Cloe Madanes on Advocating for the Most Vulnerable

In the 1970s, when I began working in this field, family therapy pioneers Salvador Minuchin and Jay Haley had turned the Philadelphia Child Guidance Clinic into a place where every child treated was also seen with his or her family. I’ll never forget one Friday evening when I was supervising a student working with the family of a severely suicidal 15-year-old girl. I could tell that the girl felt abandoned by her biological father and threatened by an overly intense relationship with her young stepfather. I needed a few days to find the father and reconnect him to the girl. To buy that time, I needed a psychiatrist willing to sign off and be on call so the girl could go home over the weekend until a session on Monday. Otherwise, I’d have to put her in the hospital—which I felt would be traumatic for her. Unfortunately, everyone on the psychiatric staff had already left.

Wandering the halls in hopes of finding someone to help, I discovered that Minuchin, the head of the clinic, whom I hardly knew at that point, was teaching a seminar to about 50 residents. I went in and said, “I’m sorry for interrupting, but I know that in this clinic the children come first.” After I explained the situation, Minuchin immediately stood up, told the students to wait, interviewed the girl and the family for half an hour, and gave them his phone number. He’d personally take the responsibility to be on call.

At the clinic and elsewhere during the height of the family therapy movement, the healing power of the family was respected, and medication and out-of-home placements were considered a last resort. For a variety of reasons, that era has passed, and countertherapeutic economic forces have come to dominate treatment decisions. Most therapists today prefer to ignore the fact that large psychiatric hospitals in the United States make enormous amounts of money out of institutionalizing, labeling, and medicating children, making between $100,000 and $200,000 a year for every bed that’s occupied. Many of these institutions are little more than warehouses and are the scene of terrible injustices against the most vulnerable of our clients.

At one institution in Virginia, 700 beds are constantly filled. That institution is privately owned and has a psychologist on staff who flies around the country scouting for disturbed children who can be taken off the hands of the department of social services and transported out of state to be institutionalized there. These children are placed in locked wards and heavily medicated, often causing them to become obese and suicidal. The mandate to keep the child in the system is one of bottom-line economics, not what’s in the best interest of these young patients.

Why have professional therapists been so ineffective in addressing the shortcomings and abuses of our current mental health system? A major problem in our field today is that we’re not only divided into schools of thought, but also separated because of the different contexts in which we work and the varying populations we work with. There are huge differences between working in private practice with the worried well and working in a locked ward in a hospital, a rehabilitation center for drug addicts, an institution for disturbed children and adolescents, a prison, the military, and the department of social services, just to name a few. Even as our decisions influence the lives of millions of people—not only through our clients, but also through the mass media—we remain unclear about our values and how we want to exert our influence.

Furthermore, because we’re fragmented and divided, we’re easily dominated by outside forces that are more powerful and better organized than we are: managed care, pharmacology, for-profit psychiatric institutions, the department of social services, and many others. We may grumble about the failures of these systems in private among ourselves, but rarely do we address them in the programs of major conferences or other professional forums. Thus, the prevailing unstated sentiment within our field is that politics and social justice aren’t part of our job description.

We need to reexamine our values as a profession and rediscover the activism of the days when the DSM didn’t so thoroughly limit our perspective and clinicians were encouraged to think beyond narrow diagnostic categories and embrace the fuller complexities of human systems in trying to serve our clients as well as possible. Back then, it was accepted that we therapists need to go beyond our own comfort level if we’re to help clients overcome the grim and sordid circumstances that perpetuate their difficulties. This was especially true in our work with children, whom it’s our professional responsibility to protect. After all, they’re usually brought to therapy because someone else wants to change them—the parents, the school, the pediatrician—and the children’s perception of what constitutes their own happiness and well-being may conflict with the wishes of others.

Often, our clinical role places us in the complicated position of protecting them from people on whom they depend. But even when there’s been abuse or neglect, our job is to support families and promote reconnection whenever possible. And we can do this by thinking systemically. Where’s the grandmother, the aunt? How can we bring out the love in the mother? Is there a kindly neighbor? In my entire career, I’ve never failed to find someone in a child’s community that wasn’t willing to take the child on. A child needs only one loving, competent parent. All it takes to know how to find that person is to believe that the child is part of a network, a community that we need to support.

We need to bridge the differences that divide us and stand up for human rights, especially children’s rights. I want to propose the following points as being essential to our commitment to serve the people who need our help:

• People can change dramatically, often in the course of a single encounter, once they tap into their dormant strengths and the resources within their relationship network are mobilized.
• Rather than defining people by psychiatric labels, we can never underestimate their capacity for self-determination in their response to the inspiring influence of those committed to expanding their senseof possibilities.
• We need to continue to deepen our appreciation of the healing power of words—because that’s all that therapy is—as well as the primary driving force underlying therapeutic change: the immense power
  of human connection.
• We must maintain our faith in the ability of the human spirit to overcome all sorts of obstacles, especially when we contribute our own creativity and resolve as therapists to helping our clients enhance their own lives.