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Treating Borderline Personality Disorder in El Barrio

An Interview with Daniel Gaztambide

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.

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 an interview with Dr Daniel Gaztambide below.

Public Seminar [PS]: In “Treating Borderline Personality Disorder in El Barrio: Integrating Race and Class into Transference-Focused Psychotherapy,” you reflect on both the utility and limits of a traditional transference-focused therapy (TFP) approach to the treatment of latino patients with Borderline Personality Disorder in the inner city. Can you tell us a bit about your process of refurbishing and expanding the approach to meet your clients needs?

Daniel Gaztambide [DG]: As a trainee I received a lot of training on the treatment of Borderline Personality Disorder (BPD), both at the Center for the Intensive Treatment of Personality Disorders (CITPD) and the St. Luke’s Adult Outpatient Psychiatry Clinic. Given the diverse population I was working with, the predominance of complex trauma and BPD, and the clinic’s accessibility to communities in El Barrio and Central Harlem, I started to think about the intersection of BPD, race, and inequality.

When I did an initial literature review on the treatment of BPD among people of color I was shocked at the meager literature available. How could there be so little clinical writing on such an important topic?

In the psychoanalytic world in particular the only paper I could find addressing the application of Kernberg’s model (which later became TFP) to people of color was Comas-Diaz & Minrath’s 1985 paper. With this piece as I guide, I realized I had to get creative. I poured over the literature on culturally adapted psychotherapy, psychodynamic treatment of BPD, and the available epidemiological literature on BPD.

There were three major findings that informed my integration of culture and race into TFP. 1) There was evidence of different “idioms of distress” for people of color, which was mediated by race and class; 2) While evidence-based treatments for BPD were effective at reducing self-harm and improving symptoms, they did not improve psychosocial functioning, such as being employed, enrolled in school, or engaged in some community activity — all areas in which people of color face greater disparities; 3) Peter Fonagy, an attachment and BPD researcher of Mentalization-Based Therapy (another psychodynamic evidence-based treatment for BPD) made a connection between BPD syndrome and Wilkinson & Pickett’s groundbreaking work on income inequality.

To make a long story short — as the level of inequality rises in a society, the greater the prevalence of social, behavioral, and mental health problems consistent with BPD. Inequality exerts this impact by reducing the level of trust people feel toward one another in a society. With impaired trust, the salience of status differences (wealth, class, race, gender, etc) increases, as does the prevalence of highly ambivalent schemas of self and other. And in psychodynamic theory as well as Liberation Psychology, of course, we have models for how these ambivalent representations of self and other become internalized, and influence our relationships with others interpersonally, but also in terms of class, culture, and race differences.

In this sense, TFP and other evidence-based treatments for people of color with BPD can then help us 1) repair channels of trust with communities that have suffered histories of inequality and injustice, which allows patient and therapist to 2) process ambivalent schemas of self and other (including cultural and racial ones), and 3) improve functioning by restoring the ability to form healthy relationships in the community, which in turn enhances the ability to pursue work, education, and opportunity. From my own point of view, this also includes building relationships of solidarity to change our communities and social systems so that they are ultimately more just.

PS: You have a background as a seminarian and as a spoken-word poet. How do these dimensions of your identity inflect your clinical work?

DG: My time at Union Theological Seminary exposed me to different streams in Latin American and Black Liberation Theology, which then led me to Liberation Psychology as a foundation for my theoretical and clinical thinking. The “preferential option” for the poor and oppressed, with its echoes of Levinasian ethics as an ethics “for the other, the poor, the widow, the orphan, the stranger,” informs my understanding of empathy as an act of recognition — but especially so for those who are most vulnerable and oppressed. Similarly, when I think of ruptures and rupture markers in the therapeutic relationship — lapses in empathic attunement — this calls forth the “cry of the other,” as understood by Enrique Dussel, but also Frantz Fanon. It is a cry that makes a demand of me, a demand that results from injury — “You have done an injustice to me! You have hurt me! Do not abandon me! Do not kill me!” The answer to this cry is to make a repair. And repair necessarily risks an act of love, an act of vulnerability. It is, to quote Emmanuel Ghent by way of Jessica Benjamin, a surrender not just to the other, but to an ethics of justice.

Interestingly enough, I actually first performed as an artist during my time at Union. I let it go for a while during my doctoral studies at Rutgers University in New Jersey, then came back to it when I returned to New York City and became more involved in the Puerto Rican community here. The work of a poet involves a certain sensibility to words and the sonic, semantic and symbolic links between them. I am a closet Lacanian in this sense. But poetry also involves what Garcia Lorca referred to as the “true struggle… with the duende” (I am indebted to my mentors, Rich Villar and Andres “Chulisi” Rodriguez, for introducing me to this). Duende “burns the blood like powdered glass” and emerges when we try “to heal that wound that never heals.” It loves dancing at the edge, where there is danger but also possibility. The coming of the duende presumes “a radical change to all the old kinds of form, brings totally unknown and fresh sensations…” Poetry that moves, that wracks the soul, takes away all pretense and performance, leaving us raw before some radical otherness that transforms by that very rawness.

Isn’t this what psychotherapy entails? Two beings having a radical encounter at the edge of knowing and relating coming closer, dangerously closer, to a wound that defies words and will not close? Duende arrives precisely at that point of intimacy, the very moment when something quite real is about to be revealed. It is in surviving that encounter together that patient and therapist create an opening for, to borrow again from Lorca, “radical change.”

PS: What’s next? Do you have other writing or research projects in the works?

DG: My first book on the history of social justice and psychoanalysis in Europe, the Caribbean, and Latin America will be coming out later this year. I’m also planning on writing a clinical book on treating people of color with BPD that will discuss culture-centered approaches to TFP and Dialectical Behavior Therapy. I am also working on a paper grounding cultural competency within an attachment theory framework, which I will present at a panel at this year’s American Psychological Association convention meeting alongside fellow faculty and director of the New School’s Clinical Psychology program, Dr. Doris Chang.

PS: Whose work has been most important in shaping your intellectual formation and clinical sensibility and why?

Paulo Freire, a Brazilian educator and author of Pedagogy of the Oppressed, and a central inspiration to Ignacio Martin-Baro’s Liberation Psychology. I fell in love with his work while I was at Union Theological Seminary, and wrote my master’s thesis on a reading of his work alongside Jessica Benjamin’s psychoanalytic-feminist model of mutual recognition. I was surprised by the parallels in their work, and only later while working on my first book did I realize this was not an accident. Paulo Freire was a good friend of Erich Fromm who recognized Freire’s work as a “historical-cultural-political psychoanalysis.” Freire also rewrote Pedagogy of the Oppressed from the ground up after reading Frantz Fanon’s The Wretched of the Earth so he could cite him. Lastly, a little known fact about Freire is that he did not originate the most important term of his work, concientizacao — “critical consciousness” — but rather adopted it from a tradition of psychoanalytically-informed Afro-Latinx thinking, going back to Alberto Guerreiro, Arthur Ramos, and Juliano Moreira. I love Freire not only because he was a brilliant thinker, but also because he drew on traditions whose insights theorize the intersections between race, economic inequality, subjectivity, and political as well as psychological liberation.

PS: Finally, what are you reading at the moment? Would you recommend this (these) book(s) to Public Seminar readers?

DG: I’m currently reading two books by the psychiatrist Fredric Wertham, The Circle of Guilt (1958) and A Sign for Cain (1966). He is perhaps infamous for being the catalyst behind the formation of the Comics Code Authority in the 1950s. Less attention is given to the fact that Wertham was an anti-Capitalist psychoanalytic psychiatrist who fought for racial justice. In A Sign for Cain Wertham articulated his criticism of racism and colonialism as symptoms of late capitalism, while in The Circle of Guilt he developed a psychoanalytically-informed and politically grounded analysis of Puerto Rico’s colonial status and labor exploitation. In our current social, economic and political landscape we need models for how to think critically about inequality from psychological, sociological, and economic perspectives, and Wertham’s work gives us one (overlooked) perspective on how to do so.

Psychoanalysis in the Barrios: Race, Class and the Unconscious is available for purchase on the Routledge website here, and on Amazon hereJoin 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.

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