References Dean, R. (2002). TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY FOR CONTEMPORARY SOCIAL WORK PRACTICE. Smith College Studies in Social Work, 73(1), 11-27. Retrieved from SocINDEX with Full Text database. Smith Studies in Social Work, 73{), 2002 TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY FOR CONTEMPORARY SOCIAL WORK PRACTICE Ruth Grossman Dean, PhD Abstract Psychodynamic theories, once an essential part of social work education but recently neglected, have been reinvigorated in recent years through contributions from social constructionism, infant research, and intersubjectivity.
These theories, with their emphasis on multiple perspectives, context, and collaborative relationships allow for important considerations of diversity as well as clients’ strengths and resilience, and can serve as formats for the broadest forms of change. In its contemporary form, psychodynamic theory offers a complex and rich understanding of human behavior and a direction for practice that is utterly consistent with social work values and interests. Theories that deal with intrapsychic phenomenon have received less attention in the social work practice literature of the 1990s and the first two years of the twenty-first century.
With the advent of collaborative, client-driven problem formulations and solution-focused treatment approaches there is less interest in formulating a client/situation from an intrapsychic perspective. Discussing the “dynamics”—that is to say, the intrapsychic and interpersonal pattems of an individual, family, or group—is considered by some to be pathologizing and disrespectful. Social workers are admonished to eschew authoritative postures often associated with psychodynamic formulations as they assess client/situations.
In the material that follows, I argue that contemporary psychodynamic theory is one of the foundational perspectives for social work practice. I begin by defining psychodynamic theory. After considering the importance of conceptualizing clinical situations and developing formulations to guide practice decisions, I offer some reasons why psychodynamic theory is an essential part of the biopsychosocial orientation that is central to social work. This is followed by a discussion of some recent contributions to contemporary psychodynamic theory. A case example is used to show the applicability of these concepts to practice.
Finally, I consider the ways that contemporary psychodynamic approaches open the way to considerations of culture and diversity. 12 R. DEAN DEFINING PSYCHODYNAMIC THEORY Bcrzoff et al. (1996) define psychodynamic theory as part of a general category of theories that deal with the psychological, intrapsychic factors in human functioning. In psychodynamic theories, “dynamic” refers to the continually shifting and changing energies that motivate and influence behavior (Berzoff et al. , p. 4). These forces are shaped by past as well as current experiences.
They emphasize internal representations of interpersonal interactions, including the relationship that develops between the clinician and client. Early relationships with primary caregivers are seen as most influential. Psychodynamic theory is interested in the ways that personal history is internalized and then influences ongoing behavior. Theories considered to be “psychodynamic” explain our states of mind, emotions, and behavior as resulting from an evolving and shifting interplay of experiences that operate in interaction with environmental factors and have a biological as well as a psychological component.
Traditional divisions between “outer” and “inner” life have recently been viewed as arbitrary, and are being challenged by newer paradigms. Even so, it has been useful to designate systemic theories as focusing primarily on social interactions: ecological theories as encompassing the “external,” environmental surround: and psychodynamic theories as being about “internal,” emotional, psychological experiences. Ecological, systemic, and psychodynamic theories are each important components of the biopsychosocial orientation that is basic to social work practice.
REFLECTIVE PRACTICE AND PSYCHODYNAMIC THEORY Goldstein argues for the centrality of experiential learning in social work education (2001). He delineates the process through which students move back and forth between field experiences and conceptualizations as they develop a capacity for reflective thinking and practice. This occurs best in a learning climate that encourages students to formulate tentative hypotheses about human behavior and client situations. Formal theories offer structure and substance to students’ speculations.
While students learn to use theories to help them think about clinical experiences, it is also important that they learn to question their hypotheses and theories and view them as partial and provisional explanations (Goldstein, 2001). This questioning is the hallmark of reflective thinking and “few would disagree that the reflective (and one may add, the analytical) thinker is the ideal product of education” (Goldstein, p. 17). In other words, students TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 13 ecome reflective practitioners through critical reflection on theoretical concepts and practice. Psychodynamic theory has been part of the conceptual base of social work since the early days of the profession. As Freudian theory took hold in this country in the 1920s, it was quickly adopted by one faction of the profession known as the Diagnostic School. This model was soon challenged by leaders of what became known as the Functional School (Robinson, 1930; Taft, 1935) who offered instead a humanistic approach in which the helping relationship was seen as the fulcrum of growth and change.
Gradually both schools were joined as other psychodynamic theories that variously highlighted the development of intemal structure (Hartmann, 1964), the social context (Sullivan, 1964; Fromm, 1941; Homey, 1937), relational concems (Klein, 1964; Winnicott, 1965), and the development of self (Kohut, 1971), were added to the social work curriculum. Beginning in the 1960s, a range of popular psychological treatment models with behavioral emphases appeared (e. g. Gestalt therapy, psychodrama, encounter groups, transactional analysis). Typically, these approaches were absorbed into the curriculum during their period of popularity and then dropped. In contrast, cognitive-behavioral approaches were introduced in the 1960s (Mahoney, 1999) through the seminal works of Albert Ellis (1975) and Aaron Beck (1967), and have remained popular as applications of cognitive behavioral therapy to depression, anxiety, and personality disorders have evolved.
More recently, behavioral approaches have received a boost from the managed care industry as insurers require problem formulations that are written in behavioral terms, compatible with brief treatment approaches, and lend themselves to evaluative research methods. Narrative approaches and solutionfocused treatment are among the newest additions to practice theory to be introduced into social work curricula. The focus on measuring results in the 1980s and on managing care in the 1990s were only the latest in a series of movements that directed social work away from psychodynamic conceptualizations of practice.
Earlier, in the 1960s and 1970s, the emphasis on casework was challenged as the civil rights and anti-war movements emerged and the pendulum in social work swung back toward social reform. Many social workers repudiated psychodynamic approaches as too narrowly focused, responsible for shifting attention away from the professions’ long-standing interest in the client’s environment and the mission of social justice. In keeping with the focus on social reform, environmentally oriented theories emphasized the ways in which social location, cultural meaning-making systems, gender. 14 R. DEAN ace, class, and sexuality shape personal meaning and identity. Concerns with developing culturally sensitive ways of practicing furthered the rejection of psychodynamic theories that evolved out of a Eurocentric foundation and reflected practice experience with White, middle- or highincome clients. Finally, the positivist psychodynamic perspective that emphasized the practitioner’s authority and expertise did not fit well with more democratic practices that were influencing social work curricula. All of these forces along with some misunderstandings of psychodynamic theory began to limit its exposure in academe.
In this paper I contend that if we are committed to teaching social work students to be reflective practitioners, then we must provide theoretical content that begins to structure their reflections. Efforts to understand how clients make sense of their lives and situations, how they experience and internalize their culture, ethnicity, and life experiences, and how past experiences, including early relationships, may relate to present difficulties, require psychological understanding and intrapsychic theories.
We need to teach students to develop hypotheses and tentative formulations that spell out the interrelationship between psychological, socio-cultural, and biological factors as they occur idiosyncratically for each client. Developing broadly integrative formulations about clients and their situations and reflecting on and changing these formulations as the work evolves, increases the probability that our interventions will be helpful (McWilliams, 1999, p. 11). Moreover, attempts to understand a person’s psychology help us relate more easily to that person’s experience (Berzoff etal. 1996). In a psychodynamic approach to clinical work, the clinician primarily offers a relationship to which she brings her own developing sense of self, a perspective that is critical to the humanistic character of the process. The clinical relationship has always been considered to be at the heart of social work practice (Perlman, 1979). Recent contributions to psychodynamic theory bring new insight to our understanding of the clinical relationship and have much to offer social work practitioners.
The challenge is to incorporate psychodynamic understanding in our teaching and practice while avoiding narrow explanations of client/situations. The next challenge is to use psychodynamic theories within a formulation matrix that includes socio-cultural and biological factors, and in a manner that is responsive to issues of diversity. Some of the contemporary developments in this theory lend themselves most readily to this agenda. TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 15
CONTEMPORARY DEVELOPMENTS IN PSYCHODYNAMIC THEORY Too often, members of the social work profession who reject psychodynamic theory make this determination based on archaic versions of the theory. If one stays within the metapsychology of early psychodynamic theory it is easy to fault its authoritarian stance, mechanistic overtones, and outmoded understanding of female development. But psychodynamic theory has changed in ways that make it more compatible with social work interests and values.
These changes have come from many different sources, among them these two: (1) a social constructionist, post-modern philosophical orientation, and (2) the confluence of recent infant research, attachment theory, and theories of infant intersubjectivity. A thorough discussion of these ideas is beyond the scope of this paper; I will briefly review aspects of each and consider the relevance for social work. The shift to a social constructionist, post-modem philosophical orientation began as post-modem thinking, with its emphasis on multiple “truths,” began to influence psychoanalytic theory.
It offered serious challenges to customary, positivist ways of thinking (Hoffman, 1983; 1992; Schafer, 1983). The post-modem sensibility declared that all knowledge is historically and culturally constructed, context driven, partial, provisional, and perspectival (Gergen, 1985). According to social constmctionists, we cannot know the world apart from the preconceptions we bring to our study of it. Meaning is based on social consensus. It is always fluid, evolving, and emergent. Some ideas become part of the dominant social discourse and have more status; others are relegated to the margins.
In keeping with a constmctivist perspective, it must be acknowledged that social constructionism, like other orientations to knowledge, is also partial, provisional, and perspectival. A critique of traditional notions about the therapeutic relationship was an inevitable outcome as psychodynamic theorists encompassed social constructionist views. No longer was the therapist able to stand outside of the therapeutic process and render objective judgments about it. Constructionism taught that the clinician does not have privileged access to an unambiguous reality that is inaccessible to the client (Hoffman, 1983; Slavin, 2001).
Post-modern social constructionists saw therapy as an interactive process in which meaning is continuously co-constructed by the participants. Once the emphasis on objective knowledge and a single “correct” way of proceeding was challenged, there was room for a more spontaneous 16 R. DEAN and open expression of the therapist’s views in therapist-client interactions (Hoffman, 1992: Mitchell, 1997: Renik, 1993). The clinician can reveal uncertainty and be more human. But the shift to a more spontaneous and authentic way of relating does not mean anything goes in clinical work.
The process of disciplined self-reflection on the part of the clinician is a necessary condition for maintaining a therapeutic direction (Hoffman, 1992: 1998). As the client’s experience of the clinician’s subjectivity became a more important aspect of the clinical work, and it was acknowledged that both clinicians and clients communicate in ways of which they are unaware, a subtle but important shift took place. Clients’ views of the clinical encounter, including views about the clinician and interpretations of clinical content, became part of a more complete understanding of the process.
Additionally, ideas of self-development were radically altered in the shift to a post-modern orientation. Instead of picturing the self as having a center or core, post-modem theoreticians offered a view of self-states as multiple and discontinuous, fluid, emergent, and contextual (Gergen, 1991; Laird, 1998: Mitchell 2001). Developmental stage theories that suggest a linear progression are suspect in an epistemology that presents a picture of multiple, simultaneous, and non-linear paths of development. Infant research and intersubjectivity.
Recent empirical infant research and writings on attachment and intersubjectivity have challenged psychodynamic theory from a different perspective. This research has demonstrated that mind develops in a relational matrix and that infants actively participate in shaping the interaction of the infant-caregiver dyad from birth (Lachmann, 2001). Early classical theorists saw babies as initially autistic and unrelated, and then symbiotically attached and overrun by drives. They underestimated “the self-organized motivations and interpersonal shrewdness of the young infant” (Stem, 2000).
Whereas earlier theories emphasized the dependence of infants on caregivers for emotional regulation and security within an attachment relationship, infant research has shown babies to have a need “for joyful dialogic companionship over and above any need for physical support, affectionate care, and protection” (Stem, 1974). Within this companionship, the baby leams, among other things, to modulate affect, share in another’s subjectivity and take in the rudiments of the cultural units into which s/he has been bom.
Because emotional and physical survival depends on it, the infant is highly motivated to preserve primary attachments and engage with other persons in interactions that guide knowing and learning (Slade, 2000: Trevarthen, 2001, p. 95). TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 17 Regularly occurring and stable pattems of defense and affect regulation develop in infants in response to caregivers’ actions as an interactive process of mutual attunement unfolds. These pattems become models for negotiating relationships. Collaborative dialogue, then, is about getting to know another’s mind and taking it into account in constructing and regulating interactions” (Lyons-Ruth, 1991, p. 583). The process of mutual attunement gives the growing child a sense of effectiveness that is a powerful motivator. At the same time, disruptions in the working out of this mutual attunement are inevitable and occur regularly. If they are not too frequent and overwhelming, they help to push the baby toward greater forms of social activity and self-regulation.
Through working to influence the caregiver, the baby broadens and strengthens interactive skills. The assimilation of culture in the child is seen as the natural outcome of a progression from imitation of the caregiver’s expressions and mannerisms, to imitation of purposeful object use (Trevarthen, Kokkinaki, & Fiamenghi, 1999, p. 101, in Trevarthen, 2001). Infants are bom with a readiness to develop a cooperative cultural intelligence; they leam about culture through interactions with particular caregivers and their ways of being and making meaning in the world (Lewis, 2000; Trevarthen, 2001).
This understanding of infant development led mental health practitioners toward a greater interest in intersubjective processes and repetitive interactional pattems. As a result there is less concem with determining the meaning of specific symptomatic behaviors and more focus on the relational context in which they occur (Zeanah et al. , 1989). The idea that development consists of a gradual evolution toward separation-individuation (Mahler, Pine, & Bergman, 1975) has been incorporated within an expanded view in which attachment and independence are seen as working together (Lyons-Ruth, 1991, in Lachmann, 2001).
The capacity for attachment is retained and then abstracted and transferred to persons other than primary caregivers as a child becomes more independent of its caregiver. Development is seen as “implicitly integrative and progressively transformative rather than as an outcome of conflict between adaptive and maladaptive forces of the mind (Seligman, 2001, p. 197). Research on the intergenerational aspects of attachment (Fonagy et al. , 1993) has shown that there are indeed “ghosts in the nursery” as postulated by Fraiberg and her colleagues (Fraiberg, Adelson, & Shapiro, 1975).
There is often congruence between parents’ and infants’ choice of defensive strategies and attachment behaviors. But what is predictive of the child’s attachment behavior is not the caregiver’s actual early life experiences but the caregiver’s capacity to reflect on these experiences and 18 R. DEAN make sense of them (Fonagy et al. , 1993). This capacity for self-reflection allows caregivers to enter into the experiences of their infants and to hold ongoing and changing representations of the child that reveal the range and complexity of the child’s feelings.
The contributions to psychodynamic theory discussed thus far—social constructionism and infant intersubjectivity—are closely related. Each forms a context for understanding the other. Social constructionism, emphasizing that knowledge is contextual, offers a backdrop that leads to the view that mind develops in a relational matrix, while infant research and intersubjective descriptions of infant development offer data that reinforces the importance of context. Let us now consider the relevance of these ideas for social work practice. CONTEMPORARY PSYCHODYNAMIC APPROACHES TO PRACTICE
Psychodynamic theory has always emphasized the influence of early experiences on people’s lives. Intersubjective theories of infant development refine our understanding of early infant/caregiver interactions, provide new insights into the process of mutual attunement in all relationships including those that are clinical in nature, and offer support for perspectives that focus on clients’ strengths (Saleeby, 1997). There is also considerable support in the new infant research for the benefits of clinical work that helps to enhance people’s reflective capacities.
The clinician’s ability to engage clients in a process of reflection can promote healing and internal consohdation as clients gradually put their experiences into words (Slade, 2000). If we think of clients as actively directing the relationships we build together, we can look closely for the clues they provide that tell us how they need us to be with them. The client, through shaping what occurs in the clinical relationship, introduces us into his or her relational world. We too bring elements of our own subjectivity into play in different ways with different clients.
Together we work out templates for an ongoing, evolving relationship. In a similar sense, just as the child is inducted into the caregiver’s cultural meaning making systems through their relationship, so too is the clinician most intimately introduced to the meaning to clients of their culture, race, ethnicity, and other identifiers through the developing clinical relationship. In a parallel process, the clinician can be seen as being in the role of the child with the client in the role of the caregiver in these efforts at understanding differences.
Through the delicate interactions with TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 19 clients and tentative attempts at attunement that are part of building a relationship, clinicians come to understand clients’ ways of being in the world. Failures, as they occur in this process, require each participant to reveal more, explore further, or explain what is needed. In models of therapy based on more traditional psychodynamic theories, when there is a break in the process of containment or an empathic failure, the problem is often located in either the client or the clinician.
In the paradigm of intersubjectivity, the failure is located in the interactive process with both parties seen as contributing. The clinician is encouraged toward a more comprehensive approach to issues of containment and empathic response. More attention is given to the client’s actions and intentions in this process and there is more recognition of the clinician’s subjectivity. For social work practitioners, the idea of a co-constructed, collaborative clinical relationship fits well with efforts to acknowledge clients’ strengths and be more responsive to diverse populations (Dean, 1993; Hartman, 1990; Laird, 1993; 1998).
Recognition of the infant’s “self-righting tendencies” and the potential of early relationships, are consistent with the appreciation of people’s inherent strengths and resilience that informs social work’s value base. It is important in our work with clients whose early lives have been marked by abandonment, loss, rejection, or trauma, to understand the potential attachment sequelae of such experiences. Clients who are initially rejecting or seem indifferent to working with us, may be using protective devices to avoid the vulnerability and anticipated disappointments that attachments have so often brought them.
We need to understand these behaviors as expressions of strength and self-protection and respect their importance to clients. Of course, clinicians bring their own attachment histories and sensitivities to clinical relationships. Understanding our own vulnerabilities in the arena of attachment can enable us to better tolerate initial rejections from clients. If we can listen carefully and find ways to enter clients’ stories over time, we can build on clients’ strengths and expand our abilities to promote healing.
Infant research supports the assertion that relationships (such as the clinical relationship) are important vehicles for change. In the example that follows, we see how insights attained from social constructionist and intersubjective perspectives promote understanding and advance the clinical work. 20 R. DEAN VIGNETTE Rosella, a 14-year-old African American girl, was referred to a community mental health center by her pediatrician because she was unhappy, angry, flunking out of school, and fighting with her parents. She is brownskinned, neatly dressed, and appears older than her years.
She came to the conference with her 40-year-old stepmother, Ann, a White Catholic woman of Irish descent, and her birth mother, Deja, an Afro-Caribbean woman, also in her forties. They told the following story. When Rosella was bom, Deja was severely addicted to cocaine. Rosella was addicted at birth, and much of the first two months of her life with Deja were spent in crack houses. After two months, her father, Tom, an African American who was raised in the southern United States, obtained custody of Rosella and brought her to live with him and Ann.
According to Ann, Rosella was a happy and good baby who rarely cried. She did have the shakes and startle reactions that gradually disappeared as her system accommodated to a new environment. Ann says that she and Rosella were together all the time and “grew up together. ” When Rosella was four, Deja, then in recovery, reentered her life and sought custody. After a court battle it was decided that Rosella would visit her birth mother regularly, but that Ann and Tom would retain custody and she would live with them.
Over time her two mothers worked out a friendly relationship. Deja has several younger children whom Rosella helps care for when she visits. Rosella speaks of a very close relationship with Ann. She says she resents it when her father’s other children (now adult) come to visit because they interfere with her time alone with Ann. She enjoys a good relationship with her father, a gregarious man, whom many people know and like. She speaks with considerable anger about her birth mother and is especially resentful of Deja’s attempts to tell her what to do. She has a right to tell me what time to come home and stuff like that when I’m at her house, but she has no business talking to me about my boyfriend and other things, and she doesn’t get to make the mles for me. ” I have had about a dozen meetings with Rosella and a couple of meetings with Rosella and Ann together. At the beginning of each session, Rosella is contained and quiet. Her affect is muted. Then, part way through the hour, she begins to speak with energy and enthusiasm and soon her affect bubbles over.
Each time it is the same—she waits and watches me and then warms up and shows more of herself I sense that she does like to come and talk with me. She says she tells me things she doesn’t talk about TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 21 with anyone else. These have included her wish to have a baby and her interest in “bad dudes. ” She thinks she will probably have a baby before she graduates from high school. When asked why she wants a baby, she explains that she sees her friends walking in the mall with their babies and boyfriends and they look nice—like a family.
She knows the boy doesn’t always stay with the girl after the baby comes but she hopes to find someone who will be there with her. Her current boyfriend, Marcus, an African American 18-year-old from an economically disadvantaged neighborhood, has been in jail many times for assault and battery. Rosella says he gets into fights with other people when they provoke him. He has never fought with her but she has seen him destroy his own belongings, such as a cell phone, when frustrated. She thinks Marcus may be part of the gang. The Bloods. She knows his brother is a drug dealer, but thinks Marcus is not.
While she recognizes that Marcus has many problems she is hoping he will reform because he cares for her. They talk about this and he knows that she will not stay with him if he continues to get into trouble. She says that even though she knows all these “bad things” about him, it is very hard to imagine leaving him because she loves him. They talk on the phone a lot—usually initiated by her, and see each other occasionally in the neighborhood near her birth mother’s home. She is a virgin and is not interested in sex now, but talks about it often with Marcus who says he will wait until she is ready.
I have used our time together to try to help her reflect on various aspects of her life. Early on, we talked about her bad grades and how she wanted to get out of the parochial school she attended but wouldn’t graduate unless she passed all her courses. She quickly changed her approach, began working, passed her courses, and graduated. She began attending a vocational high school this fall that was chosen by Ann. She told me she was unhappy because there are very few Black students at that school. At first hesitant to tell this to Ann, she suggested that I tell Ann her reasons for wanting to transfer to the more diverse city high school.
We discussed having a meeting that included Ann and she liked that idea. At the meeting, with my encouragement, she voiced her concems. Ann agreed to a transfer, after expressing some sadness about her “baby” becoming more independent. She and I agreed that adolescence is a process for parents as well as for teenagers. Rosella and I also talk a lot about her interest in Marcus, about what it’s like to love someone who may not be a person you can build a future with, and what it would be like to have a baby with him. Like any adolescent, she changes her mind frequently.
Right now she is less interested in having 22 R. DEAN a baby as she thinks about how difficult it has been taking care of her young step-siblings on weekends. She mentioned wanting to go to the University of North Carolina which is near the homes of her father’s family. She doesn’t know much about it but her friends are talking about going there. She seems to have many friends including a best friend, and says she makes friends easily. Through our work together, she is gradually becoming more reflective and better able to evaluate various people and happenings in her life.
READING A CLIENT’S NARRATIVE: FROM CONTEMPORARY PSYCHODYNAMIC PERSPECTIVES With these few details in mind, let us see how social constructionism, and intersubjective theories of development lead to different readings of the narrative Rosella and I have co-created. Let’s begin with Rosella’s statement of resentment about visits from her father’s other children. In a more traditional formulation in which she is “assessed” according to certain normative standards, we might see this as an expression of her neediness and possible over-dependence on Ann.
But from the perspective of infant intersubjectivity, this reaction could be viewed as possibly indicating a failure of attunement on Ann’s part and an effort by Rosella to express her need to get her stepmother to respond. Similarly, in a more traditional orientation, her hesitance in telling Ann of her desire to transfer from the vocational school could be seen as further evidence of conflict around dependency. Conflicted about her efforts toward separation, she fears creating tension and distress between herself and Ann if she announces her wish to be with Black adolescents.
But in an intersubjective reading, her discussion with me, a White therapist, could be seen as her way of beginning a sensitive negotiation in which she gets me to understand her need and help her convey it to her mother. She first states her concern to me because it is less threatening to do so. There is a delicate process of attunement occurring between the three of us as Rosella asserts herself and helps two White women understand her growing need to identify as a young Black woman.
In social constructionist terms, I am not an “expert” who is able to appraise her mental health or the meaning of her communications from some outside, “objective” place. I depend on her to tell me how she makes sense of her world. I ask a lot of questions and she talks about life in Sunset Hills, the subsidized housing development where she lives. For example, she says her mother gets angry at her for “talking ghetto. ” TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 23 “What does that mean? ” I ask. She explains that it means talking like the kids on the street in her neighborhood.
She says, “I know the difference. I talk ‘ghetto’ with them, and I talk the regular way in school and with other people. I know how to talk the right way. ” She conveys that she needs to be like her peers but also understands her mother’s concems. In this conversation, she is telling me that she is bicultural—able to move back and forth between the Black street culture of her friends and the White culture that she experiences in other parts of her life (including her relationship with her stepmother and with me).
We could not have a meaningful relationship if I were not willing to recognize her expertise and be open about the things I don’t understand. She is fluent in the dominant discourses in each of her neighborhoods and communities. As we talk, she is teaching me about her life and the meaning of her words and in the process, she considers, reflects on, and expands her life narrative. Theories of infant intersubjectivity are also extremely relevant, given Rosella’s complicated beginnings and ongoing relationships with two mothers.
I try to pay close attention to her different ways of being with me. In these early stages of our work, it is hard to know what to attribute to shyness, cultural differences, or adolescence, and what to attribute to more lasting pattems of attachment, defense, and affect regulation. She seems a little guarded at first, taking my measure carefully. Then she relaxes and reveals her exuberant, intense, and energetic adolescent enthusiasms—mostly about boys. As the dialogue between us expands, I see how she actively participates in shaping our interaction and works to preserve it.
I do not know yet enough of the details about her early life to understand the antecedents of these interactional pattems. However, I see in her current relationship with her stepmother that she moves back and forth between accommodation and assertion. She comfortably complains about her stepmother in true adolescent style, yet remains in close dialogue with her. The anger toward her birth mother is of a deeper, more caustic nature. In a traditional psychodynamic reading one would wonder if Rosella has felt rejected by her birth mother who is only there for her intermittently.
Rosella tends to minimize the importance of this relationship, which might be taken as a clue as to how painful this loss has been. One could see her as trying to repair the failures in this relationship with a baby and through her efforts to reform Marcus who, like her birth mother, has close associations with drugs and crime. It is not uncommon for the yearning for a baby to surface in young girls in early adolescence when they are beginning to detach from their primary families (Fraiberg, 1987). A more 24 R. DEAN ntersubjective reading might see Rosella’s anger as a healthy response to her birth mother’s failure to recognize her and respond to her needs, and as an effort to change their interactions. Rosella rejects the one way conversations she has with Deja saying, “She doesn’t get to make the rules for me. ” Her relationship with me is just beginning. We each bring multiple selves to this encounter as we work out a process of attunement. She is the savvy Black teenage girl teaching me about her culture. She is the young person longing to be special to a baby and to a man who care about her.
She is a rebellious teenager, wanting to be independent and in control of her life. She is a confused teenager seeking guidance—eager to talk about her hopes and dreams and how to make them happen. I am the older White woman, very much on the margin when it comes to understanding her communities and culture. I am a woman who remembers what it is like to be a teenager in love for the first time with someone who loves you back, and how powerfully that enhances one’s sense of self. I have been a stepparent of teenagers, and remembering that experience, I understand Ann’s position.
I feel connected to Rosella’s states of mind but also protective and parental. It is very tempting to negatively assess Rosella’s pairing with Marcus and her wish for a baby. But in doing so I would again be claiming an expertise that I do not have, and would be stepping outside of our relationship and it’s potential for mutual attunement and influence. It is important that I not intrude my agenda and collapse the intersubjective space between us. It is only through our interactions that we bring our different selves into play as I help Rosella reflect on her choices.
Her growing sense of effectiveness is enhanced as she gradually works out and helps me understand what she needs. CONTEMPORARY PSYCHODYNAMIC THEORY AND PRACTICE There has been a concem in social work that psychodynamic theories lead to narrow explanations of client/situations that are not sensitive to cultural differences or issues of diversity. In the above material, I have argued for the importance of the intrapsychic perspective and of contemporary psychodynamic theory for clinical understanding. By examining my work with Rosella, I have tried to show the application and relevance of these theories for contemporary social work practice.
Psychodynamic theories have been expanding and evolving as modemist constructions are gradually incorporated and reworked in post-modem conceptualizations. 1 would suggest that the contributions of social TEACHING CONTEMPORARY PSYCHODYNAMIC THEORY 25 constructionism and infant intersubjectivity, with their emphasis on multiple perspectives, context, and collaborative relationships, open the way for considerations of diversity and clients’ strengths and resilience. These theories not only expand our theoretical base, they also lend support to the idea that relationships with clients can become formats for the broadest kinds of change.
According to the theory of infant intersubjectivity, primary relationships are the cmcible in which one’s mind develops, emotions become regulated, defensive structures evolve, and culture is transmitted (Lachmann, 2001). If this is so, then important later relationships—clinical, familial, peer, and others—can be powerful vehicles for change. This theory further suggests that because we leam how to be with one another in relationships, it is through relationships that we transmit values and culture (Trevarthen, 2001).
Understandings of difference are gradually folded into clinical relationships and become intrinsic to the ways we are with clients. As Rosella and I continue to work together, we will shape and be shaped by our developing relationship. We will share understandings of race and culture and see our differences and similarities. To do the work we will each need to hold onto simultaneous, multiple, and sometimes, contradictory views, as we talk about how to go about having a life that provides what Rosella needs.
As seen in the analysis of my work with Rosella, contemporary psychodynamic theory offers a complex and rich understanding of human behavior and provides a direction for clinical practice that is utterly consistent both with social work values and the interests of our profession. I believe it to be an essential part of the social work practice curriculum. (2004). In Blackwell Handbook of Childhood Social Development. Retrieved from http://www. credoreference. com/entry/bkhcsd/chapter_23_prosocial_and_helping_behavior References Weisler, S. (2006). Cancer as a Turning Point in Life.
International Journal of Reality Therapy, 26(1), 38-39. Retrieved from Academic Search Complete database. Cancer as a Turning Point in Life Sara Weisler The author is a school counselor in Ramat Hasharon, Israel ABSTRACT: A personal narrative and research on using RT/CT as a coping strategy in dealing with a catastrophic illness. Cancer associations throughout the world devote considerable time and resources to informing the public and educating people to take greater responsibility for their personal health. New causes of cancer which can be avoided are constantly being found, means of early detection nd diagnosis are improving, and of course progress has been made in treatment methods which improve the quality of life and extend life itself. When I was diagnosed with cancer, I decided that I would fight for my life, and that I would not be a victim of my disease. I wanted to take personal responsibility for both my health and my life. I tried to develop tools and understanding to help myself and other people strengthen those qualities that would help us protect ourselves from cancer, as well as develop coping strategies to deal with the experience of having cancer. I invented ways and tools to cope ith the difficult situation in which I was suddenly involved. When I was working toward a master’s degree, I first learned about Reality Therapy and Choice Theory. I suddenly realized that someone else, William Glasser, had found a formula of coping tools similar to mine. My learning of RT motivated me to improve the theory, use it as a way of life, and spread the ideas, especially among individuals ill with cancer. The study was done at Ichilov Hospital in Tel Aviv, Israel. As a result of advertising for volunteers, 10 individuals were interviewed. The research tools were onstructed as self report measures and structured interviews with open ended questions to allow the respondents to express their thoughts and feelings openly All data were grouped to protect the anonymity and confidentiality of the respondents. The study integrated the naturalistic approach with the quantitative data analysis. The study was based upon three different models. The first was the Talma Bar-Av Model of Coping. This included ways of coping with undesirable reality: 1) Go along with the reality; 2) Change reality; 3) Do nothing and complain; and 4) Separation and disengagement.
The second was Lahad’s Integrative Model of Coping and Resiliency, relating to six major coping resources that are at the core of an individual’s coping style: Belief and Values, Affect, Social, Imagination, Cognition, and Physiology The third model was based on the theories of William Glasser’s Reality Therapy and Choice Theory Reality Therapy is based on the fundamental principle that we are motivated by five innate human forces: Love and Belonging, Fun, Freedom, Power, and Survival. Reality Therapy teaches people how to direct their own lives, take etter control of their lives, and make more effective 38 • International lournal of Reality Therapy • Fall 2006 • Vol,XXVI, number 1 choices. It helps people identify what they want and need, evaluate each stage of their lives, and develop the strength to better handle the stresses and problems of life. The main findings of the research were as follows: • Sick people can navigate and take command of their disease and enhance their ability to cope and reduce their suffering. • Sick people must make cognitive, emotional and social efforts to create a sense of control in their lives. The meaning individuals attribute to what befell them, the cancer, is the key determining factor in their ability to better cope, to turn their struggle toward hope and success. • There are several vital elements in the recovery process: 1) To choose life, to touch death and stay alive. 2) To gain a perspective on life and create expectations for the future, to create motivation for change, and to develop an active approach and belief in the future. • To enhance coping strategies and resiliency that have the following goals: 1) Develop and strengthen coping capabilities and create esiliency. 2) Recognize and accept stressful situations as a part of the dynamics of life. 3) Increase awareness of personal coping patterns under stressful conditions. The conclusions are as follows: • Sick patients have to control their lives and take responsibility for what is going to happen, and how to face their cancer. • People who want to gain in the struggle against a disease have to adopt a positive attitude and continue to lead a normal life while dealing with and/or recovering from a disease; to change the disease from a stressful situation to the most important project of ife; to grow and develop inspiration from all travails; to make sickness a turning point in life instead of a milestone signifying its end. • To focus on life rather than death; to choose to contend with the challenges of life and the future; to set new goals that would help motivate and prolong life. 1 strive to serve as a model for other patients struggling to live a life of meaning, to gather the strength needed to fight for their right to live full and quality lives, mobilizing all the resources available to them in their difficult battle. It is important to earn how to gather mental and spiritual strengths for the struggle; not to give up, rather to face the cancer and not let the disease stop life and living. Individuals can transform themselves from victims to heroes by changing the way of coping with an unexpected crisis. Cancer has to be an impetus for improvement and growth, turning the struggle into a challenge, reducing its destructive impact. REFERENCES Bar-Av, Talma Reaching Out To Life Lahad, Mooli On Life and Death. The author may be reached at saraweisler@yahoo. com International References (n. d). CHAPTER 26 – Therapeutic Groups.
Retrieved from XRefer XML database. Social learning Most therapists, when contrasting individual and group therapies, stress the interpersonal resources of group approaches. The patient learns from the therapist in one-on-one therapy, but in group therapy the patient can learn from the therapist, from other group members, and by watching the interactions between the therapist and other group members (Lieberman, 1980; Yalom, 1975, 1995). When a group member appropriately expresses pent-up hostility, observing group members learn how they can express emotions that they have been suppressing.
When the group leader skillfully draws a reticent group member into the discussion by disclosing some personal information, the other group members learn about the relationship between self-disclosure and intimacy. Group leaders also model desirable behaviors by treating the group members in positive ways and avoiding behaviors that are undesirable (Dies, 1994). Vicarious learning (modeling), interpersonal learning, and guidance (direct instruction) all occur in therapeutic groups (see Table 26. 1). Modeling. Researchers confirmed the importance of modeling in a study of phobias.
People seeking help for their disabling fear of spiders were randomly assigned to small (3 or 4 members) or large (7 or 8 members) groups. The groups then spent three hours observing a model who showed no fear when handling a spider. Members of both groups showed sharp reductions in their fear of spiders, although improvement rate was slightly higher in the small group rather than the large group (Lars-Goeran, 1996). Groups that use explicit modeling methods show greater improvement than groups that only discuss the problematic behaviors (Falloon, Lindley, McDonald, & Marks, 1977). Interpersonal learning.
All groups provide members with direct feedback about personal qualities (“You are a warm, sensitive person,” “You seem lonely,”), but also indirect feedback in the form of nonverbal signals and reactions. Group members themselves tend to appreciate the feedback they get from their groups, for when rating the most valuable aspect of the group experience they give high scores to interpersonal processes: “the group’s teaching me about the type of impression I make on others,” “learning how I come across to others,” and “other members honestly telling me what they think of me” (Yalom, 1975, p. 9). Extended contact with others in a group setting may provide individuals with corrective information about their skills and abilities. Some therapeutic groups exchange so much evaluative information that members withdraw from the group rather than face the barrage of negative feedback (Scheuble, Dixon, Levy, & Kagan-Moore, 1987). Group leaders must intervene to regulate the flow of information between members so that individuals learn the information they need to change in positive ways.
Group members also tend to deny the validity of information that is too discrepant from their own self-views. Jacobs and his colleagues, for example, arranged for subjects to participate in a short-term, highly structured “sensitivity” group (Jacobs, 1974). When subjects rated one another on a series of adjectives, Jacobs found that they consistently accepted positive feedback, but consistently rejected negative feedback.
This “credibility gap” occurred despite attempts to vary the source of the information (Jacobs, 1974), the sequencing of the information (Jacobs, Jacobs, Gatz, & Schaible, 1973; Schaible & Jacobs, 1975), the behavioral and affective focus of the feedback (Jacobs, Jacobs, Cavior, & Feldman, 1973), and the anonymity of the appraisals (Jacobs, Jacobs, Cavior, & Burke, 1974). These findings attest to the potential value of group interventions as self-esteem-enhancing mechanisms, for the tendency to accept only positive feedback screens the group members from negative, but therapeutic, social information. Guidance.
Groups also influence members by guiding, directly and indirectly, their opinions, attitudes, and values. As Newcomb (1943) verified in his study of college students, when individuals move from one group to another they more often than not abandon their old group’s outlook and adopt the view of their new group. An individual having problems regulating his use of alcohol may, for example, believe that he can learn to drink in moderation. If he joins an AA group, however, he will be repeatedly exposed to a different set of values and beliefs: ones that maintain that alcoholism is a disease that can only be controlled by abstinence.
Over time the individual’s beliefs will likely change to match the group’s opinion (e. g. , Crandall, 1988; Fisher, 1988; Miller & Prentice, 1996). Fisher (1988), for example, developed an extensive educational program designed to change people’s perceptions of norms related to sexual conduct. His AIDS Risk Reduction Project changed participants’ attitudes toward condoms and anti-condom norms by exposing them to videotaped testimonials of medical experts and fellow students (Fisher & Fisher, 1993).
Participants also watched videotapes of couples discussing safe sexual practices, negotiating the use of condoms, and exiting threatening situations, and they practiced these behavioral skills with other members of the group, who provided them with encouragement and social support (Fisher & Fisher, 1992). An important part of your cancer care treatment plan At our Cancer Care Program, we know that cancer challenges not only the body, but also the mind and spirit. That’s why we partner with you during each stage of your care process-from diagnosis through treatment, and beyond-to provide you with excellent, comprehensive, integrated care. Psychosocial Care During Cancer Treatment • Role of the Medical Social Worker • Frequently Asked Questions • Contact Information Psychosocial Care During Cancer Treatment What affects a person physically, also affects them emotionally, intellectually, spiritually, sexually and socially. Receiving a cancer diagnosis can also impact an individual’s sense of self or identity. At PAMF, your entire care team recognizes that a diagnosis of cancer may feel overwhelming and be far-reaching.
Therefore, along with your physician and nurses, we have highly trained medical/clinical social workers available to help with the emotional and psychological needs of patients, their caregivers and loved ones, during this challenging time. Back to top Role of the Medical Social Worker Professionally trained medical/clinical social workers have earned their master’s degree in social work (MSW) and specialize in applying clinical, advocacy and community-based skills to enhance the life experience of the individual, couple and/or family. PAMF’s Medical Social Workers: • Listen with compassion Focus on identifying, building or enhancing the existing strengths of the cancer patient/survivor • Provide support to the patient/survivor and his or her caregivers • Identify and help arrange community resources, and work with doctors and other individuals to obtain necessary referrals • Refer patients, survivors and caregivers to support groups • Assist in crisis intervention, if and when needed, with solution-focused sessions • Discuss the emotional challenges of dealing with a potentially life-limiting illness, and make referrals to local mental health professionals • Help patients/survivors create a “road map” with tangible tasks so that the individual with cancer can learn to live with a chronic illness rather than be defined by it • Help patients/survivors examine their lifestyle choices and determine if their actions support good health • Discuss Advance Health Care Directives, a ocument that: o Names an individual who will be their Medical Power of Attorney (or proxy) who will help make or implement the patient’s medical decisions o States which medical treatments and procedures the individual would or would not want implemented if a health crisis occurs • Work with other health care team members to file a mandated report with Adult Protective Services if allegations of abuse or neglect of a vulnerable adult arise • Social workers provide compassion, counsel to cancer patients and families • [pic] • AML patient Janna Paster (R) has received tremendous support from social worker Mary Lou Hackett (L). • Janna Paster was a 28-year-old schoolteacher and a bride of just seven weeks when she left her home one winter morning in 2005. Unbeknownst to her, she wouldn’t be returning for more than two months — after extensive treatment at Dana-Farber/Brigham and Women’s Cancer Center for acute myeloid leukemia (AML). • Now, with a cord blood transplant, chemotherapy, radiation, and other challenges behind her, Paster remains uncertain about her future. • She is, however, sure of one thing: she and her family could “never, ever have made it through this last year” without the help of her social worker, Mary Lou Hackett, LICSW. • “She’s been such an incredible, knowledgeable support system for us,” says Paster, who is regularly accompanied on outpatient visits by her husband, Mark, and mother-in-law, Nancy, both of whom have also benefited from Hackett’s counsel. “If something is bothering us physically, emotionally, or in any other way, we can see or call Mary Lou. If she doesn’t have the answer, she’ll be a sympathetic ear and tell us where to get it. ” • Hackett is one of a core team of clinical social workers in the Care Coordination Department, available to adult patients with cancer and related diseases, along with their families. • Their pediatric counterparts, one of whom is assigned to each young cancer patient and family seen in the Jimmy Fund Clinic and at Children’s Hospital Boston, operate out of the clinic’s Pediatric Psychosocial Unit. • These caregivers provide psychosocial assessments nd intervention and serve as sounding boards for patients with cancer and their families throughout treatment and beyond. • “Social workers offer a commitment to the whole patient within the Dana-Farber/Brigham and Women’s Cancer Center environment,” explains Michael Hubner, LICSW, program manager for Care Coordination and director of adult social work at Dana-Farber. • “As a profession, social work is not only concerned with the wellbeing of individuals and their families, but also with the economic and social forces that affect our patients’ lives, such as changes in health-care policy, health insurance coverage, access to care, and any cultural or societal barriers to receiving help. ” • A critical service for cancer patients Assigned to disease-based teams, social workers can serve as a key team member, along with physician, nurses, and other caregivers. Hackett, for instance, sees Paster and other adult leukemia patients under the care of Richard Stone, MD, of Medical Oncology, who says Mary Lou and her colleagues “provide a critical service” by addressing the emotional needs of patients and families while physicians focus on the medical issues. • “Taking care of a patient with cancer is truly a team approach, and the social worker deals with some of the toughest issues: loss of ‘normal’ life, loss of work and income, and, of course, fear of dying,” says Stone. • “Our social workers handle this challenge with grace, compassion, and expertise. We simply couldn’t do our jobs without them. • Stone says Hackett has been with the Pasters “through every turn,” a sentiment shared by the family. “You can’t think of everything when you’re meeting with the doctors,” says Janna’s husband, Mark. “I’ve come to look at Mary Lou as someone we can call to help us deal with things as they pop up. ” • For Janna herself, this approach — and relationship — has given her peace of mind. • “Mary Lou has taken care of me, of course, but she’s also been able to help the family in a way that I couldn’t,” Paster says. • “I knew how upset Mark was when it looked like I might not make it, but there was nothing I could do. He and I could only talk about it so much, but Mary Lou always took the time to make sure Mark was OK.
Her caring for him has made my recovery easier. ” • Back to Social Work Our Services Follow-up care is an important part of returning to and maintaining health after treatment for cancer. The LAF Adult Survivorship Program at Dana-Farber provides patients with a range of services designed to help manage health in the years after cancer treatment. A visit to the LAF Program’s adult survivorship clinic can help patients manage possible long-term and late effects from treatment, and make changes to live a healthier lifestyle. The clinic also provides help with referrals to any other testing or specialists that may be needed for a survivor’s follow-up care.
For each appointment, a nurse practitioner from the LAF clinic will review the patient’s medical records, including past cancer diagnosis and treatment, current health status, and general quality of life. This is done to provide patients with the best recommendations to help maintain good health. Patients are evaluated for long-term and late effects of cancer treatment and, together with their provider, can discuss their survivorship needs. LAF providers focus on developing a complete, individually tailored assessment of each patient’s survivorship needs. Each patient receives a treatment summary and follow-up care plan after his or her visit.
This comprehensive follow-up plan includes recommendations for the patient and his or her health care providers, an outline of potential late effects, and any medical information related to the patient’s past treatment and future care. Appointments are available Monday, Tuesday, Wednesday, and Friday, depending on the patient’s diagnosis. The adult survivorship clinic also offers appointments with an endocrinologist, a physiatrist, and an expert in sexual health. Your LAF clinic provider can talk with you about your potential options for a referral. Psychosocial services At the LAF Adult Survivorship Program, cancer survivorship is recognized as more than a physical process. Completing treatment may also affect emotional, mental, social, and spiritual aspects of an individual’s life.
As part of clinical care, psychosocial providers (clinical social workers and psychologists) are available to meet with patients and their family. The clinic also screens patients for depression and anxiety. Meeting with a LAF psychosocial provider is an interactive and supportive process, offering patients the opportunity to: • Discuss their experience as a cancer survivor • Discuss the experiences their family and caregivers may have had • Address emotional well-being • Learn about education and available support for off-treatment mental health issues • Talk about survivorship concerns and develop a plan to address these concerns • Learn more about the process of integrating the cancer experience into daily life Additional resources
The staff of the LAF Adult Survivorship Program includes a Community Resource Specialist who can help patients find resources in their local communities. Cancer survivors may encounter unfamiliar issues with insurance, employment, and other practical matters. A Community Resource Specialist can help patients learn more about: • Support groups • Advocacy • Employment rights • Retreats • Financial support • Transportation • Fertility resources • Health insurance What is progressive muscle relaxation? Progressive muscle relaxation, or PMR, involves tensing and releasing the muscles, one body part at a time, to bring about a feeling of physical relaxation. Some studies of breast cancer patients have shown that PMR can help to reduce: • nausea • vomiting • anxiety • depression
What to expect with progressive muscle relaxation Researchers report that relaxation training methods, including PMR, work best if a person is trained before cancer treatment starts. The researchers also said that after 2 hours of training from an expert, patients are usually experienced enough to successfully practice the techniques on their own. For a better idea of what to expect with PMR, try this exercise: • Begin by tensing and relaxing the toes of one foot. • Inhale as you briefly tense your muscles and exhale when releasing the tension. • Gradually, work your way up into the muscles of one leg, tensing and relaxing. • Repeat on the other leg. Continue up your body, tensing and relaxing each muscle group: your abdomen, torso, chest, fingertips, arms, shoulders, neck, and face. • As you purposely release tension in each area, you may experience a feeling of relief. Progressive muscle relaxation practitioner requirements There are no licensing or certification requirements for teaching PMR, but many health care professionals have had PMR training as part of their formal education. Health care professionals who teach PMR can include: • psychologists • psychiatric nurses • health care professionals trained in hypnosis • clinical social workers Many cancer hospitals and clinics offer programs in relaxation training that includes PMR, so ask your doctor for recommendations.
For more information about finding a qualified complementary medicine practitioner, see our Finding a Practitioner section. Research on progressive muscle relaxation in people with breast cancer In studies of people with breast cancer, progressive relaxation training has been shown to help reduce nausea, vomiting, anxiety, and depression. In a South Korean study published in 2005, 30 patients with breast cancer received training in PMR and guided imagery. An additional 30 patients in the study received no training. Both groups then began a 6-cycle chemotherapy regimen. Researchers found that the patients trained in PMR and guided imagery experienced less chemotherapy-related nausea and vomiting than the patients who had no training.
In addition, the trained patients had much lower levels of anxiety and depression than the untrained patients. Six months after treatment ended, the trained group still experienced a higher quality of life than the untrained group. In a study published in 2002, 38 breast cancer patients used PMR 1 hour before they received chemotherapy, followed by daily PMR for an additional 5 days. Each PMR session lasted 25 minutes. The 38 patients were compared with a group of 33 patients undergoing chemotherapy without PMR. In the PMR group, the duration of nausea and vomiting was significantly reduced. Important things to consider before trying progressive muscle relaxation
Progressive muscle relaxation is generally thought to be a safe practice, but as with all relaxation techniques, there are some risks: • Rare increases in anxiety. In rare cases, the increased body awareness that comes with relaxation training has led to more anxiety instead of a reduction in anxiety. • Very rare physical symptoms. In some people who u
