Friday, August 12, 2011

Size Advocacy: An Inclusive Vision of Justice

Size Advocacy: An Inclusive Vision of Justice

Leah Krandel
New Orleans, LA
It became a question of airline seats.  It always becomes a question about something trivial like airline seats.  I told my fellow graduate social work students, the policy issue about which I care deeply is the inclusion of size as a protected category in anti-discrimination legislation. Immediately, my professor asked, “So, who should pay for the extra airline seat? What if you’re fat and need two seats, who should pay for it?”

“We should all pay for it,” I said.  Immediately, there was an outcry. “Why should I pay more for their bad choices?” etcetera, etcetera, insert comparison between fat people and smokers, here. 

I tried to reason with them.  I tried to explain to my classmates, “everyone’s bodies are just different. Discriminating against fat people is like discriminating against tall people.”  But they would not have it.  Vague, indignant references to “science” abounded- didn’t I know that if people are fat it is a) their own fault b) a choice?

I realize now my mistake.  I should never have engaged in that level of dialogue.  I know, and have supporting research, that fat is often just biology, and that while there are some studies that show a correlation between fat and negative health outcomes, there is not a causal relationship .  Furthermore, there are also studies that show a correlation between fat and positive health outcomes.  But that doesn’t really matter.

“Social workers elevate service to others above self interest…Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people .” Regardless of why people are fat, to allow fat folks to be marginalized and oppressed is a blatant disregard of our social work code of ethics. When we make ourselves the judges of who is “deserving” and “undeserving,” when we attempt to discern who is marginalized “by choice,” a socially just world becomes an impossibility, as does true adherence to our social work code of ethics. 

It is not our job to discern how “deserving” one is of full inclusion and support in our society.  It is our job to be critical of and to challenge a society in which people are thought to be “deserving” or “undeserving” of things such as respect, value, and support. It is our job, furthermore, to create the environment in which everyone can be included.  We are charged with creating a society that acknowledges, we are all different, we are all important, and we all deserve a goddamn seat on the airplane. 

[1] See, for example:

Parker-Pope, T. (August 13, 2008) “For health, body size can be misleading.” The New York Times. Retrieved from: http://well.blogs.nytimes.com/2008/08/13/for-health-body-size-can-be-misleading/?emc=eta1#comment-50695

Solovay, S. and Rothblum, E. (2009) The Fat Studies Reader. New York: New York University

2 National Association of Social Workers. (2008) “Social Work Code of Ethics.” Retrieved from: http://www.socialworkers.org/pubs/code/default.asp

Retooling Mental Health Models for Racial Relevance

Retooling Mental Health Models for Racial Relevance

Gail K Golden, MSW, EdD
Rockland County, NY

Psychotherapy has helped many people to fulfill their creative and productive potential. Yet, its core ideas and theories have White, European, patriarchal roots. Focusing on intrapsychic issues and individual pathology, most mental health theories have failed to incorporate an analysis of societal oppression into their understanding of human behavior. This failure has created a system which has sometimes done violence to members of marginalized groups by establishing Eurocentric and privileged notions of normal.

This violence can take many forms. One is the 'diagnosis industry', which categorizes people based on deficits, symptoms, and pathologies. When this perspective is filtered through the ever-present lens of white supremacy and privilege, people of color are as damaged by the Mental Health System as they are by every other system in this country.

We dehumanize people by failing to develop asset-based models which incorporate curiosity and respect about the survival skills which whole communities have had to mobilize in order to confront genocidal affronts to their being.

Credentialing is another aspect of white privilege which, though valuable in certain respects, does violence in other ways. Credentialing is a 'gate keeping' device which can exclude people with important cultural expertise from participating in program and policy decisions. This can result in impoverished and ignorant forms of treatment. (The term gatekeepers refers to people in organizations who control access to resources and opportunities.)

The umbrella concept which is pervasively harmful remains white supremacy: the idea white people of European descent unconsciously hold that deep down we are really better and smarter than other groups. Moreover, white privilege assures that we are the ones who define the rules, the terms, the labels, the treatment, the problems and the remedies. We distrust people from other groups to take a turn at the helm and we resist taking leadership from people who do not look like us. In what ways, then, can we assist other people to feel well and whole?

As white people, and thus members of the dominating group in this country, we have always been the ones who get to define 'normal'. As mental health practitioners, we then determine who is healthy and who is not, how we think families should function, when and how mental health interventions should occur. 'Undoing Racism' training provided by the People's Institute for Survival and Beyond1 enables one to review what one 'knows' through another set of lenses. As a result of this 'reviewing,' there are no easy answers. However, one gets much better at asking questions.

All persons in the United States who are perceived as non-white become part of the racial construct embedded in the history of this country. We must also acknowledge that African-Americans have a very particular set of historical experiences here. The following questions, therefore, have significance for all people of color seeking mental health services in the United States, and have particular relevance for African- Americans. This list is just a beginning.

* How do we know that the models of human development that we learn in social work school apply to all cultural groups? Has the West over emphasized models that stress individualism and autonomy while ignoring social models which more accurately reflect other cultural experiences (and maybe more accurately reflect the human experience altogether)?

* Embedded in the history of this country is a set of beliefs which suggest that people who try really hard will succeed and that those who do not succeed are deficient in some way. How does this influence the way those of us who have some privilege see our clients who do not exemplify American ideas of success?

* How do white human service providers assess people of color who are reluctant to seek or utilize help at white agencies?

* What are our thoughts about how psychotherapy might help an African American adjust in a racist society?

* Could there be a connection between a community's history of enslavement and racist oppression and their current child rearing practices?

* What kinds of survival strategies have been helpful to many African-Americans as they have had to navigate two different cultures?

* If there are social rewards for being 'good' and severe sanctions for being 'out of line', how likely is it that African Americans would be authentic in settings where they are being evaluated or assessed?

* What might be the relationship of an African American woman to a white woman in an authority position? What is the historical background for this experience?

* What about the relationship of an African American woman to a white man?

* How might an African American man relate to a white woman in authority? A white man? What is some of the historical background for this experience?

* How might a person of color deal with their anger towards a white person in a mental health setting? What is socially sanctioned and what is not? How could a person of color figure out the rules?

* Do our diagnostic categories help or hurt people? Do they help us? How? Are they flexible enough or elastic enough to incorporate experiences of oppression?

* When making assessments, are we able to identify the resilience and assets of people who are not like ourselves?

* If we work in agencies, are we gatekeepers? If so, do we frequently examine our rules and procedures for their impact on diverse communities? With whom do we confer to check this out?

* Graduate schools of social work, psychology and counseling are not graduating nearly enough mental health professionals from diverse communities to mirror the changing demographics in many areas of the United States. This means that many agencies serving populations of color will continue to have staff which is largely white. As a professional community how can we find creative and culturally sensitive ways to serve our clients?

* Does our profession's commitment to credentials hurt our ability to expand our range of services?

* According to many research studies, the reliability of the DSM is not terrific. (That is, several clinicians who use the book and see the same patient will get a different diagnosis.) Reliability is especially poor for general clinicians, as opposed to structured interviewers conducting research. Why have many of us been so quick to treat the DSM like a sacred text, and how has this effected our clients. (For more about this see the Article The Dictionary of Disorder by Alex Spiegel in The New Yorker Magazine, 1/3/05, p.56-63.)

I believe that as a profession, we need to begin asking these and other similar questions over and over. We also need to seek responses from people outside of the profession who may have important and illuminating thoughts including: people who are perceived as non-white, people from other countries, people who are not middle or upper class, people who are deeply rooted in cultures which are not American (or white).

Anamnesis

Anamnesis

Stacey Prince
Seattle, WA
Therapeutic Justice Project

I learned this beautiful word today while reading the book Cutting for Stone (which, by the way, is a great read so far). In addition to having a lovely sound, like a sea creature or a generative biological process of some kind, anamnesis (from the Greek word for “remembrance”) has the following three interesting and varied definitions:
• The remembering of things from a supposed previous existence,
• A patient’s account of a medical history, and
• The part of the Eucharist in which the Passion, Resurrection, and Ascension of Christ are recalled.

Wow! A recollection, a patient’s self-reported medical history, and a Catholic sacrament all in one! What fascinating word. What it got me thinking about, though, was particularly the middle definition, “a patient’s account of a medical history”. Think about how important that is to all of us who are healers and providers of health care. Whether you are a massage therapist, an internal medicine specialist, or a psychotherapist, careful collecting of the patient’s medical history is critical both to accurate diagnosis and effective treatment planning. In Cutting for Stone the physician narrating the story recalls the words of her professor: “Milk the history! Exactly when and exactly how did it start? Onset is everything! In the anamnesis is the diagnosis!”

So, in the anamnesis is the diagnosis. Yet now think about how incredibly culture-bound this taking of the patient’s history is. Whether you are patient or caregiver, what you look for in tracing the origins and history of your pain, your symptoms, your distress is bound by what you have been taught to look for, what likely etiologies and processes and mechanisms your cultural context has provided you with. In your search for an explanation, you include some pieces of information and exclude others based on these cultural boundaries. A great example of this is the book The Spirit Catches You and You Fall Down, in which a young Hmong woman born in the US shortly after her family’s immigration is thought to have epilepsy and to need medication or surgery by her Western physicians, while members of her family believe she is possessed by spirits and needs shamanistic intervention and sacrifices. Told with compassion and balance, the author depicts the struggle to define her illness which leads to disastrous consequences as she is denied the benefit of both perspectives.

Now, think about how social justice and inequities come into play. Who defines the cultural boundaries, who gets to determine what is normal, what is pathological, what causes distress? Primarily those who hold privilege and are members of dominant groups. Those who hold this fearsome power differ by culture, of course, but in Western culture they are primarily highly educated with advanced degrees, often male, often White, and almost always owning class. While members of an individual’s community may have their own set of explanations for illness or distress, if they are not in power their explanations of their own or their family member’s illness may not prevail and will have little bearing on diagnosis and treatment of the individual in question.

So, here is a place where social justice and healing come together in ways that have profound and lasting impacts for individuals. Look at how the course of a person’s life can be altered by the ways that their medical histories are defined by
those in power. A recent series on CNN explored reparative or conversion therapy, efforts (usually through aversive behavioral means) to change an individual’s sexual orientation from gay or lesbian to heterosexual. In “The Sissy Boy Experiment,” Anderson Cooper explores the history of such efforts to change sexual orientation. He focuses on the tragic story of one individual treated with conversion therapy as a youth by George Rekers, one of the leading proponents of conversion therapy. Initially deemed a “success” by Rekers, this young man by all reports led a terribly unhappy life and then committed suicide at age 38. His family members firmly believe that conversion therapy, which included both verbal and physical punishment for feminine behavior, was to blame.

Imagine such a patient’s anamnesis. He might tell you that he is unhappy and depressed because he is gay. This is what he has been told – by his church, the media, his family, and his doctor. In this cultural context he likely would be unable to recognize that there is a confounding variable, homophobia (and its internalized version), that might better explain both his own low self-esteem, feelings of unworthiness and depressive symptoms and other peoples’ opinions about him. Seeking treatment, he might then feel hopeless and suicidal because the treatment failed to change him. Ultimately, this internalizing, self-blaming anamnesis leads him to see no alternative but to take his life. How many young men and women have similar stories?

How could this narrative be different? Certainly the patient’s own anamnesis would need to be different. I see this process often in therapy, as my clients who struggle with substance abuse, social anxiety, and feelings of worthlessness begin to relate their symptoms to rejection by family or church, harassment, and constantly feeling the need to hide their identity and their relationships. A light bulb goes off, and suddenly there is a chance for hope, where before there was despair.

But even more than that, the cultural definition of homosexuality as an illness, a problem, and a deviation from the norm would need to change. Because even if a client’s anamnesis is transformed – even if he is able to say to his treatment providers, hey, I’m absolutely fine with being gay, it’s other people’s homophobia that’s causing my distress, that won’t be enough if his providers have a different story. Unfortunately, some practitioners continue to use conversion therapy despite the preponderance of evidence indicating that such treatment has little lasting effect on sexual orientation and can cause depression, anxiety, and suicidality, and despite the fact that numerous professional organizations including the American Psychological Association have deemed it unethical and harmful. Even among those practitioners who do not practice this abusive and overtly heterosexist form of therapy, biases and microaggressions based on sexual orientation still take place all too often (see for example my recent
blog article reviewing research on this topic). Problem is, these same institutions of power that are now deeming conversion therapy and sexual orientation microaggressions unethical only stopped defining homosexuality as a mental illness a short 38 years ago.

Now a new but painfully familiar battle is being fought over the definition of acceptable gender identities. In our strict Western binary in which only “male” and “female” are acceptable categories, individuals who define themselves as both, or neither, or whose internal gender experience does not match their biological sex and who decide to transition, are still deemed by many to be deviant. They often cannot even receive treatment without receiving a diagnosis of “Gender Identity Disorder” (previous TJP
blog article Transcending Diagnoses provides more information about the struggle to change this diagnosis and its criteria in the next version of the DSM; see also this recent article from The Bilerico Project in which the proposed DSM-V diagnosis “Gender Dysphoria” is discussed.) Yet how culture bound this is! This map shows the many places around the globe where gender is not constricted by the binary, where genders other than male and female are honored and not pathologized. This interactive map is fascinating and full of information; I hope you’ll take a look. Yet these individuals and cultures are generally not at the table when the folks in charge determine Western definitions of “normal,” so transgender individuals in our country are still harassed, discriminated against, and denied crucial medical and social services. The third segment of “The Sissy Boy Experiment” draws a clear parallel between conversion therapy and efforts to change gender identity in children who exhibit cross-gender behaviors.

While I have been focusing on sexual orientation and gender identity, an individual’s anamnesis is similarly impacted, interpreted and distorted when we look at ethnicity. What is defined as normal is largely defined by White, middle class, Western, Eurocentric men. So, for example, being emotionally expressive, relationally focused, and angry are all deemed unhealthy, while being logical, autonomous, calm and detached are seen as normative. It infuriated me when on a recent episode of “So You Think You Can Dance” a Black krumper who was clearly at the top of his game but expressed a lot of anger (both in his words and in his dance) was sent home, while another Black break dancer who in my humble opinion was no more talented or proficient in his style was sent through to the next round of competition. The latter young man was smiling, humble, a little obsequious, and deemed “adorable” by the judges, while the former was reprimanded for his arrogance and “frustration”. Not only was this a great example of the ways that personal discrimination can lead to systematic access to or denial of resources, since being on this show and advancing to later stages of the competition can lead to jobs and opportunities, but it also seemed to indicate a lack of understanding (or denial?) by the judges regarding the style of dance, krumping, demonstrated with great proficiency by the first dancer. Krumping IS about anger – at injustice, at racism, at systemic oppression. It’s a street dance giving the dancer a way to express anger, rage and frustration in a non-violent way. So to critique a krumper for being angry is, well, sort of missing the point. Also notable on this particular evening was the fact that the judging
panel that night was all white; I wished there was one person of color, or one white ally, to argue with the head judge (a white, British, middle aged male executive producer) in favor of keeping the krumper for another round.

So in the end, I guess I agree with the quote from Cutting for Stone, but only with a big IF. “In the anamnesis is the diagnosis” - but only IF both the teller and listener are not bound by culturally prescribed definitions of health. Otherwise, the definitions of the dominant paradigm will prevail.

Social Workers - Defenders of Justice or Patch Up Providers?


Social Workers - Defenders of Justice or Patch Up Providers?

Lyndal Greenslade
Brisbane, Australia

Social work has long embraced a number of core values and as a profession we point with pride to these, as though we are caped crusaders of social justice and human dignity and guardians of the fair go. But do we really deliver on these in any meaningful way? Do we really know what they mean, beyond reciting them as the reason why we chose the profession?

And then what about ‘maximising human potential’? Social workers are meant to do that too. What are we talking about here? Humans as a whole? Because if that’s the case then we might need to make some tough decisions about individual humans who might get in the way of our grand plan for humanity’s maximisation. And what grand plan is that? Or are we talking only about maximising an individual’s potential, maybe the one right in front of us at work? How can we do that? What is the maximum of an individual’s potential? Nobody knows the answer to that. Social workers have some ideas about communities of empowered folk joining together to adjust well to their world. But is it healthy to be well adjusted to this world? Maybe maximising potential is less about walking alongside people to assist them to fit into society and more about finding methods and means of waking people up from the slumber of modern life? Take your medication, join a book club and do a parenting class or two. Feeling better? Feeling ‘maximised’?

And if we think maximising potential is just a good idea anyway, then why are we stopping only at humans? Surely this is not sound, admitting that we are concerned only with our own species. Surely we should be concerned with the potential of all species? How about the environment? For that matter, we don’t maximise potential when we buy coffee that isn’t fair trade, or clothing that we are uncertain of the conditions it was made in, or food that involved unspeakable levels of suffering just because we like to eat it.

This line of thinking led me to take a look at the other words our profession is based on. Around the globe, social work has a few values that most of us agree should serve as the foundation of the profession.  The two big ones are Human Dignity and Worth and Social Justice. These were my calling to the profession and the reason that I believed doing this work mattered. When I first started studying, they were mighty welcoming words. They told me that I was not alone, that there were others who also believed. But I don’t think I had really explored what it would mean to deliver on these values.  I thought I wanted to and I suppose I even thought I could. When I’ve asked other social workers, they also speak about the way the values of the profession called them. Certainly, as a group, we enjoy the nobility of pointing to these core values as evidence that we are somehow different. But today’s world doesn’t want you to mess with the system. Start talking about social justice and affording everyone some dignity and then start trying to do something about it and see what happens to your career. Or your place in society for that matter. If you can forget about the fact that we’re probably not even sure what these values mean, beyond a sense of rightness about them, how can we know what we’re supposed to do about it as social workers? Learning about evidence based practice and crisis intervention and filling out pscyho-social assessments will earn you a living, but shouldn’t we be teaching our social work students how to break the system? If it truly is social justice we’re after and if we want to afford dignity, then by anyone’s account, the society we live in runs pretty counter to giving anything other than a tick box approach to those lofty plans. No more so than in some of our big ‘welfare’ agencies. So how fair is it to put pretty words in a code of ethics and charge each other with a modern day quest of delivering but provide little practical advice on how to do this? Downfall anyone? Why are we surprised when we struggle to do this, when the system that we live in does not want us to and furthermore, we’re not really sure how to do it anyway.

If the profession of social work wants to continue to use these values as some kind of banner, then it needs to get a whole lot more critical of the world we live in. If we are to avoid being nothing more than band-aids for the wounded, patching them up and sending them on their way, providing a useful service to the system in re-habilitating folk that don’t seem to fit in, we better face the reality that our society is not about to turn around now and decide that we really all should be nice to each other. It’s not going to roll over. It’s going to take a fight to change things. It’s going to take more than words of encouragement. It’s going to take outrage and action and possibly destruction.

This isn’t to suggest that social work shouldn’t continue to embrace these values. I just think we need to be honest about what it means to try and implement them in practice. When I talk of social work, I talk of critically examining the world, our place in it as humans, the way our society functions, the potential for evolution for ALL systems and most importantly, what we intend to do about it. Alongside each other, gaining strength from our resistance and sustaining a movement that tugs and pulls at a world gone mad. That’s social work in the 21st Century.