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Chapter 1
Introduction
This book grew out of discussions with students training to be clinicians at Smith College School for Social Work. They valued their psychodynamic clinical training but recognized that it omitted the element of social action that had attracted many of them to the profession. They were disturbed that advocacy and social action, asserted in the profession's values and ethics, were generally absent and sometimes discouraged in the training they received, and that their training was dichotomized. This historical dichotomy between clinical work and social action, between the approaches of Mary Richmond and Jane Addams, continues today in social work schools and social agencies, despite lip service to the contrary.
Our students identified the contradiction (a central concept for us) between their own and the profession's values, theories, and practice. We shared and were encouraged by their concerns. At their urging, we designed an advanced elective course, given for the first time in 1992, that attempted to resolve the contradictions we were all experiencing. This book, including its title, grows out of that course.
A social work student placed at a family service agency in a major city records a typical clinical encounter (see Appendix A for a full transcript of the process recording):
Mary, the client: Let's see. Where to begin? I'm really concerned about my boyfriend [Larry]. I don't know where to start. I guess I'm mostly concerned about the fact that he's gotten a hold of a handgun and, well, he's been acting pretty strange lately.
Worker*: So, you're concerned about what he might want to do with a handgun?
Mary: Yeah. It was weird. Things have not been going well for him.
(Client proceeds to tell that her boyfriend has lost his job, and as a result will have to quit school because work was subsidizing his coursework. Although the client has been distancing from this boyfriend for the past two months, and they have had fights, she felt sorry for him and went to his apartment to console him on Saturday.)
Most reasonably, the worker's first response was a question related to the client's personal safety. This intervention was supported both by the supervisor in her marginal notes and, subsequently, our class's beginning discussion about the case. All reasonable clinicians would want to engage the real potential for danger to the client. All good clinicians, we would expect, would see this as necessary and many, if not most, would see this as sufficient. The client's safety needs to be assured.
This approach, however, omits a major concern expressed by the client in her first statement. Specifically, she was "really concerned about my boyfriend." The concern she expressed was both about his possession of a handgun and about his well-being. He lost his job and had to leave school. To respond to the full range of client concerns would require being open to larger social and economic issues such as layoffs, domestic violence, social class, unequal access to education, and availability of handguns, among others. The worker would have to engage the client in discussion of both the social and individual issues the client raised. These discussions would move us to work on individual and social action levels simultaneously: to bridge the false dichotomy between clinical work and social action.
Our objective is to develop a model of practice that integrates clinical work and social action for human service workers. Practice takes place where intrapersonal, interpersonal, and institutional forces come together. The interaction between and among these forces precipitates effects within workers, clients, agencies, and other institutions and organizations that are connected to the process of work. A worker's awareness of the personal and institutional forces will direct him or her to the structures that need to be changed to accommodate the needs of particular clients. For example, an agency's intake structure may encourage or discourage a person's willingness to become a client. This would depend on the "goodness of fit" (Germain and Gitterman, 1980) between a client's needs and personality and the agency's structures and procedures.
Though we would reverse the order, we agree with those scholars who have emphasized that a practice model seeking to affect the psychosocial interface ought to be "under the conscious guidance of knowledge and values" (Gordon, 1962, p. 5).
No practice is value free. In all clinical encounters, there are a multitude of possible interventions. The choice of intervention a given worker makes reflects many complex forces. These include the worker's values, theories, experiences, training, feelings, and ideas as well as an agency's goals, structures, and policies. In addition, the needs and interests of funding sources, including third party payers, licensing bodies, and policymakers have an impact. Finally, other social forces including racism, classism, heterosexism and sexism are in the mix that influences a worker's interventions.
Similarly, no theory is value free. Theoretical ideas reflect prevailing social, economic, and political interests. The current dichotomy between clinical work and social action serves particular institutional interests. Individualizing problems and solutions deflects attention from wider social forces as a cause of personal and social problems (Mills, 1961). For example, homelessness is blamed on mental illness, substance abuse, or personal failure rather than declining funding for affordable housing and lack of employment (Blau, 1992).
Maintaining the dichotomy between clinical work and social action is a practice that maintains the politics of the status quo. It focuses the worker's and client's attention on a client's private troubles (Mills, 1961). Bridging the dichotomy develops a practice that includes the possibility of social change. It focuses a worker's and a client's attention simultaneously on the client's (and worker's) inner world as well as how the inner world reflects social institutions (Fanon, 1967). This connection points to possibilities for linking social action and clinical work. It also opens the door to changing the social institutions and structure of a society. For example, in the model that we propose, an unemployed highly skilled client who could not pay an agency's fee would not immediately be seen as "resistant." He or she more properly would first be seen as just not having money. The worker would need to consider problems in the political economy that foster internalized oppression, diminishing the client's self-esteem, and arousing anger against an agency that defines the effects of social issues as a personal weakness or deficit.
Rarely has the psychosocial interface actually been the central focus of values, theory, and practice. Rein and White (1981) noted that knowledge, and we add values, rather than informing practice, is used primarily as a justification for practice. "[Values], knowledge, and practice are split." For example, "burnout" and "hard-to-reach client" are concepts that deflect attention away from racist and classist values as well as social issues that cry out for deep reflection and action. In a model that truly takes account of these issues, this reflection would call forth strategies of social action as part of clinical work.
We need both a clearly defined value base that will inform the vision, mission, goals, and direction of practice and a theory or integrated set of theories that will provide the knowledge a practitioner needs to do good workāclinically and politically. A practice model and/or the practice of any practitioner can then be observed to conform to or conflict with these values and theories. Finally, a method to observe and address contradictions must be an integral part of this model.
It is our conviction that the theories we choose to inform our practice must be those which are consistent with our values and that our practice must be consistent with both our values and our theory. We underscore this point because, to the best of our knowledge, current practice theories express a commitment to this formulation but have not carried it out.
What follows is a summary of the values and knowledge that are central to informing our practice model. We offer several key ideas and concepts, many of which highlight contradictions in work with clients and classroom teaching. This will provide the context for the in-depth discussions and analyses of theoretical issues and case material that will be presented in this book.
Values
The central values we propose to direct and guide practice are as follows:
- Self-determination of communities, groups, families, and individuals. This implies both knowledge of one's world and the means to act on it (Freire, 1989a). The clinical encounter is a setting in which this ought to be realized.
- Economic and political justice. It is our contention that social justice, a term used with great regularity, if not clarity, in the human services, is meaningless without political and economic justice. Our model for economic and political justice draws heavily on politically progressive formulations.
- A belief and commitment to dialogical praxis (Freire, 1989a). This is a process of action and reflection between two Subjects (people who accord each other equal worth) who meet to examine and transform their world.
These values reflect a commitment to work where psychological and social forces interact. They are rooted in ideas that value raising people's consciousness about themselves and the social institutions that affect their lives. They demand the exploration of unconscious processes at the intrapsychic level (Freud, 1915/1963c) as well as the processes that produce false consciousness about race, class, gender, sexual orientation, and ethnic issues at the social-institutional level.
Obviously, there are other important values, which have a place in practice. These generally can be subsumed under one or another of the values noted above. For example, we see confidentiality as part of self-determination, and nondiscrimination included under economic and political justice as well as self-determination.
Theoretical Knowledge
Our model integrates phenomenological (Husserl, 1967; Schutz, 1967; Luckman, 1978), psychoanalytic (Freud, 1900; Langs, 1981; Fanon, 1967), symbolic interaction (Mead, 1934), critical theory (Florkheimer, 1937; Wiggershaus; 1994; Roderick, 1986; Marcuse, 1966, 1969), and their modern derivatives. These are the primary theoretical lenses we have chosen to use for analyzing the structures and dynamic processes that interact in practice. The selective use and integration of these theories will guarantee a close reflective inspection of practice in a way that is compatible with our values:
- Phenomenology forces the observer's attention to the structures and processes, both psychological and sociological, that interact constantly among individuals, families, groups, communities, and the institutional context that surrounds them.
- Psychoanalytic concepts and ideas provide a powerful tool to analyze unconscious structures and motivational processes of the individual.
- Symbolic interaction theory provides an understanding of the ways in which the contents of the social world are internalized by the individual, including the internalization of the social world into the individual's unconscious.
- Critical theory provides a powerful analysis of the social structure and its effects on the lives and consciousness of individuals, groups, families, and communities.
Integrating and using the seemingly disparate ideas of such a wide range of theorists and theoretical formulations need not dissuade us. It can actually facilitate a fuller understanding of the interaction between psychological and social forces. For example, Smelser (1973) noted:
some formal parallels in the thought of Karl Marx and Sigmund Freud. Both their theories concern a system that maintains an equilibrium-in-tension between conflicting forces. For Marx, the tension is expressed at bottom in contradictions between the mode of production and the social relations of production, but manifests itself in the antagonism between two classes. For Freud the tension is between instinctual impulses (the id), and various personality establishments engaged in the management and control of these impulses. . . . Both theorists stress, moreover, that the main strategy for control is a form of repression, political-economic in one case and psychological in the other. Furthermore, in each case the repressive forces are buttressed by a number of ancillary devices that lead to distortions of reality and consciousness. For Marx, one of the main functions of religion, philosophy, morality, and so on is to disguise the true interests of the workers, and to contribute to a false consciousness in them; for Freud various mechanisms of defense such as projection, isolation, rationalization, and displacement distort the true nature of the impulses and obscure them from the individual. For Marx, moreover, the structure of society results from the efforts of the dominant class to save itself from the destructive impact of societal contradictions; for Freud, the structure of the personality (character traits, symptoms, and so forth) is geared in large measure to saving the individual from the d...
