The Analyst in the Inner City

Race, Class, and Culture Through a Psychoanalytic Lens

Neil Altman

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781135468521
• Edition: 2
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

In 1995, Neil Altman did what few psychoanalysts did or even dared to do: He brought the theory and practice of psychoanalysis out of the cozy confines of the consulting room and into the realms of the marginalized, to the very individuals whom this theory and practice often overlooked. In doing so, he brought together psychoanalytic and social theory, and examined how divisions of race, class and culture reflect and influence splits in the developing self, more often than not leading to a negative self image of the "other" in an increasingly polarized society.

Much like the original, this second edition of The Analyst in the Inner City opens up with updated, detailed clinical vignettes and case presentations, which illustrate the challenges of working within this clinical milieu. Altman greatly expands his section on race, both in the psychoanalytic and the larger social world, including a focus on "whiteness" which, he argues, is socially constructed in relation to "blackness." However, he admits the inadequacy of such categorizations and proffers a more fluid view of the structure of race. A brand new section, "Thinking Systemically and Psychoanalytically at the Same Time, " examines the impact of the socio-political context in which psychotherapy takes place, whether local or global, on the clinical work itself and the socio-economic categories of its patients, and vice-versa. Topics in this section include the APA's relationship to CIA interrogation practices, group dynamics in child and adolescent psychotherapeutic interventions, and psychoanalytic views on suicide bombing.

Ranging from the day-to-day work in a public clinic in the South Bronx to considerations of global events far outside the clinic's doors (but closer than one might think), this book is a timely revision of a groundbreaking work in psychoanalytic literature, expanding the import of psychoanalysis from the centers of analytical thought to the margins of clinical need.

Part I

Background

Chapter 1

Clinical experiences
from a public clinic

LIFE IN THE INNER CITY

Life in the inner city entails a greater burden of stress, loss, and trauma than life in working-class-and-up communities. These conditions predispose to psychopathology (Brown & Harris, 1978) and complications in parenting young children (Halpern, 1993) and form part of what is enacted and experienced in the transference and countertransference when one works psychoanalytically with inner-city patients. The upper-middle-class therapist who goes to work in an inner-city public clinic frequently enters, psychologically, a realm of trauma and loss that she may have been able to avoid, to some degree, in her own life. The countertransference, to the extent that one is open to the experience, brings to the therapist more than the usual doses of anger, fear, and despair.

Poverty places stress on people in many ways, for example, inadequate housing with little or no heat in winter or protection from rats and other vermin; relatively greater exposure to crime of all kinds, especially violent crime; poor educational and employment opportunities; inadequate income for the essentials of life, not to speak of entertainment or distraction; racism; the exposure of one’s children to the temptations of drugs and crime. Impoverished people have more children, on average, than middle-class people and are more likely to raise them without support of a co-parent. Fathers, with the deck stacked against their ability to take on a traditional provider role, often come and go, creating experiences of loss and abandonment for mothers and children. The primary caretaker of children is more likely to be very young in the inner city. Parents, already stressed and distracted by the conditions of their own lives, are more likely than nonpoor parents to have greater demands put on their parenting skills by children with various forms of neurological and behavioral difficulties. Persistent poverty has been shown to correlate with a higher incidence of premature births, perinatal complications, and reduced access to resources to treat the sequelae of perinatal complications. Children living in poverty are more likely to have toxic levels of lead exposure. Lower levels of growth-enhancing cognitive stimulation at home, low expectations on the part of teachers, and inadequate schools are likely to lead to reduced school performance, compared to nonpoverty populations. Faced with such difficulties, parents living in poverty are more likely to be irritable and to respond inconsistently and punitively in their disciplinary efforts (McLoyd, 1998).

Trauma, of both the cumulative, chronic type and the acute type (being the victim of, or exposed to, violence and physical or sexual abuse), is relatively common in poor communities. Erikson (1994) has detailed some of the possible post-traumatic effects of the cumulative effect of the trauma of poverty:

… a numbness of spirit, a susceptibility to anxiety and rage and depression, a sense of helplessness, an inability to concentrate, a loss of various motor skills, a heightened apprehensiveness about the physical and social environment, a preoccupation with death, a retreat into dependency, and a general loss of ego functions. (p. 21)

The sequelae of more acute trauma (van der Kolk, 1987), post-traumatic stress disorders, and dissociative disorders are also widespread and transmitted from generation to generation, as is child maltreatment (Lyons-Ruth & Zeanah, 1993). When these people—adults, parents, children—enter our offices, they enter with the full range of transference expectations born of trauma. The analyst must expect, in the transference, to take on the role of rescuer, victim, abuser, and neglectful parent, in the ways Davies and Frawley (1992) and Gabbard (1992) have shown to occur in the analysis of adult survivors of childhood sexual abuse.

Adversity can also breed uncommon strength, as documented in the studies of “resilient” children (Anthony & Cohler, 1987; Neiman, 1987). Inner-city people may also be buffered from the effects of stress in certain ways unavailable to other people. For example, residents of inner cities sometimes retain the extended family or community support network, retaining this element of a traditional culture. It is not uncommon in the community where I worked, for example, for an entire block or a building to have families from a village in Puerto Rico or the Dominican Republic. Members of families often share parenting responsibilities. Support from church or mosque and its fellow members and clergy is commonly available and utilized. There are also traditional healing methods (e.g., the religiously based systems known as espiritismo and santeria) widely available in the inner city. Inner-city people may bring to the therapy situation great resources, as well as expectations of a healing relationship that may be unfamiliar to the middle-class North American mental health professional.

Inner-city life typically entails complications in the development of ethnic identity, a crucial aspect of personal identity formation. Immigrant people are involved in a complicated process of assimilation into American life while preserving ties to the cultures of the native land. Splits within families often occur when adolescent children assimilate in a way that disturbs parents who are more rooted in the “old country.” Adolescent assimilation may reflect a wish to differentiate from parents that itself is culturally specific to the United States and that may be interpreted by parents only as unwarranted defiance. (See the case of Rosa for a description of how the prospect of assimilation and differentiation led to internal conflict for an adolescent.) The form of American culture into which inner-city adolescents may wish to assimilate is “street culture,” which is especially disturbing to parents worried about drugs and crime.

The stabilization of ethnic identity is especially difficult for members of discriminated-against groups (Herron, 1994). As children become aware of their group’s and family’s relatively powerless position within society at large, it may be complicated to sustain the sense of pride in one’s family and group that reinforces a strong sense of identity. On the other hand, as awareness of societal discrimination has grown in the last four decades, there have been increasing efforts at reinforcement of awareness of the strengths of nonmainstream cultures in our cities. There is also richness available to immigrant groups and to the culture as a whole from the cross-fertilization among the peoples who are creating the current American mosaic.

PERSONAL BACKGROUND

My experience doing therapeutic work in the public clinic was conditioned, inevitably, by who I was and what I brought with me to my work there. The personal information I provide in this section helps set the stage for the clinical material to follow.

Since beginning my graduate training, I had always worked in the public sector. I was raised upper-middle class, white, privileged. What drew me to work with culturally, ethnically, socioeconomically different people, the poor? On a broadly cultural level, one might say that I had a traditionally Jewish social consciousness. I was also a member of the 1960s generation that had lived amid the civil rights movement, the women’s movement, the anti–Vietnam War movement. I had been a Peace Corps volunteer in India, where I became fascinated with culture as a phenomenon and with the capacity for cross-cultural relatedness that I discovered in myself. Living in India reinforced an impatience, which I had felt as an adolescent, with the limited horizons of the homogeneous American suburban community in which I grew up. I had been acutely aware, at least since college, of social inequities and uncomfortable doing nothing to address them.

On a more personal level, the meaning to me of work in a poor community was conditioned by events before I was born. My mother grew up in a poor neighborhood. Her father was a cigar maker. After he died, my grandmother made her living from a grocery store in front of their apartment, which was in a racially mixed community. My father, on the other hand, came from an affluent family across town. His father, legend has it, had big cars even in the middle of the Great Depression. My father swept my mother up in one of those cars and took her away from her modest circumstances into the lap of luxury.

My experience working in poor communities was, in significant ways, shaped by connections with both of my parents. On one hand, I have a sense of having connected with my mother through having worked in an environment that I identified with her. On the other hand, I had an identification with my father as a “white knight” who would ride into the ghetto with his big car and rescue the inhabitants. Work in the ghetto allowed me to feel special and admirable. This feeling helped compensate for whatever feelings of insecurity I had as a therapist and made it seem more desirable to avoid competition for jobs in more affluent neighborhoods, jobs that were more sought after by many of my peers.

In short, working in poor communities had resonances with various aspects of my background and associated fantasies about myself and other people. These personal considerations, along with my social commitments and ideals of social justice, made my public clinic work a complex, multifaceted experience.

SNAPSHOTS OF WORK IN THE PUBLIC CLINIC

A tipsy telephone call

In the child psychiatry clinic where I worked, the staff took it for granted that men, whether fathers or surrogates, would not participate in therapy. For example, when the initial call came to the clinic from a parent or another referring person, the staff member who took the call routinely said that the mother should bring the child to the first appointment. I protested from time to time that the father or stepfather should be invited to the first session, but my suggestion never caught on, and I never followed up as persistently as I might have. It was also very common to discover, in the course of doing an intake, that the father had abandoned the mother and child or children, was abusive, abused drugs and alcohol, or any or all of these. As part of the overall treatment plan for the family, I would make some attempt to engage this man. Often, he would respond positively to the invitation to meet me but later would not follow up consistently. In extreme cases, I would end up working with mothers around crises in which they were being physically abused by their husbands or boyfriends. After one such crisis, I continued treating a woman individually. She once brought her cousin to see me, who also had a troubled son and an abusive husband.

One day I got a call from these two women from a pay phone on the street. They were, I thought, tipsy. As one of them began to talk to me, they both began giggling uncontrollably. Some readers may have already made connections with my personal history; as I began treating these patients, however, I was only dimly aware of any connections. But when I got this flirtatious call from my two patients, it was as if the veil were drawn away. I could not avoid seeing my role here as the male knight in shining armor who had come to rescue these two damsels in distress from their evil male villains. I had to acknowledge the ways in which I may have been acting in a seductive manner and the ways in which I had portrayed myself as the “good” man, counterposed to the “bad” men with whom they had relationships.

At the time this incident took place, many years ago, I did not have the conceptual tools I have now to understand the dynamics of the situation. In hindsight, it seems to me that the phone call was a somewhat dissociated (taking place as it did in an altered state of consciousness) commentary on the transference-countertransference situation in which my patient and I colluded to let her husband be the bad man, with me as the good one. The phone call did several things: It exposed this splitting operation, while simultaneously revealing my own not-so-good aspect, that is, my competitiveness with their husbands. By undermining my sense of being the virtuous white knight, the phone call was a potential corrective to the defensive splitting operation in which we were engaged through heightening my awareness of how I was positioning myself in relation to these women and their husbands and by providing an opportunity for inquiry into my impact on these patients.

Food in the public clinic

It should not be surprising that food and eating are issues in therapy that takes place between a relatively affluent therapist and poor patients in a public clinic. In the clinic where I worked, food easily became a focus because the clinic kept food on hand for the children to have as snacks and because the clinic threw holiday parties for the patients at which food was present in abundance.

Certain children, especially severely deprived children who had experienced multiple losses in their lives, became preoccupied with food. In a typical scenario they would request more of this and more of that. At a certain point, the therapist, who might initially have been comfortable with the idea of a snack, would start to become uncomfortable. The child seemed to be inordinately greedy or seemed ready to take so much of the food that there would be little left for others. The therapist might say, “Why don’t you start with two packs of cookies, and we can get more later if you’re still hungry?” At this point, the child might say: “How about three? And an apple or two? I need juice too. I’m very thirsty and hungry. I didn’t eat the school lunch today.” If the therapist turned away for a second, he or she might become aware that the child had stuffed his pockets with food and drink. If the therapist tried to push the point that enough was enough or said something like, “We’re not going to have much time left for our session if you keep eating or taking more food,” a power struggle would ensue. The therapist ultimately had the resources to prevail in such a power struggle, but it would feel as if an activity that initially had seemed to be an act of generosity had been transformed into a hostile and depriving act.

What is going on in such situations? While I am sure that some of the children were genuinely hungry, most certainly were not that hungry. The children’s behavior could be seen as reflecting an institutional transference configuration. That is, the clinic was often seen as part of the social service network, which included welfare, Medicaid, and Social Security. These agencies, which control much of the income of impoverished people, fit the mold of what Fairbairn (1952a) called “exciting” and “rejecting” internalized object relationships. That is, these agencies are seen as having enormous resources that they can make available to poor people but that they often withhold. As part of this social service network, the assistance of the mental health clinic and its staff is often enlisted by patients in their efforts to obtain one sort of benefit or another. An upper-middle-class therapist working in the public system is, in this transference configuration, easily perceived as the guardian of social service resources.

From this point of view, the children in the snack room might be seen as playing out this institutional transference. The child and therapist find themselves inadvertently orchestrating an enactment of the exciting and rejecting object transference. One might say that there was no need for the therapist to pull the child away from the food so the session could start. An enactment, with therapeutic potential, was going on, in a very powerful way, around the food itself.

Why did the clinic have food on hand for the children? Of course, one might say that there is a need to offer snacks to families who otherwise might not be able to afford them; however, it was a rare family in which the children were not usually loaded with snacks, no matter how economically besieged their families. We had more self-interested motives for having that food available. For example, one therapist once said to me that giving food to her patients made her feel that at least she was able to do one clearly helpful thing for them. They had so many intractable problems, she said, that she often felt useless. The food, for a brief moment, counteracted that feeling. Shifting to a larger lens, the clinic administration believed that having food in the clinic would bring in more patients and increase our billable visits. This aspect of the situation became particularly apparent at Christmastime, when the clinic put out a spread for the patients that would have rivaled a corporate Christmas party. Why?

The Christmas party idea always came up in the context of a discussion about how to keep up our billable visits during the Christmas vacation. How does one get families to come to the clinic during vacations? The plan: Feed them. Sure enough, patients came to see their therapists on the day of the party by the hundreds. I was sometimes serving food and I would notice something I found strange: Many of the patients did not want to eat. They looked embarrassed. Some, to be sure, ate quite comfortably, and others, usually children, were quite unrestrained as they loaded their plates. How are we to understand the reluctance of some of the patients to eat? Was this a reaction formation against greed? Perhaps. But, in addition, some people may have been wondering, why is a mental health clinic feeding us? One answer would have to be: because we get reimbursed for seeing you at a rate much higher than the cost of feeding you. Or, because it counteracts our feeling of helplessness as we confront the problems you face. With the situation thus laid out baldly, it seems no longer a mystery that many of us, patients and staff, felt awkward.

We were meeting our own needs, then, in feeding our patients. By implying that we were looking out only for the welfare of our patients, we were perpetuating a myth, similar to one cited by Racker (1968), that the therapist is high-minded, healthy, altruistic, and giving, while the patient is sick, needy, and dependent. Searles (1979a) notes how therapists may need their patients to be sick so they can feel healthy. Providing food to our patients may have helped us feel resourceful and healthy, at the cost of perpetuating our patients’ feelings of being sick, poor, helpless, and needy. Thus, the patients may have felt condescended to, one down, in relation to us. Stereotypes based on social class and race may have been covertly maintained in the relationship between the clinic and its patients. If we had been able to facilitate our patients’ exploration of our motives in providing food to them, perhaps in exploring their embarrassment at holiday parties, we might have discovered a mutuality to our relationships that would have counteracted such stereotypes.

A numbers game in the public clinic

A patient in a public clinic began her session by saying: “You’re lucky I came today.” The therapist was struck dumb. She had been feeling lucky the patient came that day. Why? The therapist worked in a clinic in which staff members were expected to see 35 patients per week. If they failed to do so, their performance was judged negatively. The week had been going poorly for the therapist—it was Wednesday and she had seen only 10 patients. The therapist had been conscious of feeling relieved that the patient showed up, increasing her chances of looking good to her superiors or at least avoiding trouble.

What did the patient know about this aspect of their interaction? It is not likely that the patient knew the specifics of the therapist’s situation, but it is likely that the patient would be at least dimly aware that the therapist’s needs, as well as the patient’s, are served by the patient’s participation in the treatment.^* Her comment was a potential opening to an exploration of her fantasies and perceptions about the ways in which she was meeting, or not meeting, the therapist’s needs and how she felt about that situation.

Missed appointments

Linda was referred to a public mental health clinic because she had been feeling nervous. She was brought into a hospital emergency room the previous night by her sister after losing her temper and throwing dishes at her boyfriend. She was angry because she suspected that he had another woman. Linda’s sister, on her behalf, said that she needed pills for her nerves. Linda had several times in the past received prescriptions for “nerve medicine.” She tended to take them irregularly, regardless of how they were prescribed. The emergency room resident, having seen Linda before and knowing that she tended not to follow up on treatment, decided not to give her a prescription that night and to send her to the outpatient clinic the next morning. She was seen there by a psychology intern who talked with her for a long time. The intern heard a story of parental abandonment as a child, of numerous betrayals by parents and boyfriends. The patient expressed a great deal of anger at many people in her life. The intern pointed out that the latest betrayal, by her boyfriend the previous night, was only the most recent in a long series of previous events and so struck a very raw nerve. The patient acknowledged the intern’s comment and promised to return the next week to talk with her again, without asking for medication. She said that talking to the intern had made her feel much better.

The next week, Linda did not show up, much to the disappointment of the in...