by Ruth Lijtmaer, Ph.D
Ivan is a Latino a handyman in his early fifties who came to see me because of a depression he has experienced for some time. He has been in therapy with me for two years and Spanish is the language of our sessions.
Early in the treatment he stated, “Doctora (Doctor), I was thinking about the last session and I realized something. When I see children I am afraid. I remembered a teacher in elementary school who used a cane to hit us if we did not understand something. I remember having difficulties with division and I was afraid of the teacher. The same thing happened with reading. But in both cases I was suddenly able to get it. I could do it. I wondered if my fear of the teacher is similar to my feelings about you? At times I am afraid that I will have nothing to say in the sessions, or that I will not understand what you tell me. I am concerned that you may be angry at me because of this. Other times I am afraid that you cannot see how hard I am working in my therapy”. He continued by also telling me that he had a dream about this. “I was very angry at my mother. I was telling her how angry I was. She did not want to hear me. This was the end of dream”. He then added, “I realized through the dream how selfish and self-centered my mother is. Injustice makes me angry as well as lack of recognition in my work”.
I asked him if there are times that he felt angry with me. He responds by saying, “Perhaps, a little, because of the fear I spoke about. But it is so little that it does not count”. I responded that as with the Math and reading, he gets it here too. He is aware of his feelings and our relationship.
In another session Ivan came with a dream and told me his observations about it. He said, “I was driving a car with a man next to me and we were going uphill. The car started to make noises and it became difficult to continue. Then I decided to put it in first gear and we were able to arrive at our destination”. His association to the dream was, “It is a hopeful dream. I know inside myself that I am going to feel better. We are driving together in this therapy, uphill on this difficult road, you and me. But we will arrive”.
An additional dream produced this association, “I had a long hair coming out of my mouth, like a string. I was pulling it out. Then it became thicker and still I was able to get it out completely”. He continues, “ But does the dream have to do with my trusting you, trusting your help, and being able to empty my guts here, with you? I believe this is a hopeful dream. I can conquer my depression. I feel that it is a miracle that I found you. I feel so good knowing that you are here to help me, and to listen to me. All these give me comfort”.
This summer, before my vacation Ivan said, “ I know that I can think of you. I feel connected in my head when you are not here”. And then he related the following dream: “My mother was in a car and it fell over a precipice. I tried to save her but I could not. I was concerned and I went down the hill where the car stopped. I see my mother safe and alive. I can see her smiling at me”. He then began to speak about his mixed feelings about me, and the up coming interruption in sessions. But, also added that at the same time, he knew that he could keep me safe and smiling in his head.
This brief recount of Ivan’s therapy, a man who only finished elementary school, is just a glimpse of his insight and emotional involvement in treatment.
I am unable to recount the number of times during and after his sessions in which I asked myself if he had read Freud, Winnicott or Relational Theories in another life? During many a session, he would describe the way he worked to fix something. When he was in doubt about how to repair it, he would go through a long problem solving process. I was amazed to hear about his reading and the inquisitiveness he used to solve some problematic work successfully. Ivan is always excited to tell me about his successes. Is it the “gleam in the mother’s eyes” that he is looking for, I wonder? Or is it the desire of wanting me to be proud of him the way his mother was not? I frequently wish he were not my patient so that he could come to my home and fix the leak in the roof, my AC that was not working, etc. As the reader can hear I always look forward to his coming to the sessions.
I have many patients in my practice who are college educated, some have advanced degrees and some are very bright, others are economically well off. But only Ivan, with his poor social class and his poor education brings to the session the richness of his internal life and his involvement in therapy.
From a theoretical viewpoint, in the context of the imprint of diverse cultures and acute social needs, it is not only the classical drive model that must be questioned but also the relational formulations on which the two-person psychologies are based. Some concepts of attachment theory and object relations may themselves be Western middle class ideas. Similarly, the symbolizing processes operate in parallel ways in treatment in different cultures and different social classes. Do the different communications styles that exist in diverse cultures and social classes indicate differences in the basic symbolizing function or should we instead say that they indicate different ways in which this function is carried out? Can the process of reconstruction of the emotional schema operate without the sharing of a central narrative in verbal form? Are there different forms of the symbolizing process involving language or operating without language for different patients and at different phases of treatment? To what extent is the symbolizing function dependent on the context of the therapeutic relationship? (Bucci, 2002)
Following this perspective: What happened with the ideas of early psychoanalysts that discuss the role of social forces in personality development? Danto (2005, in Borden, 2006) enlarges our appreciation of the social and political concerns of a divergent group of thinkers, including Ferenczi, Adler, Fenichel, Reich, Erikson, Horney, Fromm and others. Over the course of her survey, she describes the development of their theories, exploring their approaches to psychosocial intervention and placing their work in the context of the clinics and the political culture. She describes the therapeutic methods that emerged during 1918-1938, noting developments in conceptions of the psychoanalytic frame, crisis intervention, short-term psychotherapy, and child analysis. Psychoanalysis, as carried out in the free clinics, was practical, flexible, and relatively brief. To make more of my point, Adler is increasingly recognized as one of the first psychodynamic thinkers to view the person as a social being, and he emphasized the interdependence of human life in his conceptions of family, community and society. He stressed the role of cultural, political, and economic conditions in his understandings of vulnerability and problems in living, tracing the origins of neurosis to social conditions that undermined the individual’s sense of dignity and self-esteem; he focused particularly on poverty, sexism, and discrimination (Borden, 2006). Or Fromm, (1970, in De Millan, 1997) who in an explicit and systematic manner emphasized the social dimensions of human experience. His fundamental principle regarding clinical practice was that the analyst needs to be “awake”. This meant for Fromm not only being aware about oneself but also of the social system and its hidden requirements. This includes the capability of developing a critical view with respect to the existing social system and to the way in which it unconsciously modulates people’s experiences. Everyone, including the analyst and the patient, is thus seen as adapting to a particular social role, inadvertently wanting to fulfill the requirements of this social system in order to maintain its stability, although it is at the same time alienating. He emphasized that the analyst also needs to examine the conflicts implicit in his or her present existence with respect to the social world: In order to remain “awake” he/she needs to scrutinize both himself/herself and society
(De Millan, 1997).
This leads to the theme of social injustice. Social injustice and inequality have become pressing themes in critiques of psychotherapy and they represent a powerful source of unnecessary suffering that, in principle, can be modified and diminished. Considerations of justice and equity suggest that the poor and racially and ethnically marginalized in our society ought to have more access to what is available to the rich, especially in matters of health and mental health services (Borden, 2006). For this reason, a number of socially conscious psychoanalytic therapists have argued that psychoanalytic treatment ought to be made more widely available to these populations. However, poverty is usually thought of as being within the domains of economics and politics. Rendon, (1991, in Herron & Javier, 1996, p. 611) has noted that, with few exceptions psychoanalysts have avoided both. Mainstream psychoanalytic theory and practice has been prominently concerned with the middle class. Working with the poor and disenfranchised individuals whose economic, cultural, sexual orientation and linguistic backgrounds may be dramatically different from that of the analyst introduces questions like: How are we to determine the extent of accessibility to psychic content as the work of the repression or as a result of different class, ethnicity, cultural and linguistic codification processes? What about a patient whose style and manner of dress, outward appearance, skin color, or linguistic accent differ greatly from those of the analyst? Furthermore, most analysts are also middle class, how do they respond to the poor patient? Are they uncomfortable with or frightened by the thought of poverty and would rather not deal with any of its representatives? Some clinicians suggest that many of these individuals, referring to the economically poor, required a period of didactic approach in which they learned a new “conceptual matrix,” that is, a verbal reformulation of their symptoms and the importance of their personal dynamic history they were eventually able to appreciate the importance of insights on the modification of their conditions (Olarte and Lenz, 1984, in Javier 1990). However, Ivan did not need that. He was able to look inside himself, be reflective and was able to associate and verbalize his experiences.
The concept of privilege is embedded in this discussion. Baldwin, (1993, in Altman, 2004, p. 54) defined whiteness in terms of privilege. Privilege, economic and political, is associated with being white; privilege is sought to provide the illusory sense of safety and security that it provides. Baldwin saw the lives of white people as impoverished, positing that their unending search for an elusive sense of security precludes a life-enhancing embrace of risk, change, and transience. White people can seek to avoid experiences of deprivation, insecurity, and powerlessness (inevitable though these are) by acting so as to make nonwhite Americans even more un-free and underprivileged than they are, creating a sense of relative wellbeing by contrast. Exploitation, criminality, greed, and unrestrained sexual passion can be similarly disavowed by white people and projected onto minorities, who might then identify with that which has been projected. There is a great deal of overlap between the ways in which race, ethnicity and class are constructed in this culture; some of the specificity of racial constructions concerns the specific attributes projected, often having to do with the psychic resonances of particular physical characteristics such as darkness and lightness, facial features and hair texture, as well as the emphasis on freedom or enslavement deriving from the history of slavery in the United States (Altman, 2004)
In reviewing studies on the poor investigating time perspective, delay of gratification, achievement motivation, expectancy for internal versus external control, the role of concrete versus abstract incentive, and the self concept among the poor, these studies failed to provide proper controls for obvious confounding effects. These studies frequently have small and non representative samples, and tended to use measuring instruments of dubious validity. The extent to which the assumptions about the poor are maintained, despite their lack of scientific and logical support, it perpetuates the perception of the poor as being psychologically and intellectually inferior and deficient. In contrast, non-poor individuals are concurrently perceived as superior and more psychologically sophisticated. When these assumptions are incorporated into the treatment process of poor individuals, they may function as a convenient scapegoat for the projection of unacceptable, negative, and hostile impulses on the analyst’s part. It may reflect, in part, our own anxiety in being unable to appreciate fully the psychological characteristics associated with these individuals. Who are the poor in our midst? According to the latest Census (2011), the majority of the poor in many urban cities are Latinos, Blacks, and other minority groups. Hence, the tendency is to apply the characteristics associated with the culture of poverty to members of the minority groups. In the case of the Latino group, such a tendency may have contributed to our difficulties in distinguishing between the cultural and ethnic characteristics of the Latino poor on the one hand, and the characteristics emanating from the pure socioeconomic and sociopolitical influence of the poverty condition on the other hand (Javier 1990).
Gelman’s paper (2003) supports the above findings talking specifically about Latinos. She stated that there are a number of theoretical articles in the literature on clinical practice with Latinos advancing the assumption that a psychodynamic approach would not benefit from, and indeed might not be capable of, introspection and insight. Furthermore, the studies necessary to make such a definitive statement about the efficacy or lack thereof of any form of mental health treatment for Latinos, let alone a psychodynamically informed one, do not in fact yet exist. There are, representing what is a “minority opinion” theoretical and anecdotal works presenting psychodynamic treatment as adequate and appropriate for this population. These writers recognize that psychodynamic treatment, like “any system of psychotherapy is embedded within a particular cultural-historical context, which shaped and conditioned the thought processes and values of both its practitioners and the clientele for which it was designed” (Wohl, 1995, p. 75, in Gelman, 2003). Thus, there is recognition of many valid criticisms made of these theories and their inherent sociocultural roots but also a belief that it doesn’t necessarily follow that all psychodynamic concepts are useless or unrelated to work with Latinos. Among the proponents of applying psychodynamic techniques with the poor, of all ethnic backgrounds is Altman (1995) who incorporates the relational, two-person model, which focuses on individuals and their interactions and the three-person model in which racial, cultural and social class status of both patient and analyst is taken into account. He also argues that we can fulfill Freud’s original belief that “a poor man should have just a much right to assistance for his mind as he now has to the life-saving help offered by surgery” (Altman, 1995, p. 30).
In approaching the psychoanalytic treatment of the poor, the concept of developing a psychodynamic formulation remains basic to the endeavor. However, in determining the role of drives, structures, and object-relations, the influences of poverty and ethnicity have to be given a particular focus because the expectable environment has been altered. Thus, an immediate question is: how has the individual adapted to poverty? This is a depriving environmental influence that exists within and outside of the family structure. The history of the individual’s survival is of special importance in its impact upon, and interaction with other psychodynamic considerations (Javier & Herron, 1992).
I believe that everyone can be understood and described from a psychoanalytic point of view. In middle-class patients less attention is devoted to influences that are more germane to the underclass because the class issue is relatively integrated into available conceptualizations. The method of therapy also incorporates these, so that analysts tend to investigate what is considered important, such as mother-child interaction or transference, within a context familiar to analyst and patient. The disadvantaged patient presents a new context and different views in the exploratory picture, but the applicability of the analytic process is a constant (Javier & Herron, 1992, p. 473).
The presenting vignettes of Ivan at the beginning of this article, hopefully demonstrated, that insight has no racial, ethnic and social class borders. The fact that he is able to use free association, engages in dream analyses, and benefit from transference interpretations, despite his initial inexperience with the psychoanalytic process, demonstrates his ability to do deep analytic work. Therefore, what are we to do with those of us who both embrace and deplore the racism and classism that this society fosters and reinforces? I believe that one form of resistance to the socioeconomic system is to be more aware of how that system affects the meaning systems operative between us and our patients (Altman, 2004). As Stern (1997, in Grand 2008, p. 686) suggested, “To be a psychoanalyst is inevitably to take a political and moral stand”
(p. 141). As citizens, and as psychoanalysts, we must continue in this type of endeavor.
Altman, N. (1995). The Analyst in the Inner City: Race, Class and culture through a Psychoanalytic Lens. Hillsdale, NJ: The analytic Press.
Altman, N. (2004). (2004). History repeat itself in transference-countertransference Psychoanalytic Dialogues, 14, 807-815
Borden (2006). Review of: Psychoanalysis, Social Justice, and the Therapeutic Endeavor: Freud’s Free Clinics: Psychoanalysis & Social Justice, 1918-1938, by Elizabeth Ann Danto. New York: Columbia University Press, 2005. Psychoanalytic Social Work, 13B, 67-76.
Bucci, (2002). The challenge of diversity in modern psychoanalysis. Psychoanalytic Psychology, 19, 1, 216-226.
De Millan, S. (1997). A socioeconomic dimension of the therapeutic relationship: The analyst’s perspective. International Forum of Psychoanalysis, 6, 241-249.
DeTubert (2006) Social Trauma: The Pathogenic Effects of Untoward Social Conditions. International Forum of Psychoanalysis, 15:151-156.
Gelman, C. (2003). Psychoanalytic treatment of Latinos: A critical review of the theoretical literature and practice outcome research. Psychoanalytic Social Work, 10B, 79-102.
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Javier, R. & Moskowitz, M. (2002). Special Section: Undeserved populations: Introduction: Notes from the trenches. Psychoanalytic Psychology, 19: 144-148.
Herron,W. & Javier, R. (1996). The psychogenesis of poverty: Some psychoanalytic conceptions. The Psychoanalytic Review, 83, 611-620.
Lijtmaer, R. (2012). Paper: “Dancing with politics in the consulting room”. Presented in the panel: “New Frontiers in Psychodynamic Psychiatry”. AADC (American Academy of Psychoanalysis and Dynamic Psychiatry), 5-4-12 to 5-5-12. Philadelphia, Pennsylvania, USA.
Watchtel, P. (2002). Psychoanalysis and the disenfranchised: From therapy to justice. Psychoanalytic Psychology. 19:199-215