged as I may be with the patient, at the end of the day it’s their life, not mine,” she continues. “The truth is that I’m not living with what they’re going through. Perspective is one of the best job perks. I’m constantly inspired by my patients.”
Bill Wertman, MSW
CEO of the Alzheimer’s Project, Inc. and an adjunct instructor at Florida State University
Bill Wertman’s grandmother was diagnosed with Alzheimer’s disease while he was working on a degree in nutrition and dietetics. She came to live with him and his family. Wertman says that move had a huge impact on his career path.
“I saw how much of a struggle it was for my mom to provide a certain level of care for her,” he says. “I was working on my degree, and there just weren’t a lot of resources available in the rural county we lived in, so my mom was often on her own.” 
After finishing his degree, Wertman went back to school get a master’s degree in social work, a decision influenced by witnessing his mother’s struggles as his grandmother’s primary caregiver. In 2006, Wertman joined the staff of Alzheimer’s Project, Inc., an organization that provides much-needed respite for caregivers by placing volunteers in patients’ homes. The organization has also incorporated support groups, counseling, educational opportunities, and much more into the local communities.
And while Wertman loves this job, he says his true passion is teaching. He believes numerous social work programs are based heavily on a textbook methodology for teaching, but as an adjunct professor, he brings some real-world perspective into the classroom. “You can read a textbook example of how XYZ looks, but it’s nice to be able to talk about how XYZ goes in real life—it’s not always picture perfect,” he says. “Students appreciate that honesty, even though it can be scary at times.”
Wertman says he sees a future for social work students in which there are numerous possibilities. “The training social work students receive prepares them to do any number of functions once they graduate,” he says. “They can work in administration, be advocates across any practice level, create their own environments, or even partner with other social workers. They can even have their own practice. The most important message I want to convey to my students is to think outside of the box that has contained us for so many years. We’ve been taught to think that as social workers, we can only become case managers or earn X amount of dollars, but that’s not how I see it. I see a future that is much brighter than that for today’s students.”
Seth Berkowitz, LCSW, CCLS
Patient Services Manager for The Leukemia & Lymphoma Society Southern Florida Chapter
Seth Berkowitz was involved in the healthcare field prior to joining The Leukemia & Lymphoma Society (LLS). He worked for Gilda’s Club South Florida running support groups and sold safety training to corporations and businesses for the American Red Cross. And prior to moving to Florida, he worked as a child life specialist at Children’s Hospital of Michigan.
But when a position became available at LLS for a full-time social worker, he knew it was his calling. “It’s such a great organization and a place I’d been working part time even before this full-time opportunity became available,” he says. “We are the frontline of support for newly diagnosed patients with leukemia, lymphoma, and other blood cancers.”
Berkowitz isn’t just a clock-in, clock-out kind of employee at LLS. He has taken on numerous leadership roles both locally and statewide within many social work organizations, including the National Association of Social Workers and the Florida Society of Oncology Social Workers. “I wanted to get more involved with those organizations because I feel like they’re making a true impact on society and moving things in the right direction,” he says. “You start to realize the impact you can have once you get more involved.”
While he’s remained involved in the healthcare field with his LLS work he says that, as a social worker, he enjoys working a bit outside the medical model. “I’ve worked with patients that have died, but I can at least walk away feeling that I know I did something to help with the process and make life better in some way for that patient and their family,” Berkowitz explains. “We are often able to make the patient’s life better or even helped them live even longer by providing interventions and support. That allows me to walk away from tough cases and still feel some sense of reward. Since the medical model is so focused on the patient outcome, I think it’s hard for the medical team to walk away from those cases where they lost a patient. We’re focused more on the journey of the patient and doing everything we can for them in terms of support.”
Christa Albert-Watson, BA, MSW, LCSW-BACS
School Social Worker Specialist for Recovery School District in New Orleans
When Hurricane Katrina struck the Gulf Coast in 2005, Christa Albert-Watson was among thousands who had to leave New Orleans. Upon returning, she found that the children’s psychiatric hospital she’d worked at had closed its doors. But she also found that there were many new opportunities where she could provide service—the greatest of which was in the school system.
“The biggest need was helping get kids back into school and also helping them adjust to all the changes that had taken place since Katrina,” says Albert-Watson. “In the beginning, a lot of my work had to do with the basics we take for granted—helping kids get clothes for school or even their birth certificates so they could enroll in school. Sometimes it was helping schedule their bus routes because the places they were living could change daily. Those early days were tough times, as everyone was starting all over again.”
Even today, Albert-Watson says there are daily struggles. Students are still returning to the area, having been away since Katrina, and Albert-Watson says many are shocked at the changes. So her job still has much to do with helping kids adjust. “There are still a lot of logistics to work out,” says Albert-Watson. “We also have a population of homeless kids whose needs we’re helping meet.”
It’s Albert-Watson’s positive attitude that helps her continue to make a difference in the lives of these children. She always looks for the bright side of a situation—even in trying times.
“I think that every day there’s at least one bright spot,” she says. “Even if it’s a day full of challenges, I always look for the moment that makes it a good day. And I’ve always found something, even if it’s just a tiny fleeting moment. I grab on to that, and it helps me get to a new day. The sign outside my door says, ‘Every day is a new beginning,’ and I really believe in that philosophy—starting fresh each and every day, no matter what happened in the past.”
Susan Signorino, MSW
Senior Living Counselor at Brooking Park in Chesterfield, MO
As a teenager, Susan Signorino realized she wanted to go into a helping profession. She was working as a candy striper at a local hospital and says she loved the atmosphere and enjoyed the sense of fulfillment from helping others. So she followed that path. In her first 17 years as a social worker, Signorino worked in home care and hospice through a rural hospital.
While Signorino interacted daily with patients at the hospital, she began to feel isolated because there weren’t many other master’s level-prepared social workers around. Seeking some support from and connection with her peers, Signorino launched an e-mail listserv to reach out to other social workers in the area. “Many organizations only have one social worker on staff, so this was a great way for all of us to communicate,” she says. “Then in the ‘90s, we went through a time when a lot of social workers lost their jobs and were in need of work, so the listserv became an opportunity to help one another by posting résumés and sharing job openings. From there, it has evolved.”
Four years ago, Signorino began working in the St. Louis area, and with the move to a larger community, the listserv truly blossomed. Today there are more than 700 social workers who use it, yet Signorino continues to manage it on her own and also keeps it free of charge despite the huge amount of time she invests in it. “This is never something I’ll charge for because it’s meant to be a community service to my fellow colleagues,” she says. “Connecting is something that benefits us both personally and professionally.”
Signorino has seen these benefits from the listserv herself. Since the recession, Signorino has been let go from three jobs in just three years because of issues such as downsized departments.
“Psychologically, it’s been devastating,” she admits. “But then I get an outpouring from other social workers who have shared their own stories of lost jobs or are sharing job opportunities with me, and it helps remind me what I love about this profession. Today I’m settled in a long-term care community doing marketing and admissions, and I feel that things have worked out great even though it’s been a roller coaster ride to get here. All along, the connection with other colleagues out there through this listserv has reminded me that I’m not alone.”
Leta Meerman, BSW, MS
Emergency Department Social Worker at Holmes Regional Trauma Center in Melbourne, FL
As an emergency department social worker at Holmes Regional Trauma Center, Leta Meerman provides crisis intervention for patients and their families during some of the most traumatic times in their life. She deals with trauma cases, homeless patients, child and elder abuse victims, and many other difficult scenarios, yet she comes to work every day ready to make a difference.      
“We deal with a lot of horrible things—gunshots, stabbings, drownings, murder attempts, domestic violence, abuse and, of course, any vehicle or motorcycle crashes,” says Meerman. “But even though it can be difficult, it’s also wonderful to be able to help someone at their worst moment in life. I’ve always had an interest in making a difference and being in a place where I can help people, and this is certainly one of those places.”
Meerman has even extended that helping hand in her free time, having volunteered to be on the board of directors at a local adoption agency. “There are so many people looking to adopt internationally, but there are a lot of kids here in our own community that need homes. That fact has driven me to help.” 
In fact, it even led Meerman to adopt a special needs child of her own. “A therapist I work with showed me a picture of this little girl and said she looked a lot like me and expressed that she needed a home,” says Meerman. “That’s something I’ve always wanted to do personally because I believe every child needs a family. Today, she’s 11 and doing very well. I’ve also helped place at least 10 other special needs children into loving families.”       
Whether it’s working with families looking to adopt or in her current position in the emergency department, Meerman says her guiding philosophy has always been the old proverb that if you give a man a fish, you feed him for a day, but if you teach him to fish, you feed him for a lifetime.
“That’s my approach to social work,” she says. “I aim to empower my patients to help themselves. That proverb reminds me that I need to ensure these patients and their families have all the resources they’ll need to be OK after they leave these horrible traumas and my service.”
Brandy Johnson, MSW, LCSW
Senior Oncology Social Worker for Cancer Care at Saint Clare’s in Denville, NJ
Brandy Johnson says she was always intrigued by cancer cases, so when she became a social worker, it was obvious that working with patients who have cancer was her calling. She later realized her grandmother, a 25-year breast cancer survivor, likely sparked the passion.
“She had breast cancer at a time when the treatment was a radical mastectomy and radiation that left you with burns all over,” recalls Johnson, who says she’s also been a cancer caregiver to her aunt. “But that never stopped her from doing anything. She was always dressed to the hilt and never let cancer get in the way of her life. Looking back at her strength has helped me go into this field and has helped me realize that cancer doesn’t have to be something to be scared of. It’s a part of life. The question is how to deal with it, and that’s where I want to help.”           
As an oncology social worker, Johnson helps ensure her patients and their families get the support and resources they need. As a tireless advocate, she’s also frequently involved in community events such as the Breast Cancer Walk and Survivor’s Day. “I find strength in participating in these additional community activities,” she says. “I may collapse at the end of the day from being tired, but I also really enjoy it.”
Additionally, Johnson sits on the board of the Operation Bling Foundation, which provides free jewelry to cancer patients. She says asking patients or their caregivers if they’ve been “blinged” is sometimes a great conversation starter, especially with a family that has been resistant to a social worker’s help. “Once they open up, they start talking about how they’ve been poked and prodded and just feel like a piece of meat,” Johnson says. “To get a piece of jewelry as a gift makes them feel human and loved.”
Johnson says she’d like to see the greater community become better educated on the value of social workers so that more conversations can be started. “We really need to strut our stuff and show the world that we’re not just people that take babies away,” she says. “I’d love to see the community educated on what we as social workers can do and how we are there to help.”
Mark Rogalsky, BASW, MSW
Unit Manager for Prevention Services at Mercy Behavioral Health, part of the Pittsburgh Mercy Health System
“It all goes back to the summer of 1974,” says Mark Rogalsky, describing what led him to the field of social work and, more specifically, to working with kids.
Though only a kid himself at the time, during the Pittsburgh Jewish Community Centers overnight camp, he had a calling—literally. One of the program’s youth workers called Rogalsky after he returned to the city from camp and asked if Rogalsky wanted to help plan another weekend-at-camp event. “I think from that point on, I was hooked on group work with kids,” Rogalsky says.
In his first job out of graduate school, Rogalsky went to Houston, but he says it wasn’t long before he got a call for a position that brought him back to Pittsburgh. From there, he has held several different positions. But ultimately an opportunity came up to be a school-based therapist. The more “normal” business hours plus time working with kids appealed to Rogalsky, plus he was in an excellent position to make a huge impact on kids’ lives. But how he did it might be a surprise—it was through dance.
Rogalsky was instrumental in bringing “dancing classrooms” into some of Pittsburgh’s highest risk schools. Coordinating the program, he works within the schools, plans competitive events, and markets the program to the community. “I had seen Mad Hot Ballroom and Take the Lead, and I began to realize how wonderfully it fit in with the idea of prevention,” says Rogalsky. “It’s like The Karate Kid in the sense that there’s a bigger picture. Kids don’t realize that dance is keeping them from getting in trouble or giving them a place to connect. They think they’re just learning to dance.”
Rogalsky says Janice Pringle, PhD, from the University of Pittsburgh, School of Pharmacy is in the process of working on hard data to determine the program’s impact in areas such as behavior and academics, but preliminary reports are “phenomenal.” Personally, he says participating in the dancing classrooms has been the greatest part of his time as a social worker. Rogalsky says it’s obvious just by watching the kids the positive impact the program has on their lives.
“I get to go from school to school and talk to the kids and watch them dance, and it’s been wonderful to see how excited they all are,” Rogalsky adds. “It’s amazing how much we can accomplish with school-based prevention. There are just some things kids will remember forever, and that’s pretty powerful. It’s the realization that you helped them look at things with a different perspective and made a positive impact on their lives in some way.”
Hanan K. Bilal, BSW
Social Service Coordinator for Gardenia Gardens Neighborhood Network Center at Gardenia Gardens Apartments, Inc. in Gainesville, FL
Hanan Bilal says her passion for “connecting people with resources and making a difference in the community” comes from growing up with activist parents. “They were concerned about education, poverty, and racial and social inequalities,” she says. “Growing up with parents that had such passion, it was automatic that I picked it up myself.”
While Bilal has traveled the world, she ultimately wound up back in the town she grew up in. “I went to school here. My daughter’s grandparents live here, and I just have background here,” she says. “It makes you want to do your best for the people that live here when it’s your own community.”            
But Bilal has truly gone above and beyond. She began working six years ago with an affordable housing community subsidized by the Department of Housing and Urban Development as a social service coordinator. Though she was told it would eventually be a funded position, that hasn’t happened, so even though she took on a full-time job as a director of volunteers for the Ronald McDonald House Charities of North Central Florida, she has continued to provide her social work services to the housing community, often going door to door to see her clients. “I have found that a lot of times, people just don’t come to you, so if you want to be effective as a social worker, sometimes you have to go that extra mile,” she says.
With the little amount of spare time she has, Bilal also founded the group Muslims That Want to Marry as a resource that would help Muslims connect with one another. “I was raised in a Muslim family that was surrounded by Christians,” says Bilal. “Most of our family is Christian, and while I love and respect Christians, as a divorced woman, I’ve realized how hard it is to meet other Muslims. As a social worker, I naturally wanted to find a solution. While people told me I could make money off of the site the way a site like Match.com does, I felt that would defeat the purpose. I understand not everyone would be able to afford it, and I want this service to be available to anyone that needs it.”            
Just like Bilal was inspired by her own parents, she says she hopes to be an inspiration to her 14-year-old daughter. “In everything I do, I realize that my child is watching me, and that always reminds me to do the right thing,” she says. “I believe in volunteering and helping people, but it has to be more than a belief—you have to actually do something about it.”
Nancy Calhoun, LMSW
Retired Social Worker for SUNY Upstate Medical University, University Hospital in Syracuse, NY
Years ago, Nancy Calhoun became a single parent and needed to pursue a new career. Her next-door neighbor, who was the dean of Syracuse University’s School of Human Development, suggested pursuing an MSW because it could be the “key to multiple careers.”
Calhoun says that’s exactly what social work has been for her, and since obtaining her degree, she’s used it for service, teaching, applied research, advocacy, and counseling. Now retired, Calhoun provided decades of dedication to the social work field and says if it weren’t for her current battle against breast cancer, she’d be doing even more.
Though she’s held various positions, for the last 15 years, Calhoun worked at SUNY Upstate Medical University, providing care to older adults with dementia and supporting their caregivers. She says she’s become accustomed to looking at the big picture and always asking herself, “How can I make this happen?” She never gets discouraged and is always looking for solutions. In fact, Calhoun says that even today the “ideas are there, just not the energy to follow through,” as she fights cancer.
Along the way, Calhoun has taught and developed a gerontology curriculum and a course on aging. “I taught until I realized I was approaching the aging population myself,” she says while laughing. “I always saw myself as the link between the younger generation of up-and-coming social workers and the older generation, but once I realized I was part of the latter group, I decided that wasn’t the role I wanted. I was no longer the middle-aged person that could interpret for both groups.”
Calhoun says that even in retirement, she can’t stop herself from always looking for a solution. That’s the life-long social worker in her.

“There’s always a way through a problem. I’m an eternal optimist,” she says. “Along with that, I have the ability not to dwell on the things that don’t turn out so well. I can move on and accept the next challenge. That’s part of how I live my life. If it weren’t for my health situation, I’d be out there now. But I’ll never stop looking around and seeing opportunities to help.”

Facebook and Suicide Prevention

Facebook and Suicide Prevention -Written by Linda May Grobman, MSW, LSW, ACSW  

Facebook announced in December 2011 a new partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Suicide Prevention Lifeline 1-800-273-TALK. Through the new service, Facebook users who see a suicidal comment posted by a friend can report this to Facebook using the “Report Suicidal Content” link or the report links found throughout Facebook. Facebook will then send an e-mail to the person who posted the suicidal comment, encouraging him or her to call the National Suicide Prevention Lifeline or to click on a link to begin a confidential chat session with a crisis worker.

    With 800 million active users, Facebook has the potential to make an enormous impact with this new service.
    “Facebook and the Lifeline are to be commended for addressing one of this nation’s most tragic public health problems,” says Surgeon General Regina M. Benjamin, MD, MBA. “Nearly 100 Americans die by suicide every day—36,035 lives every year. These deaths are even more tragic because they are preventable.”
    Social worker Brad A. Palmertree, BSW, who is co-chair of the Gay, Lesbian, and Straight Education Network (GLSEN) of Middle Tennessee, says of the partnership, “[It] is a natural progression of social service professionals meeting the clients where they are. Social media has become a place where individuality and personal expression is not just accepted but expected and embraced. So it’s only natural that life’s troubles show up alongside its triumphs.”
    He adds, “I think it’s a wonderful step in the right direction. As someone who works daily on creating and maintaining safe spaces for lesbian, gay, bisexual, transgender, or questioning (LGBTQ) youth, social media has been a double-edged sword. It allows young people to freely express themselves while building community with others who are navigating the murky waters of adolescence with an identity that is not always easily accepted or understood. But it also allows for a space where the bullies come at full force, often anonymously. Those who self-identify as LGBTQ, or even those who do not but are labeled as such because of preconceived gender norms, are bullied and harassed at a rate much higher than their heterosexual and cisgender counterparts. When school is not a safe haven and neither is home, LGBTQ youth turn to the Internet to seek answers, counseling, or simply validation.”
    The Lifeline has actually partnered with Facebook since 2006, but the new partnership adds the option of chatting online with a crisis counselor. John Draper, Ph.D., the Lifeline’s project director, says, “We have heard from our Facebook fans and others that there are many people in crisis who don’t feel comfortable picking up the phone. This...provides a way for them to get the help they need in the way they want it.”
    Ellen Fink-Samnick, MSW, ACSW, LCSW, of EFS Supervision Strategies LLC, believes the new collaboration, “on face value alone...is a promising means to enhance suicide intervention.” However, like others, she thinks that related ethical concerns warrant equal attention.  “Courtesy of rapidly emerging technology innovation, the framing of professional ethics has changed from ‘what one does while nobody watches,’  to ‘what one does while everyone watches, 24/7 in cyber-space,’ ” she points out.
    For social workers and other clinical professionals who may be involved in these efforts, Fink-Samnick says ethical concerns include:

State-to-state licensure: It would seem  there is a high likelihood that professionals will find themselves practicing across state lines as they assess clients in cyberspace. Will the professionals be appropriately licensed, credentialed in all jurisdictions?
With respect to “duty to warn,” what will the turn-around time be from identification to assessment to intervention?
How will professional liability be addressed?

    Others have brought up concerns about privacy and “Big Brother”-like worries. What happens when Facebook sends an e-mail to a suicidal user, and that e-mail address is a shared address with the user’s spouse, parents, children,  or co-workers? Is this a violation of the person’s health information privacy? And if so, is it excusable, given that it is for the purpose of saving the person’s life? Does the answer to this question depend on who is employed by Facebook to perform this task? And while we’re at it, what is a social worker’s responsibility when he or she comes across suicidal content, on Facebook or elsewhere online?
    Any effort to prevent suicide is commendable. At the same time, the best way to implement this plan is yet to be seen. The suicide reporting tool may be hard to find. There is no obvious “Report Suicidal Content” button in big red letters.

How My Field Placement Showed Me Why I Wanted To Be a Social Worker

People often ask, “Why social work?” It is almost inevitable that a social work student will be asked to answer this question multiple times during his or her social work education. Of course, many people will answer with something along the lines of “wanting to help people.” Personally, I have always hated this question. I knew I wanted a career in social work, but I could never find the words to fully explain why. Becoming a social worker was something that just seemed right, an unexplainable feeling that this is what I am supposed to do. Having a feeling is great (especially in this field), but I needed a more definite answer. I needed a universal answer I could tell to salesclerks, my 80-year-old grandfather, and potential employers. So how do you capture your passion for social work in words? I struggled with this question for a long time, and it wasn’t until the end of my field placement that I finally understood what social work actually means to me.My first official field placement was at Families Moving Forward, a supportive program to assist families experiencing homelessness. This field placement was everything I could have hoped for: an amazing field instructor, friendly staff, meaningful work, support, independence, and my very own caseload. The abundance of knowledge I obtained during my placement was something for which I will forever be grateful.
    As my hours were coming to an end, I began to invest less of myself at my internship. As many social work students understand, I was juggling far too many things to finish school. Papers, tests, work, field placement, family, friends were taking a toll on me. I was on a race to the finish line, counting hours until I could breathe again. It was in the midst of this chaos that I finally began to answer the infamous question, “Why social work?”
    My last case started out seeming ordinary. Little did I know Mary would have such an influence me. Mary was a hardworking single mother who came to Families Moving Forward seeking shelter. She was a delight to be around and was a breath of fresh air to the emergency shelter program. Mary had an associate’s degree and was considered highly employable. I would often find her diligently working on the computer to find housing programs and applying to new jobs.
    In one of our case management meetings, Mary shared with me the devastating news—she had been diagnosed with cancer and needed to be treated with chemotherapy and radiation immediately. My heart broke for this woman; being homeless is one thing, but having to go through a serious illness while being in a shelter seemed like cruel and unusual punishment. As social workers know, when it rains it pours. A series of unfortunate events followed as Mary began treatment. As her case manager, I felt completely powerless. What could a social work student such as myself have to offer someone facing cancer in a homeless shelter?
    My internship was coming to an end. I only had a few more appointments scheduled with Mary, and I did the average things that needed to be done. Mostly, I just listened to Mary share her experience. I felt bad for not having any profound resources for her and didn’t think she would bat an eyelash when I told her a new case manager would be taking over for me because my field placement was coming to an end.
    The day I told Mary I was leaving completely shocked me. She cried hysterically and disclosed that I was the only person who had taken the time to just let her talk about the cancer. She didn’t want me to go, because in the midst of all the pain, our weekly meetings were what held her together. Knowing that someone would just be sad with her made the week bearable. All of these weeks, I had been feeling bad about myself for not knowing what to do, and in the end just sitting with her was the most influential thing I was able to do for her.
    Mary’s response to my leaving was sadness and anger. This makes perfect sense when I look back on the situation, but in the moment I truly thought Mary barely even knew my name, let alone would be angry at me for leaving (oh the joy of being a student!). I felt horrible that I had to leave her and hated that I had to add another piece of sadness to her already fragile plate.
    This experience hit something inside me, and for the first time, I finally understood what being a social worker looks like to me. In all of my scrambling to get to the finish line, I finally knew in a logical way, not just an “it feels right” way, why social work is the right profession for me. Social work is acting out of love for strangers in tangible ways. We are made to represent love so that all people we encounter have a more profound sense of hope and faith within themselves. We do the hard, intimate, sometimes painful work, and in return bring a little more of the divine into daily life. We get to remind one another about the bigger, more beautiful picture that we can’t always see from where we are.
    Sometimes the bottom just falls out, and nobody is exempt. Everything is not okay. And one of the most profound gifts we can give to our clients is the willingness to hunt down tissues or offer a safe place to be upset. Because in the end, what else is there to do? I can’t take away the cancer, although I would if I could. I can’t buy my client a house, although I would if I could. I can’t say that it’s never going to happen again and everything will be okay. But I can be there, and I can listen to their stories, of funny things the doctors said, and the strange and annoying things that people think are helpful to say in these situations. I can sit in silence in the moments of rage, knowing that everything is not okay, but that this tiny moment is.
    Thanks to my field placement, I now feel confident as to why I am dedicating my career to social work, and I couldn’t be more grateful for the amazing people who allowed me to be a part of their journey.

Katie Ullman is a student in the University of St. Thomas/St Catherine University School of Social Work. Her field placement for 2010-2011 was at Families Moving Forward, a faith-based program in Minneapolis that provides temporary housing and supportive services to children and families. Katie recently became a volunteer at the Angel Foundation where she provides support to adults facing cancer. Her favorite activities are yoga and watching movies with friends. She plans on attending graduate school next year to become an LICSW

How My Field Placement Showed Me Why I Wanted To Be a Social Worker

Written by Katie Ullman

Duty to Warn, Duty to Protect

Since the Tarasoff case in l974, duty to warn and duty to protect have become important as concepts in the field of social work and other helping disciplines. Being able to protect potential victims from harm and protecting clients from self-harm have become ethical obligations in social work practice. This area needs to be explored and understood by social work practitioners, educators, and social work students. Duty to warn and duty to protect have ethical implications for all social workers Walcott, Cerundolo, and Beck (2001) describe the facts of the Tarasoff case. Prosenjit Poddar and Tatiana Tarasoff were students at UCLA. Poddar stated to the university health science psychologist that he intended to kill an unnamed woman, who was identified as Tatiana Tarasoff. Although the psychotherapist did not directly warn Tarasoff or the family, the psychologist notified the police, who interviewed Poddar for commitment. The police only warned Tarasoff to stay away. After Poddar returned for the summer from Brazil, he murdered Tatiana with a knife. Tarasoff’s family sued the campus police and the university health service for negligence. Walcott, Cerundolo, and Beck (2001) cite the second Tarasoff case When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of the duty may require the therapist to take one or more various steps, depending on the nature of the case. Thus, it may call for him to warn the intended victim or others likely to appraise the victims of that danger, to notify the police or take whatever steps are reasonably necessary under the circumstances (p. 340).

    The Tarasoff case imposed a liability on all mental health professionals to protect a victim from violent acts. The first Tarasoff case imposed a duty to warn the victim, whereas the second Tarasoff case implies a duty to protect (Kopels & Kagle, 1993). There are many concerns about the implications of the Tarasoff case, especially around the confidentiality of the client-social worker relationship and violent clients avoiding treatment.
    Since the second Tarasoff decision in 1976, there has been argument and debate as to the applicability of this judgment to the client-social worker relationship. The environment has changed for social work and confidentiality, as social workers now divulge confidential information to third-party payers. Tarasoff is an important decision with legal implications, and only 13 states in the U.S. lacked Tarasoff-like provisions at the time of Herbert’s report in 2002.
    Duty to warn means that the social worker must verbally tell the intended victim that there is a foreseeable danger of violence. Duty to protect implies a therapist determining that his or her patient presents a serious danger of violence to another and an obligation to use reasonable care to protect the intended victim against danger (Harvard Mental Health Letter, 2008, January). This may entail a warning, police notification, or other necessary steps.
    Duty to warn and duty to protect have implications for social work practitioners in the fields of mental health, HIV/AIDS, domestic violence, and medical social work. There are also serious implications for malpractice and unethical behavior. What began as a mental health issue has been expanded to other fields of social work practice.

Duty to Warn and Duty to Protect in Mental Health  

    In the field of mental health, it is difficult to actually make predictions of client violence. The Harvard Mental Health Letter (2006, January) makes recommendations for handling duty to protect with homicidal and suicidal patients.
  
The principles for managing a threat of violence are generally the same as those for dealing with a suicidal threat. Therapists should find out whether a patient has ever seriously injured or thought about seriously injuring another person. Especially with new patients or any patients whose symptoms are becoming worse, it is important to know whether they are dangerous to others and whether the danger is due to mental illness. Is the patient losing the capacity to control violent impulses? (p.4)

    Duty to protect can involve warning the potential victim, notifying the police, starting a commitment hearing, informing mental health evaluators of the threat, and utilizing professional supervision. Duty to protect involves working with homicidal and suicidal clients. The obligation of duty to protect varies from state to state (Dolgoff, Loewenberg, & Harrington, 2009).
    Failure to protect potential victims of violence can result in losing one’s job at an agency. Consider the following hypothetical example.
  
A professional social worker conducted an intake interview with a client with a history of mental health problems and violence toward his father. The client was somewhat delusional and stated that he might hurt his father that evening. The social worker made no effort to commit the patient for hospitalization. That evening, the patient became violent and broke his father’s leg. The next day, the social worker was fired for negligence.   

    Protecting the well being of homicidal and suicidal clients is the obligation of professional social workers. Social workers should frequently utilize supervision and consultation when working on this issue of duty to protect, because it has ethical and malpractice considerations.
    
Duty to Warn and Protect in HIV/AIDS Cases  

    Social workers often work with clients who are HIV-positive or have AIDS. Confidentiality is very important to such clients, because of the stigma attached. Huprich, Fuller, and Schneider (2003) consider the question as to whether the therapist has the obligation to warn a third party of risk of transmission of HIV if his or her client is actually putting another party at risk. Stanard and Hazler (1995) report a case in which duty to protect seems important.
  
Brian is a 24-year-old married bisexual man entering counseling to deal with grief and depression associated with a recent diagnosis of HIV infection. During the course of counseling, Brian discloses that he continues to be sexually active with his wife and also occasionally with anonymous male partners. Brian has not disclosed his diagnosis to anyone and maintains that it is not necessary to do so because he practices “safe sex.” (p. 397)

    Melchert and Patterson (1999) discuss how being HIV-positive may pose a different situation from that of the Tarasoff case. Mental health professionals do not have the legal right to disclose that a person is HIV-positive to another person. This is at the discretion of physicians in many states. However, social workers and mental health professionals must struggle with this legal situation if a client insists on potentially harming another person through risk of transmission of HIV.

Domestic Violence

    In domestic violence situations, there can be an identified threat of harm to a victim. Domestic violence is a cross cutting issue that affects the daily lives of many people receiving social services (Danis, 2003). People who commit domestic violence will often commit criminal acts such as homicide, assault and battery, criminal trespass, terroristic threats, stalking, and sexual assault. Depending on the state, social workers have a legal obligation to report threats of violence and to warn the potential victims. Attorneys sometimes play a similar role to that of social workers and are privy to information about potential violence. Different states have varying levels of obligation to report specific threats of violence or intention to act (Buel & Drew, 2007).
    In working with clients who have a history of domestic violence, it is important to do a risk assessment of the situation to determine if there is a potential for harm. Also, the social worker needs to make every effort to try to defuse any potentially violent situation. Good clinical practice encourages social workers to send battering partners to groups to work on issues of anger management. Social workers also need to protect potential victims by referring them to safe places where they are not exposed to violence. Couples therapy can work when each person has contracted for no further incidents of violence.
    Consider this hypothetical case vignette, in which duty to warn a potential domestic violence victim presents a dilemma for a social worker.

A social worker is counseling a couple around issues of domestic violence. The husband reports that he has made threatening comments to his wife in the past. The wife has threatened to divorce her husband. The husband has stated that he would hurt his wife if they divorced.

    The social worker must make a decision. Should she report the case to the police as a threat? Is this threat serious? How is she going to assess the situation to possibly carry out a duty to warn?

Duty to Warn and Protect in Medical Social Work

    Social workers practice in the medical field, where many ethical dilemmas may arise with respect to duty to warn and duty to protect. With an increasing population of older clients in the United States, there are issues around caring for the frail elderly. Their children may not be willing to accept the recommendations that social workers make for their parents’ care. Following is a hypothetical vignette of just such a situation.

A social worker has recommended that an 88-year-old woman receive home health care. The family refuses this request, feeling that the 88-year-old woman can care for herself in her home. There is extreme danger of falling, missing meals, and not remembering to take medication at scheduled times. The social worker considers reporting this situation to Adult Protective Services.

    Social workers may be consulted by medical personnel to help resolve issues in genetic counseling. Issues of duty to warn and duty to protect may come into play, for example, if a patient refuses to disclose genetic information or test results to a relative. A physician may need to consult a medical social worker to work with the family on this critical issue, because sharing the information may save the relative’s life.
    Following is a hypothetical situation:

A 34-year-old woman receives the results of testing for cystic fibrosis, showing the probability of transmission of the disease through genetics. She wants to become pregnant but does not want to tell her husband about the test results. This presents a dilemma for the social worker who is counseling her.

    Pullman and Hodgkinson (2006) discuss the issue of whether duty to warn in situations of genetics overrides considerations of confidentiality. In the United States, case law is expanding the responsibility of clinicians beyond patients to include family members.

Ethical Concerns and the Duty to Warn and Duty to Protect

    Since the first Tarasoff decision in 1974, there has been an expansion of the debate around duty to warn and duty to protect, in that the social work literature has expanded to include mental health, HIV/AIDS, domestic violence, and medical issues. Social workers are confronted every day with difficult ethical concerns around duty to warn and duty to protect beyond the mental health field. Social work educators, practitioners, and students need to become knowledgeable about these concepts and their application in various specialties of social work.
    A social worker must assess whether and when to apply duty to warn or protect and when to protect confidentiality, and this is not an easy decision. Appelbaum (1985) states that since the time of Tarasoff, mental health professionals have been concerned about confidentiality and the prediction of dangerousness. He sees three stages to making this decision: (1) gather relevant data to evaluate dangerousness and make a determination based on this data, (2) once determining a situation to be dangerous a course of action must be taken, and (3) the therapist must implement this decision.   
    Borum and Reddy (2001) believe that a fact-based deductive approach is effective in dealing with the issue of duty to warn and duty to protect. They posit that the challenges to making a decision about duty to warn and to protect are based on whether the client poses a serious risk of violence to another and what steps are necessary to protect an intended victim. The question for the clinician is whether in this situation something should be done and then what to do. The ethical obligation of confidentiality may conflict with the objective of preventing harm to others. To make this determination, Borum and Reddy (2001) state that the clinician must distinguish between making a threat and posing a threat, inquire into attack-related behavior, and conceptualize and gauge the client’s risk as a dynamic pathway to action.
    Two hypothetical cases illustrate the duty to warn and duty to protect as they relate to confidentiality.

Case 1

John is a 35-year-old delusional mental health client who has been hospitalized numerous times. He states that he does not like his brother who lives in California and states that he has threatened him in the past. Today, the client has made a phone call to his brother again and threatened to beat him up. The social worker in assessing the dangerousness of the situation decides that there is no duty to protect or warn. The social worker determines that the threat posed is not serious. The social worker refers him to his psychiatrist for a medication check.

Case 2

David is a 35-year-old male who has a history of domestic violence toward his wife. Both David and his wife are in counseling separately for David’s violence toward his wife. In the counseling session, David insists that he is going to hurt his wife tonight at the house. He says that he is going to use a club or hurt her if she does not straighten up.The social worker questions further and determines that this threat is very serious. David has hurt his wife three times with moderate injury each time. The social worker decides that there is a duty to warn based on the threat posed to David’s wife.
 
    A social worker failing to become knowledgeable about these critical issues can be subject to ethical and legal problems, including malpractice and ethical complaints before licensing boards. Social workers need to seek out knowledge in this area to be effective practitioners and educators. NASW provides a valuable Web site (http://www.naswdc.org/ldf/legal_issue/2008/200802.asp?back=yes ) on duty to warn laws in different states (NASW, 2011)

Happiness and Positive Psychology

Positive Psychology sheds light on how and what can make us happy. It is concerned with the pursuit of happiness, as well as how we can lead more enriching, fulfilling and satisfying lives. Since the beginning, psychology has concentrated on mental illness but ever since the landmark book – “Authentic Happiness” by Martin Seligman, psychology has been striving towards focusing on well-being, happiness, and how can we successfully lead a better life. The science of positive psychology lays emphasis on investigating the potential concepts with statistically sound experiments and the research results are subject to stringent scientific standards, previous literature and critical peer review. This makes the concepts and findings of positive psychology more helpful.

Some people are naturally happier than others and there are people who have the ability to be happy most of the time and are optimistic looking at the brighter side of things and can bounce back from setbacks of life with greater ease and equanimity. Research shows as how we can do the things which elevate our natural level of happiness farther up the happiness scale as well as how we can stay happy. In fact, it is believed that we have control over a great part of opportunity for our total happiness, which gives us enough space to grow toward greater and more consistent happiness.

Here you may try the “Good Things” activity for a week. Each night before you sleep, recall three good things that happened to you that day. The good things don’t have to be dramatic or some earth-shattering events, just simple satisfying events such as finishing some delayed household chore, submitting some project before deadline, reading a good book, listening to some good uplifting music, meeting with some long lost friend or enjoying a happy meal – simple daily life events that made you feel gratified and happy. Now savour each moment – let it swirl around in your mind for some as you “taste” its goodness and enjoy the good vibes and feelings embrace you. Positive Psychology indicates that indulging in such an activity correlates with greater feelings of well-being and happiness.