Psychoanalysis in an Age of Accelerating Cultural Change

Spiritual Globalization

Neil Altman

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317515678
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychanalyse

Psychoanalysis in an Age of Accelerating Cultural Change: Spiritual Globalization addresses the current status of mental health work in the public and private sectors. The careful, thorough, approach to the individual person characteristic of psychoanalysis is mostly the province of an affluent few. Meanwhile, community-based mental health treatment, given shrinking budgets, tends to emphasize medication and short-term therapies. In an increasingly diverse society, considerations of culture in mental health treatment are given short shrift, despite obligatory nods to cultural competence.

The field of mental health has suffered from the mutual isolation of psychoanalysis, community-based clinical work, and cultural studies. Here, Neil Altman shows how these areas of study and practice require and enrich each other - the field of psychoanalysis benefits by engaging marginalized communities; community-based clinical work benefits from psychoanalytic concepts, while all forms of clinical work benefit from awareness of culture. Including reports of clinical experiences and programmatic developments from around the world, its international scope explores the operation of culture and cultural differences in conceptions of mental health. In addition the book addresses the origin and treatment of mental illness, from notions of spirit possession treated by shamans, to conceptions of psychic trauma, to biological understandings and pharmacological treatments. In the background of this discussion is globalization, the impact of which is tracked in terms of its psychological effects on people, as well as on the resources and programs available to provide psychological care around the world.

As a unique examination of current mental health work, this book will appeal to psychoanalysts, psychotherapists, community-based mental health workers, and students in Cultural Studies.

Neil Altman is a psychoanalytic psychologist, Visiting Professor at Ambedkar University of Delhi, India, and faculty and supervisor at the William Alanson White Institute. He is an Honorary Member of the William Alanson White Society and Editor Emeritus of Psychoanalytic Dialogues. Author of The Analyst in the Inner City: Race, Class, and Culture through a Psychoanalytic Lens (Routledge, 2nd edition, 2010)

Chapter 1
Introduction

Psychoanalysis, Community-Based Clinical Work, Culture

In writing this book, my starting point is my unease about social injustice in the world of psychotherapy and mental health services more generally. Those who are materially privileged, especially in the United States, have access to careful, thorough attention to the origin and resolution of their psychological distress through psychoanalytically informed therapy. By and large, people who are materially disadvantaged have access only to time-limited, narrowly goal-oriented, and cost efficiency-focused psychotherapy and medication-based treatments. In the private sector, people can choose the form of treatment or intervention they wish and find useful and fulfilling. In the public sector, people’s choices take a back seat to whatever promises to save money for governments in the short run. At the present budget and tax-cutting moment, government-funded mental health services are focused on saving money in all health-related areas. The integration of “behavioral health” (as mental health is now termed), with general health, entails a focus on higher rates of obesity leading to diabetes and heart disease and asthma among mentally ill people. Behavioral change leading to weight loss and to compliance with treatment for diabetes, in particular, is now a favored goal of public sector-funded psychological treatments. Governments want to save money and insurance companies and drug companies want profits for their shareholders; these factors affect the way psychological services are provided in both the private and public sectors around the world. As a reputedly cost-ineffective form of treatment, anything smacking of psychoanalysis seems out of step with the times.

Meanwhile, psychoanalysis as a field has colluded with its own marginalization by an inattention to—and a splendid isolation from—the material concerns of the larger society. Private practice-based, psychoanalytically informed psychotherapy survives, if not thrives, where there are high levels of income inequality. Those practitioners who have access to the materially privileged few can do the careful, thorough work of psychoanalytic exploration. For those with successful private practices, there is no material inducement to challenge this situation; on the contrary, there is a vested interest in maintaining the status quo. Those who practice with the less materially privileged live and work in a different world of public budget cuts and insurance company oversight that seems inimical to the ethos of psychoanalysis. A practice that, in theory, honors the humanity of people ends up in danger of dehumanizing, by inattention and marginalization, the great majority. Over time, it comes to seem only natural that psychoanalytic therapy is meant for the economically privileged with their educational attainments and value systems. It comes to seem only natural that the economically and educationally disadvantaged lack whatever it takes to benefit from psychoanalytic therapy, even if they could afford it. What gets lost when these conclusions are taken for granted is the notion that psychoanalytically cultivated attention to feelings in the context of relationships could be at least as important to those who can only be reached in the public sector. Practitioners risk getting emotionally overwhelmed and burnt out when they leave the relative comfort of the private office to engage the suffering of the economically disadvantaged in the communities where they can be reached. What if clinicians who work in the public sector, or with the less materially advantaged in the private sector, need the psychoanalytic orientation to process feelings, their own and those of their patients, as much as clinicians working in private offices? That question is the starting point of this book.

At this point, a word about what I mean by “psychoanalysis” is in order. Freud (1914) said that any method of treatment that focused on transference and resistance could call itself psychoanalysis. Elsewhere, he defined psychoanalysis as the science of unconscious mental processes (Freud, 1925). In the sense in which I am using the word in this book, psychoanalysis is a theory and technique that focuses on the unconscious aspects of the emotional relationship between patient and therapist. In other language, the psychoanalytic method is directed toward drawing out and exploring the patient’s meaning-making systems, especially as they are manifest in the patient-therapist relationship. Freud prescribed, as do some of today’s classically oriented practitioners, a particular frame for doing this work, e.g. the couch, multiple meetings per week, a neutral, anonymous stance in relation to the patient. This frame has been called into question more recently by other analysts, as will be discussed below; I regard these “technical” prescriptions as secondary. Specific technical practices have cultural and personal meanings that themselves must be explored in a psychoanalytic therapy. Flexibility in technique in the service of establishing a psychoanalytic relationship is key to reaching a wide range of people across cultural and socioeconomic groups. But the principle of helping people develop increased awareness and understanding of themselves and their interactions with others remains. Consciousness-raising with respect to self and others is itself a goal with cultural and personal meanings. Self-awareness is not for everyone; self-awareness may be discouraged or considered irrelevant in some cultural contexts. Everyone has some conflict about the degree to which they want to know themselves and significant others. Psychoanalysis does not transcend culture any more than any other discipline or practice. What saves psychoanalysis from being simply partisan with respect to the value of awareness of self and others is that the field and its practitioners are enjoined to be self-reflective about its values and commitments.

So, this book is about psychoanalysis, about community mental health work, and about culture. All three. And necessarily so. I suggest that one thinks best about any of these subjects in the context of the other two. I further suggest that each of these fields benefits from a degree of integration with the other two. A key aim of this book is to demonstrate the validity of this proposition.

Psychoanalysis, community-based clinical work, cultural studies. Each of these fields tends toward constructing a world of its own with a distinctive, often insular, point of view. In a sense, each field constitutes a culture of its own—with its own language and concepts and practices—based on the job it is trying to do, what it is trying to understand, and the context in which it operates. Psychoanalysts are trying to unearth hidden meanings and patterns. Many, as noted, tend to think that they require a fairly controlled and standardized environment in which to study the interactions with and communications from their patients.

Community-based clinicians tend to have little control over the environments in which they work. They are usually confronted with communities in economic poverty that are subjected to various forms of oppression and discrimination. They tend to work with large numbers of patients with relatively severe psychological problems, along with problems of socioeconomic origin. There is a premium on symptom relief, on surviving the crush of patients in crisis, on survival. Community-based clinical workers tend to see the intensive rigorous work of psychoanalysts as a luxury not feasible in the environments in which they work. Psychoanalysts tend to think of community-based workers as doing necessary and admirable work that is not analytic because the environment is too chaotic, the patients too challenged with nonpsychologically based problems, and perhaps too besieged to introspect in the analytically required way.

Culture is a primary focus for some clinicians and theoreticians. In academia, cultural studies tend to draw on psychoanalysis, along with other fields, to explore hidden or obscure meanings in cultural productions, including popular culture. These theorists may be interested in the cultural dynamics of oppression and denigration.

Community-based clinicians may focus on culture for pragmatic reasons: their clientele, as well as the clinicians themselves, have always been culturally diverse. Community-based clinicians focus on culture to more easily form an alliance and to understand their patients.

In an effort to bring together psychoanalysis, cultural studies, and community-based clinical work, we will look backward and forward and outward. Backward in time to ponder how these three fields came to be as disconnected as they are. We will review some of the ways in which narratives of spirit possession, the summoning of spirits, and exorcism were transformed under the influence of the European Enlightenment. At the core of the Enlightenment was a splitting, a parting of the ways, between religion, faith, and spirituality on one side, and science and reason on the other. We track how the narratives of psychoanalysis moved away from spirit possession as the field evolved from a religious framework to a scientific one in the understanding and treatment of what contemporary people now call “mental illness.” The disavowal of religion and faith in favor of science and reason is by no means total, however. We consider how overcoming this split and reclaiming some of the spiritual sensibility can reunite psychoanalysis with people around the world who otherwise turn only to spiritual healers of various sorts when they suffer. The Enlightenment-bred split between reason and faith or emotion is a cultural phenomenon. When reason is placed in the superior position, the stage is set for many forms of prejudice and colonial domination, as we will see.

We look forward to speculate about where some of the trends often referred to as “globalization” appear to be taking us. Globalization refers to the ascendance of free market capitalism all around the world. Faith in free markets, and I use the term “faith” advisedly, has resulted in the rise of competitive values globally (another cultural phenomenon). Free market ideology also leads to the enforced shrinking of the public sector that supports mental health services for economically disadvantaged people at the very time that they need it most (i.e., when many of them find themselves uprooted from traditional ways of living and traditional ways of making a living). We will reflect on the ways in which mental health services are evolving and changing in response to the ever-increasing pressure to do more with less.

Finally, we will look outward to various parts of the world to learn about cultural differences and about how people are responding to globalization. We will focus especially carefully on the United States and India, where I have had the most experience, as well as on Portugal and other parts of Europe and Asia. We will note, for example, that there has not been the same kind of split between science and spirituality in India that occurred in Europe. Comparing how psychoanalysis and public sector mental health services have evolved in the United States and in India, for example, can expand the horizons of all involved about the impact their particular cultural situation has had on their own theories and practices. We will consider how people in India and Europe, to take another example, resist global capitalism in a way that is relatively rare in the United States, with consequences in how people feel about, and respond to, their shrinking public sector.

This book is not a textbook in psychoanalysis or public sector mental health nor in global capitalism. I do not attempt a comprehensive look at any of these fields. A degree of familiarity with psychoanalysis and public sector mental health services is assumed, though I aim to present my ideas in an accessible form that will speak to a wide range of readers. My sensibility throughout is nonlinear and contextual, particularly with respect to culture and personality. If you wonder what exactly I mean by that, please read on.

Chapter 2
Psychoanalysis and Culture

Psychoanalysts may gravitate toward an interest in culture as a source of unconscious structuring of the mind. Freud (2002) believed that culture itself had psychological origins in the dynamics of superego formation. Layton (2006) coined the term “normative unconscious” to refer to the way in which culturally conditioned norms operate outside of awareness to mold feelings, attitudes, and behavior. I have referred to cultures as worlds of meaning that exist largely out of conscious awareness (Altman, 2010). Nonetheless, psychoanalysts have, until quite recently, largely ignored culture, seeing it as a sociological factor that is extra-analytic. Psychoanalytic patients and practitioners tend to be quite homogenous culturally. With cultural diversity on the rise in the countries where analysts function, it has begun to be recognized that effective analytic work requires an understanding of the interaction of cultural worlds of meaning between patient and analyst. The relational turn in psychoanalysis has facilitated the recognition that one cannot so easily separate the inner, intrapsychic world from the cultural worlds of meaning in which people are socialized.

As a psychoanalyst who has worked cross-culturally, I have been impressed with the serviceability of psychoanalysis in contemporary contexts of cultural flux. With Indian patients, for example, I have noted that psychoanalytic introspection seems to open up and enrich private mental space for people whose culture is evolving to add an individual dimension to a traditional focus on community. Psychoanalytic introspection, in particular, opens up an individual, private space filled with myth and the unknown—qualities that often speak to an Indian sensibility. Psychoanalysis, with its focus on the unconscious (or, as I prefer to say, unconsciousness, or better, unknowability) has a way of straddling fences, speaking to both sides of a contradiction, and generating paradoxes. In other words, psychoanalysis provides a place for self-exploration for those who are in the midst of cultural shifts, conflicts, and contradictions (i.e., all of us these days, but some of us more obviously than others). Psychoanalysis also contains enough undefined space to leave room for various cultural groups to fill in the gaps with their own material and sensibility. This very quality, however, leaves psychoanalysis open to co-optation by cultural forces that may militate against its inclusiveness. In the United States, as we will see, psychoanalysis and psychoanalysts have found a place for themselves in a competitive, capitalist context that yields materialism and a high degree of economic inequality. Psychoanalysis has become a treatment for the well-to-do in a way that reduces, but does not eliminate, its intercultural location.

As a function of having addressed very different socioeconomic groups in the United States, psychoanalysts and community-based clinicians live in largely different worlds, speak different languages, and have different agendas. Each of these different worlds needs an integration or accommodation with the other in order to advance our understanding of human beings and to work with people productively. Community-based workers would benefit from the understanding of transference, countertransference, and the unconscious that psychoanalysis provides. Psychoanalysts would likewise benefit from the contact with the real world and the perspectives found in community-based clinical work on how race, social class, and culture shape people. Community-based workers are familiar with how being underprivileged shapes people. Psychoanalysts may be much less familiar with how privilege shapes people. Community-based workers are familiar with how experience as a member of a discriminated-against racial or ethnic group shapes people. Psychoanalysts may be less familiar with how the experience of discriminating against others may shape people. Bringing the perspectives of psychoanalysis and of community-based clinical work together will help community-based workers perform their jobs, and it will help analysts note and work with the blind spots around the shaping influence of being white, of being affluent, and of being culturally mainstream that comes with being insulated. The challenge in this book is to find a middle ground that is neither psychoanalytic-centric, nor symptom management-centric, nor cultural-centric. I seek to be “multicultural” in the sense that immigrants or other people who travel between worlds can have a rich perspective on each. I tack back and forth between psychoanalytic, community, and cultural points of view in the interest of putting all three perspectives into play. In that spirit, I now examine these three perspectives in interaction, hoping to keep all of them in mind as we proceed.

Psychoanalysis Suffers from Elitism and Isolation

Psychoanalysis is commonly thought to be an office-based practice. This preconception derives from both theoretical and socioeconomic factors: there is the idea that the analysis of transference, at the core of psychoanalysis, can only be carried out when the analyst is anonymous, when his personality is not exposed, and when he is neutral in the sense of not taking sides in the patient’s conflicts. Classically, being neutral entails restricting one’s interventions to objective interpretations. From this classical point of view, the patient’s internal, psychological reality can only come into focus when external reality, including the reality of the analyst’s personality, can be factored out. The private office offers a protected, standardized environment in which anonymity and neutrality can be preserved. Public clinics and community-based venues, like the patient’s home or a nearby diner or park bench, expose the patient to all sorts of random and unforeseen eventualities that threaten to compromise confidentiality and the analyst’s professional composure. Too much can happen that the analyst must handle spontaneously. Contemporary, relationally oriented analysts, however, have come to believe that anonymity and neutrality are impossible in principle. According to this view, everything the analyst does exposes her personality, including any effort she might make to be anonymous. All interpretations are also actions in the sense that they express and convey the analyst’s personal and subjective experience of the patient, not simply objectively derived information. The community-based venue, while certainly less controlled than the private office in some ways, is not qualitatively different from the private office. The patient’s internal reality and the context created by external reality, including the analyst’s participation, constantly interact. It is not impossible, in principle, to carry out the analysis of transference, or countertransference in a public clinic or in a community-based environment.

When the European analysts, fleeing the Nazis, relocated to North America, they found a comfortable and secure niche for themselves in the medical model/private practice system that was dominant, then, as now, in the United States. Thus located, psychoanalysis came to serve a largely white, affluent clientele. In the process, psychoanalysis became culturally and socioeconomically limited in terms of clientele and background of the analysts themselves. Psychoanalysis came to be seen as less than relevant to people from nonmainstream cultural backgrounds, from lower or even middle socioeconomic status, and to those who were beset by poverty, prejudice, or other socioeconomic problems. Psychoanalysis removed itself, to a significant extent, from the social world.

The pre-World War II analysts of Europe, however, had made serious efforts to make psychoanalytic therapy available to people of limited means, as Elizabeth Danto (2005) documented in Freud’s Free Clinics. In the United States, some analytically trained or inclined practitioners were always working in schools, hospitals, or public sector clinics. To one degree or another, they used analytic concepts in processing their clinical experiences in these settings. In the analytic community, however, and in society at large, this sort of clinical work was not seen as essentially analytic. A distinction was made between psychoanalysis, carried out under conditions of anonymity and neutrality in a strictly regulated frame, and psychotherapy, which was adaptable to the less-than-ideal conditions obtaining out in the world. Psychoanalysis was seen as the elite treatment for the elite of society, in contrast to psychotherapy for those who did not have the time or the money for the “pure gold” (Freud, 1919).

As societies become more culturally diverse all over the world, and as the reputation of psychoanalysis has suffered among mental health practitioners and the public at large, analysts are seeking to expand the cultural and socioeconomic applicability of their theory and practice. This book seeks to demonstrate that taking psychoanalysis out into the world can enrich and expand the field, making it more culturally aware and sensitive, and making it more appealing to more practitioners in more settings and to more potential recipients of mental health services. The focus on the isolated individual of the medical-model-derived form psychoanalysis has taken, especially in the United States, does not speak to many people around the world. For example, in many cultural contexts, what Western workers with a medical model might refer to as ...