The Bradley FamilyTiffani Bradley is a 16-year-old heterosexual .docx

The Bradley Family
Tiffani Bradley is a 16-year-old heterosexual Caucasian female
referred to me after being arrested for prostitution. I worked
with Tiffani at Teens First, a brand new court-mandated teen
counseling program for adolescent victims of sexual
exploitation and human trafficking. At Teens First we provide a
holistic range of services for our clients. Tiffani has been
provided room and board in our residential treatment facility
and will meet with a number of social workers to address her
multiple needs and concerns.
Tiffani has been arrested three times for prostitution in the last
2 years. Right before her most recent charge, a new state policy
was enacted to protect youth 16 years and younger from
prosecution and jail time for prostitution. The Safe Harbor for
Exploited Children Act allows the state to define Tiffani as a
sexually exploited youth and therefore the state will not
imprison her for prostitution. She was mandated to services at
our agency, unlike her prior arrests when she had been sent to
detention.
Tiffani had been living with a man she has identified as Donald
since she was 14 years old. She had had limited contact with her
family members and had not been attending school. She
described Donald as her “husband” (although they were not
married) and her only friend. She had contacted her sister,
Diana, a few times over the previous 2 years and stated that she
missed her very much. Donald had recently sold Tiffani to
another pimp, “John T.” Tiffani reported that she was very
upset that Donald did this and that she wanted to be reunited
with him. She had tried to make contact with him by sending
messages through other people, as John T. did not allow her
access to a phone.
During intake it was noted that Tiffani had multiple bruises and
burn marks on her legs and arms. She reported that Donald had
slapped her when he felt she did not behave and that John T.

burned her with cigarettes. Tiffani has been treated for several
sexually transmitted infections (STIs) at local clinics and is
currently on an antibiotic for a kidney infection. Although she
was given condoms by Donald and John T. for her “dates,” there
were several “Johns” who refused to use them. It appears that
over the last 2 years, Tiffani has had neither outside support nor
interactions with anyone beyond Donald, John T., and some
other young women also being prostituted.
Other members of the Bradley family include Tiffani’s 33-year-
old mother, Shondra; Tiffani’s 38-year-old father, Robert; and
Tiffani’s 13-year-old sister, Diana. Shondra and Robert have
been separated for a little over a year and have started dating
other people. Diana currently resides with her mother and
Anthony, her mother’s new boyfriend. Shondra and Anthony
abuse a variety of drugs, including marijuana and
methamphetamine.
Robert also abuses a number of drugs and has recently been
arrested for possession of crack cocaine. Robert has been
arrested several times over the last 5 years: twice for domestic
violence calls and twice for drug possession. He is currently in
jail awaiting sentencing.
The goals Tiffani and I set in our initial sessions centered on
helping her feel safe and secure in her new home and utilizing
as many of the available resources as possible. Through
individual and group counseling, Tiffani will have the
opportunity to discuss her experiences prior to coming to Teens
First, including what led to her relationship with Donald. A
long-term goal I presented was to help her understand that
Donald, the person who she maintained “is the love of my life,”
had actually had a negative impact on her life. Tiffani listed
some of her own long-term goals, including obtaining a General
Education Development (GED) credential, getting her own
apartment, getting a job, and reunifying with her sister.
During our sessions over the year, Tiffani gave a rather in-depth
description of her childhood. At first Tiffani provided a family
history that was filled with only happy memories. She

remembered her life up to age 8 as filled with moments of joy.
She remembered going to school, playing with her sister, and
her mother and father getting along.
As we continued to meet, Tiffani shared what she remembered
as a gradual but definitive change in the family dynamics
around the time when she turned 8 years old. She remembered
being awakened by music and laughter in the early hours of the
morning. When she went downstairs to investigate, she saw her
parents along with her uncle Nate passing a pipe back and forth
between them. She remembered asking them what they were
doing and her mother saying, “adult things” and putting her
back in bed.
Tiffani remembered being woken up by noise several times after
that and seeing her father and her uncle passing the pipe
between them. Sometimes her mother was there and sometimes
she was not. Often when her mother was not there, Nate would
see her and ask her to come over. Her father would sometimes
ask her to show them the dance that she had learned at school.
When she danced, her father and Nate would laugh and offer her
pocket change. Sometimes they were joined by their friend
Jimmy.
The Bradley Family
Robert Bradley: father, 38
Shondra Bradley: mother, 33
Nate Bradley: uncle, 36
Tiffani Bradley: daughter, 16
Diana Bradley: daughter, 13
Donald: Tiffani’s self-described husband and her former pimp
Shondra currently lives with her boyfriend, Anthony
For years the music and noise downstairs continued, later
accompanied by screams and shouting and sounds of people
fighting. One morning, Shondra yelled at Robert to “get up and
go to work.” Tiffani and Diana saw Robert come out of the
bedroom and slap Shondra so hard she was knocked down.
Robert then went back into the bedroom.
Tiffani also noticed significant changes in her home’s

appearance. The home, which was never fancy, was almost
always neat and tidy. Tiffani noticed that dust would gather
around the house, dishes would pile up in the sink, dirt would
remain on the floor, and clothes would go for long periods of
time without being washed. Tiffani remembered cleaning her
own clothes and making meals for herself and her sister during
this period. Sometimes Tiffani and her sister would come
downstairs in the morning to find empty beer cans and liquor
bottles on the kitchen table along with the pipe. Her parents
would be in the bedroom, and Tiffani and her sister would leave
the house and go to school by themselves. Tiffani was unclear if
her parents were working or how the bills were paid. Often
there was not enough food to feed everyone and she would go to
bed hungry.
During one session, Tiffani described an incident of sexual
abuse. One night she was awoken by her uncle Nate and his
friend Jimmy in her room. Her parents were apparently out, and
they were the only adults in the home. They asked her if she
wanted to come downstairs and show them the new dances she
learned at school. Once downstairs, Nate and Jimmy put some
music on and started to dance. They asked Tiffani to start
dancing with them, which she did. While they were dancing,
Jimmy spilled some beer on her. Nate said she had to go to the
bathroom to clean up. Nate, Jimmy, and Tiffani all went to the
bathroom. Nate asked Tiffani to take her clothes off so she
could get in the bath. Tiffani hesitated to do this, but Nate
insisted it was okay since he and Jimmy were family. Tiffani
eventually relented and began to wash up. Nate would tell her
that she missed a spot and would scrub the area with his hands.
After this incident, others occurred, with increasing levels of
molestation each time. Tiffani felt very bad about this, but had
difficulty explaining why, even to herself. She was very afraid
of everyone in her family except her sister Diana. She was also
afraid that Diana might be subjected to the same thing.
The last time it happened, when Tiffani was 14, she pretended
to be willing to dance for them, but when she got downstairs she

ran out the front door of the house. Tiffani ran down the block
to her school because, as she said, it was one of the few places
where she felt safe. She said she was barefoot and in her
pajamas and it was very cold. About halfway to her school, a
car stopped, and a man inside asked her where she was going.
When Tiffani replied that she was going to school, the man
asked why she was going to school in the middle of the night.
Tiffani did not want to tell him the whole story, so she told him
that there was trouble at home and she just wanted to go to
school early.
The man introduced himself as Donald and asked her why she
did not go to her boyfriend’s house. When Tiffani said she did
not have a boyfriend, Donald replied that if she had a boyfriend,
she would have somebody to take care of her and keep her safe
when these things happened. He then offered to be her
boyfriend. Tiffani did not say anything, but when Donald then
offered to give her a ride, she agreed and got in the car.
Donald took Tiffani to his apartment, explaining that the school
would be closed for hours. When they got to his apartment,
Donald fed Tiffani and gave her beer, explaining that it would
help keep her warm. Tiffani did not like the taste of the beer,
but at Donald’s insistence, she drank it.
When Tiffani was drunk, Donald began kissing her, and they
had sex. Tiffani knew about sex from school and some of her
girlfriends but she had never had it with anyone before. She was
grateful to Donald because he had helped her get away from
Nate and Jimmy. Donald had also told her that he loved her and
they would be together forever. Tiffani was also afraid that if
she did not have sex, Donald would not let her stay and she had
nowhere else to go.
For the next 3 days, Donald brought her food and beer and had
sex with her several more times. Donald told Tiffani that she
was not allowed to do anything without his permission. This
included watching TV, going to the bathroom, taking a shower,
and eating and drinking.
Donald bought Tiffani a dress, explaining to her that she was

going to “find a date” and get men to pay her to have sex with
her. When Tiffani said she did not want to do that, Donald hit
her several times. Donald explained that if she didn’t do it, he
would get her sister, Diana, and make her do it instead. Out of
fear for her sister, Tiffani relented and did what Donald told her
to do.
Key to Acronyms
GED: General Education Development
STI: Sexually Transmitted Infection
Tiffani and I met over the course of a year for individual
sessions. We talked often about her continued desire to be
reunited with Donald. We discussed what Donald represented
for her and why he was such an important part of her life. She
often described him as the person who “saved” her and felt she
owed much to him. She vividly remembered the fear she felt the
nights Nate and Jimmy touched her, and she was convinced they
would have raped her that last night. My efforts were to help
her recognize that Donald was not a savior, but someone who
did, in fact, rape her and then force her into prostitution. A lot
of time and discussion went into changing this cognition around
Donald and their relationship.
After about six months at Teens First, Tiffani said that she had
a strong desire to see her sister and her mother, and I helped to
arrange a family session at the agency. Tiffani and I talked
about what her hopes were for the meeting and her intent for
scheduling this session. Tiffani first and foremost just wanted to
see them and hug them. She had not seen either of them in over
two years and missed them very much. Tiffani also felt some
anger toward her mother that she wanted to able to share in a
safe environment. She said she felt that both her parents did not
do enough to protect her and that they should have known better
than to have let Nate and Jimmy into the house when they were
not home. She also said she felt her mother should have tried
harder to find her when she was with Donald. I wanted her to be
realistic about the potential outcome of the meeting, so I did my
best to explain that the session might not provide all of the

answers she hoped for. We were aware, through a conversation
with her sister, that her mother was still using drugs, and we
talked about how this might cloud her mother’s ability to
engage in a substantial conversation.
In the family session, Shondra was very critical of Tiffani and
her current situation. She ultimately blamed Tiffani for her
current state. When Tiffani confronted her mother about the
drug use and the lack of parental guidance and protection,
Shondra denied ever having used drugs. She told Tiffani she
was exaggerating and a liar and that neither she nor Tiffani’s
father ever put her in harm’s way.
Throughout our time working together, Tiffani utilized all of
the services at the agency and stopped trying to contact Donald.
She had learned that he had actually gotten married to one of
the other women that worked for him, and this made her very
angry. She has passed her GED test and started working at a
local fast food restaurant. She plans on applying to a community
college and a fashion institute.
Assessing client strengths: clinical assessment for client
empowerment.
Authors:
Cowger CD
Affiliation:
School Social Work, Univ Illinois Urbana, 1207 W Oregon,
Urbana IL 61801
Source:
Social Work (SOC WORK), May94; 39(3): 262-268. (7p)
Publication Type:
Journal Article
Language:
English
Major Subjects:
EmpowermentSocial WorkEvaluation -- Methods
Minor Subjects:

Social Identity; Professional-Patient Relations
Abstract:
The proposition that client strengths are central to the helping
relationship is simple enough and seems uncontroversial as an
important component of practice. Yet deficit, disease, and
dysfunction metaphors are deeply rooted in clinical social work,
and the emphasis of assessment has continued to be diagnosing
abnormal and pathological conditions. This article argues that
assessment in clinical practice, among other things, is a
political activity. Assessment that focuses on deficits provides
obstacles to client exercise of personal and social power and
reinforces those social structures that generate and regulate
unequal power relationships that victimize clients. Clinical
practice based on metaphors of client strengths is also political
in that it is congruent with the potential for client
empowerment. This article discusses the importance of a client
strengths perspective for assessment and proposes 12 practice
guidelines that foster a strengths perspective.
Journal Subset:
Allied Health; Peer Reviewed; USA
ISSN:
0037-8046
MEDLINE Info:
PMID: 8209288 NLM UID: 2984852R
Entry Date:
20050425
Revision Date:
20150820
Accession Number:
107452079
Assessing Client Strengths: Clinical Assessment for Client
Empowerment
Contents
1. Theory of Strengths Assessment
2. Assessment as Political Activity

3. Client Strengths and Empowerment
4. Importance of Assessing Strengths
5. Guidelines for Strengths Assessment
6. Conclusion
7. References
Full Text
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The proposition that client strengths are central to the helping
relationship is simple enough and seems uncontroversial as an
important component of practice. Yet deficit, disease, and
dysfunction metaphors are deeply rooted in clinical social work,
and the emphasis of assessment has continued to be diagnosing
abnormal and pathological conditions. This article argues that
assessment in clinical practice, among other things, is a
political activity. Assessment that focuses on deficits provides
obstacles to client exercise of personal and social power and
reinforces those social structures that generate and regulate
unequal power relationships that victimize clients. Clinical
practice based on metaphors of client strengths is also political
in that it is congruent with the potential for client
empowerment. This article discusses the importance of a client
strengths perspective for assessment and proposes 12 practice
guidelines that foster a strengths perspective.
Key Words: clients; clinical assessment; empowerment; practice
effectiveness; strengths perspective
A focus on client strengths has received recent attention in the
social work practice literature (Goldstein, 1990; Hepworth &
Larsen, 1990; Saleebey, 1992; Weick, Rapp, Sullivan, &
Kisthardt, 1989). The proposition that client strengths are
central to the helping relationship is simple enough and seems
uncontroversial as an important component of practice. Yet
much of the social work literature suggests otherwise.
Review of the social work literature on human behavior and the
social environment reveals that it provides little theoretical or
empirical content on strengths. Much of the social work
literature on practice with families continues to use treatment,

dysfunction, and therapy metaphors and ignores work on family
strengths developed in other disciplines. The assessment
literature, including available assessment instruments, is
overwhelmingly concerned with individual inadequacies. Taking
a behavioral baseline of client deficits and examining the ability
of social workers to correct those deficits have become the
standard for evaluating the effectiveness of social work practice
(Kagle & Cowger, 1984). Deficit, disease, and dysfunction
metaphors are deeply rooted in social work, and the focus of
assessment has "continued to be, one way or another,
diagnosing pathological conditions" (Rodwell, 1987, p. 235).
This article discusses the importance of a client strengths
perspective for assessment and proposes 12 practice guidelines
to foster a strengths perspective. Though not addressed
specifically to a strengths perspective, work on assessment by
Logan and Chambers (1987), Rodwell (1987), and Meyer (1976)
is particularly congruent with a strengths perspective and has
been important to the author's thinking.
Given that social work is expanding its influence into nearly
every social institution, it is not surprising that its knowledge is
diverse, lacks unity, and has significant gaps. In the excitement
of this rapid growth some people lament epistemological
problems and incongruities, whereas others proclaim they have
found the answer or, at least, an answer that will help give unity
and boundaries to the profession's purpose and knowledge base.
Although such a proclamation has its appeal, the profession is
simply too diverse, and existing paradigms that emphasize
client deficiencies are too entrenched for a strengths perspective
to become a unifying metaphor. However, a strengths
perspective does provide an alternative for practitioners who
find the constructs of the approach consistent with their own
views of practice.
Saleebey (1992) has argued that the relevance of a strengths
perspective is generic and represents "good, basic social work
practice" (p. 43). It is particularly important for mandated or
involuntary clients because of the powerlessness implicit in the

involuntary nature of the client-worker relationship. Rapp
(1992), Kisthardt (1992), and Poertner and Ronnau (1992) have
described the use of a strengths perspective with involuntary
clients.
Theory of Strengths Assessment
This article is based on a mainstream contextual understanding
that the primary purpose of social work is to assist people in
their relationships with one another and with social institutions
in such a way as to promote social and economic justice
(Council on Social Work Education, 1984). Clinical practice
focuses on the transactions between people and their
environments. However, taking seriously the element of
promoting social and economic justice in those transactions may
not lead to a mainstream conception of practice. Indeed, clinical
practice that considers social and economic justice suggests a
type of practice that explicitly deals with power and power
relationships.
This perspective understands client empowerment as central to
clinical practice and client strengths as providing the fuel and
energy for that empowerment. Client empowerment is
characterized by two interdependent and interactive dynamics:
personal empowerment and social empowerment. Although
social work theories that split the attributes of people into the
social and the psychological have considerable limitations
(Falck, 1988), such a differentiation is made in this article to
stress the importance of each element.
The personal empowerment dynamic is similar to a traditional
clinical notion of self-determination whereby clients give
direction to the helping process, take charge and control of their
personal lives, get their "heads straight," learn new ways to
think about their situations, and adopt new behaviors that give
them more satisfying and rewarding outcomes. Personal
empowerment recognizes the uniqueness of each client.
The social empowerment dynamic recognizes that client
definitions and characteristics cannot be separated from their
context and that personal empowerment is related to

opportunity. Social empowerment acknowledges that individual
behavior is socially derived and identity is "bound up with that
of others through social involvement" (Falck, 1988, p. 30). The
person with social empowerment is a person who has the
resources and opportunity to play an important role in his or her
environment and in the shaping of that environment.
A person achieves personal and social empowerment
simultaneously. For the client to achieve empowerment assumes
that the resources and opportunity for that empowerment are
available. Social justice, involving the distribution of society's
resources, is directly related to client social empowerment and,
therefore, simultaneously to personal empowerment.
Clinical practice based on empowerment assumes that client
power is achieved when clients make choices that give them
more control over their presenting problem situations and, in
turn, their own lives. However, empowerment-based practice
also assumes social justice, recognizing that empowerment and
self-determination are dependent not only on people making
choices, but also on people having available choices to make.
The distribution of available choices in a society is political.
Societies organize systems of production and the distribution of
resources, and that affects those choices differentially. Across
societies, production and distribution are based on varying
degrees of commitment to equity and justice: "Some people get
more of everything than others" (Goroff, 1983, p. 133). Social
work practice based on the notion of choice requires attention
directed to the dynamics of personal power, the social power
endemic to the client's environment, and the relationship
between the two.
Assessment as Political Activity
Assessment that focuses on deficits provides obstacles to clients
exercising personal and social power and reinforces those social
structures that generate and regulate the unequal power
relationships that victimize clients. Goroff (1983) persuasively
argued that social work practice is a political activity and that
the attribution of individual deficiencies as the cause of human

problems is a politically conservative process that "supports the
status quo" (p. 134).
Deficit-based assessment targets the individual as "the
problem." For example, from a deficit perspective the person
who is unemployed becomes the problem. Social work
interventions that focus on what is wrong with the person--for
example, why he or she is not working--reinforce the
powerlessness the client is already experiencing because he or
she does not have a job. At the same time such an intervention
lets economic and social structures that do not provide
opportunity "off the hook" and reinforces social structures that
generate unequal power. To assume that the cause of personal
pain and social problems is individual deficiency"has the
political consequences of not focusing on the social structure
(the body politic) but on the individual. Most, if not all, of the
pain we experience is the result of the way we have organized
ourselves and how we create and allocate life-surviving
resources" (Goroff, 1983, p. 134).
Personal pain is political. Clinical social work practice is
political. Diagnostic and assessment metaphors and taxonomies
that stress individual deficiencies and sickness reinforce the
political status quo in a manner that is incongruent with clinical
practice that attempts to promote social and economic justice.
Practice based on pathology is subject to the "blaming the
victim" characterization of Ryan (1976). Clinical practice based
on metaphors of client strengths and empowerment is also
political in that its thrust is the development of client power and
the equitable distribution of societal resources.
Client Strengths and Empowerment
Promoting empowerment means believing that people are
capable of making their own choices and decisions. It means not
only that human beings possess the strengths and potential to
resolve their own difficult life situations, but also that they
increase their strength and contribute to society by doing so.
The role of the social worker in clinical practice is to nourish,
encourage, assist, enable, support, stimulate, and unleash the

strengths within people; to illuminate the strengths available to
people in their own environments; and to promote equity and
justice at all levels of society. To do that, the social worker
helps clients articulate the nature of their situations, identify
what they want, explore alternatives for achieving those wants,
and achieve them.
The role of the social worker is not to change people, treat
people, help people cope, or counsel people. The role is not to
empower people. As Simon (1990) argued, social workers
cannot empower others: "More than a simple linguistic nuance,
the notion that social workers do not empower others, but
instead, help people empower themselves is an ontological
distinction that frames the reality experienced by both workers
and clients" (p. 32). To assume a social worker can empower
someone else is naive and condescending and has little basis in
reality. Power is not something that social workers possess for
distribution at will. Clients, not social workers, own the power
that brings significant change in clinical practice. A clinical
social worker is merely a resource person with professional
training on the use of resources who is committed to people
empowerment and willing to share his or her knowledge in a
manner that helps people realize their own power, take control
of their own lives, and solve their own problems.
Importance of Assessing Strengths
Central to a strengths perspective is the role and place of
assessment in the practice process. How clients define difficult
situations and how they evaluate and give meaning to the
dynamic factors related to those situations set the context and
content for the duration of the helping relationship (Cowger,
1992). If assessment focuses on deficits, it is likely that deficits
will remain the focus of both the worker and the client during
remaining contacts. Concentrating on deficits or strengths can
lead to self-fulfilling prophecies. Hepworth and Larsen (1990)
articulated how this concentration might also impair a social
worker's "ability to discern clients' potentials for growth,"
reinforce "client self-doubts and feelings of inadequacy," and

predispose workers to "believe that clients should continue to
receive service longer than is necessary" (p. 195).
Emphasizing deficits has serious implications and limitations,
but focusing on strengths provides considerable advantages.
Strengths are all we have to work with. Recognition of strengths
is fundamental to the value stance and mission of the
profession. A strengths perspective provides for a leveling of
the power relationship between social workers and clients.
Clients enter the clinical setting in a vulnerable position and
with comparatively little power. Their lack of power is inherent
in the reason for which they are seeking help and in the social
structure of service. A deficit focus reinforces this vulnerability
and highlights the unequal power relationship between the
worker and the client.
A strengths perspective reinforces client competence and
thereby mitigates the significance of unequal power between the
client and social worker and, in so doing, presents increased
potential for liberating people from stigmatizing diagnostic
classifications that reinforce "sickness" in individuals, families,
and communities (Cowger, 1992). A strengths perspective of
assessment provides structure and content for an examination of
realizable alternatives, for the mobilization of competencies
that can make things different, and for the building of self-
confidence that stimulates hope.
Guidelines for Strengths Assessment
Assessment is a process as well as a product. Assessment as
process is helping clients define their situations (that is, clarify
the reasons they have sought assistance) and assisting clients in
evaluating and giving meaning to those factors that affect their
situations. It is particularly important to assist clients in telling
their stories. The client owns that story, and if the social worker
respects that ownership, the client will be able to more fully
share it. The word "situation" has a particularly important
meaning because it affirms the reality that problems always
exist in an environmental context.
The following guidelines are based on the notion that the

knowledge guiding the assessment process is based on a socially
constructed reality in the tradition of Berger and Luckmann
(1966). Also, the assessment should recognize that there are
multiple constructions of reality for each client situation
(Rodwell, 1987) and that problem situations are interactive,
multicausal, and ever-changing.
Give preeminence to the client's understanding of the facts. The
client's view of the situation, the meaning the client ascribes to
the situation, and the client's feelings or emotions related to that
situation are the central focus for assessment. Assessment
content on the intrapersonal, developmental, cognitive, mental,
and biophysical dynamics of the client are important only as
they enlighten the situation presented by the client. They should
be used only as a way to identify strengths that can be brought
to bear on the presenting situation or to recognize obstacles to
achieving client objectives. The use of social sciences behavior
taxonomies representing the realities of the social scientists
should not be used as something to apply to, thrust on, or label
a client. An intrapersonal and interpersonal assessment, like
data gathered on the client's past, should not have a life of its
own and is not important in its own right.
Believe the client. Central to a strengths perspective is a deeply
held belief that clients ultimately are trustworthy. There is no
evidence that people needing social work services tell untruths
any more than anyone else. To prejudge a client as being
untrustworthy is contrary to the social work-mandated values of
having respect for individuals and recognizing client dignity,
and prejudgment may lead to a self-fulfilling prophecy. Clients
may need help to articulate their problem situations, and "caring
confrontation" by the worker may facilitate that process.
However, clients' understandings of reality are no less real than
the social constructions of reality of the professionals assisting
them.
Discover what the client wants. There are two aspects of client
wants that provide the structure for the worker-client contract.
The first is, What does the client want and expect from service?

The second is, What does the client want to happen in relation
to his or her current problem situation? This latter want
involves the client's goals and is concerned with what the client
perceives to be a successful resolution to the problem situation.
Although recognizing that what the client wants and what
agencies and workers are able and willing to offer is subject to
negotiation, successful practitioners base assessments on client
motivation. Client motivation is supported by expectations of
meeting one's own goals and wants.
Move the assessment toward personal and environmental
strengths. Obviously there are personal and environmental
obstacles to the resolution of difficult situations. However, if
one believes that solutions to difficult situations lie in
strengths, dwelling on obstacles ultimately has little payoff.
Make assessment of strengths multidimensional.
Multidimensional assessment is widely supported in social
work. Practicing from a strengths perspective means believing
that the strengths and resources to resolve a difficult situation
lie within the client's interpersonal skills, motivation, emotional
strengths, and ability to think clearly. The client's external
strengths come from family networks, significant others,
voluntary organizations, community groups, and public
institutions that support and provide opportunities for clients to
act on their own behalf and institutional services that have the
potential to provide resources. Discovering these strengths is
central to assessment. A multidimensional assessment also
includes an examination of power and power relationships in
transactions between the client and the environment. Explicit,
critical examination of such relationships provides the client
and the worker with the context for evaluating alternative
solutions.
Use the assessment to discover uniqueness. The importance of
uniqueness and individualization is well articulated by Meyer
(1976): "When a family, group or a community is . . .
individualized, it is known through its uniqueness, despite all
that it holds in common with other like groups" (p. 176).

Although every person is in certain respects "like all other men
[sic], like some other men, and like no other men" (Kluckholm,
Murray, & Schneider, 1953, p. 53), foundation content in human
behavior and social environment taught in schools of social
work focuses on the first two of these, which are based on
normative behavior assumptions. Assessment that focuses on
client strengths must be individualized to understand the unique
situation the client is experiencing. Normative perspectives of
behavior are only useful insofar as they can enrich the
understanding of this uniqueness. Pray's (1991) writings on
assessment emphasize individual uniqueness as an important
element of Schon's (1983) reflective model of practice and are
particularly insightful in establishing the importance of client
uniqueness in assessment.
Use language the client can understand. Professional and social
sciences nomenclature is incongruent with an assessment
approach based on mutual participation of the social worker and
the client. Assessment as a product should be written in simple
English and in such a way as to be self-explanatory. Goldstein
(1990) convincingly stated, "We are the inheritors of a
professional language composed of value-laden metaphors and
idioms. The language has far more to do with philosophic
assumptions about the human state, ideologies of
professionalism, and, not least, the politics of practice than they
do with objective rationality" (p. 268).
Make assessment a joint activity between worker and client.
Social workers can minimize the power imbalance inherent
between worker and client by stressing the importance of the
client's understandings and wants. The worker's role is to
inquire and listen and to assist the client in discovering,
clarifying, and articulating. The client gives direction to the
content of the assessment. The client must feel ownership of the
process and the product and can do so only if assessment is
open and shared. Rodwell (1987) articulated this well when she
stated that the "major stakeholders must agree with the content"
(p. 241).

Reach a mutual agreement on the assessment. Workers should
not have secret assessments. All assessments in written form
should be shared with clients. Because assessment is to provide
structure and direction for confronting client problem
situations, any privately held assessment a worker might have
makes the client vulnerable to manipulation.
Avoid blame and blaming. Assessment and blame often get
confused and convoluted. Blame is the first cousin of deficit
models of practice. Concentrating on blame or allowing it to get
a firm foothold on the process is done at the expense of getting
on with a resolution to the problem. Client situations
encountered by social workers are typically the result of the
interaction of a myriad of events: personal interactions,
intrapersonal attributes, physical health, social situations, social
organizations, and chance happenings. Things happen; people
are vulnerable to those happenings, and, therefore, they seek
assistance. What can the worker and client do after blame is
ascribed? Generally, blaming leads nowhere, and, if delegated
to the client, it may encourage low self-esteem. If assigned to
others, it may encourage learned helplessness or deter
motivation to address the problem situation.
Avoid cause-and-effect thinking Professional judgments or
assumptions of causation may well be the most detrimental
exercises perpetrated on clients. Worker notions of cause and
causal thinking should be minimized because they have the
propensity to be based on simplistic cause-and-effect thinking.
Causal thinking represents only one of many possible
perspectives of the problem situation and can easily lead to
blaming. Client problem situations are usually
multidimensional, have energy, represent multidirectional
actions, and reflect dynamics that are not well suited to simple
causal explanations.
Assess; do not diagnose. Diagnosis is incongruent with a
strengths perspective. Diagnosis is understood in the context of
pathology, deviance, and deficits and is based on social
constructions of reality that define human problem situations in

a like manner. Diagnosis is associated with a medical model of
labeling that assumes unpopular and unacceptable behavior as a
symptom of an underlying pathological condition. It has been
argued that labeling "accompanied by reinforcement of
identified behavior is a sufficient condition for chronic mental
illness" (Taber, Herbert, Mark, & Nealey, 1969, p. 354). The
preference for the use of the word "assessment" over
"diagnosis" is widely held in the social work literature.
Conclusion
Inherent in the guidelines is the recognition that to focus on
client strengths and to practice with the intent of client
empowerment is to practice with an explicit power
consciousness. Whatever else social work practice is, it is
always political, because it always encompasses power and
power relationships. The guidelines are not intended to include
all the assessment content and knowledge that a social worker
must use in practice. Indeed, important topics such as assessing
specific obstacles to empowerment, assessing power
relationships, and assessing the relationship between personal
empowerment and social empowerment of the individual client
are not considered. The use of the guidelines depends on given
practice situations, and professional judgment determines their
specific applicability. They are proposed to provide an
alternative approach to existing normative and deficit models of
diagnosis and treatment. The guidelines may also be of interest
to practitioners who wish to use them to supplement existing
assessment paradigms they do not wish to give up.
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Accepted October 30, 1992
~~~~~~~~
By Charles D. Cowger
Charles D. Cowger, PhD, ACSW, is associate professor and
director, graduate studies, School of Social Work University of
Illinois-Urbana, 1207 West Oregon, Urbana, IL 61801.
Choose Language
Mental Health Diagnosis in Social Work: The Case of Miranda

Miranda is a 35-year-old, Scottish female who sought
counseling for increased feelings of depression and anxiety. Her
symptoms include constant worry, difficulty sleeping,
irritability, increased appetite, unexplained episodes of panic,
feelings of guilt and worthlessness, and feelings of low self-
esteem. She denied any suicidal/homicidal ideation but
verbalized feelings of wanting to be dead. She maintained these
thoughts were fleeting and inconsistent. She reported an
increase in alcohol consumption, although clarified it was only
when she felt anxious. She denied any blackouts or
reckless/illegal behavior while drinking. She denied any other
drug use. Miranda works in the fashion industry and reported
that she is very well liked by her peers and clientele. She is
regularly chosen to train other staff members and comanage the
store. However, she is often given a heavier workload to
compensate for coworkers who are unable to perform at the
expected level of her employer. Miranda stated that she has
trouble saying no and feels increasingly irritable and frustrated
with her increased workload. Miranda has been married to her
husband for 3 years, and they have no children. She reported
that both her mother and father have a history of mental illness.
Miranda’s parents are divorced, and when they separated,
Miranda chose to live with her mother. Miranda’s mother
remarried a man she described as “vicious and verbally
abusive.” Miranda stated that her stepfather called her names
and told her that she was worthless. She said he made her
believe that she was sick with chronic health issues and many
times forced her to take medicine that was either unnecessary or
not prescribed by a doctor. Eventually he asked Miranda to
leave her mother’s home. Miranda stated that her mother was
well aware of her stepfather’s behavior but chose not to
intervene, stating, “He is a sick man. Just do what he says.” She
denied any physical or sexual abuse in the home. In order to
treat Miranda’s symptoms, we first addressed the need for
medication, and I provided a referral to a psychiatrist. The
psychiatrist diagnosed her with panic disorder and major

depressive disorder and prescribed appropriate medications to
assist her with her symptoms. Miranda and I began weekly
sessions to focus on managing her boundaries both at work and
with her family. We discussed her behavior around boundary
setting as well as the possibility of enlisting her husband as a
support person to encourage and promote healthy boundaries.
We also discussed unresolved issues from her childhood. This
approach enabled Miranda to gain insight into the self and how
her maltreatment as a child affected her functioning in the
present time. This insight enabled Miranda to validate her
feelings of anger, frustration, and sadness about her upbringing
and further give herself permission to set appropriate
boundaries in her relationships. We also discussed the need for
relaxation and stress management. Miranda was able to identify
that she used to enjoy cycling and running but had not been
engaging in them because of the demands at work. After
discussing the importance of self-care, Miranda began to
exercise again and set a goal to enter local running and cycling
events to encourage herself to continue. After 1 year of therapy,
Miranda decided to taper down her medication, which was
monitored by her psychiatrist. She has chosen to remain in
therapy weekly to monitor her mood as she decreases her
medication. Miranda’s overall presentation has improved
greatly. With the use of medication, behavioral therapy,
relaxation techniques, and psychodynamic therapy, Miranda’s
affect presents as stable and her symptoms of depression are
gone. Miranda is a client that is able to verbalize the benefits of
treatment in helping her gain insight and empower herself to
validate her own emotional needs. She has been a highly
motivated patient who enjoys the safety of being able to express
her thoughts and feelings without judgement.
Paula is a 43-year-old HIV-positive Latina woman originally
from Colombia. She is bilingual, fluent in both Spanish and
English. Paula lives alone in an apartment in Queens, NY. She
is divorced and has one son, Miguel, who is 20 years old. Paula

maintains a relationship with her son and her ex-husband, David
(46). Paula raised Miguel until he was 8 years old, at which
time she was forced to relinquish custody due to her medical
condition. Paula is severely socially isolated as she has limited
contact with her family in Colombia and lacks a peer network of
any kind in her neighborhood. Paula identifies as Catholic, but
she does not consider religion to be a big part of her life.
Paula came from a moderately well-to-do family. She reports
suffering physical and emotional abuse at the hands of both her
parents, who are alive and reside in Colombia with Paula’s two
siblings. Paula completed high school in Colombia, but ran
away when she was 17 years old because she could no longer
tolerate the abuse at home. Paula became an intravenous drug
user (IVDU), particularly of cocaine and heroin. David, who
was originally from New York City, was one of Paula’s “drug
buddies.” The two eloped, and Paula followed David to the
United States. Paula continued to use drugs in the United States
for several years; however, she stopped when she got pregnant
with Miguel. David continued to use drugs, which led to the
failure of their marriage.
Once she stopped using drugs, Paula attended the Fashion
Institute of Technology (FIT) in New York City. Upon
completing her BA, Paula worked for a clothing designer, but
realized her true passion was painting. She has a collection of
more than 100 drawings and paintings, many of which track the
course of her personal and emotional journey. Paula held a full-
time job for a number of years before her health prevented her
from working. She is now unemployed and receives
Supplemental Security Insurance (SSI) and Medicaid.
Paula was diagnosed with bipolar disorder. She experiences
rapid cycles of mania and depression when not properly
medicated, and she also has a tendency toward paranoia. Paula
has a history of not complying with her psychiatric medication
treatment because she does not like the way it makes her feel.
She often discontinues it without telling her psychiatrist. Paula
has had multiple psychiatric hospitalizations but has remained

out of the hospital for at least five years. Paula accepts her
bipolar diagnosis, but demonstrates limited insight into the
relationship between her symptoms and her medication.
Paula was diagnosed HIV positive in 1987. Paula acquired
AIDS several years later when she was diagnosed with a severe
brain infection and a T-cell count less than 200. Paula’s brain
infection left her completely paralyzed on the right side. She
lost function of her right arm and hand, as well as the ability to
walk. After a long stay in an acute care hospital in New York
City, Paula was transferred to a skilled nursing facility (SNF)
where she thought she would die. It is at this time that Paula
gave up custody of her son. However, Paula’s condition
improved gradually. After being in the SNF for more than a
year, Paula regained the ability to walk, although she does so
with a severe limp. She also regained some function in her right
arm. Her right hand (her dominant hand) remains semiparalyzed
and limp. Over the course of several years, Paula taught herself
to paint with her left hand and was able to return to her beloved
art. In 1996, when highly active antiretroviral therapy (HAART)
became available, Paula began treatment. She responded well to
HAART and her HIV/AIDS was well controlled.
In addition to her HIV/AIDS disease, Paula is diagnosed with
hepatitis C (Hep C). While this condition was controlled, it has
reached a point where Paula’s doctor is recommending she
begin treatment. Paula also has significant circulatory problems,
which cause her severe pain in her lower extremities. She uses
prescribed narcotic pain medication to control her symptoms.
Paula’s circulatory problems have also led to chronic ulcers on
her feet that will not heal. Treatment for her foot ulcers
demands frequent visits to a wound care clinic. Paula’s pain
paired with the foot ulcers make it difficult for her to ambulate
and leave her home. As with her psychiatric medication, Paula
has a tendency not to comply with her medical treatment. She
often disregards instructions from her doctors and resorts to
holistic treatments like treating her ulcers with chamomile tea.
Working with Paula can be very frustrating because she is often

doing very well medically and psychiatrically. Then, out of the
blue, she stops her treatment and deteriorates quickly.
I met Paula as a social worker employed at an outpatient
comprehensive care clinic located in an acute care hospital in
New York City. The clinic functions as an interdisciplinary
operation and follows a continuity of care model. As a result,
clinic patients are followed by their physician and social worker
on an outpatient basis and on an inpatient basis when admitted
to the hospital. Thus, social workers interact not only with
doctors from the clinic, but also with doctors from all services
throughout the hospital.
After working with Paula for almost six months, she called to
inform me that she was pregnant. Her news was shocking
because she did not have a boyfriend and never spoke of dating.
Paula explained that she met a man at a flower shop, they spoke
several times, he visited her at her apartment, and they had sex.
Paula thought he was a “stand up guy,” but recently everything
had changed. Paula began to suspect that he was using drugs
because he had started to become controlling and demanding.
He showed up at her apartment at all times of the night
demanding to be let in. He called her relentlessly, and when she
did not pick up the phone, he left her mean and threatening
messages. Paula was fearful for her safety.
The Cortez Family
David Cortez: father, 46
Paula Cortez: mother, 43
Miguel Cortez: son, 20
Given Paula’s complex medical profile and her psychiatric
diagnosis, her doctor, psychiatrist, and I were concerned about
Paula maintaining the pregnancy. We not only feared for
Paula’s and the baby’s health, but also for how Paula would
manage caring for a baby. Paula also struggled with what she
should do about her pregnancy. She seriously considered having
an abortion. However, her Catholic roots paired with seeing an
ultrasound of the baby reinforced her desire to go through with
the pregnancy.

The primary focus of treatment quickly became dealing with
Paula’s relationship with the baby’s father. During sessions
with her psychiatrist and me, Paula reported feeling fearful for
her safety. The father’s relentless phone calls and voicemails
rattled Paula. She became scared, slept poorly, and her paranoia
increased significantly. During a particular session, Paula
reported that she had started smoking to cope with the stress she
was feeling. She also stated that she had stopped her psychiatric
medication and was not always taking her HAART. When we
explored the dangers of Paula’s actions, both to herself and the
baby, she indicated that she knew what she was doing was
harmful but she did not care. After completing a suicide
assessment, I was convinced that Paula was decompensating
quickly and at risk of harming herself and/or her baby. I
consulted with her psychiatrist, and Paula was involuntarily
admitted to the psychiatric unit of the hospital. Paula was
extremely angry at me for the admission. She blamed me for
“locking her up” and not helping her. Paula remained on the
unit for 2 weeks. During this stay she restarted her medications
and was stabilized. I tried to visit Paula on the unit, but the first
two times I showed up she refused to see me. Eventually, Paula
did agree to see me. She was still angry, but she was able to see
that I had acted with her best interest in mind, and we were able
to repair our relationship. As Paula prepared for discharge, she
spoke more about the father and the stress that had driven her to
the admission in the first place. Paula agreed that despite her
fears she had to do something about the situation. I helped
Paula develop a safety plan, educated her about filing for a
restraining order, and referred her to the AIDS Law Project, a
not-for-profit organization that helps individuals with HIV
handle legal issues. With my support and that of her lawyer,
Paula filed a police report and successfully got the restraining
order. Once the order was served, the phone calls and visits
stopped, and Paula regained a sense of control over her life.
From a medical perspective, Paula’s pregnancy was considered
“high risk” due to her complicated medical situation.

Throughout her pregnancy, Paula remained on HAART, pain,
and psychiatric medication, and treatment for her Hep C was
postponed. During the pregnancy the ulcers on Paula’s feet
worsened and she developed a severe bone infection,
ostemeylitis, in two of her toes. Without treatment the infection
was extremely dangerous to both Paula and her baby. Paula was
admitted to a medical unit in the hospital where she started a 2-
week course of intravenous (IV) antibiotics. Unfortunately, the
antibiotics did not work, and Paula had to have portions of two
of her toes amputated with limited anesthesia due to the
pregnancy, extending her hospital stay to nearly a month.
The condition of Paula’s feet heightened my concern and the
treatment team’s concerns about Paula’s ability to care for her
baby. There were multiple factors to consider. In the immediate
term, Paula was barely able to walk and was therefore unable to
do anything to prepare for the baby’s arrival (e.g., gather
supplies, take parenting class, etc.). In the medium term, we
needed to address how Paula was going to care for the baby
day-to-day, and we needed to think about how she would care
for the baby at home given her physical limitations (i.e., limited
ability to ambulate and limited use of her right hand) and her
current medical status. In addition, we had to consider what she
would do with the baby if she required another hospitalization.
In the long term, we needed to think about permanency planning
for the baby or for what would happen to the baby if Paula died.
While Paula recognized the importance of all of these issues,
her anxiety level was much lower than mine and that of her
treatment team. Perhaps she did not see the whole picture as we
did, or perhaps she was in denial. She repeatedly told me, “I
know, I know. I’m just going to do it. I raised my son and I am
going to take care of this baby too.” We really did not have an
answer for her limited emotional response, we just needed to
meet her where she was and move on. One of the things that
amazed me most about Paula was that she had a great ability to
rally people around her. Nurses, doctors, social workers: we all
wanted to help her even when she tried to push us away.

While Paula was in the hospital unit, we were able to talk about
the baby’s care and permanency planning. Through these
discussions, Paula’s social isolation became more and more
evident. Paula had not told her parents in Colombia that she was
having a baby. She feared their disapproval and she stated, “I
can’t stand to hear my mother’s negativity.” Miguel and David
were aware of the pregnancy, but they each had their own lives.
David was remarried with children, and Miguel was working
and in school full-time. The idea of burdening him with her
needs was something Paula would not consider. There was no
one else in Paula’s life. Therefore, we were forced to look at
options outside of Paula’s limited social network.
Key to Acronyms
AIDS:
Acquired Immunodeficiency Syndrome
HAART:
Highly Active Antiretroviral Therapy
HIV:
Human Immunodeficiency Virus
IVDU:
Intravenous Drug User
SNF:
Skilled Nursing Facility
SSI:
Supplemental Security Insurance
WIC:
Supplemental Nutrition Program for Women, Infants, and
Children
After a month in the hospital, Paula went home with a surgical
boot, instructions to limit bearing weight on her foot, and a list
of referrals from me. Paula and I agreed to check in every other
day by telephone. My intention was to monitor how she was
feeling, as well as her progress with the referrals I had given
her. I also wanted to provide her with support and
encouragement that she was not getting from anywhere else. On
many occasions, I hung up the phone frustrated with Paula

because of her procrastination and lack of follow-through. But
ultimately she completed what she needed to for the baby’s
arrival. Paula successfully applied for WIC, the federal
Supplemental Nutrition Program for Women, Infants, and
Children, and was also able to secure a crib and other baby
essentials.
Paula delivered a healthy baby girl. The baby was born HIV
negative and received the appropriate HAART treatment after
birth. The baby spent a week in the neonatal intensive care unit,
as she had to detox from the effects of the pain medication
Paula took throughout her pregnancy. Given Paula’s low
income, health, and Medicaid status, Paula was able to apply for
and receive 24/7 in-home child care assistance through New
York’s public assistance program. Depending on Paula’s health
and her need for help, this arrangement can be modified as
deemed appropriate. Miguel did take a part in caring for his half
sister, but his assistance was limited. Ultimately, Paula
completed the appropriate permanency planning paperwork with
the assistance of the organization The Family Center. She
named Miguel the baby’s guardian should something happen to
her.
The Bradley Family
Tiffani Bradley is a 16-year-old heterosexual Caucasian female
referred to me after being arrested for prostitution. I worked
with Tiffani at Teens First, a brand new court-mandated teen
counseling program for adolescent victims of sexual
exploitation and human trafficking. At Teens First we provide a
holistic range of services for our clients. Tiffani has been
provided room and board in our residential treatment facility
and will meet with a number of social workers to address her
multiple needs and concerns.
Tiffani has been arrested three times for prostitution in the last
2 years. Right before her most recent charge, a new state policy
was enacted to protect youth 16 years and younger from

prosecution and jail time for prostitution. The Safe Harbor for
Exploited Children Act allows the state to define Tiffani as a
sexually exploited youth and therefore the state will not
imprison her for prostitution. She was mandated to services at
our agency, unlike her prior arrests when she had been sent to
detention.
Tiffani had been living with a man she has identified as Donald
since she was 14 years old. She had had limited contact with her
family members and had not been attending school. She
described Donald as her “husband” (although they were not
married) and her only friend. She had contacted her sister,
Diana, a few times over the previous 2 years and stated that she
missed her very much. Donald had recently sold Tiffani to
another pimp, “John T.” Tiffani reported that she was very
upset that Donald did this and that she wanted to be reunited
with him. She had tried to make contact with him by sending
messages through other people, as John T. did not allow her
access to a phone.
During intake it was noted that Tiffani had multiple bruises and
burn marks on her legs and arms. She reported that Donald had
slapped her when he felt she did not behave and that John T.
burned her with cigarettes. Tiffani has been treated for several
sexually transmitted infections (STIs) at local clinics and is
currently on an antibiotic for a kidney infection. Although she
was given condoms by Donald and John T. for her “dates,” there
were several “Johns” who refused to use them. It appears that
over the last 2 years, Tiffani has had neither outside support nor
interactions with anyone beyond Donald, John T., and some
other young women also being prostituted.
Other members of the Bradley family include Tiffani’s 33-year-
old mother, Shondra; Tiffani’s 38-year-old father, Robert; and
Tiffani’s 13-year-old sister, Diana. Shondra and Robert have
been separated for a little over a year and have started dating
other people. Diana currently resides with her mother and
Anthony, her mother’s new boyfriend. Shondra and Anthony
abuse a variety of drugs, including marijuana and

methamphetamine.
Robert also abuses a number of drugs and has recently been
arrested for possession of crack cocaine. Robert has been
arrested several times over the last 5 years: twice for domestic
violence calls and twice for drug possession. He is currently in
jail awaiting sentencing.
The goals Tiffani and I set in our initial sessions centered on
helping her feel safe and secure in her new home and utilizing
as many of the available resources as possible. Through
individual and group counseling, Tiffani will have the
opportunity to discuss her experiences prior to coming to Teens
First, including what led to her relationship with Donald. A
long-term goal I presented was to help her understand that
Donald, the person who she maintained “is the love of my life,”
had actually had a negative impact on her life. Tiffani listed
some of her own long-term goals, including obtaining a General
Education Development (GED) credential, getting her own
apartment, getting a job, and reunifying with her sister.
During our sessions over the year, Tiffani gave a rather in-depth
description of her childhood. At first Tiffani provided a family
history that was filled with only happy memories. She
remembered her life up to age 8 as filled with moments of joy.
She remembered going to school, playing with her sister, and
her mother and father getting along.
As we continued to meet, Tiffani shared what she remembered
as a gradual but definitive change in the family dynamics
around the time when she turned 8 years old. She remembered
being awakened by music and laughter in the early hours of the
morning. When she went downstairs to investigate, she saw her
parents along with her uncle Nate passing a pipe back and forth
between them. She remembered asking them what they were
doing and her mother saying, “adult things” and putting her
back in bed.
Tiffani remembered being woken up by noise several times after
that and seeing her father and her uncle passing the pipe
between them. Sometimes her mother was there and sometimes

she was not. Often when her mother was not there, Nate would
see her and ask her to come over. Her father would sometimes
ask her to show them the dance that she had learned at school.
When she danced, her father and Nate would laugh and offer her
pocket change. Sometimes they were joined by their friend
Jimmy.
The Bradley Family
Robert Bradley: father, 38
Shondra Bradley: mother, 33
Nate Bradley: uncle, 36
Tiffani Bradley: daughter, 16
Diana Bradley: daughter, 13
Donald: Tiffani’s self-described husband and her former pimp
Shondra currently lives with her boyfriend, Anthony
For years the music and noise downstairs continued, later
accompanied by screams and shouting and sounds of people
fighting. One morning, Shondra yelled at Robert to “get up and
go to work.” Tiffani and Diana saw Robert come out of the
bedroom and slap Shondra so hard she was knocked down.
Robert then went back into the bedroom.
Tiffani also noticed significant changes in her home’s
appearance. The home, which was never fancy, was almost
always neat and tidy. Tiffani noticed that dust would gather
around the house, dishes would pile up in the sink, dirt would
remain on the floor, and clothes would go for long periods of
time without being washed. Tiffani remembered cleaning her
own clothes and making meals for herself and her sister during
this period. Sometimes Tiffani and her sister would come
downstairs in the morning to find empty beer cans and liquor
bottles on the kitchen table along with the pipe. Her parents
would be in the bedroom, and Tiffani and her sister would leave
the house and go to school by themselves. Tiffani was unclear if
her parents were working or how the bills were paid. Often
there was not enough food to feed everyone and she would go to
bed hungry.
During one session, Tiffani described an incident of sexual

abuse. One night she was awoken by her uncle Nate and his
friend Jimmy in her room. Her parents were apparently out, and
they were the only adults in the home. They asked her if she
wanted to come downstairs and show them the new dances she
learned at school. Once downstairs, Nate and Jimmy put some
music on and started to dance. They asked Tiffani to start
dancing with them, which she did. While they were dancing,
Jimmy spilled some beer on her. Nate said she had to go to the
bathroom to clean up. Nate, Jimmy, and Tiffani all went to the
bathroom. Nate asked Tiffani to take her clothes off so she
could get in the bath. Tiffani hesitated to do this, but Nate
insisted it was okay since he and Jimmy were family. Tiffani
eventually relented and began to wash up. Nate would tell her
that she missed a spot and would scrub the area with his hands.
After this incident, others occurred, with increasing levels of
molestation each time. Tiffani felt very bad about this, but had
difficulty explaining why, even to herself. She was very afraid
of everyone in her family except her sister Diana. She was also
afraid that Diana might be subjected to the same thing.
The last time it happened, when Tiffani was 14, she pretended
to be willing to dance for them, but when she got downstairs she
ran out the front door of the house. Tiffani ran down the block
to her school because, as she said, it was one of the few places
where she felt safe. She said she was barefoot and in her
pajamas and it was very cold. About halfway to her school, a
car stopped, and a man inside asked her where she was going.
When Tiffani replied that she was going to school, the man
asked why she was going to school in the middle of the night.
Tiffani did not want to tell him the whole story, so she told him
that there was trouble at home and she just wanted to go to
school early.
The man introduced himself as Donald and asked her why she
did not go to her boyfriend’s house. When Tiffani said she did
not have a boyfriend, Donald replied that if she had a boyfriend,
she would have somebody to take care of her and keep her safe
when these things happened. He then offered to be her

boyfriend. Tiffani did not say anything, but when Donald then
offered to give her a ride, she agreed and got in the car.
Donald took Tiffani to his apartment, explaining that the school
would be closed for hours. When they got to his apartment,
Donald fed Tiffani and gave her beer, explaining that it would
help keep her warm. Tiffani did not like the taste of the beer,
but at Donald’s insistence, she drank it.
When Tiffani was drunk, Donald began kissing her, and they
had sex. Tiffani knew about sex from school and some of her
girlfriends but she had never had it with anyone before. She was
grateful to Donald because he had helped her get away from
Nate and Jimmy. Donald had also told her that he loved her and
they would be together forever. Tiffani was also afraid that if
she did not have sex, Donald would not let her stay and she had
nowhere else to go.
For the next 3 days, Donald brought her food and beer and had
sex with her several more times. Donald told Tiffani that she
was not allowed to do anything without his permission. This
included watching TV, going to the bathroom, taking a shower,
and eating and drinking.
Donald bought Tiffani a dress, explaining to her that she was
going to “find a date” and get men to pay her to have sex with
her. When Tiffani said she did not want to do that, Donald hit
her several times. Donald explained that if she didn’t do it, he
would get her sister, Diana, and make her do it instead. Out of
fear for her sister, Tiffani relented and did what Donald told her
to do.
Key to Acronyms
GED: General Education Development
STI: Sexually Transmitted Infection
Tiffani and I met over the course of a year for individual
sessions. We talked often about her continued desire to be
reunited with Donald. We discussed what Donald represented
for her and why he was such an important part of her life. She
often described him as the person who “saved” her and felt she
owed much to him. She vividly remembered the fear she felt the

nights Nate and Jimmy touched her, and she was convinced they
would have raped her that last night. My efforts were to help
her recognize that Donald was not a savior, but someone who
did, in fact, rape her and then force her into prostitution. A lot
of time and discussion went into changing this cognition around
Donald and their relationship.
After about six months at Teens First, Tiffani said that she had
a strong desire to see her sister and her mother, and I helped to
arrange a family session at the agency. Tiffani and I talked
about what her hopes were for the meeting and her intent for
scheduling this session. Tiffani first and foremost just wanted to
see them and hug them. She had not seen either of them in over
two years and missed them very much. Tiffani also felt some
anger toward her mother that she wanted to able to share in a
safe environment. She said she felt that both her parents did not
do enough to protect her and that they should have known better
than to have let Nate and Jimmy into the house when they were
not home. She also said she felt her mother should have tried
harder to find her when she was with Donald. I wanted her to be
realistic about the potential outcome of the meeting, so I did my
best to explain that the session might not provide all of the
answers she hoped for. We were aware, through a conversation
with her sister, that her mother was still using drugs, and we
talked about how this might cloud her mother’s ability to
engage in a substantial conversation.
In the family session, Shondra was very critical of Tiffani and
her current situation. She ultimately blamed Tiffani for her
current state. When Tiffani confronted her mother about the
drug use and the lack of parental guidance and protection,
Shondra denied ever having used drugs. She told Tiffani she
was exaggerating and a liar and that neither she nor Tiffani’s
father ever put her in harm’s way.
Throughout our time working together, Tiffani utilized all of
the services at the agency and stopped trying to contact Donald.
She had learned that he had actually gotten married to one of
the other women that worked for him, and this made her very

angry. She has passed her GED test and started working at a
local fast food restaurant. She plans on applying to a community
college and a fashion institute.

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