Mark B. Borg, Jr. PhD
William Alanson White Institute
Borg, Jr., M. B. (2004). Community Intervention as Clinical
Case Study. Clinical Case Studies, 3 (2): 250-270
In the field of community psychology, empowerment is analogous with health, and the concept of intervention, synonymous with treatment, is intended to foster and sustain long-term prevention of both acute and chronic problems in the target community. Community empowerment interventions that include prevention techniques and focus on interpersonal functioning are the most successful form of intervention for communities that have undergone crisis or disaster. In this paper, the author briefly reviews the theoretical and research basis for integrating community revitalization techniques with a psychoanalytic model that specifically highlights and addresses interpersonal functioning as the cornerstone of community health and well-being. An illustrative case study includes a conceptualization of the underlying pathological problems that were treated, and the adaptive resources that were developed, in a four-year intervention in one circumscribed South Central Los Angeles community after the 1992 riots there. It is this synthesis of community theory and interpersonal psychoanalytic theory that underlies the clinical case study method that the author suggests is applicable to this community intervention.
1. Theoretical and Research Basis
IN THE FIELD OF COMMUNITY PSYCHOLOGY, empowerment is analogous with health, and the concept of intervention, synonymous with treatment, is intended to foster and sustain long-term prevention of both acute and chronic problems in the target community. In response to the riots in the community of South Central Los Angeles in 1992, city officials there sought a community-based approach to address this explosive community crisis and the underlying chronic trauma in the area. A community empowerment organization, of which I was a part, was contracted to implement an intervention that would address such chronic issues as poverty, race-based problems, drug/alcohol abuse, and such acute problems as rioting, looting, and violence. This paper explores the clinical implications of the processes of individual and community change in one low-income housing project in South Central Los Angeles called Avalon Gardens, and considers them through the lens of contemporary interpersonal psychoanalytic theory. It highlights specifically the development of a men's organization formed to foster, support, and sustain the empowerment process. This organization eventually enabled the working through of a community-wide sense of loss related to chronic traumatic experience and associated themes of dissociated and enacted conflict that had, over generations, infiltrated the community's underlying character structure.
Using concepts from both interpersonal psychoanalytic theory and community empowerment theory, I present a case study of the group of men who formed the Avalon Gardens Men's Association (AGMA), and the process wherein which this organization became an increasingly recognized entity of change in the community. It is impossible, of course, to capture the complex texture of a four-year community project in a single brief paper. But I hope to highlight salient dynamics and to pull out several themes and incidents from our work to illustrate the ways in which clinical issues and problems played out throughout the intervention. The interactive processes among these men, the other residents of the community, and representatives of the outside world may be usefully examined in light of contemporary interpersonal psychoanalytic theory. Interpersonal theory is a theoretical model that captures and explains the changes in individual self-esteem, management of trauma-related anxiety, group interaction, and indeed the overarching character of the community that occurred during, and as a result of, the intervention.
The empowerment processes of change and growth in Avalon Gardens can best be understood through the lens of interpersonal theory (Borg, Garrod, & Dalla, 2001). Interpersonal psychoanalysis is based on Sullivan's (1964) tenet that "everything that can be found in the human mind has been put there by interpersonal relations" (p. 302). Though interpersonal theory covers a wide range of techniques and applications, there are some broadly defining features that uniquely mark this school's clinical psychoanalytic orientation. These include: 1) a broadly relational metapsychology; 2) an interactive conception of the intrapsychic world; 3) a clinical focus on the interpersonal and intersubjective field in the analytic situation; 4) an operationist perspective that endeavors to hold theoretical constructs close to empirical observation; and 5) a pragmatic orientation and philosophy that provide room for a radical flexibility and open-endedness in technique (Fromm, 1955; Lionells, Fiscalini, Mann, & Stern, 1995; Sullivan, 1953).
Recently, interpersonal theory has made use of the idea of an interpersonal field (Gill, 1983; Mitchell, 2000). The interpersonal field is the intersection of two or more persons' experience. This co-created experience operates consciously and unconsciously, in the present and the past, in reality and in fantasy, in the inner world and the outer one (Bromberg, 1998; Stern, 1997). The interpersonal field is the ceaseless and ever-changing setting of human sentience and experience. Experience and conduct take shape and meaning from the continuous series of interpersonal fields within which each of us exists from the beginning of life to its end.
Personal empowerment is the foundation for community empowerment and is, therefore, intimately related to mental health and well-being (Rappaport & Hess, 1984; Reissman, 1986). Empowerment theory describes the processes whereby communities develop collaborative solutions their own solutions that work for them (Albee & Gullotta, 1997; Seidman & Rappaport, 1986; Warren, 2001). Empowerment emphasizes the cyclical nature of growth in which, ideally, the accumulation of change makes it possible for even more change to occur. Health, which may be understood as a measure of personal and community empowerment, shows in behaviors, affective and cognitive states, and overall general functioning. The clinical implications of empowerment are clear when the experience of powerlessness is recognized as an underpinning in major forms of psychopathology, such as many DSM-IV mood and anxiety (APA, 1994; Sadock & Kaplan, 1998) and personality disorders (Sperry, 1995).
By empowerment, I mean the enhancement of people's possibilities to control their own lives. Empowerment work is a collaborative project where poor functioning is assessed as a result of social factors and lack of resources that make it difficult for existing competencies to operate. Empowerment theory implies that in those cases where competencies need to be learned, they are best learned in the context of living life, rather than in artificial programs where everyone, including the person who is learning, knows that it is really the expert who is in charge. Empowerment facilitates the possibility of a variety of solutions that are community-, rather than institutionally-, controlled. Solutions reached in collaborative ways are responses to the differing needs of differing communities, settings and neighborhoods (Bright, 2000). Treatment, intervention, and even social policy are empowering to the extent that they enable people to develop their own solutions to their problems. Empowerment theory asserts that people, whether they are in therapy, or in communities working within an intervention, benefit from goals that foster more, rather than less, control over their lives (Berger & Neuhaus, 1977).
Rappaport (1986) stresses that "given the nature of social problems, there are no permanent solutions, no single this-is-the-only-answer-possible solutions, even at any moment in time. Divergent, dialectical problems must have many solutions that...change with the currents" (p. 149). This philosophy exemplifies both empowerment theory and interpersonal psychoanalytic theory. Both seek to expand people's options for dealing with problems in living and to support the agency of individuals in finding creative, health-promoting, and sustainable approaches for dealing with the complexities and inevitable anxieties of everyday life. Interpersonal psychoanalysis and empowerment theory, at core, hold to philosophies that stress the maintenance of paradox and the effort to sustain, rather than foreclose, the tensions between myriad opposing forces or conflicts such as autonomy vs. dependence; inside vs. outside; etc. (Ghent, 1992; Mitchell, 2000; Rappaport, 1986).
2. Case Introduction
THE INTERVENTIONS OF THE AVALON GARDENS PROJECT, the concepts behind them, and the specific work of the Men's Association there were derived from contemporary primary prevention and community empowerment theories (Bloom, 1996; Rappaport & Seidman, 2000). The overriding mission of the community organization that was funded to facilitate the intervention was to help residents develop solutions to increase the overall functioning and reduce the incidence of behavioral maladjustment in the community. Based on this mission, the following prevention guidelines were suggested to the residents as a means of facilitating change in the community: 1) competency-building programs, 2) coping skills training, 3) strengthening care-givers, 4) support system interventions, 5) ecological interventions, 6) sociopolitical change strategies, and 7) community organization (Mills, 1996).
The Avalon Gardens Men's Association (AGMA) itself was founded on a set of tested community action guidelines (Borg, 1997; Mills 1995). Admittedly, the intervention team had not initially looked to the men of Avalon Gardens to initiate the project. However, the community members who initiated the men's group shared one characteristic that was absolutely essential they were volunteering to develop and sustain the process of change and growth in the community. Therefore, they were able to take ownership for the community into their organization from the start and they used this mutual readiness to enhance the group's cohesiveness. Over the course of the four-year project, they were able to promote communication and define their roles, boundaries, and expectations. Ultimately they created a structure that outlasted the intervention while simultaneously increasing the involvement of other community organizations in Avalon Gardens.
3. Presenting Complaints
THE RIOTS SPARKED BY THE VERDICT in the Rodney King police brutality case on April 29, 1992 were perceived by the Los Angeles government as the equivalent of the "presenting problem" in individual therapy; this led to the implementation of a community revitalization program. The program addressed both the acute and chronic distress of the community. The riots themselves were considered a symptom indicative of much deeper (and, I argue, depressive) problems within the character of this community. By community character I mean the unconscious representation of the unwritten, unstated, but ever-present laws that govern and limit interactive patterns within a community that operating as a closed system (Borg et al., 2001). From this vantage point, character is the repetitive interpersonal behaviors or interactive patterns that are the relational manifestations of the community's underlying defensive structure. It is a social construct defined by interpersonal patterns and community-sanctioned rituals and contextual signs and representations, rather by idiosyncratic individual givens.
AVALON GARDENS IS A DEPARTMENT of Housing and Urban Development (HUD) low-income housing project in the center of South Central Los Angles. At the time of the intervention, it had 161 housing units and 473 residents. The racial composition of the community is 82% African-American, 17% Latino, and 1% Caucasian. Eighty-five percent of the residents were on public assistance.
Rather than detail the actual history and development of Avalon Gardens itself, I will focus on the general environment within which Avalon Gardens exists. The data presented also support the city's belief that there were chronic indications for intervention not reflected in the "presenting problem" section. The demographic data of South Central had been stable over time, and reflected its status as a "distressed (depressed?) community" (Mills, 1996). According to HUD, this status alone was a valid rationale for the intervention. Avalon Gardens was chosen as the focus for the intervention because HUD considered its population to be representative of the South Central community in general.
Of the 22,913 estimated households in South Central, LA in 1995, 65.7% had incomes of under $24,999 (as compared to 30.9% county-wide). Of the total labor force only 38.6% were employed (as compared to 62.2% county-wide). Of the population 25 years or older, 82.0% had a high school diploma or equivalent or less, with 3.3% possessing a bachelor's or graduate degree (as compared to 50% and 22.3% county-wide). Of the 1990 population, 33% were enrolled in school. Of school-age children, 43.6% live in a married couple household, 43.6% live with a female head of household, and 12.8% live with a male head of household (as compared to 70%, 22%, 8% county-wide). In the first three-quarters of 1995, attempted and committed crimes within the Southeast Division of Los Angeles Police Department numbered 9,243. Of those crimes, 2,620 (28%) were aggravated assaults; 1,580 were burglaries (16.8%); and 1,676 were robberies (17.8%). The 71 murders in this period accounted for 10% of all murders in the city of Los Angeles. There is an 82% arrest rate for crimes attempted.
ASSESSMENT TECHNIQUES IN THE AVALON GARDENS intervention were used both as a means of measuring the outcomes and progress within the community's general functioning, and as an intervention themselves that would help to sustain the empowerment process. An assessment process called capacity asset mapping was implemented during the initial site visits to Avalon Gardens. The asset-based approach replaced the more traditional approach called needs assessment. In a needs-assessment, experts outside the community give an accounting of the community's needs; they do not enlist the community itself to undertake the accounting. The asset-based approach at Avalon Gardens started with people in the community assembling for themselves a full description of their own situation, as well as a comprehensive inventory of their community's strengths. The intervention team and community residents used this accounting to help the community frame its own sense of priorities, develop new relationships internal to the community, and determine its need, if any, for engagement with outside resources. This process resulted in a partnership with outside agencies, but one in which the community itself initiated contact and articulated what it needed. This set up a process of self-assessment wherein the people who expect benefits were able themselves to create the goals of their community intervention, determine the alliances needed to reach those goals, and evaluate the results of their own efforts. New needs, alliances, projects, and goals were constantly formulated. The underlying philosophy of the asset-based approach supports the idea and practice of building healthy communities from the inside out, and assumes that even the most devastated communities contain the foundation for their own development.
Another assessment technique was the physical quality of life plan. This entailed an assessment of the physical environment, inventorying and recording current the current states of buildings, residences, playgrounds, etc., accounting for changes that had been made in the physical structures in the community, and using this information as a possible point of reference for general progress in the community.
The primary assessment technique in the community intervention was the Mental Health Inventory (Stewart & Ware, 1992). The dimensions of the MHI used in this study include the following measures: 1) Anxiety; 2) Depression; 3) Behavioral/Emotional Control; 4) General Positive Affect; 5) Loneliness; and, 6) Belonging. The MHI is a general population mental health survey, a self-administered questionnaire, designed to measure mental health in terms of psychological distress and well-being. Community (as well as clinical) assessment measures have traditionally focused on negative states such as depression and anxiety. Using such definitions, the absence of distress is the best possible definition of mental health. However, positive states such as feeling cheerful, interested in life, or peaceful, and having a sense of control over one's behavioral and emotional responses are increasingly being included in current measurements of mental health (Goldburg & Hillier, 1978). Additionally, some clinically and socially relevant changes are not tapped by measures of distress (Ware, 1986). Perhaps the most important in this respect is the nature of empowerment and the need to assess areas that are indicators of the well-being that it facilitates (Viet & Ware, 1983).
Three other types of evaluation were also used: 1) process evaluation, which examined what happened to people during their participation in program activities; 2) outcome evaluation, which would examine the achievement of the short-term objectives after the project was completed; and, 3) impact evaluation, which examined the extent to which the program achieved its long-term goals.
Both the residents and the professionals who participated were tested using scales measuring mental health status, self-esteem, and self-efficacy, and a control group study was conducted at a nearby housing project with similar demographic variables. Objective data were also collected on crime rates, educational and school conduct, truancy, absenteeism, employment rates, family violence and abuse rates, teen pregnancy and juvenile justice referrals, and other data as defined by the residents' as they developed their own list of priorities.
6. Case Conceptualization
FROM ITS INCEPTION, INTERPERSONAL PSYCHOANALYSIS has maintained a pragmatic focus upon "problems in living" and the ways these may stultify growth in specific areas of functioning (Sullivan, 1953). Drawing on contemporary interpersonal perspectives in psychoanalysis (Greenberg & Mitchell, 1983; Mitchell, 1988), I conceptualize psychopathology as the recurrent maladaptive patterns of interpersonal behavior that underlie such problems in living. Examples of such maladaptive patterns in this community included racial, ethnic, and gender stereotyping, out-group suspicion and hostility, and ubiquitous manifestations of behavioral acting out (e.g., violence, substance abuse). In our conception, problems resulted from disturbances in relationships within ongoing interactions with significant others, especially early ones, as well as within more expanded social and cultural environments.
The community intervention in Avalon Gardens began as a series of workshops. It started with a question familiar in more traditional psychoanalytic circles: "What do you (as a community) want?" Over the next four years, as members of the community formed groups to undertake and internalize the empowerment process, this question would reverberate throughout the social fabric of the community. It revealed the interactive patterns that ran through the community and maintained the intergenerational transmission of a deeply entrenched sense of depression, anxiety, distrust, hopelessness, and futility. Such patterns of interacting are manifestations of defensive/protective mechanisms that operate to decrease or diminish a more conscious awareness of the day-to-day anxieties that impact community members; these are the patterns that, when they become entrenched, we call "community character" (Borg et al., 2001).
In a community that has undergone a crisis, much opportunity for learning may occur as a result of the jolting and displacement of the community's traditional patterns of defense (Tedeschi, Park, & Calhoun, 1998). This, of course, does not necessarily weaken them; defensive patterns of interaction may also strengthen. Yet, even in this scenario, transitory opportunities for intervention arise. Like an individual, a community in acute crisis will manifest reactions to the changing patterns of interaction; this may result in the equivalent of a "call for help." Unless a given crisis leads out into a field previously unfamiliar, no tensions arise, and the awareness of such tensions are the stimulus to reinitiating stalled development. The process of overcoming difficulty stimulates growth. In the context of community empowerment, it requires an arousal of interest and involvement in community action. New experiences obtained through community action become the ground for further experiences in which new problems are presented and conjoint solutions actively developed.
Unless the process of empowerment can be worked through experientially, habitualized, previously internalized reactive patterns are likely to thwart programs or interventions imposed by outside sources. Empowerment, as a concept and as a process, opposes the idea that learning can be imposed from outside the life-experience of the learner. Things that have been learned and accomplished in the past provide the only means for understanding the present (Hoffman, 1998). The nature of the issues underlying the character structure of the community and its members cannot be understood until we know how they came about. All characterological problems, at individual and community levels, have a history. As in individual therapy, to deal with community problems simply on the basis of what is obvious in the present results in the adoption of superficial measures that, in the end, only render existing problems more difficult to understand, easier to miss, and more difficult to solve.
The South Central intervention required that the community practitioners be extremely flexible throughout the intervention about their roles. Interventions included participation in family dinners, weddings, graduations, funerals, and numerous daily activities. In addition, practitioners assumed active roles within the community empowerment process, initially serving as representatives of smaller community groups and their concerns. These interactions provided a fertile ground for the enactment a co-created relational activation and manifestation in analytic treatment (in this case, intervention) of salient transference configurations in both patient (in this case, resident) and analyst (in this case, practitioner) of unconscious conflict (Jacobs, 1986; Levenson, 1991). During the empowerment process, longstanding conflicts among members of the community were highlighted and made amenable to intervention as they were enacted in the transference and countertransference.
Transference-countertransference enactments experienced in the group interactions allowed the boundaries and margins extant within the community to begin to emerge.
During the initial phases of the intervention, for example, a deep sense of rivalry had been discovered (and addressed) between the men of AGMA and women of the community. The women claimed that the men had been lazy and irresponsible and would, most likely, sustain the community's problems rather than work to ameliorate them. This competition, however, was only the most recognizable manifestation of competitive forces that worked to keep various subgroups (e.g., Latinos, African-Americans, elderly, gang members, church members of specific denominations, adolescents, etc.) separate, so that they did not form functional alliances with one another.
Guided by their overriding goals of personal and community empowerment, the men agreed to present their ideas to the women's group and the Resident Advisory Council (RAC), and to suggest ways that they could collaborate rather than compete with each other. Once the already-established leadership of the community had validated their intentions and goals, AGMA was able to establish itself as a legitimate source of community action. In the process of establishment, though, the men in the group learned how pervasively women of Avalon Gardens had stereotyped the men in the community. This discovery enabled them to explore how they had all, in their own ways, enacted the very stereotyped behaviors and attitudes that they were being charged with, and so fed into a vicious cycle that supported the traditional character of the community.
The ways that AGMA members enacted the stereotyped views of men in the community was explored in the context of weekly group meetings. For instance, members would argue over who was supposed to inform community members about the time and place of the meetings; often, at first, members who were involved in specific projects would "forget" altogether about the meeting at which they were expected to present their ideas. We raised the questions: What defensive purpose might such stereotyped roles serve for the men in the community? How might being perceived as irresponsible, apathetic, or lazy allow the men in the community preserve some unconscious connection with their own individual history? Might the men, enacting such behaviors, in some way be lessening the likelihood of being perceived as targets in this hostile environment? What fear or anxiety might be sustaining their traditional, albeit unconscious, commitment to sustaining the stereotypes? What recursive themes might these enactments represent?
The practitioners wondered how the process of entering into a relationship with the community and its recursive enactments could provide an entry point into the deeper conflicts within the community character. It is assumed in interpersonal theory that the current of repetition can be joined by a current of growth, allowing for differentiation of present from past (Mitchell, 2000). Individuals in the community had, after all, been molded by the historical events in the community throughout their lifetimes. When the men enacted these stereotyped roles, they were complying with historically prescribed scripts and unwittingly playing out scenarios that enforced the status quo. By focusing on empowerment rather than exclusively on pathology of the community, the men of AGMA were opening up possibilities for themselves and their community. We emphasized not only the factors that impede and constrict growth (maintenance of the status quo, resistance to change), but also what can enhance and mobilize it. Ultimately the aim was to help the community to develop new patterns of interaction, understanding, and experience.
Once AGMA itself had become a cohesive and functioning group, patterns within the community began to play out transferentially in the weekly group meetings. These patterns, it would be revealed, expressed underlying tensions and conflicts within the general Avalon Gardens environment, and perhaps more broadly South Central itself. There was a pervasive feeling in the group and community prior to the riots and continuing well into the intervention of catastrophic loss. It seemed as if a chronic sense of trauma had haunted the community for as long as anyone could remember.
At times a group member would discuss the feeling that there was something that he imagined other people possessed, but that he lacked. When a group member talked about feeling this way, a deep sense of loss would reverberate through the group and the members would feel strong empathy for one another. In our team meetings, other community practitioners noted similar experiences in other community groups. Yet no one seemed to be able to speak about or feel this loss directly. No one could specify exactly what it related to. Consistently, a community member would spontaneously state, "It's just that it [the sense of loss] has always existed." The underlying affective environment in Avalon Gardens was one that could be described as being depressive.
The central threat in depression is the loss of someone or something "viewed as necessary for the continuing functioning of the individual" (Salzman, 1972, p. 111). Therefore, depression is part of a dissociative effort to squelch an unbearable experience of loss (Bose, 1998). Yet by contributing to an avoidance of the traumatic loss, depression deepens it, thus becoming an obstacle to the necessary process of remembering and mourning (Bose, 2001).
What Freud (1923) called the "character of the ego" (p. 29) is the crystallization of internalized others who were 'loved and lost' the remnants of unresolved grief. This is the basis of depressive character. The depressive character structure of Avalon Gardens was based on the absence or "loss" of a benevolent cultural environment (reflected in chronic states of poverty and crime).
Traumatized individuals may blame themselves or their community for the failure to prevent the painful experiences in the first place (van der Kolk & McFarlane, & Weisaeth, 1996). Sullivan (1954) described this perspective epigrammatically in his statement that "the depressive always hits the target and usually unhappily does this by self-destruction" (p. 297). The murderous rage of the depressed person is visible when the target becomes the self (as in suicide), but we cannot assume that distressed/depressed communities do not have violent potential in the world outside their circumscribed borders. The emotional survival of communities such as Avalon Gardens sometimes requires that rage be redirected against the lost other as Butler (1997) says, "against the dead in order not to join them" (p. 193). After witnessing the Los Angeles riots, can the world outside such communities rest assured that the violent, though generally suppressed, depression of such a community will be turned only against itself? Can the outside world maintain the necessary ruthlessness to sustain its explicit apathy about such depressive processes and, if it can, might not the rage in these communities target such apathy in violent protest?
Individuals attempting to deal with their personal conflicts often make use of society as an arena in which conflicts can find expression and resolution (Smelser, 1998). In a person plagued by vehement internal turmoil, the provocation of a corresponding violent turmoil in the outer world can serve as catalyst for sparking the enactment of the violence that perpetuates itself on a daily basis within oppressed, beleaguered communities (Ashcroft, Griffiths & Tiffin, 1995; Jones, 1964; Virilio & Lotringer, 1997). Born of ungrieved loss and intractable depression, fury takes the manic turn, finds an adequate target which represents the lost neglectful other, attacks, and ultimately induces a reaction/response from the significant other. The attention and response of the indifferent other is demanded. We can understand the LA riots, therefore, as a social defense (Jaques, 1955; Menzies, 1960) against South Central's underlying depression, one that manifested suddenly as a manic rage targeting both itself and the significant other (i.e., the representatives of the oppressing system that would absorb and react to the attack).
Herman (1992) says that "traumatic events have primary effects not only on the psychological structures of the self but also on the systems of attachment and meaning that link individual and community" (p. 51). Trauma has been associated with depression in interpersonal theory (Bose, 1998, 2001) as the terrifying, though dissociated, experience that all the functional nurturing resources supplied by the environment have been destroyed. Depression is an experience of being detached from oneself. It results in a sense of personal alienation and emotional isolation (Bose, 1995; Freud, 1917). Transformation of a community's chronic depressive character into a rebellious uprising may occur when circumstances in the external world reflect the internal state of deprivation of the community. When this happens the defense against awareness of a day-to-day reality fraught with deprivation, oppression, and trauma breaks down, and an acute experience of loss and impending threat erupts into awareness.
The awareness of the loss that depression defends against may create an opportunity to make a formerly unrecognized impact upon the environment. While this can result in potential for reparation, it can also bolster a sense of manic grandiosity that reinstates new defenses against awareness of the loss. This may set up a cyclic process as the disturbing event (reflecting the ungrieved loss) is re-experienced, and so can usher in either further depressive or newer manic defenses.
The L. A. riots, therefore, may be seen as an extremely dramatic, but short-lived, manic reaction to the chronic depression in South Central, overlapping with and perpetuating community's deep-seated experience of collective trauma. After all, if depression is the effect of a loss that is ungrieved and unacknowledged, acting-out may be the only way to signal the loss. Bose (1998) says:
The ultimate toxic experience in deprivation trauma is dehumanization, the experience of an inhuman environment in which the lack of human resonance and response leads to a sense of dejectedness. The rejections and cruelties that are perpetrated daily build a sense of rage and vengefulness that cannot be transcended (p. 3).
The riots in South Central Los Angeles certainly did not cure its underlying depression. However, they did serve as a call for help, by which the pain, character structure, and symptomatology of the community were at last made palpable, acknowledged, addressed, and understood.
In the aftermath of the riots the community an opportunity to initiate a mourning process. Phillips (1997) says "mourning is immensely reassuring because it convinces us of something we might otherwise doubt; our attachment to others" (p. 153). In the years that followed the riots, mourning allowed the community to put its underlying sadness and sense of loss, until then manifested in defensive reactions like depression, rage, hopelessness, and powerlessness, into a new context.
7. Course of Treatment and Assessment of Progress
Course of Treatment
THE COURSE OF TREATMENT (that is, the intervention) at Avalon Gardens started as a series of workshops; this developed into a set of ongoing group processes wherein community members could establish safe environments for working through the community's deep-seated conflicts.
Throughout the intervention, the issues of depression, anxiety, and mourning could be addressed and expressed by members of groups representing different interests and subdivisions within the community. I have been focusing, specifically, on the course of treatment within one of those groups AGMA.
Because members of this community had not had the experience of a trustworthy facilitating environment (Winnicott, 1965), the men of AGMA had come to the conclusion that they had to take over the caretaking role for themselves. The consequence of such insular self-sufficiency had been a chronic sense of depression and a sense of something missing. And truly, something was. When the safety of a dependable environment or attachment figure is missing, a child will tend precociously to fill in the missing parental function, and so opportunities for a worry-free surrender to one's own experience is foreclosed (Ghent, 1990). The organization that AGMA was to become, however, was premised on expanding the men's individualized care-taking to include the community as well as themselves, and thereby increase the flexibility and options for roles and responsibilities which they, as a group and as individuals, could undertake.
Areas of conflict became manifest in transference-countertransference interactions in the group settings. The groups had been organized around the major areas in which the community had expressed developmental goals (Bion, 1959), and they aimed at targeting outcomes that had been developed in the assessment of the their community's unrecognized and untapped assets. These groups met regularly and they became a primary source of community change. Once a plan of action had been established, group members decided what part of their needs could be met through existing community resources and what aspects would need to be negotiated with external agencies and service providers. They then worked with the community practitioners to develop strategies for meeting their needs. By the end of the first year, the groups had taken on a sense of identity that in turn served to indicate the subdivisions, perhaps fractures, within the community character itself.
For example, the sense of pervasive deprivation and loss was perpetuated within the interactive patterns of community members themselves, as well as in their interactions with "outsiders" such as the intervention staff. Therapeutic interactions addressed both dependent and avoidant aspects of depression, as well as the resulting stereotypes that residents enacted. Bonime (1965) suggests that the way to enter into the depressive's resistant patterns may be through an expressive, effective gesture on the part of the therapist. Thus, some flexibility and open-mindedness were required from the practitioners, who had to be willing to participate and interact within the ongoing daily life of the community. Cohen et al. (1954) thought that the therapeutic endeavor, or the "call for help" that initiates it, requires something startling enough to shake the stereotypical reaction pattern of the patient (in this case, resident) to loosen the defensive armor. This allows the patient to become involved in more genuine emotional interchanges. Was the riot startling enough? If so, could it then lead to an increased awareness of chinks in the community's character armor? Bose (1995) states, "the essence of therapeutic work with depressive patients lies in identifying the underlying trauma, which leads to a reactivating of the stalled process of mourning for the losses encountered and in helping the patient return to the full experience of affect" (p. 459).
Enactments occurred within the context of the intervention itself, especially where the personal experiences of the residents could be brought to light, such as in information-gather processes like the history-taking of individuals and groups, assessment measures such as the MHI, capacity asset mapping, and process evaluations. They also occurred, most especially, within the workshops and the group meetings.
The transference in the group settings revealed the great expectations and great fears with which the community members approached the intervention team. Unavoidable disillusionment was experienced as a repetition of both the Avalon Gardens and outside community's failure to provide for residents' essential needs, specifically for safety, satisfaction, and nurturance. The goal of treatment to replace stereotyped complaining and self-flagellation with a "more meaningful self-awareness" (Fromm-Reichmann, 1949, p. 255) is quite difficult to reach in this kind of work because therapeutic interventions are "reworked into the old pattern of concealed disapproval, covered over with the sugar of artificial reassurance" (Cohen et al., 1954, p. 261). Still, the staff members were, nonetheless, perpetually engaged by residents' continued demand to be provided with concrete help.
The group format that developed out of the intervention reflected the subdivisions within the community (men/women, African-American/Latino, etc.). Each group seemed to tap into salient underlying trauma in the community. This was brought to life in the interactions and enactments between community residents and staff, as well as among the residents themselves. The underling depression of this "distressed community" became the target of the deeper, and more structural, areas of program implementation.
Therefore, as the work went on, the staff increasingly focused on the recurrent patterns in different areas of community functioning, and how these patterns were highlighted and played out transferentially in the groups. Extrapolations from group process to community functioning in general were also consistently elaborated.
Transference-countertransference experience can be an effective diagnostic tool, as well as a manifestation of symptoms. Thus relationships between practitioners and residents revealed interactive patterns wherein depressive patterns were enacted, interpreted, and worked through. Practitioners were able to attain first-hand experience of the dependency of residents, as well as their stereotyped approaches to others. The various manifestations of depression were experienced in both avoidant and oppositional behaviors, such as the residents' tendency to ask for help while simultaneously prohibiting a "too close" approach to community members. These responses evoked strong emotional responses in the practitioners that, when registered, allowed a more accurate sense of the community's character and underlying mental state.
From a clinical psychoanalytic perspective, the course of treatment and assessment of progress are reflected in the process of working through. In psychoanalysis, the working through process consists of recognitions, insights, and incremental changes that occur throughout the treatment. Applying this concept to the South Central empowerment intervention, such recognitions, insights, and changes were transformed into durable and manifest qualities in the community's overall character. The working through process involved repetitive, progressive, and elaborate exploration of the Avalon Gardens community's resistance to change. The intervention, from a psychoanalytic point of view, thus consisted of an ongoing cycle of enacting, disembedding, and understanding thereby increasing behavioral, emotional, and cognitive options. These increases were reflected most significantly in the ways that community residents became able to increase their repertoire of sanctioned interactions with each other, as well as with members of the outside world.
To address the work of AGMA is also to address the ways that the larger community confronted and worked through resistances to change that had, over generations, kept the community in a state of safe, but stifling, homeostasis. Freud (1937) referring to individuals in classical psychoanalytic treatment wrote of such resistance: "No stronger impression arises from the resistances during the work of analysis than of there being a force which is defending itself against recovery and which is absolutely resolved to hold on to illness and suffering" (pp. 141-142). Working through is the work of countering resistance. For AGMA members, this process became a means of countering the inertia of the familiar. Depression can be seen as the ultimate means of maintaining the status quo, as it is an emotional state consistently supportive of the delusion that, as one AGMA member put it, "every day is just like every other day."
To counter this inertia, practitioners supported the curiosity of participants, enabling them to raise their tolerance for uncertainty, anxiety, and apprehension. These were emotional experiences that before had essentially existed in dissociated states, maintained by a layering of depressive experience. With the encouragement of the intervention team the men were able to foster, among themselves in the community, and outside it, the introduction and reintroduction of new experiences.
Once the depressive aspects of the community character had been enacted and engaged, other areas of resistance to community change surfaced. These had to do with anxiety aroused by threats to self-esteem, and were defenses upheld in the community character by community members and by sustained fear of the unfamiliar and unknown. A force in the community seemed determined to hold onto, and enact, the defensive status quo. Yet through resistance and its manifestations in the relationship patterns within the community through what is defined as transference in psychoanalytic terminology people in the community were able to challenge ways of life that were clearly not working well.
In Avalon Gardens, calling into question and redeveloping problematic ways of living was fraught with danger. After all, patterns of sanctioned interaction had been developed as a means of controlling anxiety by limiting conscious exposure to threatening interpersonal experiences. Such limitations had traditionally provided a measure of safety. Unfortunately, they were so stringent that they felt imprisoning. Still, a safe prison was preferable to an anxiety-ridden freedom. The chronic reluctance of Avalon Gardens' residents to incorporate new experience was historically related to the anxiety that reinforced the community members' habitual ways of pursuing and maintaining security. In the context of the LA riots, the community's characteristic security operations did not work. This, in turn, gave residents an opportunity to confront, over the course of the four-year intervention, the resistances that had sustained the community's character structure and to work through these resistances through ongoing and expanding collaborative processes.
Assessment of Progress
THE STATISTICAL RESULTS of the research investigation showed that the intervention decreased the community-wide sense of psychological distress, and simultaneously increased the general sense of well-being (Mills, 1998). Specifically, the intervention was associated with a significant increase (p < .01) in the subjective experience of belonging. Inversely, the intervention was associated with significantly decreased (p < .01) behavioral/emotional impulsivity, and decreases in the subjective experience of anxiety, depression, and loneliness (Borg, 1997). The study also accounted for changes in factors such as criminal behavior, drug and alcohol use, employment rates, and violence; each of these factors was thought to be related to underlying depressive symptomatology, and each showed significant improvement (Boyd, 1998). Accordingly, the physical health of the community also improved significantly as seen on various statistical measures (Borg, 2002).
Most significantly of all, perhaps, a community service organization initiated by AGMA solidified an alliance among the groups in the community, and so provided a formalized means of sustaining the collaborative empowerment process of change and growth in Avalon Gardens. This continued after the intervention was completed.
8. Complicating Factors
COMMUNITY INTERVENTIONS SELDOM OCCUR in a vacuum, and they are rarely the only interventions being implemented in a given community. It is especially important when conducting evaluations of interventions in community settings to be aware of any other interventions (whether planned or naturally occurring) that could be affecting outcome variables. For example, an evaluator assessing the effects of a housing-based drug use reduction program must consider that most urban communities have multiple drug-use education programs operating simultaneously (through schools, treatment programs, etc.). Having well-chosen comparison groups may be able to control for these competing interventions (HUD, 1997).
Furthermore, community programs, like long-term psychotherapy, face risks of their own. Rappaport (1986) warned that:
- Community programs aimed at so-called high-risk populations, especially programs under the auspices of established social institutions, can easily become a new arena for colonization, where people are forced to consume our goods and services, thereby providing us with jobs and money (p. 152).
We must beware, both in clinical and in community psychology, lest we find ourselves trying to save so-called high-risk people from themselves whether they like it or not by "giving" them, programs that we develop, package, sell, operate, or otherwise control. This is a grim possibility, and because of it, much as the analytic frame reminds the psychoanalyst of his or her limitations, empowerment as an explicit philosophy must be a constant reminder of our role as invited collaborators and not all-knowing experts. Rappaport (1986) states:
- The pervasive idea that experts should solve all of our problems in living has created a social and cultural iatrogenesis which extends the sense of alienation and loss of ability to control one's own life...We must begin to develop a social policy that gives up the search for one monolithic way of doing things according to the certified expert (i.e., the symbolic parent)...Diversity of form rather than homogeneity of form should dominate if the process is empowerment (p. 156).
Community psychology offers its practitioners about some tendencies that must be avoided lest our efforts become coercive, namely: 1) victim-blaming, 2) setting and maintaining a single standard for health and "normalcy", 3) generalization from extreme examples, 4) problemizing specific populations (e. g., "at risk" populations), and 6) implementing uniform solutions to diverse problems. Because these biases are so pervasive in our society, they are always potentially complicating factors in community work, and clinical practitioners may find these cautionary principles useful in their practices as well.
9. Managed Care Considerations
THE SOURCES OF FUNDING FOR COMMUNITY PROJECTS (that is, foundations and private and government grant-funding sources) correspond to managed care organizations in clinical practice. Whoever initiates it, an empowerment program is developed and maintained by the community members who are the stakeholders. This fact echoes current theorizing that sees the work as being a co-participatory process, "participant/observation" (Hirsch, 1996; Lionells et al., 1995; Sullivan, 1953; Thompson, 1964). The Avalon Gardens intervention focused on identifying, developing and maximizing community resources by encouraging community members to find specific solutions that work for them. Managed care companies, like funding agencies, in theory at least, ask us to be responsible for the outcomes that we suggest in our treatment modalities. Community practitioners have long been accustomed to being held responsible in this way, and have had to sharpen the functionality and applicability of our interventions as a result. The application of the co-participatory philosophy common in community work enhances clinical practices, whether the approach to treatment is psychoanalytic, cognitive-behavioral, family-system, or any other.
However, the most essential aspect of obtaining funding for community projects hinges on the relationships that community organizations and funding agencies establish between them. It seems certain that managed care companies are not going to disappear anytime soon (even Medicaid and Medicare are establishing managed care approaches to reimbursement), so the relationship-building framework between community psychologists and their funding sources may have implications for other clinicians who must deal with managed care companies.
As I do not want to present a nave or overly optimistic view regarding the influence of managed care companies on clinical practice, or of funding agencies on community interventions, for that matter, I want to address one complicating factor. This relates to the issue of iatrogenesis. It is not uncommon for clinical treatments to cause adverse reactions that may be worse than the original malady. Illich (1976) has referred to social and cultural forms of iatrogenesis that, in the context of managed care systems, are relevant to clinical and community psychology. Social iatrogenic effects are those created by the medical model bureaucracy that increase stress and dependence while reducing individual choice and self-care. Cultural iatrogenesis exists when members of a community, or a society, are robbed by treatment of the will to understand their own pain, sickness, suffering, and dying. The darkest side of the managed care enterprise becomes all too evident when a potentially help-giving enterprise is turned over to a technocracy, rather than left in the hands of its constituents. Numerous studies (e. g., Rappaport & Seidman, 2000) have documented cases where community interventions and agencies have had to abandon their stated missions to meet funding requirements. It may be helpful for clinicians to examine these incidents as we address the ways that clinical treatment has been (or is being) influenced/shaped by the requirements/ policies of managed care companies, and the ways that they may overshadow the stated treatment goals of their clients.
UPON FOLLOW-UP IN 2000, the members of AGMA had formed alliances with the other organizations established within the intervention. These alliances formed the foundation of the Avalon Gardens community had developed a resident-driven comprehensive community revitalization program that had been formalized and manifested in the Avalon Gardens Community Service Association (AGCSA). This organization was the culmination of all the group work accomplished during the intervention. Working in conjunction with an umbrella organization, AGCSA had obtained non-profit organization status, and was now able to develop and receive funding for its own community service projects. The catchment area for AGCSA roughly coincided with the patrol areas of the Southeast Division of the LAPD, and it allowed AGCSA to parallel the LAPD/AGMA block captain program underway in the area of crime prevention. This development enabled the development of a new project towards making this area a healthier and safer community. AGCSA would extend its goals and work in synchrony with the non-profit organizations operating within the four housing projects in the area. AGCSA, through its links with other community service organizations, eventually formed the Los Angeles Urban Communities Task Force. This task force remains a vehicle for promoting the healing of distressed neighborhoods.
11. Treatment Implications of the Case and Recommendations to Clinicians and Students
IF I HAVE SUFFICIENTLY DETAILED AND EXPLORED the clinical underpinnings of the Avalon Gardens intervention, then the treatment implications of this case as I have presented them also serve as my recommendations to clinicians. The obvious implication and recommendation is also an invitation. I hope I have encouraged clinical practitioners to bring their skills into community interventions. Whether they serve as actual intervention team members or as consultants, I hope that I have shown that intervention team members bring clinical perspectives to the work that appear to be essential to accomplishing the success of the project. Reciprocally, it is possible that clinicians may benefit from observing the interactive processes that have been historically established and maintained between funding agencies and community practitioners as a model of increasing the functionality of managed care relationships in their own practices. Ultimately, my aim has been to provide a theoretical and practical bridge between the seemingly disparate worlds of community and clinical practice.
Psychoanalysis is undergoing tremendous change at the moment, and long-cherished theoretical and technical assumptions are being questioned. At the same time there are powerful economic and societal pressures in play. These make it advisable that we ask ourselves serious questions about what alternative approaches, and what their roles, if any, should be in contemporary clinical thinking.
Albee, G. W., & Gullotta, T. P. (1997). Primary prevention works. Thousand Oaks, CA: Sage.
Ashcroft, W. D., Griffiths, G., & Tiffin, H. (1995). The post-colonial studies reader. London: Routledge.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington, DC: American Psychiatric Association.
Berger, P. L., & Neuhause, R. J. (1977). To empower people: The role of mediating structures in public policy. Washington, DC: American Enterprise Institute.
Bion, W. R. (1959). Experience in groups. London: Tavistock.
Bloom, M. (1996). Primary prevention practices. Thousand Oaks, CA: Sage.
Bonime, W. (1965). A psychotherapeutic approach to depression. Contemporary Psychoanalysis, 2, 48-53
Borg, M. B. (1997). The impact of Health Realization training on affective states of psychological distress and well-being. Ann Arbor, MI: UMI.
Borg, M. B. (2002). The Avalon Gardens Men's Association: A community health psychology case study. Journal of Health Psychology, 7, 345-357.
Borg, M. B., Garrod, E., & Dalla, M. R. (2001). Intersecting 'real worlds': Community psychology and psychoanalysis. The Community Psychologist, 34, 16-20.
Bose, J. (1995). Depression. In M. Lionells, J. Fiscalini, C. H. Mann, & D. B. Stern (Eds.) Handbook of interpersonal psychoanalysis (pp. 435-469). Hillsdale, NJ: Analytic Press.
Bose, J. (1998). The inhumanity of the other: Treating trauma and depression. The Review of Interpersonal Psychoanalysis, 3, 1-4.
Bose, J. (2001). Melancholia and addiction. In J. Petrucelli & C. Stuart (Eds.) Hunger and compulsions (pp. 209-220). Northvale, NJ: Jason Aronson.
Boyd, C. (1998). Avalon Gardens: Report to Weingart Foundation. Los Angeles: CSPP.
Bright, E. M. (2000). Reviving America's forgotten neighborhoods. New York: Garland.
Bromberg, P. M. (1998). Standing in the spaces. Hillsdale, NJ: Analytic Press.
Butler, J. (1997). The psychic life of power. Stanford, CA: Stanford University Press.
Cohen, M. B., Cohen, G., Fromm-Reichmann, F., & Weigert, E. V. (1954). An intensive study of twelve cases of manic-depressive psychosis. In J. C. Cove (Ed.) Essential papers on depression (pp.82-139). New York: New York University Press.
Fiscalini, J. (1994). The interpersonally unique and the uniquely interpersonal: On interpersonal psychoanalysis. Contemporary Psychoanalysis, 30, 114-134.
Freud, S. (1917). Mourning and melancholia. Standard Edition, 14, 237-258. London: Hogarth.
Freud, S. (1923). The ego and the id. Standard Edition, 19,12-66. London: Hogarth.
Freud, S. (1937). Remembering, repeating, and working through. Standard Edition, 12, 145-156. London: Hogarth.
Fromm, E. (1955). The sane society. New York: Rinehart & Winston.
Fromm-Reichmann, F. (1949). Intensive psychotherapy of manic depressives: A preliminary report. Confina Neurologica, 9, 158-165.
Ghent, E. (1990). Masochism, submission, surrender. Contemporary Psychoanalysis, 24, 108-136.
Ghent, E. (1992). Process and paradox. Psychoanalytic Dialogues, 2, 135-159
Gill, M. M. (1983). The interpersonal paradigm and the degree of the therapist's involvement. Contemporary Psychoanalysis, 1, 200-237.
Goldburg, D., & Hillier, V. (1978). A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145.
Greenberg, J. R., & Mitchell, S. A. (1983), Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press.
Herman, J. (1992). Trauma and recovery. New York: Basic Books.
Hirsch, I. (1996). Observing-participation, mutual enactment, and the new classical models. Contemporary Psychoanalysis, 32, 359-383.
Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process. Hillsdale, NJ: Analytic Press.
HUD (1997). U. S. Department of Housing and Urban Development healthy and safe communities training manual. Washington, DC: HUD.
Illich, I. (1976). Medical nemesis: The expropriation of health. New York: Panthenon.
Jacobs, T. (1986). On countertransference enactments. Journal of the American Psychoanalytic Association, 34, 289-307.
Jaques, E. (1955). Social systems as a defense against persecutory and depressive anxiety. In M. Klein, P. Heimann, & R. E. Money-Kyrle, (Eds.) New directions in psychoanalysis (pp. 478-498). London: Tavistock.
Jones, E. (1964). Essays in applied psychoanalysis. New York: International Universities Press.
Levenson, E. (1991). The purloined self. New York: Contemporary Psychoanalysis Books.
Lionells, M, Fiscalini, J., Mann, C.H., & Stern, D.B. (Eds.) (1995). Handbook of interpersonal psychoanalysis. Hillsdale, NJ: Analytic Press.
Menzies, I. (1960). A case-study in the functioning of social systems as a defense against anxiety. Human Relations, 13, 95-121.
Mills, R. C. (1995). Realizing mental health. New York: Sulzburger & Graham.
Mills, R. C. (1996). Psychology of Mind/Health Realization: Summary of prevention and community empowerment applications outcomes. Los Angeles: CSPP.
Mitchell, S. A. (1988). Relational concepts in psychoanalysis. Cambridge, MA: Harvard University Press.
Mitchell, S. A. (1997). Influence and autonomy in psychoanalysis. Hillsdale, NJ: Analytic Press.
Mitchell, S. A. (2000). Relationality. Hillsdale, NJ: Analytic Press.
Phillips, A. (1997). Keeping it moving. In J. Butler The psychic life of power. Stanford, CA: Stanford University Press.
Rappaport, J. (1986). In praise of paradox. In E. Seidman & J. Rappaport (Eds.) Redefining social problems (pp. 141-164). New York: Plenum.
Rappaport, J., & Hess, R. (1984). Studies in empowerment. New York: Haworth.
Rappaport, J., & Seidman, E. (2000). Handbook of community psychology. New York: Kluwer Academic/Plenum Press.
Riessman, F. (1986). Support groups as preventative intervention. In M. Kessler & S. Goldston (Eds.) A decade of progress in primary prevention (pp. 275-288). Hanover, NH: University Press of New England.
Sadock, B. J., & Kaplan, H. I. (1998). Synopsis of psychiatry: Behavioral sciences, clinical psychiatry. Baltimore, MD: Williams & Wilkins.
Salzman, L. (1972). Interpersonal factors in depression. In F. Flach & S. Draghi (Eds.) The nature and treatment of depression (pp. 43-56). New York: Wiley.
Seidman, E., & Rappaport, J. (Eds.) (1986). Redefining social problems. New York: Plenum.
Smelser, N. J. (1998). The social edges of psychoanalysis. Los Angeles, CA: University of California Press.
Sperry, L. (1995). Handbook of diagnosis and treatment of the DSM-IV personality disorders. Levittown, PA: Brunner/Mazel.
Stern, D.B. (1997). Unformulated experience. Hillsdale, NJ: Analytic Press.
Stewart, A. L., & Ware Jr., J. E. (1992). Measuring functioning and well-being: The medical outcomes study approach. London: Duke University Press.
Sullivan, H. S. (1940). Conceptions of modern psychiatry. New York: W. W. Norton.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W. W. Norton.
Sullivan, H. S. (1954). The psychiatric interview. New York: W. W. Norton.
Sullivan, H. S. (1964). The fusion of psychiatry and social science. New York: W. W. Norton.
Tedeschi, R.G., Park, C.L., & Calhoun, L.G. (1998). Posttraumatic growth: Positive changes in the aftermath of crisis. Mahwah, NJ: Lawrence Erlbaum.
Thompson, C. (1964). Interpersonal psychoanalysis. New York: Basic Books.
van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.) (1996). Traumatic stress. New York: Guilford.
Virilio, P., & Lotringer, S. (1997). Pure war. New York: Semiotext(e).
Veit, C. T., & Ware, J. E. (1983). The structure of psychological distress and well-being in general populations. Journal of Consulting and Clinical Psychology, 51, 730-742.
Ware, J. E. (1986). The assessment of health status. In L. H. Aiken & D. Mechanic (Eds.) Applications of social science to clinical medicine and health policy (pp. 211-234). New Brunswick, NJ: Rutgers University Press.
Warren, M. R. (2001). Dry bones rattling: Community building to revitalize American democracy. Princeton, NJ: Princeton University Press.
Winnicott, D. W. (1965). The maturational process and the facilitating environment. New York: International Universities Press.