I was at The Association for the Psychoanalysis of Culture & Society conference this weekend presenting a paper on social conformity and Lacanian technique at Rutgers University. This conference is primarily attended by academics and clinicians committed to psychoanalysis and social justice. I heard a variety of interesting talks but one of the most interesting comments I heard was from Dr. Jama Adams from the John Jay College of Criminal Justice. He made a comment during his talk about the class biases underlying the delivery of psychotherapy to the general public. He noted that poor and working class folks primarily receive treatment that focuses on regulating their behavior (e.g. CBT or anger management) whereas the treatment of middle to upper class folks is non-directive and insight-oriented with a focus on performance and production. The underlying bias is that poor and working class folks are not intelligent or psychologically minded enough to benefit from a more exploratory, open-ended treatment.
I wanted to explore this idea in more depth. First, the majority of my patients are in the working class or on SSI disability and I attempt to provide psychoanalytic psychotherapy, basing my style of treatment not on class but on level of pathology (more supportive treatment for individuals who suffer from psychosis and more exploratory treatment for individuals who are neurotic). One of my major frustrations in the past has been working in a process group with a fellow group leader who continued to claim that “these types of clients” (read uneducated) couldn’t handle an open-ended process group and that they required structure and prepared topics for discussion. It never occurred to me until this weekend just why I found her claim offensive. Her comment betrayed a low belief and estimation of those patients’ capacity to engage in exploratory, insight-oriented group work. Second, this bias seems to confuse psychological mindedness with level of education and intelligence. I’ve heard some of the most amazing insights from individuals who would not normally classified as “intelligent” (although our notion of intelligence is obviously class-biased). Intelligence has always been a class-construct and it’s no surprise that the SAT is consistently predicted by family income level. Third, I’ve consistently found that courage is one of the most important characteristics that enables a patient to benefit from psychoanalytic therapy. Freud’s ethic was always driven by his desire-to-know. This means helping patients confront truths and traumas that they have spent their entire lives trying to avoid. Of course, a person’s education does not strengthen courage and does not make one more open to examining her unconscious. Finally, one needs to be aware of how the social order is treated in treatment of both poor and rich folks. Presumably, working class folks are given behavioral management treatment to fix individual problems, implicitly suggesting that their problems are their own fault and not due to larger social forces. This explains the insane focus on attitude in CBT that is provided to working-class folks. The current ideology is that suffering and psychopathology are a result not of the social order and shitty life experiences but due to the individual’s negativistic outlook. This idea is not only woefully naïve but it betrays a sense of omnipotence to defend against feeling out of control in an economically insecure time. Insight-oriented treatment for middle-class and rich folks focuses on production and performance, particularly emphasizing problems in work and love. Again, this approach treats the individual as the problem, failing to recognize that bourgeoisie suffering might be the result of false social dreams and not individual pathology. There’s more to say about how class impacts transference, especially when one considers the importance of the therapist’s dress as a symbol of class status, but I’ll end it here.