© Springer International Publishing Switzerland 2015S. Megan BertholdHuman Rights-Based Approaches to Clinical Social WorkSpringerBriefs in Rights-Based Approaches to Social Work10.1007/978-3-319-08560-9_1
1. Introduction: Rights-Based versus Conventional Needs-Based Approaches to Clinical Practice
School of Social Work, University of Connecticut, West Hartford, Connecticut, USA
S. Megan Berthold
Henry1, a white male 45-year-old former schoolteacher, has come for the first time to a homeless shelter where Susan works as a social worker. As Susan sits down to get to know Henry, she notices that he occasionally appears to be laughing and talking as though he were having a conversation with someone in the corner of the room, although nobody is there. Henry informs her that he ran out of his medicine for diabetes a week ago. Upon questioning by Susan, Henry says that he was dumped on the street after a short stay at a local psychiatric hospital with only a 3-day supply of medicine and no follow-up appointment. He had nowhere to go and no resources. A man he met on the street introduced him to Susan’s shelter.
How might you approach your work with Henry if you were Susan? What, if anything, might a clinical social worker contribute that would be valuable to Henry? A referral to a physician? Assistance in applying for stable housing? Both? Or might there be a different approach to interacting with and working with Henry? A social worker operating from a human rights frame would likely conceptualize and engage with Henry in a very different manner than one focused on identifying and addressing Henry’s immediate needs. Mentally ill individuals facing homelessness like Henry have had their rights violated, their dignity trampled on, and their most basic needs ignored.
Overview of the Book
Clinical social workers that seek to apply a rights-based frame to guide their practice or inform their ethical decision making can find little explicit direction in the existing literature. Fundamentally, a rights-based approach goes deeper than addressing individuals’ immediate needs (Jewell, Collins, Gargotto, & Dishon, 2009), both working to realize their rights through service provision and advocating for the advancement of human rights more broadly (Libal, Berthold, Thomas, & Healy, 2014).
Children, the mentally ill, the disabled, homeless individuals and families, and those who are incarcerated are among those who are often marginalized, left without a voice, and are at particular risk for having their rights violated. It can be argued that social and clinical service providers, our schools, and society at large do not appear to be engaged in sufficient prevention or the early identification or treatment of mental health and other serious problems that have been linked to perpetration of violence or other human rights abuses. Those who perpetrate mass murder and other human rights violations often show signs of distress earlier in life, such as Adam Lanza who shot and killed 26 members of the Sandy Hook Elementary School and his mother in Connecticut in 2012. In hindsight, these tragedies often uncover a failure to respond (or adequately respond) to the needs and rights of these individuals for treatment. Why are these individuals marginalized and left out of the system of care? Why are their rights not promoted and what difference would human rights-based approaches make in their lives and the lives of others? One of the lessons learned from Sandy Hook and other tragedies is arguably that a rights-based approach may help to prevent the perpetration of some rights violations. Clinical social workers are needed as part of a team that includes rights-based community, policy, legislative, and administrative partners to prevent distressed children and other marginalized individuals and groups from being left out. Their rights matter too.
Human rights, by their nature, are political. It is the responsibility of States (governments), the United Nations, and other official bodies to protect and ensure that the rights of all are respected and fulfilled. Unfortunately, even when governments sign and ratify human rights treaties, adherence to their treaty obligations are often overlooked, purposively ignored, or only partially implemented. Social workers, acting as individual clinical practitioners and collectively, can make a difference by practicing from a rights-base. Largely absent from the clinical practice curriculum and literature until recently, rights-based approaches to clinical practice are emerging (Berthold, 2014; New Haven Trauma Competencies, 2013).
This introductory chapter presents a framework for a human rights-based approach to clinical social work practice. It defines human rights and provides a conceptual overview of a rights-based approach to clinical social work practice and how this differs from conventional needs-based approaches. Core principles of a rights-based approach to clinical social work practice are examined and illustrated. These core principles include: reframing needs as entitlements or rights, operating from a stance of cultural humility and intersectionality, fostering a therapeutic relationship and reconstructing safety, providing trauma-informed care, and drawing from the recovery-model and a strengths and resilience orientation. These principles are reinforced throughout the book and applied to diverse case material. The similarities and differences between needs- and rights-based approaches to clinical practice at the various stages of work with individuals (e.g., preparation for the work, engagement phase, assessment, working phase, and termination) are discussed.
Chapters 2 to 4 provide a more in-depth look at rights-based clinical social work practice with survivors of several major human rights issues, including torture, human trafficking, and intimate partner violence (IPV) within a US context. A rights-based approach to working with perpetrators is also explored, in the context of IPV. Although examples of torture and human trafficking have often been used to point to human rights violations that have occurred outside of the United States, this text will present an argument against US exceptionalism (Hertel & Libal, 2011). Examination of the use of solitary confinement of minors and the US’ involvement in the torture of enemy combatants in Chapter 2 will illustrate that human rights concerns are not solely external to a domestic US context.
Chapters 2 to 4 will include an opening case example followed by three main sections: (1) definitional and contextual issues; (2) relevant human rights mechanisms/tools; and (3) clinical interventions and illustration of selected core principles of a rights-based approach to clinical practice with the population discussed in each chapter. At the end of each chapter is a section that includes activities and resources for further study. The concluding chapter, Chapter 5, examines the social work practitioner’s use and care of self in engaging in rights-based practice. It explores the impact of rights-based practice on the social work practitioner, including the risk of vicarious trauma. The chapter highlights the practitioner’s ethical duty to remain deeply self-reflective and aware of the impact of his or her reactions to the work on the people he or she serves and emphasizes the importance of self-care.
The case material woven throughout this manuscript stems from the author’s long-term experience in working with survivors of torture, trafficking, and IPV. While some of the case examples may not be representative of the types of cases encountered most frequently by social workers practicing in the United States, the rights-based principles illustrated can apply to work with a much broader range of populations. This text will not comprehensively address clinical approaches to work with these populations as that material has been covered elsewhere. The focus in this book is on rights-based aspects of the work and the intended audience includes social work practitioners, field instructors, students, and educators.
Definitions and Context
Definition of Human Rights
In order to apply a rights-based approach, it is necessary to understand what human rights are. Although the Universal Declaration of Human Rights (UDHR) never precisely defined what human rights are, the drafters agreed that the concepts of intrinsic fundamental rights for all by virtue of being human and shared human dignity were core features (Reichert, 2007). According to the United Nations, “Human rights are rights inherent to all human beings, whatever our nationality, place of residence, sex, national or ethnic origin, color, religion, language, or any other status. We are all equally entitled to our human rights without discrimination. These rights are all interrelated, interdependent, and indivisible” (Office of the High Commissioner for Human Rights, n.d., para. 1). Human rights are fundamentally universal and inalienable. Individuals have rights, for example, to bodily security, to family, to be free from arbitrary detention, to never be tortured, to adequate healthcare, to housing, and to food. Not only do human rights involve the rights of all persons but they also entail obligations on behalf of States to respect, protect, and fulfill peoples’ rights.
Context for a Human Rights-Based Approach
Advancing human rights was recognized as a core competency for social workers in the Global Standards put forth by the International Federation of Social Workers and International Association of the Schools of Social Work (IFSW/IASSW, 2004) as well as in the Educational Policy and Accreditation Standards of the Council on Social Work Education in the United States (CSWE, 2008). The CSWE Standards cite the IFSW/IASSW standards as providing a foundation for making ethical decisions in keeping with the ethical principles and codes of the social work profession2. This may be considered, perhaps, a linking of the obligation of social workers to uphold core human rights treaties with their obligations to adhere to the social work code of ethics (NASW, 1999). Social work has long been concerned with advancing social justice, including in clinical practice (Aldarondo, 2007; Council on Social Work Education, 2012; Finn & Jacobson, 2003; Sachs & Newdom, 2011). A human rights-based approach also promotes social justice.
Core Principles of a Rights-Based Approach to Clinical Practice
The focus and scope of this book do not allow for a detailed and complete presentation of the theory and techniques of different treatment approaches, but rather highlight some core aspects of treatment that are particularly relevant to a rights-based clinical social work approach. Rights-based clinical social workers should draw on evidence-based research matched to the population they are working with, along with practice wisdom regarding best and promising practices. It is an ethical and professional responsibility for clinical social workers to keep abreast of the research literature regarding evidence-based and best practices in their field. Clinical social workers are encouraged to obtain advanced training in several evidence-based treatment approaches, including those developed for trauma survivors. Information is provided at the end of the chapter regarding where one can obtain further information about some of these treatment approaches.
Clinical social workers operating from a rights-base know that one of the core principles of a rights-based approach is reframing needs as entitlements or rights. Essential also is the practitioner’s fundamental orientation toward cultural humility (explained below) (Ortega & Faller, 2011) and intersectionality, and advanced knowledge and expertise in providing trauma-informed care. In addition, they are oriented toward a recovery model that recognizes and builds on strengths and resilience and are informed by an indigenous rights perspective in the sense of not seeking to control or impose values or decisions on those they work with (Brydon, 2011). Rights-based practitioners eschew and organize against the common practice of acting as agents of social control through the implementation of policies that do not support the dignity or rights of others, such as with internal immigration controls (Humphries, 2004). Underlying all of their work is the importance of the therapeutic relationship itself, a key component that shapes the nature of the work and its outcomes. These core principles are relevant to work with diverse populations, including those covered in this book, and will be discussed below.
Reframing Needs as Entitlements or Rights
Social workers have a long history of engaging in casework, group work, and family therapy (Gitterman & Germain, 2008; Toseland & Rivas, 2012). The dominant social work paradigm, however, that has been taught and practiced is aligned with a deficit-based medical model. It is focused on assessing and meeting needs rather than rights. Typically the emphasis is on the provision of clinical services to address disorders and overcoming obstacles to accessing services rather than a more fundamental critique of existing services, structures, and prevailing diagnostic and other systems. In addition, in some countries such as the United States, clinical services that promote the realization of peoples’ rights are often not provided or even identified as an appropriate target.
One of the key principles of a rights-based approach to clinical practice is that clinicians empower those they work with by reframing needs as entitlements or rights (Cemlyn, 2008a, b; Lundy & van Wormer, 2007). Rather than a need for medical care or safety, for example, the social worker focuses on the individual’s right to healthcare and safety. The voices of those served are honored and respected, and drive the clinical work. Rights-based clinicians work in a participatory and democratic style and their work may be repoliticized and in keeping with a critical theory of practice (Adams, Dominelli, & Payne, 2007; Lundy, 2011). Rather than pathologizing individuals, families and community members, problems are viewed within their sociopolitical and structural contexts, and these contexts become targets for intervention (Engstrom & Okamura, 2004; Lundy, 2011). In Henry’s case, rights-based practitioners would target the policies and practices of the hospital that allowed him to be dumped on the streets in violation of his right to health and well-being. When rights are violated, individuals are supported in claiming their right to reparation or redress. Rights-based clinical social workers no longer confine themselves solely to micro practice concerns, but open themselves up to practicing across the micro/macro divide (Androff & McPherson, 2014).
While the rights of those engaged in clinical services are routinely addressed formally through the use of such documents as Privacy Practice forms to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) and Consent for Services forms, in practice they often are not fully realized in conventional clinical work. In contrast, a rights-based approach to clinical practice goes well beyond the legalistic attention to the rights of those served to infuse attention and realization of rights throughout every phase of person-centered practice (Tondora, Miller, Slade, & Davidson, 2014). Rights-based clinical practice, for example, holds that the person’s voice and active participation and partnership in the selection and delivery of clinical services is essential. Such an approach also holds governmental and societal institutions accountable for ensuring the individual’s rights are upheld and informs every interaction between the individual and his or her practitioner.
Increasingly, social workers engage with diverse individuals and communities and must be adequately prepared to do so in a way that respects the rights, dignity, unique perspective, ways of knowing, and experiences of each, as well as the self-defined meaning and impact of their cultures (Brydon, 2011; Ortega & Faller, 2011; Tervalon & Murray-Garcia, 1998). Brydon (2011) cautions of the dangers of what she calls the hegemony of Western social work and its values and characteristics that she describes as being inconsistent and incompatible with the cultural orientations of other non-Western societies. Healy (2007) argues for the benefit of a stance of moderate universalism to resolve the ethical dilemma of universalism and relativism in social work practice.
A rights-based approach to working with those who are culturally different from the practitioner is consonant with an approach grounded in cultural humility (rather than cultural competence). The concept of cultural competence, long advocated for in social work education, has been criticized by some for placing too strong an emphasis on characteristics shared by a group to the detriment of recognizing and working with individual differences, and for intensifying the power imbalance between the worker and the person they serve through the privileging of the social worker’s knowledge and expertise about the person’s culture (Ortega & Faller, 2011). Some critics of cultural competence have called for practitioners to develop their critical awareness capacities instead, and emphasize respect for each individual’s own definition of their cultural experiences and associated meanings (Furlong & Wight, 2011). Cultural humility is offered as an alternative approach to cultural competence, one that supports the social worker in engaging those they serve more actively in the therapeutic process. This approach can be valuable for working with anyone, not just with those from cultural backgrounds dissimilar to the practitioner’s own background. If someone appears to come from the same culture as the social worker, it is important that the social worker does not assume that the meaning and expression of that culture will be the same for everyone.
At its core, the cultural humility framework is a respectful and non-paternalistic approach that is fundamental to a human rights-based approach to clinical social work practice. As Ortega and Faller (2011) stress, individuals are, “in the best position to define for themselves the meaning of their culture and cultural experiences” (p. 43). Social workers who practice from a standpoint of cultural humility develop their abilities to work across difference; emphasizing strong communication and interaction skills that are attuned to the unique individual they are working with. Such an approach does not emphasize or require the social worker to learn all about the culture of the populations they work with. It reduces their need to seek mastery about the extensive range of cultural practices and beliefs that those they work with may possess (Ortega & Faller, 2011). Becoming “culturally competent” and an “expert” about multiple cultures is arguably an impossible task, and is furthermore fundamentally inconsistent with cultural humility. Putting oneself forth as an “expert” on a culture runs the risk of stereotyping and incomplete or inaccurate understanding of how culture influences the life experiences of a particular person. Rather, practicing with cultural humility opens the social worker to learn from those that he or she works with, recognizing that each individual is the expert on his or her own life. Cultural humility is not viewed as an outcome or a goal to be attained. Rather, the practitioner enters into a professional relationship with an individual, family, group, or community with an unknowing stance, ready to engage in an ongoing process of learning.
Ortega and Faller (2011) advocate that social workers working within the child welfare arena should embrace and follow the following six practice principles, principles that are relevant to practice grounded in cultural humility with other populations as well:
“Embrace the complexity of diversity” (p. 43)
“‘Know thyself’ and critically challenge one’s ‘openness’ to learn from others” (p. 43)
“Accept cultural difference and relate to [others] in ways that are most understandable to them” (p. 43)
“Continuously engage in collaborative helping” (p. 44)
“Demonstrate familiarity with the living environment of [those] being served” (p. 44)
“Build organizational support that demonstrates cultural humility as an important and ongoing aspect of the work itself” (p. 44)
It is important to emphasize that a rights-based approach to clinical social work does not relegate the practitioner to narrowly focus on clinical issues with the particular individual, family, couple, or group they are working with. Instead, a rights-based approach requires that the clinical practitioner look beyond the micro into the structural or larger forces at play in the lives of those they work with, thereby breaking down and working across the micro/macro divide in social work (Androff & McPherson, 2014). The fifth Practice Principle put forth by Ortega and Faller (2011), as outlined above, relates to bridging this divide. This principle extends, for example, to examining whether the organization is structured in a fashion to promote and support cultural humility. Further, the practitioner must address structural contributions to rights violations through advocacy and other forms of collective action, ideally in collaboration with the person(s) they serve. Whenever possible, rights-based practitioners should support the individuals they work with to do for themselves rather than doing for them (Brydon, 2011). In understanding the environment(s) of the persons they work with, the worker “is challenged to identify, understand, and build on assets and adaptive strengths of [these individuals] and perhaps engage in efforts to disrupt or dismantle the kind of social forces that act to disenfranchise and disempower them as members of society” (Ortega & Faller, 2011, p. 44). For example, social workers must remain alert for and address the microaggressions (van Sluytman, 2013) that the individuals they serve may have experienced (particularly those who are of color or otherwise marginalized in society), including in the context of trying to access or receive services. Microaggressions are conscious and unconscious insults and expressions of bias that serve to minimize and silence others who have less power, and include microinsults, microinvalidation, and microassaults (Hopkins, 2010; Solórzano, Ceja, & Yosso, 2000; Sue, Bucceri, Lin, Nadal, & Torino, 2007). They can be verbal, nonverbal, or visual in nature. The subtlety and pervasiveness of microaggressions generally make them challenging to confront and contribute to their being frequently ignored or justified (Sue et al., 2007). The presence of microaggressions in settings where social workers practice may contribute to barriers to the fulfillment of rights and must be confronted and addressed.
Practicing from a stance of cultural humility has a lot in common with traditional social work practice (Hepworth, Rooney, Rooney, Strom-Gottfried, & Larsen, 2010; Ortega & Faller, 2011). Ortega and Faller (2011) emphasize that it is the social worker’s responsibility to bridge the differing perspectives, cultural experiences, histories, and worldviews that they and the individuals they serve bring to their interactions. In order to bridge perspectives and demonstrate cultural humility, Ortega and Faller (2011) state that reserving judgment, active listening and reflecting, and entering the other person’s world are all essential skills for practitioners. Strong foundational social work skills and putting the profession’s values into practice are central to the practice of cultural humility (Ortega & Faller, 2011). This includes, in part, the practitioner’s ongoing efforts at self-awareness, learning from those they work with and starting from where they are at, and affirming the dignity and positive worth of and demonstrating respect and empathy for those they serve.
Another critical concept for rights-based clinical social workers to be versed in is intersectionality, a concept closely linked to the human rights principles of the dignity and worth of the person, equality, and nondiscrimination. This perspective holds that individuals occupy various positionalities or positions at the same time in the structural and socio-cultural-political framework in their society (Crenshaw, 1995; Hill Collins, 2000; Hernandez & McDowell, 2010). A person’s gender, age, race and ethnicity, socioeconomic class, gender identity, sexual orientation, religious or spiritual beliefs, and other factors all intersect and contribute to a person’s positionality and individuality. These facets are all central to notions of dignity and humanity. According to Ortega and Faller (2011), “Intersecting group memberships affect people’s expectations, quality of life, capacities as individuals and parents, life chances, and so on. They draw attention to the whole person, power differences in relationships, different past and present experiences based on positionalities and social contexts, and potential resources (or gaps)” (p. 43). The multiple positions or identities of the individual have an effect on the way he or she expresses his or her culture and on his or her worldview (Ortega & Faller, 2011). These must be attended to by the social worker practicing with cultural humility.
Social workers who approach their practice with cultural humility are grounded in an understanding and application of critical race theory and intersectionality (Abrams & Moio, 2009; Murphy, Hunt, Zajicek, Norris, & Hamilton, 2009; Ortiz & Jani, 2010). Such an approach is holistic and respects the diversity of each person. It attends to the power dynamics and differences between social workers and those they serve and the variety of microaggressions and other experiences that individuals who seek services may have had. In addition, it assesses the limitations and resources available and the impact of power, authority, and control on the social worker’s decision making and the choices available to those they serve (Ortega & Faller, 2011). It works to counteract the forces of power, bias, discrimination, racism, sexism, and other forms of oppression that have resulted in the denial of or limited access to services and resources and ultimately, the denial of rights (Finn & Jacobson, 2003; Hernandez & McDowell, 2010; Sengupta, 2006).
Fostering a Therapeutic Relationship and Reconstructing Safety
Rights-based clinical social work practitioners understand that the nature and quality of the relationship between the practitioner and those they serve matters. Mental health professionals who work with survivors of mass and other forms of complex trauma3 have long understood this (Briere, 2002; Kinzie, 2001; Mollica, 2006). Of course, what is therapeutic to one person may not be to another. Expert panelists reviewed a series of meta-analyses on evidence-based therapy relationships as part of the American Psychological Associations’ second Task Force on Evidence-Based Therapy Relationships. The task force found support for the effectiveness of various methods of treatment adaptation and elements of the therapeutic relationship (Norcross & Wampold, 2011). Some of the task force’s conclusions are highlighted here. The task force found that the therapeutic relationship makes independent, consistent, and substantial contributions to the outcome of psychotherapy separate from the particular type of treatment. They determined that, in order to be complete and not misleading, evidence-based and best practice guidelines must include attention to the therapy relationship. Outcomes are improved when interventions tailor the therapy relationship to the characteristics of the particular individual in therapy. Treatment effectiveness is determined by the combined impact of the characteristics of the person seeking therapy, qualities of the practitioner, treatment approach, and nature of the therapy relationship.
The experts identified that the following elements of the therapy relationship were demonstrated to be effective: alliance in individual, youth, and family psychotherapy; collecting feedback from the person served; and cohesion in group therapy (Norcross & Wampold, 2011). Other aspects of the therapy relationship had less evidence of effectiveness. The task force concluded that collaboration, positive regard, and goal consensus were probably effective elements of the relationship, while managing countertransference, congruence/genuineness, and the repairing of ruptures to the alliance showed promise.
Research has also identified things that therapists should not do if they want to be effective, some of which are highly relevant for rights-based practitioners (Norcross & Wampold, 2011). For example, adopting a strongly confrontational approach was not effective (Miller, Wilbourne, & Hettema, 2003), nor was attacking the person rather than the unhealthy thoughts or behavior (Norcross & Wampold, 2011). Motivational interviewing techniques, in contrast (e.g., demonstrating empathy, supporting self-efficacy, rolling with resistance), showed large positive effects in relatively few sessions (Lundahl & Burke, 2009). The therapy alliance is enhanced and there is less premature termination when therapists respectfully and explicitly ask the persons they work with in therapy for their perceptions of and satisfaction with the therapy relationship and treatment rather than making assumptions (Lambert & Shimokawa, 2011). Treatment outcomes are better predicted by observations of the person receiving treatment about the relationship rather than those of the therapist (Orlinsky, Ronnestad, & Willutzki, 2004). Tailoring the therapy to the person being served (Norcross & Wampold, 2011) and avoidance of inflexible or strongly structured approaches (Ackerman & Hilsenroth, 2001) contributes to more efficacious and appropriate treatment and lessens the risk of empathic failures.
Fabri (2001) elaborates on techniques for and the importance of developing a therapeutic relationship and reconstructing safety with torture survivors that are in keeping with a rights-based approach to practice. She calls for empowering the survivor through, in part, adjusting the therapeutic frame to attend to issues of safety and power that are of paramount concern to survivors. Fabri’s (2001) approach is consonant with cultural humility. The survivor serves as the guide and expert regarding modifications to the treatment approach in order to prevent his or her revictimization. Modifications may be made to seating arrangements, roles, boundary definitions, and meeting space.
Clinical social workers are advised to proactively look for opportunities for the survivors they work with to be in control of as many aspects of their work together. This includes whether or not the survivor chooses to disclose their traumatic experiences, and if they do, how much, when, at what pace, and to whom they chose to disclose. Social workers must ensure that informed consent is truly informed and that the consent is freely given rather than coerced. It is important to ensure that the survivor understands what the consent for services and other forms say, a goal that can be made harder if there is no professionally translated version in the survivor’s language, if it is necessary to have the forms interpreted on the spot (particularly if the interpreter is not a trained professional interpreter), or if the survivor is not literate in any language (Miletic et al. 2006). Rather than rushing through the explanation of the consent and other forms or worse, merely telling the survivor that they need to sign the form(s) in order to be helped, a rights-based clinical social worker should patiently go over the meaning and detail of the form(s), using it as an opportunity to start building a therapeutic relationship.
Building trust in survivors of human rights violations for whom trust has been shattered is essential. Establishing trust and safety is a process that takes time and is furthered when the social worker follows through on the commitments they make to the survivor and when they are clear not to promise things that they may not be able to deliver or are unlikely to happen. Clinicians have been asked on many occasions by trauma survivors such things as whether their traumatic memories will ever stop completely and forever, and whether they will ever see their disappeared child again. While tempting to say yes, particularly when the survivor asks over and over, it is never a good idea clinically (or ethically) to give false hope. Rather, the clinician should work with the survivor to come to terms with the reality as it is, no matter how painful.
Rights-based clinical social workers must be competent trauma-informed practitioners. Many persons served by social workers have had one or more traumatic experiences and often have had significant rights violated prior to seeking treatment or in the course of seeking treatment (e.g., right not to be abused, right to informed choice). These rights violations are traumatic in and of themselves. The majority of those who utilize public mental health services have trauma histories (Jennings, 2004a, b). Potentially traumatic events (PTEs) are experienced by approximately one-quarter of all children and adolescents in the community in the United States (Costello, Erkanli, Fairbank, & Angold, 2002