Sharon Berlin has spent her career showing how social workers can stretch and adapt psychotherapy to a patient's needs
It's a long way from the Upper West Side to the poorest sections of Chicago's South Side. That's true for anybody, no less so for a practicing therapist. But while the common image of psychotherapy might be a weekly appointment on a nice leather couch in Manhattan, the reality is more likely to be a patient from a beleaguered background talking with a social worker about how to repair a life scarred by poverty or deprivation.
Filling the gap between psychoanalytic theory that suits a middle- class patient and that for a social worker's clients is at the heart of the work of Sharon Berlin, the Helen Ross Professor at the School for Social Service Administration. The synthesis of a 40-plus-year career is captured in her 2002 book, Clinical Social Work Practice: A Cognitive-Integrative Perspective, which lays out her take on how current life conditions and memory impact our view of the world—and what to do when they collide.
Cognitive therapy is an increasingly popular method of helping patients from all walks of life deal with psychiatric troubles. In her cognitive-integrative perspective, Berlin deftly synthesizes a wide range of therapeutic techniques and theories into a model explicitly for social workers, then adds her own twist: When people whose life circumstances are terrifically difficult show up at the mental health center door, it is quite probable that their problems are not all in their heads. A part of helping such clients psychologically involves helping them get on their feet.
"I find the cognitive-integrative approach to be extremely useful. The framework allows social workers to recognize the complexity of the clients we work with, while also being practical and flexible enough to be applied to the diverse work environments social workers are involved in," says Lynette DePeter, A.M. '05, a former student of Berlin's who uses different pieces of the approach in her role as a school social worker and in work with people who have experienced the loss of a loved one through suicide.
In many ways, Berlin's personality infuses the cognitive-integrative approach. Her ability to hold and incorporate many different complex theories, her compassion for those who have been dealt a hard hand, her calm demeanor are all reflected in the theory. "Sharon is a very deep thinker, but she also is deeply committed to what happens in the field. She has a sense of balance in terms of thinking very constructively and creatively about a problem without being co-opted or distracted by irrelevant issues or insignificant considerations," says Jeanne Marsh, the dean of SSA and co-author with Berlin of a 1993 book, Informing Practice Decisions.
"Sharon has a certain kind of grace and passion and moral energy," says Bill Borden, a senior lecturer at SSA who has been a student and colleague of Berlin and now is planning a day-long event for academic experts to gather to discuss and expand upon her work. The conference, entitled "The Play and Place of Theory in Social Work Practice," will be a swan song for Berlin, who is retiring in June after a distinguished career that has included winning SSA's teaching excellence award in 1997 and the 2002 Richard Lodge Prize for contributions to Social Work Theory. "She's provided a crucial reorientation of cognitive theory for social workers," Borden says. "I think that her work has really yet to be fully appreciated."
Berlin leans forward a bit on her feet in front of class, her hands knotted around a paper cup of coffee as she gently asks for input from the 20 or so students in her course, "A Cognitive Perspective for Social Work Clinical Practice." With her all-black outfit, stylish glasses, and an easy-going manner, she's reminiscent of a favorite, hip aunt, the one who always listens to your troubles when she visits. To the side, a PowerPoint projection of a psychiatric org chart looms, illustrating the complexity of how she wants her students to see a client's psyche: boxes and arrows delineating input patterns, compensatory themes, internal cues.
The class starts suggesting how to fill the boxes with details from the last reading, a case study of a Ms. M, a part-time nurse's aide who presents a confounding list of troubles. She was abandoned by her mother, then abused by her stepmother. Married twice to abusive husbands the second marriage ending when her husband left her for her sister—she is barely in contact with her adult children. She has type 1 diabetes, and recent renal failure caused her to lose her job. It is, quite literally, depressing: Ms. M had come to seek treatment for ongoing depression.
Berlin starts the discussion with Ms. M's history because the cognitive school of therapy is built on the idea that we use our memory patterns, or cognitive schemas, to interpret events in the present. Usually this reliance on organized memories works well, but when someone becomes unable to recognize when different circumstances require different thinking, they can become stuck in old and unhelpful ways of understanding. And with that can come feelings of depression, fear, or rage. "Cognitive theory says that people are meaning makers. Whatever a person thinks a thing means, that's what it is," Berlin explains. "But the idea behind cognitive therapy is to help people consider how to enlarge their realities."
With a current emphasis in psychology on evidence-based practice, the cognitive model has become increasingly popular over the last 20 years. The therapy lends itself to outcome measurement, where it performs well. Insurance firms like it; mental health centers like it. "It's really one of the ascendant areas of empirically based medicine," says Mark Reinecke, a professor and the chief of the division of psychology at the Feinberg School of Medicine at Northwestern University. "For example, the British government has now mandated its use in their healthcare system."
Berlin has been impressed with cognitive concepts for years. Much of the cognitive-integrative perspective is connecting the standard approach with a wide variety of other therapeutic techniques, including neuroscience, personality theory, social psychology, narrative studies, relational psychoanalysis, and most importantly, the emphasis on real-life circumstances that comes from social work. Colleagues consider it a bravura performance, a melding of many different ideas into a comprehensive and comprehensible whole.
In Berlin's eyes, there is no one way to approach all clients; the best route to wellness depends on how much of the client's difficulty stems from negative information that comes from life circumstances and how much comes from relying too heavily on out-dated memory patterns. "Sometimes the information coming to the patient overwhelms their level of skills and knowhow, so the clinician can borrow ideas from behavioral approaches to help the client gain new skills and increased competency. Or the negative information coming in might have a lot to do with family conflict. In those times we sometimes borrow tools from the family therapy domain," she says.
"Sharon is very suspicious of mechanistic solutions that don't look at the complexity and the context of the clients' lives," says Jim Clark, Ph.D. '95, the associate dean for research at the College of Social Work at the University of Kentucky and a former student of Berlin's. "It's really hard work, but her approach as a clinician is that, yes, it's hard, but you have to do it to be effective."
The big idea woven through Clinical Social Work Practice: A Cognitive-Integrative Perspective is a re-evaluation of the role of social worker in therapy. Berlin argues that—in certain situations— to help a patient change her perspective on life, a social worker needs to help that patient to change her life. "Cognitive theory says that people's sense of helplessness or an overriding sense of sadness are a function of negatively biased understanding of their prospects in the world," Berlin says. "I think that notion is accurate to a degree, but it suggests that distorted thoughts are behind people's feelings. That seems overly simplistic to me. It puts all the onus on the person. From my earliest social work training, I learned that part of the reason people feel so demoralized about their lives is because their life situation leaves them with so few options."
If it is true that people change their minds when they repeatedly encounter events or find personal capacities that are different from what they already know, then a social worker needs to be sure that there are actually discrepancies to be noticed. "We need to create them or work with clients to create them, and then focus the client on making something meaningful from them," Berlin says. "That could mean helping the client get better housing or assisting her in cleaning up and organizing her current place. It could mean cutting through bureaucratic red tape so the client can get the services he needs; or it could mean sticking with the client no matter how many times she forgets or doesn't show up."
"The cognitive behavior theory is built on the idea that people construct their own reality. What Sharon has brought to the field is a counterpoint: The context in which they're living can contribute to their psychopathology, and we should understand the cognition in that context. That's a valuable contribution. It's useful, and I happen to agree with it. I also think it fits well with the position a social worker is in. You bring what works to people," Reinecke says.
Berlin began her social work career on the child care staff at the Children Home Society in Seattle, Wash., after earning her bachelor of arts at the College of Idaho in the state where she was born and raised. Her Master's of Social Work and Ph.D. in Social Welfare are from the University of Washington in Seattle. To this day, her tidy office gives away her love of the Pacific Northwest with a few postcards and a Native American totem pole image in a 1992 Distinguished Alumni Award from her alma mater. When she retires this year, she will return back to a home she owns on Whidbey Island in Washington State.
Berlin first joined the faculty at SSA as a visiting associate professor in 1983. Over the years she has helped provide the spark that any academic institution requires to thrive. She served for a time as the School's associate dean for academic affairs. She directed a National Institute for Mental Health program to train Ph.D. students in research in the field. After student requests, she introduced a class into the curriculum that examines the intersection of human rights and social work. All along she has inspired students with her passion for the work and her comfortable yet challenging classes.
"Her courses are one of the best things I encountered at SSA. Sharon is incredibly relaxed and open to what people have to say. She believes that this is hard and valuable work and is open to discussions about how to go about it," says DePeter. "She would often focus on 'What does work?' It is so refreshing to hear her say that learning is open to change; it's a process."
When she arrived at the School, Berlin had already written a few working papers that sketched out her ideas about the role of the environment in psychotherapy, and with her curious nature, she continues to explore its ramifications. "Since I wrote the book, in some ways my understanding has become more refined," she says. For example, in a 2005 paper published in Social Service Review, she wrote at length about the history and value in social work direct practice of the concept of acceptance, the balance of compassion for a client with an appreciation for his or her autonomy.
The paper also touches on another of Berlin's areas of interest: mindful meditation as a therapeutic tool. It's a concept that is grounded in Buddhist philosophy and stems from Marsha Linehan's work to help patients with borderline personality disorders. "Some of the newer work in the field suggests that instead of fighting to change your mental state and wrestle negative thoughts away, you should just allow them—notice them, accept them, and decenter from the experience," Berlin says.
These are concepts that a practitioner can use to help a client in the cognitive-integrative approach, and they certainly match well with Berlin's demeanor. While she says she doesn't regularly practice meditation herself, she has taken a trip to Tibet last summer, as part of a University of Chicago, Rockefeller Chapel program available for students, staff, and faculty and has read extensively on Eastern meditation. "I try to use the acceptance and decentering technique in my own life at times," she says. "If something seems to work, why not, right?"
Despite the enthusiasm for the cognitive-integrative approach by many, sales of Clinical Social Work Practice: A Cognitive-Integrative Perspective have been relatively slow. Supporters say that the long-term impact of Berlin's thinking may come from her teaching, as her students use the technique in practice and teach it to a new generation of social workers.
Take, for example, Justin Heilenbach, A.M. '05, a program administrator and therapist at Dragonfly Transitions, a residential treatment center for young men with mental health and substance abuse issues in Kalmath Falls, Ore. Heilenbach says Berlin's courses and her approach have become infused into his work. "The idea of bringing in new information to the patient is huge, whether it's a new experience that he can have where he's more successful than in the past or insight into old memories where he can see himself in a different light," he says. "Linking that 'social worker' work with the work in therapy, having that concept be part of your global way of viewing things, that can make a real difference."
Heilenbach views Berlin as a mentor, even though since his graduation she has been two time zones away. "Sharon is very much on the ground and present whenever you talk with her," he says. "She sees clients' lives as important and valued. She's a true social worker that way. She completely embodies those values."