Assignment 2: (RA 1): Maladaptive Behavior Case Study
You learned about some of the person, environment, and time dimensions (i.e., biological, psychological, spiritual, and physical environment). In this assignment, you will generate a case study of an individual, highlighting his or her maladaptive behaviors, and then create a report demonstrating how you would work toward improving this individual’s healthy functioning.
In a 5 page paper, describe an individual who demonstrates maladaptive behavior. In your case study:
· Describe in detail the individual and his or her behavior.
· Explain how this individual demonstrates maladaptive behavior. Include behavioral characteristics, problems, and symptoms.
· Discuss factors that contributed to the development of maladaptive behavior in the individual.
· Identify and apply appropriate theories of maladaptive behavior to this individual.
· Propose strategies and services for improving healthy functioning in this individual. Remember to include the specific patterns of change in the individual and in his or her environment needed to promote healthy
Here are some notes to help write this assignment
THE CONCEPT OF STRESS
One of the main benefits of good nurturing is, as you have seen, the way it strengthens our ability to cope with stress. Stress can be defined as any event in which environmental or internal demands tax our adaptive resources. Stress may be biological (a disturbance in bodily systems), psychological (cognitive and emotional factors involved in the evaluation of a threat), and even social (the disruption of a social unit). Dan experienced psychological stress, of course, as evidenced by his negative feelings resulting from marginalization and perceived rejection, but he also experienced other types of stress. He experienced biological stress because, in an effort to attend all his classes and study every day, he did not give his body adequate rest. As a result, he was susceptible to colds, which kept him in bed for several days each month and compounded his worries about managing coursework. Dan also experienced social stress, because he was functioning in a social system that he perceived to be threatening, and he had few positive relationships there.
Three Categories of Psychological Stress
Psychological stress, about which we are primarily concerned in this chapter, can be broken down into three categories (Lazarus, 2007).
1. Harm. A damaging event that has already occurred. Dan minimized interactions with his classmates during much of the semester, which may have led them to decide that he is aloof and that they should not try to approach him socially. Dan has to accept that this rejection happened and that some harm has been done to him as a result, although he can learn from the experience and try to change in the future.
2. Threat. A perceived potential for harm that has not yet happened. This is probably the most common form of psychological stress. We feel stress because we are apprehensive about the possibility of the negative event. Dan felt threatened when he walked into a classroom during the first semester because he had failed once before and, further, anticipated rejection from his classmates. We can be proactive in managing threats to ensure that they do not in fact occur and result in harm to us.
3. Challenge. An event we appraise as an opportunity rather than an occasion for alarm. We are mobilized to struggle against the obstacle, as with a threat, but our attitude is quite different. Faced with a threat, we are likely to act defensively to protect ourselves. Our defensiveness sends a negative message to the environment: We don’t want to change; we want to be left alone. In a state of challenge, however, we are excited, expansive, and confident about the task to be undertaken. The challenge may be an exciting and productive experience for us. Because Dan has overcome several setbacks in his drive to become a physician, he may feel more excited and motivated than before when resuming the program. He might be more aware of his resilience and feel more confident.
Photo 5.2 This woman is experiencing psychological stress; she is challenged by the task at hand but feels equal to the task.
Stress has been measured in several ways (Aldwin & Yancura, 2004; Lazarus, 2007). One of the earliest attempts to measure stress consisted of a list of life events, uncommon events that bring about some change in our lives—experiencing the death of a loved one, getting married, becoming a parent, and so forth. The use of life events to measure stress is based on the assumption that major changes, even positive ones, disrupt our behavioral patterns.
More recently, stress has also been measured as daily hassles , common occurrences that are taxing—standing in line waiting, misplacing or losing things, dealing with troublesome co-workers, worrying about money, and many more. It is thought that an accumulation of daily hassles takes a greater toll on our coping capacities than do relatively rare life events.
Sociologists and community psychologists also study stress by measuring role strain —problems experienced in the performance of specific roles, such as romantic partner, caregiver, or worker. Research on caregiver burden is one example of measuring stress as role strain (Gordon, Pruchno, Wilson-Genderson, Murphy, & Rose, 2012).
Social workers should be aware that as increasing emphasis is placed on the deleterious effects of stress on the immune system, our attention and energies are diverted from the possibility of changing societal conditions that create stress and toward the management of ourselves as persons who respond to stress (Becker, 2005). For example, it is well documented that the experience of discrimination creates stress for many African Americans (Anderson, 2013). With the influence of the medical model, we should not be surprised when we are offered individual or biomedical solutions to such different social problems as discrimination, working motherhood, poverty, and road rage. It may be that the appeal of the stress concept is based on its diverting attention away from the environmental causes of stress. This is why social workers should always be alert to the social nature of stress.
Stress and Crisis
A crisis is a major upset in our psychological equilibrium due to some harm, threat, or challenge with which we cannot cope (James & Gilliland, 2013). The crisis poses an obstacle to achieving a personal goal, but we cannot overcome the obstacle through our usual methods of problem solving. We temporarily lack either the necessary knowledge for coping or the ability to focus on the problem, because we feel overwhelmed. A crisis episode often results when we face a serious stressor with which we have had no prior experience. It may be biological (major illness), interpersonal (the sudden loss of a loved one), or environmental (unemployment or a natural disaster such as a flood or fire). We can regard anxiety, guilt, shame, sadness, envy, jealousy, and disgust as stress emotions (Zyskinsa & Heszen, 2009). They are the emotions most likely to emerge in a person who is experiencing crisis.
Crisis episodes occur in three stages:
1. Our level of tension increases sharply.
2. We try and fail to cope with the stress, which further increases our tension and contributes to our sense of being overwhelmed. We are particularly receptive to receiving help from others at this time.
3. The crisis episode ends, either negatively (unhealthy coping) or positively (successful management of the crisis).
Crises can be classified into three types (Lantz & Walsh, 2007). Developmental crises occur when events in the normal flow of life create dramatic changes that produce extreme responses. Examples of such events include going off to college, college graduation, the birth of one’s child, a midlife career change, and retirement from work. People may experience these types of crises if they have difficulty negotiating the typical challenges outlined by Erikson (1968) and Gitterman (2009). Situational crises refer to uncommon and extraordinary events that a person has no way of forecasting or controlling. Examples include physical injuries, sexual assault, loss of a job, major illness, and the death of a loved one. Existential crises are characterized by escalating inner conflicts related to issues of purpose in life, responsibility, independence, freedom, and commitment. Examples include remorse over past life choices, a feeling that one’s life has no meaning, and a questioning of one’s basic values or spiritual beliefs.
Dan’s poor midterm grades during his first semester of taking courses that would help him qualify for medical school illustrate some of these points. First, he was overwhelmed by the negative emotions of anger and sadness. Then, he occasionally retreated to church and his hometown, where he received much-needed support from his friends, mother, and sister. Finally, as the situation stabilized, Dan concluded that he could try to change some of his behaviors to relieve his academic-related stress.
Although a single event may pose a crisis for one person but not another, some stressors are so severe that they are almost universally experienced as crises. The stress is so overwhelming that almost anyone would be affected. The term traumatic stress is used to refer to events that involve actual or threatened severe injury or death, of oneself or significant others (American Psychiatric Association, 2013). Three types of traumatic stress have been identified: natural (such as flood, tornado, earthquake) and technological (such as nuclear) disasters; war and related problems (such as concentration camps); and individual trauma (such as being raped, assaulted, or tortured) (Aldwin, 2007). People respond to traumatic stress with helplessness, terror, and horror. Many trauma survivors experience a set of symptoms known as post-traumatic stress disorder (American Psychiatric Association, 2013). These symptoms include persistent reliving of the traumatic event, persistent avoidance of stimuli associated with the traumatic event, and a persistently high state of arousal. The symptoms of post-traumatic stress disorder (which we discuss in more detail later) may occur as soon as 1 week after the event, or even years later.
Some occupations—particularly those of emergency workers such as police officers, firefighters, disaster relief workers, and military personnel in war settings—involve regular exposure to traumatic events that most people do not experience in a lifetime. The literature about the stress faced by emergency workers refers to these traumatic events as critical incidents and the reaction to them as critical incident stress (Prichard, 2004). Emergency workers, particularly police officers and firefighters, may experience threats to their own lives and the lives of their colleagues, as well as encounter mass casualties. Emergency workers may also experience compassion stress, a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the pain (Adams, Boscarino, & Figley, 2006). Any professionals who work regularly with trauma survivors are susceptible to compassion stress. Many social workers fall into this category.
Vulnerability to Stress
Many social work practitioners and researchers use a biopsychosocial risk and resilience framework for understanding how people experience and manage stress (Scholz, Blumer, & Brand, 2012). Although the biological and psychological levels relate to the individual, the social aspect of the framework captures the positive or adverse effects on the family, community, and wider social culture. The processes within each level interact, prompting risks for stress and impaired coping and the propensity toward resilience, or the ability to function adaptively despite stressful life circumstances. Risks can be understood as hazards occurring at the individual or environmental level that increase the likelihood of impairment. Protective mechanisms involve the personal, familial, community, and institutional resources that cultivate individuals’ aptitudes and abilities while diminishing the possibility of problem behaviors. These protective influences may counterbalance or buffer against risk and are sometimes the converse of risk. For instance, at the individual level, poor physical health presents risks while good health is protective. The biopsychosocial framework provides a theoretical basis for social workers to conceptualize human behavior at several levels and can assist them in identifying and bolstering strengths as well as reducing risks. The framework offers a balanced view of systems in considering risks and strengths, as well as recognizing the complexity of individuals and the systems in which they are nested.
Individual factors encompass the biological and psychological realms. Within biology these include genes, temperament, physical health, developmental stage, and intelligence. At the psychological level it is useful to examine one’s self-efficacy, self-esteem, and coping strategies. Social mechanisms include the family and household, the experience of traumatic events, the neighborhood, and societal conditions, including poverty, ethnicity, and access to health care.
Within the risk and resilience perspective, social workers can complete comprehensive assessments to determine the nature of their clients’ problems. Knowledge of the risk and resilience influences helps social workers focus interventions onto the relevant areas of the client’s life. Finally, the strengths perspective encourages social workers to build on the client’s areas of real or potential resilience in recovering from, or adapting to, mental disorders and in so doing helps the client develop a greater sense of self-efficacy.
Critical Thinking Questions 5.3
Why do you think we easily get diverted from thinking about societal conditions that create stress and come, instead, to focus on helping individuals cope with stress? How does such an approach fit with social work’s commitment to social justice?
COPING AND ADAPTATION
Our efforts to master the demands of stress are referred to as coping . Coping includes the thoughts, feelings, and actions that constitute these efforts. One method of coping is adaptation , which may involve adjustments in our biological responses, perceptions, or lifestyle.
The traditional biological view of stress and coping, developed in the 1950s, emphasizes the body’s attempts to maintain physical equilibrium, or homeostasis , which is a steady state of functioning (Selye, 1991). Stress is considered the result of any demand on the body (specifically, the nervous and hormonal systems) during perceived emergencies to prepare for fight (confrontation) or flight (escape). A stressor may be any biological process, emotion, or thought.
In this view, the body’s response to a stressor is called the general adaptation syndrome . It occurs in three stages:
1. Alarm. The body first becomes aware of a threat.
2. Resistance. The body attempts to restore homeostasis.
3. Exhaustion. The body terminates coping efforts because of its inability to physically sustain the state of disequilibrium.
The general adaptation syndrome is explained in Exhibit 5.1.
In this context, resistance has a different meaning than is generally used in social work: an active, positive response of the body in which endorphins and specialized cells of the immune system fight off stress and infection. Our immune systems are constructed for adaptation to stress, but the cumulative wear and tear of multiple stress episodes can gradually deplete our body’s resources. Common outcomes of chronic stress include stomach and intestinal disorders, high blood pressure, heart problems, and emotional problems. If only to preserve healthy physical functioning, we must combat and prevent stress.
This traditional view of biological coping with stress came from research that focused on males, either male rodents or human males. Since 1995, the federal government has required federally funded researchers to include a broad representation of both men and women in their study samples. Consequently, recent research on stress has included female as well as male participants, and gender differences in responses to stress have been found.
Recent research (Cardoso, Ellenbogen, Serravalle, & Linnen, 2013; Taylor & Stanton, 2007) suggests that females of many species, including humans, respond to stress with “tend-and-befriend” rather than the “fight-or-flight” behavior described in the general adaptation syndrome. Under stressful conditions, females have been found to protect and nurture their offspring and to seek social contact. The researchers suggest a possible biological basis for this gender difference in the coping response. More specifically, they note a large role for the hormone oxytocin, which plays a role in childbirth but also is secreted in both males and females in response to stress. High levels of oxytocin in animals are associated with calmness and increased sociability. Although males as well as females secrete oxytocin in response to stress, there is evidence that male hormones reduce the effects of oxytocin. This is thought to, in part, explain the gender differences in response to stress.
The psychological aspect of managing stress can be viewed in two ways. Some theorists consider coping ability to be a stable personality characteristic, or trait ; others see it instead as a transient state —a process that changes over time, depending on the context (Lau, Eley, & Stevenson, 2006).
Exhibit 5.1 The General Adaptation Syndrome
Those who consider coping to be a trait see it as an acquired defensive style. Defense mechanisms are unconscious, automatic responses that enable us to minimize perceived threats or keep them out of our awareness entirely. Exhibit 5.2 lists the common defense mechanisms identified by ego psychology (discussed in Chapter 4). Some defense mechanisms are considered healthier, or more adaptive, than others. Dan’s denial of his need for intimacy, for example, did not help him meet his goal of developing relationships with peers. But through the defense of sublimation (channeling the need for intimacy into alternative and socially acceptable outlets), he has been an effective and nurturing tutor for numerous high school science students.
Those who see coping as a state, or process, observe that our coping strategies change in different situations. After all, our perceptions of threats, and what we focus on in a situation, change. The context also has an impact on our perceived and actual abilities to apply effective coping mechanisms. From this perspective, Dan’s use of denial of responsibility for relationship problems would be adaptive at some times and maladaptive at others. Perhaps his denial of needing support from classmates during the first academic semester helped him focus on his studies, which would help him achieve his goal of receiving an education. During the summer, however, when classes are out of session, he might become aware that his avoidance of relationships has prevented him from attaining interpersonal goals. His efforts to cope with loneliness might also change when he can afford more energy to confront the issue.
Exhibit 5.2 Common Defense Mechanisms
SOURCE: Adapted from Schamess & Shilkret, 2011; Goldstein, 1995.
The trait and state approaches can usefully be combined. We can think of coping as a general pattern of managing stress that allows flexibility across diverse contexts. This perspective is consistent with the idea that cognitive schemata develop through the dual processes of assimilation and accommodation, described in Chapter 4.
Another way to look at coping is based on how the person responds to crisis. Coping efforts may be problem focused or emotion focused (Sideridis, 2006). The function of problem-focused coping is to change the situation by acting on the environment. This method tends to dominate whenever we view situations as controllable by action. For example, Dan was concerned about his professors’ insensitivity to his learning disability (auditory processing disorder). When he took action to educate them about it and explain more clearly how he learns best in a classroom setting, he was using problem-focused coping. In contrast, the function of emotion-focused coping is to change either the way the stressful situation is attended to (by vigilance or avoidance) or the meaning to oneself of what is happening. The external situation does not change, but our behaviors or attitudes change with respect to it, and we may thus effectively manage the stressor. When we view stressful conditions as unchangeable, emotion-focused coping may dominate. If Dan learns that one of his professors has no empathy for students with learning disabilities, he might avoid taking that professor’s courses in the future or decide that getting a good grade in that course is not as important as being exposed to the course material.
U.S. culture tends to venerate problem-focused coping and the independently functioning self and to distrust emotion-focused coping and what may be called relational coping. Relational coping takes into account actions that maximize the survival of others—such as our families, children, and friends—as well as ourselves (Zunkel, 2002). Feminist theorists propose that women are more likely than men to employ the relational coping strategies of negotiation and forbearance, and some research (Taylor & Stanton, 2007) gives credence to the idea that women are more likely than men to use relational coping. As social workers, we must be careful not to assume that one type of coping is superior to another. Power imbalances and social forces such as racism and sexism affect the coping strategies of individuals (Lippa, 2005). We need to give clients credit for the extraordinary coping efforts they may make in hostile environments.
Richard Lazarus (1999) has identified some particular behaviors typical of each coping style:
• Problem-focused coping: confrontation, problem solving
• Emotion-focused coping: distancing, escape or avoidance, positive reappraisal
• Problem- or emotion-focused coping (depending on context): self-control, search for social support, acceptance of responsibility
Lazarus emphasizes that all of us use any or several of these mechanisms at different times. None of them is any person’s sole means of managing stress.
Using Lazarus’s model, we might note that Dan used many problem-focused coping strategies to manage stressors at the university, even though he was mostly ineffective because of the specific strategies he used. For example, he directly confronted his peers, teachers, family members, and social worker, and he also tried with limited success to control his moods through force of will.
I probably don’t need to tell you that college students face many predictable stressors when attending to the demands of academic work. A few years ago, I wanted to learn more about how students use both problem- and emotion-focused coping strategies in response to stress. I surveyed social work students in several Human Behavior in the Social Environment courses at a large urban university, at the beginning of an academic year, about their anticipated stressors and the ways they might cope with them. The results of this informal survey are outlined in Exhibit 5.3. The students chose problem- and emotion-focused coping strategies almost equally—a healthy mix (although they may not have been forthcoming about some socially “unacceptable” strategies).
Given our discussion in Chapter 4 of conceptions of the self, it may be interesting to review a stress/coping model that focuses on the tripartite self. Hardie (2005) proposes that the self includes three domains, the relational (experiencing the self most fully in relationships), individual (a strong sense of independence, autonomy, and separateness), and collective (a preference for social group memberships), and that the relative strength of a person’s domains will guide his or her preferences for coping styles. Those with a well-developed self in all three domains will possess a full range of coping options, and those with a more limited self-experience will have fewer. A person with a sense of self that encompasses three domains will also experience more sources of stress, but Hardie’s model suggests that when a source of stress matches one’s developed self-domain, coping will be most effective. That is, if a highly relational person experiences relational stress (such as a conflict with a friend), he or she will be inclined to address the issue in an effective manner. Dan, on the other hand, has a stronger sense of an “independent” self than others, so when he experiences interpersonal conflict, his range of available coping strategies is limited due to the mismatch. And while Dan is attached to persons from his cultural group, he has a limited sense of a broader collective self and thus tends to have limited judgment or skill in how to deal with conflict with representatives of other social groups (including his school peers).
Exhibit 5.3 Coping Styles Among Social Work Students
Coping and Traumatic Stress
People exhibit some similarities between the way they cope with traumatic stress (described earlier) and the way they cope with everyday stress. However, coping with traumatic stress differs from coping with everyday stress in several ways (Aldwin & Yancura, 2004).
• Because people tend to have much less control in traumatic situations, their primary emotion-focused coping strategy is emotional numbing, or the constriction of emotional expression. They also make greater use of the defense mechanism of denial.
• Confiding in others takes on greater importance.
• The process of coping tends to take a much longer time, months or even years.
• A search for meaning takes on greater importance, and transformation in personal identity is more common.
Although there is evidence of long-term negative consequences of traumatic stress, trauma survivors sometimes report positive outcomes as well. Studies have found that 34% of Holocaust survivors and 50% of rape survivors report positive personal changes following their experiences with traumatic stress (Koss & Figueredo, 2004). A majority of children who experience such atrocities as war, natural disasters, community violence, physical abuse, catastrophic illness, and traumatic injury also recover, demonstrating their resilience (Husain, 2012; Le Brocque, Hendrikz, & Kenardy, 2010).
However, many trauma survivors experience a set of symptoms known as post-traumatic stress disorder (PTSD) (American Psychiatric Association, 2013). These symptoms include the following:
• Exposure to actual or threatened death, serious injury, or sexual violence either directly, by witnessing it, or by learning about it
• Persistent reliving of the traumatic event: intrusive, distressing recollections of the event; distressing dreams of the event; a sense of reliving the event; intense distress when exposed to cues of the event
• Persistent avoidance of stimuli associated with the traumatic event: avoidance of thoughts or feelings connected to the event; avoidance of places, activities, and people connected to the event; inability to recall aspects of the trauma; loss of interest in activities; feeling detached from others; emotional numbing; no sense of a future
• Negative alterations in cognition or mood after the event, such as memory problems, negative emotions, and distorted beliefs about the event (such as self-blame)
• Persistent high state of arousal: difficulty sleeping, irritability, difficulty concentrating, excessive attention to stimuli, exaggerated startle response
Symptoms of post-traumatic stress disorder have been noted as soon as 1 week following the traumatic event or as long as 20 years after (Middleton & Craig, 2012). It is important to understand that the initial symptoms of post-traumatic stress are normal and expectable and that PTSD should only be considered a disorder if those symptoms do not remit over time and result in serious, long-term limitations in social functioning. Complete recovery from symptoms occurs in 30% of cases, mild symptoms continue over time in 40%, moderate symptoms continue in 20%, and symptoms persist or get worse in about 10% (Becker, 2004). Children and older adults have the most trouble coping with traumatic events. A strong system of social support helps to prevent or to foster recovery from post-traumatic stress disorder. Besides providing support, social workers may be helpful by encouraging the person to discuss the traumatic event and by providing education about support groups.
Critical Thinking Questions 5.4
What biases do you have about how people should cope with discrimination based on race, ethnicity, gender, sexual orientation, and so on? How might the coping strategy need to change in different situations, such as receiving service in a restaurant, being interviewed for a job, or dealing with an unthinking comment from a classmate?
In coping with the demands of daily life, our social supports—the people we rely on to enrich our lives—can be invaluable. Social support can be defined as the interpersonal interactions and relationships that provide us with assistance or feelings of attachment to persons we perceive as caring (Hobfoll, 1996). Three types of social support resources are available (Walsh, 2000):
1. Material support: food, clothing, shelter, and other concrete items
2. Emotional support: interpersonal support
3. Instrumental support: services provided by casual contacts such as grocers, hairstylists, and landlords
Some authors add “social integration” support to the mix, which refers to a person’s sense of belonging. That is, simply belonging to a group, and having a role and contribution to offer, may be an important dimension of support (Wethington, Moen, Glasgow, & Pillemer, 2000). This is consistent with the “main effect” hypothesis of support, discussed shortly.
Our social network includes not just our social support but all the people with whom we regularly interact and the patterns of interaction that result from exchanging resources with them (Moren-Cross & Lin, 2006). Network relationships often occur in clusters (distinct categories such as nuclear family, extended family, friends, neighbors, community relations, school, work, church, recreational groups, and professional associations). Network relationships are not synonymous with support; they may be negative or positive. But the scope of the network does tend to indicate our potential for obtaining social support. Having supportive others in a variety of clusters indicates that we are supported in many areas of our lives, rather than being limited to relatively few sources. Our personal network includes those from the social network who, in our view, provide us with our most essential supports (Bidart & Lavenu, 2005).
Exhibit 5.4 displays Dan’s social network. He is supported emotionally as well as materially by his family members, with whom he keeps in regular contact, although the relationship with his father is strained. Dan particularly looks to his sister for understanding and emotional support, while at the same time being critical of her failure to be adequately supportive of him. Dan does not see his grandmother except for the trips he takes to China every 3 or 4 years, but he feels a special closeness to her and writes to her regularly. Dan has had an on-again, off-again relationship with his girlfriend Christine, who lives 1 hour away in his hometown and keeps in touch with him primarily by e-mail. Their communications are civil, and Dan seems to enjoy giving her advice when she needs to make certain decisions about her jobs and daily living activities. Dan has instrumental relationships with his landlord and several other tenants in his apartment building, and one neighbor is a friend with whom he has lunch or dinner every few weeks. Dan is further instrumentally connected with several other students because they represent consistency in his life and are casually friendly and supportive. This is also true of two peers with whom he performs volunteer work in the medical center lab. It is apparent from Dan’s social network that he receives most of his emotional support from peers at the church where he attends services and social activities every Sunday.
In total, Dan has 19 people in his social support system, representing seven clusters. He identifies 9 of these people as personal, or primary, supports. It is noteworthy that 7 of his network members provide only instrumental support, which is important but the most limited type. Because people in the general population tend to identify about 25 network members (Uchino, Holt-Lunstad, Smith, & Bloor, 2004), we can see that Dan’s support system, on which he relies to cope with stress, may not be adequate to meet his needs at this time in his life. The social worker might explore with Dan his school, neighborhood, and work clusters for the possibility of developing more active or meaningful supports.
Exhibit 5.4 Dan’s Social Network
* = Identified as close personal support.
Dan is not alone in having an inadequate support network. McPherson, Smith-Lovin, and Brashears (2006) found that 43.6% of their 2004 sample reported having either no one or only one person with whom they discuss important matters in their lives, in contrast to an average of three such persons reported in a 1985 sample. These findings raise several important questions for further exploration: Is it possible that people today have larger but less intimate networks? How is the level of intimate exchange affected by time spent in electronic communication? Do the trends in the United States toward increased time spent at work and in commuting have a negative impact on social support networks?
I don’t need to tell you, of course, that much social support is now provided through connective technologies that allow people to be “in contact” without being physically present with one another. Facebook, Skype, e-mail, blogging, tweets, and texts put people in touch with one another instantaneously, regardless of where they are or what they are doing. While there is much to be admired about these developments, and they clearly allow us to be in touch with significant others we might never otherwise see, they also create the potential for us to reduce the frequency of, and even our desire for, face-to-face contacts and thus redefine the nature of relationships, support, and intimacy. The number of people with whom people physically interact has fallen in recent years. Dan, like many of his peers, spent several hours per day on the Internet communicating with others; in his case it was primarily through e-mail. Spencer believed this was a mixed blessing for his client, because while it did help Dan feel connected to his support system, it prevented any efforts he might otherwise expend for intimate interaction with people whose lives physically intersected with his own. Turkle (2011), among others, is concerned about the unpredictable ways social technology may alter the nature of our relationships. As one disconcerting yet very real example of this process, she writes at length about the coming use of robots to provide people with major interpersonal support, existing as their full-time companions.
How Social Support Aids Coping
The experience of stress creates a physiological state of emotional arousal, which reduces the efficiency of cognitive functions (Caplan & Caplan, 2000). When we experience stress, we become less effective at focusing our attention and scanning the environment for relevant information. We cannot access the memories that normally bring meaning to our perceptions, judgment, planning, and integration of feedback from others. These memory impairments reduce our ability to maintain a consistent sense of identity.
Social support helps in these situations by acting as an “auxiliary ego.” Our social support—particularly our personal network—compensates for our perceptual deficits, reminds us of our sense of self, and monitors the adequacy of our functioning. Here are 10 characteristics of effective support (Caplan, 1990; Caplan & Caplan, 2000):
1. Nurtures and promotes an ordered worldview
2. Promotes hope
3. Promotes timely withdrawal and initiative
4. Provides guidance
5. Provides a communication channel with the social world
6. Affirms one’s personal identity
7. Provides material help
8. Contains distress through reassurance and affirmation
9. Ensures adequate rest
10. Mobilizes other personal supports
Some of these support systems are formal (service organizations), and some are informal (such as friends and neighbors). Religion, which attends to the spiritual realm, also plays a distinctive support role (Caplan, 1990). This topic is explored in Chapter 6.
Two schools of thought have emerged around the question of how we internalize social support (Bal, Crombez, & Oost, 2003; Cohen, Gottlieb, & Underwood, 2001).
1. Main effect model. Support is seen as related to our overall sense of well-being. Social networks provide us with regular positive experiences, and within the network a set of stable roles (expectations for our behavior) enables us to enjoy stability of mood, predictability in life situations, and recognition of self-worth. We simply don’t experience many potential stressors as such, because with our built-in sense of support, we do not perceive situations as threats.
2. Buffering model. Support is seen as a factor that intervenes between a stressful event and our reaction. Recognizing our supports helps us to diminish or prevent a stress response. We recognize a potential stressor, but our perception that we have resources available redefines the potential for harm or reduces the stress reaction by influencing our cognitive, emotional, and physiological processes.
Most research on social support focuses on its buffering effects, in part because these effects are more accessible to measurement. Social support as a main effect is difficult to isolate because it is influenced by, and may be an outcome of, our psychological development and ability to form attachments. The main effect model has its roots in sociology, particularly symbolic interaction theory, in which our sense of self is said to be shaped by behavioral expectations acquired through our interactions with others. The buffering model, more a product of ego psychology, conceptualizes social support as an external source of emotional, informational, and instrumental aid.
Social constructionist perspective; psychodynamic perspective
Perceived support is consistently linked to positive mental health, which is typically explained as resulting from objectively supportive actions that buffer stress. Yet this explanation does not fully account for the often-observed main effects between support and mental health. Relational regulation theory hypothesizes that main effects occur when people regulate their affect, thoughts, and actions through ordinary, yet affectively consequential, conversations and shared activities, rather than through conversations about how to cope with stress (Lakey & Orehek, 2011). This form of regulation is primarily relational in that the types of people and social interactions that help recipients are mostly a matter of personal taste. Dan reports that he receives emotional support from nine people, but he is not necessarily drawn to these people to the same degree, which is partly why he does not experience adequate social support.
How Social Workers Evaluate Social Support
There is no consensus about how social workers can evaluate a client’s level of social support. The simplest procedure is to ask for the client’s subjective perceptions of support from family and friends (Procidano & Smith, 1997). One of the most complex procedures uses eight indicators of social support: available listening, task appreciation, task challenge, emotional support, emotional challenge, reality confirmation, tangible assistance, and personal assistance (Richman, Rosenfeld, & Hardy, 1993). One particularly useful model includes three social support indicators (Uchino, 2009):
1. Listing of social network resources. The client lists all the people with whom he or she regularly interacts.
2. Accounts of supportive behavior. The client identifies specific episodes of receiving support from others in the recent past.
3. Perceptions of support. The client subjectively assesses the adequacy of the support received from various sources.
In assessing a client’s social supports from this perspective, the social worker first asks the client to list all persons with whom he or she has interacted in the past 1 or 2 weeks. Next, the social worker asks the client to draw from that list the persons he or she perceives to be supportive in significant ways (significance is intended to be open to the client’s interpretation). The client is asked to describe specific recent acts of support provided by those significant others. Finally, the social worker asks the client to evaluate the adequacy of the support received from specific sources and in general. On the basis of this assessment, the social worker can identify both subjective and objective support indicators with the client and target underused clusters for the development of additional social support.
NORMAL AND ABNORMAL COPING
Normality is characterized by conformity with our community and culture. We can be deviant from some social norms, so long as our deviance does not impair our reasoning, judgment, intellectual capacity, and ability to make personal and social adaptations (Bartholomew, 2000). Most people readily assess the coping behaviors they observe in others as “normal” or “abnormal.” But what does “normal” mean? We all apply different criteria. The standards we use to classify coping thoughts and feelings as normal or abnormal are important, however, because they have implications for how we view ourselves and how we behave toward those different from us (Francis, 2013). For example, Dan was concerned that other students at the university perceived him as abnormal because of his ethnicity and social isolation. Most likely, other students did not notice him much at all. It is interesting that, in Dan’s view, his physical appearance and demeanor revealed him as abnormal. However, he was one of many Asian American students at the university, and his feelings were not as evident to others as he thought.
Social workers struggle just as much to define normal and abnormal as anybody else, but their definitions may have greater consequences. Misidentifying someone as normal may forestall needed interventions; misidentifying someone as abnormal may create a stigma or become a self-fulfilling prophecy. To avoid such problems, social workers may profitably consider how four disciplines define normal.
The Medical (Psychiatric) Perspective
One definition from psychiatry, a branch of medicine, states that we are normal when we are in harmony with ourselves and our environment. Significant abnormality in perceived thinking, behavior, and mood may even classify as a mental disorder. In fact, the current definition of mental disorder used by the American Psychiatric Association (2013), which is intended to help psychiatrists and many other professionals distinguish between normality and abnormality, is a “syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (p. 20). Such a disorder usually represents significant distress in social or occupational functioning. This represents a medical perspective, only one of many possible perspectives on human behavior, although it is a powerful, socially sanctioned one. The medical definition focuses on underlying disturbances within the person and is sometimes referred to as the disease model of abnormality. This model implies that the abnormal person must experience changes within the self (rather than create environmental change) in order to be considered “normal” again.
In summary, the medical model of abnormality focuses on underlying disturbances within the person. An assessment of the disturbance results in a diagnosis based on a cluster of observable symptoms. Interventions, or treatments, focus on changing the individual. The abnormal person must experience internal, personal changes (rather than induce environmental change) in order to be considered normal again. Exhibit 5.5 summarizes the format for diagnosing mental disorders as developed by psychiatry in the United States and published in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). Many people in the helping professions are required to follow this format in mental health treatment facilities, including social workers.
One major difference between psychiatry and psychology is that psychiatry tends to emphasize biological and somatic interventions to return the person to a state of normalcy, whereas psychology emphasizes various cognitive, behavioral, or reflective interventions. That is, through their own decisions and determination, and sometimes with the help of a professional, the person can change certain problematic (abnormal) characteristics into more agreeable, functional (normal) ones.
Psychological theory is quite broad in scope, but some theories are distinctive in that they postulate that people normally progress through a sequence of life stages. The time context thus becomes important. Each new stage of personality development builds on previous stages, and any unsuccessful transitions can result in abnormal behavior—that is, a deviant pattern of coping with threats and challenges. An unsuccessful struggle through one stage implies that the person will experience difficulties in mastering subsequent stages.
Exhibit 5.5 DSM-5 Classification of Mental Disorders
One life stage view of normality well known in social work is that of Erik Erikson (1968), who proposed eight stages of normal psychosocial development (see Exhibit 5.6). Dan, at age 24, is struggling with the developmental stage of young adulthood, in which the major issue is intimacy versus isolation. Challenges in young adulthood include developing a capacity for interpersonal intimacy as opposed to feeling socially empty or isolated within the family unit. According to Erikson’s theory, Dan’s current difficulties would be related to his lack of success in negotiating one or more of the five preceding developmental phases or challenges, and reviewing this would be an important part of his intervention.
From this perspective, Dan’s experience of stress would not be seen as abnormal, but his inability to make coping choices that promote positive personal adaptation would signal psychological abnormality. For example, at the university, he was having difficulty with relationship development and support seeking. He avoided social situations such as study groups, recreational activities, and university organizations in which he might learn more about what kinds of people he likes, what interests he might share with them, and what insecurities they might share as well. From a stage theory perspective, Dan’s means of coping with the challenges of intimacy versus isolation might be seen as maladaptive, or abnormal.
Exhibit 5.6 Erikson’s Stages of Psychosocial Development
The Sociological Approach: Deviance
The field of sociology offers a variety of approaches to the study of abnormality, or deviance, one of which is derived from symbolic interactionism. It states that those who cannot constrain their behaviors within role limitations that are acceptable to others become labeled as deviant. Thus, deviance is a negative label assigned when one is considered by a majority of significant others to be in violation of the prescribed social order (Curra, 2011). Put more simply, we are unable to grasp the perspective from which the deviant person thinks and acts; the person’s behavior does not make sense to us. We conclude that our inability to understand the other person’s perspective is due to that person’s shortcomings rather than to our own rigidity, and we label the behavior as deviant. The deviance label may be mitigated if the individual accepts that he or she should think or behave otherwise and tries to conform to the social order. (It should be emphasized, however, that sociologists are increasingly using the term positive deviance to describe those persons whose outstanding skills and characteristics make them “outliers” in a constructive sense.)
Social constructionist perspective
From this viewpoint, Dan would be perceived as abnormal, or deviant, only by those who had sufficient knowledge of his thoughts and feelings to form an opinion about his allegiance to their ideas of appropriate social behavior. He might also be considered abnormal by peers who had little understanding of his Asian American cultural background. Those who knew Dan well might understand the basis for his negative thoughts and emotions and, in that context, continue to view him as normal in his coping efforts. However, it is significant that Dan was trying to avoid intimacy with his university classmates and work peers so that he would not become well known to them. Because he still views himself as somewhat deviant, he wants to avoid being seen as deviant (or abnormal) by others, which in his view would lead to their rejection of him. This circular reasoning poorly serves Dan’s efforts to cope with stress in ways that promote his personal goals.
The Social Work Perspective: Social Functioning
The profession of social work is characterized by the consideration of systems and the reciprocal impact of persons and their environments (the bio-psycho-social-spiritual perspective) on human behavior. Social workers tend not to classify individuals as abnormal. Instead, they consider the person-in-environment as an ongoing process that facilitates or blocks one’s ability to experience satisfactory social functioning. In fact, in social work, the term normalization refers to helping clients realize that their thoughts and feelings are shared by many other individuals in similar circumstances (Hepworth, Rooney, Rooney, & Strom-Gottfried, 2013).
Three types of situations are most likely to produce problems in social functioning: stressful life transitions, relationship difficulties, and environmental unresponsiveness (Gitterman, 2009). Note that all three are related to transitory interactions of the person with other persons or the environment and do not rely on evaluating the client as normal or abnormal.
Social work’s person-in-environment (PIE) classification system formally organizes the assessment of individuals’ ability to cope with stress around the four factors shown in Exhibit 5.7: social functioning problems, environmental problems, mental health problems, and physical health problems. Such a broad classification scheme helps ensure that Dan’s range of needs will be addressed. James Karls and Maura O’Keefe (2008), the authors of the PIE system, state that it “underlines the importance of conceptualizing a person in an interactive context” and that “pathological and psychological limitations are accounted for but are not accorded extraordinary attention” (p. x). Thus, the system avoids labeling a client as abnormal. At the same time, however, it offers no way to assess the client’s strengths and resources.
Exhibit 5.7 The Person-in-Environment (PIE) Classification System
With the exception of its neglect of strengths and resources, the PIE assessment system is appropriate for social work because it was specifically developed to promote a holistic biopsychosocial perspective on human behavior. For example, at a mental health center that subscribed to psychiatry’s DSM classification system, Dan might be given an Axis I diagnosis of adjustment disorder or dysthymic disorder, and his auditory processing disorder might also be diagnosed. With the PIE system, the social worker would, in addition to addressing mental and physical health concerns, assess Dan’s overall social and occupational functioning, as well as any specific environmental problems. For example, Dan’s problems with the student role that might be highlighted on PIE Factor I include his isolation, the high severity of his impairment and its 6-month to a year’s duration, and the inadequacy of his coping skills. His environmental stressors on Factor II might include a deficiency in affectional support, of high severity, with a duration of 6 months to a year. Assessment with PIE provides Dan and the social worker with more avenues for intervention, which might include personal, interpersonal, and environmental systems.
Critical Thinking Questions 5.5
How important is virtual support to you? Which types of virtual support are the most meaningful to you? What have you observed about how social technology is affecting the way people give and receive social support? What do you see as the contributions of the medical, psychological, sociological, and social work perspectives on normal and abnormal coping? What do you see as the downsides of each of these perspectives?
Implications for Social Work Practice
Theory and research about the psychosocial person have a number of implications for social work practice, including the following:
• Always assess the nature, range, and intensity of a client’s interpersonal relationships.
• Help clients identify their sources of stress and patterns of coping. Recognize the possibility of particular vulnerabilities to stress and the social and environmental conditions that give rise to stress.
• Help clients assess the effectiveness of particular coping strategies for specific situations.
• Use the risk and resilience framework to understand the nature of a client’s resources, assets, and limitations.
• Where appropriate, help clients develop a stronger sense of competence in problem solving and coping. Identify specific problems and related skill-building needs, teach and rehearse skills, and implement graduated applications to real-life situations.
• Where appropriate, use case management activities focused on developing a client’s social supports through linkages with potentially supportive others in a variety of social network clusters.
• Recognize families as possible sources of stress as well as support.
• Recognize the benefits that psychoeducational groups, therapy groups, and mutual-aid groups may have for helping clients cope with stress.
• Where appropriate, take the roles of mediator and advocate to attempt to influence organizations to be more responsive to the needs of staff and clients. Where appropriate, take the roles of planner and administrator to introduce flexibility into organizational policies and procedures so that agency–environment transactions become mutually responsive.
• For clients who experience stress related to inadequate community ties, link them to an array of formal and informal organizations that provide them with a greater sense of belonging in their communities.
• When working with persons in crisis, attempt to alleviate distress and facilitate a return to the previous level of functioning.
• Assess with clients the meaning of hazardous events, precipitating factors of hazardous events, and potential and actual support systems. When working with persons in crisis, use a here-and-now orientation and use tasks to enhance support systems. Help clients to connect current stress with patterns of past functioning and to initiate improved coping methods. As the crisis phase terminates, review with the client the tasks accomplished, including new coping skills and social supports developed.
general adaptation syndrome
person-in-environment (PIE) classification system
post-traumatic stress disorder (PTSD)
social identity theory
1. You have been introduced to four ways of conceptualizing normal and abnormal coping: mental disorder, psychosocial development, deviance, and social functioning. Which of these ways of thinking about normality and abnormality are the most helpful to you in thinking about Dan’s situation? For what reasons?
2. Think of your own social support network. List all persons you have interacted with in the past month. Next, circle those persons on the list whom you perceive to be supportive in significant ways. Describe specific recent acts of support provided by these significant others. Finally, evaluate the adequacy of the support you receive from specific sources and in general. What can you do to increase the support you receive from your social network?
3. Consider several recent situations in which you have used problem-focused or emotion-focused coping strategies. What was different about the situations in which you used one rather than the other? Were the coping strategies successful? Why or why not? How does the tripartite conceptual framework help you to understand your choice of strategy?
American Psychiatric Association DSM-5 Implementation and Support: www.dsm5.org/Pages/Default.aspx
Site includes information on implementation of the manual, answers frequently asked questions, lists DSM-5 corrections, and provides a mechanism for submitting questions and feedback regarding implementation of the manual. Links are provided to educational webinars about the DSM-5 and trainings being conducted throughout the United States and abroad.
Institute of Contemporary Psychotherapy and Psychoanalysis: www.icpeast.org
Site contains information on conferences, training, and links to other resources on contemporary self and relational psychologies.
Jean Baker Miller Training Institute (JBMTI): www.jbmti.org
The JBMTI at the Wellesley Centers for Women is the home of relational-cultural theory (RCT), which posits that people grow through and toward relationships throughout the life span and that culture powerfully impacts relationship. JBMTI is dedicated to understanding the complexities of human connections as well as exploring the personal and social factors that can lead to chronic disconnection.
MEDLINEplus: Stress: www.nlm.nih.gov/medlineplus/stress.html
Site presented by the National Institute of Mental Health presents links to the latest news about stress research, coping, disease management, specific conditions, and stress in children, seniors, teenagers, and women.
MIT Initiative on Technology and Self: http://web.mit.edu/sturkle/techself/welcome.html
The goal of the MIT Initiative on Technology and Self is to be a center for research and reflection on the subjective side of technology and to raise the level of public discourse on the social and psychological dimensions of technological change. The initiative features seminars, work groups, conferences, research, and publications.
National Center for Post-traumatic Stress Disorder: www.ptsd.va.gov
Site presented by the National Center for PTSD, a program of the U.S. Department of Veterans Affairs, contains facts about PTSD, information about how to manage the traumatic stress of terrorism, and recent research.
Hutchison, Elizabeth D.. Dimensions of Human Behavior: Person and Environment, 5th Edition. SAGE Publications, Inc, 10/2014. VitalBook file.
The citation provided is a guideline. Please check each citation for accuracy before use.
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