Minding Race and Class in Psychodynamic Psychotherapy
Integrating Race and Class into Transference-Focused Psychotherapy
Psychoanalysis in the Barrios: Race, Class, and the Unconscious demonstrates that psychoanalytic principles can be applied successfully in disenfranchised Latino populations, refuting the misguided idea that psychoanalysis is an expensive luxury only for the wealthy. As opposed to most Latin American countries, where psychoanalysis is seen as a practice tied to the promotion of social justice, in the United States psychoanalysis has been viewed as reserved for the well-to-do, assuming that poor people lack the “sophistication” that psychoanalysis requires, thus heeding invisible but no less rigid class boundaries. Challenging such discrimination, the authors testify to the efficacy of psychoanalysis in the barrios, upending the unfounded widespread belief that poor people are so consumed with the pressures of everyday survival that they only benefit from symptom-focused interventions. Sharing vivid vignettes of psychoanalytic treatments, this collection sheds light on the psychological complexities of life in the barrio that is often marked by poverty, migration, marginalization, and barriers of language, class, and race. Join the editors of Psychoanalysis in the Barrios, Patricia Gherovici and Christopher Christian, for the book launch on March 8th.
In his chapter, “Treating Borderline Personality in El Barrio: Integrating Race and Class into Transference-Focused Psychotherapy”, Dr. Daniel Gaztambide outlines an integration of cultural difference, race, class, and identity into Transference-Focused Psychotherapy (TFP), a psychoanalytic evidence-based treatment for Borderline Personality Disorder (BPD), using a systemic lens to understand those differences within a context of socioeconomic and political inequality. This inequality — between those psychically and socio-politically configured as “have” and “have-nots,” the richest and the poorest, oppressor and oppressed — is integrated with the psychoanalytic literature on the impact of race, culture, and inequality on the psyche, with insights from Liberation Psychology. Liberation Psychology, with its emphasis on the dynamics of internalized oppression, is used to outline a “cultural adaptation” of TFP, and discuss how reflection on these dynamics can inform psychoanalytic treatment for Latinos and other people of color with BPD in the inner city. Read a case illustration from Dr. Gaztambide’s chapter below.
“Felix” (pseudonym) was a 35 year-old, bilingual (Spanish-dominant), Afro-Colombian man who initially presented for treatment complaining of “chronic major depression” in the context of years of unemployment after being fired from his last job. He had been previously treated with psychiatric medication and a combination of short-term counseling and anger management. Upon further assessment, Felix reported an extensive history of difficulty managing anger and hostile behavior, self-harm via putting out cigarettes on his arms, emotional lability, a pattern of unstable relationships characterized by idealization and devaluation, chronic feelings of emptiness, identity diffusion, and stress induced paranoid ideation, meeting diagnostic criteria for BPD.
Felix reported a history of involvement with the criminal justice system, with multiple arrests for getting into fights with others, including police officers. His aggressive behavior and history of incarceration impaired his efforts to find and maintain steady work, as he often left jobs impulsively, or was fired as a result of an angry outburst. Part of what emerged in the assessment phase was Felix’s persistent sense of feeling targeted by the police, “stopped and frisked” on a regular basis, due to the color of his skin. As a Puerto Rican man, I resonated with his experience of police harassment. At the same time, I noted how Felix related to others in life as if they were persecutory, intrusive others with malignant intent. As we were conducting the sessions in Spanish, he also detected my accent and identified me as a Puerto Rican, commenting on how he’s “had good relationships with Puerto Ricans, they are good people.” I tracked the emergence of two interrelated object relational dyads — that of a victimized, powerless self/person of color before an intrusive, persecutory other/police officer, alongside a (split-off) positively toned dyad characterized by identification between two Latino men.
In negotiating the treatment contract, attention was given to Felix’s experience of his aggressive and self-harm impulses being wholly outside of his control. The alternative to fighting, for Felix, was to pace while smoking cigarettes, ruminating about the violence he wished he had delivered on someone who wronged him, often ending with putting out his cigarette on his arm to “release the tension.” These behaviors were explored, resulting in the stipulation that to engage in treatment, Felix had to agree to physically withdraw from or avoid altercations with others, and draw on support resources, including visiting the nearest emergency room, if he felt in danger of acting on his self-harm or aggressive impulses. Felix initially scoffed as this prospect, defiantly responding that he “would punch the first son of a bitch who crossed me.” I expressed to him that while his reaction was understandable, and it would certainly be important to discuss his anger in more detail, we would not be able to engage in therapy effectively if he could not agree to these terms, as I could not help him if he were dead or in jail. I added that if Felix chose not to participate in this treatment, he could be referred to another clinician or treatment setting.
Felix verbalized an understanding of my reasoning, and following further discussion, agreed to our safety plan. In addition, given his history of depression and unstable work, I discussed the importance of his engaging in some form of productive activity as a part of his treatment. While acknowledging the barriers he faced as a man of color with a prior criminal record, we discussed a plan for him to participate in a vocational rehabilitation program as part of his care. Upon being connected to a job, the contract was revised to include a requirement that he discuss any aggressive thoughts or impulses to suddenly leave his job in session. Having established our treatment contract, we engaged in twice weekly psychoanalytic therapy informed by TFP’s principles.
Felix’s fantasies about our “shared” identity became a topic of ongoing exploration. I increasingly pointed out how he alternated between an intense level of closeness or “confianza” (trust) with others in life, by whom he would “inevitably” feel betrayed, and then viciously attack them in response before cutting them off, now taking on the role of the persecutory other. I also began to note that he seemed to go to great pains to cast me in the role of an almost omnipotently benign Latino other, whom he trusted without reservation, almost as if any slight or momentary misattunement on my part would be intolerable, requiring him to attack me and cut me off. Felix initially dismissed my interpretation, citing his warmth toward me and our shared cultural background as proof of the strength of our relationship.
Over the next few sessions, however, Felix became increasingly irate with me, discussing how the stipulations of our treatment contract felt like “chains that keep me from fighting back.” He now saw the safety plan as my attempt to “declaw” him and render him docile before his oppressors, referring to me as a “traitor” to the Latino community, someone who was “basically white.” Felix berated me as “just another part of the system,” whose purpose was to control him. Being a Puerto Rican with white skin, this series of attacks triggered my own anxieties as someone who “made it” and achieved a middle class income, professional/managerial class status through my education, and in no small part benefiting from white privilege. My anxieties centered on the perception, within and without, that I was not “really, authentically” Latino, my own body drawing praise (for “being white”) as much as scorn (for not “being brown”). I felt the impulse to defend myself and validate my identity and my sense of goodness. As I reflected on my experience of being attacked, put down, and belittled for my body, I began to disembed from my immediate emotional arousal, working my way through the counter-transference back to Felix’s own experience.
I struggled to maintain a reflective, neutral stance, non-defensively inviting Felix to tell me more about his experience of me as a traitorous white Latino looking over his shoulder, ready to stab him in the back and send him off to the authorities to be locked up. I clarified with him the “actors and the action” of the dyads which were crystallizing in the transference. I interpreted that in negotiating the treatment contract, to ask Felix to withdraw from a confrontation and go to the emergency room (if he could not restrain the impulse to fight or harm himself) felt to him like I was tying his arms behind his back, leaving him defenseless before a world that attacked his black body as something “dangerous,” suspect, and intrinsically bad. I added that feeling “restrained” with me also meant being vulnerable in a way he was not used to with another person, something he needed to defend against lest he be inevitably hurt and betrayed. Felix’s affect shifted, from rage to a mournful sadness, remarking on how he is always “waiting for the other shoe to drop” with others in his life, filled with fear and anxiety at how they would “turn on him.” Further clarification of this dyad led to us confronting (pointing out discrepancies between) how he split off his yearnings for safety and care from his fear of vulnerability. It soon surfaced that a part of him experienced our initial treatment contracting, and the establishing of the parameters for safety, as my caring enough about him to set limits on his destructive behavior.
In the months following this series of confrontations and interpretations, Felix reported an incident in which a police officer helped him with directions to a building related to his job. He reflected on this experience in treatment, taken aback by the kindness and professionalism he experienced from this officer, feeling that he “took care of me.” He began to make a distinction between individual police officers — who could be “good,” or “good and bad” — and a larger system of racial injustice that could “turn” even good officers into problematic cops (e.g. Alexander, 2012). With this more systemic perspective on issues such as police brutality or harassment — not to mention the increasingly visible incidents of police-related deaths of people of color — Felix developed a more integrated perspective on himself and others. He began to see other Latinos and people of color in less idealized terms, while also seeing individual white people in a more nuanced light. He maintained an awareness of white privilege and racial inequality, but no longer defined himself one-sidedly in terms of race and ethnicity, allowing for a fuller range of human experiencing. Felix discovered an affinity for the spoken word, and found himself not only expressing his political and cultural views using poetry and art, but also musing on topics related to love, vulnerability, and creating a home for the heart.
The use of art further allowed Felix to identify the aggression he regularly disowned and projected upon others, by writing his poems from the perspective of the other as well as his own. This helped Felix develop insight into how his intense anger drove others away, and impaired his ability to work and function. It was in this stage of the work that Felix was able to observe, in its rawest form, how his behavior reflected his own “inner police officer,” participating in his oppression. Exploration of this material further revealed his expression of anger not only as a response to fear or perceived injury, but as a pleasurable affect he wanted to see if I would tolerate, accept in him, and help him regulate (via limit setting).
Excerpted with permission from Taylor & Francis Group. Psychoanalysis in the Barrios: Race, Class and the Unconscious is available for purchase on the Routledge website here, and on Amazon here. Join the editors of Psychoanalysis in the Barrios, Patricia Gherovici and Christopher Christian, for the book launch on March 8th.
Dr. Daniel Gaztambide is a psychologist in private practice in New York City. He is an assistant professor of psychiatry at the Icahn School of Medicine, and assistant professor of psychology at the New School for Social Research.