Ch. 1 - The Severely Vulnerable: An Emergent Clientele and Practice Mode

At mid-century a set of societal currents in America profoundly altered the role of the human service professions. New client populations with a special set of problems emerged. These client types existed previously, but their numbers expanded enormously and the pressure to accommodate them produced a novel phenomenon.These were people with long-term vulnerabilities, whose disabilities and impediments were not amenable to the usual professional approaches aimed at adjustment and curative results. Rather, they required protracted and multifaceted service, often extending over a lifetime.

The Elderly
Individuals with Physical Disabilities
The very young
Those with mental illness

Advances in medical science resulted in prolonged life expectancy, dramatically increasing the proportion of older adults in the population. The traditional extended family contracted to a nuclear cluster that excluded the older generation, leading to a significant reduction in the basic responsibility assumed by families for members encumbered by the problems of later life (Frankfather, Smith & Caro, 1981). Other arrangements became necessary in the community to meet the needs of this expanding circle of aging citizens (Cantor, 1994).

Individuals with Physical Disabilities The lives of persons with physical disabilities were also transformed by developments in the health field. They were afforded greater proficiency and mobility through medical technology, which freed them from institutions (Brightman, 1984). Their exodus was also affected by legislation and court rulings mandating better access to facilities and more convenient public transportation. Nevertheless, substantial limitations remained, and ongoing support was needed for them in the community (Cioschi & Goodman, 1994).

The Very Young The child welfare field was also transforming as a result of deteriorating family life-divorce, drug addiction, violence, and a crescendo of child abuse. These circumstances created a class of dependent and harmed children, cut adrift from dependable, natural parents (Goldstein, Freud & Solnit, 1973). These many children required alternative sources of nurturing to bring them safely through the formative years of childhood and adolescence (Glisson & James, 1992) .

The mental health field offers a further informative illustration. Here, the advent of psychotropic drugs provided a means to stabilize symptoms of severe mental illness and increased the ability of many patients to function in normal social situations. About the same time, professional and humanistic voices began calling for the deinstitutionalization of state hospital facilities, so that patients could live and be cared for in the least restrictive environment possible. This movement was joined by conservative politicians who saw the closing of state hospitals as a cost cutting bonanza. Through this convergence of influences, millions of clients with mental illnesses were shifted from closed institutions to open community settings, where their need for professional help persisted (Blodgett, 1993).

Severity Those with severe mental illnesses, the frail elderly, and persons with physical disabilities are in circumstances of profound hardship. Their handicaps are beyond those of the more typical client who goes to a social agency to deal with marital discord or to a psychotherapist in private practice to work through a mid-life crisis. These grand scale impairments often have tragic elements, not rectifiable through adjustments in cognition or behavior patterns. They affect the individual in fundamental and pervasive ways and are outside of the person's volition for their cause or solution. Vulnerable clients, according to Gitterman (1991, p. 1), are overwhelmed by "circumstances and events they are powerless to control."

The impediments of these clients are by nature long term and intractable (Applebaum & Austin, 1990). Children who are separated from their parents at an early age need substitute care until they can manage independent living-typically at age 18 or older. Persons with physical disabilities have a condition that is permanent and, ordinarily, irreversible. The infirmity of an elderly individual is not only irreversible, but progressive: hearing defects get worse, visual acuity continues to diminish, and the heart gets weaker. In the mental health field, schizophrenia and other psychotic ailments are generally viewed as persistent conditions with a physiological and probable chemical base that is constitutional. These mental ailments are controllable to a degree through a continuing course of medication, but periods of relative remission are interspersed with episodes of crisis and decompensation. The disability is life-long and cyclical in form.

Additionally, this client group has a wide range of needs, given the severity of their circumstances. A dependent child needs the array of fundamental material and emotional supports that would ordinarily be extended by a loving family. An elderly individual may require financial help, assistance in homemaking and personal care, medical attention, and transportation. There is a similar extent of need for the individual with a severe mental illness or developmental disability living in a community-based setting, whether with the family or in a board and care facility. Clearly, the difficulties that these individuals face are not particular and focused, as with the typical client seeking counseling or temporary financial assistance, but extremely general and diverse (Geron & Chassler, 1995).

In addition to specialized problem conditions, such as limited dexterity in those with physical disabilities or the emotional instability of those with mental illnesses, vulnerable client populations have certain difficulties in common. These include deficits in the skills of everyday living, a lack of information, and low selfesteem.

These skills deficiencies can be viewed as a secondary loss that follows in the wake of the primary disability. For example, an individual with psychiatric troubles may not have learned how to make friends, and an elderly person with reduced vision may have lost the ability to navigate on public transportation. People in these circumstances may fail in areas that for others are routine and may also experience a greater number of crisis episodes.

Lack of information is closely related to poor coping abilities. A salient factor impeding all vulnerable populations, according to Gitterman (1991), is that they are missing necessary information or are guided by misinformation. Because they require a great deal of support from community resources, and the support environment is complex, accurate information is both vital and hard to obtain and keep current.

He losses and deficiencies of vulnerable people are real and can be devastating. In comparison to others, these individuals are at actual disadvantage in specific areas. The dependent child does not have a natural parent to teach him carpentry skills and an amputee may not be able to move about as quickly as others. Dwelling on the inadequacy or disadvantage by the individual can easily result in despondency and low self-esteem. Being rejected, disdained, or mocked by other people, as is the frequent reality, or being turned away by service providers favoring higher functioning clients can generate a feeling of defeatism and powerlessness. These attitudes, if not checked, add to the sense of encumberment felt by many vulnerable individuals.

They possess an underutilized capacity for growth and change, even within the context of handicapping circumstances (Fast & Chapin, 1996). These are the "shoulders" that the earlier proverb noted. Such assets, Gerhart (1990) indicates, may be environmental (an adequate income, caring family, friends, a lovely garden) or personal (good health, a sense of humor, religious beliefs, an ability to learn).

Internal deficits need to be balanced by strong external supports. But another social trend accompanied those we already identified, and it operated in a countervailing way. A growth spurt in social programs was one of the notable developments in the sixties. The War on Poverty and the Great Society spawned a proliferation of human services, often in disjointed and even contradictory form.
It is here the Peer Support Specialists began.