Work For Expert Ahmed. Clinical II. Week 5

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Psychoanalytic Theory and Diverse Populations Carol E. Bonner LICSW, MBA, BCD a a Simmons College Graduate School of Social Work, Boston, MA, USA

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Psychoanalytic Theory and Diverse Populations:

Reflections on Old Practices and New Understandings

Carol E. Bonner

ABSTRACT. Transference and countertransference and the uncon- scious are critical concepts from psychoanalytic theory that are central to social work education and training about the therapeutic process. How- ever, assessment and treatment of diverse populations requires the incor- poration of new theories and concepts for understanding the intersection of clinicians�’ and clients�’ racial and ethnic identities. Intersubjectivity, ethnocultural transference and countertransference and racial enactments are three key concepts that deepen psychoanalytic and psychodynamic work with racial and ethnic populations. These concepts are described and illustrated by a case example. This article supports the incorporation of this knowledge in the supervision, teaching and training of psychoan- alysts, professional social workers, and other mental health profession- als. Professional social workers in the American Psychoanalytic Association are encouraged to take a leadership role in supporting the in- clusion of this knowledge in psychoanalytic training. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2002 by The Haworth Press, Inc. All rights re- served.]

Carol E. Bonner, LICSW, MBA, BCD, is Associate Dean and Associate Professor at the Simmons College Graduate School of Social Work, Boston, MA.

Originally presented at the Fall Meeting of the American Psychoanalytic Associa- tion, December 21, 2001.

Psychoanalytic Social Work, Vol. 9(2) 2002 http://www.haworthpressinc.com/store/product.asp?sku=J032

© 2002 by The Haworth Press, Inc. All rights reserved. 61

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KEYWORDS. Leadership, cross-cultural work, graduate training in so- cial work, diverse populations, psychoanalytic training

In December 2001, a panel of professional social workers presented at the meeting of the American Psychoanalytic Association. �“Renewed Alliances and New Directions�” examined the past, present, and future relationship of psychoanalysis and graduate training in the field of social work. The stimulat- ing dialogue between panelists and audience examined decreased emphasis on teaching psychoanalytic theory in schools of social work, the unique strengths of the social work perspective, and the role of the Council on social work edu- cation in determining educational standards. Panelists agreed that psychoana- lytic theory was a critical foundation for quality social work practice.

This paper examines psychoanalytic theory in relation to diverse popula- tions; it describes key concepts in cross-cultural work that enhance and strengthen traditional psychoanalytic practice. The dimensions of race and class in clinical work remain overlooked despite the fact that the context sur- rounding mental health practice has rapidly changed. Racial and ethnic back- grounds (and other identities, i.e., gender, religion, sexual orientation, socioeco- nomic class) of clinicians are frequently neglected as is the set of experiences and assumptions that those clinicians bring to their client work. Similarly, the population of clients is significantly more diverse racially and ethnically than when psychoanalytic theory dominated the learning landscape in clinical pro- grams in social work. In addition to tremendous growth in the Latino popula- tion in the United States, increasing numbers of people are not native English speakers. These realities result in significant challenges to our traditional ways of thinking and knowing in the mental health fields. The challenges to clini- cians today include learning to recognize and deal effectively with the dimen- sions of race, class, and culture in practice and learning to examine actively the set of biases and assumptions that is brought to our clinical work. In short, no two therapeutic dyads are the same.

This paper is organized into four sections. The first section gives a brief overview of the events that resulted in new concepts and models for cross-cul- tural practice in social work education. The next section will summarize three key conceptual contributions that support and complement psychoanalytic un- derstanding of diverse populations. These concepts are intersubjectivity, ethnocultural transference and countertransference, and race and transference or racial enactments. The third section describes a case and relates how the lack of knowledge of the above concepts may have impeded therapeutic prog- ress. The conclusion advocates for deeper understanding and training in

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cross-cultural dynamics and encourages social workers within the American Psychoanalytic Association to take leadership around these issues.

For over a century, the role of the professional social worker has included advocacy, activism and a commitment to work with underserved populations. However, like other mental health disciplines, the profession was (and contin- ues to be) affected by the environmental changes that shape the nature of prac- tice. The following simplified historical review highlights key events that contributed to the inclusion of new theory and practice with populations of color.

Examining the profession�’s history, social work education shifted in the 1920s to embrace psychoanalytic theory and practice. For the next five de- cades, social work practice in a growing number of social work programs was grounded in psychoanalytic and psychodynamic practice. During the period of the late 1960s and early 1970s, social workers from diverse racial and ethnic backgrounds and their mentors began to challenge traditional institutions to teach about populations of color. During these years, courses in racism and op- pression were designed and required for graduating students. Grasping the im- portance of power, context, and history in work with clients was a focus of social work teaching. Demographic change, political and social movements, and economics also deeply impacted the educational process.

In the 1990s, many writers contributed to the literature about culturally competent practice and the application of psychoanalytic perspectives to un- derstanding culturally diverse populations (Berzoff, Flanagan, & Hertz, 1996; Comas-Diaz & Jacobson, 1991; Holmes, 1992; Leary, 2000). The depth of this work significantly enhanced the knowledge about clinical work with popula- tions of color and enabled clinicians to provide more relevant quality services.

Assessment and treatment of people of color requires a theoretical perspec- tive that encompasses expertise in both the internal (intrapsychic) realities and the external (environmental and cultural) realities. For this reason, educating students about the psychoanalytic concepts of the unconscious and transfer- ence and countertransference is critical but is not sufficient to the understand- ing of racial and cultural realities in the treatment dyad. Similarly, understand- ing the cultural dimensions of the client experience and the impact of racism and oppression are not sufficient to the understanding of the fundamental di- mensions of the unconscious and the power of the transference and countertransference.

While there have been many valuable contributions to the literature about cross-cultural work, three particular concepts are pivotal to understanding clinical work with diverse populations. The three concepts are intersubjectivity, ethnocultural transference and countertransference, and race and transference. Although each of these three concepts is grounded in a psychoanalytic founda- tion, they deepen and broaden the traditional meaning of transference and countertransference in the therapeutic dyad.

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INTERSUBJECTIVITY

Social work education is committed to work with the poor and marginalized populations. In addition, the social work perspective requires the understand- ing of clients within the context of their environments.

A critical dimension of work within the client/worker dyad has been called �“intersubjectivity�” (Bowles, 1999; Perez-Foster, 1999). Bowles states, �“Intersubjectivity focuses on the interaction between the therapist�’s subjective experience and the client�’s subjective experience, emphasizing their reciprocal, mutual influences on the clinical relationship and the treatment process�” (p. 365). Beginning with the work by Stolorow and Atwood (Atwood & Stolorow, 1984; Stolorow, Brandchaft, & Atwood, 1987), the concept of intersubjectivity became critical to describing the unique experiences brought to the relationship by both client and clinician grasping the importance of each other�’s cultural and racial reality. Ap- preciating these realities and working with them in the clinical dyad helped to avoid breached alliances in the therapy.

ETHNOCULTURAL TRANSFERENCE AND COUNTERTRANSFERENCE

Comas-Diaz and Jacobson (1991) describe ethnocultural transference and ethnocultural countertransference; both are useful concepts in the therapy pro- cess. Comas-Diaz and Jacobson state, �“As they do in the traditional psycho- therapy dyad, transference and countertransference have critical significance for the cross-cultural clinical encounter�” (p. 393). Dividing their paper into a discussion of the �“interethnic�” and �“intraethnic�” aspects of transference and countertransference, they elucidate the unconscious reactions experienced in dyads where the client and clinician share similar backgrounds and those where the backgrounds of the client and therapist are different.

In the interethnic dyad, Comas-Diaz and Jacobson (1991) describe a range of transference reactions that occur when the clinicians and clients are from differ- ent cultural backgrounds. They include overcompliance and friendliness, denial of ethnicity and culture, mistrust and hostility, and ambivalence. Through case examples, these transference reactions are illustrated in their article. Also, in the interethnic dyad, these authors discuss interethnic countertransference and illus- trate some of the typical ethnocultural countertransference reactions that clini- cians bring to the work. These include denial of ethnocultural differences, the �“clinical anthropologist syndrome�” (the �“tell me more about yourself�” posture that detracts from the therapeutic process), guilt, pity, aggression, and ambivalence.

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When the ethnocultural background of the clinician and client is similar, unique transference and countertransference reactions can, again, influence the therapeutic process. Comas-Diaz and Jacobson (1991) describe the trans- ference reactions in intraethnic dyads as the �“omniscient-omnipotent thera- pist,�” the traitor, the autoracist and, again, ambivalence. Descriptively, the omniscient-omnipotent therapist is the idealized therapist with ethnic similari- ties. The traitor is the devalued therapist whom the patient resents and views as a betrayer of the culture. The autoracist transference occurs when a client pro- jects his or her own negative images onto the therapist. Ambivalence is charac- terized by the wish to be close to the person with a shared background while at the same time fearing the closeness.

Lastly, the therapist in the intraethnic dyad brings a complex set of uncon- scious issues to work with clients who have similar ethnocultural back- grounds. Comas-Diaz and Jacobson (1991) define these countertransference reactions as overidentification, �“us and them,�” distancing, cultural myopia and ambivalence. Additional reactions they described include anger, survivor�’s guilt, and hope and despair. Reactions are determined by various factors. The factors include therapists�’ level of comfort with their own images and culture (overidentification, ambivalence and distancing), therapists�’ ability to tease out clients�’ cultural issues from the complexity of other client life issues (cul- tural myopia), therapists�’ capacity to successfully separate their own painful issues from those of clients (anger); and therapists�’ ability to be at peace with their own growth and success (survivor�’s guilt and hope and despair).

The concepts of ethnocultural transference and ethnocultural countertransference help to illuminate added dimensions of traditional transference that greatly impact the therapeutic process and help to facilitate healing and growth.

RACE AND TRANSFERENCE

The discussions of race in the psychoanalytic process have been increas- ingly more prevalent during the past couple of decades. The literature includes work by psychoanalysts of various disciplines who have illuminated how race can help to facilitate transference reactions and, therefore, promote progress in treatment (Goldberg et al., 1974; Holmes, 1992; Leary, 2000; Schachter & Butts, 1968). Holmes (1992) states, �“Though long-neglected, patients�’ refer- ences to race may provide an additional point of entry to transference reac- tions. This particular vehicle is available in varying degrees in same-race and cross-race therapist-patient dyads and along the treatment continuum of psy- chotherapy to psychoanalysis�” (p. 8). Similarly, Leary (2000) described racial enactments, a term used to �“designate those interactive sequences that embody

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the actualization in the clinical situation of cultural attitudes toward race and racial difference�” (p. 640).

If race and racial dialogues are critical to facilitating the transference process, then what are some of the implications for teaching and training graduate social workers? The first, and most obvious, answer is that students must be given per- mission to have these discussions regularly during the course of their training. This requires their teachers and supervisors to appreciate the importance of race in clinical work and to teach students the delicate balance required in this work. Second, students must be taught about the central psychoanalytic concepts of transference and countertransference to fully understand the process of healing and change. Third, students must be educated about some of the theories and concepts described in this paper to fully comprehend the power and richness of the treatment process and the therapeutic dyad.

A CASE EXAMPLE

Mrs. L., a 28 year-old White mother of three young children, lived in a housing project in Boston, Massachusetts in the 1970s. Her son was referred to a children�’s developmental clinic for poor school performance, behavioral problems and enuresis. I was asked to visit Mrs. L. at her home, take a develop- mental history of the referred child and work with her around both parenting and personal issues. Each week, I, a young African-American student, faith- fully visited the home at the appointed time for our meeting. During the first three months of my visits, Mrs. L. was home only three times for our visits. I saw Mrs. L. as moderately depressed and generally overwhelmed.

As I traveled weekly to this client, I sat with my internal feelings about be- ing an African-American student from a middle-class background visiting a White woman from a different socioeconomic background in a historical pe- riod of racial unrest and tension, both in the city of Boston and in the country. I was anxious about walking into a predominately White housing project. I was concerned about safety and concerned about acceptance.

When I had the chance to present this case to my social work practice class, I described a shift that had taken place in my work with Mrs. L. as the months passed. She was home for most of our appointments and she was more readily sharing the painful feelings she experienced parenting her children alone with few supports or resources. My practice teacher, who was White, remarked �“You are her good Black mother.�”

The discussion of this case relates to the aforementioned three concepts. Most remarkable about this case example is the absence of discussion in my practice class or in supervision about my race and ethnicity and the intersec-

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tion of my racial and ethnic identity with those of Mrs. L. Although this exam- ple occurred years ago, absence of discussion of race and class dimensions in clinical learning remains commonly prevalent. The White professor�’s effort to use race to label one aspect of the transference was noble. Yet, the professor�’s comment was not sufficient to permit and encourage a deeper exploration of race in class, supervision, and with the client.

Mrs. L. and I each brought an independent set of assumptions and experi- ences to the therapeutic dyad. The question is, How can clinicians, teachers, and supervisors encourage and support exploration of these experiences safely and productively? In this case example, a supervisor or teacher could ask the following questions to encourage discussion:

What did you expect to see when you first visited Mrs. L.?

How did you feel when you made the home visit to her and what struck you about her reactions to you?

Was there direct or indirect reference to race or class issues and how were they handled?

As you reflect upon the visit and your feelings, how did dimensions of race and class affect your observations and interventions?

Answers to these questions would elicit potentially rich and significant in- formation regarding the countertransference dimensions. Similarly, by listen- ing for and exploring the area of race and class with Mrs. L., I would have learned important information to facilitate our work. In summary, supervisors and teachers must give permission to students to explore the intersections where the lives of clients and the lives of workers converge. With education and practice, the dialogues of race will become routine and readily replicated in the therapy arena with clients.

The previous discussion addresses the intersubjective process in the thera- peutic dyad. When clinicians are comfortable with articulating the intersubjective dimensions relative to race and class in treatment, then clients are more likely to experience permission to raise and explore these issues. In the absence of understanding this concept and process, I was left alone to grapple with anxi- ety that was aroused by the interethnic dyad and assumptions and biases that were impacting the transference, but not being acknowledged. In retrospect, if I had articulated my assumptions and the anxiety about how Mrs. L. perceived me (young, Black, educated social worker coming to talk about her problems and vulnerabilities) during supervision, then I would have been able to bring

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this dialogue into the therapy and give Mrs. L. permission to address race and class issues

On reflection, the client and I colluded in denial of the ethnic and cultural differences between us. This may have contributed to Mrs. L.�’s suspicion and distrust and to my guilt. The denial of our racial and class differences diluted the therapeutic work and served to avoid the charged and highly affective dia- logues taking place in Boston at that time targeting certain racial and ethnic groups with racial insensitivity and bigotry. Subjectively, I worried that the re- lationship would fracture if Mrs. L�’s true feelings about me as a Black person were revealed (an example of projective identification on my part). However, the salient point is that Mrs. L�’s subjective experiences of the client/therapist dyad remained unattended to in our work and themes that might have emerged and in what directions they might have taken our work remains pure specula- tion.

The racial enactment in this treatment was characterized by the silences around race and class. Related to the ethnocultural transference and countertransference previously highlighted, the silences may have complicated the formation of early alliances and bogged down the progress in the relationship.

IMPLICATIONS FOR CONTEMPORARY PRACTICE

Contemporary practice requires clinicians to re-examine practice methods and develop new methods and strategies for dealing with diverse populations. While contemporary analytic perspectives recognize the importance of the an- alyst�’s subjective experiences and the role they play in racial enactments, the prevailing analytic method adheres to analyst neutrality, devoid of an active and rich set of internal experiences that can impact the treatment in positive and negative ways when it is brought out into the open.

The social work profession has trained its students to address the client within the context of the environment. The assessment and treatment process, therefore, attended to more than the client/therapist dyad. The efforts in most schools of social work have been to develop multicultural approaches to prac- tice that provide more relevant and effective treatment to diverse populations than some of the traditional theories alone were able to offer. Similarly, the in- clusion of the concepts of intersubjectivity, ethnocultural transference and countertransference, and racial enactments has moved clinicians toward frameworks for addressing difference.

Yet, the recognition and inclusion of contemporary theory in practice is only the beginning of a major process of change in the ways that traditional psychoanalysis works with diverse populations. The change process needs to

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target the education and training of supervisors, faculty and candidates. Spe- cifically, in light of the changing demographics in our country, the education of psychoanalysts must include knowledge of intersubjectivity and the requi- site skills for effectively addressing the dimensions of race, culture and class in analytic work. As psychoanalysis has guided clinicians of different disciplines to work with transference and countertransference, so too must psychoanalysis help to research and teach the balance required for listening and interpreting the complex and fascinating nuances of race and class dimensions in interethnic and intraethnic dyads.

As previously described, contemporary practice requires new directions in training and education designed to bring cross-cultural considerations directly into psychoanalytic practice. There are other requirements that deserve con- sideration when we discuss contemporary practice with diverse populations. One other consideration is the inclusion of the concepts of social justice and social action; another is community practice.

Since September 11, 2001, many people in the United States have experi- enced the consequences of actions that are beyond their control. The feelings experienced by Americans have included fear, vulnerability, rage, helpless- ness, and tremendous anxiety. We have experienced what it is like to be tar- geted and hated just because we are American.

Significant numbers of African-Americans, Latinos, Asians, and Native Americans (among many other oppressed and vulnerable populations) live with these feelings daily as the targets of the discrimination and oppression (conscious and unconscious) of dominant groups. While racism and oppres- sion are not the root of all problems for persons of color, the concepts of social justice and social action are central to changing unfair and unjust situations. In contemporary practice, we need to review our commitments to social action and social justice.

Finally, community practice has resurged as a result of managed care and the recognition that one of the most effective ways to reach people is to meet them in their own communities and environments. Community practice af- fords the opportunity for reaching diverse populations who might not other- wise seek mental heath services. Simultaneously, the repertoire of skills necessary for work in communities circles back to the expectation that clini- cians be aware of their subjective experiences and that they be prepared for ad- dressing the multiplicity of practice issues and priorities that community practice presents.

In conclusion, one remaining question is, Who takes the leadership for ac- tivism around services to populations of color? In organizations such as the American Psychoanalytic Association, where does the drive for educational change originate? An increasing number of social workers are becoming

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analysts and the analytic community is reaching out to social work programs more actively than in years past. As our colleagues become analysts, do we forget our responsibility to social justice and social action on behalf of our cli- ents?

Under the auspices of a multidisciplinary organization, such as the Ameri- can Psychoanalytic Association, there are exciting opportunities to organize discussion groups or �“think tanks�” for examining new perspectives on trans- ference and countertransference in analytic work. Building on the exciting the- oretical work that has been done with psychoanalysis and race, the dialogues could lead to new understandings and constructions of the therapist/client ex- perience. The thought provoking and stimulating dialogue at the American Psychoanalytic Association meetings confirmed the strong role that social workers could play in providing leadership for best practices with populations of color.

REFERENCES

Atwood, G., & Stolorow, R. D. (1984). Structures of subjectivity. Hillsdale, NJ: Ana- lytic Press.

Berzoff, J., Flanagan, L. M., & Hertz, P. (Eds.). (1996). Inside out and outside in. Northvale, NJ: Jason Aronson.

Bowles, D. (1999). Intersubjectivity: Expanding our understanding of the worker-cli- ent relationship. Smith College Studies in Social Work, 69(2), 359-369.

Comas-Diaz, L., & Jacobson, F. M. (1991). Ethnocultural transference and countertransference in the therapeutic dyad. American Orthopsychiatric Association, Inc., 61(3), 392-402.

Goldberg, E. et al. (1974). Some observations on three interracial analyses. Interna- tional Journal of Psychoanalysis, 55(495-500).

Holmes, D. E. (1992). Race and transference in psychoanalysis and psychotherapy. In- ternational Journal of Psycho-analysis, 73(1), 1-11.

Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic Dialogues, 10(4), 639-653.

Perez-Foster, R. (1999). An intersubjective approach to cross-cultural clinical work. Smith College Studies in Social Work, 69(2), 269-291.

Schachter, J., & Butts, H. (1968). Transference and countertransference in interracial analyses. Journal of the American Psychoanalytic Association, 16, 792-808.

Stolorow, R. D., Brandchaft, B., & Atwood, G. (1987). Psychoanalytic treatment: An intersubjective approach. Hillside, NJ: Analytic Press.

Manuscript Submitted: February 14, 2002 Final Revision Received: March 11, 2002

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