In its long and frequent expression in the United States, the social clinic has become a broadly sanctioned, well-funded, and often attended institution of society. It is a touchstone, a defining totem of American values that is carved into the goals and practices of the social services and social policy itself; it circumscribes many of the functions of charity and public social welfare. The social clinic is also a frequent instance of the sacred beliefs and tenets of American citizenship. Even more subtly, it defines the national psyche.
The social clinic manifests itself most obviously as programs of psychotherapy (including its behavioral adaptations), mentoring, and counseling to address a variety of mental, social, and personal problems such as substance abuse, trauma and depression , mental and psychiatric problems, weight problems, major and minor criminal transgressions, and many others. Less often, it also provides supportive services and other nonmedical interventions designed to change undesirable behavior. Indeed, the view has long persisted in American social welfare that poverty itself is principally a result of character flawsâlaziness, promiscuity, and hedonismâthat require clinical attention. In addition, an enormous group of people voluntarily seek care from the social clinic to better their lives, to find greater psychic comfort, to improve performance at work, to sharpen social skills, and to enrich family life. Without any appreciation for irony, the social clinic frequently offers professional counseling to improve self-help .
The social clinic employs the disciplines of social work , counseling, clinical psychology, community psychology and community psychiatry, community nursing, and others. Its programs of psychotherapy and personal support usually attend to mental and emotional disorders but also adjustment problems, criminal rehabilitation, motivation, and to a much lesser degree social support among many others. It typically functions as free-standing agencies and solo practices but also within prisons, reformatories, courts, mental hospitals, churches , universities, the military, many police forces, public and private schools, community centers, and others. The social clinic has also seeped into unexpected areas of American life. It is present in organized religion as pastoral counseling and in the workplace often as employee assistance programs, industrial psychology, the disciplines of management such as organizational development programs that rely on worker counseling and motivation. Many professional and amateur sports organizations seek clinical assistance to motivate their athletes. It is paid for through a variety of public programsâe.g., Medicaid, Medicare and Title XX of the Social Security Actâas well as through private insurance, local and state subsidies, charitable contributions, and cash.
Even while the central talk therapies of the social clinic are creations of clinical psychology, the majority of professional talk therapy and perhaps administrative leadership is provided by social workers. Bledsoe and Grote (2006) report that social workers account for more than 60% of psychotherapists (p. 114). The interventions of the social clinic are largely based on one form of talk therapy or another since the social clinic rarely if ever dispenses material support and rarely provides supportive care. Indeed, clinical services are usually predicated on the assumption that attitude change, achieved through processes of ârational induction,â that is, discussions and evaluations of the patientâs behavior, precedes behavioral change. The corollary assumption prevails in the United States that material support and thus public welfare create a moral hazard that inhibits behavioral change while encouraging deviant behavior, particularly dependency on charity and public welfare.1
The history of social work mirrors the other occupations of the social clinic , contradicting an institutionalized role as the heroic advocate of systemic change. If anything, it consistently looked toward a revolution in human consciousness, if even that, rather than in politics. Social work and the other clinical disciplines have customarily been obedient to romantic social normsânotably the pursuit of human perfection through self-help and counseling based on the possibility of self-invention. The social clinic did not choose its goals, service groups, or types of intervention. It yielded to dominant social and cultural changes. Indeed, social work as one typical example continues to take refuge in established tolerances, promoting social causes such as diversity and empowerment when they are safely two generations old and have matured from pursuits of liberation to practices of restraint. Advocacy is rare; programmatic success is even rarer, idiosyncratic, and thus sterile.
The social clinic was easily realized. It was not a fiercely contended victory over the forces of rebarbative tradition by the professions of helping. There was little if any opposition to a practice of social reform that put the onus of change on the service recipient. Its popularity was presaged by established practices and assumptions of American religion. Even before the advent of modern psychotherapy, the tenets of the social clinicânotably a sense of personal responsibility for personal failure and needâcustomarily defined the center of social work . The field sought professional standing early on by adopting a psychological practice, initially Freudian therapy, and then others built on assumptions of individual agency rather than social causation. Social work found convenience in the romantic traditions of psychological practiceâinsight, intuition, subjectivity, and self-evident truthâthat rejected the substance of science but conveniently adopted its form.
Nonetheless, social welfare histories, when they touch on the social clinic or are addressed largely to it, pay little attention to the issue of service effectiveness. This is not surprising since program evaluation until fairly recently relied on intuitive assessments by practitioners and administrators as well as other nonsystematic and unreliable reviews. At best, partial descriptions of personal, recipients, and services were drawn from institutional accounts. Moreover, with few exceptions the histories fail to appreciate the obedience of the social clinic to the romantic tenets of American society and its immense popularity. Instead, most impose a biblical narrative on the history of the social clinic in the United States, imagining a heroic struggle of virtuous social reform in overcoming rebarbative resistance. However, the journalism of David and Goliath is insufficient to address the actual role of the social clinic or to acknowledge that willingly, quietly, and knowingly it purveys inadequate services to needy populations. Paraphrasing the late president Lyndon Johnson, getting ahead depends on getting along and the social clinic was an obliging miracle of congeniality rather than effective opposition to racism, poverty, and social inequality.
At least superficially, the social clinic was modeled on the medical clinic and accepted its core assumption of practice that the presenting problem could be treated in isolation from its social context. That is, the individualâs problems could be successfully and efficiently addressed without the immense expense of addressing either the initial or sustaining social causes. Yet the medical clinic is twinned with public health while the social clinic is devoid of scientific coherence .
Throughout their development, the medical clinic and the social clinic faced similar challenges but took different paths. Medical practice embraced science. Social treatment rejected it in reality, reducing science to a ritual of evidence-based practice and its even weaker form, evidence-informed practice. Through credible science, medicine achieved the ability to treat physical disease. In contrast, the social clinic has failed to develop scientifically credible evidence of success. Yet neither field chose freely. Each realized different prevailing social goals, expectations, and roles in becoming institutions of popular consent. In short, the practice of medicine is sustained by a pragmatic ability to treat physical disease. The social clinic performs a ceremonial role in affirming romantic social preferences.
Medicine has professionalized applied science. The social clinic, employing the techniques of belief and cultural loyalty rather than evidence of reason, has professionalized a form of religion but one in which theology is displaced by an ideology of dominant social values. The conclusion of ideological consistency would not be justified if the social clinic pursued vastly different goals that reflected different social assumptions and values. However, American social policy choices including the goals, assumptions, and interventions of the social clinic are dependably romantic. As a result of its loyalty to social values, the social clinic has achieved a sanctioned and licensed franchise to treat individual behavioral problems that imitates the near-monopoly granted to medicine and the allied health professions to treat physical disease.
As part of its ritual of science, the social clinic claims professional standing on the basis of specialized knowledge that is effective in treating personal and social problems. Yet deprived of credible science, its knowledge remains uncertain and contrived. Not surprisingly, the defining goals of the social clinic are not achieved. Nonetheless, the alleged specialized knowledge of the social clinic constitutes the core of professional training in a variety of university-based programs âprominently social work, child and family practice, clinical and counseling psychologyâand contributes peripherally to othersâpublic administration, management, public health, and even psychiatry and physical therapy.
Part of the reason for the social clinicâs lack of good information lies with the corruption of its research, its failure to successfully apply randomized designs even when they are possible. The social clinic like the medical clinic seems ideal for the application of controlled research to test whether interventions are successfulâwhether recipients of social clinic services have recovered or improved. Both treat large numbers of individuals and both are testing interventions that are not proven to be effective. However, much of the social clinicâs knowledge problem rests with intractable and near intractable issues of testing.
At its root, the social clinic emerged from the Enlightenment hope of realizing a science of the individual and society. Yet it is customarily impossible to apply credible science to discover the cause of most social problems and thus to eliminate the âgermsâ of social pathology. In contrast, medical science has progressed because of a theory of disease that led to the identification of its causes and then successful treatment and containment. Yet it is not possible to divide any society into testable groups over long periods of timeâgenerationsâto test the degree to which structural or personal conditions create problematic outcomes. Furthermore, much of the instrumentation of the social clinicâthe tools to measure service effectsâis impaired and inadequate. As a result, much of its outcome data, solicited without corroboration from service recipients, is presumably unreliable and subject to reporting and measurement biases. Even worse, replications are rare, uncertain, and uneven; protections against biases are weak; and research intended to test the state of the art is customarily conducted as optimal demonstrations that include rigorous accountability and that employ presumably gifted clinicians. Thus, these demonstrations fail to test the outcomes of the social clinicâs interventions under the customary, suboptimal conditions of practice. Yet even taken at its word, the most credible of the research usually reports only small gains. It is difficult to ignore the conclusion that the social clinic is a cultural form without much of an ability to talk people o...