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Psychoanalysis and the urban poor Neil Altman Ph.D. a b a Supervisor in the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis , 425 Riverside Drive #13D, New York, NY, 10025 b Faculty and is a supervisor at the National Institute for the Psychotherapies , Published online: 02 Nov 2009.
To cite this article: Neil Altman Ph.D. (1993) Psychoanalysis and the urban poor , Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 3:1, 29-49, DOI: 10.1080/10481889309538958
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Psychoanalytic Dialogues, 3(l):29-49, 1993
Psychoanalysis and the Urban Poor*
Neil Altman, Ph.D.
This paper considers, from a psychoanalytic point of view, work with urban poor patients. A previous attempt, from an ego psycho- logical perspective, to adapt psychoanalytic theory and technique for work with such patients is reviewed. An attempt is then made to elaborate an object relations perspective, based largely on the work of Fairbairn. The two approaches are compared and contrasted, especially with respect to common problems that arise in work with this group of people, such as missed appointments, crises, and requests for "concrete" help. Finally, there is a review of how the structure and policies of the public clinics in which most poor patients are seen impact on analytically oriented work.
ALTHOUGH THERE HAVE BEEN EFFORTS in Europe Qacoby, 1983) andLatin America (Langer, 1989) to apply a psychoanalytic ap-proach to people from a lower socioeconomic class background, in this country there have been few such attempts. In the United States, psychoanalytic treatment has generally taken place in a private practice setting where the lower-class patient cannot afford the fee. Yet economic factors do not fully explain the traditional exclusion of the lower-class patient. Even in low-fee training clinics attached to universities, insti- tutes, and hospitals, lower-class patients have often been "selected out" if they applied for treatment. Criteria of "analyzability," to be discussed further below, were often cited. Psychoanalysis came to be a treatment for the educated, middle-to-upper-class patient, as documented by
Dr. Altman is a supervisor in the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis. He is also on the faculty and is a supervisor at the National Institute for the Psychotherapies.
*I gratefully acknowledge the editorial work of Adrienne Harris, who helped me dis- cover and express clearly what needed to be said in this paper. I am also grateful to Alan Horwitz, Wendy Lubin, and Saul Scheidlinger for their careful reading of earlier drafts of this paper and their helpful comments. Finally, I want to thank the psychology staff and interns with whom I worked in the inner city for the stimulation and encouragement they gave me.
2 9 © 1993 The Analytic Press
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30 Neil Altman
Hollingshead and Redlich (1958) in their empirical study of social class and mental illness in New Haven of the 1950s.
In recent years, there has been some degree of reversal of this tendency to exclude the lower socioeconomic status patient from psychoanalytic treatment. As fewer people seek out psychoanalysis, patients from lower- class backgrounds have sometimes been accepted in training clinics out of necessity. Moreover, clinicians with psychoanalytic training often spend part of their professional time in public clinics where such patients are increasingly the vast majority, no matter where the clinic is located.
As psychoanalysts embark on work with inner-city people in public clinics, they often wonder about the extent to which the psychoanalytic treatment model is applicable or adaptable in this context. The purpose of this paper is to argue that, beyond being thus applicable and adapt- able, the psychoanalytic model is essential to work with such patients. Further, I attempt to demonstrate that a psychoanalytic model is neces- sary to understand the impact of the institutional context on work with these patients. In these ways, my effort is to breach the polarity that has developed in psychoanalysis between work with relatively affluent pa- tients and work with the poor and between work in private practice and work done in public clinic settings.
Any attempt to understand the meaning of what an inner-city patient presents in treatment must take account of the institutional context of that work, as well as the patient's and analyst's ethnicity, culture, and socioeconomic status. Therefore I will take a moment to describe the community in which the clinical work was done that forms the basis of this paper. I will provide the reader with relevant data regarding the ethnic groups in the community, the poverty in which they live, and the unexpected sources of strength and richness to be found there.
The clinical work discussed in this paper was done in a community mental health center associated with a large inner-city hospital in New York City. The community in which this hospital is located, in the early-to-mid-20th century, was home to working-class and middle-class people of Jewish, Irish, and Italian descent. They were first- and second- generation immigrants who had recently escaped the poverty and over- crowded conditions of the Lower East Side of Manhattan. The construc- tion of expressways in the 1950s and 1960s had a profound impact on the area. One expressway cut through the heart of the community, causing one side to become "the other side of the tracks," an undesirable place to
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Psychoanalysis and the Urban Poor 31
live. At the same time, the expressways stimulated the development of suburbs, which drained this community of many of its upwardly mobile people.
As middle-class people left this area, other social forces led to the immigration into the community of new groups of people. The industri- alization of Puerto Rico, other Caribbean islands, and the southern part of the United States led to the displacement of many rural Puerto Ricans and Afro-Americans from the South and the Caribbean who came to New York in search of new opportunities. When they found such opportunities, these immigrants, like upwardly mobile people of the previous generation, tended to move "uptown" or to the suburbs. Those who did not find the opportunities they sought had no choice but to stay. The community sank into ever-deeper poverty. Landlords began aban- doning their properties, which often burned, leading to a massive depletion of the housing stock in the 1960s. Blocks that once housed middle-class people were turned to rubble in an astonishingly short period of time.
The community has nonetheless remained a culturally rich and dynamic center of New York life. New immigrants have continually reinforced the cultural diversity of the area, bringing with them new hopes and aspirations. In the last ten years there have been immigrants, some of whom entered this country legally and some of whom did not, from the Dominican Republic and from the war-torn countries of Central America. Those who are not here legally often do not seek out social services for fear of being revealed and deported. The first genera- tion of these immigrants generally consists of people who do not speak English and who live in close proximity to family members or people from the same country, even the same town or village. The traditional emphasis on family life is reinforced by the need to have sustaining human connections in an alien environment. The second generation, the children and adolescents, learn to speak English in school and from their peers and begin to become acculturated. Much family conflict is stimulated when second-generation adolescents begin to rebel against the traditional values of their parents, demanding more freedom and autonomy, for example. Some adolescents fall in with a drug- and crime-prone subculture that, with its expensive cars and clothing, is easily noticeable on the streets, further alienating them from their parents.
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At present, the social class of the people who live in this community is somewhat diverse within a limited range. By all the indicators of social class cited by Hollingshead and Redlich (1958), that is, residential address, education, and occupation, the people of this area are in the lowest social classes. There are working-class people who do blue-collar or clerical jobs. Many other people in this community have found themselves lacking skills for the available jobs in a service economy; as a result, welfare rolls have swelled in the community, and there are a large number of families who subsist on public assistance, some for three or more generations. School dropout rates are high, although a significant number of female heads of households (at least second generation in this country) attempt to go back to school in their 20s and 30s, once their children are in school. Many families are single-parent families, usually headed by females. The absence of men reflects a process of marginalization that began with the undermining of their traditional breadwinning role when unable to find jobs. Adolescent pregnancy and childbirth are very common, reinforcing the school dropout rates and, in many cases, resulting in the raising of young children by grandmothers. The death of some young parents from AIDS or their inability to parent due to crack abuse further increases the role of grandparents in child care.
The ethnicity of the people in this community creates a complicated mosaic. Not only are there people from many different countries and cultures, but there are various levels of acculturation to North American industrial and postindustrial society. The first-generation people brought with them a culture born in a rural, agricultural context, with traditional values related to family life, religion, and so on. Further social changes in this community are aspects of the so-called feminization of poverty, alluded to previously.
For purposes of dealing with a manageable level of complexity in this paper, I attempt to deal with social class as a variable in psychological work in some degree of isolation from culture and ethnicity. The reader should bear in mind that this is an artificial isolation, which results in some degree of oversimplification.
The Theoretical Background of this Paper
As mentioned previously, there is a polarity in psychoanalysis between work with the poor in public clinics and work with the well-to-do in
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Psychoanalysis and the Urban Poor 33
private practice. This polarity has been reinforced, it seems to me, by two traditional currents in psychoanalytic thinking. The classical Freudian model, with its emphasis on creating a "blank screen" context for psychoanalytic work, is not adaptable to work in a public clinic in which the therapist is often called upon to fill multiple roles, for example, advocate with other social welfare agencies, in addition to one's primary role as therapist. Second, the ego psychological approach, with its tendency to define pathology in terms of defect or deficit, lends itself to a stratification of patients according to "ego strength" that often mirrors stereotypes based on class, ethnicity, or race. Concepts of what consti- tutes ego strength are context-bound. Frustration tolerance, for example, or ability to delay gratification, is seen as an ego strength in a particular culture heavily influenced by Calvinism. In another cultural context, affiliativeness, quite at odds with Calvinist individualism, can appear as a prominent ego strength. Such context-bound judgments find their way into classical theory and technique in their requirement that the "analyzable" patient be able to tolerate the abstinence of the analyst. One can thereby be led to find lower-class or culturally different patients unsuitable for psychoanalytic work or to address their ego "deficits" with a modified technique. The result is a two-tiered psychoanalysis unwit- tingly reflective of the social class differential between lower-class patient and higher-class patient or between lower-class patient and higher-class analyst. As pointed out by Sennett and Cobb (1972), social class differences are often interpreted as reflecting "questions of character, of moral resolve, will, and competence" (p. 256). That is, in a society in which everyone is presumed to have equal opportunity to advance socially, one's lower-class standing is easily seen as evidence of personal failure. The two-tiered psychoanalysis that may result when ego psychol- ogy is applied to psychoanalysis colludes with and reinforces this view of such patients as inferior.
I hope to demonstrate in this paper that a psychoanalytic approach based on object relations theory avoids this tendency toward stratifica- tions of patients and nicely accommodates the influence of a public clinic context on psychoanalytic work. With respect to the stratification of patients, let us consider, for example, contrasting views on "analyzability." A classical/ego psychological approach, in which insight is the sole mechanism of analytic change, naturally places a premium on verbal intelligence in the selection of patients (Bachrach and Leaff, 1978). The ability to tolerate frustration without "acting out," specifically, the
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ability to tolerate the analyst's abstinence, is also crucial. Such criteria clearly favor the relatively highly educated and sophisticated patient, thus introducing a bias against many lower-class people who are less likely to have had the same educational background as a middle- to upper-class patient. By contrast, in many object relations approaches in psychoanalysis, the patient-analyst relationship is presumed to carry the therapeutic impact. Analytic anonymity and reserve per se are not considered essential to a neutral stance (Greenberg, 1986). Object rela- tions approaches, as I argue later, do not necessarily draw a hard and fast line between verbalization and so-called acting out. The patient's nonverbal actions can be seen as having useful communicative value. Therefore, verbal intelligence becomes a less central prerequisite for analytic work. Criteria of analyzability thus become considerably more flexible (see Green, 1986 for such a reconsideration of analyzability). In general, the relational emphasis on the interconnectedness of people easily accommodates the focus on the family or the social group embed- ded in the cultures of many inner-city patients.
In developing an object relational approach to the issues that com- monly arise in work with lower-class patients, I draw heavily on the concepts of W. R. D. Fairbairn (1952, 1958). Fairbairn was a Scottish psychoanalyst contemporary with Melanie Klein and D. W. Winnicott. His work elaborated on Klein's concept of "internalized objects." Specif- ically, he elaborated on the nature of the "bad" internalized object; he also developed a concept of linkages between self- and object represen- tations that formed one of the bases of the work of Kernberg. I compare this object relational approach with the work of Fred Pine (1985) with inner-city patients, from an ego psychological perspective. I focus on how the approaches vary in their views of analyzability and in the under- standing and clinical management of such issues as missed appointments, crises, and concrete advocacy (e.g., help with socioeconomic problems).
The Case of Linda
Let us begin with a clinical vignette. A patient, Linda, is referred to a public mental health clinic because she has been feeling nervous. She was brought into an emergency room the previous night by her sister after losing her temper and throwing dishes at her boyfriend. She is angry
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Psychoanalysis and the Urban Poor 35
because she suspects that he has another woman. Linda's sister, on her behalf, says that she needs pills for her nerves. Linda has several times in the past received prescriptions for "nerve medicine." She tends to take them irregularly, regardless of how they are prescribed. The emergency room resident, having seen Linda before and knowing that she tends not to follow up on treatment, decides not to give her a prescription that night and to send her to the outpatient clinic the next morning. She is seen there by a psychology intern who talks with her for a long time. The intern hears a story of parental abandonment as a child, of numerous betrayals by parents and boyfriends. The patient expresses a great deal of anger at many people in her life. The intern points out that the latest betrayal, by her boyfriend the previous night, is only the latest in a long series of previous events and so strikes a very raw nerve. The patient acknowledges the intern's comment and promises to return the next week to talk with her again, without asking for medication. She says that talking to the intern has made her feel much better.
The next week, Linda does not show up, much to the disappointment of the intern, who felt she had established a strong and meaningful connection with her in their first meeting. Since Linda has no phone, the intern writes her a letter. There is no response for two weeks from Linda. In the third week, however, the intern is called by the receptionist to say that Linda is in the waiting room to see her. She knows she has no appointment but would like to see her for just a moment. The intern feels confused, irritated, worried. When Linda comes into her office, she apologizes for not returning to the clinic, explaining that she has been getting the runaround from welfare and that she has decided to apply for SSI (Supplemental Security Income; a Social Security program to pro- vide money to people who cannot work because of a physical or mental disability) on the basis of her mental condition. Would the intern please send her medical records to the Social Security Administration on her behalf?
The intern feels quite disoriented. Linda's actions seem to be an indirect, yet powerful, communication of hostility and despair, provok- ing similar feelings in the intern. She had thought that this woman could benefit from psychotherapy. Linda seems to be settling for crumbs from life. Why accept the status of a mentally disabled person so easily? Is she trying to exploit the system? Perhaps, in her world, there are no options. You either find a secure source of income from the "system," or you do not eat. And, anyway, what should a would-be psychotherapist say to
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Linda? The intern feels caught between rejecting her, on one hand, and colluding with her exploitativeness, hostility, and despair, on the other. Should she go along with Linda's request as a temporary expedient to establish a relationship with her? Would a rejection undermine any chance that Linda would come back? Would acceding to Linda's request be a collusion with Linda's devaluation of herself and her exploitation of the system? Which course of action would less seriously undermine a therapeutic relationship? Besides all that, Linda really does not seem to want psychotherapy. Should the intern urge it on her? After all, Linda does not come from a background where people go for therapy when they are in trouble. Perhaps the intern needs to start with her where she is and work toward being a therapist. But along the way, how does one avoid foreclosing one's ability to take a therapeutic stance in the future? The intern, trying to deal with all these thoughts, not to mention her feelings and her anxiety, asks Linda about the experiences that led up to her decision to apply for SSI and about whether she sees herself as being able to work. She inquires as to how the patient would feel if she got SSI. She also conveys her opinion that the patient could benefit from psychotherapy and that perhaps psychotherapy would lead Linda to see other options in her life. Linda agrees to give it a try and leaves with another appointment.
Theoretical Perspectives
This vignette contains elements common to work in public clinics with lower-socioeconomic status patients. Missed appointments, presentation in crisis, and a focus on assistance with concrete, bread-and-butter issues are typically encountered in this context. From a classical psychoanalytic or ego psychological point of view, this clinical situation is highly problematic in terms of a psychoanalytic treatment model. The patient is seen as having very limited tolerance for anxiety (defined in relation to the emerging awareness, in treatment, of repressed drives and their derivatives) and frustration (defined in relation to the "abstinence" of the classical psychoanalytic situation). These ego "defects" result in the patient's attempt to break the frame in a very disruptive way by missing appointments. Her conscious motivation in relation to her would-be therapist is to obtain concrete help in a way that would compromise the
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Psychoanalysis and the Urban Poor 37
therapist's neutrality and abstinence. Although she seems potentially psychologically minded, there appear to be major obstacles to the establishment of a viable therapeutic alliance. Are these obstacles insur- mountable from a classical/ego psychological point of view?
Fred Pine (1985),1 drawing on his work supervising trainees with inner-city patients, whom he describes as "socioeconomically distressed" and from "destructive familial and social backgrounds," attempts to adapt classical theory and technique to patients such as Linda. He frames the basic problem in work with such patients as adapting to their limited tolerance for anxiety and frustration. Pine believes that such patients require support from the therapist in one form or another in order to tolerate the anxiety attendant upon interpretation. For example, he might warn a patient a moment in advance that he was about to say something that would be difficult to hear, in order to give the patient an opportunity to orient to the stressful situation. Or he might refrain from interpreting a transference wish or feeling while it is active in relation to the therapist, commenting on it only in retrospect some days later, when the anxiety level is lower. Pine calls this technique "striking while the iron is cold."
Pine finds that he can offer such support to patients who need it, without compromising the basic goal of analytically oriented treatment, which, for him, is insight through interpretation. In summarizing his position, he challenges the traditional notion that supportive therapy and insight-oriented therapy are mutually exclusive. Instead, he says that a distinction can be made between interpretation in the context of abstinence and interpretation in the context of support. Patients with
1Pine's work is characterized here as classical and ego psychological in its theoretical orientation. I recognize that in his latest work (Pine, 1990) he attempts to integrate the four psychologies of drive, ego, object relations, and self. However, I believe that, while he has moved toward assimilating an object relations psychology in his theorizing, he remains essentially rooted in classical and ego psychological theory. For example, he (1990) writes, "I propose repetition in the effort at mastery of the strain trauma in old object relationships as a primary and the most distinct motive force in the domain of the object relations psychology at the clinically relevant level" (p. 84). This is actually an ego psychologically-based approach to object relations. An approach that stresses the primacy of object seeking per se, not in an effort at mastery of trauma, is more properly spoken of as an "object relations" theory. Pine moves in this direction elsewhere in the same book when he writes, "Significant for the clinical relevance of the object relations psychology is the tendency to repeat these old family dramas, a repetition propelled by efforts after attachment or after mastery or both" (p. 35).
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limited tolerance for anxiety and frustration, for Pine, can be reached only through interpretation in the context of support.
This polarity between abstinence and support rests on culture-bound notions of ego strength and creates a two-tiered psychoanalysis, as noted above. The polarity arises within the context of drive-theoretical con- cerns about gratification's interfering with the emergence of transference and leading to nonanalytic cures based on suggestion. Within a classical context Pine begins to breach the polarity between "analyzable" and "nonanalyzable" by sacrificing analytic purity and rigor in favor of a pragmatic attempt to impart insight effectively to those who are consid- ered otherwise unreachable. Pine defends the "analytic" nature of this sort of work by a far-reaching reworking of classical theory and tech- nique. Taking off from his perception that some patients need support from the therapist, he then develops a conception of curative factors in the analytic situation based on a parent-child model (Pine, 1985, chaps. 10-12). The therapist' reliability, nonjudgmental attitude, and ability to recognize, distinguish, and name feelings, for example, are seen as potentially curative factors in themselves. Just as such qualities in a parent facilitate growth in children, in the therapist, they facilitate growth in patients. In essence, Pine adds the relationship with the therapist per se not only as the context for the development of insight but as a curative factor aside from the development of insight. He believes that these relational factors are operative in all analyses. A polarity is reintroduced, however, when Pine states that in patients with "strong egos" these relational factors operate in the background of the analysis. In work with patients with "weak egos," that is, with a history of early deprivation and poor capacity to tolerate anxiety and frustration, the analyst's "parenting" qualities are in the foreground as curative factors. Pine gives as an example his work with a young woman whose anxiety about the therapeutic work with him led her to miss a large number of sessions. Pine made an arrangement with her in which a certain hour would be available to her whether she used it or not. (Although he does not discuss the fee, it appears that the patient was not charged when she did not use this hour.) This was an hour in which he did administrative work at his hospital office. She came regularly, but very infrequently. If Pine were to be away at the time of her hour, he would inform her, even if she had not used her hour for many weeks or months. Under these conditions, Pine felt that his reliability and availability were facilitative of growth and change in his patient, aside from any insight through interpretation in the sessions that did occur.
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Psychoanalysis and the Urban Poor 39
In considering a patient such as Linda, then, Pine would see a picture of impaired ego functioning. Missed sessions, presentation in crisis, and focus on concrete help would be the reflections in treatment of this impaired ego. Insofar as relational, preoedipal issues predominate in the clinical picture, Pine would likely believe that relational, "parent-child" issues would be prominent in the transference. Insight through interpre- tation would be in the context of support rather than abstinence. The behavior of the analytically oriented therapist working with Pine's model would likely be less frustrating and more welcoming, supportive, and engaging with a patient such as Linda than with a patient seen as better able to tolerate anxiety and frustration.
The polarity between ego strength/abstinent analytic stance, on one hand, and ego weakness/supportive analytic stance, on the other, is further undermined by Mitchell's (1988) concept of the "developmental tilt." Such a "tilt" occurs when relational needs are seen as relatively early developmentally or as primitive, in comparison with drive-defense con- flicts. One is easily led, thereby, to an emphasis on the deficits of a patient such as Linda, at the expense of her strengths and resources. When the "parent-child" model of treatment is reserved for those with "ego weak- nesses," which are only too readily associated with lower-class member- ship, the result, again, can be a paternalistic/maternalistic attitude that reflects and perpetuates our society's class structure.
The issues raised by work with a patient such as Linda can be approached from a different angle—from the point of view of object relations theories. Interactions such as occurred with Linda and the intern are reframed, such that they can be understood and handled in an uncompromisingly analytic manner. When a therapist working from this point of view sits down with a patient, the question he is likely to ask himself is, Who am I in this patient's object world? That is, the therapist assumes that the transference will involve his being seen by the patient through the template of the patient's internalized objects. For Fairbairn (1952), for example, the transference involves the patient's seeing the analyst as an exciting (i.e., tempting, promising) or a rejecting object. The technical problem that arises for people working from this point of view is, How does one open up the closed system of the patient's internalized object relations? How does one get seen as a new object, rather than simply a new version of an old object?
Greenberg (1986) points out that the problem is more complicated than that. The therapist must first enter the patient's world, must become a new version of an old object, in order to attain significance in
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40 Neil Altman
the patient's life. The problem then becomes striking a balance between being seen as enough of an old object to be significant and being seen as enough of a new object so that there is room for change. From this point of view, the issues with Pine's patient, discussed just above, no longer revolve around the support that she needs. The question now is what sort of object the analyst is for her and how to strike the proper balance between new and old object to facilitate analytic work.
The issue of analyzability is now also strikingly different. The criteria from this point of view no longer have to do with intelligence or verbal ability, with qualities that facilitate the attainment of insight through interpretation. The criteria now have to do with a capacity to experience multiple realities in the analytic situation, with what Mitchell (1988) and Winnicott (1971) would call the capacity to play in the interaction with the analyst. As Green (1986, p. 36) points out, the criteria for analyzability may have more to do with the analyst's instrument than with the capacities of the patient.
With this object relations point of view in mind, let us return to the issues raised by work with poor patients. I begin with some typical relational configurations that tend to get established with such patients in the context of a public clinic. I emphasize the role of this context on the way in which the therapist is viewed by the patient.
When a patient of lower socioeconomic status walks into a public clinic, from her point of view she enters another of the institutions that control crucial aspects of her life. A frame is already established for the therapy that is about to occur. A hospital or a hospital clinic is part of the network of institutions and bureaucracies that include public assistance, Medicaid, and Social Security. These institutions both provide and frustrate. At least, they are the potential source of provision. In fact, a person dealing with one of these systems is likely to encounter an overworked, harassed clerk whose mandate is not to provide benefits to anyone who cannot demonstrate impeccable qualifications of need. Could there by an external situation better calculated to evoke Fairbairn's inner world of exciting (that is, tempting) and rejecting (that is, frustrating) objects? In Fairbairn's picture of the inner world, the self is seen as split into two, a needy, desirous self (the libidinal ego) attached to the exciting object and a self that rejects need (the antilibidinal ego) attached to the rejecting object. Thus is depicted the combination of desperate need and hatred of both self and other that is felt by many poor patients as they apply for, or are asked to come for recertification of their need for, public assistance.
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Psychoanalysis and the Urban Poor 41
An object relations approach can thus lead us to re-conceptualize the relationship that economically deprived patients have to the institutions in their lives, including mental health clinics. Such relationships can be described as transferential, that is in object relations terms, as evocative of internalized object relationships, in the same way that Joseph (1988) discusses transference as a reaction to the "total situation" of the analysis. The nature of the institution in which psychoanalytic work takes place helps establish the relational context of that work. The relationship to the therapist and to the institution in which their work takes place allows patients to maintain and to elaborate their internal object worlds on an external stage. Fairbairn's depiction of that object world seems particu- larly apt in elucidating the sort of internalized object relationships likely to be elicited by the sort of stage that is presented to the patient in public clinics.
Recall now the intern and her patient, Linda. As Linda requests help from the intern with SSI, the intern finds herself identified, despite their conversation about her life, with the entire tantalizing social welfare system. In principle, is this situation different from any other trans- ferential situation? Perhaps there are echoes here of what we would presume was Linda's experience with a parent. As one considers the therapeutic possibilities in this situation, Linda herself becomes a sort of exciting and rejecting object. A would-be therapist would like to engage her in an examination of these issues, but she is so elusive. Counter- transference is induced, which, as Bollas (1987) points out, can be the analyst's entree into the patient's inner world.
Let us examine one likely transference-countertransference configura- tion that can be created by a patient such as Linda when she misses appointments. Particularly when there has been a session that stimulates some hope for productive work together, such a patient can leave the therapist feeling rejected, abandoned, angry. The therapist in a public clinic may, after many such experiences, bypass such feelings and say to herself, in effect, "Good. Now I have time to relax or catch up on my reading." She may hesitate to call the patient, if it seems too much like pursuing her. On the other hand, she may feel that she is abandoning the patient, perhaps in a retaliatory way, if she does not pursue her.
From an object relations perspective, what we are dealing with here can be seen as the patient's way of processing her own experiences of unreliability on the part of important people in her life. As the therapist feels rejected, despairing, or angry in relation to the patient, the therapist is sampling the patient's own experience. The situation provides the
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opportunity to feel one's way into the patient's object world, into her experience. This is a process described by Bollas (1987) as follows: "The analysand not only talks to the analyst about the self; he also puts the analyst through intense experience, effectively inviting the analyst to know his self and his objects" (p. 250).
Sometimes there is an added twist to this scenario. After missing several weeks, perhaps after the case is closed in the clinic, the patient may show up without an appointment, as Linda did. The patient may, in addition, be in crises. With some patients, this pattern can become the modus operandi in the clinic. In extreme cases, patients may come only in crisis, without appointments, and rarely, if ever, keep the appointments that are offered to them. From an object relations perspective, one can find in such a situation the patient's attempt to maintain contact, a connection, with people who are experienced as basically rejecting, unreliable, and ungiving. That is, a crisis coerces a response. A crisis dramatizes the need of the patient to such an extent that a caretaking response is virtually guaranteed. Ogden (1986) makes a similar point in stating that self-other boundaries are blurred in a crisis. For Ogden, crises are a way of reestablishing the "unmediated sensory closeness" charac- teristic of Melanie Klein's paranoid-schizoid position. In the later de- pressive position, whole object relatedness is associated with a sense of isolation, which can be reversed when a crisis brings people together, Ogden writes: "Crises are not events which occur between separate people. They are events in which patient and therapist are 'in it togeth- er' " (p. 123). In responding to crises, the therapist experiences the patient's way of maintaining or attempting to maintain object ties in a depriving environment.
The therapist is in a very uncomfortable position as she begins to empathize with and sample the patient's experience of abandonment and despair. The "burnout" with which therapists in public clinics struggle is akin to a generalized "burnout" that can be observed in poor patients. In other words, one is tempted to withdraw, to give up, in the face of the anxiety, sense of futility, and despair that are engendered both by the patient's psychological situation and by the overwhelming social prob- lems that impact on him or her. One way of coping with these feelings is to question the suitability for psychoanalytic therapy of inner-city pa- tients. One may thereby justify not engaging the pain of these patients' lives, while taking the focus off one's own sense of helplessness and futility.
Problems such as missed appointments and presentation in crisis are
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formidable therapeutic obstacles; how are we to approach the issue of the feasibility of dynamically oriented therapy with patients such as Linda? I hope to have demonstrated in this paper that these clinical phenomena can also be seen to have a communicative function that is potentially therapeutically useful. Linda's behavior can be received and processed by a dynamically oriented therapist in the service of understanding the patient's experience. This is so even when there are many missed appointments; in fact, from an object relations point of view, one might say that missed appointments, crises, and requests for concrete help are necessary for the therapist to begin to feel his or her way into the patient's world. By contrast, from an ego psychological point of view, as presented and expanded by Fred Pine, such clinical phenomena are evidence of ego deficits, rather than modes of induction into the patient's inner world. These deficits then call for supportive measures and attention to the so-called nonspecific therapeutic factors, such as the analyst's reliability and nonjudgmental attitude, rather than an examination of the inter- nalized object relationship that is being replayed.
Can one intervene in a therapeutic way under these conditions? Pine, as we saw, provides us with a rich array of supportive measures so as to make the situation less anxiety-provoking to the patient, while increasing the ability of the patient to manage anxiety-provoking experiences.
From an object relations perspective, missed appointments, crises, and so on are the ways in which the therapist becomes what Greenberg calls an "old object," a modern representative of an internalized object. The therapeutic issue is whether the therapist can also be enough of a new object for the patient to allow for change to occur in the patient's inner world as a consequence of the analytic work. In Fairbairn's (1958) terms, can the analyst avoid being "press-ganged" into the patient's internal object world, like everyone else in the patient's life?
This is a knotty problem with any patient. It is not easy to find the proper balance between being an "old" and a "new" object in the patient's world. In the case of a patient from the lower socioeconomic classes, I submit that there is an additional complication, which is that depriva- tion is an ongoing and real factor in the patient's life. The therapist's position as a modern version of the internalized exciting and rejecting object is reinforced by the socioeconomic differential between patient and therapist, by his or her position as part of the social service network, and by the real power he or she potentially has as an advocate. Some of these issues can be illustrated now with a second vignette.
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The Case of Nancy
An 18-year-old woman, Nancy, from a lower-class family now in its third generation on public assistance, was in her second year of once-a-week treatment. She reported a dream to her male therapist in which she surreptitiously put her hand in his pocket and found a $100 bill. This session was the first in which the therapist had asked Nancy for dreams. Her associations explicitly to the dream had to do with thinking that perhaps she was about to come into some money, but she had no idea how the therapist might be involved. She went on to talk about feeling re- sentful that the father of her year-old baby was failing to provide financial support as promised. She said that she hoped to be able to locate her father, who had been released from prison, she thought, and might be somewhere now in the community. He had always been supportive when she was a little girl, she said with tears in her eyes, but every man in her life who was ever supportive let her down sooner or later.
At the end of this session, the therapist wrote out a slip for Nancy that allowed her to receive bus fare from the clinic receptionist. Patients such as Nancy who are on Medicaid are entitled to reimbursement for their travel expenses to medical appointments. On this occasion, Nancy took the slip and then asked the therapist if he would write out slips for two of her younger brothers, who had accompanied her to the clinic and were sitting in the waiting room. The therapist hesitated. The therapist was in the habit of writing a slip for one of her brothers who accompanied her, because Nancy said she never ventured out alone in the neighborhood where she lived. The therapist felt some justification, but he also felt uneasy about giving bus fare at all. One of Nancy's brothers, who lived at home, was a daily drug user, despite having no visible source of income. The two other brothers probably used drugs as well, at least occasionally. Was it right to give money for bus fare to her brother, knowing that he was probably spending considerable sums on drugs? With these thoughts in mind, the therapist said he could give a slip for bus fare only to Nancy and one brother. Only after Nancy left did the therapist note the parallel between the dream and the request for extra bus fare at the end of the session.
How are we to understand this dream, along with the ensuing events in the session? O n one hand, they suggest that the patient sees the therapist quite literally as a source of money to be exploited. What are the deeper resonances of this view of the therapist? A drive-based view
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Psychoanalysis and the Urban Poor 45
might give primacy to a sexual element, insofar as she is putting her hand into the therapist's pocket to find money. Perhaps the money can be seen as a symbolic representation of the therapist's penis, and a sexual wish is being portrayed in the dream. An ego psychological perspective might call attention to the patient's difficulty with frustration tolerance. The frustration involved in the therapeutic situation leads to an attempt to get the therapist to gratify the patient in a concrete way, whether the gratification is seen in sexual or monetary terms. This attempt could be seen as "resistance" to an analysis of the underlying wish as a manifesta- tion of an ego weakness that must be managed in order to make interpretive work possible, or as both. There might be seen here evidence of an antisocial personality structure, perhaps based on defenses against underlying feelings of deprivation.
A Fairbairnian perspective would call our attention to the way in which the therapist is portrayed in the dream as an exciting object. The exciting quality can be linked to the therapist as the bearer of money, as a sexually exciting object, or both. The dream, in fact, seems to imply an identifi- cation of sexuality and money, or nurturance, more broadly. The ther- apist as rejecting object also seems inherent in the dream. Why else would Nancy need to take the money from the therapist surreptitiously? The way in which the session ended, in fact, seems to leave the therapist in the role of depriving object. From this perspective, then, the bus fare issue has provided a focus for the manifestation of the patient's internal object world in the therapeutic setting. The therapist has become an "old object." The therapeutic problem is how to shift one's position away from enacting the internal drama with the patient, to examining with the patient the nature of the dream and the ways in which the script is written.
I would like to call attention at this point to the way in which the administrative structure of this clinic plays a role in this vignette. The fact that the therapist fills out the bus fare slip means that he is put in the role of deciding who gets the reimbursement and who does not. From one point of view, the therapist's neutrality and anonymity are compromised when he is in the role of dispensing or withholding money. The trans- ference becomes uninterpretable because the therapist has taken action in reality. From this perspective, the bus fare decisions should be made by clerical or administrative staff to preserve the therapist's neutral position, so that the patient's transference fantasies can be properly analyzed.
From a relational perspective, the administrative issue brings us back to the question of how the therapist can strike the proper balance
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46 Neil Altman
between being an old object and being a new object for the patient. As with Nancy, when the therapist manages the dispensing or withholding of money, the stage is set for the therapist to be seen as an exciting and rejecting object by the patient. A focus is provided. Is this a desirable development from the point of view of the treatment? In some cases, it may be so. The bus fare issue may provide a focus for the analysis of these transference issues when the therapist is being seen primarily as a new object by the patient. In other cases, the therapist may already be seen, in an excessively concrete way, as an exciting and rejecting object. The socioeconomic differential between patient and therapist makes it quite likely that the therapist will be seen in this way by many patients. In these instances, the therapist's involvement with bus fare may "heat up" the transference feelings further and work against the development of a view of the therapist as a new object. It may become difficult to find any sort of detached perspective from which to view, with the patient, the transferential perceptions that have developed.
Administrative Issues
Moving beyond the specifics of Nancy's case, I would now like to conclude with some further observations on the administrative structure of public clinics, based on the need to think psychoanalytically about the context in which we work. In particular, I would like to focus on how administrative policies and structures may have an impact on the therapist's attempt to find the optimal new object-old object balance for facilitating analytic work. I focus on three ways in which I think that administrative factors are conducive to the perception of the therapist as exciting and rejecting object. For some patients, the result may be that the closed system of internal reality is reinforced; the therapist does not become sufficiently the new object for therapeutic work to proceed.
Medicaid, that is, public funding for medical care for poor people, is a source of two problems at present. One problem is that patients on Medicaid pay nothing for their treatment; the second is that missed appointments are not reimbursable.
When patients pay the therapist for their treatment, an egalitarian element is added to the situation. The therapist is being hired to provide a service. While transference tends to put the therapist into a parental
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Psychoanalysis and the Urban Poor 47
role, the economic arrangements provide some degree of counterpoint. When Medicaid pays, the therapist and the psychotherapy itself become a benefit. How could the therapist be more effectively set up as an exciting object? Requiring at least token payments would facilitate the therapist's assumption of new object status.
In private practice, the therapist is able to tolerate some missed ap- pointments as long as the patient is willing to pay for them. Whether missed appointments are seen as defensive or as the reflection of an in- ternal object situation, they can become part of the therapeutic work. When Medicaid does not pay for them, the therapist comes under ad- ministrative pressure not to continue treatment when appointments are not consistently kept. With deprived patients one is most likely to be drawn into their inner world through their missed appointments. If missed appointments endanger the treatment, the therapist is put in the position of becoming an unreliable, if not retaliatory, object. It would facilitate the work, then, if Medicaid allowed for some missed appoint- ments. Aside from the rationale presented here, there are reasons to do so even from within a medical model. Insofar as compliance with treat- ment is an issue within medicine, it would make sense for physicians to be able to work on an ongoing basis with initially noncompliant patients.
Next, let us consider the way in which public clinics deal with emer- gencies. Emergency situations often lead to hospitalization, which is a very expensive treatment modality. In an attempt to minimize cost, there have recently been established "crisis teams" to do intensive crisis intervention on a short-term basis. When the crisis is past, the patient is returned to her therapist or referred to one. Insofar as crises and emergencies are the way in which some patients attempt to establish contact with a depriving object, however, it is critical that the therapist who does crisis interven- tion be able to follow the patient beyond the crisis. If the patient comes to an emergency room or a crisis team and is transferred out as soon as he or she is stable, the likelihood is that stability will become associated with loss and further deprivation. In this way one encourages a crisis-based approach to establishing contact with caregivers. As crisis manager, the therapist becomes like the parent who is not available to a child unless the child can foment an emergency. It would facilitate the work, then, if crisis intervention were integrated, as far as possible, into the usual clinical responsibilities of the staff in a clinic.
Lately, insurance companies and Medicaid have been moving toward putting caps on the length of treatment. Behavioral goals are set up, and
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treatment must be rejustified if it continues beyond a fixed number of sessions, if it is reimbursed beyond that point at all. From any psychodynamic point of view, such arrangements are problematic ther- apeutically. Symptom relief, whether it is seen as "transference cure" from a Freudian perspective or "compliance" from Winnicott's point of view, leaves unchanged the less tangible psychopathological situation. From a parent-child model, it would be as if economic considerations deter- mined when children had to grow up. From an object relations perspec- tive, the economic factors potentially put the therapist in the position of reinforcing the patient's expectation of abandonment. As society be- comes less willing to pay for psychotherapeutic treatment, the opportu- nity to work with the patient's inner object world diminishes. In order to work effectively with a patient such as Linda, then, the length of treatment needs to be based on the patient's need-I want to emphasize that I am not thereby advocating long-term treatment for everyone, since I believe that patients need to leave treatment, as well as to be able to stay in it for a period of time. We should be free, however, to adapt to our patients' need to stay and to leave, as they see fit.
In conclusion, at this historical moment, the influence of psychoanal- ysis on work in public clinics seems to be on the wane. I mean to buck this trend in this paper, to argue for more, rather than less, influence for a fully psychoanalytic approach to lower socioeconomic-status patients in public clinics. I hope to have demonstrated that the psychoanalytic per- spective is necessary for a full and rich understanding of the influence of the institutional context of the work, for an enlightened approach to mental health administration, and for the clinical management of many events that tend to occur in therapy in this context. I further hope to have demonstrated that an object relations-based approach potentially coun- teracts the common tendency toward a two-tiered psychoanalysis, in which lower-class patients are often shunned or treated in a "modified" fashion.
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