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Study of the differences in and practice of advocacy among clinical social workers, marriage and family therapists, and mental health counselors
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Table of Contents
    Title Page
        Page i
    Acknowledgement
        Page ii
        Page iii
    Table of Contents
        Page iv
        Page v
        Page vi
    Abstract
        Page vii
        Page viii
    Chapter 1. Introduction
        Page 1
        Page 2
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    Chapter 2. Review of the related literature
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    Chapter 3. Methodology
        Page 52
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    Chapter 4. Results
        Page 59
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    Chapter 5. Discussion
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    Appendix A. Memo
        Page 103
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    Appendix B. Marriage and family faculty
        Page 105
    Appendix C. Marriage and family practitioners
        Page 106
    Appendix D. Mental health/professional counselor faculty
        Page 107
    Appendix E. Mental health practitioners/professional counselors
        Page 108
    Appendix F. Social work faculty
        Page 109
    Appendix G. Clinical social work practitioners
        Page 110
    Appendix H. Consent form--Study 2
        Page 111
        Page 112
    Appendix I. Delphi questionnaire--Study 2
        Page 113
        Page 114
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        Page 117
    References
        Page 118
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        Page 122
        Page 123
    Biographical sketch
        Page 124
        Page 125
        Page 126
        Page 127
Full Text










STUDY OF THE DIFFERENCES IN AND PRACTICE OF ADVOCACY AMONG
CLINICAL SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS,
AND MENTAL HEALTH COUNSELORS










M yE
MEREDITH ANNE DELK


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE
UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2002













ACKNOWLEDGMENTS

The completion of this research project has been a true challenge to my ability to

persevere and meet tremendous change with flexibility and grace. This project has at

times been my solace and at times my frustration.

I believe that one's expression of gratitude is of great importance, and so writing

these acknowledgments is, for me, a critical part of this process. I must first thank my

parents, John Wayne Delk and Kathryn Kay Delk. My father read to me from the time I

was born, and as soon as I could read he stuck a book in my hand. Some of my most

fond memories of him are the many occasions that we spent time in bookstores. He

taught me to read for the love of reading. As an adult I still view reading as one of my

most cherished pleasures. As an educator herself, my mother taught me that education

was the key to tremendous growth and lifelong freedom. These lessons had a tremendous

impact on my ability to persevere and complete this degree. I thank them both.

I am particularly thankful to Dr. Mary Beth Diamond. Her continued wisdom

throughout this process was a constant source of support. Our friendship is truly the

fruition of many blessings.

I am also thankful to Christy Holthaus Stuart. Christy's constant support while

we simultaneously worked through our research projects was an unmatched experience. I

look forward to sharing a lifetime of personal friendship and professional success.








I am thankful to all of my committee members. Their participation and the

sharing of their wisdom for the duration of this project will be remembered throughout

my professional career. They have all been tremendous role models.

I am thankful to all of the participants in this study. The giving of their time and

intellect to this project is appreciated. This research was an effort to provide a forum for

dialogue, and their participation made this project a reality.

Many thanks go to Dean Ira Colby. Dr. Colby's enthusiasm for social welfare

policy and efforts for social justice are extraordinary. He was my first mentor, and his

early presence in my career had a life-changing impact. I thank him for the many years of

support.

Working with my chairperson, Dr. Peter Sherrard, these last three years has been

an experience for which I am deeply grateful. Dr. Sherrard's presence in my life is a true

blessing. If I do become governor one day, it will be in part because of his continued

support, tremendous wisdom, and his friendship.

Finally, I must thank my husband, David. David never waned in his belief that I

would finish this project; he has supported me emotionally and financially throughout

and for this I thank him. This project was completed during our first year of marriage,

one that will always remain in my memory as full of friendship and love. I thank him for

his many gifts to our marriage.














TABLE OF CONTENTS

Page


ACKNOWLEDGMENTS ................................................................1i

ABSTRACT ........................................................................................................... vii

CHAPTERS

I INTRODUCTION ....................................................................................... I

Scope of the Problem ................................................................................... 2
Statement of the Problem .............................................................................. 3
Need for the Study ....................................................................................... 4
Purpose of the Study ..................................................................................... 6
Rationale for the Approach .......................................................................... 7
Guiding Questions ....................................................................................... 8
Definition of Terms ....................................................................................... 9

2 REVIEW OF THE RELATED LITERATURE ........................................... 12

Historical Context ........................................................................................ 15
Related History of Human Services .................................................... 15
History of Advocacy .......................................................................... 16
Theoretical Constructs Underlying the Study ...................................... 17
M arriage and Family Profession ................................................................. 20
History .............................................................................................. 20
M arriage and Family Therapist Advocate ........................................... 22
Foci of Advocacy in Marriage and Family Therapy ............................ 22
Mode of Advocacy in Marriage and Family Therapy ......................... 24
Training and Evaluation of Marriage and Family Advocates .............. 25
M ental Health Counseling Profession ........................................................ 25
History .............................................................................................. 25
M ental Health Counselor as Advocate ............................................... 27
Foci of Advocacy in Counseling ........................................................ 29
M odes of Advocacy in Counseling .................................................... 30
Training and Evaluation of Mental Health Counselor Advocates ...... 31
AM HCA vs. ACA .............................................................................. 33








Social W ork Profession .............................................................................. 34
H istory ................................................................................................... 34
Social W orker as Advocate ............................................................... 35
Foci of Advocacy in Social W ork ...................................................... 36
M odes of Advocacy in Social W ork .................................................. 38
Training and Evaluation of Social Work Advocates ........................... 40
M aco vs. M icro Practice ................................................................... 44
The Im pact of M anaged Care ...................................................................... 46
Collaboration Am ong the Professions ........................................................ 49
Conclusion .................................................................................................. 50

3 M ETH ODOLO GY ..................................................................................... 52

Research Design ......................................................................................... 52
Sam ple .............................................................................................. 53
Instrum ents ....................................................................................... 55
Research Procedures ................................................................................... 57
Data Analyses ............................................................................................ 57
Lim itations .................................................................................................. 58
Conclusion .................................................................................................. 58

4 RESU LTS .................................................................................................. 59

Study I ...................................................................................................... 59
Participants ....................................................................................... 59
Analysis .............................................................................................. 60
Results/Them es ................................................................................... 61
Study 2 ...................................................................................................... 63
Data Entry and Cleaning ................................................................... 63
Data V isualization ............................................................................... 64
Descriptive Data Analysis ................................................................. 64
Data Analysis for Guiding Questions ................................................. 64
Additional Analyses for Items Not Included in Factor Analysis ...... 73
Exploratory Analyses ........................................................................ 76
Analyses by Faculty Status ............................................................... 84
Analyses by Combined Professional Affiliation and Faculty Status ........ 87

5 DISCU SSION ........................................................................................... 91

Evaluation and Discussion of the Results .................................................... 91
Guiding Questions 1-3 ....................................................................... 91
Guiding Questions 4-6 ....................................................................... 92
Factor Analysis Results .............................................................................. 95
Guiding Question 7a .......................................................................... 95
Item s N ot Included in the Factor Analysis ......................................... 96




v








Lim itations of the Study .............................................................................. 97
Implications and Recommendations for Further Research ........................... 99
C onclusions .................................................................................................. 100

APPENDICES

A M E M O ......................................................................................................... 103

B MARRIAGE AND FAMILY FACULTY ..................................................... 105

C MARRIAGE AND FAMILY PRACTITIONERS ........................................ 106

D MENTAL HEALTH/PROFESSIONAL COUNSELOR FACULTY ............ 107

E MENTAL HEALTH PRACTITIONERS/PROFESSIONAL
CO U N SELO R S ................................................................................... 108

F SOCIAL WORK FACULTY ........................................................................ 109

G CLINICAL SOCIAL WORK PRACTITIONERS ........................................ 110

H CONSENT FORM--STUDY 2 ..................................................................... 111

I DELPHI QUESTIONNAIRE--STUDY 2 ..................................................... 113

R E FER EN C E S ..................................................................................................... 118

BIOGRAPHICAL SKETCH ................................................................................. 124














Abstract of Dissertation Presented to the Graduate School of the University of Florida
in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy

STUDY OF THE DIFFERENCES IN AND PRACTICE OF ADVOCACY AMONG
CLINICAL SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS,
AND MENTAL HEALTH COUNSELORS

By

Meredith Anne Delk

May 2002

Chairperson: Peter Sherrard
Major Department: Counselor Education

Clinical social workers, marriage and family therapists, and mental health

counselors seek to protect the integrity of the mental health professions, their ability to

engage in compassionate clinical practice, and, ultimately, their ability to deliver

efficacious client care. Many mental health practitioners are concluding that macro

practice, or "advocacy," is the most efficient method of responding to the current climate

of service delivery.

This research explored the emphasis on and practice of advocacy among trained

psychotherapists across the United States from three disciplines. There is discussion

within and between these professions in an effort to define advocacy, whether or not

students ought to be trained as advocates, how students ought to be trained as advocates,

and how much time is currently being devoted to advocacy training and practice. The

purpose of the study was to survey faculty and practitioners and explore their attitudes








and beliefs about advocacy work in academic and clinical settings. The professional

affiliations of the respondents were a variable in this research.

One significant finding of this research was found in the unexpected similarities

among the professions. Five of the six groups in the study reported no statistical

difference on a series of questions related to advocacy practice and training with only the

social work faculty group scoring much higher than the others. Another significant

finding was the inclusion of an ethics question that ultimately suggested that one

successful method of training advocacy is to include advocacy as part of ethical practice.

The results of this study imply that there are definitions of advocacy that may be useful

across disciplines, that training is a priority for many faculty members, and that many

more similarities exist between three professions than may have been thought prior to this

study.













CHAPTER 1
INTRODUCTION


The managed health care model of clinical service delivery and accountability has

challenged mental health service providers and clinical faculty to explore alternative

response strategies that can enable them to exercise a reasonable degree of professional

judgment in the application of therapeutic principles. Marriage and family therapists,

mental health counselors, and clinical social workers seek to protect the integrity of the

mental health professions, their ability to engage in compassionate clinical practice, and,

ultimately, their ability to deliver efficacious client care. Many mental health

practitioners are concluding that macro practice, or "advocacy," is the most efficient

method of response to managed care. Further, many suggest that advocacy is mandatory

if we are to maintain an ethical level of practice (Allen-Meares, 1998; Glauser, 1996;

Kochunas, 1997).

The recent professional literature of marriage and family therapists, mental health

counselors, and clinical social workers has engaged in significant debate about the need

for advocacy (Brawley, 1997; Chapman & Richman, 1998; Epstein, 1995; Eriksen, 1999;

Figueria-McDonough, 1993; Kurpius & Rozecki, 1992; Lee & Sirch, 1994; Osborne et

al., 1998; Verschelden, 1993; Walz, Gazda, & Shertzer, 1991; Wolk & Pray, 1996).

This discussion about the inclusion of advocacy in training and practice is fueled by

current societal conditions (which also have inspired the development of managed care)

such as rampant poverty, drug abuse, an ever-growing population, and an increasing








life-expectancy rate coupled with diminishing resources (Allen-Meares, 1998; Berger &

Kelly, 1993; Faul & Hudson, 1997; Kochunas, 1997). Mental health practitioners and

policymakers are being forced to respond in new and creative ways to service delivery

issues as a result of these trends.


Scope of the Problem

The mental health professions share a commitment to promoting public

protection, public service, and public welfare in the United States. Although unified in

many ways because of their commitment to "the fifth profession" (i.e., providing

psychotherapy), that unity is often obscured by differences in their historical roots,

service philosophy, academic training, and treatment emphases (Henry, Sims, & Spray,

1973). Despite these differences, marriage and family therapists, mental health

counselors, and clinical social workers all provide psychotherapy to and promote

advocacy on behalf of the clients and client groups they serve.

We can predict that there are varying degrees of emphasis on advocacy for clients

and client groups within the three professions because marriage and family therapy,

mental health counseling, and clinical social work differ in the ways in which they

manage the tension between micro and macro practice. Thus, they differ in the degree to

which their focus is on the individual, the family, or the larger community context, but

we do not know exactly how the members of these professional groups and their teachers

view the exercise of advocacy.

We do know that experts do not agree on one single definition of advocacy. The

work of advocates has been quite varied throughout history; therefore, formulating a








general definition of advocacy is difficult. Tompkins, Brooks, and Tompkins (1998)

observed that

there are numerous definitions of advocacy, each of which have certain values
and some utility in the particular system in which it is used. Most of the
definitions take their meaning from the contexts in which they are used. This
relativity is part of the difficulty. (p. 33)

Because the work of the advocate is often very personal, pinpointing when advocacy

ought to take place or when it is taking place and exactly what advocacy behaviors look

like becomes quite challenging.


Statement of the Problem

Advocacy is ubiquitous. Despite considerable disagreement regarding how great

the need is for all three of the professions to train and/or engage in advocacy work,

significant numbers of faculty and practitioners in all three professions assert that

advocacy ought to occupy a primary position in clinical training and clinical practice

(Brawley, 1997; Chapman & Richman, 1998; Epstein, 1995; Eriksen, 1999; Figueria-

McDonough, 1993; Kurpius & Rozecki, 1992; Lee & Sirch, 1994; Osborne et al., 1998;

Verschelden, 1993; Walz et al., 1991; Wolk & Pray, 1996). Very little empirical data

exist on exactly what constitutes advocacy, how it is taught in clinical training programs,

and how it is practiced among mental health professionals. Also little data exist

summarizing the clinical faculty's beliefs and attitudes about advocacy and the degree to

which faculty perspectives influence practitioner beliefs and attitudes (and vice versa).

These three mental health professions may be at a stage where empirical data can be quite

useful in resolving the role and function of advocacy in clinical training and practice.

There is a need for data on faculty perspectives, attitudes, and beliefs surrounding

the inclusion of advocacy training in clinical programs. Furthermore, there is a need to








review similar data regarding advocacy practices with practitioners active in these three

professions. This research may prove worthwhile for the professions and possibly the

larger community of public servants. Therefore, this dissertation explored the promotion

and practice of advocacy among these three mental health professions. It examined

advocacy as practiced by professionals working in the field and advocacy as promoted by

faculty who teach in the three professions' respective clinical training programs in order

to determine the most efficient and effective advocacy practices.


Need for the Study

This study gathered data from two groups--faculty and practitioners. A large

random sample of faculty from nationally accredited marriage and family therapy, mental

health counseling, and clinical social work programs was taken in order to determine the

presence and extent of advocacy training and faculty attitudes and beliefs towards said

training.

Members from each of the three state chapters representing marriage and family

therapy, mental health counseling, and clinical social work were sampled. Members from

Alabama, Connecticut, Georgia, Illinois, Maryland, Massachusetts, Missouri, New

Hampshire, New Jersey, North Carolina, Oregon, South Carolina, Texas, and Virginia

were included in the study. These states have state chapters and licensure in all three

professions and thus met the research criteria. The purpose of this poll was to explore

attitudes, beliefs, and the extent of advocacy work in practice. Training practices were

identified among faculty and the degree of practitioner involvement in advocacy

delineated.








This research provides information about the advocacy work engaged in by each

of the three professions and highlights where their respective strengths lie in this

advocacy work. For example, correlating the ways and extent to which faculty address

advocacy issues in the classroom with the actual practice of advocacy among clinical

professionals may be significant in determining the future of advocacy training.

Furthermore, a study of differences in emphasis on advocacy among faculty may serve as

a training tool for faculty across professions and possibly connect professions that have

remained somewhat disparate. For example, if one profession excludes advocacy

training while another promotes it, understanding how and why will hopefully benefit all

three professions participating in the study and stimulate the development of a more

active advocacy model for all professionals.

Several theoretical implications could come from this study. If it is found that

one profession engages in advocacy training that yields advocates in the field while those

who do not engage in advocacy training have a lower number of advocates in the field,

we may conclude that incorporating advocacy training in all training programs is to be

promoted. On the other hand, if professionals suggest that they are skilled advocates even

though they have received no academic training in this area, then we may conclude that

further study should be pursued regarding the ways in which mental health professionals

gain on-the-job training to engage in advocacy.

There are significant implications for research as well. Most importantly, this

study could encourage other professionals not only to think about the importance of

advocacy in clinical settings but also to engage in research about advocacy as well.

Further, if this study yields significant data showing that faculty and professionals see








advocacy as imperative for the future of these professions, then practitioners may be

more apt to engage in research related to training needs and effective training. Future

research may also widen the scope in terms of reasons behind engaging in advocacy

work. I hope the results of this study will serve professionals as a window into advocacy

work in each profession as well as a solid comparison between the advocacy work of

these three kinds of mental health professionals.

The implications of this study serve a much broader audience then just the mental

health field. Many other professions are contending with similar constraints: managed

care, poverty, and population issues. In addition, individual Americans are faced with

these issues on a personal level. Americans are being forced to navigate highly technical,

complicated systems in order to achieve basic means, creating the necessity to advocate

on behalf of oneself. This research could serve a broad context by providing insights on

who is doing successful advocacy work as well as how and why.

In summary, the issue of advocacy in mental health must be brought to the

forefront. This research explored in detail what is being taught in representative graduate

schools all over the country as well as what is being done in practice. With a better

understanding of these issues, clarity may be gained regarding the kinds of advocacy

work being done, where the gaps exist, where and how advocacy is being taught, and

how to address this issue across these varying groups of professionals.


Purpose of the Study
In this study, the issue of advocacy among marriage and family therapy, mental

health counseling, and social work faculty and practitioners was investigated. The

purpose of the study was to survey faculty and practitioners in these three fields and








explore their attitudes and beliefs about the issue of advocacy work in academic and

clinical settings. A further purpose of the study was to explore the extent to which

students are being trained as advocates and the kinds of advocacy training they receive.

The professional affiliations of the respondents were a variable in this research.

Data were gathered from faculty and practitioner representatives of each of the

three professional groups (i.e., marriage and family therapy, mental health counseling,

and clinical social work) engaged in clinical practice. During phase one, the research

faculty and practitioners were asked similar but different questions. Faculty were asked

questions about how important they believe it is to include advocacy as a topic in the

classroom and to what extent they believe students view themselves as advocates upon

graduation. Practitioners were asked questions related to the extent of advocacy training

they received in school and the extent to which they currently define themselves as

advocates in their daily practice. During phase two of the research all participants were

asked the same questions. All respondents were asked questions such as the following:

What role does advocacy have in your teaching/practice? What percentage of your time is

devoted to advocacy?


Rationale for the Approach

As noted, data were collected from clinical practitioners and faculty members

from three different professions (i.e., marriage and family therapy, mental health

counseling, and clinical social work). The study included faculty who teach in

departments with national accreditation (Council on Clinical Social Work Education

[CSWE], Council for Accreditation of Counseling and Related Educational Programs

[CACREP], and American Association for Marriage and Family Therapy [AAMFT]) and








practitioners active in their state chapters (American Mental Health Counselors

Association [AMHCA], CSWF, and AAMFT). Faculty were chosen in order to find the

degree to which they support advocacy among practitioners and train students to be

advocates upon graduation. Practitioners who were members of state chapters were

chosen because these practitioners are most likely to represent clinicians who are

committed to their profession and knowledgeable regarding the challenges and demands

of professional affiliation.


Guiding Questions

The following guiding questions framed this study:

1. What does the term "advocacy" mean in marriage and family therapy?

2. What does the term "advocacy" mean in mental health counseling?

3. What does the term "advocacy" mean in clinical social work?

4a. How do marriage and family therapists view their roles as advocates?

4b. How do marriage and family therapists view the need for advocacy work in
this country?

5a. How do mental health counselors view their roles as advocates?

5b. How do mental health counselors view the need for advocacy work in this
country?

6a. How do clinical social workers view their roles as advocates?

6b. How do clinical social workers view the need for advocacy work in this
country?

7a. What are the formal training methods used in marriage and family therapy,
mental health counseling, and clinical social work to train advocates?

7b. How are these training programs evaluated and are these evaluation
procedures sufficient?








Definition of Terms

One purpose of this study was to provide a consistent definition of advocacy

across the professions of marriage and family therapy, mental health counseling, and

clinical social work. In general terms and for the purpose of this study, advocacy is

defined as the defense or promotion of a cause (Ezell, 2001). Ezell also provided in his

text, Advocacy in the Human Services, a discussion of types of advocacy. He was able to

define advocacy in the human services in a way that may prove useful in this study.

Case advocacy is defined as "partisan intervention on behalf of an
individual client or identified client group with one or more secondary
institutions to secure or enhance a needed service, or entitlement"
Class advocacy is defined as "an intervention on behalf of a group of
clients who share the same problem or status."
Systems advocacy "is promoted to change policies and practices
affecting all persons in a certain group or class"
Policy advocacy is defined as those efforts to influence those who
make policy "with laws, public programs, or court decisions"
Self-advocacy is defined as "clients/consumers leam[ing] their rights
and how to protect them or a process in which an individual, or a
group of people, speak or act on their own behalf in pursuit of their
own needs and interests"
Clinical advocacy is defined as the "delivery of services accompanied
by efforts to alter 'ecological mismatches' at the root of problem
behaviors." (Ezell, p. 27)

Advocacy training is the training of professionals on issues of macro practice.

For this study, professional refers to any mental health professional who is a member of

one of the three national associations discussed here. Faculty refers to a member of a

department accredited by one of the national accrediting bodies from professions

involved in this study. Clinical practice refers to the practice of psychotherapy as

conducted by clinical social workers, marriage and family therapists, and mental health

counselors.








Since there is considerable debate among mental health professionals as to what

constitutes legitimate professional identities, the distinctions below may elicit

disagreement. For example, does the title, mental health counselor, refer to those

engaged in a specialty area of professional counseling practice or those independently

engaged in community mental health practice? Does the title social worker, take

precedence over the title, clinical social worker? Resolution of these distinctions lies

beyond the scope of this dissertation. Rather, this study addressed the members of the

"fifth profession" (Henry et al., 1973), psychotherapy, as identified by their membership

in the professional associations specified below.

The American Association for Marriage and Family Therapy (AAMFT) is the

professional association of marriage and family therapists that represents the interests of

marriage and family therapists throughout the United States. For the purpose of this

dissertation, marriage and family therapy practitioners are all members of AAMFT.

Further, faculty members polled from marriage and family therapy programs are all from

departments accredited by the Commission on Accreditation for Marriage and Family

Therapy Education (COAMFTE). The COAMFTE is the national accrediting body that

accredits master's degree, doctoral degree, and postgraduate degree clinical training

programs in marriage and family therapy throughout the United States and Canada

(AAMFT, 2001).

The American Mental Health Counselors Association (AMHCA) is the

professional association of mental health counselors that represents the interests of

mental health counselors throughout the United States. For the purpose of this

dissertation, mental health counselor practitioners are all members of AMHCA. Faculty








members polled from mental health counseling programs are all from departments

accredited by the Council for Accreditation of Counseling and Related Educational

Programs (CACREP). The CACREP is the national accrediting body for mental health

counseling programs across the United States. The CACREP was formed as an affiliate

of ACA, and its mission coincides with that of ACA--"to promote the advancement of

quality educational program offerings" (CACREP, 2001, para. 1).

In this study, the Clinical Social Work Federation (CSWF) differentiates social

workers from clinical social workers not engaged in clinical practice. The CSWF is a

confederation of 31 state societies for clinical social work. The state societies are "formed

as voluntary associations for the purpose of promoting the highest standards of

professional education and clinical practice. Each society is active with legislative

advocacy and lobbying efforts for adequate and appropriate mental health services and

coverage at their state and national levels of government" (Clinical Social Work

Federation, 2001, para. 1). Further, members polled from clinical social work programs

are all from departments accredited by the Council on Clinical Social Work Education

(CSWE). The CSWE is the national accrediting body affiliated with the NASW whose

purpose is "to promote and maintain the high quality of Social Work education. In

addition, CSWE strives to stimulate knowledge and curriculum development, to advance

social justice, and to strengthen community and individual well-being" (CSWE, 2001,

para. 1.)













CHAPTER 2
REVIEW OF THE RELATED LITERATURE

This study examined the role and function of advocacy as practiced by marriage

and family therapists, mental health counselors, and clinical social workers currently

working in academic or clinical settings across the country or both. The study solicited

the beliefs and attitudes of these trained professionals regarding advocacy practice. This

review of literature focused on relevant academic information from the professions of

marriage and family therapy, mental health counseling, and social work. This distinction

between clinical social work, the focus of the study, and social work, the focus of the

literature review, is because the current academic literature does not distinguish and most

often uses the term "social work" even when discussing clinical practice. It is only in the

opinions provided by the authors that one could begin to make this distinction. In-depth

discussion of this topic is beyond the scope of this dissertation.

Members of the helping professions have in common the desire to make a
difference.... They want to rid the world of undesirables.... This is why
advocacy should be done. When people focus their mind's eye, they can see both
the ugliness they wish to eliminate and the dream they want to reach. (Ezell,
2001, p. 5)
With Ezell's words in mind, the purpose of this study was to highlight advocacy as one

way "to make a difference" and to identify and differentiate the advocacy activities and

strategies utilized by marriage and family therapists, mental health counselors, and

clinical social workers in their practice.








We begin consideration of advocacy by reviewing the historical context, training,

and practice of each of these three professions and establishing a useful definition of

advocacy for this study. This is important because of the confusion that exists for

practitioners across disciplines regarding the role of advocacy in their work. A

significant finding of this research may be consensus regarding an acceptable definition

of advocacy.

This chapter contains a review of the literature on advocacy within the three

professions addressed in this study. A historical context is provided as well as a

theoretical frame for the study. The issues related to defining advocacy, the role of

advocacy in the professions, and the focus and mode of advocacy also are addressed.

Also, a discussion of managed care and its impact on clinical practice is presented.

Finally, literature is provided regarding collaboration among professions as a viable

method of responding to current constraints facing each of these three professions.

The work of advocates has been quite varied throughout history. This variety in

advocacy work makes it difficult for advocates to agree on a general definition.

There are numerous definitions of advocacy, each of which has certain values and
some utility in the particular system in which it is used. Most of the definitions
take their meaning from the contexts in which they are used. This relativity is
part of the difficulty. (Tompkins et al., 1998, p. 33)

In her discussion on theories of advocacy, DeGregorio (1997) suggested that "by

virtue of the fact that we live in a democracy, advocacy is each person's right in this

country" (p. 6).

The contextual nature of advocacy work as well as the beliefs and assumptions

associated with advocacy make it a rather complex issue. "Every conceptual framework,

theoretical model, or practice intervention operates on a set of assumptions; sometimes








they are identified explicitly, but not usually" (Ezell, 2001, p. 31). These beliefs and

assumptions clearly impact each advocacy situation and, therefore, may contribute to the

ways in which one defines one's role as an advocate.

In an effort to provide a foundation from which to work for the purposes of this

study, it is useful to review a few definitions of advocacy that are widely agreed upon.

Hepworth and Larsen (1986) defined advocacy as

the process of working with and/or on behalf of clients (1) to obtain services
or resources for clients that would not otherwise be provided, (2) to modify
extant policies, procedures, or practice that adversely impact clients, or (3) to
promote new legislation or policies that will result in the provision of needed
resources or services. (p. 569)

Ezell (2001) quoted what he calls a frequently used definition of advocacy, "to defend or

promote a cause" (p. 22) and describes advocacy as consisting "of those purposive efforts

to change specific, existing or proposed policies or practices on behalf of or with a

specific client or group of clients" (p. 23). The data gathered in this study contribute to a

consensually validated definition of advocacy for the three professions studied here.

Ezell (2001) provided a general framework for summarizing what an advocate of

any kind or from any background hopes to accomplish:

(1) create a society that is just, in which all persons have equal opportunities
to pursue their potential. (2) ensure that programs and services are accessible,
effective, appropriate, flexible, comprehensive, adequate, and efficient.(3)
protect existing individual rights and entitlements and to establish new rights
and entitlements as needed. (4) eliminate the negative and unethical impact
that social institutions, organizations, programs, and individuals may have on
people. (5) assure that the least intrusive intervention is utilized to meet the
client's needs and achieve the service goal. (p. 6)








Historical Context

Related History of Human Services

Social welfare can be traced back to 1792 BC when King Hammurabi of Babylon

issued the Code of Hammurabi, which created the first code of laws. Included in this

code was the protection of widows, orphans, and the weak against the strong (Edwards,

1999). However, it was only many years later that recorded history shows evidence of

organized human services. During the 1500s King Henry VIII of England was the first to

state that government would take responsibility for caring for the disadvantaged. Until

this point, the Church is documented as responsible for those who were not self-

sufficient. Later, in 1601, the Elizabethan Poor Law was passed, which for the first time

officially provided shelter and care for the poor. Thus, the concept of human services as

we know it in the modem world began (Schmolling, Youkeles, & Burger, 1997). In

January 1843 Dorothea Dix made a statement that marked her as the person who alone

was responsible for beginning the American asylum movement. Dix was an ordinary

woman, a little-known schoolteacher, who submitted a petition to the Massachusetts

General Court in January 1843. This petition exposed the conditions of asylums

throughout the state. "I proceed, Gentlemen," she announced, "briefly to call your

attention to the present state of insane persons confined within the Commonwealth, in

cages, closets, stalls, pens! Chained, naked, beaten with rods, and lashed into

obedience." Dix's draft is considered among "the most powerful documents ever written

in the history of American social reform" (Gollaher, 1993, p. 149).








History of Advocacy

King Henry VIII and Dorothea Dix represent two of the many people who

contributed to the evolution of mental health care throughout history. These leaders of the

mental health movement were our early advocates. In fact, advocacy and advocacy work

has been a driving force for change throughout history. It is quite possible that King

Henry VIII and Dorothea Dix would not have called themselves advocates; however, one

could argue that in fact they served as key advocates in making changes quite significant

to the modem world.

Historically speaking, the Bible uses language that could be interpreted to suggest

that one's charge is to advocate on behalf of others. The Bible states, "... do justice to

the afflicted" (Psalms 82:3). Even the Constitution of the United States in at least two

sections makes reference to the need for Americans to engage in advocacy on behalf of

themselves or other Americans or both. It reads, "We the people of the United States, in

order to form a more perfect Union, establish justice, insure domestic tranquility,

provide for the common defense, promote general welfare, and secure the blessings of

liberty.... ." The first amendment to the constitution goes on to state, "Congress shall

make no law abridging the freedom of speech or of the press; or the right of the people

peaceably to assemble and to petition the government for redress or grievances." These

historical documents assert powerful ideas concerning the "rights" of "the people" to

"liberty," "justice," and the "redress of grievances" that have become the fabric of

America, past and present. Advocates typically fight to maintain liberty, to secure justice

where it is lacking, and to make decisions affirming the basic rights of people.

Suggesting that advocacy resides in the fabric of the constitution rests on the notion that,








as Americans, we all have the right and duty to advocate on behalf of ourselves and/or

one another and that the study of such practices is a worthwhile pursuit.


Theoretical Constructs Underlying the Study

The focus of this study involved three human services professions with distinct

differences. These differences are examined through the lens of each profession's ethical

principles and codes. These codes provide consensually validated standards by which

each of the professions defines itself. In particular, this study highlights the principles and

codes written by each profession that relate to advocacy as a legitimate professional

activity.

The marriage and family therapy profession looks toward AAMFT for its codes of

principles and ethics. Currently, the AAMFT uses its Code of Principles for Marriage

and Family Therapists as its guide (American Association of Marriage and Family

Therapy Code of Ethics, 1998). Within this code there are several sections pertinent to

this study. They are as follows:

1. RESPONSIBILITY TO CLIENTS
1.6 Marriage and Family Therapists assist persons in obtaining other
therapeutic services if the therapist is unable or unwilling, for appropriate reasons,
to provide professional help.
1.7 Marriage and Family Therapists do not abandon or neglect clients in
treatment without making reasonable arrangements for the continuation of such
treatment. (American Association of Marriage and Family Therapy Code of
Ethics, 1998, section 1)

6. RESPONSIBILITY TO THE PROFESSION
6.5 Marriage and Family Therapists participate in activities that
contribute to a better community and society, including devoting a portion of their
professional activity to services to which there is little or no financial return.
(American Association of Marriage and Family Therapy Code of Ethics, 1998,
Section 6)








The mental health counseling profession uses several organizational codes of

ethics as guideposts; one of these is the American Counseling Association (ACA). "The

American Counseling Association Strategic Plan, 2000-2003" provides several

statements pertinent to this study. The Preamble states,

The ACA is an organization of professional counselors who work in
diverse settings and embrace the following common values:
1.Mentoring and training members to advocate on behalf of clients and the
profession
2.Working in a collaborative and ethical manner for the overall benefit of
the Association and the profession. (ACA, 2000)

INCREASE PUBLIC AWARENESS FOR COUNSELING
1. To take proactive positions with public media in response to social
issues.
2. To design and implement public awareness and advocacy training for
members and leaders at all levels.
3. To develop collaborative relationships with organizations with whom
we share common concerns. (ACA, 2000)

PROMOTE PUBLIC POLICY AND LEGISLATION FOR COUNSELING
1. To monitor public policy and legislation on issues of concern to the
profession.
2. To provide training in public policy and legislation through lobbying
and coalition building.
3. To influence public policy and legislation through lobbying and
coalition building. (ACA, 2000)

The social work profession looks toward the National Association of Social

Workers (NASW) and the Code of Ethics of the National Association of Social Workers.

This document includes three sections--a preamble, ethical principles, and ethical

standards. From the Ethical Principles section, two values relate to the topic discussed

here, service and social justice. These principles state, "Social Workers' primary goal is

to help people in need and to address social problems" and "Social Workers challenge

social injustice" (National Association of Social Workers Code of Ethics, Ethical

Standards, 2001, para. I and 2). The following is from the ethical standards portion:








6. SOCIAL WORKERS' ETHICAL RESPONSIBILITIES TO THE
BROADER SOCIETY
6.01 Social welfare--Social Workers should promote the general welfare
of society, from local to global levels, and the development of people, their
communities, and their environments. Social Workers should advocate for living
conditions conducive to the fulfillment of basic human needs and should promote
social, economic, political, and cultural values and institutions that are compatible
with the realization of social justice.
6.02 Public participation- Social Workers should facilitate informed
participation by the public in shaping social policies and institutions.
6.03 Public emergencies- Social Workers should provide appropriate
professional services in public emergencies to the greatest extent possible.
6.04 Social and political action-
(a) Social Workers should engage in social and political action that seeks
to ensure that all people have equal access to the resources, employment, services,
and opportunities they require to meet their basic human needs and to develop
fully. Social Workers should be aware of the impact of the political arena on
practice and should advocate for changes in policy and legislation to improve
social conditions in order to meet basic human needs and promote social justice.
(b) Social Workers should act to expand choice and opportunity for all
people, with special regard for vulnerable, disadvantaged, oppressed, and
exploited people and groups.
(c) Social Workers should promote conditions that encourage respect for
cultural and social diversity within the United States and globally. Social Workers
should promote policies and practices that demonstrate respect for difference,
support the expansion of cultural knowledge and resources, advocate for
programs and institutions that demonstrate cultural competence, and promote
policies that safeguard the rights of and confirm equity and social justice for all
people.
(d) Social Workers should act to prevent and eliminate domination of,
exploitation of, and discrimination against any person, group, or class on the basis
of race, ethnicity, national origin, color, sex, sexual orientation, age, marital
status, political belief, religion, or mental or physical disability. (National
Association of Social Workers Code of Ethics, Ethical Standards, 2001, Section
6)

An argument could be made for the presence of advocacy practice as necessary,

based on the ethical principles and codes provided here. Each of these statements speaks


at least indirectly to advocacy and its practice in these disciplines.









Marriage and Family Profession

History

Many view the post-World War II era as the beginning of the family therapy

movement. It was a time when tremendous social, interpersonal, cultural, and situational

changes were taking place in American culture, which created an impetus for therapists

and researchers alike to look toward family units as opposed to simply viewing the

individual (Goldenberg & Goldenberg, 2000). Social changes such as tremendous

numbers of reuniting families after the war; the repercussions of hasty wartime

marriages; the baby boom; and changing ideas about sex, divorce, and job opportunities

all brought families to the therapy room (Goldenberg & Goldenberg, 2000). With these

changes in American life therapists also began to view families as having a "role in

creating and maintaining psychological disturbance of one or more family members" (p.

83).

After World War II ideas among mental health professionals about who could

provide therapy services to families also began to change. Clinical psychologists, social

workers, pastoral counselors, and marriage counselors began to offer care in addition to

psychiatrists, who had been the primary psychotherapists in the United States

(Goldenberg & Goldenberg, 2000). Early pioneering figures of the family therapy

movement include Virginia Satir, Nathan Akerman, Don Jackson, Milton Erickson, and

Carl Whitaker (Hoffman, 1981).

Definitions of therapy also expanded during this postwar period. No longer were

Americans only going to therapy for severe psychological concerns. Americans sought

counseling services for issues such as marital discord, divorce, problems with in-laws,








childrearing, and the like. More and more outpatient counseling was taking place as

opposed to counseling occurring in in-patient environments (Goldenberg & Goldenberg,

2000).

Ultimately, leaders in the field of family therapy agree that five significant

developments set the foundation for the emergence of the family therapy movement:

Systems theory, exploring how relationships between the parts of a system
make up an integrated whole; schizophrenic research, helping establish
the role of the dysfunctional family in the etiology of schizophrenia and
setting the stage for studying interaction patterns in other kinds of
families; marital and premarital counseling, bringing couples into
conjoint treatment to resolve interpersonal conflicts rather than treat
participants separately; the child guidance movement, focusing on
intervention with entire families; and group dynamics and group therapy,
employing small-group processes for therapeutic gain and providing a
model for therapy with whole families. (Goldenberg & Goldenberg, 2000,
p. 107)
By the 1980s there were two dozen professional family therapy journals and more

than 300 family therapy institutes in the United States alone. Also, several professional

organizations were in existence. Some major groups include the American Association

for Marriage and Family Therapy (which had 16,000 members by 1989); the American

Family Therapy Association (now the American Family Therapy Academy); the

International Association of Marriage and Family Counselors, which is a division of the

American Counseling Association; the Division of Family Psychology of the American

Psychological Association; and the International Family Therapy Association

(Goldenberg & Goldenberg, 2000, p. 103). By the mid-1980s the family therapy

movement had become an international presence with active programs spanning the

globe. Attendance of thousands of family therapists at annual conferences all over the

world clearly indicates the presence and impact of the family therapy movement.








Marriage and Family Therapist as Advocate

The marriage and family literature does not contain many explicit references to

advocacy. This does not mean, however, that advocacy is not taking place. One could

argue that advocacy was a motivating force in the adoption of the systems orientation.

For example, Bowen's family systems theory "represents the intellectual scaffolding

upon which much of mainstream family therapy has been erected" (Goldenberg &

Goldenberg, 2000, p. 166).

Family systems theory is "not fundamentally about families, but about life. . and

attempts to account for humanity's relationship to other natural systems" (Goldenberg &

Goldenberg, 2000, p. 168). Wylie (1990) stated, "Bowen considered family therapy a by-

product of the vast theory of human behavior that he believed it was his real mission to

develop." This theory is based on eight "interlocking theoretical concepts"(p. 26). One of

these eight concepts, societal regression, directly addresses the dynamic tension between

society and the individual. The inclusion of this societal or macro view in marriage and

family therapy is significant for the investigation of advocacy within this profession. In

its most basic form, advocacy is the practice of taking a macro view. In early theories of

family therapy, this macro view--and thus advocacy--is considered a fundamental part of

clinical practice.


Foci of Advocacy in Marriage and Family Therapy

If one views the marriage and family profession through the lens of Bowen's

theory, it is easy to view the focus of advocacy work for the therapist as expanding the

view of a "problem" to include a whole system as opposed to just viewing the individual

parts of the system. Often, it is this view of the whole that the advocate must adopt in








order to advocate successfully. For the marriage and family therapist advocacy is often

related to enhancing the functioning of a larger system, that is, the family within society.

A pioneer in the marriage and family profession, Salvador Minuchin understood

the impact that socioeconomic conditions have on families. In his landmark book

Families in the Slums, Minuchin suggested that only focusing on the internal experiences

of the family while ignoring the poverty and societal forces impacting that family system

would be insufficient at best (Friedman, 1993, p. 278). Minuchin (1991) believed that

"families of poverty have been stripped of much of the power to write their own stories.

Their narratives of hopelessness, helplessness, and dependency have been cowritten, if

not dictated by social institutions" (p. 49). He suggested that the real work needs to be

done at the social policy level (Friedman, p. 296).

E. H. Auerswald, also a leader in the field of marriage and family therapy,

brought the "ecological systems" approach to the profession. The ecological systems

approach is "directed at the total field of a problem, including other professionals,

extended family, community figures, institutions like welfare, and all overlapping

influences and forces" (Hoffman, 1981, p. 257). This is not to suggest, however, that

Auerswald believeed that simply creating a team of professionals is enough; he believed

that therapists must take a "holistic or systems view" of the problem (Hoffman, p. 257).

The feminist movement within marriage and family therapy is another example of

those who work to bring the individual experience into a larger societal frame. Goldner

(1991) wrote that the feminist "preoccupation with and critique of power, secrecy,

hierarchy, control, and expertise produced a commitment towards creating alternative,

participatory, democratic forms [of therapy]" (pp. 120-121). Feminists have also








criticized the politics of marriage, family structure, and therapy itself "as unfair to

women, and many feminist family therapists have suggested that therapists are socially

responsible to address these imbalances of privilege and power" (Mills & Sprenkle, 1995,

p. 373). The feminist movement required that all therapists acknowledge family

violence and insisted that direct action be taken to stop the violence (Mills & Sprenkle,

1995).

White and Epston (1990) defined the "problem-saturated description" of family

life with therapy clients and discussed the importance of employing "externalization" in

response to this view. They encouraged therapists to view the client as part of the larger

reality and to give a name and face to problems external to themselves. They advocated a

method where dialogue is used so that people can unite against the problem, which then

opens up possibilities for people to take action in their lives (1990, p. 39). Many clients

come to therapy who have been inundated with negative and often disenfranchising

stories on an individual, familial, cultural, and societal level. White and Epston's work

brings the very personal into a larger context.


Mode of Advocacy in Marriage and Family Therapy

Marriage and family therapists are most often found in clinical positions with

direct clinical service as their main role. Within that role of therapist, a member of the

marriage and family profession is trained to view the client within a fluid, living system

and forced to advocate on behalf of the client within that system.

With the current climate of managed care, more and more professionals are being

forced to engage in political advocacy positions, lobbying and working on behalf of client

groups and marriage and family professionals.









Training and Evaluation of Marriage and Family Advocates

Currently there are 74 accredited training programs for marriage and family

therapists. No published research was found on "advocacy" training or evaluation within

these programs.


Mental Health Counseling Profession

History

The historical roots of mental health counseling (although not termed mental

health counseling at this stage) have been traced back to 1793 when Phillippe Pinel,

director of the largest mental hospital in Paris, defined mental health care to include the

principles of "liberty, equality, and fraternity" (Smith & Robinson, 1995, p. 158). Pinel

was the first to oppose corporal punishment and demanded a more humane method of

treating the "inmates," thereby eliminating the chaining of these persons (Smith &

Robinson, 1995).

Counseling as a profession began during the new industrial world. This was a

time of great turmoil in this nation's history and many dedicated teachers saw the need to

respond to its impact on the youth during that time

The counseling profession was organized largely by men and women who
were clearly discontented with the world.... The pioneers of the profession
were primarily "social reformers" [who were] actively involved with the
social issues and social reform movements of the day. (Blocher, 1987, p. 4)

These social reformers became the leaders in what became the guidance

movement, which is considered the "forerunner of the modem counseling profession"

(Blocher, 1987, p. 4). "Guidance was originally practiced both in schools and in a variety

of other community settings, such as settlement houses, social welfare organizations,








youth clubs, and other agencies" (Blocher, 1987, p. 5). Frank Parsons is considered the

founding father of the guidance movement; he had training as a civil engineer, a laborer,

taught in several colleges, studied law, and ran for mayor of the city of Boston. This was

all before he began a career in guidance.

By the 1950s a transformation occurred within the guidance movement, shifting it

into what we identify today as the modem counseling profession. "One of the most

profound influences on this transformation was the work of Carl Rogers and his "client-

centered therapy.... The changes brought by the ideas introduced in the 1950s were

profound" (Blocher, 1987, p. 6). For many years the guidance movement and the

counseling movement were teeming with persons committed to creating social change.

However, the introduction of Carl Rogers' work is considered the beginning of a

profession that would eventually call themselves psychotherapists. "The original role

model of the counselor as social activist was by this time largely forgotten.... The image

that began to shape the emerging identity of the counseling profession was that of the

therapist" (Blocher, 1987, p. 6). By the 1960s, human service programs coupled with the

passage of the Community Mental Health Centers Act in 1963 resulted in many

counselors defining themselves as psychotherapists rather than social activists (Blocher,

1987).

In 1972, E. G. Williamson wrote an article titled "The Future Lies Open." This

article was published in the Personnel and Guidance Journal and was dedicated to a

historic look at the years from 1922 to 1972. Williamson asked,

One need not enter any form of the ghetto in the United States or in other
countries to perceive the many who are restricted by society.... How can
we aid such persons?... Or have we no moral responsibility to awaken
these persons to the uncultivated potential of their existence? (p. 428)








Williamson's questions echo much of the guidance movement's main philosophy since

its inception, dedicated to issues of social responsibility in this country.

Other authors in this historic journal advocate a response from the profession

regarding the federal government's cutting counseling and guidance services in the

United States. They stated that by 1975 "only 57 percent of the country's need for

counselors will be met" (Whitley & Sprandel, 1972). This article goes on to propose that

the APGA must develop a political arm on behalf of the interests of its 27,000 members

and the hundreds of thousands of school children and other clients and institutions they

serve (Whitely & Sprandel, 1972). These calls to advocate on behalf of the profession

and on behalf of those not being served are noteworthy. They provide clear examples of

the activism still present within the profession many years after some thought this

advocacy voice had fallen by the wayside as the therapy movement took precedence.


Mental Health Counselor as Advocate

Because of its focus most often on working in clinical settings with individuals

and/or families, the academic counseling literature contains very little information that

directly discusses mental health counselors as advocates. However, many authors discuss

advocacy in counseling either as a part of the whole in terms of direct service, training,

and education or as a future trend in the field (Eriksen, 1999; Kurpius & Rozecki, 1992;

Lee & Sirch, 1994; Osborne et al., 1998; Walz et al., 1991).

Those counselors who are calling for an advocacy presence in the field of mental

health counselors make a strong argument that the skills used by counselors and the skills

needed by advocates are the same--and thus mental health counselors can easily engage

in advocacy work. Some argue that the generalist skills all counselors are trained in are








the same skills needed for successful advocacy work. Those universal skills such as

listening, asking questions, and paraphrasing used in clinical settings can prove quite

useful in other macro settings (Kurpius & Rozecki, 1992).

During her presidential address ACES President, Barbara Griffin, discussed

professionalism, collaboration, and advocacy work and suggested that it was one of her

main goals as president during the years 1993 to 1994. Her list of goals included a

legislative agenda that spanned local, state, and federal work and suggestions on ways for

all counselors to take political action in their communities (Griffin, 1993).

Eriksen (1999), a counselor educator, conducted a qualitative study that was

devoted completely to the issues of advocacy perceptions, and activities. The purpose of

Eriksen's research was to "generate a broad understanding of the ways in which

counselors advocate for their profession--the essential elements of an advocacy effort, the

possible strategies for advocating, and the people or organizations counselors target when

advocating" (p. 35).

She observed that much of the progress made during the last 100 years in

promoting client rights and professional identity is because counselors aggressively

emphasized social responsibility. She insisted that advocacy must become a larger part

of the counseling professions in the future. Because there is so little research on

advocacy efforts in the counseling profession, Eriksen (1999) chose to draw from

political science and public relations research in order to promote a "broad understanding

of counselor advocacy" (p. 35). Results from the research suggest that counselors seem

reluctant to involve themselves in advocacy. Although the values, personalities, and

skills of mental health counselors differ dramatically from those of professional








advocates (for instance, lobbyists), both research participants and public policy experts

concur that the values, theories, and skills taught in counseling programs and necessary to

success in counseling also contribute to success in advocacy. The inclusion of public

policy and public relations books of chapters similar to those in counseling textbooks

confirms these conclusions (Eriksen, 1999, p. 44).

Eriksen's research showed that many of the same skills used in clinical settings

(with which counselors felt quite comfortable) were the same skills necessary for

successful advocacy work. "Successful counselor advocates approached decision-makers

the same way they approached clients--they listened, asked questions, gathered

information from a one-down, not-knowing position and clarified what they were hearing

to check their understanding" (Eriksen, 1999, p. 46). Finally, the research suggests that

despite widespread reluctance among counselors to involve themselves in advocacy,

many different counselor personalities were successful advocates. "Some counselor

advocates were energetic, forceful, enthusiastic, upbeat, intelligent, and possessed a can-

do attitude. However, just as many were shy, soft-spoken, introverted, and understated"

(Eriksen, 1999, p. 46).


Foci of Advocacy in Counseling

The mental health counseling profession prides itself on advanced clinical skill;

thus, counselors are most often found in micro practice implementing individual and

small group interventions (Kurpius & Rozecki, 1992). For example, it is common to find

a mental health counselor providing individual counseling services to teens on issues

surrounding pregnancy. However, this same mental health counselor working in the

same setting as an advocate might approach the issue of teen pregnancy quite differently.








The counselor might use the media to get the word out to teens regarding information on

single-parent families, pregnancy, AIDS, and depression. He or she might "join" with

the client for the purpose of encouraging and supporting the client's assertion of rights

and/or request for access to pertinent services. At times, however, mental health

counselors in the advocacy role may work alone on an issue. In all cases the goal is

always to work on behalf of a client or client group.

Advocacy is distinct from individual or group work in that an advocate works

with a client to educate and connect the client to appropriate community resources. This

often involves a great deal of investigation and networking on the part of the mental

health counselor so that appropriate referrals are made and the client is supported his/her

quest for a service (Schmolling et al., 1997, p. 241). Finally, these authors pointed out

that "advocating often means speaking out, confronting agencies, and risking one's job"

(Schmolling et al., p. 284).

Because mental health counselors subscribe to a strict code of ethics and are in

fact, bound to speak if they see some ethical infraction, ethical concerns are often the

motivation for advocacy work. As an example, March (1999) urged counselors to consult

the ACA code of ethics and other professional codes for guidance on how to respond to

the often incorrect media portrayals of the mentally ill. She suggested that counselors

take an advocacy approach in response to this injustice and provided steps that counselors

can take to advocate for justice regarding the ways that the mentally ill are depicted.


Modes of Advocacy in Counseling

Usually mental health counselors and other professional counselors work in micro

practice; from this position, advocacy work often surfaces. Because of the counseling








movement's presence in school systems, it is very common that school counselors find

themselves in advocacy positions on a daily basis. The sheer number of family members,

teachers, administrators, and community members with which a school counselor

interfaces with each day elicits advocacy on behalf of clients served, including mental

health advocate, family advocate, and community advocate (Kurpius & Rozecki, 1992).


Training and Evaluation of Mental Health Counselor Advocates

Exploring the single issue of advocacy training for mental health counselors

yields very little in the academic literature. Nonetheless, a clear voice is heard among

counselor educators who suggest that advocacy work, social responsibility, and macro

practice are issues that must be addressed in training programs for the continued strength

of the counseling profession (Eriksen, 1999; Lee & Sirch, 1994; Osborne et al., 1998;

Walz et al., 1991).

Osborne et al. (1998) suggested that the notion of mental health counselors as

social advocates is not new to the profession; they quoted Dworkin and Dworkin (1971)

as saying: "Counselors can sit on the sidelines and hope that everything turns out all

right, or they can become actively involved and try to have an impact on the direction of

the change process and the means by which change will occur" (Dworkin & Dworkin, as

cited in Osborne et al., 1998, p. 190). These counselor educators believe that counselors

must be trained to understand and implement macro issues to achieve success in this

current tumultuous time. Eriksen (1999) said, "You have to educate your own people

before they can do a lot of direct advocacy" (p. 44).

Oregon State University has developed a model curriculum for a counselor

education program that promotes a "social advocacy model of counselor preparation."








The program faculty have adopted the position that "counselors with a belief in the

possibility of an enlightened world society must adopt a sense of social responsibility"

(Osborne et al., 1998, p. 192). Their program's mission statement states this position

clearly: "We believe that professional counselors stand for social, economic, and political

justice and therefore must be prepared to be proactive educators, change agents, and

advocates in the face ofjustice" (Osborne et al., p. 201). That position permeates every

step of the admission process, curriculum, faculty, and students. The faculty make sure

that applicants know that social advocacy is the foundation of the curriculum.

During new-student orientation, students are reminded of the importance
placed on preparing proactive counselors who are advocates, who respond to
societal justice ... students [must] reflect [on] their role in shaping
communities that will promote a just society where all people may flourish.
(Osborne et al., p. 196)

The faculty recognizes that the affirmation of "social responsibility" within the

department sounds very similar to a social work philosophy, but they are quick to state

that their program is not attempting to imitate a social work program. Rather, there is a

commitment to a social advocacy model in counseling that is congruent with the training

philosophy and program standards of the Council for Accreditation of Counseling and

Related Educational Programs. Nonetheless, the Oregon State curriculum presents a

model unique to the counselor education profession and may parallel the political social

work curriculum at the University of Houston. Clearly, the minimal emphasis given the

advocacy role in the counseling profession contributes to its minimal presence in training

programs in the United States.

To strengthen the practice of advocacy among counselors, counseling leaders

suggest training strategies such as holding workshops, hosting conferences, and having








legislative days to assist members in assessing their resources and contacts. Counselors

who participate can dialogue about and develop consensus on important issues, articulate

clients' needs, and present solutions that are empirically based (Eriksen, 1999).


AMHCA vs. ACA

There is a cohort within the counseling profession that is tremendously concerned

about the lack of cohesiveness in the profession. Many comparisons are made with the

social work and marriage and family professions, which exhibit clearer professional

identities with direct connections to national associations and accrediting bodies. Some

feel that the absence of a clearly defined identity linked in a linear fashion to a national

organization and a national accreditation weakens the profession considerably. "In

essence, by the 1970s, mental health counselors found themselves a loosely defined

profession without a clear identity or a professional organization around which to rally or

form the nucleus of an organizational structure for support or networking capabilities"

(Smith & Robinson, 1995, p. 159). According to some, the existence of two professional

counseling organizations, AMHCA and ACA, divides loyalties and contributes to a

fragmentation of the counseling profession (Beck, 1999; Fong, 1990; Smith & Robinson,

1995). The relationships between AMHCA and ACA "were often stormy and fraught

with miscommunication and misunderstanding" (Smith & Robinson, p. 159). Beck

(1999) suggested that there are several unresolved conflicts, which in his opinion have

hindered the professional development of mental health counseling:

(1) The miniscule presence of only 17 CACREP approved Mental Health
Counseling counselor education programs after AMHCA and CACREP
adopted the standards in 1987 (2) The resistance of professional Mental
Health Counselors to become certified as Certified Clinical Mental Health
Mental Health Counselors by the Academy of Clinical Mental Health








Mental Health Counselors or licensed as Mental Health Mental Health
Counselors, using the 60 hour standard. (3) The approach-avoidance
conflict we have with professionally identifying and organizing with other
professional Mental Health Counselors which has turned into the creation
of disparate, frequently uncoordinated independent professional units,
creating confusion, dysfunction, and delay. (p. 210)

Beck (1999) further stated that "Mental Health Counseling as a distinct profession

is on life-support, in need of heroic and visionary critical care" (p. 213). He voiced great

concern about AMHCA and ACA and has a vision that one day AMHCA will have a

professional certification track for membership similar to AAMFT and NASW. Beck's

position is that the efforts of CACREP and NBCC have "stifled the growth and stature of

Mental Health Counseling" (p. 214).


Social Work Profession

History

Jane Addams and Ellen Gates Starr founded Hull House in 1889. Historically,

this action has been considered the birth of social sork. Many considered Addams a

radical because she was committed to bringing to the forefront the plight of the urban

poor. Addams and Gates provided the urban poor with housing and a continuum of

services including childcare; an art museum; and classes in history, music, language,

painting, and dancing. The mission of Hull house was to serve the whole person, and the

beginnings of the person-in-environment philosophy, on which so much of social work

theory is based, was born. This dual practice, macro and micro, was present from the

beginning: "Jane Addams and others in the settlement house movement campaigned for

changes in ordinances that involved residents at the neighborhood ward level" (Allen-

Meares, 1997, p. 4).








Hull House became a national model for community care and social reform, and

Addams became increasingly committed to the political arena, advocating at the national

level for these causes. Even at the earliest national conferences on social work during the

early 1900s, papers were presented on the role of social workers in affecting state and

national legislation (Allen-Meares, 1997). Jane Addams won the Nobel Peace Prize in

1931 for her impact on war efforts and social welfare in the United States. Addams' work

would set the stage for social workers' commitment to creating change at the community

and national level, a commitment that remains strong within the profession to this day.


Social Worker as Advocate

Jane Addams' work laid the foundation for social workers to create a profession

committed to words like justice, advocacy, community organizing, social action, and

policy practice. The NASW authored a national code of ethics that further embodies

these terms for all social workers and organizes this group around common goals and

ideology. Social workers are committed to social justice for all Americans, and one

means of achieving this goal is through advocacy.

The commitment to advocacy work is paramount. Social workers are taught not

only to advocate for their clients but also to encourage advocacy as a basic human right

under the Constitution of the United States. This commitment to advocacy is fueled by

the professions' charge to fight for social justice. "If Social workers have been

consistently concerned with anything throughout the history of the profession... it has

been the concept ofjustice" (Lynch & Mitchell, 1995). Figueira-McDonough (1993)

added that the role of social workers.., is straightforward. Their commitment is to act








as advocates.... Their concern is to support policies that promote the social rights of

poor people and oppose any policies that further restrict those rights" (p. 182).


Foci of Advocacy in Social Work

The main focus of advocacy within the social work profession is social justice.

There are a multitude of ways that social workers engage in advocacy for social justice,

more ways than can be illustrated in this dissertation. Social workers take positions on

welfare policy initiatives, child abuse, poverty, racism, sexism, homophobia, and human

rights. Some more recent foci for social justice advocacy include the legal system,

economics and fiscal responsibility, and national budget initiatives directly relating to

defense budgets (Lasch, 1965; Lynch & Mitchell, 1995; Renner, 1989; VanSoest, 1994;

Verschelden, 1993).

For example, in March 1986, NASW made a call to social workers to consider the

justice system an important focus for the social work profession. They documented many

instances in which responsible social work practice requires contact with law

enforcement and the court system. Lynch and Mitchell (1995) observed that recent trends

indicate that collaboration between social workers and the legal system has been on the

rise, resulting in positive gains for the social worker and the mission of social justice.

Oftentimes social workers interface with clients who, in addition to their social

issues, have legal issues. Social workers are held by the code of ethics to advocate on

behalf of these clients and, therefore, are being called to learn more about the legal

system in order to advocate effectively. Although the legal and social work professions

have some basic common goals--fighting for justice and rights of people--there are many

issues on which the two professions do not agree. The similarities must be used to the








benefit of the client, and the social worker must work to negotiate the differences in the

best way he/she is able. Informed legal advocacy is the goal (Lynch & Mitchell, 1995).

Fiscal responsibility is another focus of advocacy work. Issues of fiscal fairness

are important. The NASW has come forward in recent years and participated in

coalitions for the purpose of addressing responsible military spending. Van Soest (1994)

reflected on the NASW position:

The policy is based on a commitment to disarmament and economic
conversion and calls on U.S. leaders to 'reduce military budget
substantially over the next 10 years and to divert most of the savings to
respond to the mounting social needs of our nation' (NASW, 1993, p.
203).

At the heart of the concern about the appropriate balance of public
expenditures for domestic versus military programs are social justice
questions about the proportionate distribution of common goods. (Van
Soest, 1994, p. 710)

Social workers support this initiative based on a claim for justice. They support

engaging in coalitions with groups such as UNICEF and the United Nations to strengthen

lobbying efforts with the President and Congress. This type of coalition building is a key

element in successful advocacy (Van Soest, 1994).

Opposing war as a professional responsibility is also directly related to the social

work code of ethics. From the very beginning Jane Addams was an active pacifist: "She

opposed war on the pragmatic grounds that it was a wasteful and ineffective method of

solving social problems; that indeed it created more problems than it solved" (Lasch,

1965, p. 218). "In addressing our commitment to social justice, the code of ethics

instructs social workers to act to ensure that all persons have access to the resources,

services, and opportunities which they require" (NASW, 1990, p. 9). Renner (1989)

addressed social justice as it relates to international warism: "When arms take precedence








over needs basic to human development, people are not secure. The present international

priorities deplete scarce resources required for meeting basic human needs" (p. 20). "As

long as people exist whose basic human needs are unmet, social workers have a

responsibility to advocate for changes in policies and an equally serious duty to actively

work against practices and institutions that contribute to injustice" (Verschelden, 1993, p.

767).


Modes of Advocacy in Social Work

There are many ways in which social workers carry out the mission of the

profession and advocate for social justice. The most common positions for social

workers include client advocates, legislative advocates, agency advocates, social

activists, community organizers, community developers, policy analysts, and legal

advocates. Some less common methods of advocacy include media advocate, report card

advocate, and social choice advocate.

"Media advocacy is a relatively new concept that has been closely associated with

the smoking control movement in England" (Wallack, 1990, p. 158). Social workers

have attempted to embrace this new form of advocacy as it has become increasingly clear

that educating the public is a significant part of the work and that a very effective method

of public education is media. Over the course of the last 15 years there has been a push

within social work to bring social issues into public view. Therefore, the NASW has

initiated a number of major media projects. These initiatives include news releases and

television and radio public service spots relating to issues such as AIDS, child welfare,

homelessness and mental health (Brawley, 1997).








To advocate pacifism, "social workers can become active in organizations that

educate the public and legislators about the negative impact of militarism on the

availability of resources to meet human needs" (Verschelden, 1993, p. 769). Social

workers are encouraged to work through the channels of the NASW in order to influence

change. One position of the NASW is that voter registration and turnout is key to

realizing social change. Responsible investment and spending are also methods to

influencing the social work agenda. For example, social workers can advocate for "social

choice" accounts at their places of employment where social workers can then chose to

invest their funds in companies that do not support military spending. Also social

workers can become educated on company's agendas and decide with whom they want to

do business (Verschelden, 1993).

Another method of advocacy is to engage in legislative advocacy, whose "purpose

is to promote and influence legislation that will benefit deprived populations that social

work represents" (Figueira-McDonough, 1993, p. 184). Major social reform through

litigation has become another avenue for social work. "Legislative advocacy enhances

the chances of promoting.., policies. Reform through litigation can best address

inequities (Figueira-McDonough, 1993, p. 188).

Social policy analysis is another method of advocacy. Taking policies apart to

expose injustices is a new but also very effective method of advocating a position.

Questions such as the following arise: Who is covered by the policy? What benefits are

provided? What is the form of delivery? Who is the financial source? These are important

questions to be asked by a social worker (Verschelden, 1993).








Report cards are a fairly simple but powerful method of advocating a position:

"Across the country, child advocacy groups and community development organizations

have published report cards on how well cities provide their constituencies with quality

education, health care, housing, employment, child care, and social justice" (Freeman,

1994, p. 204). This written explanation of services with an evaluative component is a

powerful method of carrying out the social work agenda.


Training and Evaluation of Social Work Advocates

There is no clear agreement on how or to what extent social workers ought to be

trained as advocates. The Council on Social Work Education (CSWE) is the accrediting

body for all social work training programs in the United States and, therefore, does take

an official position on training initiatives. The theme of social justice is prominent

throughout the revised NASW code of ethics and the current "Curriculum Policy

Statement" of the CSWE. In training and practice, Social workers are expected to

influence social policy, engage in social action, and advocate for disadvantaged groups

(Swenson, 1998). The CSWE states that the major premise underlying social work

education as reflected in policy statements B3.1 and M3.1. The policy statements suggest

that social work education should prepare students for a professional practice that is

committed to the pursuit of social justice and service to the disenfranchised of our society

(CSWE, 1992a, 1992b). The extent to which this mandate by the CSWE involves

actively engaging in macro practice continues to be debated within the profession.

Brawley (1997) used the code of ethics written by the NASW in support of his position

that both micro and macro practice are the responsibility of the social worker and,

therefore, ought to be addressed in training programs. Brawley stated,








In carrying out their generalist functions, front line Social Workers
routinely advocate for specific clients- that is, 'case advocacy.' But they
are likewise expected to influence the development of social policies,
programs, or services addressed to the needs of particular groups of actual
or potential clients- that is 'class advocacy.' The responsibility to engage
in class advocacy underlies the section of the professional code of ethics
that addresses the 'Social Worker's Ethical Responsibility to Society'
(National Association of Social Workers, 1994). The responsibility of
Social Work educators to provide instruction in this area has long been
implicit in the Curriculum Policy Statements of the CSWE, including the
latest version requiring that baccalaureate programs show how students
learn to promote social and economic justice (CSWE, 1994, p. 102).
Graduate and undergraduate programs typically address this instructional
responsibility in macro practice courses like policy practice or community
Social Work. (Brawley, 1997, p. 448)

There is some disagreement as to the priority advocacy work ought to take in

training. Should students be required to engage in practica strictly devoted to macro

issues or is engaging in a clinical practica with the opportunity for macro practice

sufficient? The CSWE requires no single social work training program to include a

macro practica. Wolk and Pray (1996) pointed out that, based on anecdotal evidence,

social work students who participate in some macro practice during their training are

more likely to continue that macro practice after graduation. These authors further stated

that, in fact, the numbers of students who engage in strictly macro practica are quite slim;

however, even those students engaged in practica at clinical sites often get opportunities

to engage in political or macro practice activities. Verschelden (1993) suggested that

these macro activities should take precedence. She believes that activities such as

lobbying should not be considered to be only for the expert. She takes the position that

these activities should be part of the training of all social workers.

Other criticism regarding training suggests that, with the heavy emphasis on

clinical practice within social work programs, that even if social work students are

interested in advocacy work after graduation, they may not be prepared for it (Figueira-








McDonough, 1993). Figueira-McDonough's position is that the "direct interpersonal

practice is greatly emphasized in the schools of social work to the detriment of policy

practice" (p. 184).

Within social work education there are "tracks" or areas of specialization in which

students are able to engage in concentrated work. For example, some students may

choose a clinical track and others a political track within a social work program.

Additional concentrated areas include child and family or gerontology. Within these

varied areas of expertise, however, social work students are expected to engage in

advocacy work. For example, a social worker with concentrated clinical training in child

and family would not only engage in clinical work but would also be responsible for

advocacy work on behalf of the client. This is not, however, to suggest that a clinical

social worker is expected to have the skills of the political social worker. Some

understanding of and commitment to advocacy work for the social worker is believed by

some to be mandatory (Brawley, 1997; Epstein, 1995; Figueira-McDonough, 1993).

William Epstein (1995) was very vocal about what he believes are the failures of

academic institutions to address social needs of people. He claims that a general sense of

responsibility is not present and that its absence is represented in the ways we teach

social work students. He suggests that advocacy for those whom social workers are

supposed to serve have actually declined over the last 25 years.

Brawley (1997) spoke to a common sentiment within the profession as to the

responsibility of not only social workers in practice--but also social work educators--to

address the issues relevant to social justice and carrying out that mission in the current

climate. She advocates that more work needs to be done and better work needs to be








done in the area of educating leaders and policy makers about the extent of major

injustices in this country. She charges that all those involved in the business of social

work must do a better job.

Chapman and Richman (1998) provided one solution by suggesting an

advocacy/empowerment model for social work students to use in field placements. The

model brings to the forefront current teaching practices related to advocacy and

empowerment models within social work field education. The model includes four main

components: outreach, partnership, direction planning, and change. Chapman and

Richman provided a detailed plan for implementing this model in training social work

students in the field. They admit that this kind of training may be challenging and require

time and flexibility but argue that as a profession we must come up with creative

solutions for training in order to have an impact and create major social change.

In response to these training issues, Robert Fisher (1995) provided a more hopeful

perspective on training social workers for macro practice. He suggested that social work

has recently turned back to a time when its focus was social change and political

involvement to promote social justice. Fisher noted the curriculum developed at the

University of Houston with its concentration in political social work. His position is that

the training program at the University of Houston is one example of a curriculum that is

providing the necessary tools to carry out the social justice mission.

Swenson (1998) suggested that the old methods of social work practice and

carrying the social justice agenda are becoming more and more archaic in the new world

of managed care. Swenson stated, "Managed-care and other cost-cutting measures

appear to be increasing social injustice, rather than increasing social justice" (p. 536).








Therefore, the creative and committed social-justice-oriented clinician must explore new

ways of doing his/her work. Swenson used the term "bilingual." In other words, social

workers must speak in both social work/social justice language and managed care

language. She suggested that clinicians must know when to use which language in order

to succeed in practice today (Swenson, 1998).

Kameoka and Lister (1991) asked the question, "How are MSW programs

attempting to assess the educational outcomes of students?" They found that programs

use a variety of assessment methods including evaluating specific courses, using self-

report alumni surveys, and sending questionnaires to supervisors of recent alumni. The

authors did admit that much more needs to be done to truly assess the impact of social

work education.

Even during the NASW's mass media campaign on homelessness during the late

1980s, no real data were collected regarding the impact it was having. This is rather

unfortunate due to the sentiment within the profession that public awareness is an

important aspect of the social worker's job and that using media is a viable way of

influencing the public (Brawley, 1997).


Macro vs. Micro Practice

Clearly social work is rooted in macro practice; the work of the advocate is

paramount to the social work identity. Even the code of ethics prescribes that social

workers "should advocate for living conditions conducive to the fulfillment of basic

human needs and should promote social, economic, political, and cultural values and

institutions that are compatible with the realization of social justice" (NASW, 1990, p.

20).








However, with the rising popularity of individual therapies and the extensive

training of clinical practice within social work training programs, a divide exists. There

are those who feel that social work is becoming a "therapy-oriented" field and those who

feel macro practice ought to be the central practice of the profession. A third group

includes those who have felt directly the recent constraints of managed care and are being

driven "back to their roots" in response to the current climate. Thus, social workers are

being challenged to engage in advocacy work in response to the injustices they view as

being perpetuated by the financial power-based of managed care companies (Swenson,

1998).

Figueira-McDonough (1993) illustrated well this divide among social workers.

She stated, "If the value of social justice is taken to mean a commitment to ensure equal

access for all to basic social goods, then the typical roles of social workers as case

managers and therapists fall short of that goal" (p. 181). She went on to say that it is not

her intention to devalue these roles, but instead wants to point out that the objective of

this practice in and of itself is to "ensure a more equitable distribution of opportunity.

Progress toward social justice requires direct involvement in the formation and

modification of social policy" (Figueira-McDonough, 1993, p. 181).

Wolk and Pray (1996) further suggested, "Although research suggests that social

workers were somewhat involved in political activity, the 1980s were alarming to many

who felt that the profession was becoming a training ground for psychotherapists" (p.

93). An argument is being made that social work is abandoning its mission to serve the

poor in favor of the popular psychotherapy conducted for the most part, with the middle

class. Wolk and Pray (1996) cited studies that "indicate that more incoming social work








students are interested in providing direct practice counseling and in many cases, private

practice counseling to socially prestigious clients than in any other practice specialty" (p.

93). To address these issues and to offset their possible circumstances, the Council on

Social Work Education (CSWE) addressed directly in its curriculum policy statement the

importance of training social workers to use skills in the political process (CSWE, 1994).

Epstein (1995) took a fairly common but unfavorable position toward the

psychotherapy movement within social work. He stated,

Social work is abandoning its noble mission on behalf of deprived
Americans. The field's enchantment with psychotherapy as its premier
treatment technique has immobilized its impulse to serve true social need.
Social work has turned up it nose at material solutions for people's
problems: food, clothing, shelter, education, substitutes for family, and so
forth. The field is well on the way to becoming an empty ceremony of
American responses to it social problems. In turn, this abandonment of the
deprived also threatens the integrity of social work's intellectual life,
which has become distorted by the demand for proof that its
psychotherapeutic role is effective. (p. 282)

Clearly, there is some disagreement within the profession as to the main role of

social workers. However, there are still many social workers who have committed their

careers to the mission of advocacy and social justice. The argument within the profession

is not that advocacy does not go on, but that it does not go on enough.


The Impact of Managed Care

Mental health care has increased at a rate far surpassing the growth of health care

in general. In 1978, the average cost of yearly benefits per employee for mental health

and substance abuse coverage was about $163 per employee. By 1992, that average cost

was over $400 per employee (Smith, 1999). With this type of data, it is easy to see the

current dilemma facing Americans. "Third party payers and practitioners have been thrust

into a heated debate at best and have become polarized at worst" (Smith, 1999, p. 271).








By 1993, about 20% of the country was covered by managed care mental health plans, or

about 60 million Americans (Mizrahi, 1993).

With the many differences between marriage and family therapy, mental health

counseling and social work regarding history, language, areas of specialization, and

professional development conflicts, the professions share a common interest when it

comes to facing managed care. As mental health service providers, we are all faced with

figuring out how to respond to the current constraints placed on us by managed care. The

arguments made by all three professions bear a likeness to taking two bites from the same

apple. They are not exactly the same in size and texture but taste exactly the same.

Managed care's broad stroke of power over mental health service delivery has

forced mental health service providers to stop, listen, and figure out a plan of action.

Some have chosen to get out of the game while others have decided to play. Many

service providers have chosen to dust off their advocacy hats in response to what they

feel are injustices at the hand of managed care companies.

"Public awareness and support have always been important in Mental Health

Counseling. They are now even more important as managed care increases its range of

influence. Self-advocacy is crucial to our future" (Glauser, 1996, p. 314). Glauser

suggested that one method of responding to this current crisis is to actively seek legal

advice, advocate on behalf of the mental health professions, and collaborate with other

professionals. Kochunas (1997) pointed out that managed care is dramatically impacting

how counseling is currently practiced and how it will be practiced in the future. "The idea

of counseling as being an occasion to engage in a wide meandering self-exploration is








diminished.., replaced by an active, targeted, time-limited approach with... concrete

goals and measurable outcomes" (p. 14).

The influence of managed care coupled with mental health counseling being the

youngest of the mental health professions is problematic. "As a young profession, it has

not fully clarified its identity or attained a wide cultural legitimacy--evidenced in the

writings of its own practitioners" (Kochunas, 1997, p. 14). Kochunas (1997) advocated a

rational perspective guided by empirical research as a method for mental health

counselors to respond to these turbulent times. She hopes for mental health counselors to

engage in practice based on proven methods and techniques for providing service within

this very new system.

Managed care is perhaps the most significant development in health care for many

years. This social worker suggests that education of students in social work programs is

paramount in responding responsibly to this dilemma. The solution she provides is to

focus on interdisciplinary training as a key to preparations. Social workers must take a

team approach and work with other professionals--medical professionals, legal

professionals, and other mental health care professionals. This combined knowledge is

imperative for success in this current environment (Allen-Meares, 1998). This

interdisciplinary teamwork perspective is in part the agenda of many managed care

companies; however, embracing this new method can serve practitioners in responding to

the managed care companies themselves. Providers must be willing and able to fit into

this new model of service delivery in order to flourish and provide service to consumers.

(Allen-Meares, 1998).








In looking toward the future, the mental health system will emphasize (a) models

that improve efficiency and cost-effectiveness, (b) services to underserved populations

that lack the knowledge or the economic resources to access the delivery system, (c) risk

factors such as smoking, inactivity, and excess weight as means of improving lifelong

health, and (d) improved treatments for a range of chronic illnesses (Alcom &

McPhearson, 1997).


Collaboration Among the Professions

Although the differences between these three professions ought not to be

overlooked, clearly practitioners are connected by the current struggles with managed

care, fewer resources, more consumers, rampant poverty, drug abuse, and an ever-

growing population with an increasing life-expectancy rate (Allen-Meares, 1998; Berger

& Kelly, 1993; Faul & Hudson, 1997; Kochunas, 1997). That said, collaboration among

the professions to determine appropriate responses to these issues from a unified position

of social responsibility and social justice may be the most effective method of action.

Although it is a minority voice, there are indeed some professionals calling for this

collaborative approach. The collaboration is not for the purpose of diluting one's

professional identity or even creating a new collaborative identity. The call is to maintain

one's heritage and professional identity and yet to work together to form a louder voice,

stronger opposition, and organized effort in responding to the current climate of mental

health care.

Scalise (1994) provided a strong argument for collaboration among the

professions. He stated,








Represented within the helping professions (such as Counseling, Marriage
and Family Therapy, Psychology, Social Work) is vast diversity in
theoretical approach, training models, philosophy, and educational
demands. This should not be looked on as a problem, but as our greatest
strength. Unfortunately, during the past few decades, there seems to have
been more of a concern about professional 'turf issues than about
professional cooperation and respect. We need to appreciate our
similarities and be less concerned about our differences. I would suggest
that perhaps a well prepared genogram of the family of helping
professions would be helpful. (Our roots are not all that different) It has
long been my contention that too many helping professionals have
forgotten their basic historical roots and commonalties that cut across
various professional designations. Rather there has been a preoccupation
with determining how we are different and an insatiable search for ways to
prove that my group is better than your group. Another serious problem is
what I would describe as 'professional opportunism.' This is a
combination of abandonment of one's professional identity, selective
memory, and the accompanying necessity to rewrite history to conform to
and support the memories. This has been most apparent in the counseling
profession. (p. 511)

Collaboration among professionals may take on many different and worthwhile

forms. Some practitioners may choose to participate in planning and discussion groups

with other professionals while others may choose to branch out their training and

experience in an effort to cross over into other specialty areas. "We also believe that all

mental health counselors will find it necessary to have at least entry-level education and

experience along the full continuum of services" (Smith & Robinson, 1995, p. 162). "A

call to action is needed as a collaborative effort by a diverse many" (Glauser, 1996, p.

316).


Conclusion

The constraints placed upon mental health professionals by managed care,

coupled with the increase in population and decrease in resources, demands that service

providers revisit their methods of delivery. In their chapter titled, "Nine Trends Which

Will Affect the Future of the United States," Walz et al. (1991) named the Rebirth of








Social Activism as one of the nine trends that will impact the country. Walz et al.

suggested that the concentration on business and economic growth has turned Americans'

attention toward social concerns such as homelessness, lack of affordable housing, social

tension, and poverty. If the people do begin to reflect on social activism, providers of

mental health services have the opportunity to position themselves in the forefront of

such a movement. Walz et al. further called mental health professionals to participate in

activism. They statee, "The future will bring an increasing need for mental health

counselors to become assertive activists who use their knowledge and skills in the pursuit

of important social needs" (Walz et al., 1991, p. 76). They then challenged practitioners

to look beyond that which divides them and to explore fully what each of us can bring to

this new social activism movement. "Some of our finest moments have occurred when

we openly and forthrightly explored our differences. It is when we refuse to examine

past beliefs and new ideas that we make our biggest mistakes and miss great

opportunities" (Walz et al., 1991, p. 73). What is advocacy? What is the emphasis on

advocacy in practices? Do clinicians see themselves as activists? Advocates? Are

clinicians concerned enough about the current state of affairs to look towards one another

in a collaborative fashion? Do training programs in these professions view advocacy as

important or even imperative for those being trained? The following chapter provides an

overview of the methodology for this study, which attempts to answer questions such as

these.














CHAPTER 3
METHODOLOGY

The current academic literature in the professions of marriage and family therapy,

mental health counseling, and social work support the importance of advocacy work.

However, many questions remain about the level of advocacy each of these professions

will support in clinical training programs and in practice. The primary goal for this study

was to provide empirical data surrounding the issue of advocacy in order to bring to the

forefront the similarities and differences discovered in each of these three professions on

this specific issue. A secondary goal of this study was to use the data regarding these

similarities and differences in order to aid practitioners in better and more efficient

service delivery. The research methodology is described in this chapter. Included is a

discussion of the research design, sample, instruments, research procedures, data

analyses, and methodological limitations.


Research Design

This study used the Delphi technique to survey experts in the fields of marriage

and family therapy, mental health counseling, and social work. The Rand Corporation

first developed the Delphi technique during the early 1950s (Dalkey & Helmer, 1963).

This technique has been used in a variety of fields and is quite useful in that it can

generate a large amount of data from experts without having to bring them physically

together. It is also cost efficient and takes very little time (Stone-Fish & Busby, 1996).

According to Linstone and Turoff (1975) the Delphi technique provides an assessment of








a group judgment or view that may not otherwise come together to share information and

the opportunity to react to and assess differing viewpoints. Within the professions

discussed here, the Delphi technique has been used to explore a variety of issues. Its uses

include specifying the important components of an adolescent AIDS/drug prevention

program (Adams & Perry, 1992), the components for a substance abuse counselor

education curriculum (Klutschkowski & Troth, 1995), and the strengths and weaknesses

of U.S. family life through the eyes of family therapists (Fish & Osborn, 1992).

The Delphi technique proved quite useful in this particular study in that it is a

technique known for bringing experts together for the purpose of generating conversation

and consensus. It also allows room for individuals to deal with very complex problems

(Stone-Fish & Busby, 1996). Another component of the Delphi technique pertinent to

this study is its usefulness in "moving a field forward.... The philosophical

underpinnings. then are concerned more with the application of useful knowledge than

with the attempt to define the truth" (Stone-Fish & Busby, 1996, p. 470).

The Delphi technique uses questionnaires in phases. For this study two rounds of

questionnaires were used. Round 1 (Delphi questionnaire 1 or DQ I) consisted of open-

ended questions written by the researcher and the committee. The second round of

questionnaires (Delphi questionnaire 2 or DQ2) used the results from DQ I to formulate a

longer, more detailed, and Likert style questionnaire.


Sample

The Delphi technique uses panelists in conducting the research. The panelists are

chosen for their knowledge and expertise and, therefore, are not chosen randomly. It is

also possible using this technique to compare and contrast different groups of experts as








well as experts with nonexperts (Stone-Fish & Busby, 1996). This study used panelists

from three professions. Within these professions two kinds of experts were used:

1. Within marriage and family therapy (a) faculty from accredited programs
and (b) members of state chapters were selected.

2. Within mental health counseling (a) faculty from accredited programs and
(b) members of state chapters were selected.
3. Within clinical social work (a) faculty from accredited programs and (b)
members of state chapters were selected.

Marriage and family therapists have a national accrediting body, the Commission

of Accreditation for Marriage and Family Therapy Education (COAMFTE) that accredits

master's degree, doctoral degree, and postgraduate degree clinical training programs

throughout the United States. Faculty from programs accredited by COAMFTE were

used as panelists to represent faculty experts within the marriage and family profession.

Although there are a total of 81 programs accredited in the United States and Canada, this

study contacted only the 74 programs in the United States.

Mental health counselors in the United States are trained in either community

counseling or mental health counseling training programs accredited by the Council for

Accreditation of Counseling and Related Educational Programs (CACREP). The

CACREP, which accredits master's degree and doctoral degree training programs, is a

corporate affiliate of the American Counseling Association (ACA) and its mission

coincides with that of ACA. Faculty from 113 community counseling and 21 mental

health counseling programs accredited by CACREP were used as panelists to represent

faculty experts within the mental health counseling profession for the purposes of this

study.








Clinical social workers have a national accrediting body, the Council on Clinical

Social Work Education (CSWE) that accredits bachelor's, master's, and doctoral degree

clinical training programs throughout the United States. Faculty from programs

accredited by the CSWE were used as panelists to represent faculty experts within the

social work profession. Only programs that have master's and doctoral degrees were

included in the study. There are a total of 158 accredited master's degree programs in the

United States.

For this study, there were only 14 states in the country that met the criteria

established for inclusion--the state must have state chapters of all three professions and

the state must have state licensure in all three professions. AAMFT, AMHCA, and

CSWF all have state chapters in Alabama, Connecticut, Georgia, Illinois, Maryland,

Massachusetts, Missouri, New Hampshire, New Jersey, North Carolina, Oregon, South

Carolina, Texas, and Virginia. State chapter members from these states were selected as

panelists for this study. Representing marriage and family therapy, AAMFT state chapter

members served as panelists. Representing the interests of mental health counselors,

AMHCA state chapter members served as panelists. Representing clinical social work,

CSWF state chapter members from these 14 states were selected as panelists.


Instruments

As stated, two rounds of questionnaires were used in this study. Panelists who

were asked to participate in Phase 1 of the study were sent by electronic mail an open-

ended questionnaire consisting of seven questions. These questions were designed to

generate detailed responses from the experts.









The following guiding questions were used to outline the first round of this study.

Generally speaking, marriage and family therapists were asked to answer questions 1, 4,

and 7. Mental health counselors were asked to answer questions 2, 5, and 7. Clinical

social workers were asked to answer questions 3, 6, and 7.

The following guiding questions framed this study:

1. What does the term "advocacy" mean in marriage and family therapy?

2. What does the term "advocacy" mean in mental health counseling?

3. What does the term "advocacy" mean in clinical social work?

4a. How do marriage and family therapists view their roles as advocates?

4b. How do marriage and family therapists view the need for advocacy work in
this country?

5a. How do mental health counselors view their roles as advocates?

5b. How do mental health counselors view the need for advocacy work in this
country?

6a. How do clinical social workers view their roles as advocates?

6b. How do clinical social workers view the need for advocacy work in this
country?

7a. What are the formal training methods used in marriage and family therapy,
mental health counseling, and clinical social work to train advocates?

7b. How are these training programs evaluated and are these evaluation
procedures sufficient?

From the results of Round 1, the second questionnaire was written. The

researcher consulted with committee members during the drafting stages for this

questionnaire. The second questionnaire consisted of 20 forced choice questions. The

second round questionnaire was also submitted to the all of the panelists including those

who participated in Round 1 of the study via electronic mail and snail mail.








Research Procedures

The researcher requested the permission of the University of Florida Institutional

Review Board to proceed with this study on two occasions--prior to beginning Phase 1 of

the study and prior to beginning Phase 2 of the study. Panelists were asked to participate

in this study via a letter of consent emailed to them along with the Round 1 questionnaire.

Once the results of the Round 1 questionnaire were collected, the researcher worked with

committee members to draft the Round 2 questionnaire. Round 2 began with an

electronic mail and conventional mail dissemination to the panelists. Both the consent

form and the survey were sent simultaneously to each possible participant. Once the

study conclusions were established, appropriate follow-up information was provided to

all panelists.


Data Analyses

A portion of the data in each phase includes descriptive statistics on the panelists

from each of the six groups. Profession, years in practice, licensure status, and current

position were included. Analysis of the data from Study 1 consisted of identifying

demographic characteristics and themes that arose from the qualitative coding of the text

responses. Analysis of the data from Study 2 also consisted of identifying demographic

characteristics. Once the data were entered and cleaned to ensure the most accurately

recorded data, a factor analysis was run. The construct from the factor analysis was then

used to run both a 2 X 3 ANOVA and two one-way ANOVAS. The data collected that

did not fit into the factor analysis construct and all exploratory analyses were conducted

using the Chi-square.








Limitations

Anticipated limitations of this study are those associated with any Delphi

technique. Regression to the mean is an issue if too many rounds are conducted.

Diversity is often minimized in an effort to achieve consensus. Time is a factor for

panelists. Often the questionnaires could take quite a bit of time to fill out, making it

difficult for experts who are also often busy people to take the time necessary to

participate completely in the study. Experts often become very specialized in their fields

when they have been in practice for a long time. This can sometimes create a very

narrow view of the issue being addressed. Typical measures of reliability and validity

can often not be used with this methodology. Great concern and, at times, creativity must

be taken to achieve the most valid and reliable data with this method (Stone-Fish &

Busby, 1996).


Conclusion

The ultimate purpose of this study was to provide empirical data regarding

advocacy practice in the United States among marriage and family therapists, mental

health counselors, and clinical social workers. The hope is that this study will provide

information that will contribute to a dialogue about advocacy training and practice. The

Delphi method was chosen for its ease in accessing experts while at the same time

providing a frame through which to view these very complex and often misunderstood

issues.













CHAPTER 4
RESULTS

This study investigated the emphasis on advocacy training and practice among

marriage and family therapists, mental health counselors, and clinical social workers.

The Delphi method was used, which requires that panelists be chosen for their knowledge

and expertise; therefore, a stratified random sample was taken from the professions of

marriage and family therapy, mental health counseling, clinical social work both (a)

faculty from accredited programs and (b) members of 14 state chapters. All panelists

were located via internet resources. The data analysis for study occurred in two steps

corresponding to the two rounds of data collection: Study 1 involving a semi-structured

questionnaire with 7 open-ended questions and Study 2 involving 20 close-ended

questions.


Study 1

Participants

A total of 65 members from the three professions included in this study

participated in Round 1, resulting in a 15% return rate. The number of participants and

return rate per group is presented in Table 1. It is important to note that due to the

method of data collection the accuracy of these return rates was compromised. The

surveys were sent out via electronic mail. There is no way to ensure that the email is

actually received by the intended recipient. Further, email accounts expire or are








published incorrectly, which resulted in a percentage of surveys "bouncing" and,

therefore, being returned to the researcher.


Table 1

Participants and Return Rates

Frequency Number Response
Mailed Rate
MFT-Faculty 10 69 14%
MFT-Clinical 10 44 23%
PC/MHC-Faculty 13 111 9%
PC/MHC-Clinical 5 31 16%
Social Worker-Faculty 24 149 16%
Social Worker-Clinical 3 28 11%
Total 65 432 15%


Analysis

The questions asked in Study 1 were influenced by guiding questions 1, 2, 3, and

7a/b. One consent form and a total of six questionnaires were used (see Appendices A-

G). The data analysis for Study 1 consisted of identifying the respondents' demographic

characteristics and themes arising from qualitative coding of the text responses. Each

survey consisted of seven questions. The questionnaires were collected over a 2-week

period via email. The researcher read none of the surveys until the analysis began.

In order to conduct an organized and methodical analysis, the researcher reviewed

each set (six sets all together) of surveys individually and drew out themes for each of the

seven questions. The themes for each question in each of the six groups were then

recorded.

Once the analysis of each of the six separate groups was complete, the researcher

began looking across the groups for more general themes. These general themes served








to guide the researcher and the committee in drafting Delphi Questionnaire #2 (DQ2).

For a review of the consent form and questionnaire #2 see Appendices H and 1.


Results/Themes

The only demographic question asked was regarding number of years in practice.

All of the respondents reported that they had been practicing for over 10 years, and many

had been in practice for over 20 years.

Guiding questions 1-3: What does the term advocacy mean in [said profession]?

Faculty and practitioner respondents answered this question in one of three ways.

Their definition of advocacy fit into a professional advocacy, case advocacy, or class

advocacy definition of advocacy. Respondent #62, who stated, "To me it means

promoting the field of MFT," illustrated examples of the professional advocacy

definition. Respondent #38 stated, "Advocating for the profession.., promoting and

marketing the profession to the consumer community and to other provider networks as

well as insurance companies."

Examples of a case advocacy definition was illustrated by Respondent #2 who

answered, "I would define advocacy as the facilitation of access for a client within a

system. This could mean acting directly for the client or helping the client act to get

something they need or are entitled to." Respondent # 50 answered, "Advocacy means

advocating on behalf of clients in systems, helping clients know their rights and

responsibilities, brokering services on behalf of clients, coordinating care among

professionals. Making referrals as needed for services, therapy, medication management,

etc."








An example of a class advocacy definition was illustrated by Respondent #25 who

answered, "The term implies political activism." Respondent #63 answered, "It is public

activity, in the political arena, in support or opposition to policy of governments or other

large institutions. That may include letters to political figures, newspapers, public

speaking, support of candidates, being a candidate... in political elections."

Another theme that came out of the study came from the question asked to

practitioners. They were asked the following question. Where did you learn about

advocacy? Only 1 out of the 18 practitioners who responded to the study said they

learned about advocacy work in school. Respondent #39's response of "on the job

experience" illustrates the overwhelming response.

Guiding Question 7a: What are the formal training methods used in Marriage
and Family Therapy, Mental Health Counseling, and Clinical Social Work to
train advocates?

The following question was asked all faculty: Do you think advocacy training is an

integral part of your department? If so, please speak to the kinds of training opportunities

students are afforded? How are these training opportunities evaluated? If training is not

available, do you see this as a future priority?"

The response to advocacy being an integral part of your department was split about

50/50, those in support and those opposed. In terms of training opportunities provided to

students, many faculty suggested that advocacy is currently one component of many of

the courses offered in their department. Not one respondent felt that advocacy should be

taught as its own course.








Guiding Question 7b: How are these training programs evaluated and are
these evaluation procedures sufficient?

Not one respondent reported formal evaluation procedures for advocacy training.

This question was therefore not revisited during study 2.


Study 2

Data Entry and Cleaning

Data were entered twice into separate Excel spreadsheets. Data in these two Excel

spreadsheets were then compared using Proc Compare in SAS to identify any

discrepancies resulting from data entry errors. Several discrepancies were identified

and then resolved by consulting the original survey forms and changing the values in

both spreadsheets. This process ensured the highest quality data for subsequent

analyses.

Table 2 shows the frequencies and percentages of respondents in the six critical

categories in the sample. It is important to note, once again, that the surveys were sent

via electronic mail, thus limiting the accuracy of the return rates due to the fact that there

is no guarantee that the intended participant received the survey.


Table 2
Frequencies for Combined Faculty Status and Professional Affiliation

Frequency Percent Number Response
Mailed Rate
MFT-Faculty 23 15.5 99 23%
MFT-Clinical 20 13.5 124 16%
PC/MHC-Faculty 22 14.9 95 23%
PC/MHC-Clinical 25 16.9 92 27%
Social Worker-Faculty 31 20.9 129 24%
Social Worker-Clinical 27 18.2 108 25%
Total 148 100.0 647 23%








Data Visualization

The second step of the data analysis involved examining the distributions of the

questionnaire items via one-way frequency counts and histograms. The key goal is to

identify items that have problematic distributions (e.g., very low variation or multi-

modal). For Q2 and Q4, 92.5% of responses reported 0 to 5% or 20%. As a result, the

40%, 60%, and 80% or more categories were collapsed into the 20% category.


Descriptive Data Analysis

Descriptive characteristics of the sample are reported in Table 3 including

professional affiliation/role, profession (Q 17), years since graduation (Q 18), years

licensed (Q19), and faculty status (Q20). In addition, the total number of responses for

professional roles was calculated.

Table 4 shows the individual professional roles identified by participants based on

checking all that apply. MFT therapist was the role checked most frequently.


Data Analysis for Guiding Questions

Before addressing the guiding questions, a factor analysis was conducted using

Items 5-13, which have ordinal distributions. The goal was to identify 2-4 dimensions

underlying these items that will help focus further data analysis. The advantages to

identifying these dimensions were as follows: (a) a reduced set of outcomes which

should be more normally distributed than the individual items and (b) reduced Type I

error resulting from fewer statistical significance tests. The Kaiser-Meyer-Olkin

Measure of Sampling Adequacy that assesses whether there are sufficient relationships

among items before conducting a factor analysis was .834, which is very good. To









Table 3

Frequencies for Sample Characteristics


Cumulative Cumulative
Frequency PercentPercent


FACULTY STATUS
Yes 76 51.35 76 51.35
No 72 48.65 148 100.00

Professional Identification
43 29.05 43 29.05
MFT
PC/MHC 47 31.76 90 60.81
Social Worker 58 39.19 148 100.00
Years in Profession
Less than 10 years 22 14.86 22 14.86
10 to 20 years 57 38.51 79 53.38
More than 20 years 69 46.62 148 100.00
Years Licensed
0 to 5 years 20 13.79 20 13.79
6 to 10 years 37 25.52 57 39.31
10 to 20 years 47 32.41 104 71.72
More than 20 30 20.69 134 92.41
1 am not licensed 11 7.59 145 100.00
Number of Professional Roles (Combined Responses to first question)
1 52 35.1 52 35.1
2 52 35.1 104 70.3
3 30 20.3 134 90.5
4 11 7.4 145 98.0
5 3 2.0 148 100.0









Table 4

Individual Professional Roles Identified By Participants

Checked Not Checked
Profession/Affiliation/Role Count % Count %
MFT Therapist 60 40.5 88 59.5


Mental Health/ Professional
Counselor 53 35.8 95 64.2
Social Worker 55 37.2 93 62.8
Academic 44 29.7 104 70.3
College Dean 12 8.1 136 91.9
College Faculty 59 39.9 89 60.1
State Chapter Officer 20 13.5 128 86.5


better understand the relationships among these variables, the intercorrelation matrix

containing items Q5 to Q13 along with Q16 was computed (see Table 5). In general,

Table 5 shows that most variables appear correlated. QII showed the least correlation of

all variables.

The factor analysis identified initial factors using a principal axis factoring

method that only looks at the squared multiple correlation of each item with all other

items (or shared variation). Three factors were identified using the criteria of having an

Eigen value over one. These three factors were then rotated using the orthogonal

Varimax rotation. Table 6 shows that only a single dimension was identified that met the

criteria of simple structure (three or more items each has high factor loadings on only a

single factor). The single factor was called Training Advocacy based on the item content.

Three individual items were not included and individual analyses were done on these

items.









Table 5

Intercorrelation Among Items Used for Factor Analysis

# Item (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
1 q5 --
2 q6 .59***
3 q7 .49*** .50***

4 q8 .49*** .30*** .35***
5 q9 .22** .27*** .18* .22**
6 ql0 .55*** .53*** .50*** .43*** .38***
7 qll -.11 -.13 -.09 .10 -.14 -.01
8 q12 .51"** .47*** .56*** .36*** .17* .49*** -.09
9 q13 -.14 -.32*** -.20* -.07 -.25** -.16 .09 .17*
10 q16 .24** .31*** .40*** .20* .16* .40*** .10 .33*** -.07
Note: = p <.05; ** = p <.01; *** = p <.001


Based on the factor analysis, a new variable was computed as the average of all

items identified as belonging to the Training Advocacy factor in Table 6. This new

variable was used for subsequent analyses in guiding questions 4-6. The mean score for

Training Advocacy was 3.71 with a standard deviation of .84.

Guiding Questions 4-6: How do MFT, MHC, and SW therapists' views differ on:

A chi-square analysis tested the independence of professional affiliation (MFT,

MHC, and SW) and Delphi questionnaire questions, Q1-Q4 and Q15. Additional

exploratory chi-square analyses examined the relationships between faculty status and the

combination of faculty status and professional affiliation (6 groups) with these questions.

Fisher's exact test was used for analyses where the expected count per cell falls below 5

for any cell in the table. Since the Exact test computation was taking several hours

without reaching an answer, an alternative method using a Monte Carlo simulation based

on 10000 random subsamples was used to closely approximate the Fisher Exact test.








Table 6

Rotated Factor Matrix with Factor Loadings (all factors loadings under .3 are suppressed)

Factor Factor Factor
Questionnaire Item 1 2 3
Q7. Some discussion of advocacy work and its importance
should be discussed in EVERY course... .75
Q5. It is important for students trained in my discipline to
be competent in CASE advocacy. .70
Q 12 It is part of my responsibility in keeping with my
professional code of ethics that I must engage... .69
Q 10: There ought to be more training in masters programs
across ALL human service professions... .64 .39
Q6: It is important for current students trained in my
discipline to be competent in CASE advocacy. .64 .30
Q8: NO advocacy training should be required for students
earning a Masters degree in my discipline. .51
Q16: It is important for current students in my discipline
to be trained in professional advocacy. .47
Q9: There ought to be a SPECIFIC course in the masters
curriculum in my discipline directly related to advocacy... .71
Q 13: CASE advocacy when NOT explicitly authorized by
my client is a violation of client confidentiality. -.30
Q1l: In my profession, advocacy work on behalf of the
profession itself is more prevalent than advocacy... .63
Percentage of Variance Explained 28.7% 9.6% 5.3%
Extraction Method: Principal Axis Factoring.
Rotation Method: Varimax with Kaiser Normalization.

Guiding Question 4b, 5b, & 6b: The need for advocacy work (DQ2: Q1 & Q3)

by professional affiliation?

Table 7 shows the cross-tabulation of professional affiliation by CASE advocacy

on part of students or clients is part of practice. The chi-square test for independence was

not statistically significant [chi-square (2) =.60, p 7412]. These results suggest that

there was no significant difference across professions as to the likelihood that a member

of a particular profession would or would not engage in case advocacy as part of their


professional practice.








Table 7

Professional Affiliation by CASE Advocacy on Part of Students or Clients (D02: Q 1)


Table 8 shows the cross-tabulation of professional affiliation by CLASS advocacy

on part of students or clients. The chi-square test for independence was statistically

significant [chi-square (2) = 7.53, p = .0232]. Looking at the row percentages, clinical

social workers reported higher agreement with use of CLASS advocacy relative to

PC/MHC or MFT respondents.

Guiding Question 4a, 5a, & 6a: Their roles as advocates? (DQ2: Q2 & Q4) by
professional affiliation

Table 9 shows the cross-tabulation of professional affiliation by CASE advocacy

for students and clients. The chi-square test for independence was statistically significant

[chi-square (2) = 9.52, p =. 0086]. Looking at the row percentages, clinical social

workers reported higher percentage of time devoted to CASE advocacy relative to

PC/MHC or MFT respondents.


Table of ql7a by qI
Q17a(ql7a) Ql(ql)
Frequency
Row Pct Yes No Total
MFT 36 7 43
83.72 16.28
PC/MHC 39 8 47
82.98 17.02
Social Worker 51 7 58
87.93 12.07
Total 126 22 148









Table 8

Professional Affiliation by CLASS Advocacy (Q3) on Part of Students or Clients

Table of ql7a by q3
ql7a(ql7a) q3(q3)
Frequency
Row Pct Yes No Total
MFT 24 19 43
55.81 44.19
PC/MHC 31 13 44
70.45 29.55
Social Worker 47 11 58
81.03 18.97
Total 102 43 145
Frequency Missing 3


Table 9

Professional Affiliation


by Percentage of Time for CASE Advocacy for Students and


Clients (Q2)

Table of ql7a by q2
ql7a(ql7a) q2(q2)
Frequency
Row Pct 0 to 5% 20% or more Total
MFT 35 8 43
81.40 18.60
PC/MHC 30 16 46
65.22 34.78
Social Worker 30 28 58
51.72 48.28
Total 95 52 147
Frequency Missing = 1









Table 10 shows the cross-tabulation of professional affiliation by CLASS advocacy

for students and clients. The chi-square test for independence was statistically significant

[chi-square (2) = 6.18, p = .0456]. Looking at the row percentages, clinical social workers

reported a higher percentage of time devoted to CLASS advocacy relative to PC/MHC or

MFT respondents.


Table 10

Professional Affiliation by Percentage of Time for CLASS Advocacy for Students and
Clients (Q4)

Table of ql7a by q4
Ql7a(ql7a) q4(q4)
Frequency
Row Pct 0 to 5% 20% or more Total
MFT 32 9 41
78.05 21.95
PC/MHC 27 17 44
61.36 38.64
Social Worker 30 26 56
53.57 46.43
Total 89 52 141
Frequency Missing = 7


Guiding Question 7a: What are the formal training methods used in MFT, MHC,
and SW?

A 3 (MFT, MHC, and SW) x 2 (Faculty versus Practitioner) Analysis of Variance

(ANOVA) was conducted using the training advocacy factor as the outcome. Table 11

shows that there was a significant effect for faculty status, professional affiliation, and the

faculty status by professional affiliation interaction.









Table 11

ANOVA Source Table for 2 x 3 Analysis of Variance

Type III Mean
Source DF SS Square F Value Pr > F
Faculty Status 1 8.36 8.36 14.97 0.0002
Professional Affiliation 2 8.26 4.13 7.4 0.0009
Faculty Status by Professional 2 3.91 1.96 3.5 0.0328
Affiliation


For the faculty status effect, faculty reported higher advocacy training (M = 3.91)

compared to nonfaculty (M= 3.43). For differences in respondents with different

professional affiliations, post-hoc multiple comparisons using the Tukey HSD adjustment

for Type I error showed that clinical social worker reported higher advocacy training (M

= 3.99) compared to PC/MHC respondents (M = 3.55) and MFT respondents (M = 3.46).

There was a statistically significant interaction (Faculty Status by Professional

Affiliation). Figure 1 shows the interaction represented by the respective means for each

group.

Simple effects were conducted using one-way analysis of variance comparing

MFT, MHC, and SW groups within each level of faculty status. For nonfaculty, there

was no statistically significant effect [F (2,69) = .34, p = .715]. For faculty, there was a

statistically significant effect [F (2,73) = 13.55, p < .0001]. Table 12 shows the results

of the Tukey HSD adjusted multiple comparisons. The clinical social worker group was

statistically significantly different from the other groups at the .05 level.











4.4

3.7

3.5
3.4 3.4


5.0 -
4.5-
4.0
I-
3.5
3.0
0
2.5-
*2.0
1.5-
1.0


MFT


PC/MHC Social Wrker
Professional Affllation


Figure 1. Interaction between Faculty Status by Professional Affiliation for Advocacy
Training


Table 12

Faculty Status=Yes: Tukey HSD Comparison

N Subset Subset
Q17A 1 2
MFT 23 3.4768

PC/MHC 22 3.6803

Social Worker 31 4.4441



Additional Analyses for Items Not Included in Factor Analysis

Table 13 shows the cross-tabulation of professional affiliation by advocacy for

profession is part of practice. The chi-square test for independence was not statistically

significant [chi-square (2) = 5.43, p =. 0661]. These results suggest that there was no

significant difference across professions as to the likelihood that a member of a particular

profession would or would not engage in advocacy work on behalf of their profession.


-,Faculty
u-Clirins









Table 13

Professional Affiliation by Advocacy for Profession ( 15)


Table of ql7a by q15
Q17a(ql7a) q15(q15)
Frequency
Row Pet Yes No Total
MFT 32 11 43
74.42 25.58
PC/MHC 40 7 47
85.11 14.89
Social Worker 53 5 58
91.38 8.62
Total 125 23 148


Table 14 shows the cross-tabulation of professional affiliation by desire for a

specific course in master's curriculum. The chi-square test for independence was

statistically significant [chi-square (8) = 17.69, p =. 0236]. Clinical social workers

reported more agreement for a specific course in the master's curriculum relative to

PC/MHC or MFT respondents.

Table 15 shows the cross-tabulation of professional affiliation and case

advocacy/violation of confidentiality. The chi-square test for independence was not

statistically significant [chi-square (8) = 7.74, p =. 4591]. These results suggest that there

was no significant difference across professions as to the likelihood that a member of a

particular profession would report a particular level of agreement as to whether or not

case advocacy when not authorized by a client is a violation of client confidentiality.









Table 14

Professional Affiliation by Desire for a Specific Course in Master's Curriculum
(DO2: Q9)

Table of ql7a by q9
ql7a(ql7a) Q9(q9)
Frequency Least Most
Row Pct Agree 2 3 4 Agree Total
MFT 7 15 10 4 7 43
16.28 34.88 23.26 9.30 16.28
PC/MHC 13 14 12 4 4 47
27.66 29.79 25.53 8.51 8.51
Social Worker 5 12 11 15 13 56
8.93 21.43 19.64 26.79 23.21
Total 25 41 33 23 24 146
Frequency Missing =2


Table 15

Professional Affiliation and Case Advocacy/Violation of Confidentiality (DQ2: Q13)

Table of ql7a by q13
ql7a(ql7a) q13(q13)
Frequency Least Most
Row Pct Agree 2 3 4 Agree Total
MFT 2 6 5 7 21 41
4.88 14.63 12.20 17.07 51.22
PC/MHC 3 2 8 12 20 45
6.67 4.44 17.78 26.67 44.44
Social Worker 5 10 11 9 21 56
8.93 17.86 19.64 16.07 37.50
Total 10 18 24 28 62 142
Frequency Missing =6









Table 16 shows the cross-tabulation of professional affiliation by professional

advocacy. The chi-square test for independence was statistically significant [chi-square

(8) = 25.88, p = .0011]. The Monte Carlo estimate of the exact probability was .0010.

Marriage and family therapists reported more agreement that advocacy work on behalf of

the profession itself is more prevalent than advocacy work on behalf of clients relative to

PC/MHC or SW respondents.


Table 16

Professional Affiliation by Professional Advocacy (DQ2: Q 11)


Table of ql7a by q1l
ql7a(ql7a) qll(ql1)
Frequency Least Most
Row Pct Agree 2 3 4 Agree Total
MFT 2 9 12 14 6 43
4.65 20.93 27.91 32.56 13.95
PC/MHC 10 6 12 14 5 47
21.28 12.77 25.53 29.79 10.64
Social Worker 21 18 9 6 3 57
36.84 31.58 15.79 10.53 5.26
Total 33 33 33 34 14 147
Frequency Missing = 1


Exploratory Analyses

How do faculty and nonfaculty differ on their roles as advocates and the need
for advocacy work in this country?

1. The need for advocacy work (DQ2: Q1 & Q3) by faculty status? The same chi-

square analysis was performed to test the independence of faculty status and several

questions related to advocacy. Table 17 shows the cross-tabulation of faculty status by









CASE advocacy as a part of professional practice. The chi-square test for independence

was not statistically significant [chi-square (1) = 1.13, p = .2882]. These results suggest

that there was no significant difference as to the likelihood that a faculty or nonfaculty

member would or would not engage in case advocacy as part of their professional practice.


Table 17

Faculty Status by CASE Advocacy (DQ2: Q1)


Table 18 shows the cross-tabulation of faculty status by CLASS advocacy. The

chi-square test for independence was statistically significant [chi-square (1) = 15.85, p <

.0001]. Faculty members reporting more often that, yes, CLASS advocacy was part of

professional practice relative to nonfaculty respondents.

2. Their roles as advocates? (DQ2: Q2 & Q4) by faculty status. Table 19 shows

the cross-tabulation of faculty status by percent time for CASE advocacy. The chi-square

test for independence was not statistically significant [chi-square (1) = 0.03, p < .8713].

These results suggest that there was no significant difference as to the percentage of time

a faculty or nonfaculty member would engage in CASE advocacy as part of their

professional practice.


Table of q20 by q1
q20(q20) ql(ql)
Frequency
Row Pct Yes No Total
Yes 67 9 76
88.16 11.84
No 59 13 72
81.94 18.06
Total 126 22 148










Table 18

Faculty Status by CLASS Advocacy (03)


Table of q20 by q3
q20(q20) q3(q3)
Frequency
Row Pct Yes No Total
Yes 63 11 74
85.14 14.86
No 39 32 71
54.93 45.07
Total 102 43 145
Frequency Missing = 3


Table 19

Faculty Status by Percent Time for CASE Advocacy (02)

Table of q20 by q2
q20(q20) q2(q2)
Frequency
Row Pct 0 to 5% 20% or more Total
Yes 48 27 75
64.00 36.00
No 47 25 72
65.28 34.72
Total 95 52 147
Frequency Missing = 1


Table 20 shows the cross-tabulation of faculty status by percent time for CLASS

advocacy. The Chi-square test for independence was statistically significant [Chi-square

(1) = 3.98, p < .0460]. Faculty members reporting more often that yes, a higher

percentage of time was devoted to class than nonfaculty.









Table 20
Faculty Status by Percent Time for CLASS Advocacy (D02: Q4)

Table of q20 by q4
q20(q20) q4(q4)
Frequency
Row Pet 0 to 5% 20% or more Total
Yes 41 33 74
55.41 44.59
No 48 19 67
71.64 28.36
Total 89 52 141
Frequency Missing = 7


3. Their focus on advocacy (DQ2: Q15) by faculty status. Table 21 shows the

cross-tabulation of faculty status by advocacy for profession. The chi-square test for

independence was not statistically significant [chi-square (1) = 6.96, p < .0083]. These

results suggest that there was no significant difference as to the likelihood that a faculty

or nonfaculty member would or would not engage in advocacy work on behalf of their

profession.

How does professional affiliation broken down by faculty and nonfaculty differ
on their roles as advocates, the need for advocacy work, and the focus of
advocacy work?

1. The need for advocacy work (DQ2: 01, Q3) by combined faculty status and

professional affiliation. Table 22 shows the cross-tabulation of faculty status and

professional affiliation by CASE advocacy for students or clients. The chi-square test for

independence was not statistically significant [chi-square (5) = 6.25, p < .2823]. Since

several cells had expected values of less than 5, a Fisher's Exact Test was performed.









Table 21

Faculty Status by Advocacy for Profession (Q15)


Table of q20 by q15
q20(q20) q15(q15)
Frequency
Row Pct Yes No Total
Yes 70 6 76
92.11 7.89
No 55 17 72
76.39 23.61
Total 125 23 148


Table 22

Faculty Status and Professional Affiliation by CASE Advocacy for Students or


Clients (Q1)


Table of q17a20 by q1
q17a20 ql(ql)
Frequency
Row Pct Yes No Total
MFT-Faculty 18 5 23
78.26 21.74
MFT-Clinical 18 2 20
90.00 10.00
PC/MHC-Faculty 19 3 22
86.36 13.64
PC/MHC-Clinical 20 5 25
80.00 20.00
Social Worker- 30 1 31
Faculty 96.77 3.23
Social Worker- 21 6 27
Clinical 77.78 22.22
Total 126 22 148









Due to computation time, a Monte Carlo approximation was used based on 10,000

random subsamples. The Monte Carlo estimate for the exact 12-value was .2893 or

statistically nonsignificant. These results suggest that there was no significant

difference as to the likelihood that a faculty or nonfaculty member of a particular

profession would or would not engage in case advocacy as part of their professional

practice.

Table 23 shows the cross-tabulation of faculty status and professional affiliation

by CLASS advocacy for students or clients. The chi-square test for independence was

statistically significant [chi-square (5) = 24.83, p < 0002]. Social work faculty answered

yes 100% that class advocacy is part of their professional practice, with mental health

faculty answering yes 85%, and least likely to say that class advocacy was part of their

professional practice were marriage and family therapy practitioners answering yes only

45%.

2. Their roles as advocates? (DQ2: Q1 & Q4) by combined faculty status and

professional affiliation. Table 24 shows the cross-tabulation of faculty status and

professional affiliation by percent time for CASE advocacy. The chi-square test for

independence was not statistically significant [chi-square (5) = 9.91, p < .0778]. These

results suggest that there was no significant difference as to the likelihood that a faculty

or nonfaculty member of a particular profession would spend a particular percentage of

time engaged in case advocacy.

Table 25 shows the cross-tabulation of faculty status and professional affiliation

by percent time for CLASS advocacy. The chi-square test for independence was

statistically significant [chi-square (5) = 15.24, p < .0094]. With 61% of social work








faculty answering more than 20% of time spent on class advocacy and 89% of marriage

and family therapy practitioners reported less than 5% of their time is spent on class

advocacy.



Table 23

Facully Status and Professional Affiliation by CLASS Advocacy for Students or
Clients (03)

Table of q17a20 by q3
Q17a2O q3(q3)
Frequency
Row Pct Yes No Total
MFT-Faculty 15 8 23
65.22 34.78
MFT-Clinical 9 11 20
45.00 55.00
PC/MHC-Faculty 17 3 20
85.00 15.00
PC/MHC-Clinical 14 10 24
58.33 41.67
Social Worker-Faculty 31 0 31
100.00 0.00
Social Worker-Clinical 16 11 27
59.26 40.74
Total 102 43 145
Frequency Missing 3


3. Focus on advocacy (DQ2: Q15) by combined faculI status and professional

affiliation. Table 26 shows the cross-tabulation of faculty status and professional

affiliation by advocacy for profession. The chi-square test for independence was

statistically significant [chi-square (5) = 12.81, p < .0252]. The Monte Carlo estimate








for the exact p-value was .0230 or statistically significant. With 97% of social work

faculty answering yes that advocacy for my profession is part of my professional

practice and 95% of mental health faculty reporting that yes advocacy for the profession

is part of my professional practice. Sixty-five percent of marriage and family

practitioners answered yes, that advocacy for the profession is part of my professional

practice.


Table 24

Faculty Status and Professional Affiliation by Percent Time for CASE
Advocacy (02)

Table of q17a20 by q2
q17a20 q2(q2)
Frequency
Row Pct 0 to 5% 20% or more Total
MFT-Faculty 19 4 23
82.61 17.39
MFT-Clinical 16 4 20
80.00 20.00
PC/MHC-Faculty 14 7 21
66.67 33.33
PC/MHC-Clinical 16 9 25
64.00 36.00
Social Worker- 15 16 31
Faculty 48.39 51.61
Social Worker- 15 12 27
Clinical 55.56 44.44
Total 95 52 147
Frequency Missing = 1









Table 25
Faculty Status and Professional Affiliation by Percent Time for CLASS Advocacy (Q4)

Table of q17a20 by q4
q17a20 q4(q4)
Frequency
Row Pct 0 to 5% 20% or more Total
MFT-Faculty 15 7 22
68.18 31.82
MFT-Clinical 17 2 19
89.47 10.53
PC/MHC-Faculty 14 7 21
66.67 33.33
PC/MHC-Clinical 13 10 23
56.52 43.48
Social Worker- 12 19 31
Faculty 38.71 61.29
Social Worker- 18 7 25
Clinical 72.00 28.00
Total 89 52 141
Frequency Missing = 7


GC 7a: Additional exploratory analyses for "Do formal training methods
differ between MFT, MHC, and SW?"


Analyses by Faculty Status

Table 27 shows the cross-tabulation of faculty status by desire for a specific

course in master's curriculum. The chi-square test for independence was statistically

significant [chi-square (4) = 9.8, p = .0439]. Faculty are less likely to agree that a specific

course ought to be included with nonfaculty more likely to agree that a specific course be

included in the masters curriculum.









Table 26

Faculty Status and Professional Affiliation by Advocacy for Profession (DQ2: Q15)

Table of q17a20 by q15
q17a20 q15(q15)
Frequency
Row Pet Yes No Total
MFT-Faculty 19 4 23
82.61 17.39
MFT-Clinical 13 7 20
65.00 35.00
PC/MHC-Faculty 21 1 22
95.45 4.55
PC/MHC-Clinical 19 6 25
76.00 24.00
Social Worker-Faculty 30 1 31
96.77 3.23
Social Worker-Clinical 23 4 27
85.19 14.81
Total 125 23 148



Table 27

Faculty Status by Desire for a Specific Course in Master's Curriculum (Q9)

Table of q20 by q9
q20(q20) Q9(q9)
Frequency
Row Pct 1 2 3 4 5 Total
Yes 15 25 14 15 7 76
19.74 32.89 18.42 19.74 9.21
No 10 16 19 8 17 70
14.29 22.86 27.14 11.43 24.29
Total 25 41 33 23 24 146
Frequency Missing = 2









Table 28 shows the cross-tabulation of faculty status by case advocacy and

confidentiality. The chi-square test for independence was statistically significant [chi-

square (4) = 11.43, p = .0221 ]. Nonfaculty were more likely to agree that case advocacy

when not authorized by a client is a violation of confidentiality with faculty less likely to

agree.


Table 28

Faculty Status by Case Advocacy and Confidentiality (Q 13)

Table of q20 by q13
q20(q20) q13(q13)
Frequency
Row Pct 1 2 3 4 5 Total
Yes 6 14 13 17 23 73
8.22 19.18 17.81 23.29 31.51
No 4 4 11 11 39 69
5.80 5.80 15.94 15.94 56.52
Total 10 18 24 28 62 142
Frequency Missing = 6


Table 29 shows the cross-tabulation of faculty status by advocacy on behalf of

the profession more so than work on behalf of clients. The chi-square test for

independence was not statistically significant [chi-square (4) = 7.68, p =. 1040]. There

was no significant difference between faculty and nonfaculty as to the degree of

agreement regarding advocacy work on behalf of the profession being more likely than

on behalf of clients.








Table 29

Faculty Status by Advocacy on Behalf of the Profession More So than Work on
Behalf of Clients (Q 11)

Table of q20 by q1l
q20(q20) qll(qll)
Frequency
Row Pct 1 2 3 4 5 Total
Yes 13 18 21 20 4 76
17.11 23.68 27.63 26.32 5.26
No 20 15 12 14 10 71
28.17 21.13 16.90 19.72 14.08
Total 33 33 33 34 14 147
Frequency Missing = 1


Analyses by Combined Professional Affiliation and Faculty Status

Table 30 shows the cross-tabulation of combined professional affiliation and

faculty status by specific course in master's curriculum. The chi-square test for

independence was statistically significant [chi-square (20) = 39.28, p = .0062]. The

Monte Carlo estimate of the exact test p-value was .0062 as well. Mental health

practitioners and mental health faculty along with marriage and family faculty seem to

agree least with having a specific course in the masters curriculum while social work

faculty and clinicians (in particular with 36% ranking the highest level of agreement)

were most likely to agree.

Table 31 combined professional affiliation and faculty status by CASE

advocacy/confidentiality (DQ2: 13). The chi-square test for independence was not

statistically significant [chi-square (20) = 24.57, p = .2186]. The Monte Carlo estimate of

the exact test p-value was. 2149. These results suggest that there was no significant









Table 30

Combined Professional Affiliation and Faculty Status by Specific Course in Master's
Curriculum (DQ2: Q9)

Table of q17a20 by q9
Q17a2O q9(q9)
Frequency
Row Pet 1 2 3 4 5 Total
MFT-Faculty 6 10 1 3 3 23
26.09 43.48 4.35 13.04 13.04
MFT- 1 5 9 1 4 20
Clinical 5.00 25.00 45.00 5.00 20.00
PC/MHC- 6 7 7 2 0 22
Faculty 27.27 31.82 31.82 9.09 0.00
PC/MHC- 7 7 5 2 4 25
Clinical 28.00 28.00 20.00 8.00 16.00
Social 3 8 6 10 4 31
Worker- 9.68 25.81 19.35 32.26 12.90
Faculty
Social 2 4 5 5 9 25
Worker- 8.00 16.00 20.00 20.00 36.00
Clinical
Total 25 41 33 23 24 146
Frequency Missing =2


difference across professions and faculty status as to the likelihood that a particular

degree of agreement exists regarding whether or not advocacy when not authorized by a

client is a violation of client confidentiality.

Table 32 shows the combined professional affiliation and faculty status for

profession relative to clients. The chi-square test for independence was not statistically

significant [chi-square (20) = 46.90, p = .0006]. The Monte Carlo estimate of the exact

test p-value was .0040. These results suggest that there was no significant difference








across professions and faculty status as to the likelihood that a particular degree of

agreement exists regarding whether or not advocacy work on behalf of the profession

itself is more likely that advocacy work on behalf of clients.


Table 31

Combined Professional Affiliation and Faculty Status by CASE Advocacy!
Confidentiality (DQ2: Q13)

Table of q17a20 by q13
q17a20 q13(q13)
Frequency
Row Pct 1 2 3 4 5 Total
MFT-Faculty 1 5 3 4 9 22
4.55 22.73 13.64 18.18 40.91
MFT- 1 1 2 3 12 19
Clinical 5.26 5.26 10.53 15.79 63.16
PC/MHC- 3 1 4 7 6 21
Faculty 14.29 4.76 19.05 33.33 28.57
PC/MHC- 0 1 4 5 14 24
Clinical 0.00 4.17 16.67 20.83 58.33
Social 2 8 6 6 8 30
Worker- 6.67 26.67 20.00 20.00 26.67
Faculty
Social 3 2 5 3 13 26
Worker- 11.54 7.69 19.23 11.54 50.00
Clinical
Total 10 18 24 28 62 142
Frequency Missing =6









Table 32

Combined Professional Affiliation and Faculty Status for Profession Relative to
Clients (DQ2: Q11)

Table of q17a20 by q1l
q17a20 qll(qll)
Frequency
Row Pct 1 2 3 4 5 Total
MFT-Faculty 0 6 6 10 1 23
0.00 26.09 26.09 43.48 4.35
MFT-Clinical 2 3 6 4 5 20
10.00 15.00 30.00 20.00 25.00
PC/MHC-Faculty 3 1 10 7 1 22
13.64 4.55 45.45 31.82 4.55
PC/MHC-Clinical 7 5 2 7 4 25
28.00 20.00 8.00 28.00 16.00
Social Worker- 10 11 5 3 2 31
Faculty 32.26 35.48 16.13 9.68 6.45
Social Worker- 11 7 4 3 1 26
Clinical 42.31 26.92 15.38 11.54 3.85
Total 33 33 33 34 14 147
Frequency Missing = 1














CHAPTER 5
DISCUSSION

According to some of the experts in the fields of clinical social work, marriage

and family therapy, and mental health counseling, there is a need for emphasis on

advocacy training and practice (Brawley, 1997; Chapman & Richman, 1998; Epstein,

1995; Eriksen, 1999; Figueria-McDonough, 1993; Kurpius & Rozecki, 1992; Lee &

Sirch, 1994; Osborne et al., 1998; Verschelden, 1993; Walz et al., 1991; Wolk & Pray,

1996). Those who support this increased emphasis view it as a necessary response to the

current societal conditions and the development of managed care (Allen-Meares, 1998;

Berger & Kelly, 1993; Faul & Hudson, 1997; Kochunas, 1997). Regardless of your

view, the majority of all human service practitioners and policy-makers agree that we

must respond in new and creative ways to service delivery issues as a result of current

trends.

The aim of the data collection from this research was an effort to collect

information among three human service professions, their faculty, and practitioners

regarding the varying emphasis on the training and practice of advocacy.


Evaluation and Discussion of the Results


Guiding Questions 1-3

Guiding question 1,2, and 3 asked the following question: What does advocacy

mean to the profession of which you are a member? The definition of advocacy has been









argued as one that is different for each person and different depending on the context

(DeGregorio, 1997; Tompkins et al, 1998). The results from Study I indicated three

definitions of advocacy from the respondents. Professional advocacy, case advocacy, and

class advocacy were three categories clearly defined in the results. Professional

advocacy is defined as advocating on behalf of one's profession. Case advocacy is

defined as an "intervention on behalf of an individual client or identified client group"

(Ezell, 2001, p. 27). Class advocacy is defined as "intervention on behalf of a group of

clients who share the same problem or status" (Ezell, 2001, p. 27).


Guiding Questions 4-6

During Study 2 specific questions were asked regarding professional advocacy,

case advocacy, class advocacy, and the percentage of time devoted to each. These

categories of advocacy taken from Study I helped to guide the writing of the questions

that needed to be asked to answer guiding questions 4-6. Guiding questions 4-6 asked the

following question: How do members of your profession view their roles as advocates

and the need for advocacy work in this country?

Advocacy work by professional affiliation. When asked by profession whether or

not case advocacy was part of professional practice, the results indicated nonsignificance.

When asked by profession whether or not class advocacy was part of professional

practice, the results indicated significance. Clinical social workers reported higher

agreement with the use of class advocacy relative to marriage and family therapists and

mental health counselors.

When asked by professional affiliation the percentage of time devoted to case

advocacy, results indicated significance. Clinical social workers reported a higher