2. Literature Review
Religious affiliated organizations (RAOs) such as The Salvation Army, and religious congregations such as churches and synagogues have long played a foundational role in the delivery of social services. Our beliefs about helping those in need have their roots in ancient spiritual teachings and these beliefs have influenced the development of American social welfare programs. As Garland notes, “Almost all modern social services can be traced back to roots in religious organizations” [3
Through history, religious organizations and congregations have provided social services for members while also acting as a voice for the poor and oppressed [4
]. Early Christians provided mutual aid and care to the needy. During the middle ages, religious organizations such as monasteries provided food, shelter, and clothing to individuals and families [5
]. In the 19th century, groups such as the Methodist Settlement Movement “staffed outreach programs to the most marginalized inhabitants of the inner cities” [6
]. Organizations such as the Baptist Training School Settlement provided services to the poor in the early 20th century [7
]. In addition, religiously affiliated organizations throughout the United States, such as urban ministry and Salvation Army organizations, have and continue to play a central role in the delivery of social services.
The leadership by religiously affiliated organizations in providing care has influenced not only American social welfare but also the development of the social work profession. Indeed, professional social work’s origins are found in the history of the rise and development of the Charitable Organization Society movement and the Settlement House movement at the turn of the 19th century, which were often affiliated or supported by churches [8
]. Faith-based social service delivery has long been an important system of care [10
] and the prominence of this delivery approach has received increased attention in the past twenty years as a result of Bush administration faith-based initiatives [11
Garland defines church social work as bringing “the social work’s profession’s knowledge, values, and skills to the church as a resource” [1
]. Despite the importance of religiously affiliated organizations in the history, development, and current delivery of social and health services, professional social work has often missed opportunities to join with these organizations in the delivery of services [14
]. While social workers in medical settings have recognized the spiritual needs of patients and the importance of collaborating with clergy, social workers in child and family settings, mental health, and schools have been less active in this collaboration. As Manthey notes, during the modern development of the social work in the 20th century, there has been a drive for professionalization and a separation from volunteerism and religious-based service delivery [15
]. This missed opportunity has been historically reinforced in social work education. Only in the past twenty years has the social work national accrediting agency, the Council on Social Work Education, required curricular content in spirituality as part of all Bachelor of Social Work and Master of Social Work programs. Despite the historical and current contributions religiously affiliated organizations have made to social work, recent research shows that building new partnerships can be challenging [16
Research has shown that individuals and families often seek help from their pastor or church staff when facing unemployment, family dysfunction, and poverty [17
]. However, church leaders may not always be skilled in recognizing or meeting the mental health needs of members. In addition, research has shown that church staff members rarely make referrals to mental health professionals [18
]. Low levels of collaboration among professional social workers and religiously affiliated organizations and resulting low referral rates have expanded the professional distance between social work mental health professionals and clergy [19
]. Social workers have been slow to embrace the importance of spirituality to many clients, while clergy do not always recognize the need for referral. Although there are exceptions opportunities for collaboration are being missed which result in low levels of service provision to people in need [20
On the other hand, there are opportunities and needs for increased collaboration. Historically, social workers are taught in their educational programs to “start where the client is”. Given the number of people who prefer seeking help in their religious organization, there are opportunities for social workers to more effectively meet health and mental health needs by reconnecting professionally with faith organizations [21
Prior research has shown that clergy are concerned about the health needs of their members. Clergy support for specific programming such as health screenings, prevention interventions, health education, and health-related classes is strong [23
]. This support provides opportunities for effective service delivery, student education, and interdisciplinary practice with congregants. Given the historical and current importance of religiously affiliated organizations in meeting the needs of people and the fact that the very roots of professional social work reflect a partnership with religious organizations and communities, social workers must work more diligently to embrace the historical importance of the religiously affiliated organizations and the significance that spirituality plays in peoples’ lives [1
]. In the current environment of sweeping changes in health and mental health delivery while continuing to face budget retrenchment, opportunities and potential benefits for collaboration are great [25
]. Such collaborations require a mutual respect for the contributions of religiously affiliated organizations, the pressures faced in meeting congregant needs by pastors and other religious leaders, and a commitment by social workers to include the importance of spirituality and collaboration with religiously affiliated organizations in everyday social work practice.
In addition to the consideration and inclusion of spirituality, social workers and social work students must begin to understand and access the vast resources that may be a part of the ministries of many community congregations. For example, the Congregational Social Work Education Initiative students have become very aware that local churches will often help with the purchase of needed medications or assist with paying utility or grocery bills for the people being served. Social welfare assistance has never really left religiously affiliated organizations but many social workers have historically relied on secular social services agencies in accessing resources. Now, churches are often at the forefront of providing food, fiscal assistance, and shelter in some cases. As exemplified by the history of the Cone family below, religious traditions often emphasize acts of philanthropy and community service. It is very important for social workers and social work students to recognize the potential to access and enhance resources by building relationships with religiously affiliated organizations at the local and regional levels in particular. No longer can social welfare be regulated to departments of social services or secular charitable aid organizations. Congregational Social Work Education Initiative students are encouraged to work closely with religiously affiliated organizations in order to foster strong relationships so that the people served have access to resources. The fact that CSWEI has become a part of the effort to enhance the health and wellness of the community it serves reflects the principles of the Cone family and the Cone Health Foundation. The time has come to re-imagine possibilities and to explore partnerships between religiously affiliated organizations, social services, and social work education.
3. The Cones: A Legacy of Care and Concern for Community
The Cone Health Foundation’s mission to support and develop activities, programs and organizations to improve the health of people in the greater Greensboro area is inextricably linked to the legacy of Moses H. Cone and Cesar Cone of Greensboro, NC. Both were visionary industrialists, establishing their leadership in textile manufacturing, international trade, finance, and philanthropy. Their American story is the story of a second-generation Jewish immigrant family’s experience in the South. Through their father’s values of hard work, love of family, and building relationships outside the Jewish community, Moses and Cesar Cone exemplified Jewish values and humanitarian ideals in business and civic dealings as they built their successful textile empire.
They drew upon their experiences as “drummers” or salesmen traveling across the South from Maryland to Alabama after the American Civil War for their father’s wholesale grocery and dry goods business located in Baltimore. They called upon merchants and small mill operators who often had little cash to purchase goods; they bartered taking cloth as payment, in-turn selling it to other customers in their travels. After taking over their father’s business in 1879, they recognized that with expanding railroad lines, merchants could re-stock their merchandise easier by rail; the elder bother Moses looked for other options. Moses Cone did not want to go into textile manufacturing but he seized the opportunity to reorganize textile manufacturing by assisting distressed small mill operators, many who had been former clients, by stabilizing textile prices and acting as an agent to sell their goods across the United States and overseas [26
]. The Cone Export and Commission Company was founded in 1891 with offices in Greensboro and New York City, expanding with twelve offices in major American cities. When the mills could not provide enough finished textiles, especially denim, Moses Cone saw the opportunity to build their own mill to complete the full process from processing raw cotton to producing a finished product.
The Cone brothers had explored locating their mill in other locations but Greensboro’s civic leaders appealed to the brothers to locate adjacent to their city in their desire to expand its economic base to build its reputation in the state and region. Greensboro had always been known as a tolerant and welcoming city. Authors attribute this to the early Quakers, Moravians, and Presbyterians, who settled the area prior to the American Revolution, and their experiences with discrimination and hostility toward their religious tenants and practices. These and other faith traditions had a positive respect for the small number of Jewish merchants in Greensboro and other small nearby towns [28
]. The city leaders envisioned such a large mill could provide needed jobs for small farmers and tenant farmers and their families, many of whom were leaving rural areas seeking better living and work opportunities.
In 1895 Proximity Manufacturing Mill was opened for the production of denim. Greensboro offered multiple advantages—lower labor costs, affordable land for mills and housing, water for hydro-power, low freight costs with seven rail lines converging in the city; it was the ideal location where raw cotton could be shipped in and finished products shipped. They would open other mills to meet increasing demand for denim, flannel, and other finished textiles. Revolution Cotton Mill opened in 1899 and their largest, the White Oak Plant in 1902. Unfortunately Moses Cone died in 1908 at the age of 51; Cesar Cone carried on the work building Proximity Printworks in 1912 and entered into the lucrative long-term contract supplying blue denim to jean maker Levi Strauss in 1915. Younger Cone brothers would join and continue managing the family enterprises [31
Lucius Wedge’s assessment of Moses Cone’s rise from merchant to industrialist to become America’s “Denim King” noted his ability to adapt quickly to the ever-changing elements in textile manufacturing and maintaining his work force [33
]. Most laborers in the early mills were illiterate, often tenant farmers, making attempts to escape rural poverty. Since mills were often built away from cities to take advantages of land and water resources, the brothers too developed separate “mill villages” to house workers, families, and provide a decent standard of living through efforts to enhance health, educational, religious, and social opportunities.
Historians and researchers have denounced many Southern mill towns, built by mill owners and operated by mill superintendents, as paternalistic and authoritarian models to exploit workers [29
]. Overall these mill families faced grinding poverty with poor work and living conditions; they suffered from pellagra, poor sanitation, substandard street maintenance, lack of health care for infants, or assistance when sickness or injury occurred [31
]. Mill owners hired ministers for church worship with sermons built around the themes of duty to the master, hard work, and acceptance of the social order [35
Moses and Cesar Cone did take a paternal role in their villages; however, they believed the welfare of their workers and families was as important as volume and profits. In his examination of Jewish business, families, and civic engagement in the South, Eli Evans noted Moses and Cesar Cone “believed that a better community for everybody was a better community for the Jewish people.” [28
]. Balliett chronicled the expansion of the Cone business and how they attended to the physical, spiritual, health, education, and well-being of their workers and families [32
]. Since building their first mill outside Greensboro in 1895, five self-sufficient villages were built to serve workers in its factories. At their peak, the villages covered 450 acres and housed 2675 workers in about 1500 houses. For African-American workers a separate mill village was built along with their school, church, and recreational center. Boarding houses for single men and family housing was constructed. Houses consisted of four to six rooms, for a nominal monthly rent of $1 per room, this included electricity and sanitary water. Each village company store provided wood and coal at absolute costs; dairy, beef, pork, flour produced on company farms were offered at prices below those charged by local merchants along with other food staples, household goods, and clothing items at prices below town prices [32
]. Each house sat on a large lot, with many residents having their own poultry house to supply eggs daily and chicken for the Sunday table. Canneries were provided in each village where residents could preserve fruit and vegetables raised in their home gardens. As the villages were incorporated into the city, by the late 1940s workers could buy their houses and join others in private homeownership [38
An organized “welfare department” was built using the new professional disciplines of nursing and social work to provide services and programs to enhance family and community life. Classes for expectant mothers, well-baby clinics, dental clinics, physician visits were provided for sick or to attend work injuries. Social workers and nursing provided classes on sanitation, the domestic areas of cooking, sewing, canning, and food preparation. Cesar Cone was especially supportive of the Y.M.C.A. movement’s ideals to develop personal character, leadership, and career aspirations for youth [27
]. Two separate large facilities were erected for social, recreational, organized sports teams, and academic activities; women and girls could access the gymnasium and in-door pools for their organized games and clubs. Community wide activities were planned by village representatives along with Y.M.C.A., teachers, and staff from welfare department, with such activities as holiday celebrations, children summer camps, day trips to mountains, music or band concerts from their own glee club or the 18–20 piece Cone Memorial Band ensemble [32
Both brothers believed in the importance of education, finding existing schools in the county to be inadequate in size, ill-equipped, and lacking competent teachers. They built schools in each village, hired and paid university trained teachers, instituted a nine-month school term, and encouraged workers to send their children to the schools and kindergartens. Night classes for adults offered reading, arithmetic, applied textile mechanics to encourage advancement plant and middle management positions. Women were encouraged to take classes in reading, writing, mathematics, and domestic sciences. New “departments” grew in the plants allowing new opportunities for men and women in such areas of technical writing, merchandising, shipping, secretarial work, and bookkeeping [26
The brothers provided land to build six churches in the mill villages, constructing one for African American residents, and providing monies to an established congregation close to one village. The company provided major financing to erect these buildings; later provided lots and paid entirely for construction of their parsonages. Protestant faiths of Methodist, Baptist, and Presbyterian were represented and followed their denomination’s practice of selecting ministers and governance. These churches continue to operate today [32
As noted, Moses H. Cone died at the age of 51 in 1908 without a will. He and his wife Bertha Landau Cone had no children. In settling his estate, his wife received 50 percent, and the remaining divided equally between his surviving brothers and sisters. Shortly after her husband’s death, Bertha Cone’s desire was to memorialize her husband by envisioning a modern hospital in Greensboro to serve its citizens, and to reflect the family’s humanitarian ideal of service to others and the greater community [33
]. This was written into the hospital’s articles of incorporation dated 1911, “that no patient be refused admission nor discharged because of the inability to pay.” Bertha Cone’s gifts consisted of real and personal property, and her company shares with the proviso of reserving the income for her lifetime. She deeded 67 acres of land in Greensboro to locate the new hospital. Monies to construct and operate the hospital would come from using funds from her portion of the estate [39
]. Their mountaintop estate, consisting of a manor house and 3600 acres near Blowing Rock, NC, also was deeded to the trust to be operated as a public park. During Moses Cone’s lifetime, visitors could wander the landscaped paths, flower gardens and orchards. He had provided money for the Watauga Academy, which evolved into Appalachian College and served on its board of trustees. Bertha Cone would live another forty years. Upon her death in 1947, the available money for the construction of Moses H. Cone Memorial Hospital was reported at fifteen million dollars [33
Moses H. Cone, a first generation Jewish American, followed the tenants of his faith along with the business practices of his father Herman Cone who had emigrated from Bavaria in 1846 at the age of 17. His oldest sister’s husband Josef Rosengart wrote a letter to Herman before his departure for America, which remains one of the family’s cherished possessions (Moses H. Cone Memorial Hospital Archives). In it his brother-in-law admonishes him to keep to the teachings and values of the Jewish faith, follow the commandments, continue prayers and to keep the Sabbath. It further directs, he be modest and polite to all, assist relatives and others, and “should you be lucky to become wealthy, do not let it make you proud and overbearing…use it for doing good and for charity.” Furthermore, it states “do not become known as a miser, be known as a philanthropist…be particularly liberal toward the poor and charitable to the needy…give assistance to the distressed.”
Moses H. Cone, his siblings, and descendants have lived by the principles given by the family patriarch in 1846. His philanthropy and that of the family, past and present, contributed to the cultural and social growth of Greensboro. Their support can be seen on the names of school buildings, buildings on area colleges and university campuses, parks, support for museum, theatre and music events as well as their present representation on boards, committees, and civic groups serving the greater community. Additionally, the efforts of the Cone family to promote health and well-being were brought to fruition with the formation of the Cone Health Foundation, which seeks to be a “primary catalyst providing leadership for overcoming selected health barriers through investment and partnership” [42
]. Founded in 1997 and following the traditions of community concern and philanthropy in the Cone family, the Cone Health Foundation is a key source for supporting the development of innovative efforts to address the Greater Greensboro community. Thus, the Jewish-based faith traditions practiced by the Cones are overarching in the work of the Cone Health Foundation, and these traditions directly impacted supporting the vision to engage in partnership with congregations, RAOs and congregationally-based nurses in order to educate future generations of social workers.
The religiously based traditions that influenced the Cone family of supporting well-being, community cohesion, creating opportunities for those in need, and promotion of healthy living are alive and well in the CSWEI and CNP programs. As each program weaves the services and supports they provide together in tandem with congregations and faith-based entities, it is quite evident that religious-based traditions are embedded in the foundations of the social services that are being delivered. The legacy of the Cones also is evident in the philanthropic efforts of the Cone Health Foundation and its focus on supporting a healthy community. While most would not acknowledge that religion-based values and beliefs are present in many social service delivery systems it appears that they indeed are often present and in the case of CSWEI and CNP, they are at the heart of who is served, why they are served, and how funding is garnered in order to serve. Perhaps it is important not to discount the impact of religion-based values, beliefs, and practices; rather, look for how they positively influence social services and how they can by embraced as we educate future human services professionals.
In the recent past, social work education has not embraced religion, religion-based approaches to care, or religiously affiliated organizations as primary or even secondary locations for the delivery of social services despite the fact that students have a generally favorable view of religion and spiritually-based approaches [43
]. While calls to join with RAOs in order to educate social workers and deliver social services have been heard, they are not always answered or embraced. Yet, we know from examining the history of social welfare that religion and RAOs have long been affiliated with efforts to address the health and well-being of people. Certainly, there are examples of RAOs, congregations, and religious traditions that seem to be antithetical to social welfare; however, at a foundational level, many religious denominations and traditions hold philanthropic and service efforts in high esteem. While attempts to engage social work students in considering the impact of religion and religiously based organizations on the lives of the people they will serve are positive, there is little to no evidence in the literature about how social work education has embraced RAOs as a serious partner in applied social work education. Tirrito and Cascio call for a comingling of social work and RAOs and give an example of how the Korean Church successfully developed a model of social service delivery for its congregants; yet, there is no evidence that their calls were headed by schools or departments of social work in terms of getting students directly involved with congregations [44
]. Smith and Teasley, “...posit that the social work profession will stand as an instrumental link between the implementation of faith-based initiatives and the accountability of social service outcomes.” [45
]. Of course what remains to be seen is just how much social work education programs will entertain partnerships with RAOs in order to link professional development and evaluation to the social welfare efforts of congregations and faith-based entities. In their recent work, Garland and Yancey present a very comprehensive examination of the way social work is affiliated with congregations and they do point out that some social work education efforts use congregations that have a social work component as locations for field internships [46
]. What is more common is that social workers practice in congregational settings and may take on student interns in their practices. Interestingly, Garland and Yancey interviewed CSWEI staff while writing their 2014 book and expressed that the model was unique in their research, particularly the close link to congregational nursing. This lead to an invitation for CSWEI and CNP staff to participate in the 2015 colloquium Congregational Social Work with Persons 55+
sponsored by Baylor University, where the model was presented to attendees. Certainly there is room for more exploration of how social work education might partner with congregations, RAOs and other faith-based entities in order to serve the community while educating the next generation of professional social workers. An example of such a partnership exists in the Congregational Social Work Education Initiative.
Originally, the conceptualization of CSWEI came from several conversations about how to better support the congregational nurses in Greensboro. The model reflected that of parish nursing, particularly with the notion that services would be embedded in congregational settings to enhance ease of access. We searched for and found a program director that was both a licensed clinical social worker and a registered nurse. She remains the program director to date. Once hired, her first task was to construct a pre-service training that focused on behavioral health and substance use topics. Students are required to complete 40 h of pre-service education before they are placed in the field. Students work closely with the congregational nurses from a holistic frame. Additionally, students and nurses interface with congregational leaders as well as community providers in order to deliver the best quality care. Now, in 2016, with continued funding from the Cone Health Foundation, the CSWEI/CNP model has achieved recognition as an innovative approach to social work field education as well as a unique community-based approach to address health and wellness [2
]. Working closely with nurses, students are active in nearly 30 congregations and 3 faith-based organizations in Greensboro, NC. Over 100 students have successfully completed their internship requirements by participating in the Congregational Social Work Education Initiative. Since it first began in fall semester 2007, CSWEI students have made over 13,982 referrals to other provider agencies, served over 4452 individuals, and provided 8222 service hours. In fall 2012 formal mental health risk-assessments were tracked; the demand has grown from an initial 22 to 210 during the 2014–2015 academic year. Using 2015 North Carolina Medicaid rates, interns provided over $1,874,214 in direct service, if these were reimbursed. Of those served over 40% were over the age of 50 and 63% were male while 36% were female. In terms of racial and ethnic identity, 62% were African-American, 22% were Caucasian, 3% were Montagnard (Vietnamese), 3% were Asian (other countries), 1.5% were Latino/Latina, and 0.7% were African. Income level averages include 54% with incomes less than $499 per month, 21% between $500–999 per month, and 13% between $1000–1499 per month. Since 2010 an increase for housing assistance was noted in the referral process: 192 people were served who were 50+ and reported having no permanent housing. The greatest needs reported by the people served included social service assistance, housing, food, medical concerns, and short-term mental health services. CSWEI emphasizes interdisciplinary, collaborative approaches to serving people in need. Currently, CSWEI is engaged in community efforts to enhance integrated care models and create new ones by partnering with medical and mental health organizations. Clearly, this project is serving people with great needs while working closely with local congregations, religiously affiliated organizations, medical and mental health clinics, and the Congregational Nurse Program. An additional grant from the Cone Health Foundation has expanded the focus of CSWEI with emphasis on people who have co-occurring mental health and substance use disorders. In this program, students work with a behavioral health nurse in conducting screenings and assessments as well as brief counseling and psychoeducation. Additionally, students create educational modules that are focused on mental wellness and health literacy. In order to ease barriers to access these modules are presented in community locations, including congregational settings. Through close work with nurses, clergy, congregants, and other staff of religiously affiliated organizations the students in CSWEI have a well-rounded experience, which is made possible through the support of the Cone Health Foundation.