The Citizen Therapist and Family‐Centered Community Building: Introduction to a New Section of the Journal

Psychotherapy in its various manifestations would appear to be the quintessentially private profession. People go to therapists to deal with personal problems, and many therapists are drawn to this work because they enjoy intimate psychological dialogue. Therapists are bound by tighter norms of privacy and confidentiality than most other professionals, and they are expected to avoid relationships with clients outside of the therapy room. It seems a big leap, then, to think of therapists as public citizens engaging in the work of building community and creating social change. A provocative exchange among four leading family therapists illustrates the gap between training for clinical practice and ideals for social change. Scott Johnson (2001a) argued against what he termed “messianic tendencies” in family therapy, the notion that we have a professional responsibility to bring justice to the world and save the planet. Johnson believes that, since we are trained to work clinically with individual families, we should be content to make our contributions to human welfare in that way. Our job is to improve human relationships; the more expansive ecological ideals of Gregory Bateson (1972) and subsequent leaders in the field have led us down a path of professional hubris by claiming that family systems theory has the power to save the world. In a series of commentaries, Ken Hardy (2001), Monica McGoldrick (2001), and Carlos Sluzki (2001), challenge Johnson for limiting the role of the therapist. They argue that matters of social justice, culture, and the larger ecology influence clients' lives and therefore must be fodder for therapy. A poor family's problems are probably related to poverty, which is a social condition stemming from societal inequities, not a clinical condition. The authors fault Johnson for narrowing the role of the therapist after more than two decades of efforts in the field to open it up to this broader context. In his response, Johnson (2001b) notes that he does not mean that therapists should ignore the larger context of clients' lives, but that he rejects the idea that we have the tools and skills, and therefore the responsibility, to take on social problems outside of the therapy room. His quarrel, it seems, is not with contextually sensitive therapy but with what he sees as illusions in our rhetoric, which he believes lead to self-righteous, intolerant, and self-deluding thinking. This exchange illuminates a dilemma for the field at the start of the twenty-first century. We think that Sluzki, McGoldrick, and Hardy are correct in stressing that therapists must be concerned with larger social issues and must treat clients in the context of these issues. Our agreement with Johnson is more complicated. We are not as disturbed as Johnson is by sweeping rhetoric about changing the world. As long as they avoid intolerance of other worthy approaches to changing the world, professionals' expansive ideas about making public contributions are important and even necessary for a publicly engaged profession. Indeed, as Brint and Levy (1995) found in their historical research on contemporary profession, until the 1930s, professional leaders often articulated larger visions of the making of contributions to the public good and the building of a democratic nation. In subsequent decades, most professions focused on guild interests and did their “public service” through committees and task forces created to educate the pubic or advocate for public policies. But expansive rhetoric has only limited utility without a set of practices for intervening in the public domain. Interestingly, Johnson's critics relied almost exclusively on clinical illustrations, a setting where we now have a set of practices to address the context of clients' lives. But talking with clients about the broader context of their problems, or even intervening on their behalf in local systems, is a far cry from taking direct public action to solve social problems. Helping clients one to one is only an indirect way to change the world, especially since only a small minority of people ever sees a therapist. Hillman and Ventura's 1992 book, We've Had a Hundred Years of Psychotherapy and the World's Getting Worse, comes to mind here. In other words, in family therapy we have an inspiring paradigm that calls for social change, but we lack models for how to work on social change beyond helping our own clients in a contextually sensitive fashion. This article introduces a new and ongoing section of this journal on “Family Centered Community Building.” We hope that the section can move the field past the current gap between ideals and models of public practice. In this Introduction, we set the stage by making a case for the public role of therapists, arguing that dichotomous thinking and misleading beliefs have limited us. We then introduce “family-centered community building” as an emerging arena that combines a family perspective with traditional community perspectives. After a discussion of the special relevance of these ideas to family therapy at this point in its history, we conclude with a discussion of what we hope for this section and the kinds of work we hope to publish in the journal. All the therapeutic professions—psychiatry, psychology, clinical social work, marriage and family therapy, psychiatric nursing, professional counseling—share assumptions about the nature of professional practice that emerged in the early twentieth century (Sullivan, 1995). We divide these assumptions into the categories of false dichotomies and misleading beliefs. First is the private/public split, the notion that some problems are purely private and others purely public. (By “public,” we mean the larger social, cultural, economic, political and environmental spheres.) On the one hand, depression in therapy literature appears almost exclusively as a private problem—depending on your orientation, either a chemical imbalance or psychological disorder or both. Widespread poverty, on the other hand, is seen as a public problem, with societal and economic origins. In our teaching and research, we generally overlook how depression and poverty mutually influence each other, for example, how poverty leads to depression and how depression keeps people mired in poverty. Or take schizophrenia, a prototypically individual medical disorder that often is treated, or not treated, in jails and prisons, which have become the de facto mental health system for many people with serious and persistent mental illness. We know that people with serious mental illness who are abandoned by society have more frequent exacerbations of their illness. Mental illness is a public problem, not just a private one, but the discourse of professional psychotherapy tends to concentrate only on the private domain, leaving the public domain to public health specialists and policy makers. The second dichotomy is provider/consumer roles. This duality runs deep in contemporary American culture (Boyte & Kari, 1996). Individuals are either the providers of a service or the recipient of a service, the former the seller and the latter the buyer. Professional providers are experts on the problems of consumer clients, and consumers are assumed to be concerned only with getting the best service for themselves as individuals, and not with anything related to the common good of a community. Our concern here is not with legitimate differences in roles, or with therapist expertise, but rather how the service provider role has come to dominate the way we think about the work of therapists (and other professionals). Missing from our discourse is a way to perceive us as citizens, not just providers, and as people engaged in partnerships with other citizens to tackle public problems. Also missing is the idea of our “clients as citizens” with something to contribute to their communities, beyond the “trickle-down” effect—the idea that when clients function better personally, they will inevitably be better citizens. The provider/consumer dichotomy leaves out a third alternative—citizen partnerships where we are neither providers nor consumers—which our world sorely needs in an era of widespread disengagement from civic life in the United States and in many other industrialized nations of the world (Putnam, 2000, 2002). The third dichotomy is individual therapy versus community work. By individual therapy, we mean work with individuals, families, or small groups, as distinguished from community-based activities for larger groups. Since at least the 1920s, U.S. professions have divided themselves into the majority of providers who work in the individual sphere and a minority who work in the public sphere (Sullivan, 1995.), and the same split occurs in varying degrees in other countries. Examples are clinical medicine versus public health medicine, clinical nursing versus public health nursing, community social work versus clinical social work, and community psychology versus clinical/counseling psychology. When a profession discovers the importance of the community, it generally spins off a sub-specialty. In most cases, that community specialty then becomes marginalized from the mainstream of the profession that spawned it (social work is the exception, but in social work, clinical work is often disparaged). In every case we know of, the two groups are cut off from meaningful interaction with each other. In mental health, community-oriented professionals focus on prevention and are often disdainful of the work of clinicians (Albee, 1990), who in turn ignore the work of community professionals. In our own work, to transcend this dichotomy, we promote the idea that therapists who work with individuals and families could also engage in a citizen project, while keeping their day job doing therapy. They would do this work in partnership with other community members and with professionals who do community work as their main focus. The dichotomies run deep in the paradigm of the psychotherapy. They keep us out of the game of public work and civic engagement. The conventional beliefs we turn to next are less central; they don't keep us off the playing field, but they limit our scope and effectiveness as citizen professionals. We don't claim that all therapists hold these beliefs, but we believe they are quite pervasive. The assumption here is that only low-income communities are in need of community-based initiatives, as if well-to-do suburbs are not also suffering from a lack of social capital and civic spirit. The upshot is that if a therapist does not have access to the inner city or a poor rural community, there is nothing meaningful to do except to write a check to groups who work with needy communities. The rest of us are off the hook. A more accurate belief, in our view, is that all communities can benefit from organized work of citizens to tackle local problems. Doherty and Beaton (2000) make a distinction between community systems (organized institutions, programs, and agencies) and communities (groups of individuals and families that have interlocking relationships and a degree of shared culture and purpose). There are a number of models of collaboration between therapists and community institutions for the benefit of clients (Imber-Black, 1988; McDaniel, Hepworth & Doherty, 1992), but fewer models showing therapists how to work directly with communities themselves, especially outside of clinical context where we might temporarily assemble members of a family's community to help with a clinical case (Speck, 1967). In our observation, many therapists equate “community work” with talking with other professionals about common clients. As useful as pro bono services are for those who cannot afford treatment, pro bono work has a number of limitations: the public need for services will never be met this way, it does not alter the provider/consumer dynamic, it does not challenge the private/public split, and it does not transcend the split between individual work and community work. Professionals who see the limitations of clinical work for social change often assume that the only alternative is public policy advocacy. While essential to the public contributions of a profession, advocacy also has downsides and limitations as the primary focus of public action by professionals. We outline these here: Advocacy often ends up as professional elites talking to political elites about the needs of non-elite people. It often does not call on the resources of communities, focusing instead on outside resources and unintentionally communicating the idea that the local community is barren of resources. It generally does not engage communities in tackling questions of larger meaning and collective action, focusing instead on specific programs, technical policies, and complex legislation. Advocacy is ineffective when viewed by policy makers as predictable, partisan, and guild promoting—characteristics often true of professional advocacy efforts. At the end of the day, most professional advocacy efforts call for more resources for the profession—not necessarily a bad idea, but subject to dismissal for being mainly self-serving. Meaningful political change requires a combination of money, votes, and systems of relationships—none of which are delivered well by professional advocacy. Let us be clear that we believe that advocacy by therapists and their professional organizations is important. It is part of being a citizen in a democracy. But it is a selectively powerful tool, not the main way to engage therapists in sustained public action. Being socially responsible requires taking liberal-left political positions. Most therapy organizations that engage issues of social responsibility appear to come from a liberal-left political stance (Redding, 2001). We are concerned about the underlying message this sends to therapists of other political views, and to other citizens we might partner with, that citizen work is inherently liberal or progressive. Most Americans are political centrists, and many are conservatives. If public work by therapists requires adherence to one subset of political views, then it will always have limited potential for engaging most communities. The work we will describe later in this issue (Doherty & Carroll, pp. 581–592) comes from a populist stance that has no political litmus test for participants. This belief assumes that a therapist is fundamentally a service provider to individuals and that the public dimension is an add-on. The same mistake was made decades ago by medical schools that trained students in anatomy and physiology, including dissecting cadavers, before they learned to interact humanely with patients. The template for professional identity is set from the first day of training. For those of us who came to a public-citizen perspective later in our careers, it is tempting to see our own developmental path as necessary for the next generation. But just as a physician can embrace a humanistic, biopsychosocial model from the first day in medical school, so too can therapy students and trainees develop, from the start, an identity as both a personal healers and a community activists. We see the inklings of a paradigm shift in new work emerging in family therapy and related fields, a shift away from the splits and misleading beliefs we have outlined here. Next we describe some of this work. The arena of community organizing, since the pioneering work of Saul Alinsky (1946) has developed of poor communities to tackle local problems. 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