African American Patients in Psychotherapy

Understanding the Psychological Effects of Racism and Oppression

Ruth Fallenbaum

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780815371380
• eBook ISBN:
  9781351181341
• Topic: Medicine
• Subtopic: Ethnopsychology

African American Patients in Psychotherapy integrates history, current events, arts, psychoanalytic thinking, and case studies to provide a model for understanding the social and historical dimensions of psychological development. Among the topics included are psychological consequences of slavery and Jim Crow, the black patient and the white therapist, the toll of even "small" racist enactments, the black patient's uneasy relationship with health care providers, and a revisiting of the idea of "black rage." Author Ruth Fallenbaum also examines the psychological potential of reparation for centuries of slave labor and legalized wage and property theft.

1 The Psyche in History

America has not been kind to its citizens of African descent. Ever. Although adaptability, resilience, and creativity have enabled African Americans to survive the abusive and exploitive American experience into which they were forced, it is no secret that since August 1619, when the first slaves stepped ashore in Virginia, for most black Americans equal access to the success, satisfaction, or even physical safety that their country seems to offer others has been held tantalizingly out of reach. Yet through it all, African Americans persisted and contributed to every aspect of American life. The music that came out of slavery survived the Klan and the indignities of racial prejudice and has become the heart and soul, the very rhythm, of our national culture. Righting the racial injustices has been a persistent challenge for black Americans, and their struggles for liberation, along with the support at times of sympathetic whites, have provided some of U.S. history’s most powerful and moving moments. Occasionally, government policy has aligned with these movements, whether for Emancipation or through the Voting Rights Act of 1964, affirmative action, or the desegregation of public schools. These policies and others represent attempts at repairing the wounds of racism as they have presented themselves in their respective eras.

But what of the accumulation of psychological injuries done to those subjected to these injustices along the way? What role can psychotherapy play in addressing the effects of racism and the challenges of “living in America while black”? Are there things that a therapist of another racial background needs to consider that are different when treating an African American client from those that need to be considered when treating non-black clients? For that matter, can white psychotherapists offer meaningful treatment to their black clients at all? In this book, I take up these questions, reflecting on and sharing lessons learned in my work as a white clinical psychologist with a history of working with African American patients.

You may wonder at the value of a book about working with African Americans written by someone who is not. Don’t think I have not wondered the same thing. Race—and particularly the black/white divide—is such a powerful signifier in our culture that a writer’s racial and ethnic identification feels significant in a way that it might not be were she writing about almost any other subject in psychology. This awkwardness among those of us living with the fabrication we call race complicates to one degree or another all biracial relationships, including the psychotherapeutic relationship. While I bring my own experience and perspective to this subject, I want to acknowledge some of the important books by psychologists and other mental health professionals on the African American experience and psychotherapy: Akhtar’s The African American Experience: Psychoanalytic Perspectives, Carter’s The Influence of Race and Racial Identity in Psychotherapy, De Gruy’s Post Traumatic Slave Syndrome, Grier and Cobbs’s Black Rage, Jackson and Greene’s Psychotherapy with African American Women, Vaughans’ and Spielberg’s The Psychology of Black Boys and Adolescents, and White’s Unmasking Race, Culture, and Attachment in the Psychoanalytic Space. Throughout the book my debt to many others as well, whose articles about race and psychotherapy are cited, will be evident.

In this chapter, I hope to provide an orientation to my approach to the material that will follow. Chapter 2 will focus on how echoes of the experience of slavery continue in the psyches of the descendants of slaves, and takes a look at the continuation of modes of resistance and creativity given birth during its brutality. The following chapter picks up the survey of African American life from Emancipation to the present, and how the cycle of progress and backlash has been processed psychologically through generations of black families. Chapter 4 takes up questions of identity and the personal meanings of race for African Americans in response to white racist mythology, considering issues including microaggressions, the role of skin hue in self-image and family relationships, and ideas about “becoming black.” Chapter 5 takes up the relationship between injustice, anger, and trauma—what happens when anger is suppressed, and what happens when it runs amok? Chapter 6 looks at the impact of the therapist’s whiteness on the experiences of African American patients in treatment, and looks more broadly at black experience with health care professionals and how that experience affects feelings an African American may have about seeking help. In that chapter, I also look briefly at the mythology of whiteness. In Chapter 7, thoughts about and experiences of racism as brought into session by patients, and areas of confusion and ambiguity around these experiences, will be discussed, as well as countertransference challenges. Throughout all of these chapters, the emphasis will be on the clients, whom you will meet shortly, and how these various topics manifest themselves in their treatments. The final chapter, however, will be different. Here I will look at the word “reparation” in its psychoanalytic incarnation and as a political movement of black Americans seeking acknowledgment of and concrete compensation for the costs they have borne for slavery and subsequent generations of discrimination. How might the success of the reparations movement contribute to the mental health of African American individuals, not to mention their white fellow Americans?

History, Justice, and Psychotherapy

Over the course of 30 years as a clinical psychologist, at least half of my caseload of both short-term and long-term psychodynamic therapy patients has been African American. What I have come to believe through my work with all of my clients, and through my own analysis and psychotherapy over the years, is the critical role that historical context, including the intergenerational transmission of trauma, plays in psychological development. Nowhere has this fact been driven home as clearly as in my work with the African American men and women who have sat in my consulting room. They have enabled me to learn with them how the injuries, past and present, inflicted by centuries of racism infuse the psychic conflicts of familial relationships and the internal worlds of those who live with these injuries. Furthermore, as my patients deal with continued experiences of racism in their daily interactions with the wider world, I am witness to the emotional processes generated by those current, real-world experiences. My learning has been a slow process in some cases, and that slowness, in turn, has given me a particular sense of urgency to pass on what I have learned.

One of the guiding principles of this book is the affirmation of the vital role of history, in its broadest sense, in the human psyche. An essential goal of psychoanalytically oriented clinical work is to help clients discover and respect their own depths and complexities as psychosocial individuals, to see themselves as whole persons. Often, however, what is explored in the course of psychodynamic psychotherapy is limited to what happens in the consulting room, within the patient’s family past and present, and possibly also at the patient’s workplace or with friends. Although all of that material is terribly important, to understand a whole person we must acknowledge that the family into which a person has been born has been created, and is currently immersed, in a particular place and moment with roots in history, and that this context is not separable from other psychological experiences in the person’s life. In other words, the history and the social environment are not to be considered in addition to familial and object relations; they must be recognized as part of those formative relationships.

As it happens, psychoanalytically oriented therapy is uniquely suited to this approach. The leisure of having time to allow to unfold, within the relationship between patient and therapist, the elaboration of the patient’s memories, thoughts, feelings, and actions can generate the kind of curiosity and imaginative space needed to develop a “thick description” of the patient’s being, to adapt anthropologist Clifford Geertz’s term, and the richer understanding so critical to psychoanalytically informed work. As I hope to demonstrate, historical realities permeate the consciousnesses of the people whom you will be meeting throughout the book. Sadly, because the history of African Americans in this country is so exceptionally rife with terrorism and violence, from slavery to lynching to yesterday’s shooting by a police officer of another unarmed African American, the traumatic nature of much of that history remains embedded in the psychological histories of black survivors, often unprocessed and thus ripe for unconscious transmission from parent to child.

Appreciation of the role of history in people’s psyches is not a new idea within psychoanalytic writing. In the decades following World War II, pioneers in the field began to report and reflect upon their observations of survivors of both Nazi concentration camps and the unprecedented destruction of the nuclear bombings of Hiroshima and Nagasaki. Their work bears witness to the long-term psychological effects on the millions of ordinary people who are victims of the events that scream out from newspaper headlines and are subsequently reconstituted into chapters in history books. Henry Krystal’s 1968 book, Massive Psychic Trauma, broke ground in documenting his and others’ work with survivors of the Nazi camps who had been resettled in the U.S. The book is a moving collection of papers and discussions by psychotherapists struggling to determine how to treat the emotional suffering of men, women, and children in the decades following their liberation from the camps, and is in many ways a fascinating historical document. Robert Jay Lifton’s Death in Life: Survivors of Hiroshima (1968/1991), based on interviews with survivors 17 years after the dropping of the atomic bomb, likewise confirms the profound effects on the psyche caused by the traumatic events that persist long after those events have receded from immediate view.

With the next generation of analysts who came of age after World War II, and who began to reflect on the impact the survivors of the Shoah had on the psychological developments of their descendants, the intergenerational transmission of trauma emerged as a field of study. Faimberg (1988, 2005) articulated the collapsing of time as the traumas of one generation become expressed in the next. Davoine and Gaudilliere’s History Beyond Trauma (2004), focused on psychotic expressions of World War II trauma in Europe as seen in their treatment of the post-war generation. In 1946, perhaps a decade after his move to the U.S. and less than a year following the end of World War II, Erik Erikson advised that the “analysis of the ego should include that of the individual’s ego identity in relation to the historical changes which dominated his childhood milieu” (Erikson, 1946, p. 395). It would have seemed irrational, given what he saw and lived through, to try to understand a person’s psychological development in isolation from the dramatic and disruptive events a child in Europe in the late 1930s and early 1940s would have experienced. And American analysts and psychologists have written about the traumatic residues of slavery on the African American psyche, as will be discussed in more detail below and particularly in the next chapter.

Related developments have enabled psychoanalysis to think about individual subjectivity not only transgenerationally, but also in the context of the effects of contemporary realities beyond the consulting room or family home. Psychoanalysts who have pushed to open up the clinical field in order to look at social and environmental implications for understanding the individual and psychoanalytic process include Altman (1995) dealing with race and class in a public clinic, and looking at history in therapy (2005); Dimen (2011) on a variety of cultural complications in the lives and practices of fellow clinicians; Boulanger on the psychic impact of immigration as discovered in her analytic work (2004, 2015), and in her work with psychotherapists in the aftermath of Hurricane Katrina (2013); Grand (2010) on analysis of a Vietnam veteran; and, as will be described further in later chapters, Leary (1997a, 1997b, 2000), Hamer (2002, 2006), Vaughans (2014a, 2014b), Suchet (2004), Gump (2010), Holmes (1999, 2006), and others describing some of the complexities regarding race and racism in psychoanalytic treatment. “Culture,” as Muriel Dimen (2011) wrote, “saturates subjective experience” (p. 4).

These writers are all talking about working with patients in a way that situates the patient in his or her real world. When historical context is sidelined, as Layton (2006) warns, a patient can mistakenly identify understandable feelings of pain over a distressing situation as an illegitimate reaction to a personal failing. Or an action by another that is felt to be an injustice can be discounted, misidentified, and perceived by its victim to be a universally accepted norm. The inability of the therapist to consider historical context can thus lead the therapist and client into sharing a distorted understanding of the meanings of events in the client’s life. However, when the therapist does think historically, clinical material may require the therapist to introduce into a session an observation or recollection of historical, sociological, or political material. Such an intervention, although atypical, may be the most clinically appropriate response. When a woman berates herself for becoming angry following an incident in which she was racially profiled, as did my patient Tracy, crying, “I used to be able to handle that stuff,” it is sometimes important to let her know that her reaction of anger to a real insult is not a sign of pathology as much as it is an understandable reaction to hostility, particularly as it was one of a life-long and intergenerational series of such insults. We will learn more about Tracy in later chapters.

Not only are patient and therapist both subjects and objects of history, but each therapy treatment also takes place in a unique historical moment, in which patient and therapist are both players and witnesses. A particularly clear examination of the inseparability of internal experience and the events of the “real world” is Boulanger’s Wounded by Reality: Understanding and Treating Adult Onset Trauma (2007), in which she elaborates on the issues that emerged while working in her Manhattan office with fellow New Yorkers suffering from the effects of trauma in the aftermath of the attacks on the World Trade Center. But therapists must also think about the impact on themselves and their patients of current events and social forces that are experienced only indirectly, through the media. These printed and televised realities of daily life in America certainly figure into the discussions of case material throughout the book, as events such as the rise of Barack Obama or the death of a teenage African American boy walking home with a bag of Skittles weave their way into the minds of both patients and therapists. From time to time, a news event may actually be the catalyst for the decision to seek therapy or to move an existing therapy in a new and unexpected direction. In 1991, a middle-aged woman came to see me at the clinic where I worked, saying she wanted to finally talk about her childhood experience of being touched inappropriately by her uncle, an event that had filled her with shame and confusion, and which she had never revealed. It was only after a few sessions that she mentioned that watching Anita Hill testify at the confirmation hearings for Clarence Thomas that year, in which Hill spoke openly about having been sexually harassed by Thomas, made the client begin to entertain the possibility that she could talk about her experience and somehow integrate it into her history.

It is not feasible to honor history without encountering the problem of injustice. On some level, all psychotherapy revolves around the experience of injustice in the context of important relationships: the sibling who takes the other’s toys, the spouse who does not pull his or her weight around the house, the tyrannical boss, and, of course, parents who, in their own emotional dysfunction, withhold the unconditional and nurturing love each child needs and deserves. The frustration, pain, rage, and loss of self-esteem that the common human experience of injustice can evoke are thus familiar to all psychotherapists. The patients I will be discussing grapple with all of these forms of injustice, but they do so within a society that forces an additional load of injustice on them, because it seems forever to be structured in ways that undermine and threaten their abilities to feel safe and comfortable in the world. These are people for whom, in varying degrees, contemporary America is not benign, and this is a reality which psychotherapists, especially white therapists, must understand when trying to comprehend the emotional lives of their African American clients.

Who We Are

The collaborative effort of individual psychodynamic psychotherapy, then, is a relationship comprised of history embodied in the psyches of two people, meeting together in a particular time and place. In the remainder of this chapter I will try to provide some basic orientation to the participants in the therapy relationships from which the vignettes of this book are drawn. You will be meeting several African American patients, and to protect their confidentiality I have given them new names and have disguised many specifics of their s...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgments
• 1 The Psyche in History
• 2 Chains
• 3 From Lash to Backlash: Invisible Chains
• 4 Identity and the Discovery of “Race”
• 5 “Black Rage” Revisited
• 6 The Color of Psychotherapy
• 7 In Session
• 8 Reparations
• Index