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Doing psychodynamic social work a basic introduction

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Doing psychodynamic social work a basic introduction ...

    Doing Psychodynamic Social Work: A Basic Introduction

Andrew Cooper

(Adapted from Wilson K, Lymbery M, Ruch G and Cooper A, Introduction to Social Work,

    Pearson Education, forthcoming 2008)

Introduction

    ‘Social work is a practical activity’. This was the pronouncement of a government minister

    responsible for social work in 2004. She was not wrong, but we strongly believe she was only capturing a part of the whole truth about actually ‘doing’ social work. In this paper we emphasise two

    other dimensions apart from ‘doing’ which are (or should be) ever-present in how a social worker

    conducts herself or himself. These are ‘thinking’ and ‘being’.

The thinking component is partly about the importance of having a solid theoretical grasp of different

    social work methods, so that each step in your plan of activity is based on a clear understanding a

    theoretically informed formulation - of the service user’s situation to which you are responding in a particular way that reflects this formulation. The thinking component is also about reflecting, learning

    to step back both during and after each phase of activity or ‘engagement’ and look at how the process

    and the relationship you are both involved in has changed, developed, deepened, or become problematic, tense, anxious…. These reflections are all in the service of evaluating how you and the service user are getting on with the ‘plans’ you should have made on the basis of your assessment (We say service user for the sake of simplicity, but of course there may be several service users involved, and quite possibly other colleagues as well).

    The being component may be less familiar to you in some ways, but it is no less important, and in fact once we have investigated it a little further it will probably seem obvious. Every time we meet, talk, engage, or develop even a superficial relationship with another person or with a group - each of us

    has adopted a particular, emotionally invested way of ‘being’ in that relationship. We might compete with the other person or with the group members; we might be drawn to listen and empathise; sometimes we want to ‘back off’ at once; some encounters seem to make us passive or withdrawn; or

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we become caught up in a feeling of elation and mischief…the possibilities are endless. But, setting

    aside the fact that each of has a more or less stable ‘personality’ (a fairly consistent tendency towards a range of ways of ‘being’) the important point is that there is no neutral, emotionally uninvolved way to ‘be’ in a relationship. Something particular is always going on in terms of feelings, emotional responses,

    patterns of interaction, the ease or difficulty of the encounter; and over time there is always some kind of development, change, or evolution which is usually quite complex at the level of emotional engagement with other people. The being component of social work interventions is about reflecting on these processes, and coming to know about them through thinking about them.

So, even if a piece of work seems to be all ‘doing’ – for example, an emergency visit because a

    severely disabled person living alone hasn’t been contactable for several days – these other levels of

    the engagement will be present; with the development of your skills, they become essential to carrying out the ‘doing’ in the most sensitive, thoughtful, attuned, and purposeful way. For example, often we can be impelled in to action by other people’s anxiety, when a better course of ‘action’ is to stop, think, reflect on the feelings that have already been mobilised in us, and only then decide what, if anything, to do. Frequently far more frequently than we often realise what someone in a state

    of anxiety finds truly helpful is not to rush into action, but to have their anxious state listened to, understood, so that they can be helped to think more clearly, as our case example of work with a young mother, Michaela, illustrates. There is a word for this way of responding to anxiety in relationships ‘containment’ which is explored in more depth in the section below on

    psychodynamic ways of working.

Case study

    Social work practice with a young Romanian mother

    Michaela was a young single mother who came to England from Romania with her daughter to work. But she quickly found that it was hard to earn enough to pay rent, live and support her daughter. Christine was the duty social worker who saw her on her first visit to the office. Michaela poured out her distress, and Christine was able to sit and listen and empathise; but she also helped Michaela to understand some practical steps she could take to improve her financial situation, and she made a couple of initial phone calls on her behalf.

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    When Michaela came to the office again she asked Christine to accompany her to the Housing Benefit Office. Christine thought about this for a moment, but said she didn’t feel that would be so helpful and that maybe Michaela could tell her of her worries about going there herself. To her shock Michaela turned on Christine in fury, saying ‘I thought you were going to be my friend’, and stormed out of the office. Christine felt immediately overcome with distress herself, as well as guilty and had to stop herself from rushing out of the office into the street to try to get Michaela to return.

    Christine reflected on this episode, and began to see that maybe Michaela was even more vulnerable than she had appeared at the first meeting. She was a very competent person who spoke good English, but emotionally it seemed she had felt desperate, and developed an intense dependency on the idea of Christine as someone who could (and should) help her in the way she imagined. Christine also wondered if she felt guilty, possibly about the situation she had placed her daughter in as well as herself?

    Christine decided to visit Michaela at home. Michaela seemed immensely relieved to see Christine, apologised for her outburst and explained that at that moment she had just felt quite panic-stricken and unable to cope. She had already been to the housing office and it had gone OK. Christine explored Michaela’s feelings and situation further, and it did emerge that she felt hugely worried and guilty about her daughter’s future as well as her own.

    This case study illustrates how doing, reflecting and being in social work are intertwined, and how the value of not rushing into action can be empowering Michaela’s panic is intense but fleeting, and she

    recovers her own competence very quickly. Had Christine agreed to go to Housing benefit, or rushed after Michaela, this might have been undermined rather than recovered. But this required a capacity in Christine to think on her feet about intense and complex feelings that arose in the encounter, and an ability not to get too ‘drawn in’ too quickly. Then she does ‘act’ by going to see Michaela, and this re-establishes a proper partnership in the work.

    These interconnected components must, as we shall illustrate, inform whichever of the methods you select for working with a particular case or situation. However, in order to be able to think, do and be, you need also to have a strong theoretical grasp of the approaches; we shall introduce you to the

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    essentials, and at the end of the chapter give you suggestions for reading to take you knowledge and understanding further.

Psychodynamic interventions

    Introduction

    In the history of social work there are probably more myths about psychodynamic practice, and more strong opinions both for and against this method, than there are in relation to any other approach to practice, perhaps in part at least because it was seen by ‘radical’ social workers in the middle decades

    of the last century as ignoring societal inequalities and the impoverished circumstances of most service users. To some extent this merely reflects how our society and culture divides strongly for or against anything to do with psychoanalysis. The word ‘psychodynamic’ is an adjective meaning ‘based on or deriving from psychoanalytic theory and practice’, and we use this adjective in preference to talking about ‘psychoanalytic’ social work. In the earlier chapters about the history and development of social

    work we saw how in Britain in the 1970s and 1980s there was almost a civil war in social work, with radical political social workers often taking psychodynamic social work as their main enemy (as we explored in chapter x, on history in the first section). But it has often been noted that key ideas based in psychoanalysis are now part of everyone’s everyday thinking and language, as we illustrated in hg and d chapter in discussing the popular use of the term ‘defence mechanism’. So, although

    psychoanalytic practice and theory is still hotly contested, in some respects it remains the most successful and influential psychological perspective of our times.

    Because it has been influential and successful, there is a vast literature about psychoanalysis and its various related practices such as psychoanalytic psychotherapy and psychodynamic counselling. There is a more limited range of writing about psychodynamic social work, and we will refer to many of these texts as well as giving you pointers should you wish to look a bit deeper into psychoanalysis. However our main aim will be to offer an accessible account of this approach that tries not to reproduce any of the myths and misconceptions that abound.

    In this section we will cover the main concepts you need to understand in order to practice simply and effectively using psychodynamic principles. We then discuss the stages, or the process, which a typical psychodynamic piece of work entails and explore how to use yourself your feelings,

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    responses and observations of your own reactions - as a central tool in doing this kind of work. We conclude the section by reviewing some of the important current research into the effectiveness of psychodynamic work

Getting started thinking about emotional experience

The best way to begin thinking about psychodynamic practice is with your own experiences on

    placement, at work, or in your own life. Psychodynamic theory proposes that people and relationships are made up of at least two ‘layers’ of experience and functioning, a conscious one and an unconscious one. The idea of the unconscious can seem mysterious and even frightening, but its

    manifestations are in fact ordinary and everyday. Some years ago one of us was teaching a group of qualifying social workers about psychodynamic work when a student said ‘You seem to be saying that these processes that relate to the unconscious are just there whether we like it or not. So we can’t help

    encountering them in our work…’. This seems exactly right, but in order to be convinced of the

    truth of such a statement, it is probably necessary to open yourself to examining your own experience.

    Some social work training courses now require students to undertake a short, usually 10 or 12 week observation of a baby or young child in an ordinary setting, either at home or in a day nursery. The observer is not asked to ‘do’ anything, but just sit and ‘take in’ what seems to be happening for the baby and then afterwards write up a detailed account of this. However, many observers find that this task stirs up very strong feelings and important memories and realisations in themselves. Watching a distressed baby who has been left alone by her caretaker for even three minutes a perfectly normal

    everyday occurrence - without doing anything to intervene or comfort the baby, can put anybody in

    touch with very powerful feelings of their own. For example, feelings of (and vivid thoughts about) our own emotional neediness, distress about times when we’ve been abandoned by a loved person

    who we depended upon, anger with people we feel have mistreated us can suddenly come to the surface. This is unconscious experience becoming conscious. But it is not necessary to do a baby observation to access this kind of experience. An encounter with a service user who is stricken with grief or guilt about the death of a loved one will almost certainly evoke powerful emotional reactions in us and these reactions will not just be ‘empathic’ or ‘altruistic’; we may find we become

    intensely emotionally preoccupied once again with experiences of loss that we thought were ‘over and

    done with’ when in fact they are still ‘alive’ in us, even if we aren’t aware of this most of the time.

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This then is the foundation of psychodynamic practice: openness to the emotional experience of

    other people, which leads on to the need to be open to our own emotional experience, which in turn leads on to the importance of us being able to hang on to the difference between our own experiences and those of other people. Most of us have no trouble with this most of the time we come away

    from an encounter saying something like, ‘She was dreadfully upset, and cried for a hour, and afterwards I burst into tears myself because I was thinking about my friend who died last year’. But

    there are important processes that go on between people, discussed below, which make it harder to know what is happening emotionally and whether it is ‘us’ or ‘them’ that feelings belong to.

Some psychodynamic processes and concepts

    For now we will think back to the case study of Christine and Michaela in the opening sections of this chapter. This involved intense and rapid emotional exchanges that Christine somehow managed to handle to good effect. It is worth thinking, step by step, about what took place between them.

    First, Michaela comes to the office and asks for help and it seems to Christine that Michaela is able to listen to the practical advice she offers despite being very distressed. Christine has listened and ‘taken

    in’ her distress, and for both of them this seemed a manageable if emotionally intense encounter. Consciously, all is going well and seems on course.

    But second, Michaela returns to the office and makes a request that Christine gently refuses. This elicits an intense outburst of rage from Michaela that takes Christine completely by surprise. Emotionally she is almost ‘knocked off her feet’. What has happened? In a way we can only reconstruct later what may have happened, when we learn that Michaela in fact went to the housing office straight afterwards and completed her tasks with them. Psychodynamic theory would suggest that two things have taken place. In the first place Michaela has projected an intense and

    unmanageable experience of frustration, despair, guilt and rage into Christine, who then becomes the one who feels incompetent, anxious, guilty and panicky. But importantly, she stops herself rushing after Michaela, and she succeeds in emotionally containing this experience. This gives her time to

    think about and reflect upon her emotional experience.

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    So, third, it seems that perhaps Michaela has rid herself of a whole bundle of feelings which at that moment she found just unbearable. She was unable to ‘contain’ and think about them, and found a

    solution that we have all used in our lives probably quite often she forced them onto someone else.

    For the time being, this makes Michaela feel more able to cope. Later Michaela admits to Christine that as she left the office she was full of hate and anger towards her for refusing to do what she had asked. In some way she had gone in there feeling ‘bad’, but left feeling good (or at least better) but having turned Christine ‘bad’ in her own mind - and in fact Christine does actually now feel pretty

    ‘bad’ herself. In psychodynamic theory the process of projection is closely tied to another one called splitting in which we project our bad thoughts and feelings into someone else, leaving us good and them bad. In this way we often create a view of the world split rather rigidly between the good and the bad. Thus, projection and splitting are examples of psychological defences against mental pain.

    They are used to preserve a sense of the ‘goodness’ of the self – but as we can see they also have a cost,

    for Christine certainly but perhaps also for Michaela.

    Then, fourth as Christine begins to think about her emotional experience, she works on the idea that maybe the feelings ‘put into her’ by Michaela may give her information about Michaela’s state of mind. In particular she wonders whether the guilt she felt might be a clue to something Michaela is struggling with, but has not been able to communicate about explicitly or consciously. This is speculation on Christine’s part, a kind of hypothesis that she must find a way to test. But if it is right,

    it is a very valuable clue she can follow up on. In psychodynamic language, this is Christine thinking about her counter-transference. You may be familiar with the psychodynamic concept of

    transference, a process in which one person ‘transfers’ feelings and images from their own inner life onto someone else, who they then treat as if they were this ‘figure’ from their own internal mental life. When you are the object of someone else’s transference, it is often difficult to spot at first.

    The clue is often that you feel as though you have been systematically ‘misrecognised’ in some way –

    perhaps excessively loved and admired, or hated and despised by the other person. Examining what this experience is all about is the process of thinking about your counter-transference. It was a big step in psychoanalysis when therapists began to realise that maybe transference was not just a ‘nuisance’, but in many ways the centre of the therapeutic process, the means by which the

    unconscious could be known about in an immediate, live way if the recipient of the transference could identify and make sense of what had ‘got into them’.

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    So fifth, when Christine visits Michaela again she finds her in a quite different state of mind. She is rather remorseful about how she treated Christine, and conveys that she knows she mistreated her although she couldn’t help this at the time. She no longer sees Christine as bad it seems. In effect, she been able to ‘take back’ some of her projections onto Christine, and see these feelings and

    constructions about the other person as her own. Often in psychodynamic work, this part of the process takes a long time because people’s defensive structures are much more entrenched than Michaela’s seem to be. But working through such processes is a key aim of much psychodynamic

    work, whether with individuals, couples, families or groups. Psychodynamic work recognises that people need to be emotionally dependent on one another, but ideally also need to retain their ‘separateness’ from each other so they can be both individuals and fully participating members of

    couples, families and other groupings.

    This is what psychodynamic thinking posits as ‘good mental health’, and contrasts this with relationships in which people are ‘mixed up with one another’ through the use of too much projection. In the latter state individuals have ‘lost’ bits of themselves in other people and their capacity to function autonomously is diminished as a result. In the case study we saw how this might have happened at the point where Christine could have agreed to go to the housing office with Michaela, thereby unnecessarily increasing her dependence on Christine. She would temporarily at least have lost part of her competence by handing it over to Christine at a point of crisis. Of course, with a different service user it might be the right decision to accompany them in this way it all depends on

    what kind of state of mind the person is in, and in crisis intervention work (which is psychodynamic in its approach) more of this kind of ego support, that is direct support for the part of the personality

    that usually is capable of functioning well, may well be appropriate. Referring back to the discussion in that section, we might therefore assess Michaela to be someone is in a state of great stress, but not in a state of crisis.

    A final point to make about this case study concerns the social and political context in which the work takes place. As we have seen, this is often a point of contention about psychodynamic work, and we can only touch on the many complex debates and perspectives in this area. Michaela has come to this country from Romania. The case study suggests that she may have been seeking ‘a better life’ for herself and her daughter. She is what we sometimes call an ‘economic migrant’. Her circumstances are therefore highly political in their nature and a consequence of social-structural forces acting on her, although her immediate predicament is very personal. Our impulse is likely to be to ‘identify’

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    strongly with the politically driven nature of a person’s circumstances. We have immediate sympathy with the motives behind her seeking a life in Britain, and with the economic and social struggle that her life entails. But of course she remains a person in her own right, who has taken decisions for herself albeit in pressurised circumstances, and who feels an appropriate sense of responsibility and worry about her daughter and the consequences for her of the decisions she has taken.

Psychodynamic work and values

    So, psychodynamic work does involve some central value principles as well as an account of how human beings develop and function psychologically. One such principle is respect for ‘psychological truth’ – for example when Michaela turns out to feel guilty and anxious about her daughter this can be taken as a sign of her being in touch with her sense of adult and parental responsibility, even though the experience of guilt is painful for her to bear. To attempt to reassure her, or excuse her from this pain, perhaps by reminding her of the difficult circumstances under which she decided to leave her country, is really to miss the point and would undermine her own sense of being a human agent who is capable of taking difficult decisions and working with the psychological consequences. Indeed, one could argue that her current social circumstances make it all the more important that she is respected and supported as a person in her own right who is experiencing pressure from external forces, and stress from internal psychic sources. One of the most influential original textbooks about psychodynamic casework used the idea that social workers are always working with a person-in-

    situation (not just one or the other), and that people in difficulties are usually experiencing a combination of ‘stress and press’. The socio-political and the psychological are brought together in

    a useful way by these concepts (Hollis & Woods, 1981).

Thinking under fire: psychodynamic practice in ordinary social work contexts

    Psychodynamic social work is not ‘psychotherapy’ although it will hopefully have ‘therapeutic benefits’ for service users and draws heavily on the principles and theories informing psychotherapy. So, how exactly does psychodynamic social work differ from counselling or psychotherapy? The brief discussion above of the idea that psychodynamic casework entails working with the interaction between the person and their situation gives a first clue. Counsellors and therapists usually see individuals, couples or families for a programme of work that focuses almost exclusively on psychological and relationship issues. They will tend not to get involved in practical matters, although good therapy in public service settings will often involve working as part of a network (see below for

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    an account of networking in social work) of other professionals who may be addressing these dimensions of the overall situation, with careful agreements about roles and boundaries, or in other words who is performing exactly what tasks. But psychodynamic casework will almost always involve attention to both sides of the equation.

    Some of the most influential policy documents in the history of British social work have stressed this. For example, the Barclay Report (1982) conceived the key roles of social workers as a combination of counselling and social care planning. Perhaps the central skill in being a good caseworker is the ability to keep both these elements continually in mind as equally important parts of the task. In fact this is one main part of what makes social work as a job so interesting and challenging on the one hand, but also so difficult. The brief case study below, as well as the story of Christine and Michaela illustrates the need to maintain this ‘binocular vision’.

Case Study From Rescuer to Persecutor

    Jamie and Tracey are both under five and were taken into care after they were discovered alone and unkempt in the family home. Their parents Kerry and Howard are both long term drug users. John became the family’s social worker after the Emergency Protection Order was taken out. He arranged a package of ‘kinship care’ in which Kerry’s parents (Jamie and Tracey’s maternal grandparents) were key, although Howard’s aunt was also able to offer important support taking the children to and from

    nursery.

    Everyone in the office, including John’s team leader, seemed to be relieved about these arrangements, and it seemed that a potentially difficult case involving contested care proceedings in court might be averted. At the case conference, there was a strong feeling of everyone being charmed by the Kerry’s parents. But over the next three weeks, John became more and more uneasy about the grandparents. Their actual care of the two small children did not seem that good, and he became suspicious that they were in fact involved in supporting Kerry’s drug habit. When he voiced these worried to his supervisor, he did not feel heard, and came away feeling that he had been subtly rebuked for casting doubt on the care plan.

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