Monday, June 25, 2012

Psychodynamic therapy with vulnerable and oppressed populations: Interview with Joan Berzoff, M.S.W., Ed.D.

[Episode 72] Today's episode of the Social Work Podcast explores the question of what makes psychodynamic theory a valuable approach for working with vulnerable and oppressed populations.

I was excited to talk with my guest, Joan Berzoff, professor of social work at Smith College, because she's an expert on psychodynamic practice and addresses this very issue in her 2012 edited text, Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations, published by Columbia University Press. In today's interview I asked Dr. Berzoff, what makes psychodynamic theory a valuable or useful approach for working with vulnerable, at-risk, and oppressed populations? Why should therapists be concerned about that which is symbolic in a client's life? Dr. Berzoff talked about the value of curiosity in psychotherapy; the use of insight; applications of psychodynamic theory to school-based programs; why don't people think of basic social work practice as psychodynamic; and how to conceptualize the role of insight-oriented work with clients whose basic needs are not being met.

Download MP3 [30:15]


Bio (from the Smith College website)
Joan Berzoff currently teaches in the doctoral, masters, and end-of-life care programs. She directs the End of Life certificate program. She formerly served as the co-director of the doctoral program and before that as the chair of the human behavior in the social environment sequence at Smith, which she now co-chairs. She has co-edited six books: Inside Out and Outside In: Psychodynamic Theories in Multicultural Contexts, Editions 1, 2 and 3; Dissociative Identity Disorders: the Controversy in the Diagnosis and Treatment (1995); Living with Dying: A Handbook for End of Life Care Practitioners published in 2004, and Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations, published in 2011.

Dr. Berzoff has written over 25 articles on a range of subjects including: women's development; intersubjectivity; curriculum development; women's friendships; death, dying and bereavement; psychodynamic theory and practice; trauma; compassion fatigue; program evaluation; telephonic teaching; end-of-life care curriculum; and disenfranchised populations. She has also been a visiting professor at the Sanville Institute in Los Angeles and at the University of Pennsylvania doctoral program. Berzoff was the recipient of one of the first Social Work Leader Awards from the Project on Death in America funded by the Soros foundation and was a recipient of the Outstanding Scholar Award from the National Academies of Practice. She was also the only social worker serving on the Compassionate Care Advisory Board for Aetna. In 2009 she received the Outstanding Teaching Award from the Massachusetts chapter of NASW. She is in private practice in Northampton, where she works with adults and lectures nationally and internationally on issues of death and dying, women's issues and psychodynamic theory and practice with multicultural and vulnerable populations.

Download MP3 [30:15]

Jonathan Singer: Today's episode of the Social Work Podcast explores the question of what makes psychodynamic theory a valuable approach for working with vulnerable and oppressed populations. I was excited to talk with my guest, Joan Berzoff, professor of social work at Smith College, because she's an expert on psychodynamic practice and I... am not. When I think about working with vulnerable and oppressed populations, for example mothers struggling with addiction or who are incarcerated, or returning vets who are debilitated by anxiety, depression, PTSD symptomology, or thoughts of suicide, I’m not thinking "boy, I better use psychodynamic therapy."

It’s not that I don’t know about these concepts. Listeners of the podcast will know that in Episode 54, Carol Tosone did a great job of addressing the relevance of psychoanalytic treatment in contemporary social work practice. But I really wanted some details. How do I use psychodynamic concepts like "symbolic communication," "insight," "enactment and reenactment," and "transference and countertransference," to help my clients? Psychodynamic practice has a reputation for looking back rather than looking forward (Reynolds, 1965 cited in Berzoff, 2012), for favoring long-term treatment and personality change over practical solutions to concrete problems.

I thought Dr. Berzoff would be a good person to answer my questions because she has argued pretty convincingly that psychodynamic practice isn’t just about looking inward and looking back, it is about taking a 365 degree perspective on a person’s life, looking inside out and outside in. Dr. Berzoff addressed this issue in great detail in her 2012 edited text, Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations, published by Columbia University Press. Dr. Berzoff and her contributors provide detailed case examples, exploration and explanation of psychodynamic practice with people struggling with addiction, involvement with the child welfare system, the stigma of incarceration, serious mental illness, physical disability, and oppression by virtue of being a racial or sexual minority. If these sound like topics you'd typically find in any social work practice text, I think that's intentional. What's not typical is how Dr. Berzoff's authors approach these topics. Yes, they use concepts from drive theory, ego psychology, object relations, trauma theory, attachment theory, self psychology, relational theories, and intersubjectivity, to understand their client's situations. But, what surprised me the most is that for a clinical practice text, Falling Through the Cracks is a surprisingly intimate read. The authors share not only their client's stories, but also their personal struggles with clients (in psychodynamic language their "countertransference reactions"). Each chapter has a narrative arc that draws in the reader. For those of us without clinical training in psychodynamic therapy, these chapters demystify the process of exploring the client's internal world, managing the therapeutic relationship, and addressing the enactment and reenactment of trauma and microagressions with their clients (Berzoff, 2012).

So, you might be wondering: "if this text is so great at answering the question of why psychodynamic practice is valuable for working with vulnerable and oppressed populations, why am I asking Dr. Berzoff instead of just reading her book?" Great question. Dr. Berzoff and I spoke before her text was published – if you listen closely you can hear that at one point I say "So, you have this text coming out…" I'm glad we talked before I read the text. We had a great conversation. And I get to share it with you.  A couple of notes about today's interview. First, it was recorded using Skype. Joan was in Northampton, MA and I was in Philadelphia, PA. There are a couple of places where the sound quality gets glitchy. It isn't a deal-breaker, but I thought I'd give you fair warning. Second, Joan and I had a much longer conversation than is presented here. The rest of our conversation focused on the use of case studies as both a tool for clinical instruction and as a form of empirical evidence, and some of the myths and misunderstandings of psychodynamic practice. Those will be published in future episodes of the Social Work Podcast. And so, without further ado, on to Episode 72 of the Social Work Podcast, Psychodynamic practice with vulnerable and oppressed populations: An interview with Joan Berzoff, Ed.D., MSW.

Jonathan Singer: Joan, thanks so much for being here on the podcast talking with us today about psychodynamic theory and vulnerable at risk and oppressed populations and my first question for you is what makes psychodynamic theory a valuable or useful approach to working with vulnerable at risk or oppressed populations?

Joan Berzoff: Psychodynamic theory gives us a way of looking into a client's heart, a client's mind and if we don't have knowledge of psychodynamic theory, we are limited to the surface, to the manifest and we're kind of blind in what may be going on relationally and what may be going on symbolically.

Jonathan Singer: And so what is the value of being able to look at what's underneath, what they're bringing to us or what's symbolic about what's going on in their lives.

Joan Berzoff: Okay. Well, thank you for asking that question because I will answer it with an example of a student in a post-master's program in which I taught who was working with an African-American mother. He was a school social worker. He is African-American himself and the mother came to him for the second time having seen him five years before and popped into his office quite unexpectedly. She popped in to say that she was very worried about her now fifth grade daughter who had witnessed domestic violence, her husband cutting himself after he had physically abuse her. And so the student said, “You need to get out of there. You need to leave right now and take your daughter with you.” But the client was unable to do so and although one's job is to provide safety first, the client had no idea about what was keeping her in this relationship and why she was tied to a relationship that was so abusive and so hurtful to her. So, upon further exploration, it turned out that this was a woman who had had a physically abusive father who had been violent towards her own mother. Her mother had been able to leave the relationship in a way that she was not able to leave her husband. The father was alive and basically told this 37-year-old woman that she was in fact worthy of the abuse and that he certainly wasn't going to provide shelter or help for her to leave the relationship, so she was internally tied to what we call a bad object. She really thought she was worthy of the abuse. She really didn't feel that she couldn't leave nor did she have some of the developmental capacities to leave and just go start a new life. She had enormous difficulty with being alone. She had a lot of difficulty with feeling that others were inside of her and with her. So, the injunction from the student to just solve the problem and go didn't take into account a complex internal world in which again, she felt that she was unworthy of being separate and being indivduated. She was unable to see herself as anything but bad and missing that the practitioner was frustrated and angry with her and somewhat disgusted by her passivity and she felt very misunderstood and not particularly helped. So, I guess what I'm saying about this young man is that he didn't have knowledge of trauma theory. He didn't have knowledge of her internalized object world. He didn't have knowledge of why she was repeating in the present that what she couldn't master in the past and without that knowledge, he was limited to the surface and to the concrete and to giving her an injunction and then being very frustrated that she couldn't make use of it.

Jonathan Singer: So, what you're saying is that psychodynamic theory is valuable in part because it gives the social worker permission to be curious about all the things that might be going on in the background that would keep somebody say in a domestic violence situation or prevent them from doing something that on the surface seems to be a healthier decision.

Joan Berzoff: It demands our curiosity about sort of the multiple ideologies and complexities that hold people in untenable situations that are often both psychological and also social. The other reason why she couldn't leave why she was a woman is not working outside of the home. She was a woman who had nowhere to go and she was a woman who didn't have the resources emotionally or financially to be able to simply up and leave. So, you know, I think the other piece of that psychodynamic theory is that it holds the complexity of both her social realities as well as her psychological internal compulsions to repeat that which she could not master.

Jonathan Singer: Can you talk a little bit more about how psychodynamic theory helps folks to understand the social and environmental context?

Joan Berzoff: There are many ways to answer that, but one way that I think I'll start has to do with what psychodynamic theory addresses when we think about discrimination, oppression, prejudice. There are many psychodynamic theories that actually help us to understand for example why we scapegoat, why we – other people, why we use defenses such as projection or projective identification to get outside of ourselves, those parts of ourselves that are intolerable and put them onto and into other people and then try to control them.

Jonathan Singer: Okay. How would you use that insight when working with either clients or let's say you're even doing more sort of mezzo level work like you're the director of a social service agency and you know you have – you know, you're directing a specific program, how would those theories or sorry, not those theories – how would that theory that understanding of where-isms come from inform what you do and the programs that you create to help these vulnerable at risk and oppressed populations?

Joan Berzoff: Well, let's see, I'm thinking a little less psychodynamically and a little more about the educational system in America at this moment, but how do we understand the lack of resources, the social and systemic inequalities. Let's say we're running/directing a program in the schools. I think that a psychodynamic understanding of what kids experience day to day in inner city schools requires many things. It requires understanding how a child's sense of trust may be undermined, how a child's physical lack of safety may lead to difficulties regulating emotions in the classroom. We might want to look at how a child's being in and out of foster homes might in fact alter that child's attachment capacities and therefore neurobiological capacities to regulate him or herself in the classroom. We need to know about whether a child has been provided a holding environment, that is whether emotional needs despite grinding poverty like racism has been provided and many holding environments are provided by many parents or parent surrogates which enable a child to function. We need to know about how a kid has coped in the past and how that child is coping now in the classroom. We need to know something about a child's sense of wholeness or fragmentation and we need to know, again, about the neurobiology of that child and the degree to which the child can deal with stimulation or has been understimulated. We know that traumatized kids may have enormous difficulty regulating emotion for example and so maybe overstimulated, may not be able to sit still in a classroom, may have rage reactions, maybe unable to tolerate frustration and so when we're thinking about how do you work – how do you develop a program in the schools for example, one needs to know about a child's neurobiology, the degree to which he or she has a disorganized attachment style, the degree to which he or she can make use of a relationship or may experience a relationship as disorganizing or overwhelming or threatening or dangerous. So, all of these things are always interacting in a classroom and so a mezzo level supervisor or a program developer needs to be aware of children's neurobiology, children's access to nutrition, children's inner lives, what is driving them, the ways in which they're coping or not, again, and also the degree to which they have access to an average expectable environment in which needs will be met or won't be met and also the degree to which the environment and particularly the school environment can serve as providing what the child's environment may not, holding, containing, providing resources, mentors, others, teachers in the environment who may provide stability and continuity, curiosity, interest that a child may not have in his or her world.

Jonathan Singer: Everything that you've said sounds...

Joan Berzoff: ... So obvious! [laughs].

Jonathan Singer: It sounds so obvious [laughs]. You know, you want to make sure that the child has a safe and supportive environment at home and at school and that if they're having difficulties in their relationships, that you understand why that is and therefore what you can do to address that, that the expectations of the adults around them and the peers are consistent with what the child can meet, you know, how they can best interact with each other and, you know, this sounds so obvious, so I guess the question is if these–

Joan Berzoff: Why is that – yeah.

Jonathan Singer: No, go ahead.

Joan Berzoff: No. Why is that psychodynamic?

Jonathan Singer: Yeah. Well, why is that psychodynamic and if it psychodynamic, why is it that people don't think of it as psychodynamic?

Joan Berzoff: Mary Richmond was talking about this in 1917. She literally talks about how the ghosts of the past inhabit the present and how we need to hold that knowledge in working with any client, be they an immigrant, be they deserted, be they a widow, whomever. We need to have some knowledge about how the ancestors of the past enter into the present and that's basically social work, but that's also psychodynamically informed social work and I think that part of the trouble, part of the danger is that when students are exhorted to do solution-focused work, they are not asked to think about the ancestors or the ghosts that inhabit a person's experience and so they're often encouraged to just fix a problem without an appreciation for who the person is in the environment with the problem. But psychodynamic theory is social work. It's not something other than social work and it's as early as our social work ancestors began. The School for Social Work at Smith started as a school in response to trauma and it was the trauma of World War I and it started with a belief that one needed to know why two people who had experienced the same trauma, internalized, metabolized that trauma so differently based on who that person was, how that person came to be constituted psychologically and socially. So, this is not new and it is very much at the heart of social work.

I think probably the only psychodynamic theory that's being taught now as far as I could see in my recent lecture at the University of Texas is attachment theory which is necessary but not sufficient, who understand how the social work – I'm sorry, how the social world, comes to be metabolized differently by every individual and how trauma comes to be metabolized differently by every individual. And so while I applaud that attachment theory is being in taught in schools for social work, I think a great deal of the richness and the texture of what social work students have traditionally learned and need to know has been lost in the attempt to solve problems, in the attempt to work harder and harder and faster and faster and in the drift that we have towards manualized treatments that treat the problem but not the person with the problem in the environment in which that person lives.

Jonathan Singer: So, you have this text coming out [Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations, published in 2012 by Columbia University Press] on– Joan Berzoff: I do.

Jonathan Singer: And we've touched on just a couple of topics here today and I'm wondering is there anything that you have written about in the text that you think is really a central or essential idea for people to be aware of–

Joan Berzoff: I think one of the important driving forces that made me write this textbook had to do with your first question which is why is psychodynamic theory relevant to populations at risk and we often hear a devaluation of or an eschewing of psychodynamic theory as if it's just for the “worried well” or it's just for people with privilege and so because in my 31-year career has been about teaching students why we can use psychodynamic theories with those who are most vulnerable and most at risk, I wanted to create a textbook that would provide case studies in which psychodynamic theory was not only necessary but crucial to understanding clients in their social context. So, there are chapters about prisoners which ask the question why would a prisoner who is you know finally released from prison compelled to commit another crime so he can go back to the safety and security of a prison or why do – let's see. Why do women who are homeless and who are coming out of incarceration have such a difficult time maintaining relationships with their children and there are very complex reasons that are biopsychosocial or why for an example, what are the effects of a country like Bulgaria on children who are institutionalized by the country itself so that mothers feel disempowered and unable to attach to or care for their children. There are 18 chapters. All of them are vulnerable and at risk populations on the basis of race or class or language or ethnicity or culture or status as person who is gay or lesbian or again, a status that has to do with disability such as deafness or blindness or cognitive impairment or there are cases that – there are chapters that are about the chronically mentally ill and the point of the book is that psychodynamic theory is absolutely crucial to whatever services are being provided as we've been talking about and again, the book provides rich rich case studies to illustrate why psychodynamic theory and practice are so necessary to understanding something as daunting and complex as another human being.

Jonathan Singer: How do you conceptualize the role of insight oriented work with clients who have basic needs that are not met?

Joan Berzoff: I'm thinking about you know you can give a housing voucher to two clients and one may accept it and see it as a sign of help and therefore appreciate that help. Someone else may see it as a sign of their – as a sign of devaluation, a sign of their worthlessness and may reject the housing voucher and it's important to understand sort of the unconscious motivation around the acceptance or the disallow of the housing voucher or five people can be given medication and one may see it as something to take as a sign of hope and someone else may see it as a danger to take inside one's self and someone else may see it as, again, a sign of hopelessness. So, understanding the most basic underlying reasons why people may or may not accept our services is essential to providing services. I would also argue that psychodynamic practice is not only organized around insight, but also around facilitating clients' capacities, their strengths so that it's not simply about insight but it's about mastery and about again, how do we help develop and facilitate the best capacities the clients have and, you know, this includes looking at psychological issues but it also includes looking at power issues and issues of disenfranchisement and oppression based on race and gender, class and culture.

Jonathan Singer: So, it sounds like it can be a really fascinating text for folks. Either those who already have a psychodynamic framework to their practice or those who were–

Joan Berzoff: Who don't. Yes.

Jonathan Singer: Who don't, which is probably the audience you're writing it for.

Joan Berzoff: It's a little like inside out. I don't know whether you know.

Jonathan Singer: Mm-hmm. Sure.

Joan Berzoff: Yeah. But that book was really written for people who either did or did not have any psychodynamic background and it was – again, it was our first attempt to say that psychodynamic theory was absolutely essential for multicultural clients and this is an extension in terms of so what does the practice actually look like and what are people really doing in the field had the psychodynamic practice look and had the psychodynamic theory inform socially complex practice.

Jonathan Singer: So, again, Joan you've made a number of you know compelling arguments for the importance of psychodynamic theory in working with that risk populations. Thanks so much for being with us today and talking about psychodynamic theory and at risk populations. I really appreciate you taking the time.

Joan Berzoff: And it was a pleasure talking with you.


References and resources

  • Berzoff, J. (2011). The Transformative Nature of Grief and Bereavement, Clinical Social Work Journal, 39, 262-269. 
  • Berzoff, J. (2011). Falling Through the Cracks: Psychodynamic Practice with Vulnerable and Oppressed Populations. New York: Columbia University Press. 
  • Berzoff, J., Hertz, P. & Flanagan, L. (2011). Inside Out and Outside In: Psychodynamic Theories in Multicultural Contexts(3nd edition). Lanham, MD: Roman and Littlefield. Berzoff, J. & Kita, E. (2010). Compassion Fatigue and Countertransference: Two Different Concepts. Clinical Social Work Journal, 38, 341-349. 
  • Berzoff, J. & Kokaliari, E. (2008). Non-suicidal self injury among non-clinical college women. Affilia: Journal of Women and Social Work, 23, 250–270. 
  •  Berzoff, J. & Swantkowski, J. (2008) Developing a renal supportive care team from the voices of patients, families and palliative care staff. Palliative & Supportive Care, 6, 133–139.

APA (6th ed) citation for this podcast:
 Singer, J. B. (Host). (2012, June 25). Psychodynamic therapy for vulnerable, at-risk and oppressed populations: Interview with Joan Berzoff, M.S.W., Ed.D. [Episode 72]. Social Work Podcast. Podcast retrieved Month Day, Year, from

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