Critical Clinical Social Work and the Neoliberal Constraints on Social Justice in Mental Health

Abstract

Despite a strong history of social justice–based social work professional education in Canada, there has not been an intentional integration of direct critical clinical mental health practice with social justice–based theory. Progressive social work has tended to view clinical work as focusing on the individual and failing to contribute to social change. In this article, I elaborate upon a critical clinical social work approach influenced by postmodern critique, and feminist-, narrative-, and collaborative-based practice rooted in critical theory. Critical clinical practice disrupts the individual/social binary through counterviewing unhelpful dominant social discourses and producing counterstories that participate in social resistance. I explore the constraints of neoliberalism on social work mental health practice and its influence on the ability of social workers to practice social justice–based social work. Neoliberalism constrains social workers’ ability to address the social and structural determinants of mental health through its focus on economic rationalization, biomedicalization, and individual responsibilization, alongside rationalized practices that emphasize evidence-based and short-term efficiency-based models. I argue that social work is facing a crisis as a disempowered profession, as it attempts to reconcile its commitment to social justice and the importance of addressing inequity, marginalization, and oppression while often working in settings that demand the subordination of social work knowledge to neoliberal biomedicalism. Under these conditions, a critical clinical approach to mental health practice is needed now more than ever.

Keywords

critical clinical social work neoliberalism social justice mental health

There has not been a substantial focus on the direct critical clinical application of anti-oppressive and social justice–based social work theory in Canadian social work. Progressive social work has tended to view clinical work as focusing on the individual and not contributing to social change and aside from feminist-, narrative-, and empowerment-based direct practice. There has not been significant focus on developing critical clinical approaches to practice in social work. In this article, I elaborate upon the need for integrating critical clinical skills consistent with an anti-oppressive and social justice paradigm of social work particularly at a time when neoliberalism constrains social justice–based practice. This article explores the impact of neoliberal economic rationalism on social work mental health practice and argues that a crisis of identity and the value of social work as a profession have emerged as social work struggles with their co-optation into dominant biomedical discourse and practice and away from social justice.

Critical Clinical Practice

Critical clinical practice seeks to reconcile the long-standing gap between social justice– and equity-based theory and direct clinical work by recognizing that personal distress and struggles often co-occur with marginalization, oppression, and inequity. There has been a deep-rooted tension between clinical and structural social work, which reflects a binary of the individual and society. While feminist, narrative, and empowerment approaches have been well developed for some time, there has not been a full and intentional integration of critical clinical practice into social work.

Social work has often abandoned the need for critique and politicization in social work mental health practice while otherwise offering social critique and advocating for social change. This is not only inconsistent, it inadvertently, reinforces the individual/social binary and through its silence in the field of mental health the dominant pathologizing biomedical discourse and practice itself. From this view, critical clinical praxis must adopt a cohesive and unified approach, which intentionally situates these struggles within their social context with the aim of contributing to social justice (C. Brown, 2020a). To accept mainstream mental health biomedicalizing discourse and practices is siding with power and inequity.

Critical clinical practice rejects the truth claims of the dominant biomedical discourse and unpacks the discursive aspects of people’s lives and experiences in collaborative therapeutic conversations (C. Brown, 2020a; C. Brown & Augusta-Scott, 2018). Through unpacking the discursive aspects of people’s stories, practitioners explore, counterview, and counterstory ways in which power and knowledge are joined together through such discourse (C. Brown, 2007a, 2007b, 2007c, 2012, 2014, 2017; C. Brown & Augusta-Scott, 2007; Foucault, 1980a, 1980b; Madigan, 2003; White, 2001, 2007; White & Epston, 1990). There are several central characteristics of a critical clinical framework, and while diverse, this framework represents social justice praxis. Consistent with social justice–based approaches to mental health and addiction, a critical clinical approach does not medicalize or pathologize people’s struggles but situates them within the social contexts and inequities in which they emerge. It seeks to make sense of people’s experiences and what they mean to them. Critical clinical social work practice explores the ways that dominant discourses shape the stories that people bring to therapeutic conversations, and by doing so, we are also unpacking power: “As stories are discursive, the living and telling of them are inseparable. We form or constitute our experiences as we speak of them, and as we speak of them, we experience them” (C. Brown & Augusta-Scott, 2007, p. xxi). At the same time, a critical clinical practitioner or social worker is always positioned and always partial. Drawing on feminist collaborative approaches to practice, we need to acknowledge that we are always in a position of power when we are the practitioner. This is often institutionally and professionally established, but it is also relational as the service user is in a vulnerable position in relation to the service provider (C. Brown, 1993, 2007b; C. Brown & Augusta-Scott, 2018). Social workers themselves may experience both power and oppression in the world and certainly often in the hierarchical contexts in which social workers practice institutionally.

Deconstructive narrative and collaborative strategies aim to unpack dominant and unhelpful social stories that keep mental health struggles alive through a variety of diverse and creative methods with a focus on helping to produce counterstories that participate in social resistance (C. Brown, 2020a). Overall, a critical clinical approach focuses on integrating postmodern and critical frameworks including feminist, narrative, anti-racist, postcolonial, and postmodern deconstructive critiques of key concepts such as power, knowledge, experience, self, emotion, and ethics (C. Brown, 2020a). Taken together, oppressive discursive and structural influences shaping people’s lives are explored alongside unhelpful internalized discursive socially constructed meanings that work to solidify the power of those structures. We need to reinvigorate the early feminist therapy idea of the “personal is political,” which integrated theory and practice, society, and the individual (Levine, 1982).

While social workers are generally aware of the social determinants of health that have been well established for some time (Raphael, 2006), the social determinants of mental health, particularly within the dominant biomedical approach to service delivery, still need to be highlighted. Beginning in the 1970s, the women’s movement and feminist therapists critiqued the medical model and the pathologization of women’s daily life (C. Brown, 1993; L. Brown, 2004; Pizzey, 1974; Smith & David, 1975). Social workers are trained to attend to the social context of people’s lives, but despite this and the ongoing critique, mainstream service delivery and practice remain strongly rooted in individualizing biomedical approach and demand social workers compliance to this hegemony. Structural social inequities based on, for instance, class, race, gender, ability, and age have a significant impact on people’s mental health and well-being (World Health Organization, 2014). As people’s pain, suffering, and struggles often arise within these marginalized and unequal contexts, critical clinical work needs to be able to skillfully address them. In order to address social inequities and injustices in society, we need to intentionally advocate for and adopt critical clinical practices. We need to address themes such as access, barriers, diversity, and equity in receiving and providing mental health care.

Neoliberalism and Mental Health Social Work

Neoliberalism is a political philosophy and set of practices of late capitalism which center on the logic of a free-market economy and reflects a small government approach. Critiques of neoliberalism and neoliberal perspectives often focus on the impact of market principles on economic and social distribution of goods (Gazso, 2012; Shamir, 2008) and the magnification of social power differences based on gender, race, and class (C. Brown, 2016, 2019). Since the 1990s, there has been an intensification of neoliberalism, and its effects are evident in labor market restructuring, privatization, and reduction of the social welfare state and its responsibilities. The individual is responsibilized, rather than the state, for social risks such as illness, disability, unemployment, and poverty with a focus on the individual’s ability to be self-managed and regulated and ultimately to be responsible for their own recovery (C. Brown, 2007b, 2019, 2020a; Liebenberg et al., 2013; Morrow & Weisser, 2012; Pyysiäinen et al., 2017; Shamir, 2008). Stark (2018) refers to the economization of social work, whereby it too has been subjected to the logic of the market and capital accumulation. Economic restraint has pressured social workers to adopt biomedicalized, short-term, and often decontextualizing strategies, with a limited number of sessions under efficiency-based models legitimized by claims of “evidence-based” practice.

Market-based principles and neoliberal thought have penetrated every sphere of social life (C. Brown, 2016), influencing how we construct ourselves and live our lives (Braedley & Luxton, 2010). This mechanism of power works by encouraging individual participation and belief in their responsibility and by focusing on disciplinary practices, which emphasize self-care, self-improvement, and misleading notions of choice and resilience (C. Brown, 2007b, 2014, 2019). The specific impact of neoliberalism on social justice in mental health is reflected in dominant medical model approaches to mental health, which reinforce social injustice through its biomedicalized and depoliticized emphasis on disorders, diagnosis, and mental illness (C. Brown et al., 2020; C. Brown & MacDonald, 2020; Morrow & Weisser, 2012).

These individualized, decontextualized, and pathologizing approaches fail to address the social and political contexts in which people live and responsibilize individuals to solve their own problems. This is reflected in the increasingly reduced provision of adequate social welfare services and supports (Baines et al., 2019; C. Brown, 2016; Pease et al., 2016). Taken together, the biomedical focus on individual pathology and the neoliberal economic austerity produce oppressive mental health care services, whereby the individual’s capacity for resilience and recovery is championed while resources and care are limited, efficiency-based, and economically managed.

Resilience, strengths, and empowerment have been important to social work practice, but under neoliberal institutional practices, these are too often taken up in individualizing and decontextualizing ways. Therapeutic discourse is itself increasingly individualistic and medicalizing while appearing to emphasize resilience, self-determination, and well-being (Baines & Waugh, 2019; C. Brown, 2014, 2018, 2019; Cabanas, 2018; Gill & Orgad, 2018; Lefrancois et al., 2016; Lemke, 2001; Morrow & Wiesser, 2012; Rottenberg, 2014; Shamir, 2008). Through problematizing the effects of neoliberalism on the reinvigorated focus on recovery in mental health and well-being, Morrow and Weisser (2012) argue we must address the social and structural impediments to recovery. They suggest:

[T]hese social and structural aspects are articulated and enacted through a number of dimensions of power such as biomedicalism, racialization, sanism, sexism, ageism, heterosexism, etc. calling out for an intersectional social justice analysis of recovery. That is, an analysis that foregrounds an understanding of power as it is distributed in the mental health care system, and the accompanying interlocking forms of oppression through which it operates. (p. 28)

Overall, the reinvigoration of individual recovery is inadequate in addressing social and structural inequities (C. Brown, 2019; Weisser et al., 2011).

The Mainstreaming of Recovery

The notion of recovery originated as part of the recovery movement in the 1970s following the deinstitutionalization of those who were psychiatrized. While the recovery movement focused on enabling people to live well in the community, it has more recently been co-opted and mainstreamed under neoliberalism (Anthony, 1993). Initially, the recovery approach emphasized empowerment, connection, and hope while challenging the sane/insane binary. Today, the focus on “recovery” involves a self-management expectation that one will comply with the biomedical expert and the best practices of healthism advocated (i.e., regulating eating, substance use, and exercise). The imperative to recovery coexists with the imperative of self-management and responsibilization. Many have emphasized the need to question this reinvigorated focus on recovery in mental health under neoliberalism and address power and the social and structural impediments to recovery (Baines et al., 2019; C. Brown, 2016, 2019, 2020a; LeBoutillier et al., 2011; Morrow & Weisser, 2012; Pease et al., 2016; Weisser et al., 2011). Importantly, the rhetoric of recovery is increasingly used to legitimate neoliberal and biomedical strategies and approaches (Poole, 2011). The subsequent reification of social injustice and inequity of this rhetoric is described by Rose (2014) as the “mainstreaming of recovery.” The discursive mechanisms of power within the biomedical hegemonic approach to mental health produce a focus on individual agency and responsibility, which serves to invisibilize the oppression and social inequity in mental health that are then often reified by mental health care itself.

Dominant Mental Health Discourse

Together critiques of reconfigured notion of recovery and its focus on individual strengths and resilience, critiques of psychiatry (Burstow, 1992, 2003; Penfold & Walker, 1983; Smith & David, 1975; Szasz, 1970), mad scholars (Burstow & Weitz, 1988; Capponi, 1992; Lefrancois et al., 2013), challenges to the biomedical hegemonic diagnostic use of the Diagnostic and Statistical Manual of Mental Disorders (DSM; Becker & Lamb, 1994; Caplan, 1995; Cermele et al., 2001; Marecek, & Gavey, 2013; Ussher, 1991, 2010), and feminist critiques of the biomedical approach to women’s lives produce significant challenges to stories of mental health struggles and care, which singularly focus on individual deficit and exclude social and structural determinants of mental health (C. Brown, 1993, 2007a, 2007b, 2007c, 2014, 2017, 2018, 2019, 2020b; L. Brown, 1992, 2004; Comas-Diaz & Greene, 1994; Courtois, 1996; Herman, 1992, 2015; Morley, 2003; Stoppard & Gammell, 2003). Even those who have contributed to the DSM such as Francis (2012a, 2012b) and Francis and Widiger (2012) have critiqued the over diagnosing and medicalizing of the human condition seen in the DSM-5.

Critics of the biomedical model argue that not only does the DSM serves to “medicalize misery” (Strong, 2012; Ussher, 1991, 2010), its master status also offers a “lure of legitimacy” (Lafrance & McKenzie-Mohr, 2013). Lafrance (2014) argues that the “hegemony of the medical model can be understood as less a matter of ‘truth’ than of power” (p. 141). Similarly, White and Epston (1990) remind us, “We are subject to power through the normalizing ‘truths’ that shape our lives and relationships” (p. 19). For instance, the biomedical dominance and the corresponding use of the DSM-5 not only represent normalizing truths (American Psychiatric Association, 2013), they also serve as a powerful example of the joining of knowledge and power (Foucault, 1980a, 1980b). From Foucault, we understand that knowledge and power are joined through discourse, yet it is typically presumed that the biomedical model is neutral, objective, and scientific and, therefore, not politically positioned.

These critiques of dominant approaches to mental health demonstrate the epistemic injustice of forcing social work to fit within the dominant medical model (Fricker, 2003). McKenzie-Mohr and Lafrance (2011) have described “tightrope talk” as a way of trying to language experiences that do not have an adequate available social framework such as in the case of women who experience rape or depression. When the hegemonic ideological or discursive framework subordinates or invisibilizes alternative accounts, Butler (1997) suggests this produces injurious speech. Often both clients and social workers rely on the dominant pathologizing discourse available to them, which creates an epistemic gap between their own experiences and knowledge and those imposed upon them (Fricker, 2003). These gaps create both individual and social injury. Importantly, social workers practicing within these dominant pathologizing discourses are often dominant and influential in relation to their clients who operate with less power in this context. When participating in the dominant injurious discourse of the biomedical approach, the social worker is accountable in the therapeutic relationship for the harmful effects on service users. Within the dominant biomedical system of mental health care, it is not an even material playing field between clients and social workers, between social workers and other professions, and between social work and medical paradigms.

Epistemic gaps reveal the social construction of knowledge, power, and truth associated with oppression and inequity. Strong (2012) refers to the power of these dominant mental health discourses as “discursive capture.” Clearly, dominant discourses of mental health are limited (Morrow & Malcoe, 2017):

Absent from this official story are perspectives and forms of evidence that start with an analysis of power and consider the social, political, cultural, and economic production of mental health problems and solutions. Absent too are the diverse voices of experience—psychiatric survivors and those who have lived with various forms of social marginalization and (not unrelated) emotional suffering and thus have important knowledge regarding the utility of mental health reforms, supports, treatment and care. (p. 6)

The tendency to focus on “facts” and discourage “values” is emphasized as important to “rational” decision making (Webb, 2001). Evidence-based practice upholds notions of control, neutrality, and rationality allowing organizations to manage individual practitioners through implementing tools of accountability through measurement, audits, and paperwork (Webb, 2001). Furthermore, social workers are always working within domain discourses as dominant themselves. However, the demand that social workers use specific evidence-based practices such as cognitive behavioral therapy (CBT) can undermine their professional judgment, autonomy, and discretion necessary when working within complex and intersectional social contexts (Bullen et al., 2020; Webb, 2001). Approaches such as CBT also happen to align with neoliberal fiscal restraint and lend themselves to correspondingly short-term work (C. Brown, 2020a). The neoliberal fiscal restraints are particularly evident in the group use of CBT, which allows not only short-term work but also the capacity to see multiple service users at once.

Conflict and Identity

Social workers have been experiencing a fragmentation between “traditional social work values” and those of the marketplace since the 1980s (Carpenter & Platt, 1997). Increasingly, social workers describe the professional disempowerment and devaluation of social work and the challenge this poses to the professional identity of social work (Arnfjord & Hiybsgiidm, 2015; Hyslop, 2018; Rossiter & Heron, 2011). This fragmentation can impact social workers’ perception of their professional identity and congruence with their social justice lens within their professional workplace (Carpenter & Platt, 1997). The threat to social work identity has particular relevance to social workers within mental health settings, as the biopsychosocial view of health is often diminished relative to the dominant biomedical perspective that focuses on diagnosis, medication, and evidence-based treatment (Bullen et al., 2020; Gibbs, 2003; McCrae et al., 2004; Nathan & Webber, 2010; Rosen, 2003; Yip, 2004).

Tensions between social workers and the neoliberal approach to service delivery largely reflect a social workers’ conflict with the increased emphasis on labeling, diagnoses, use of DSM, the biomedical model, and growing focus on neuroscience. The co-optation of social workers into neoliberal constructions of mental health can be seen through the expectation in the workplace that social workers will accept and support the biomedicalization, pathologization, individualization, responsibilization, and privatization of services.

Consistent with the existing literature, a recent study on repositioning social work mental health practices in Nova Scotia found that in addition to conflict with the dominant biomedical model, social workers reported a lack of autonomy; lack of professional freedom, value, and respect; lack of power, position, opportunity, and voice to influence practice and policy; fear of replacement; diminishment of social work values; standardization that constricted their scope of practice; an increase of metrics and measurement as seen through a growth in paperwork; a decreased number of permitted counseling sessions; and a lack of choice about their model of practice (C. Brown et al., 2020). Social workers expressed conflict with the taken for granted expectation they comply with practice approaches that emphasize a limited number of sessions using evidence-based models such as CBT, as this reduces their capacity to adequately address the social and structural determinants of mental health. Overall, their practice is constrained within state-funded models that reflect a neoliberal emphasis on efficiency rather than quality and care. On the one hand, it may be more challenging to address social and structural determinants of mental health struggles in group-based CBT, and on the other hand, creative social workers may be able to find a way to move conversations away from individualizing struggles to collectivizing the conversation by focusing on shared elements of people’s experiences and the social contexts in which they emerge. Within individual CBT, the social workers may also choose to contextualize people’s mental health concerns, despite the individual focus of CBT.

Overall, however, the current rationalized approach to social work mental health service delivery is often too narrowly focused and time limited to allow for the development of the strong therapeutic alliance needed to adequately address the level of distress and suffering that arise within the conditions of mental health inequity. Baines and Waugh (2019) argue, “One of the main victims of this rationalisation of practice has been the hallmark trust-based, dignity-enhancing, time-intensive relationships generally thought to form the impetus and means for change within social work endeavour” (p. 250). While neoliberal service delivery emphasizes one size fits all evidence-based models, existing research has shown that the therapeutic alliance or relationship is the most significant determinant of how service users perceive the effectiveness of therapy especially where there is relational injury from trauma and intergenerational trauma (Herman 1992, 2015; Norcross & Wampold, 2011).

The implications of neoliberalism for social work were also explored in a six-country study, which found that levels of economic inequality have increased under neoliberalism (Spolander et al., 2014). It is argued that social work is facing challenges and conflicts internationally and that “it is important for the profession to find its collective voice to understand, analyse, promote and develop strategies to deal with the impact of neoliberal reform if it is to remain relevant” (p. 309). As such, there has been a growing call for a reconfiguration or restructuring of social work in response to neoliberalism (Baines et al., 2019; C. Brown et al., 2020; C. Brown & Macdonald, 2020; Fergus, 2004; Harlow et al., 2013). When social work is co-opted under the institutional and social climate of neoliberalism with its emphasis on fiscal constraint and the rationalization of all practices, our social justice–based professional identities are at risk (Goodman et al., 2004; Gray et al., 2015). This is also the case when the workplace requires social work practitioners to subordinate our own knowledge and practices to those of psychology, psychiatry, and medicine.

Arguably, neoliberalism has created a mental health service crisis for social workers (Carney, 2008). Ferguson and Lavalette (2013) suggest that social work in Britain is in a state of crisis with very low morale among social workers. Research on mental health and neoliberalism in the United Kingdom has found that managerialism has had an oppressive effect on social work practitioners and has produced conflicts and power struggles. This has resulted, they suggest, in a fragmented system, in which social workers are ambivalently compliant to the values of neoliberalism and their de-professionalization (Ramon, 2008).

Some practitioners resist neoliberal governance and managerialist pressures through spending more time with clients and critiquing the expected structure of services with their clients (Gray et al., 2015; Strier & Breshtling, 2016; Thomas & Davies, 2005). Research on the impact of neoliberalism and the demands for austerity and accountability on the practices of directors of Canadian schools of social work was explored by Barnoff et al. (2017). They found that the directors engage in practices that comply with, negotiate, and resist neoliberalism through how they address for instance performance measurement and output and their struggles with fiscal constraints.

The Neoliberal Self

Not only does neoliberalism emphasize free-market politics and a reduction in the provision of social resources, it also emphasizes a corresponding ideal citizen (Haydock, 2014). This mechanism of power works by encouraging individual participation and belief in their responsibility by focusing on disciplinary practices, which emphasize self-care, self-improvement, and misleading notions of choice and resilience (C. Brown, 2007b; Chen, 2013). The “self is a vehicle of power in which individuals enact and reify culturally encoded normative practices of self” (C. Brown, 2014, p. 176). According to Foucault (1980b), “individuals participate in normalizing and disciplinary practices of self, wherein we turn ourselves into subjects, absorbed by improvement, management and performance of self” (C. Brown, 2014, p. 176). While people are then active in the creation of themselves, it is not always in a way that benefits them. Individual focus on self-discipline has intensified as a normalization process of self under neoliberalism and reflects the corresponding imperative of self-management discourse (C. Brown, 2014; Foucault, 1980a; Gremillion, 2003) that also requires a tightly controlled subjectivity (Ahmed, 2004; C. Brown, 2014, 2019).

Women, more often than men, are required to work on and transform the self and to regulate every aspect of their conduct while presenting these actions as freely chosen (Gill, 2008). For Gill (2008), “power operates psychologically” and hence emotionally by “governing the self” (p. 443). In the neoliberal era, we need to question how larger socioeconomic and political discourses of extreme austerity, division, and individual responsibilization are increasingly taken up in everyday mechanisms of power, evident in dominant approaches to the self and mental health.

One of the problems with this focus on autonomous choices is that it remains complicit with, rather than critical of “postfeminist” and neoliberal discourses both of which center on notions of individual choice and freedom (Barker, 2013; Chen, 2013; Gill, 2008). We are reminded by Butler (1997) that all choice is constrained—there is no completely free choice. We do not have endless self-determination or agency, and yet, we are not simply puppets or victims of culture. While we may believe we are making choices and believe ourselves to be self-regulating, we are also being socially managed or regulated.

It becomes apparent that social justice–based social workers can unwittingly take up concepts like resilience, trauma-informed, evidence-based, self-management, self-mastery, recovery, happiness, success, individual choice, and empowerment, which are central to notions of the neoliberal subject today. The construction of the neoliberal subject often aligns well with the dominant biomedicalized, individualized, pathologized, and decontextualized mental health care service delivery system, which responsibilizes individual recovery. Challenging of our own discursive participation in the neoliberal co-optation of many of these ideas is necessary to resisting them. Following Ahmed’s (2004) thinking on the politics of emotion that stresses we need to ask “what emotions do” in social terms, we correspondingly need to ask what neoliberal concepts actually do. The creation of a collective social work voice through professional associations of social work, social work education, and the creation of social work unions may together work to resist the dominant neoliberal discourse and to gain greater control over the practice of social work.

Conclusion

It has been argued that we need to acknowledge and address the extent to which social workers are aware of, resist, and comply with the impact of neoliberalism on their work place (i.e., lack of autonomy, lack of professional freedom, diminishment of social work values, standardization, metrics, increased client load, decreased number of sessions) and to what extent social workers support a neoliberal approach to service delivery (i.e., labeling, diagnoses, use of DSM, biomedical model, neuroscience). This article has explored how social workers are often co-opted into neoliberal biomedicalized constructions of mental health (i.e., biomedicalization, pathologization, individualization, responsibilization) and the extent to which social workers’ mental health services are co-opted by the needs of the state and the effect of this on treatment approaches (efficiency focused, evidence-based, fiscally restrained, short term, and standardized interventions). Social workers struggle to reconcile their own professional training and values and its focus on social justice with the demands of the workplace and on individual pathology and service efficiency. Clearly, social workers’ professional and ethical focus on social justice is constrained in the workplace by neoliberal managerialism and fiscal constraint.

A critical clinical approach seeks to confront the long-standing gap between social justice theory and social justice approaches to mental health practice and argues this process must be deliberate, intentional, and critical. Given the crisis identified in social work mental health practices under neoliberalism, it is imperative that social work as a profession explores ways to enhance the value and identity of social work as a profession committed to social justice. We need to resist the neoliberal psychological turn if we wish to advance a social justice approach to mental health. We know that many experience extreme social and economic disadvantage and/or struggle with co-occurring mental health, trauma, and addiction issues, which often require long-term practice and the building of trusting collaborative therapeutic relationships. As social workers, we need to provide mental health care that addresses struggles that often arise in tandem from the combination of adverse life experiences such as trauma and relational injury and marginalization, oppression, and inequity (C. Brown, 2017, 2019, 2020b; Government of Canada, 2020; Herman, 1992, 2015).

I have argued that the current rationalized approach is too narrowly focused and time limited to allow for the development of the strong therapeutic alliance needed to adequately address the level of distress and suffering that arise within the conditions of mental health inequity. All told, these challenges have been described as a “crisis” of the social work profession, as they invisibilize and immobilize the social justice values, insights, and contributions of social work knowledge and praxis. With growing social inequities and injustices in society, there is now an even greater need to intentionally advocate for and adopt critical clinical social justice practices. Moving forward, we need to resist co-optation into neoliberal constructions of service provision. On the whole, dominant neoliberal discourse is at odds with a social justice approach to providing mental health care. We need to be on our guard for the ways that neoliberalism can co-opt and reshape the very idea of social justice itself.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Catrina Brown

References

Ahmed

(2004). Affective economies. Social Text, 79(22), 117–139.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://www.psychiatry.org/psychiatrists/practice/dsm

Anthony

W. I.

(1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11–23.

Arnfjord

Hiybsgiidm

(2015). Problems of professional disempowerment: An initial study of social work conditions in Greenland. Intersectionalities: A Global Journal of Social Work Analysis, Research, Polity, and Practice, 4(1), 40–58.

Baines

Bennett

Goodwin

Rawsthorne

(Eds.). (2019). Working across difference: Social work, social policy, and social justice (pp. 247–260). Red Globe Press.

Baines

Waugh

(2019). Afterword: Resistance, white fragility and late neo-liberalism. In Baines

Bennett

Goodwin

Rawsthorne

(Eds.), Working across difference: Social work, social policy, and social justice (pp. 247–260). Red Globe Press.

Barker

(2013). New femininities: Postfeminism, neoliberalism and subjectivity. Psychology & Sexuality, 4(3), 323–325.

Barnoff

Moffatt

Todd

Panitch

(2017). Academic leadership in the context of neoliberalism: The practice of social work directors. Canadian Social Work Review/Revue canadienne de service social, 34(1), 5–21.

Becker

Lamb

(1994). Sex bias in the diagnosis of borderline personality disorder and posttraumatic stress disorder. Professional Psychology: Research and Practice, 25(1), 55–61.

10.

Braedley

Luxton

(2010). Competing philosophies: Neo-liberalism and challenges of everyday life. In Braedley

Luxton

(Eds.), Neo-liberalism and everyday life (pp. 3–21). McGill-Queen’s University Press.

11.

Brown

(1993). Feminist therapy: Power, ethics, and control. In Brown

Jasper

(Eds.). Consuming passions. Feminist approaches to weight preoccupation and eating disorders (pp. 120–136). Second Story Feminist Press.

12.

Brown

(2007a). Dethroning the suppressed voice: Unpacking experience as story. In Brown

Augusta-Scott

(Eds.), Narrative therapy: Making meaning, making lives (pp. 177–196). Sage.

13.

Brown

(2007b). Situating knowledge and power in the therapeutic alliance. In Brown

Augusta-Scott

(Eds.), Narrative therapy: Making meaning, making lives (pp. 3–22). Sage.

14.

Brown

(2007c). Discipline and desire: Regulating the body/self. In Brown

Augusta-Scott

(Eds.), Narrative therapy: Making meaning, making lives (pp. 105–131). Sage.

15.

Brown

(2012). Anti-oppression through a postmodern lens: Dismantling the master’s tools. Critical Social Work, 3(1), 34–65.

16.

Brown

(2014). Untangling emotional threads, self-management discourse and women’s body talk. In LaFrance

McKenzie-Mohr

(Eds.), Women voicing resistance: Discursive and narrative explorations (pp. 174–190). Routledge.

17.

Brown

(2016). The constraints of neo-liberal new managerialism in social work education [The Forum]. Canadian Review of Social Work, 33(1), 115–123.

18.

Brown

(2017). Creating counterstories: Critical clinical practice and feminist narrative therapy. In Baines

(Ed.), Doing anti-oppressive practice: Building transformative, politicized social work (3rd ed., pp. 212–232). Fernwood Press.

19.

Brown

(2018). The dangers of trauma talk: Counterstorying co-occurring strategies for coping with trauma. Journal of Systemic Therapies, 37(3), 42–60.

20.

Brown

(2019). Speaking of women’s depression and the politics of emotion. Affilia—Journal of Women and Social Work, 34(2), 151–169.

21.

Brown

(2020a). Critical clinical social work: Theoretical and practical considerations. In Brown

McDonald

(Eds.), Critical clinical social work: Counterstorying for social justice (pp. 16–58). Canadian Scholars’ Press.

22.

Brown

(2020b). Feminist narrative therapy and complex trauma: Critical clinical work with women diagnosed as “borderline.” In Brown

McDonald

(Eds.), Critical clinical social work: Counterstorying for social justice (pp. 82–109). Canadian Scholars’ Press.

23.

Brown

Augusta-Scott

(2018). Reimagining the intersection of gender, knowledge and power in collaborative therapeutic conversations with women and eating disorders and men who use violence. In Pare

Audet

(Eds.), Social justice and narrative therapy (pp. 143–158). Routledge.

24.

Brown

Augusta-Scott

(Eds.). (2007). Narrative therapy: Making meaning, making lives. Sage.

25.

Brown

Johnstone

Ross

(2020). Repositioning social work practice in mental health in Nova Scotia [Report]. Nova Scotia College of Social Workers.

26.

Brown

MacDonald

(Eds.). (2020). Critical clinical social work: Counterstoring for social justice. Canadian Scholars’ Press.

27.

Brown

(1992). A feminist critique of personality disorders. In Brown

L. S.

Ballou

(Eds.), Personality and psychopathology: Feminist reappraisals (pp. 206–228). Guilford Press.

28.

Brown

(2004). Feminist paradigms of trauma treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 464–471.

29.

Bullen

Deane

Meissel

Bhatnager

(2020). What constitutes globalised evidence? Cultural tensions and critical reflections of the evidence-based movement in New Zealand. International Journal of Psychology, 55(1), 16–25.

30.

Burstow

(1992). Radical feminist therapy: Working in the context of violence. Sage.

31.

Burstow

(2003). Toward a radical understanding of trauma and trauma work. Violence Against Women, 9(11), 1293–1317.

32.

Burstow

Weitz

(1988). Shrink resistant. The struggle against psychiatry in Canada. New Star Books.

33.

Butler

(1997). Excitable speech: A politics of the performative. Routledge.

34.

Cabanas

(2018). Positive psychology and the legitimation of individualism. Theory & Psychology, 28(1), 3–19.

35.

Caplan

(1995). How do they decide who is normal? In They say you’re crazy. How the world’s most powerful psychiatrists decide who’s normal (pp. 1–32). Addison-Wesley.

36.

Capponi

(1992). Upstairs in the crazy house: The life of a psychiatric survivor. Viking Press.

37.

Carney

(2008). The mental health service crisis of neoliberalism—An antipodean perspective. International Journal of Law and Psychiatry, 31, 101–115.

38.

Carpenter

Platt

(1997). Professional identity for clinical social workers: Impact of changes in health care delivery systems. Clinical Social Work Journal, 25(3), 337–350.

39.

Cermele

Daniels

Anderson

(2001). Defining normal: Constructions of race and gender in the DSM-IV casebook. Feminism & Psychology, 11(2), 229–247.

40.

Chen

(2013). Neoliberalism and popular women’s culture: Rethinking choice, freedom and agency. European Journal of Cultural Studies, 16(4), 440–452.

41.

Comas-Díaz

Greene

(Eds.). (1994). Women of color: Integrating ethnic and gender identities in psychotherapy. Guilford Press.

42.

Courtois

(1996). Healing the incest wound: Adult survivors in therapy. W. W. Norton.

43.

Fergus

(2004). Neoliberalism, the third way and social work: The UK experience. Social Work and Society, 2(1), 1–9.

44.

Ferguson

Lavalette

(2013). Crisis, austerity and the future (s) of social work in the UK. Critical and Radical Social Work, 1(1), 95–110.

45.

Foucault

(1980a). Power/knowledge: Selected interviews and other writings 1972-1977. Patheon.

46.

Foucault

(1980b). The history of sexuality: Vol. 1. An introduction. Vintage Books.

47.

Francis

(2012a). DSM 5 is guide not bible—Ignore ten worst changes. APA approval of DSM-5 is a sad day for psychiatry. https://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

48.

Francis

(2012b). Two fallacies invalidate the DSM-5 field trials. Psychology Today. http://www.psychologytoday.com/blog/dsm5-in-distress/201201/two-fallacies-invalidate-the-dsm-5-field-trials

49.

Francis

Widiger

(2012). Psychiatric diagnosis: Lessons from the DSM-IV past and cautions for the DSM-5 future. Annual Review of Clinical Psychology, 8, 109–130.

50.

Fricker

(2003). Epistemic injustice and a role for virtue in the politics of knowing. Metaphilosophy, 34, 154–173.

51.

Gazso

(2012). Moral codes of mothering and the introduction of welfare-to-work in Ontario. Canadian Review of Sociology/Revue Canadienne de Sociologie, 49(1), 26–49.

52.

Gibbs

(2003). Evidence-based practice for the helping professions. Brooks/Cole-Thomson Learning.

53.

Gill

(2008). Culture and subjectivity in neoliberal and postfeminist times. Subjectivity, 25, 432–445.

54.

Gill

Orgad

(2018). The amazing bounce-backable woman: Resilience and the psychological turn in neoliberalism. Sociological Research Online, 23(2), 477–495.

55.

Goodman

Liang

Helms

Latta

Sparks

Weintraub

(2004). Training counseling psychologists as social justice agents: Feminist and multicultural principles in action. The Counseling Psychologist, 32(6), 793–837.

56.

Government of Canada. (2020). Federal framework on posttraumatic stress disorder recognition, collaboration and support. Minister of Health, Canada. https://www.canada.ca/en/public-health/services/publications/healthy-living/federal-framework-post-traumatic-stress-disorder.html

57.

Gray

Dean

Agllias

Howard

Schubert

(2015). Perspectives on neoliberalism for human service professionals. Social Service Review, 2, 368–392.

58.

Gremillion

(2003). Feeding anorexia: Gender and power at a treatment center. Duke University Press.

59.

Harlow

Berg

Barry

Chandler

(2013). Neoliberalism, managerialism and the reconfiguring of social work in Sweden and the United Kingdom. Organization, 20(4), 534–550.

60.

Haydock

(2014). The rise and fall of the ‘nudge’ of minimum unit pricing: The continuity of neoliberalism in alcohol policy in England. Critical Social Policy, 34(2), 260–269.

61.

Herman

(1992). Trauma and recovery: The aftermath of violence—From domestic abuse to political terror (1st ed.). Basic Books.

62.

Herman

(2015). Trauma and recovery: The aftermath of violence—From domestic abuse to political terror (2nd ed.). Basic Books.

63.

Hyslop

(2018). Neoliberalism and social work identity. European Journal of Social Work, 21(1), 20–31.

64.

Lafrance

(2014). Depression as oppression: Disrupting the bio-medical discourse in women’s stories of sadness. In McKenzie-Mohr

Lafrance

(Eds.), Creating counterstories: Women resisting dominant discourses in speaking their lives (pp. 141–158). Routledge.

65.

Lafrance

McKenzie-Mohr

(2013). The DSM and its lure of legitimacy. Feminism& Psychology, 23(1), 119–140.

66.

LeBoutillier

Leamy

Bird

Davidson

Williams

Slade

(2011). What does recovery mean in practice? A qualitative analysis of international recovery oriented practice guidance. Psychiatric Services, 62(12), 1470–1476.

67.

Lefrancois

Beresford

Russo

(2016). Editorial: Destination mad studies. Intersectionalities, 5, 1–10.

68.

LeFrancois

Menzies

Reaume

(Ed.) (2013). Mad matters. A critical reader in Canadian mad studies. Canadian Scholars’ Press Inc.

69.

Lemke

(2001). The ‘birth of bio-politics’: Michel Foucault’s lecture at the Collège de France on neo-liberal governmentality. Economy and Society, 30(2), 190–207.

70.

Levine

(1982). The personal is political: Feminism and the helping professions. In Finn

Miles

(Eds.), Feminism in Canada: From pressure to politics (pp. 175–210). Black Rose Books.

71.

Liebenberg

Ungar

Ikeda

(2013). Neo-liberalism and responsibilisation in the discourse of social service workers. British Journal of Social Work, 45(3), 1006–1021.

72.

Madigan

(2003). Counterviewing injurious speech acts: Destabilizing eight conversational habits of highly effective problems. International Journal of Narrative Therapy and Community Work, 1, 43–59.

73.

Marecek

Gavey

(2013). DSM-5 and beyond: A critical feminist engagement with psychodiagnosis. Feminism & Psychology, 23(1), 3–9.

74.

McCrae

Murray

Huxley

Evans

(2004). Prospects for mental health social work: A qualitative study of attitudes of service managers and academic staff. Journal of Mental Health, 13(3), 305–317.

75.

McKenzie-Mohr

Lafrance

(2011). Telling stories without the words: Tightrope talk in women’s accounts of coming to live well after rape or depression. Feminism & Psychology, 21(1), 49–73.

76.

Morley

(2003). Towards critical social work practice in mental health: A review. Journal of Progessive Human Services, 14(1), 61–84.

77.

Morrow

Malcoe

(2017). Critical inquires for social justice in mental health. University of Toronto Press.

78.

Morrow

Weisser

(2012). Towards a social justice framework for mental health recovery. Studies in Social Justice, 6(1), 27–43.

79.

Nathan

Webber

(2010). Mental health social work and the bureaubio-medicalisation of mental health care: Identity in a changing world. Journal of Social Work Practice, 24(1), 15–28.

80.

Norcross

J. C.

Wampold

B. E.

(2011). Evidence-based therapy relationships: Research conclusions and clinical practices. In Norcross

J. C.

(Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 423–430). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780199737208.003.0021

81.

Pease

Goldingay

Hosken

Nipperess

(Eds.). (2016). Doing critical social work: Transformative practices for social justice. Allen & Unwin.

82.

Penfold

Walker

(1983). Women and the psychiatric paradox. Eden Press.

83.

Pizzey

(1974). Scream quietly or the neighbours will hear. Penguin Books.

84.

Poole

(2011). Behind the rhetoric: Mental health recovery in Ontario. Fernwood Publishing.

85.

Pyysiäinen

Halpin

Guilfoyle

(2017). Neoliberal governance and ‘responsibilization’ of agents: Reassessing the mechanisms of responsibility-shift in neoliberal discursive environments. Distinktion: Journal of Social Theory, 18(2), 215–235.

86.

Ramon

(2008). Neoliberalism and its implications for mental health in the UK. International Journal of Law and Psychiatry, 31(2), 116–125.

87.

Raphael

(2006). Social determinants of health: Present status, unanswered questions, and future directions. International Journal of Health Services, 36(4), 651–677. https://doi.org/10.2190/3MW4-1EK3-DGRQ-2CRF

88.

Rose

(2014). The mainstreaming of recovery. Journal of Mental Health, 23(5), 217–218.

89.

Rosen

(2003). Evidence-based social work practice. Social Work Research, 27(4), 197–208.

90.

Rossiter

Heron

(2011). Neoliberalism, competencies, and the devaluing of social work practice. Canadian Social Work Review/Revue canadienne de service social, 28(2), 305–309.

91.

Rottenberg

(2014). Happiness and the liberal imagination: How superwoman became balanced. Feminist Studies, 40(1), 144–169.

92.

Shamir

(2008). The age of responsibilization: On market-embedded morality. Economy and Society, 37(1), 1–19.

93.

Smith

David

(Eds.). (1975). Women look at psychiatry: I’m not mad, I’m angry. Press Gang Publishing.

94.

Spolander

Engelbrecht

Martin

Strydom

Pervova

Marjanen

Tani

Sicora

Adaikalam

(2014). The implications of neoliberalism for social work: Reflections from a six-country international research collaboration. International Social Work, 57(4), 301–312.

95.

Stark

(2018). The neoliberal ideology, its contradictions, the consequences and challenges for social work. Ljetopis Socijalnog Rada [Annual of Social Work], 25(1), 39–63.

96.

Stoppard

Gammell

(2003). Depressed women’s treatment experiences: Exploring themes of bio-medicalization and empowerment. In Stoppard

J. M.

McMullen

L. M.

(Eds.), Situating sadness: Women and depression in social context (pp. 39–61). New York University Press.

97.

Strier

Breshtling

(2016). Professional resistance in social work: Counterpractice assemblages. Social Work, 61(2), 111–118.

98.

Strong

(2012). Talking about the DSM-V. International Journal of Narrative Therapy & Community Work, 2, 54–64.

99.

Szasz

(1970). Ideology and insanity: Essays on the psychiatric dehumanization of man. Anchor Books.

100.

Thomas

Davies

(2005). Theorizing the micro-politics of resistance: New public management and managerial identities in the UK public service. Organizational Studies, 26(5), 683–706.

101.

Ussher

(1991). Women’s madness: Misogyny or mental illness? Harvester Wheatsheaf.

102.

Ussher

(2010). Are we medicalizing women’s misery? A critical review of women’s higher rates of reported depression. Feminism & Psychology, 20(1), 9–35.

103.

Webb

(2001). Some considerations on the validity of evidence-based practice in social work. British Journal of Social Work, 31, 57–79.

104.

Weisser

Morrow

Jamer

(2011). A critical exploration of social inequities in mental health recovery literature. Centre for the Study of Gender, Social Inequities and Mental Health.

105.

White

(2001). Narrative practice and the unpacking of identity conclusions. Gecko: A Journal of Deconstruction and Narrative Ideas in Therapeutic Practice, 1, 28–55.

106.

White

(2007). Maps of narrative practice. W. W. Norton.

107.

White

Epston

(1990). Narrative means to therapeutic ends. W. W. Norton.

108.

World Health Organization. (2014). Social determinants of mental health. https://www.who.int/mental_health/publications/gulbenkian_paper_social_determinants_of_mental_health/en/

109.

Yip

K.-S.

(2004). Bio-medicalization of social workers in mental health services in Hong Kong. British Journal of Social Work, 34, 413–435.