The Recuperation of Moral Agency through Structural Erasure in Clinical Social Workers’ Accounts of Career Path and Treatment Decisions

ABSTRACT

Although the field of clinical social work has historically distinguished itself among the helping professions by its attentiveness to the ecological systems within which client struggles are embedded, the role of structural factors in shaping the professional activities of clinicians themselves often goes under-theorized. This paper argues that the erasure of structure and political economy from clinical social workers’ accounts of their own career trajectories and treatment decisions is not oversight. Rather, it occurs in response to social workers’ ambivalence or guilt regarding their aspirations to upward class mobility – feelings that arise, in part, out of a set of contradictory imperatives into which workers are socialized through their clinical training. By disavowing the impact of structural constraints on their own work, clinicians preserve a sense of professional integrity and moral agency under what are often compromised, frustrating, or heart-wrenching working conditions. However, this tactic of self-preservation may lead clinical social workers to inadvertently naturalize and reproduce some of the very structural inequalities that the profession is committed to redressing.

KEYWORDS:

• Structural competency
• moral economy
• clinical ethnography
• mental illness
• self-management discourse analysis

Acknowledgments

I am grateful to my clinician informants for sharing their experienes and stories. I thank Jennifer Cole, Judith Farquhar, Eugene Raikhel, Jill Korbin, Bridget Haas, Pinky Hota, Joyce Everett, Joan Lesser, Eevie Smith, Matt Spitzmueller, Allison Schlosser, and two anonymous reviewers for their helpful commentary at various stages in the development of this work.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

¹ Portions of this and subsequent sections are reprinted with permission from Anthropological Quarterly (Weiner, 2019).

² Throughout this article, I (loosely) following the terminological conventions of my research informants and use the word “consumer” in relation to the city’s public mental health clinics, “client” in reference to those receiving services from not-for-profit community mental health facilities, and “patient” for those treated by private psychotherapy practitioners.

³ In a minority of instances, interviews were conducted via written correspondence.

⁴ The belief that the types of interventions encompassed by the “Community Support” billing code are intrinsically more useful or desirable to working-class clients than are “Therapy/Support” services is confounded by findings from a recent investigation of self-directed care for adults with serious mental illness (Cook et al., 2019). When given “direct control over public funds to purchase health care services, supports, and material goods,” the study authors found, individuals “spent less on average per person, compared with the control group, on skills training, psychosocial rehabilitation, case management, in-patient hospitalization, psychiatric crisis services, substance abuse treatment, medication management, and medications” (p. 191) and “more on average on psychotherapy and peer services” (Ibid., p. 195; see also Jones, 2019).

Additional information

Funding

Data collection for the research on which this article is based was supported by the Wenner-Gren Foundation, the National Institutes of Health (Grant Number T32 AG 000243), and the University of Chicago Department of Comparative Human Development.

Notes on contributors

Talia Weiner

Talia Weiner LPC, Ph.D., is an Assistant Professor in the Department of Psychology at the University of West Georgia. She completed her doctoral studies at the University of Chicago, followed by a T32 post-doctoral research fellowship in the Department of Bioethics at Case Western Reserve University. As a medical/psychological anthropologist and a mental health professional, Dr. Weiner specializes in topics including structural inequalities in mental healthcare, theories of biomedical subjectivity and agency, the professional life course of psychotherapists, narrative and discursive processes in clinical encounters, the intersections of social justice and mental health, reproductive health ethics, and cross-cultural accounts of psychiatric categories and treatments.