Social Analysis in the Clinical Setting
This essay examines the use of social analysis in clinical practice. Although the author is a psychoanalytically-oriented clinician, she advances the view of the self as both psychologically and socially constituted. When applied to therapy this concept of self leads to presenting a picture of reality that includes both social dynamics and psychodynamics. Based on clinical case material, the author demonstrates how social analysis contributes to psycho-analysis in changing clients' self-concept and social identity. In addition, she identified conditions under which social analysis advances or retards the healing process.
by Dorothy M Jones
Rated "G" by the Author.
edited: Tuesday, March 22, 2011
Posted: Monday, March 21, 2011
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This article emphasizes the importance of including the oft neglected social element in psychotherapy, of the benefits of seeing clients as socially as well as psychologically situated.
SOCIAL ANALYSIS IN THE CLINICAL SETTING
My interest lies in fostering appreciation of the social dimension in clinical theory and practice. Although the founding father of psychoanalysis strover for a social psychology, when it came to theories of causation he considered the social aspect secondary, as a derivation of intrapsychic tensions and conflits. Subxsequently, psychoanalysis and clinical theory in gernal have adopted Freud's formulation about the relationship between self and society.
While I'm a psychoanalticallty oriented clinician, I hold to a different concept. I view the relationship between self and societ5y as an interpenetrating system in which the self is both product and potential transformer of society(Sampson, 1989). When applied to therapy, the concept of the self as socially and historically constituted leads to presenting a picture of reality that includes both social and psychological dynamics.
But, one might ask, why is the social dimension relevant in a therapy concerned with intrapsychic change? Becasuse, as recent feminist analyses have highlighted, the social context of experience has a powerful impact on individuals' internal realtiy, shaping both its conscious and
unconscious content (see for example, Rubin, 1983; Miller, 1973). The consciousness-raising groups that sprouted all over the nation in the 1960s and 1970s demonstrated this effect. Summarizing her observations of these groups, psychologist Juanita Williams (1977) pointed out that as women came to see themselves in relation to social realities, they developed new, more androgynous definitions of self. Other research consistently buttresses Williams' conclusion (see review by Kravetz, 1980).
Despite the compelling nature of the consciousness-raising experience, many participants in these groups encountered tenacious inner resistence
to changing their concept of femininity, of what constitutes a "good women," for these ideas, acquired in the family and the culture, are deeply engraved in women's psyches. Some of these women, buffeted back and forth between the promise and lure of growth and independence on the one hand and the stubborn hold of internalized conceptions of femininity on the other, turned to psychotherapy for resolution of this tension.
That they did so does not impugn the significance of the consciousness-raising group experience; more to the point, it underscores the vital interconnection between social and psychological influences on individ· uals' psyches. I am not proposing an equal weight to each dimension in the therapy experience; the psychological is clearly dominant there. But, that doesn't mean that social interpretation and explanation are superficial or simply preliminary to deeper psychological work. Rather, social analysis penetrates the process of personal change in profound ways. One benefit is its potential for expanding clients' identity to include a self-in-the-world. As Robert Bellah and his colleagues (1985) so cogently argue, traditional psychoanalysis enables clients to experience themselves as psychological entities with a psychological history but not as social beings with a social history and culture. I consider a sense of connection to the world an important therapeutic goal, especially pertinent in this era marked by widespread anonymity and isolation. In addition to this value, social analysis makes a direct and significant contribution to healing intrapsychic wounds.
How will I support these contentions in view of the reality that in a clinical setting many kinds of verbal and nonverbal communication mold the interaction, and thus specific responses can't be easily traced to specific interventions? Nonetheless, systematic observations as a clinician and clinical consultant provide abundant support for my thesis. The observations on which I draw derive from detailed process notes recorded immediately after sessions. I paid special attention to data in which clients themselves linked social analysis to changes in their selfconcept. My recall capacity is well trained from many years of both clinical experience and field research in Alaska native villages (see, for example, Jones, 1976).
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Since my clients are usually aware of my interest in social dynamics, one might question whether their assertions about its benefits simply reflect a desire to please me? Perhaps they do in part, but no more so then when clients relate dreams knowing of my particular interest in dream analysis, or delve into early history knowing I'm also keenly interested in that. Moreover, many times clients' references to the value of social analysis occurred in a late stage of treatment when they were past the idealizing phase, when they had achieved the capacity to tolerate ambivalence toward me, and when their attention was directed toward consolidating their therapeutic gains.
I shall develop my thesis first with a brief overview illustrating that social analysis does, indeed, have an impact on self-structure. The overview will be followed by a more detailed discussion of one case to demonstrate the interaction between social and psychological analyses and some specific conditions under which social analysis furthers or interferes with the healing process. While any social characteristic that influences psychological development is relevant in the clinical setting, those that are reflected in the ensuing case material refer primarily to gender socialization, the position of women, family structure, and class structure, based on such works as Bernard
(1971,1982), Chodorow (1978), Dinnerstein (1976), Laslett (1973), Poster (1978), Sennett (1974), Sennett and Cobb (1973), Harris (1981), and Rubin (1983).
SOCIAL ANALYSIS AND RESTRUCTURING THE SELF
Social interpretation figured prominently in strengthening clients' sense of themselves in the world. Thirty-eight year old Martha, a fulltime homemaker and mother of a twelve year old daughter, spoke cogently about this effect.
I hadn't considered isolation a significant issue for Martha, for she maintained regular contact with a large extended family and a stable network of friends. However, relating
I came in the door that first day I felt all bound with my problems. I felt like I was trapped in these problems, like they were my whole world. And now that I'm about to leave, well I don't feel so isolated. I feel like I have a big perspective on how my own emotional being fits into the community, the community of Western man, not of Anchorage. I have the feeling of being validated in relation to the larger picture. I'm trying to imagine what I'd feel like if I didn't have this feeling. I think I'd feel very small. to a personal network is quite a different matter than a sense of connection to society. And it was from the latter that Martha had felt uncoupled. She hadn't identified this 396
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isolation from society as a therapeutic issue until hindsight analysis created an awareness of its lack and a keen desire to fill the gap. This development was valuable not only in strengthening Martha's social identity but also for society in the sense that heightened social awareness creates the potential for change. I'm not suggesting that social change is the goal of psychotherapy, for it embodies different modes of operation, such as persuasion and proselytization, approaches that oppose therapeutic goals of autonomy and self-direction. However, if a social awakening is a by-product of treatment, then, if clients choose, it can lead to social action.
THE BROKEN SELF
Forty-two year old Betsy, a single professional woman, expressed a similar appreciation of social analysis in reducing her sense of isolation in the world. But Betsy also indicated the impact of this expanded social identity on distortions in her internalized sense of self.
When I first came to see you I thought of myself as a broken person and the world as okay. I felt I couldn't be in that world because I was broken. I didn't deserve to be in it. And if I went into it, people would see that I was broken. I didn't have a clear picture of what the world was like. But some of the things you said made me realize there are many people with the same or similar issues and that relieves me of the burden of having to feel so broken. And other things you said made me realize it's not a "pie in the sky" place out there. It's just an ordinary place with broken parts too. And if the world is just an ordinary place with real people and real problems in it then I can walk
THE ANGRY SELF
Anger management frequently occupies center stage in clinical work, for clients fear the destructive potential of this emotion more than others. George, a forty-three year old fireman, childless and married four thnes, came to therapy partly because of fear that his anger was related to his marriage breakdowns. He expressed grave concern about his rage at his current wife, Mona, for maintaining a friendship with a man who had been her lover twenty years earlier. With flushed face and agitated speech, George railed against this relationship. As his venting gained momentum, he also expressed resentment at Mona's other longterm friendships. Exploration of the intensity of his reaction revealed a
too where they walk. I can play too. I don't have to just go to the movies. I can be in the world practicing how to be an okay person.
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complex set of factors. One concerned a deep-seated anxiety about his own inadequacies in relationships. Since he had no long-term relationships, acknowledging the value of Mona's stirred up acute feelings of inadequacy. Better to deny their value and attribute sexual or self-interested motives
THE SUPERWOMAN SELF
The belief that "we can have it all"-careers, husbands, children, self-development, sisterhood, community activity-took firm root during the recent feminist movement, creating intense performance pressures on women from all walks of life. My clinical consultation with the staff of a women's eounseling center furnished a striking illustration of the role of social analysis in dealing with that tension.
Staff members, all female, were discussing emotional burnout and their acute feelings of guilt either for failing to do more or for failing to set realistic limits.
"Where do you think this problem originates?" I asked.
Sarah, a forty-year old staff member, began to explore her parents' role in generating the problem.
to them. Even though George described Mona as loyal, a "true blue," in his words, he convinced himself that she had a sexual aim in maintaining the relationship with her former lover. In this way, George converted his feelings of inadequacy into anger at Mona's presumed dereliction. After he gained insight into his pattern of displacement, I talked to him about gender socialization, emphasizing the reality that men don't receive the training women do in fostering and maintaining relationships; that, in fact, social norms and family practices deprive men of opportunities to learn these skills. Identifying these social roots contributed to relieving George's sense of sense of personal defect and enabled him to shift attention from his jealousy of Mona's friendship to the sources and meaning of his own feelings of inadequacy.
They didn't have trouble helping me set limits at all. When I wasn't satisfied with my performance, when I wanted to do better in math, when I wanted to join more groups, they'd say, "Why do you have to become so upset? Why can't you be satisfied with how things are?" I felt so mediocre and they kept telling me not to worry about it,
to take things as they are, to stop pushing myself.
Although Sarah didn't make the association, her comments suggested the process by which cultural norms about traditional femininity, norms emphasizing passivity, acceptance, and resignation, were transmitted via her parents. When I alluded
to and elaborated the cultural context of this gender socialization, Sarah sat bolt upright.
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Something just hit me, something I never put together before. I've been in rebellion my whole life against their thinking I wasn't capable of great things. And I've been hell-bent ever since to prove I was. That's why I keep trying to do the impossible. I never related it to sexism before or to my rebellion against it.
Leaning forward in their seats, taut and involved, other staff members examined the social origins of their burnout. They recalled their activities in the youth movement of the 1960s and the feminist movement that accompanied it. They wanted their lives to disprove cultural stereotypes about women's limitations. They were determined to show that women could combine family and work roles and do a stellar job at both. The result was a swing to the posture of superwomen, a shift common to many women in the 1980s.
Exploring other sources that created pressures to be superwomen, staff members identified their secondary status, as a women's center in the social service community itself, dramatically expressed in the limited responsiveness of funding agencies to their needs. As a result the women had to concentrate energies on finding new financial resources each year, an obligation that took a substantial toll on their vitality. To do this without depriving their clientele required superwoman commitment.
The recognition of these social roots of intrapersonal stress helped the women understand that they had been punishing thE:mselves for failings that lay outside themselves in the social system. They realized that their resistence to setting limits and the impossible performance demands they placed on themselves reflected not only a generalized revolt against their soCialization but also a strong desire to prove to the community that, indeed, they were worthy of primary status.
While this experience occurred in a collegial rather than a client group, it demonstrates the salience of social dynamics in relieving guilt and strengthening self-esteem, two outcomes that stand high in the scale of therapeutic goals.
INTEGRATING SOCIAL AND PSYCHOLOGICAL DYNAMICS IN THE TREATMENT OF SHAME
Until now I've presented material to show that social interpretation does have a meaningful role in psychotherapy. Next, I shall examine how social and psychological dynamics work together. In the course of this analysis I shall specify some conditions under which social analysis advances or retards the healing process. The identification of these conditions is far from exhaustive; it represents an effort to contribute to
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knowledge for a social/psychological therapy. I shall develop this section of the paper with a case presentation in which shame dynamics were at the center of treatment. Analysis of the complexities involved in the treatment of shame brings
I treated thirty-eight year old Teresa, a white, Protestant, divorced and childless woman who works as an alcohol counselor twice weekly for the past four years. At the start of therapy, Teresa complained of depression and feelings of inadequacy, which she connected to a six year marriage
flecting the operation of a deep-seated sense of shame. Helen Block Lewis (1987), a pioneer theorist in the psychoanalysis of shame, considers it
to light some considerations in the integrated use of social and psychological interpretations. to a man who was chronically angry and verbally abusive. The reality of her relationship, indeed, was depressing. But beyond that, Teresa's preoccupation with crises operated as a defense against facing some longstanding intrapsychic conflicts. After the first year of treatment when Teresa ended her marriage and the external source of distress abated, her resistence to self-examination stubbornly persisted, reto be an underlying cause of therapeutic resistance and failure.
The Dynamics ofShame
Teresa is beset by a continuous tension between a grandiose self and a shamed self. The two are inextricably intertwined. Grandiosity, as Lewis (1987) points out, is, in part, a defense against shame. Conversely, shame is an inevitable outcome of grandiosity, for the grandiose self experiences limitations and imperfections as a fundamental defect. Teresa's intense fear of the pain of her shame stifled her curiosity about her psyche. Indeed, defending against rather than probing inner feelings typified her early responses in treatment.
The distinction between shame and guilt is critical in understanding shame dynamics (Lewis, 1987). Guilt refers to behavior and thus it's reparable; shame, on the other hand, is felt at the very core of a person's being. Teresa experienced failure not as an ordinary inadequacy or lack but as an indictment of her worth. Her sense of shame manifested itself in subtle ways that, except in hindsight, are difficult to illustrate. Like an invisible enemy, shame shows itself in silence, denial, withholding, and concealment.
It has a circular quality that is hard to break into. Because Teresa felt searing shame, she kept many secrets. Then she felt ashamed for having kept the secrets. The same self-perpetuating shame cycle occurred in relation to her obesity. She overate, in part, to dull the agony of her shame; then she felt ashamed for being fat. Teresa's grandiose self was ferlile ground for perpetual shame, for she impeached herself for every imperfection. The course of treatment repeatedly exemplified how reduction of one side of the shame/grandiosity equation inev400
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itably led to reduction of the other. This dynamic is sharply illustrated in three areas of work on which Teresa concentrated-grandiosity, obesity, and passivity.
My initial aim in treating Teresa was to establish a holding environment in which she felt safe enough to reveal her secrets, fears, and shames. This meant not only offering acceptance, support, empathy, and comfort, but also protection against observations and interpretations that could set off her shame and related emotional pain. When Teresa began to allow glimpses into her internal life, we encountered acutely raw vulnerabilities. She showed a particular vulnerability to observations about her current intrapsychic and interpersonal patterns. For example, Teresa firmly believed that she could control the responses of others to her, that if she acted loving and caring toward others, inevitably they'd feel the same toward her. When I referred to the magical quality in her perception, she felt criticized, exposed, and ashamed. Was her anguished response a warning to stay away from interpretations entirely at this early period of treatment? I found interpretations useful when they concerned not contemporary manifestations of her patterns, but their origins, both social and psychological. To illustrate in the psychological realm: Teresa wept copiously in grief when I related her grandiosity to her early experience as an only child trying to adapt to two seriously depressed parents; a mother who crumbled and took
to bed at the least stress, and a father who withdrew whenever anger threatened, his own or anyone else's. Understanding these circumstances helped Teresa accept and respect the survival value of her omnipotence defense. As a result, she began to experience some shred of sympathy rather than shame in regard to her grandiosity.
Teresa's shame about omnipotence continued to abate as we dealt with different aspects, for example, her early deprivation of a "normal" omnipotence, and her parents' emotional neglect which she interpreted as carrying a mandate for handling her emotions independent of them. As her shame lessened, she came in touch with long-repressed anger at her parents. Struck by its intensity and volume, she recalled with amazement, how at the outset of treatment, she had presented such a highly idealized picture of them. As her ability to perceive their limitations and the deprivations they subjected her to grew, so did her anger at them.
Although the reduction in shame served to release Teresa's anger, its very expression set off more shame, for she still felt culpable for failing to control emotions in a designated direction. For instance, Teresa believed she could or should be able to program her anger out of
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existence. She directed her hostility not only outward at her parents but inward at herself for failing to eliminate these unwanted feelings. While psycho-analysis dominated our work on grandiosity, social analysis furnished an important piece in counteracting Teresa's belief that she could purge her anger, as the following comment suggests.
My anger at my parents is close to the omnipotence thing. It's not only that they thought I could handle everything, but when it came to the anger thing, society thought so too-the way little girls are raised not to be angry. How could I be responsible when the whole social fabric led to narrowing me down that particular emotional path?
Teresa elaborated the issue of societal constraints on female anger when dealing with her eating disorder, a subject that surfaced repeatedly throughout her therapy. Teresa's compulsive eating was an integral part of her grandiosity; she was convinced that she possessed a secret, surefire mechanism for handling any stress. "It made me feel powerful to know that no matter what happened,
1could handle it with food." But overeating was also a major source of her shame, not only because it was out of control but also because "My weakness is on public display." Psycho-analysis of her obesity produced substantial insight. For example, she came to understand that exposure to emotional neglect by chronically depressed parents made her feel compelled to take over the maternal comfort function herself. "I had to do something to comfort myself, especially on Sundays when 1was with them all day and 1felt so alone," Teresa repined. "Food was my friend, my protection against loneliness, my pacifier." But this was only part of the process of shame reduction in regard to her eating problem; analysis of gender socialization and cultural stereotypes about femininity added another dimension.
I'm not through with this fat issue, the vicious cycle that I eat because I feel badly about myself and I feel badly about myself because I eat. But the socialization business takes it deeper than that. I used to see my fat as a horrible defect in myself. But when I realized that society puts women in a bind-be nice little girls, don't make waves, don't rock the boat, then we had to do something with our anger. If the society said, we don't value women who are angry, if you can't express your negative feelings without censor, then for many of us eating was the only way we knew to handle that. I think understanding the dynamic of socialization and anger, of eating to keep the anger under control, has made me feel sympathetic rather than judgmental toward myself and other fat women.
While Teresa's grandiosity entailed the belief in great power, her passivity reflected the opposite idea. We analyzed those feelings of infe
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riority that comprised the underside of her grandiosity psychologically, for example, in relation to the rejection she came to anticipate as a child of two depressed and withdrawn parents. Intertwined with these interpretations were social ones, again about gender socialization.
When I think about why I didn't stand up for myself, why I didn't go out there and fight for what
I wanted, it helps to think about the fact that that is how girls were raised in the 1950s. Part ofmy neurosis is that I felt responsible for that so this explanations hits right to the heart of it, that I'm not so abnormal. It takes away from my selfdefinition that something is wrong with me. I'm still not happy I was so passive but it is more understandable, more acceptable now.
A caution in the use of social analysis.
Clearly, social dynamics played a significant part in easing Teresa's movement into deeper psychological exploration and disclosure. At the same time, as the uncovering process was underway, it became apparent that social analysis was a two-edged sword, for it also threatened to defeat the discovery process by diverting Teresa from emotional experience to intellectualization. When clients are experiencing and revealing long-hidden pain, it's essential that clinicians remain sensitively attuned to opportunities for encouraging further exploration and expression of feelings. Referring to social realities at such times can shift attention from the experiential to abstraction and generalization. This occurred with Teresa, as well as with other clients, for whom discussion about society often provided a welcome relief and "escape from internal pain. Thus, when the focus was on uncovering buried emotions, I used the utmost caution in social explanation, giving careful consideration to its potential for encouraging or discouraging the emotional work. To use social interpretation or other cognitive interpretations loosely at such times runs the risk of abetting rather than reducing clients' resistance.
Timing in the use of social analysis.
I've indicated how stage and focus in treatment influence the way in which social analysis is integrated with psycho-analysis. Teresa suggested another important condition, that is, the timing of social interventions.
If you had asked me when I started therapy what I thought about the way women are socialized, I would have said some of the things you introduced later. But before I didn't relate what I knew to my own shame, not at that deep emotional level of knowing. The main thing was that together we looked at things that I couldn't look at alone because they were too painful and overwhelming. The impact came from you making the connection at that crucial time. When I'm actually looking at my shameful parts, it's tremendously relieving to have that social overview. I guess it's part of putting it into perspective that even though I'm having intense feelings and even though
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I'm relating it to what happened in my family, there are pieces that are parts of a much bigger picture.
Teresa's comment deepens understanding of the complexities involved in using social analysis. When the focus was on gaining access to buried emotions, social analysis helped reduce Teresa's shame sufficiently to facilitate deeper probing. Once access was gained, when the focus shifted to increasing her tolerance for emotional pain, then social analysis tended to be distracting and counterproductive.
Social analysis probably has its clearest application in the later stages of therapy when clients are tying together the various strands of their life experience into a new perspective and new self-concept. It's important to note that therapists' social orientation isn't distinct from the transference experience. In fact, the two can go hand in hand, for the images clients internalize in treatment include the ideas therapists communicate about self and society. Trained as a counselor, Teresa was sensitive to the importance of my social orientation in the transference relationship, as she indicated near the end of her treatment.
When I think back to that early time, I realize that the sociological piece was an important part of the transference, of what a good mother does. My mother didn't help me to see the world clearly. She didn't help me to understand how things worked out there so I felt unprepared. Now there's a piece of the social in the very way I think about you.
While Teresa relied extensively on my explanations of gender socialization and cultural norms about femininity, her new perspective also reflected the incorporation of other social realities, such as the influence of economic deprivation of her mother's life.
I think differently about my mother, now, like her lack of education, the depression, her being lower class and feeling she had to prove herself because of that.
"But," I commented, "You knew about her economic struggles before you entered therapy; it's not something you learned here."
"Yes," she rejoined, "but tying my own problems
It helped me to forgive her when I saw these patterns in her life over which she had no control. to a social framework allowed me to see my mother's problems in the same way and that helped me to forgive her in a very deep way."
Similar to Martha, referred to earlier, Teresa's expanded social identity was part of her deepening perspective. It provided not only internal comfort but a sense of herself as a social being connected to the world.
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Teresa ended treatment recently. Her impressive psychological gains were accompanied by an equally impressive loss in weight. She summarized what she considered the essence of her therapy in her last session.
I don't see things as an intrinsic deficiency in myself as I did before.
My work with Teresa was typical in illustrating how access to previously submerged feelings and conflicts sets in motion a fundamental shift in clients' perception of the problem. She and other clients came to view pathology, which earlier they had attributed solely to themselves, as part of a family system. The link between their psyches and their parents' is a step in a progression that leads to examining parents' psychological histories with a more realistic eye. "Yes, my mother, as one of nine children, didn't get much love so she didn't know how to give me what I needed"-a typical late stage therapy integration. Clients experience considerable relief when they locate their problems historically, when they synthesize their parents' psychological realities with their own. This relief generates a strong desire
But forgiveness is an act directed toward sinners, in this case toward psychological sinners. The typical therapeutic framework, which emphasizes the pathological or flawed selfand flawed heritage, produces a partial integration, limited by its omission of the social context of a client's family drama. In my experience, addressing that social gap leads to a broader understanding and therefore a greater inner peace than otherwise occurs. As Teresa said, "if it's about my family, it's still about me. But if it's about society, then my shame doesn't get set off."
George, the fireman mentioned above, affinned the benefit of integrating a broader perspective. Early in our work together, George viewed himself as deficient, impaired, lacking the capacity for successful relationships. He experienced relief from self-blame when he linked his
As a woman I used to feel responsible for everything, apologetic for everything. I was real aware when I shared the story of being so responsible that it's no longer just about me; it's about other women too because they're coming from that same place. When I was complemented for the way I organized that meeting, I really felt like a feminist, like a part of something out there. That's real new for me, to feel connected, me personally, to something political.
It helped me when I couldn't cope to stop beating myself about it. Being stressed doesn't mean I'm a horrible person. I'm more tolerant, less judgmental of myself. I mean I can't believe the way I feel. to forgive.
problems to early deprivations in the family, reshuffiing his image of his parents, and, in the process, of himself. Still, on the external front, a sense of potential danger lingered, danger associated with the flawed heritage model which caused him to keep his guard up with parents. Consideration of the social framework of family life chipped away at his guard. When he could see his parents as victims of forces that may have been beyond their control, forces that weren't unique to them but were broadly characteristic, his image of them underwent another change. "I not only feel more positive, more sympathetic toward them, but also safer. Understanding the system protects me, like they can't cut such a deep wound anymore." From this larger, more realistic sense of his family's social and psychological reality, George experienced a new level of internal safety and self-confidence.
If we think of the individual as a self-contained unit, motivated and shaped primarily by internal forces, then we give clients the full burden of responsibility for the evolution of their troubles. This causes not only unnecessary pain, but it's an incomplete explanation of the human experience. My clinical work repeatedly demonstrates that clients' self-esteem and internal cohesion are enhanced as they integrate greater complexity of contexts. Viewing individuals as both psychologically and socially situated leads inevitably to a social/psychological orientation in therapy, which, I'm convinced represents an advance over the "flawed self, flawed heritage" model.
In sum, I've demonstrated that social analysis is one part of a process that leads to changing individuals' personal and social identities. I've indicated some of the circumstances in which social analysis retards or facilitates the therapeutic process-level of clients' vulnerability, timing, and stage and focus of treatment. These observations represent a contribution to what I hope will be a continuing effort by clinicians to develop guidelines for integrating social dynamics into the clinical experience.
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Clinical Social Work Journal Vol. 18, No.4, Winter 1990