Advancing Social Justice Through Clinical Practice

Etiony Aldarondo, Etiony Aldarondo

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781135601874
• Edition: 1
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

There is a healthy development in the human service professions these days. At community clinics, private practices, and universities around the country mental health professionals and service providers are working with increased awareness of the toxic effects of social inequities in the lives of people they aim to help. Quietly, by acting out thei

PART

I

STEPS TOWARD A SOCIAL JUSTICE THERAPEUTIC PRACTICE

CHAPTER

1

Rekindling the Reformist Spirit in the Mental Health Professions

Etiony Aldarondo
University of Miami

Vladimir: Let us not waste our time in idle discourse. Let us do something, while we have the chance! It is not everyday that we are needed. Not indeed that we personally are needed… To all mankind they were addressed, those cries for help still ringing our ears! But at this place, at this moment of time, all mankind is us. Pozzo: Help!

Vladimir: Whether we like it or not. Let us make the most of it, before it is too late!… It is true that when with folded arms we weigh the pros and cons we are less a credit to our species. The tiger bounds to the help of his congeners without the least reflection, or else he slinks away into the depths of the thickets. But that is not the question. What are we doing here, that is the question. And we are blessed in this, that we happen to know the answer. Yes, in this immense confusion one thing alone is clear. We are waiting for Godot to come.

Estragon: Ah yes!

Samuel Beckett, from Waiting for Godot (Knowlson, 1993, p. 73)

When Samuel Beckett wrote Waiting for Godot in the late 1940s, the world was going through a time of considerable confusion and apprehension not unlike our current times. World War II made clear that we have an extraordinary capacity for destruction, which is only surpassed by our desire for power and domination. Beckett knew then what many mental health providers learn as they witness people's suffering and attempt to help them live better lives, that our commitment and effort to promote wellness and happiness seem absurd in a society so capable of negating them. We live in a society with unprecedented levels of material comfort, luxury, and safety. Ours is also a society where half of the citizens are expected to meet criteria for a mental illness at some point in their lives and where “[p]sychosocial problems are the single most common reason for consulting a doctor, and the largest group of drug prescriptions are for psychoactive drugs or painkillers to help us cope with depression, anxiety, sleeplessness, and so on” (Wilkinson, 2005, p. 4).

Care, justice, equality, and dignity are foundational values of our society that are embraced by the mental health professions (i.e., clinical psychologists, counseling psychologists, family therapists, psychiatrists, psychiatric nurses, and social workers). We know this and try to practice these values while being aware that a small number of families own the overwhelming majority of the country's financial assets; that the income and wealth inequality in the United States is wider than it has been for 50 years; that poverty and inequality are the strongest determinants of health problems in our nation; that more than a third of our people do not have medical insurance; that about a third of the insured do not have enough to cover the cost of medication; that the average life expectancy is much shorter for people living in poor communities compared with those of the richest neighborhoods; that mental health problems are extremely unevenly distributed across our communities according to class, race, and gender; that people of color are significantly overrepresented in our prisons; that children in public schools spend much of their classroom time preparing for “high-stake tests,” whereas children in private schools enroll in “enriched” curriculums; that women continue to earn considerably less than their male counterparts and that more than a third of them will be victims of domestic violence during their lifetime; and so on.¹ There is no question, as Kovel (1981) asserts, to practice psychotherapy in our society “is to be enmeshed in contradictions” (p. 252).

Over the years, I have come to believe that good mental health professionals are neither strangers to the pervasive presence of inequality and injustice in our society nor are they naïve about its effects in the inner life of people. Most competent clinicians try to do the best they can in a context that favors restrictive biologically oriented services while state and federal governments aim to thin down their historical responsibility to care for their most disenfranchised citizens. Not surprisingly under these conditions, an increasing number of therapists from different persuasions, like Vladimir in Beckett's play, have been asking out loud “what are we doing here?” (e.g., Albee, 2000; Doherty, 1995; Fratarolli, 2001; Hillman & Ventura, 1992; Miller, 2004; Richards, 2004; Richardson, Fowers, & Guignon, 1999).

This brings me back to Beckett's Waiting for Godot The play consists of two similar acts. Vladimir and Estragon meet beside a bare tree to wait for Mr. Godot. They vaguely remember doing this before, but don't dwell on it. We know, however, that they have been there before. They share some general concerns in their lives and amuse each other with stories. They want help for a problem, which they hope will be resolved by Godot. Then they meet Pozzo, the owner of the area, and Lucky, his slave, pulled by his master with a piece of rope tied to his neck. Pozzo amuses the waiting pair before cruelly ordering Lucky to entertain them. After enduring considerable abuse from his master, Lucky produces a stream of meaningless words. Vladimir and Estragon demand better treatment of Lucky, who responds with anger and attacks them, kicking Estragon. Vladimir and Estragon then help Pozzo get an agitated Lucky under the control of his master. Pozzo and Lucky leave, and a young fearful boy who had witnessed much of this brutal event comes by to tell Vladimir and Pozzo that Mr. Godot “won't come this evening but surely tomorrow.”

Act II takes place the next day. Vladimir and Estragon wait near the tree, which now has leaves. Estragon does not remember much of what happened the day before. They chat and keep each other busy while waiting for Godot to show up. Vladimir gets a better hat and Estragon a more comfortable pair of boots. Pozzo and Lucky walk by, but this time Pozzo is blind and Lucky is mute. The boy comes back again to let them know that Godot would not be coming today but tomorrow. Vladimir and Estragon, feeling despair, talk about leaving for good or coming back tomorrow, which is what we are led to believe will happen.

Beckett knew not only of the profound paradox faced by Vladimir and Estragon, but also of the deforming consequences social injustices and internalized oppression have on our individual, relational, and communal life. Lucky's voice is lost, the slave master can no longer see, Estragon forgets, and Vladimir tries to make sense of it all. They all need help, but who would do it? Why? Doing nothing is an option that brings only minimal comfort to Vladimir and Estragon but to no one else.

In my interpretation of Beckett's play, Pozzo and Lucky are like many people who end up in our offices and clinics looking for help—some do not see how their actions are oppressive and destructive to themselves and those around them, and others seem unable to articulate their struggles and suffering. Estragon embodies people in insurance companies, mental health agencies, and training programs who have a very short memory for social inequality and injustice and as a result are not troubled by focusing on their comfort first. Vladimir represents a large number of good mental health professionals who know that something is wrong, feel like it is their responsibility to do something about it, but are not clear about what to do and are missing the encouragement, training, and support to risk doing something that may be better than waiting for Godot to come with the one solution, the one study, or the one policy that would make things better. This book was designed in part to assist and empower these clinicians to act.

To be sure, the preference to circumvent the humanistic inclination to act when faced with social injustices and inequities is not unique to mental health professionals. Indifference to the misery of others and failure to take corrective action are forms of “passive injustice” all too common in our society (Shklar, 1990). However, unlike other participants in our society, mental health professionals have proclaimed a commitment not only to witness and decrease human suffering, but also to promote human values of equality and justice. And, our ability to fulfill this commitment is constantly being tested within the current system of mental health care.

This book attempts to transcend the conclusion to Beckett's drama within the mental health professions by disseminating the insights of clinicians and trainers who have been making a deliberate effort to address both individual suffering and social inequities fueling this suffering. Writing from various vantage points within the system of mental health care in the United States, these authors aim to rekindle a reformist spirit, long present in our professions, while offering an array of conceptual and practical tools for the development of social justice-oriented therapeutic practices. As prelude to the book, this chapter presents a brief history of efforts made by social justice-oriented clinicians to promote forms of mental health practice responsive to the social realities of those we serve.

SOCIAL JUSTICE LEGACIES IN THE MENTAL HEALTH PROFESSIONS

For many clinicians and students today, the expression of social justice concerns and aspirations in the field of mental health is synonymous with the work done by feminist therapists and community psychologists. That this would be the case is not surprising because, for decades, these groups have persistently reminded us of the need to understand people's lives within the social contexts in which they develop, highlighted the political nature of mental health problems, and advocated an activist stance for human services providers and scholars (e.g., Brown, 1993, 1994; Rappaport, 1981). Moreover, feminist therapists and community psychologists continue to play a leadership role in the development of social justice-oriented theories and practices (e.g., Enns, 2004; Nelson & Prilleltensky, 2005; Prilleltensky & Nelson, 1997; see also chapters by Perilla, Lavizzo, and Ibanez, and by Goodman and her colleagues in this volume).

The history of social justice oriented practices within the mental health professions, however, is considerably broader in scope. Every major discipline in our field today includes important social justice legacies, which have remained largely absent from our institutional memory (e.g., Cushman, 1992; VandenBos, Cummings, & DeLeon, 1992). Lack of awareness about this history is, in our view, a significant obstacle to the growth and development of social justice-oriented theories and practices. We present here a selective review of social justice legacies in social work, psychoanalysis, counseling psychology, psychiatry, and family therapy with the dual purpose of helping readers appreciate the commitment and struggles of previous generations of social justice-oriented clinicians and locating the contributions included in this volume within their appropriate historical traditions.

Social Work

Social work is arguably the discipline with the strongest tradition of commitment to social justice concerns and ambitions among the mental health professions. According to social work historians (Reisch & Andrews, 2002; Specht & Courtney, 2000), the field was born in the context of the charities and correction movement and the settlement houses of the late 19th century and their efforts to promote charitable giving for the poor, community and trade union organizing, and safety, health, and labor legislation among other things. Later during the Great Depression of the 1930s, social workers formed the rank and file movement (Fisher, 1936, 1980), which was critical of New Deal programs aiming to reduce social unrest without directly addressing the social inequities of the time. In addition, rank and file members “organized unions among social service workers, published a radical journal, Social Work Today (1934–1942), initiated local political discussion groups, and supported labor unions and organizations of unemployed workers” (Gil, 1998, p. 83).

During the 1940s and 1950s, the reformist spirit of many social workers was tempered in part by the government's effort first to undermine suspected “left-wing groups” and later in the McCarthy era to persecute anyone suspected to be communist or “communist sympathizer.”² Facing negative consequences for themselves and their loved ones, many social workers, like many other dissenting voices at the time, kept their social justice concerns and aspirations to themselves (Reisch & Andrews, 2002).

In the 1960s, the social justice spirit of social workers was again openly expressed. As Gil (1998) says, in the 1960s

a social justice orientation reemerged among social workers, under the influence of civil rights, peace, and feminist movements. Social workers became involved in community organizing in antipoverty and Model Cities programs, and in the Welfare Rights movement. These unconventional practice experiences led to a renewal of a radical critique of capitalist society and culture … The critique stimulated the founding of local networks of radical human service workers and of a socialist journal, Catalyst, which, was published by a social workers’ collective for about ten years before being reorganized in 1998, as The Journal of Progressive Human Services, (p. 84)

In the past three decades, even as a mix of corporate and socially conservative ideologies has swayed the country and the privatization of social work services has grown (Specht & Courtney, 2000; Wakefield, 1988), concerns about equality and justice have continued to fuel the development of structural, radical, empowerment, and anti-oppressive models of social work (e.g., Bailey & Brake, 1976; Finn & Jacobson, 2003; Gil, 1998; Gutierrez, Parsons, & Cox, 1998; Lundy, 2004; Mullaly, 2002). Although there are theoretical and practical differences between these models, they all highlight the debilitating role played in the mental health of our citizens by power imbalances built into the structure of our society and the importance of unmet material needs for psychological well being; they call for social workers to assist their clients in understanding the nature of these imbalances, developing skills to deal with oppressive social realities, redressing the negative impact of these dynamics in their personal and interpersonal lives, and promoting the development of strategies that link individual and social change. Chapters by Almeida et al., Kamya, Ackerson and Korr, and Reeser in this volume build on this reformist tradition in social work and expand on its implications for family therapy, narrative therapy, policy development, and training.

Psychoanalysis

Although many students and young clinicians today associate psychoanalytic theory and practice with the promotion of an ideology seemingly irrelevant to social justice concerns and aspirations, the development of psychoanalysis in Europe prior to World War II, psychoanalytic critiques of society in the United States in the aftermath of the war, and more recent social critiques of psychoanalytic practices³ provide testimony to a reformist spirit present throughout the history of the psychoanalytic movement.

The development of psychoanalysis in the years between World War I and World War II was characterized by strong links to political activism on behalf of the poor. “Freud always believed that psychoanalysis would release the reasoning abilities in oppressed individuals and that personal insight (combined with critical thinking) naturally led to psychological independence” (Danto, 2005, p. 302). For that to happen, Freud said in 1918, “treatment shall be free. The poor m...