Inside Out and Outside In: Psychodynamic Clinical Theory and Practice in Contemporary Multicultural Contexts (Book Review)

Author:  Berzoff, Joan, Laura Melano Flanagan, and Patricia Hertz
Publisher: Northvale, NJ: Jason Aronson, 2002
Reviewed By: Mary Ellen Griffin, Summer 2005, pp. 60-62

Here is excellent book for people who want to learn more about how to conduct psychodynamic psychotherapy with clients of diverse racial or cultural backgrounds. Given the demographic trend toward increasing cultural diversity in the United States, that should include most of us! Inside Out and Outside In: Psychodynamic Clinical Theory and Practice in Contemporary Multicultural Contexts, by Joan Berzoff and her colleagues from Smith School of Social Work. But why focus on multiculturalism within psychodynamic treatment? Isn’t the psychodynamic therapist always reaching across a boundary of human particularity and difference, in attempting to appreciate the other person’s subjective experience, from within the constraints of his or her own subjective experience? As Berzoff and colleagues say, it’s not enough to understand a person from “the inside out” by developing a psychodynamic formulation. We must also learn to understand them from “the outside in,” appreciating how sociocultural as well as biological factors contribute to their experience of self and others. This book provides theoretical constructs and clinical examples to show us how we can become more culturally responsive therapists, and thereby increase our empathy for, and thus our clinical effectiveness with clients from whom we are culturally or racially different.

Inside Out and Outside In: Psychodynamic Clinical Theory and Practice in Contemporary Multicultural Contexts was released in hard cover in 1996. This review reflects the 2002 release of the soft cover edition. “Inside out and outside in” is a helpful metaphor that summarizes the authors’ biopsychosocial approach. The authors rework Freud’s statement that anatomy is destiny: ‘“everything is destiny”: every factor—biological, psychological, and social—makes its impact’ (p. 2). They show how this is so in two important ways. The first and largest part of the book is an overview of psychodynamic theoretical models. The second section integrates psychodynamic formulations of major psychopathological diagnostic categories with biological and sociocultural considerations.

The theoretical overview is thorough, yet succinct. It includes chapters on drive theory, structural theory, ego psychology, Erikson’s psychosocial developmental theory, object relations theory, self psychology, and Sullivan’s interpersonal theory and its influence on modern relational theories. One of the strengths of this particular overview is that it situates each theory in the social and cultural matrix that gave rise to the theory. This permits readers to appreciate the insights offered by each theory, but also some of their particular blind spots or shortcomings related to time and place. The authors promote a “critical thinking” approach to psychological theories, noting, “every theory is a social construction” (p. 10).

With sensitive case vignettes, the theoretical chapters demonstrate the value of each theory in helping the clinician to understand what the patient is up against. However, chapters vary in the extent to which they integrate cultural issues into case vignettes. Chapters 2 and 3, about Freud’s drive and structural theories, don’t provide enough information about how each theory does and does not lend itself to use in cross-cultural psychotherapy. It is not until Chapter 4, “Ego Psychology,” when Gerald Shamess finally offers concrete examples of taking culture into account when applying the theory. He points out that assessing clients’ ego functioning is highly dependent on cultural norms of what is socially appropriate. For example, when assessing a client’s ability to modulate affect, one must be aware that the individual is expected to monitor and express affect according to “established social norms” (p. 75). Widely varying cultural norms regarding emotional expressiveness during grief is a case in point.

The authors comment that colleagues “more interested in teaching about external realities and oppression would tell us that what we said about race, class, gender, and culture was always ‘just tacked on at the end’” (p. 9). While they recognize this as a critique of Inside Out and Outside In, they nevertheless hope that their sociocultural emphasis does indeed add something traditionally lacking in psychodynamic writing. The theory section ends with separate chapters “tacked on” that address psychoanalytic perspectives on race and racism, and the psychology of women, respectively. The advantage of having these chapters separate may be that these issues can be addressed in a focused, in-depth way. For example, in her chapter on race and culture, Lourdes Mattai highlights the ways that each of the targeted psychodynamic theories both help and hinder understanding the interplay of race, culture and individual psychology. In one such analysis, she explains how self psychology can elucidate the impact of living in a racist society. Based on race, members of some groups have much greater “opportunities for self-enhancing self-object experience...(Clinicians) must ask how the larger society contributes to or interferes with opportunities for growth-producing mirroring or idealization” (Donner, quoted on p. 233).

The latter part of the book describes psychodynamic formulations of major types of psychopathology, integrating dynamic formulations with biological and social contributions to clinical presentations. Categories of psychopathology are discussed in separate chapters on psychoses and schizophrenia, borderline and narcissistic personality disorders, other personality disorders, biopsychosocial aspects of depression, and anxiety.

Inside Out and Outside In is strongest in helping the reader learn to conceptualize psychotherapy cases psychodynamically, integrating social, cultural, and biological factors into the formulation. If these are your learning goals, this book is an excellent choice

Mary Ellen Griffin is in private practice in Sylva, North Carolina, and teaches part-time at Western Carolina University

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