Application of Attachment Theory to a Case Study

The Analytic Principle and Attitude: Mobilizing Psychoanalytic Knowledge to Maximize Social Work Students’ Practice Competence

Les Fleischera and Eunjung Leeb

aDepartment of Social Work, Lakehead University Orillia, Orillia, Ontario, Canada; bFactor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada

ABSTRACT Although psychoanalytic approaches have been marginalized in the foundations of contemporary clinical social work practice, there are core themes in various psychoanalytic theories that can be made accessible to maximize students’ practice competence. We elucidate the psychoanalytic principle of unconsciousness as well as the analytic attitude of inquisitive listening and its components. Using vignettes, we demonstrate how we teach this attitude in bachelor’s in social work (BSW) and master’s in social work (MSW) classrooms. This approach can help students begin to think and listen psychoanalytically. It offers them a way to better understand the person beyond the symptoms.

KEYWORDS analytic principle and attitude; psychoanalysis; social work students; practice competence

Social workers strive to develop a comprehensive understanding of the person in their environment, often with respect to the person’s presenting concerns and their underlying formations, and accordingly, to intervene in a way that will facilitate change. To achieve this professional task, social work curricula and training teach various psychological and social theories to guide students’ practice. Integrating various approaches to custom fit a particular client in a specific environment is an episteme of clinical social work practice.

To understand the uniqueness of each person, various psychological theories in general and psychoanalytic theory in particular have been widely incorporated into clinical social work practice and education in a manner that is consistent with social work values, ethics, and ideas (Berzoff, Flanagan, & Hertz, 2011; Borden, 2009; Mishna, Van Wert, & Asakura, 2013; Smaller, 2002). More specifically, psy- choanalysis has enriched social work through its understanding of unconscious processes, intrapsychic and interpersonal dynamics, developmental factors, and the therapeutic relationship. At the same time, social work values and core

CONTACT Les Fleischer, PhD [email protected] Lakehead University Orillia, Faculty of Health and Behavioural Sciences, Department of Social Work, 500 University Avenue, Orillia, ON L3V 0B9, Canada. © 2016 Taylor & Francis Group, LLC

PSYCHOANALYTIC SOCIAL WORK 2016, VOL. 23, NO. 2, 99–118 http://dx.doi.org/10.1080/15228878.2016.1149776

principles have contributed to contemporary psychoanalytic thinking and concepts by situating the person’s characteristics within the context of their complex envi- ronment (Brandell, 2002, 2004, 2013; Goldstein, 2001, 2009; Miehls, 2011; Smaller, 2002). This close, strong tie between social work and psychoanalysis has a long his- tory that continues to the present day (see Goldstein, 2009).

Despite the ongoing cross-fertilization between social work and psychoanal- ysis, prominent clinical social work scholars have expressed growing concern about the increasing marginalization of psychoanalytic concepts in contempo- rary social work (Applegate, 2004; Berzoff & Drisko, 2015; Berzoff et al., 2011; Brandell, 2002, 2004, 2013; Goldstein, 2009). Brandell (2002) notes that, in the current social work curricula in mental health courses, students rarely explore the “dynamics and etiology” of clients’ presenting symptoms, and that “instructors, in effect, are far better prepared to furnish students with a list of the symptoms of posttraumatic stress disorder, its associated features, and an impressive recital of its demographics than to discuss the concept of trauma itself” (p. 44, italics in original). Although reducing symptoms is a part of any treatment goal, many social work approaches/models strive to intervene in a manner that goes beyond reducing symptoms. It is especially important that social work students develop an understanding of the person, beyond symp- toms and diagnostic categories, and that they use their self in creating a rela- tional context for the client’s changes. This very capacity is social work students’ fundamental competence.

Based on their multi-project program of research, Bogo and colleagues (2012) developed a holistic model of competence emphasizing “the link between the cog- nitive processes involved in conceptualizing practice, the subjective experience of the practitioner, and the performance of skilful behavior” (p. 429). While there are multiple theories and practice models that could be incorporated into their model, we propose that the psychoanalytic approach is especially useful for enhancing social workers’ understanding of the person-in-environment, because it is “the most complex model of mental functioning ever invented for clinical purposes” (Auchincloss, 2015, p. xv). Instead of marginalizing analytic approaches, clinical social work could enhance social workers’ competence by positioning these approaches as one of the foundational practice theories. To make the most of the analytic approaches in clinical social work, psychoanalytic social work scholars suggest discerning common core themes and principles of various psychoanalytic theories (Berzoff, 2011; Berzoff et al., 2011; Borden, 2009; Goldstein, 2009; Goldstein, Miehls, & Ringel, 2006; Werkmeister Rozas & Grady, 2011). We concur with these scholars.

Since there is a dearth of pedagogical information on a core meta-approach such as what to teach, how to teach, and where and when to teach psychoanalytic con- cepts and skills to social work students, we aim (a) to propose one such approach for teaching the core psychoanalytic principle as well as the psychoanalytic attitude and its components to social work students; and (b) to illustrate how we utilize the

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analytic principle and the analytic attitude’s various components in undergraduate and graduate social work classes. We close our discussion by explicating the bene- fits of focusing on the psychoanalytic attitude.

The psychoanalytic principle and attitude: A critical contribution to being a social worker

Most social workers will never become analysts and may not practice analytically. Nevertheless, some social work students may elect to focus more intensively on psychoanalytic theories and develop their analytic knowledge and treatment skills later. In fact, there are growing numbers of social workers in analytic training pro- grams (Brandell, 2013). Whether or not practitioners eventually employ psycho- analysis substantially, we have found with our students that their exposure to the core psychoanalytic principle and attitude is a crucial component of their social work education and practice.

Why use the psychoanalytic principle and attitude in social work education?

Numerous scholars have discussed the psychoanalytic principle or attitude, and/or aspects of it, but it has been an ongoing challenge to formulate it in a complex, concise, and generally acceptable way (Brenner, 2006; McWilliams, 2004; Schafer, 1983). Our suggested approach for teaching psychoanalytic theories combines con- temporary theories including ego psychology, self-psychology, relational theory, and intersubjectivity approaches. The contemporary ego psychology approach focuses on insight and promoting healthy ego functioning, which includes helping clients develop awareness of defenses/coping skills, affects/impulses, relatedness, and strengths (Brenner, 2006; Marcus, 2003). We also stress the value of the con- temporary relational and self-psychological schools that place greater emphasis on interpersonal/relational processes, empathy, and the corrective emotional experi- ence, and less emphasis on insight (Miehls, 2011; Ornstein & Ganzer, 2005). We incorporate aspects of all the contemporary major psychoanalytic schools in devel- oping our approach to the psychoanalytic principle and attitude. Therefore, we emphasize that the insight contributing to change occurs within the context of the relationship, and that both insight and the therapeutic relationship are fundamen- tal components of therapeutic action. We acknowledge that there are controversies about the extent to which different psychoanalytic schools can be integrated. (For detailed discussions of the contrasts between classical and contemporary relational psychoanalysis, see Eagle, 2011; Ellman, 2010; Greenberg & Mitchell, 1983; and Rangell, 2007). The extent to which we delve into these debates varies, according to the nature of the course, time constraints, and class expertise and interest. Rather than focusing on the theoretical controversies, our emphasis is on helping students develop understanding of the core common psychoanalytic principle and attitude. While social work interventions often focus more on directly supporting their clients’ functioning, providing concrete services, and/or advocacy, we

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emphasize that all analytically oriented clinical practice contains a continuum of supportive, educational, and expressive elements (Fleischer, 2015; Wallerstein, 2009).

What is the psychoanalytic principle and attitude?

Despite many controversies, there seems to be one unifying psychoanalytic princi- ple across all psychoanalytic approaches: that we have an unconscious mind (con- taining contents and processes) that has a very powerful impact on normal and pathological human behavior. Hence, from a psychoanalytic frame of reference, problems are often caused by thoughts, feelings, and memories that are out of awareness (i.e., pre-conscious or unconscious) and helping people become aware of them is an integral part of treatment (Cabaniss, 2011; Mitchell & Black, 1995).

The analytic attitude refers to a therapist’s mode of listening that utilizes a curi- ous and inquisitive manner to more thoroughly understand the client. It is a rela- tional condition or context a therapist creates within which clients are supported to gain access to their internal worlds that are largely beyond awareness. The ana- lytic attitude is part of a therapeutic undertaking—the therapist wants to be helpful to the client (Brenner, 2006). Such analytic help has several characteristics. It con- tains an emotional and intellectual sensibility. It is a way of listening, experiencing, and knowing the client in a very deep way. It is a type of listening that respects and hears the surface content, but at the same time is looking for latent themes, often not apparent to the client, that are pushed away from consciousness (as a result, for example, of being under stress with multiple overwhelming pressures or trau- matic experiences in life). A key point of the analytic attitude is defined by the therapist’s desire to understand. According to Brenner (2006),

If one were to try to describe a proper analytic attitude by one word, a single word, the word would be “why?” Why did this thought follow that? Why this emotional expression just now? Why did the patient act in just this way outside the analytic situation? And why this response to what the analyst just said? Whatever a patient does he should be curious about their words and actions. (p. 53)

Analytic help is offered through careful and complex levels of listening. The therapist listens to content and process—not only what is said, but how it is said, when it is said, and what is omitted. Utilizing this perspective, the therapist is curious, nonjudgmental, nonauthoritarian, and tactful and respects complexity (Brenner, 2006; Fritsch, 2013; McWilliams, 2004; Schafer, 1983). While the social worker may offer the client practical help, reassurance, or suggestions, the analytic attitude focuses on helping people understand themselves (and how their minds work) within the context of a therapeutic relationship.

This approach suggests that all aspects of what people present to their social worker—that is, all mental activities (i.e., thoughts, feelings, symptoms, dreams, parapraxes, jokes, and fantasies)—have meaning (Brenner, 2006). Thus, behavior that appears irrational or dysfunctional can be understood. Conveying this

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understanding to clients can be transformative and a corrective emotional and relational experience. This is not to eliminate the role of biology, social-contextual factors, or chance in human life, or to suggest everything is driven by unconscious motivation. However, biological symptoms, social-contextual factors, and random events also have meaning to the client, which have to be explored and understood with and by the therapist.

How to teach the psychoanalytic principle and attitude

How we teach may be as important as what we teach in demonstrating the psycho- analytic attitude (Marcus, 1999). This idea is consistent with the growing emphasis on the impact of the implicit curriculum in all social work programs (for details of the implicit curriculum, see Bogo & Wayne, 2013). For example, we attempt to demonstrate the psychodynamic attitude through our efforts to deeply understand client materials, our commitment to carefully listen to student concerns, our atten- tion to class affects and dynamics, our respect for student defenses, and our effort to develop a positive relationship with the class overall and with individual stu- dents. We aim to have the class affectively and intellectually engaged. We do not mean that classroom teaching should be like therapy. However, social work educa- tors note the significance of affective engagement with students (Ikebuchi & Rasmussen, 2014; Rasmussen & Mishna, 2003). We assume the analytic attitude in the classroom. That is, we are curious and inquisitive about all clinical work, theo- ries, and classroom interaction. We encourage students to assume this analytic atti- tude toward all aspects of the course and the instructor. We believe that healthy questioning, curiosity, and skepticism is part of teaching the psychoanalytic atti- tude (Mintz, 2013). In addition, we are validating, encouraging, and interested in the students’ quest to learn this challenging material.

Key components of the analytic attitude

We communicate the psychoanalytic attitude and core principles to the class and then we attempt to illustrate them, breaking them down further into a series of (jargon-free) components, demonstrating with clinical examples from our own or ideally students’ practice or everyday life (Plakun, Sudak, & Goldberg, 2009; Shedler, 2010). The degree to which we discuss and/or focus on all components of the analytic attitude depends on the nature of the course. The benefit of this approach to teaching psychoanalytic knowledge is that any of these components can be introduced in any clinical course or curriculum at varying levels of depth and complexity. Following our literature review on various contemporary psycho- analytic theories, we have discerned six key components of the analytic attitude:

1. focus on affect and expression of emotion; 2. understanding symptom formation and defenses/coping mechanisms; 3. identifying organizing patterns in intrapsychic and interpersonal realms; 4. focus on relationships in a client’s life and therapy;

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5. focus on developmental history that affects the present; and 6. focus on biological and sociocultural impacts.

Focus on affect and expression of emotion We stress that affects (feelings and emotions) are primary—they provide life with vitality, color to human experience, and they are signals that help us determine what is good or bad for us; they also promote adaptation (Cabaniss, 2011). The therapist therefore carefully listens to a client’s surface and underlying emotional states and the emotional quality of his or her relationships. It is considered helpful to explore and talk about emotions, including those that are contradictory, fright- ening, or not immediately apparent (Shedler, 2010). Identifying, understanding, and verbalizing emotions may provide access to critical pre-conscious or uncon- scious conflicts, themes, and issues, promote management of intense affects, and enable clients to reflect on their possible actions rather than acting out.

The focus is on using therapy to gain emotional and intellectual insight or understanding through the medium of the therapist’s curious, inquisitive, and wondering mind about the client’s internal experiences. Ideally, insight enables a client to reconsider life patterns that once seemed uncontrollable and leads to the identification of new choices (Harvard Mental Health Letter, 2010). The insight can help a client make changes. Social work students often do not realize how help- ful they are when they help clients put their affective experiences into words. In our teaching, we demonstrate how focusing on a client’s emotional state during an intake interview often elicits critical data, helps clients feel understood, and strengthens the alliance. We also demonstrate how asking clients to find words for their tears elicits their understanding of manifest or underlying emotions.

Understanding symptom formation and defenses/coping mechanisms Clients bring presenting problems and symptoms to social workers’ attention. If we do not help clients ameliorate these problems or symptoms, they will soon drop out of service (Gambrill, 2012). In some instances, addressing clients’ presenting problems and symptoms may be sufficient in helping them to carry on with their life. However, other times clients’ symptoms may return or seemingly unexpected other crises occur, and they may come back to us through a revolving door (Lee & Kealy, 2014). Presenting issues and symptoms are a client’s offering to the social worker that she or he needs some help, and may be an invitation to explore under- lying conflicts (Balint, 1957/2000). Symptoms serve critical functions—they attempt to bind or alleviate dysphoric affect, mask underlying conflict, and may decrease awareness of painful experiences (Brenner, 2007; Freud, 1915). Without acknowledging these critical functions, alleviating symptoms might result in unex- pected impasses (which are often related to clients’ ambivalence about change despite their seeking help). Therefore, in addition to helping them reduce and alle- viate symptoms, we suggest that social workers may help clients understand and

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manage/cope with their underlying affects and conflicts, and then help them develop alternative coping methods.

The therapist needs to be interested in the client’s coping mechanisms that are “defenses.” Defenses refer to how the individual copes with conflict or stress. Social workers explore how the client employs defenses to attempt to avoid distressing thoughts, feelings, and interpersonal interactions (e.g., assessing flexible or rigid use of certain ranges of defenses. For detailed descriptions on defenses, see Goldstein, 1995; Schamess & Shilkret, 2011; Trevithick, 2011). Since all defenses have adaptive and maladaptive potential and components, the benefits and limita- tions of all defenses are recognized, respected, and explored. We may also examine client coping behaviors that impede treatment progress, and discuss ways to understand their functions. The therapist promotes the more pervasive use of healthy, adaptive coping mechanisms.

We ask the students for examples of how their clients cope with stress. Students often cite examples of clients making themselves busy with many activities, or other preoccupations such as substance use or other self-destructive behaviors. We then discuss how clients often use substances or other behaviors in an attempt to regulate dysphoric affect states. We demonstrate that targeting symptom change in and of itself may not sustain once-achieved short-term changes. In this way, we aim to help them explore the function of the maladaptive coping mechanisms, how they developed, and under what conditions and why they are maintained. The social worker listens in a curious, respectful, and inquisitive way and through this process the client feels accepted and thereby gains increased understanding of his or her maladaptive coping methods’ functions and can assume more responsi- bility for his or her actions. The social worker then can use a range of methods, such as psycho-education, slowly introducing and reinforcing the use of flexible and adaptive methods, and/or interpretation of the defense to help the client more effectively manage stress.

Identifying organizing patterns in intrapsychic and interpersonal realms Analytically oriented therapists are interested in recurrent themes in the client’s thinking, feeling, behavior, and interpersonal relations that the client may or may not be aware of, but that she or he typically finds difficult to stop (Shedler, 2010). We emphasize that it does not matter where they start or what they talk about in therapy since clients’ organizing patterns will surface anywhere and everywhere in treatment, as long as the client is encouraged to say what comes to mind, and the interview is not overly structured. Also, because of the very nature of one’s recur- rent organizing themes in life, working on one aspect of life stressors in therapy makes it possible to penetrate seemingly solid life patterns. The social worker thus listens for these themes in interviews and may help the client bit by bit to recognize and understand them and develop an alternative pattern. Even if the organizing pattern is not directly interpreted, this information may help the social worker

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respond more empathically, and can create therapeutic space for clients to experi- ence alternative organizing patterns in therapy.

Focus on relationships in a client’s life and therapy The social worker listens carefully for the quantity and quality of relationships. Relationships are viewed as essential for survival and adaptation, and they can sat- isfy needs and desires. The capacity for secure attachment, empathy, trust, and rec- iprocity are considered vital components for healthy relatedness (Flanagan, 2011; Tosone, 2013). Thus, working from the analytic attitude, the social worker attempts to understand and support the client’s capacity for mature and satisfying relationships, and helps people attain more freedom from dysfunctional or unsatis- fying bonds. We encourage the student to get to know the person: exploration or curiosity about important relationships helps us to understand their personality style and important aspects of their lives and functioning.

Furthermore, a therapist is curious about how the client’s interpersonal patterns in life play out and are re-enacted in the therapy process (Goldstein et al., 2009). The therapist seeks to understand and work with the transference—that is, how repetitive themes, patterns, wishes, and feelings from the past affect present diffi- culties and/or one’s relational experiences affect other interpersonal experiences in the present. The unique characteristics of the therapist and client also inevitably have an impact on the quality of the transference and the therapeutic relationship. We stress that transference takes place in all relationships and is a ubiquitous, nor- mal part of life. The unique feature of a psychodynamic approach is that the thera- pist understands and/or analyzes it, rather than responding to it in conventional ways. We ask students for or provide demonstrations of transference, explaining that clients’ excessive, intense, unusual, or tenacious responses to social workers may be signs of transference (Greenson, 1992).

We also emphasize that what the client thinks and feels toward the therapist is a vital source of data that often provides insight into relational patterns in the client’s life (Ornstein & Ganzer, 2005). The therapist may help the client recognize dys- functional patterns, including discussion of how these patterns get played out in the therapeutic relationship. However, even if the social worker chooses not to explicitly discuss the transference with the client, she or he uses this information to understand the client’s relational patterns and avoid untoward enactments; it may also affect how the social worker intervenes. The therapeutic relationship is viewed as a major mediator of change, whether or not it is explicitly discussed.

The therapist’s countertransference—that is, the therapist’s total reaction to the client (including all conscious and unconscious feelings, attitudes, and fantasies)— is considered a vital source of data that can help us to understand the client and/or be an impediment to effective treatment (Usher, 2013). The social worker attempts to distinguish the extent to which his or her response reflects client feeling states, the pull to enact the client’s relationship patterns, and/or whether it primarily reflects his or her own childhood experience, personality, and culture. This process

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of critical self-reflection may assist the therapist to recognize his or her own blind spots, distortions, or problematic interactions with the client and change or alter his or her interventions (if indicated).

Focus on developmental history that affects the present Although the extent to which the social worker utilizes the client’s past or child- hood will vary, the analytically oriented social worker recognizes the influence of the past on the present and thus is curious about the client’s life history (Shedler, 2010). While childhood plays a critical role in development of the personality, development is viewed as a lifelong progressive process, unfolding innately over time. Disruptions in development can result in inflexible rigid templates of self and others and/or a developmental arrest (Beebe et al., 2012). While present expe- rience is never an exact veridical replication of the past, “ghosts” from the past influence present-day perceptions and behavior. Exploring the past and the ability to make connections between past and present may allow clients to develop a new understanding of old narratives and to not repeat old patterns.

Exploring clients’ developmental history is crucial in identifying and fostering their strengths, as well as honoring their dignity, despite conflicts and suffering. Many clients who suffer from mental health challenges note that they feel like they became a different person after the onset of mental illness, as if their personality characteristics discontinue far from who they were (Selzer & Schwartz, 1994). The very idea of the “discontinuity of personality” significantly injures their self-per- ception and dignity to the point that they often become almost amnesic to their own strengths. Listening carefully and exploring clients’ past developmental his- tory would provide in-depth information to identify and highlight their strengths and convey an important belief about the continuity of their personality.

Focus on biological and sociocultural impacts The analytically oriented social worker pays attention to how clients feel about and experience their bodies, including their ability to satisfy biological needs, manage impulses/passions (sexual and aggressive), and experience pleasure (Berzoff, 2011). Conflict or disturbances in any of these areas can profoundly influence life satisfac- tion, and may significantly affect many sectors of the client’s life (Brenner, 2006).

The analytically oriented social worker is interested in the biological makeup of the person, and considers how neuro-biological and psychosocial factors and their interaction affect client functioning. For example, life events (e.g., trauma) can modify brain structure and function, while brain structure and function, through genetics, and temperament have an impact on personality and behavior (Basham, 2011; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Thus, working from an analytic perspective, the social worker considers the possibility that a range of different interventions that target both biological and psychosocial issues/ symptoms may be effective. This stance is supported by a growing body of evi- dence for the efficacy of combined pharmacotherapy and psychosocial treatments,

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particularly for clients who suffer from complex mental health problems and/or psychosocial issues, and/or patients who have had a poor response to single treat- ments (Busch & Sandberg, 2007; Thase, 2003).

Analytically oriented social workers are also interested in how the outside gets inside clients (Berzoff et al., 2011). Deprived geographic environments, prejudice, discrimination, racism, poverty, political estrangement, refugee experiences, migrant situations, and other marginalized sociocultural experiences influence how clients see themselves and others (Berzoff, 2011, 2012). Instead of doing harm by letting clients internalize various discriminatory and structural inequities, pro- viding a therapeutic space that invites clients to reflect on these factors and their impact on the client’s life is of paramount importance. The psychodynamic per- spective also sheds light on the pathogenesis of prejudice and therefore may be helpful for working with clients who espouse prejudiced views (Parens, 2012; Rasmussen, 2013).

Overall, the psychodynamic perspective aligns with social work values and ethics in that the social worker is interested in much more than just symptom management or the client’s diagnosis. While the goals of treatment will vary depending on client interests and motivation, agency mandates, resources, and cli- nician training, the core belief that “understanding helps” and the value in the therapeutic relationship are consistent with social work’s traditional emphasis on the whole person and their environment and the attempt to promote optimal func- tioning and help people live freer and more fulfilling lives.

Teaching vignettes

We have found that one of the best ways for students to develop a greater apprecia- tion for the psychodynamic attitude is to ask them to apply it to their cases, whether in formal or informal class presentations or papers. Many of the compo- nents of the analytic attitude emerge, separately or together, in these discussions. We found that case presentations help students grapple with core concepts and demonstrate how the psychoanalytic attitude can help with challenging clients and situations. The first two vignettes occurred in an advanced theory course on mental health practice at the master’s level. Students were invited to present a challenging case or situation where the application of a psychoanalytic attitude might help. The third vignette occurred in an undergraduate clinical theory course in which class/instructor dynamics were used to illustrate the psychoanalytic attitude.

Vignette 1

A 26-year-old student presented a case that she said had greatly upset her. She had been working in a senior citizens’ home with an elderly depressed man who had recently lost his wife. All of his other relatives and friends were dead, he had no children, and he seemed to be quite withdrawn. His isolation and possible depres- sion precipitated nursing staff to refer him to social work. She thought the sessions

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were going well because he seemed to look forward to seeing her and spoke openly about how much he missed his wife, family, and friends. What disturbed the stu- dent most was the client’s behavior in his final session. When saying goodbye, and thanking her, he quickly kissed her on the lips before she could do anything. The student said she felt “shocked and disgusted” and wanted to understand what had happened.

The instructor (the first author) commended the student for her inquisitiveness and curiosity (as indicated by her interest in understanding the incident and its meaning), and began by asking the class to address this case using the psychody- namic attitude. The class began by discussing the transference and countertransfer- ence. A student suggested that perhaps the client was looking for a replacement or substitute for his wife. A number of students agreed, but said that they did not like to think about the possibility that this man had sexual feelings for the social worker. One student said, “It makes me think about my parents and their sex life. Ooh—who wants to think about that?” A number of students nodded, and laughed, a little awkwardly, and then spoke about how much easier it was to think about this man’s need for “support,” rather than thinking of him as having sexual feelings, especially for his social worker, who was so much younger than he was. This led to a discussion of societal attitudes toward the elderly and sexuality, and students discussed examples of nursing staff’s and families of residents’ discomfort with any overt or covert displays of sexuality among the residents. The instructor highlighted its resonance in us as countertransference: how the outside—implicit social values and norms (e.g., the elderly as being asexual)—gets inside, while denying and omitting the very fact that he was a biologically and psychologically fully functioning human being with sexual and intimacy desires.

Then one student asked what the student did after the kiss. She answered that she was stunned. She walked away, and was relieved that she would not see him again because the experience occurred on her last day at the seniors’ residence. Another student commented how it is often difficult to think clearly, or respond appropriately, if one is in shock or disgusted. The instructor then asked the class what they would suggest she do, if she were to meet with him again. The students were at a loss about how to intervene and they asked the instructor what he would recommend. The instructor offered a similar example in which a client unexpect- edly tightly hugged a very traditional analyst when the therapy was ending. When she finished hugging him, he said “Let’s talk about it,” and they then discussed why she chose to put her gratitude into action rather than words. The class thought that this was a good idea but a number of students commented on how they identi- fied with the presenter’s wish to avoid the entire situation. This led to a discussion of emotion regulation and how we (clients and social workers) all use a range of defenses to cope with challenging situations. In this case, we discussed the defense of avoidance, sometimes used by workers and/or clients when faced with some- thing uncomfortable. We then returned to discussing the student’s perception of what happened. Instead of solely focusing on the client, taking moments for the

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class to reflect on their own activated emotional reactions appeared to assist them to better understand defense mechanisms and how emotion colors our experience.

The student said that when she thought about it now, she noted that the client had frequently spoken about how much he missed his wife and his loneliness, and although she addressed what he missed emotionally, they did not ever discuss any aspect of his sexual relationship with his wife, or his current sexual life. She also said that he used to sometimes make jokes about their going to lunch, or he would ask her about what she did on weekends, but she always dismissed these comments as chit-chat. Upon reflecting further, she said she always felt a little uncomfortable about these inquiries, but she did not give it any further thought. She said she now wondered whether the death of his wife made him feel insecure about his masculinity and whether the kiss might have been his attempt to restore his feelings of potency. A class member asked about his childhood, and his self- esteem/relationship history, but the student said she did not know very much about his early life because he mostly talked about his recent experiences. Another student also wondered about how the man dealt with boundaries in the long-term care facility. The students agreed that assessing his organizing patterns of relation- ships (in the past and the present) and his developmental history would have pro- vided crucial information that would have deepened our understanding of the client. Inviting the students to pause and consider what happened by using the analytic attitudes certainly stimulated their curiosity about the person and opened their eyes to look at him more deeply, and at multiple levels, which is the very point of the analytic approach in clinical social work practice.

Vignette 2

The student was frustrated by her client’s repeated episodes of self-cutting. She said she had used a feminist, cognitive-behavioral, and strengths-oriented approach and that things had started off very well. They quickly formed a close bond and the client seemed eager to work on her problems. Together they identified triggers for her self-cutting and developed alternative healthier strategies to cope when the client felt the urge to cut. Although the client stopped cutting for a month, she gradually resumed the behavior, despite her motivation to stop. She said “it” made her feel guilty and “out of control.” The student said they had discussed triggers, and she emphasized the client’s strengths, including her motivation to change and her intelligence, but nothing seemed to help. The student was at a loss about how to understand the client’s cutting or help her.

With the instructor’s prompt to consider the psychoanalytic attitude, the class tried to understand why the client cut. A student said that we had heard about her motivation to stop, but we had not heard anything about why she cuts. The instructor commented that a symptom often served multiple functions—it had advantages and disadvantages and perhaps we needed to hear more about the advantages. One student speculated that perhaps it made her feel better afterward,

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which stimulated the class to develop a hypothesis about her symptom formation. Another student then said she wanted to know more about the client and her life: was there anything troubling her now or in the past (i.e., her developmental histo- ry)? The student explained that her client functioned well in most areas of her life despite having endured her parents’ tumultuous relationship, which ended in divorce when she was seven, with ongoing disputes around custody and access. The student commented that her client said she used to cry a lot when she was lit- tle, but her parents told her, “You have to be strong,” and she always lived by that motto. She did well in school, developed friendships, and had hobbies. This explo- ration helped the class to see how her previous developmental history was affecting her current organizing patterns (e.g., seemingly well-functioning and almost prob- lem-free) using coping skills/defenses (e.g., repressing and isolating emotions).

This exploration further opened up the students’ curiosity about the client’s emotional life. The class asked the student how the client managed her anger, and the student said her client rarely discussed anger. It became apparent to the class that the client used denial and repression to fend off any negative and aggressive emotions in life, which emerged in her self-harming behaviors. The symptoms were signals of her compromised capacity for regulating emotions.

To guide the class to see how this pattern of defenses works in therapy, the instructor asked the student about her relationship with the client and she said that it was very pleasant—the student provided the client with a lot of support and focused on her ability to move forward in life and “look at the bright side.” Another student questioned whether perhaps together they avoided negative feel- ings—the student said yes, and then said she would like to go back to the client and ask her more about what she experiences before and after she cuts. The instructor explicitly noted that the student should discuss this possible approach with her supervisor in her practicum since this discussion was not meant to over- ride their work.

The student came back next class, reporting that she had asked the client to tell her more about whether she experiences any positive feelings after she cuts herself, and the client said that she felt “better—relieved. Like I got rid of something—like I got it all out of me. I watch myself bleed and then I don’t feel so bad anymore. I feel more alive, not so numb, but it does not last long because then I start to feel guilty that I did it.” The student said that she learned a lot in this session. She felt that her former focus on the client’s motivation to stop cutting and on her strengths had perhaps prevented the client from discussing the benefits of her symptoms or the depth of her pain. The instructor invited the class to reflect on this moment, in the here-and-now, to augment their understanding of counter- transference. A number of classmates then commented on how hard it was to tol- erate hearing about very painful feelings, and/or thinking about harmful symptoms as something that had positive meanings to the client. The instructor commented on the defense of projective identification—the client’s unwanted knowledge and feeling that the cutting worked for her were unconsciously

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disavowed in her mind and projected onto the clinician/student, which the clini- cian/student then identified with and acted on by focusing only on the client’s motivation to change.

Then the class opened up with discussion around how to help clients effectively manage emotions (especially painful ones) instead of denying them and rescuing the client. The class further reflected on the current pervasive professional culture in which many clinicians experienced pressure to quickly achieve a measurable outcome instead of deeply engaging with the client and searching for meanings in the client’s symptoms. Some students further commented on how women in cer- tain cultures often have difficulty managing anger because of cultural taboos that may prohibit women from holding and expressing some negative emotions. This discussion opened up to consider various clients who might have different norms for expressing anger, which then enabled the class to position individual patterns of defenses within their cultural contexts.

We then further reflected on the client’s pleasant demeanor, which could have been her offering of her core interpersonal conflicts for the clinician. To make sense of this offering as the organizing pattern of her relationships, the instructor encouraged the class to consider how her pleasantness could be an enactment of transference and countertransference. The client’s parents did not know about her severe self-harming behaviors until she attended an outpatient counseling service because she had presented herself as so well-put-together. Also, it seemed that her parents were not attuned to listening to her struggles. Perhaps this interpersonal dynamic was re-enacted in the counseling sessions and the student was behaving as if she was taking her parents’ role in the interaction with her (e.g., focusing on strengths and bright sides). In the end, considering the key components of the ana- lytic attitude deepened the students’ understanding of the client and further assisted them to reflect on their own makeup as clinicians.

Vignette 3

When relevant, we use classroom processes to demonstrate psychodynamic princi- ples. This example comes from teaching a social work clinical theory class to undergraduate students. In one instance, the class seemed very quiet, and unusu- ally withdrawn, whereas they were typically engaged and very vocal. All of the instructor’s attempts to engage the students failed. When the instructor com- mented on how quiet they were, nobody responded. The instructor was puzzled by their reaction until he recalled that he had scheduled a test for the next class. He then remembered that the class had not done well on the previous test, and they’d had relatively little discussion about it. When he finally inquired about whether they were worried about the upcoming test, they let out a huge sigh of relief and told him more about how the previous test had affected their sense of competence in knowing the course materials in particular, and their confidence in general as

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knowers/students. They then talked about how anxiety can have an impact on the ability to learn or participate actively.

The instructor encouraged them to take a moment to reflect on the here-and- now moment, using components of the analytic attitude. The students began to talk about the defense of withdrawal and/or withholding. The class members said that they were not consciously withholding, but that they were upset with the instructor and their silence might have been their way of communicating while acknowledging their fear of bringing it up with him. They spent a great deal of time talking about their feelings about the last test and upcoming test, which they had pushed away until now. The instructor joined with them in this moment of unearthing emotions and disclosed that he forgot to bring up this topic in class. He said that he had been concerned that the previous test might have been unfair but he put it out of his mind. It only came back to him when he finally became aware of the class’s reaction. They then talked about how they repressed their anger toward the instructor. The instructor noted how both the students and he colluded unconsciously to act out their repressed emotions in the beginning of the class. This was a very powerful teaching moment. The students experienced their own enactment of their unconscious conflicts in action, truly using the classroom as an experiential laboratory. They also appreciated the instructor’s openness to acknowledging his participation in the enactment, which modeled for the students how to humbly own their part in an enactment when working with their clients.

In sum, all three teaching vignettes illustrate how the ability to utilize the psy- choanalytic attitude can better equip students (a) to work with clients who have highly complex and multiple problems and (b) to be mindful of their own contri- bution to complicated transference/countertransference dynamics, enactments, and treatment impasses or ruptures.

Discussion

There is a growing body of empirical evidence that identifies the need to incorpo- rate psychoanalytic understanding into clinical social work practice (Abbass, Hancock, Henderson, & Kisely, 2006; Brandell & Ringel, 2004; Busch & Sandberg, 2013; Drisko, 2011; Drisko & Simmons, 2012; Leichsenring & Rabung, 2008; Mishna et al., 2013). Using the classroom vignettes as pedagogical models, we pro- pose that a psychoanalytic perspective is an important component of a social work- er’s training and therapeutic armamentarium.

We find that students are most open to the psychoanalytic attitude if they are clear about the reasons for learning about it and its components, if the materials are accessible to them, and if they can see and experience how they can employ such material in their own practice. By focusing on the psychoanalytic attitude applied to their cases and the here-and-now classroom moments, they are less likely to be overwhelmed by complex, seemingly esoteric analytic concepts or what may appear to be irrelevant theoretical debates. This approach to teaching the

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psychoanalytic attitude is consistent with the core principles of adult learning the- ory, which suggest that adult learners are most likely to be engaged if the material is relevant to their everyday work or professional lives, and if they are actively involved in their learning (Cabaniss, 2011; Knowles, Holton, & Swanson, 2005).

The instructors are likely to be more effective if they open up space to invite the students’ inquisitiveness and curiosity, including their criticisms about psychody- namic approaches. For example, students commonly question whether a psycho- analytic attitude can result in “blaming the victim.” That is, if people can bring about their own misfortunes through repeating destructive unconscious patterns, are we ignoring the influence of social factors and factors that are beyond the cli- ent’s control? We emphasize that the focus on the unconscious does not negate the influence of societal factors as well as biological impacts and chances in life, as indicated by one of the key components of the analytic attitude. We explain our belief that providing clients with awareness of forces that are pre-consciously or unconsciously influencing may free them up to regain control over their life and make better choices. This idea is consistent with the hallmark social work emphasis on self-determination and empowerment.

We also confront the idea that psychoanalytic theory is relevant for only the “worried well.” For example, we stress how the idea that people who are disadvan- taged or oppressed are not interested in or cannot benefit from insight is a form of prejudice that discriminates against most of our clientele. We illustrate how psy- chodynamic theory has been effectively utilized with such diverse populations as the homeless, survivors of abuse and trauma, clients with severe mental illness, and structurally disadvantaged/oppressed populations (Berzoff, 2012; Edward & Sanville, 1996; Loewenthal, 2015), and emphasize its applicability and efficacy for both short- and longer-term treatments (Abbass et al., 2006; Leichsenring & Rabung, 2008). Often the goals are restorative and supportive, and short-term models aim at selective personality change, and/or focused work on core issues (Goldstein & Noonan, 1999; Harvard Mental Health Letter, 2010).

One of the advantages of focusing on the psychoanalytic attitude is that its aspects can be introduced in a wide range of courses in clinical curriculum (Lee, 2013; Mintz, 2013). While it is preferable to have the luxury of having at least one course focused on psychodynamic practice, these ideas can be introduced in virtu- ally any clinically oriented course. In fact, psychodynamic ideas are often discussed in clinical courses without giving credit to their psychoanalytic origin or meaning. A discussion of the psychoanalytic basis for the ideas may enhance students’ ability to utilize and understand analytic concepts (Brandell, 2013).

Our goals are modest. If teaching the psychoanalytic attitude has enhanced stu- dents’ ability to more deeply understand challenging clients’ seemingly irrational behavior or symptoms; increased their appreciation for the value of focusing on client affect, defenses, and relational factors in clinical work; and/or helped them manage difficult transference and countertransference, we will have met our objec- tives. There is some evidence that therapists who are trained in the use of

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psychodynamic concepts have greater empathic capacity, enhanced reflective func- tioning, and increased job satisfaction (Bettmann, 2006; Hartmann et al., 2015; Mintz, 2013; Treloar, 2009). If we have inspired some students to pursue further learning or training in psychodynamics and/or increased their curiosity about their own and others’ mental life, that is another benefit.

Notes 1. Students at a few selected major U.S. social work schools (such as Smith College School for

Social Work or New York University) acquire sound knowledge of psychodynamic practice because these schools continue to teach psychodynamic theory as a foundational theory in their curriculum. However, this excellent exposure to psychodynamic knowledge is not typical for the majority of contemporary social work students.

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