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Feminist Clinical Social Work in the 21st Century

Feminist Practice in the 21st Century

Helen Land

The challenges of feminist clinical social work practice in the 21st century are complex and multifaceted. Resources remain scant, and the intersection of sociopolitical, economic, health, and psychological stressors culminate in a troubling set of client problems. Domestic violence is rapidly increasing: Reports of wife abuse, child abuse, and incest have never been higher. We see an aging society with limited resources for employment opportunity and health care, especially for frail elderly people. Women of color and other vulnerable groups are more represented in the changing face of acquired immune deficiency syndrome (AIDS). Increased immigration from Third World countries results in populations at risk for poverty, poor health care, and lack of educational opportunity. Increased heterogeneity in the workforce, as engendered by these changes, often results in workplace stress. Women are overworked, underpaid, and undersupported by our social programs. Burgeoning pressures on family life, as it is diversely defined, include fewer resources for children; greater caregiving responsibilities for aging, ill, and disabled family members; and consequent role overload and stress. The family structure in the United States is no longer represented by the conjoint spousal unit in which the mother stays at home to care for children. Stepfamilies, extended families, multigenerational families, homosexual families, joint employment of spouses, and single parenthood are common family scenarios. Families have grown in complexity but often must survive on limited financial, social, and emotional resources.

Many of these societal problems translate into particular social and psychological problems for women, leaving them at risk for physical and mental health problems. Women commonly are seen in health and mental health clinics with depression; eating disorders; substance abuse problems; anxiety and its somatic complaints; and a multitude of medical conditions, including AIDS, cancer, and hypertension. Although reform in health care is promising, managed health care often leaves the client short of a complete service plan.

How do feminist approaches to clinical social work define intervention in these problems? What makes intervention feminist in orientation? And what about the intervention is particular to social work? Such social and psychological problems are formidable, yet approaches to problem solving are rooted in the historical values of social work, many of which were enunciated by those developing the profession. Although we must view them within their historical context, many early leaders in the field could be called feminists because they began to define problems, often family problems, and the concerns of women as being borne from societal forces interacting with interpersonal and psychological issues. Early visionaries such as Jane Addams attempted to provide social support services to aid in the acculturation process for immigrants (Fisher, 1971). Mary Richmond (1917) conceived of problems as requiring a social diagnosis where it was important to examine family interactions and family ecology. She was particularly concerned with deserted wives and women who were mentally ill (Perlman, 1971). Bertha Reynolds (Hollis, 1971) brought a perspective based in the precepts of socialism, and Gordon Hamilton (1951) constructed a close link among social casework, social welfare services, the economic factors of families in distress, and social action and advocacy (Hollis, 1970, 1971). These were women concerned with developing approaches to stem day-to-day problems that are strikingly similar to those faced by clinical social workers in the 21st century: the feminization of poverty, family discord, few social resources for immigrant groups, poor health care, and children at risk.

Clearly, our foremothers who helped define the profession of social work were much concerned with disenfranchised groups and women's issues. Adding a structural-social component to problem definition, these women conceived of problem evolution differently from other professions of their day, and they developed a stance on problem resolution that collided with other fields. In fact, Abraham Flexner (1915), at the 1915 National Conference on Charities and Corrections, questioned the validity of social work as a profession because it lacked individual responsibility and educationally communicable techniques.

These early feminist pioneers planted the seeds for the cardinal principles of clinical social work as we know them today: the biopsychosocial approach, the person-in-situation paradigm, and empowerment practice. Much in the same way that our foremothers were questioned about the contribution of their developing field, feminist practitioners today are questioned about what constitutes feminist theory and feminist clinical practice. Many of the root principles of feminist practice can be traced to the constructs developed by these women who defined clinical social work practice, that is, practice designed to provide direct, diagnostic, preventive, developmental, supportive, and rehabilitative services to individuals, families, and groups whose functioning is threatened or adversely affected by social and psychological stress or health impairment (Meyer,1983).

COMPONENTS OF FEMINIST CLINICAL SOCIAL WORK

Feminist clinical social work can be described as a philosophy of psychotherapeutic intervention rather than a perspective set of techniques. Clinical social workers who practice from a feminist philosophy may practice from a variety of theoretical orientations, including cognitive-behavioral, psychodynamic (Chodorow, 1978; Eichenbaum & Orbach, 1983; Gould, 1984; Jordan & Surrey, 1986), psychosocial (Ruderman, 1986), problem solving, family systems (Ault-Riche, 1986; Luepnitz, 1988; Robbins, 1983), constructivist (Neimeyer, 1993), or interpersonal approaches, and they may use a variety of treatment modalities (individual, couple, family, or group). However, although feminist clinical social work may be reflective of a hybrid, there exists a body of theory and core principles that inform practice.

Theory stems from the Greek word meaning to look or see. Feminist therapy has its origins in the civil rights and women's liberation movement of the 1960s. At that time, consciousness-raising groups evolved whose purpose was akin to many empowerment-oriented self-help groups today. Women began to understand that through talking with one another and sharing experiences, feelings, thoughts, and behaviors, they could frequently begin to make sense of what often seemed to be an oppressive, stigmatizing, limited, and disabling outcome. New life paradigms were born during the turmoil of the early women's movement. Women began to understand that each woman's experience was not unique but had common ground with the experiences of other women. Women began to achieve new understandings of their experiences and recognized that internalizing the patriarchal mentality and structured gender-based role sets of society often resulted in a negative identity, self-doubt, and few choices for change. Through these groups and through other methods of exchange, feminist theory evolved.

Feminist theories articulate varied ways of seeing (or asking questions) and of understanding women's lives and experiences, the nature of inequality between the sexes, and the structuring of gender. Such theories have emerged from and are tied to movements to stem the oppression and disenfranchisement of women. Much of feminist theory centers on the connection among gender, privilege, social class, culture, sexuality, and the concept of self. Clinical feminist social work has blended many of the social work theories such as the person-in-situation paradigm, the biopsychosocial approach to treatment, and the ecological framework (Meyer, 1983) with feminist theories.

Validating the Social Context

Primary to the values of many feminist clinical social workers is close attention to the effects of the social context on the difficulties of the client as they are jointly assessed by client and practitioner. Such a stance is not new to social work; however, here attention is given to environmental pressures, gender roles, and gender-based discrimination that affects the client's experience, including identity formation, cognitive structure, and patterns of interpersonal behavior (Brodsky, 1980; Day, 1992; Rawlings & Carter, 1977). Feminist therapists hold that theories of human behavior must be understood within the broader social context. Our interpretations of behavior must attend to the impact of external realities on internal and subconscious processes (Brown & Brodsky, 1992). For example, many feminist practitioners believe that when women have common signs and symptoms of depression, there may be a reason for such a reaction; hence, the symptoms should be validated rather than labeled as a deviant reaction to an ambiguous set of circumstances. Depression may result from any number of factors including environmental inequity, interpersonal stress, cognitive schema, and intrapsychic issues. Whatever the etiology, depression often has a legitimate basis and should be recognized as a valid reaction. Subsequently, factors fostering the depression may be investigated by the client and therapist to alleviate the immobilizing condition. Thus, gender-related issues, particularly issues of equity, are given consideration in the assessment of the client's problems.

Revaluing Positions Enacted by Women

Many feminist practitioners feel that mainstream psychotherapies have benefited the dominant people in our society, namely white heterosexual men. As a result, that which is conceived as being normative and valuable tends toward those stances and activities that have been assumed by men. For example, striving toward upward mobility in a competitive manner is often valued because these behaviors are reflective of the white male experience. Conversely, enacting behaviors that are often performed by women, such as compromising, cooperating, seeking consensus, providing nurturing to others, and caregiving (including working in the service-oriented fields) are often devalued, ostensibly because they reflect a female experience (Freedberg,1993; Hare-Mustin & Maracek, 1988). These behaviors and service roles are vitally important to the well-being of society; they often result in positive behavioral outcomes and should be valued (Morrison Dore, 1994).

Recognizing Difference in Male and Female Experience

Carol Gilligan's (1982) insightful research on the different courses of human development in male and female children is one example of theory that suggests men and women often have different experiences, yet one should not be overvalued and the other undervalued. Before Gilligan's research, little attention had been paid to female developmental life. Theorists assumed that all development reflected the experience of the male child with his parent figures. Gilligan elucidated the differences in relationship patterns that female children have with parent figures in our society and how their subsequent socialization and consequent behavioral actions may take different courses than those of their male counterparts. Because female children are socially permitted to have more intimate contact, especially with their mothers, for longer periods in their life, they are socialized to behavior patterns that reflect parenting concerns such as greater concern for the well-being of others, nurturing, cooperation, and collaborative problem solving. Many feminist theorists purport that developmental theories assume a gender-blind stance and suggest that the emotional worlds of men and women are the same. Central to feminist discourse is the position that to understand the internal psychic structure of women, and women's concepts of self, the effect of external and oppressive structures on women's psychological development must be acknowledged. This knowledge may then assist clinicians in understanding how the therapeutic relationship can address women's needs (Day, 1992).

Rebalancing Perceptions of Normality and Deviance

A parallel feminist corollary is that behavior which is conceived as being dysfunctional or deviant by our society often reflects behavior of less-privileged groups, such as women, people of color, poor people, older people, and gay men and lesbians. For example, feminist psychotherapists have attempted to block the diagnostic category in the Diagnostic and Statistical Handbook of Mental Disorders (American Psychiatric Association, 1994) of self-defeating personality disorder because they feel it defines a segment of our society as pathological. There is no attempt, they point out, to create a category for dominating personality disorder, a behavior that could be conceived as being disordered and is seen with greater frequency in men. Hence, many feminist practitioners point to the need to balance, especially within the professional psychotherapeutic community, normality and deviance and to include the experiences and perceptions of women and people from all ethnic, racial, class, sexual orientation, age, and religious groups.

Inclusive Stance

An inclusive stance mandates reexamination of our Anglocentric assumptions. For example, the strength of the kinship system among women in many African American and Latin cultures provides social support that buffers stress and increases well-being. However, such a family structure may be interpreted from an Anglocentric stance as signifying an enmeshed, collusive family system. These suppositions must be redefined because much value, such as the support offered through the female kinship system, may be lost or excluded.

Attention to Power Dynamics in the Therapeutic Relationship

Another precept of feminist clinical practice theory involves the attention to power dynamics in the therapeutic relationship. Developing an egalitarian clinical relationship is a desired goal. Social work has historically noted the importance of client self-determination in the problem-solving process. This precept elaborates the value of client-clinician equity. Many feminist clinicians believe that the historical asymmetry in the psychotherapeutic relationship between therapist and client is inimical to the goals of feminist clinical social work practice. Empowerment models (Levine et al., 1993; Solomon, 1976) that seek to harness client strength in self-advocacy and problem solving, the use of connectedness within self-psychology (Kohut, 1977), and constructivist and narrative approaches (Neimeyer, 1993; Saari, 1986) that define, at the vortex of therapy, the client's meaning and definition of the conflict are examples of rebalancing the relationship between clinician and client and renewing equity within it.

Recognizing How the Personal Is Political

Feminist practitioners often acknowledge in their work with clients the ways that the personal issues clients work with are political in nature and may reflect power inequities in relationships with others. Sexual harassment is an obvious example. A female worker who is sexually harassed by her male superior is evading more than sexual aggression. Implicit in the overture is a power component that places her at risk for job loss or demotion if she does not comply. The political context in which the sexual advance occurs must be recognized and resolved.

Many times, the components of the political context are multifaceted, covert in nature, and defined by those in power as problems residing within the individual rather than in the system. For example, an immigrant woman is told by her boss that she is not allowed to speak about personal issues or in her native language to coworkers while on the job. Such a stance, situated within its political context, results in an inability and immobility for women workers to communicate with each other, to become more assertive, or to organize and voice their concerns about work, family pressures, and other needs. Subsequently, these women may experience work stress, depression, and anomie. Given this scenario, feminist clinicians might help clients speak with one another, organize for the common cause, and recognize and vocalize how their personal issues are enacted within a political context. Hence, problems may be resolved more equitably.

Deconstructive Stance

Feminist clinicians often look to assess how culture-bound definitions of right and wrong as well as appropriate and inappropriate behaviors require reexamination and reconceptualization. The deconstructive stance (Derrida, 1976) in feminist theory is helpful in clinical practice. Many feminist clinicians believe that to gain recognition as professionals, the male-dominated world asks women to become "honorary males" intellectually and interpersonally. Often, conceptual barriers in clinical theory are based in existing male-oriented language and, often, language defines experience (McCannell, 1986). Hence, what is given power, what is seen as devalued or dysfunctional, what is recognized as valuable, and what is included in history making often reflects the patriarchal position. Perhaps this reason explains the attention of feminists to sexist language that often echoes the patriarchy in which it was born. The deconstructive clinical stance seeks to take apart and reexamine the structure of language and experience, within the dominant culture, so as to stem the effects of privilege.

Partnering Stance

Traditional psychotherapy eschews the practice of therapist self-disclosure, except in rare instances. Many feminist clinicians believe that their clients may learn from the clinician's experience as a woman living in a male-dominated society; hence, elements of self-disclosure, especially in situations where the personal is political, are used with greater frequency in feminist clinical practice.

Inclusive Scholarship

There is a trend among feminist social work clinicians to rely on a variety of scholarly traditions including quantitative and qualitative methods and postpositivist scholarship. Moreover, many feminist scholars challenge the traditional assumption that science is objective; hence, feminist scholars see the need for inclusive research agendas and seek to critically analyze and uncover androcentric bias both in lines of inquiry and in methodology (Lott, 1985). Feminist clinical practice has been the impetus for developing lines of scholarship that seek to explain how culture constructs gender and scholarship on the formidable exigencies that women face in our society, such as the sequelae of personal violence and sexual assault, depression, eating disorders, and anxiety reactions. In contrast to knowledge that flows from the quantitatively empirical to the clinical, valuing a variety of scholarly traditions and noting the knowledge-building interplay between feminist clinical practice and feminist scholarship is a key principle in feminist clinical social work.

Challenging Reductionistic Models

Although feminists value behaviors traditionally enacted by women, the division between male and female behavioral traits such as the woman being the social and emotional caretaker and the man assuming the instrumental role is often eschewed by feminist clinical practitioners. Reductionistic models that seek to codify gender-based behaviors are seen as limiting and nonproductive for both genders. Attending to a balance between autonomy and relationship competence, for both genders, is a key component of feminist clinical practice.

Empowerment Practice

Feminist clinical practice is empowerment practice, although the means for psychotherapeutic growth may vary among feminist clinicians. Within this tradition, therapeutic goals for clients are generated cooperatively between clinician and client, and the focus is often on empowering the client to change the social, interpersonal, and political environments that have an impact on well-being rather than on helping the client adjust to an oppressive social context. Hence, feminist clinicians value a number of goals for clients that may include intrapsychic, interpersonal, and behavioral change and a changed perspective on the sociocultural aspects that affect life in whatever context clients live (Brown & Liss-Levinson, 1981). The modalities used to achieve these goals may include individual counseling, couple or family therapy, and group experiences for women. Group counseling remains a valued tradition within feminist clinical work because of the therapeutic and empowering effects of group cohesion and support, universality, and the corrective emotional experience gained in group settings.

Myth of Value-Free Psychotherapy

Many feminist clinical social workers reject the myth of value-free psychotherapy. By making their biases explicit, feminist clinicians facilitate client ownership of their values and choices. This stance is regarded as an important part of the empowerment process, and client problem solving is seen as a cooperative relationship in which both client and clinician perspectives are equally valued, although they are inevitably different in nature (Brown & Brodsky, 1992).

CHALLENGES OF THE 21ST CENTURY

How will feminist clinical social work practice meet the needs of clients in the 21st century? Many feminist practitioners believe that the principles of feminist clinical practice will become generalized throughout the psychotherapeutic community. Because of the proliferation of health maintenance organizations and managed health care, clients will by necessity become more consumer oriented, and clinicians will need to make their approaches and values known to clients as they shop for a more defined product.

With the increasing ethic-cultural-racial diversity of clients seen by clinical social workers, the principle of recognizing, understanding, valuing, and using nondominant cultural values in the therapeutic process will become primary. Building on the historical commitment of social work to understanding the client within the situation, feminist clinical social workers and others will need to become even more conversant in how the social environment is affected by and transacts with the client's perceptions. Inclusion ideology has always been a tenet of feminist practice; however, in reality, feminist therapy and theory research to date have been largely dominated by middle-class white women (Brown, 1990; Brown & Root, 1990b; Kanuha, 1990).

Feminist clinical social workers must continue to extend themselves outside the mainstream. Just as our views of human behavior have been influenced by a patriarchal society, our views of women's development have been influenced by the experience of white individuals. This state suggests that we must continue to assess dominant norms and to incorporate nondominant ones as a means of enlarging our comprehension of women's experiences from nondominant groups. We must enlarge the paradigm to include attention to gender-relational development across cultural and class groups (Palladino & Stephenson, 1990). In other psychotherapeutic fields, feminist theory development is beginning to emerge on a multicultural basis (Boyd, 1990; Bradshaw, 1990; Brown & Root, 1990a; Ho, 1990; Kanuha, 1990; Sears, 1990). These new perspectives will continue to foster theory growth and clinical interventions. Their traditions also will be of importance to white women and society as a whole.

In the 21st century, feminist clinical social workers will need to continue to pursue knowledge building in the area of feminist theory. One difficulty in this pursuit is that many scholars of theory have been trained in the dominant culture; it is difficult to perceive outside the intellectual culture that has formed our worldview. As Daly (1983) and Johnson (1987) purported, the language and culture of patriarchy are imbued within us. It is difficult to foresee a feminist perspective that is not an amalgam of influences of other theories. A goal, therefore, is to create human behavior that is feminist in nature. Subsequently, human psychic hurting and its alleviation will be understood from a feminist orientation. This goal suggests that we must draw on multiple methodologies and ways of knowing, as we have begun to do (Ballou, 1990; Belenky, Clinchy, Goldberger, & Tarule, 1986).

We must continue the exchange among clinical practice, research, and scholarship if we are to continue to be informed from the grassroots up. Several institutes have already been established in this direction, including the Stone Center on Personality and Relational Development (Jordan, Surrey, & Kaplan, 1983); the Women's Therapy Centre Institute, which treats eating disorders and fosters growth in mother-daughter relationships (Eichenbaum & Orbach, 1983); and the Feminist Therapy Institute (Rave & Larsen, 1990). As centers of learning develop and become a part of the institutional history of feminist theory and therapy, these approaches gain greater stability and validity. What is generated by feminist scholars and clinicians becomes part of mainstream clinical intervention, a goal of many feminist practitioners.

Yet another direction for feminist clinical social work points to health and medical concerns. Feminist scholars have had a historical interest in women's reproductive health, infertility, menstruation, and menopause and health behavior centered around these issues (Sayette & Mayne, 1990). Particular attention has been directed to choice in and ownership of reproductive health. Feminist clinical scholars must now turn their attention to other health issues of women, including the prevention of and care of people with chronic diseases and illnesses such as AIDS and caregiving issues for women who often provide the only care for significant others in their lives (Land, 1992). Stress, coping, and support among female formal and informal caregivers of all cultural backgrounds should be targets for a primary academic and clinical agenda.

Moreover, children and family issues would be well served by greater feminist analysis of problems and their solutions (Walker & Edwall, 1987). Although feminist scholars were among the first to speak out about sexual abuse of children and adult incest survivors, little attention has been devoted to developing nonsexist methods of child development or work with children in their family context. We must seek to understand how institutions such as residential treatment facilities and schools have fostered gender inequality, and must remediate their extant inequities (Kerr, 1992).

With respect to new populations, feminist treatment has tended have been conceived as a paradigm applicable for women only. Although the origins of feminist therapy centered on issues particular to adult women, feminist therapists have always practiced with a variety of populations. In the future we need to see an expansion of inclusiveness in feminist practice with diverse populations. The problems of women are problems of the world, and what is good scholarship and practice for women is good for the whole of society. Such a view encompasses values of the uniqueness of the individual; egalitarianism among genders, races, and cultures; nurturing; relationships; and family responsibility. These are values that would benefit society as a whole (Wetzel, 1986).

Because feminists value an inclusive stance and elucidate the needs of diverse populations, feminist clinical theory should address the interactive concerns and realities of men, children, families, people of color, gay men and lesbians, older people, and individuals with physical disabilities. For example, practitioners with a feminist perspective could offer a valuable stance for men who batter, because often these men have been victimized in their youth (Bograd, 1984). The cultural pairing of masculinity with dominance, power, and violence is oppressive for everyone. This work has begun to emerge and should be fostered (Ganley, 1988; Sonkin, Martin, & Walker, 1985).

In addition, feminist family therapy will see a growth of interest based on need in the 21st century. To date, feminist family theorists have begun to critique existing theories of family development, function, and dysfunction, stating that although feminism and systemic practice have traditionally been seen as two incompatible standpoints, they can be conceptualized as two parallel traditions. Both work toward understanding the intersubjective experience that makes up the interpersonal field. Both have analogous concerns that include problems of confronting and combating power misallocation, issues of hierarchy, and the process-product debate (Goldner, 1991). Feminist revisions of family treatment need to be addressed in the future to eliminate hierarchical models and generate more egalitarian and culturally diverse representations of family life.

Because they are important to the future of feminist clinical social work, standards for education and training will need to include a feminist, multicultural perspective at all levels of social work education and licensing for clinical social workers (Morrison Dore, 1994). Feminist clinical practice is ready for greater formalization of standards. Feminist clinical social work is no longer for believers only but has become part of the mainstream because it represents an emphasis on human rights and inclusion. For example, topics such as the sexual exploitation of therapy clients, sexual harassment in the workplace, and domestic violence are now considered part of the essential knowledge base for practitioners, ethics committees, and academicians. We need to recognize that it is not feminist scholarship that has moved into the mainstream; rather, feminists have acted as a part of the conscience of ethical social work practice, helping move mainstream thought away from destructive paradigms toward new ones that are influenced by feminist thought.

Because feminist scholarship has a history of only about 25 years, what is available as practice models and research, scholarship, and teaching methods is still developing. The 21st century will see a demand for knowledge production; hence, the need to foster and promote feminist scholars and practitioners is compelling.

CONCLUSION

The role of feminist clinical social workers in the 21st century will be multifaceted and generative. We will continue creating a more egalitarian stance in the clinical world, reminding the field that gender is a cardinal construct that requires attention in theory, practice, research, and scholarship. Attention to gender and issues of power are areas that cannot be minimized. We will continue to change theories that inhibit the growth of women and men of all ages and cultures because the assumption underlying both feminism and social work values is that people realize their full potential through effective social functioning (Collins, 1986). We will make continued efforts to generate feminist theory by taking an inclusive stance in theory building and drawing on the experiences of people of color and those who have not been marginated in our society. We will set a scholarly agenda that values reciprocity in the learning process between clinical practice and quantitative, qualitative, and postpositivist approaches. We will build on the work of our foremothers in their efforts to forge a practice that attends to the needs of those in society who are often overlooked and dismissed. Their needs for service are often a result of environmental inequities, family stress, and psychological conflicts emblematic of the biopsychosocial precept that defines social work practice. In addition, feminist clinical social workers will examine policy and practice agendas within our field as both traditions develop within a shared sociopolitical context (McCannell, 1986). If we are to be true to our historical roots, we must realize for our clients an active understanding of the person-in-environment perspective that frames the solutions to personal problems within social work (Hagen & Davis, 1992). If these goals are not realized, not only will our future clients be denied a service they deserve, but also our culture as a whole will be diminished by the gap in information that is so desperately needed for the functioning of a just society.

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