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.
Tuesday, October 23, 2012 at 3:28 am
the fact that what I shall refer to as your intelligence is ‘obviously class-based’ does not seem to stop you from being quite confident in judging that those from outside your own class group can make intelligent comments. You see your dilemma.
Tuesday, October 23, 2012 at 6:34 am
Hi
I found your article on class distinction an types of psychotherapy very interesting. We don’t have quite that disctinction here in Canada where CBT is all the rage. Once can get insight oriented treatment if one pays out of pocket. However, insurers, for all classes, prefer time limited, evidence heavy CBT. I was involved in a study of whether folks living in very marginalized circumstances with mental health issues could benefit from psychotherapy. We chose CBT simply because it is the most widely researched therapy. I have training and both, but in this case, for study reasons, we were confined to CBT. When we pitched it at the local health centre, members of the staff, hardened veterans of working in these neighbourhoods swore up and down it was a waste of time because they patients would not show up or do their CBT homework. One of my collaborators spoke up; “I have news for you. Rich people don’t show up and don’t do their homework too”. We went ahead with the project. The only barrier to access was referral. Only the physicians referred to me for the first year. No nurses, no social workers. They were very slow to take this up despite being me being “the only game in town”-the only place to get therapy. Once the psychistry department heard about me offerring free CBT, I got a lovely office space on the 17th floor and threereferrals initially. The first was an octegenarian millionaire who was passively suicidal. In the end, I found that working with folks living in marginalized circumstances was very rewarding. They came, they did their homework, and most of all, I loosed the boundaries of CBT and found myself working from a psychodynamic perspective more and more, because that is what they wanted. What I found was that lots of insight was generated. Some could, some could not. But in the end, insight was rarely enough to help them change years and years of maladaptive behaviour. In the end, I think that what many of my patients in the study wanted was a combination of insight and technique oriented treatment, just for much much longer than the 12 weeks we were able to offer.
Tuesday, October 23, 2012 at 6:51 am
This is strikingly similar to how lower-class people are shunted into highly disciplined, assessment-oriented educational environments, while it turns out that the children of the upper class do just fine with open-ended, exploratory styles of learning (i.e., “actual education”).
Tuesday, October 23, 2012 at 7:23 am
Jason,
That is an interesting study and I have also heard the whole “community mental health patients are too [stupid, lazy, irresponsible] to do homework.” I”m not against providing people with skills and this is consistent with psychodynamic supportive psychotherapy but I think the way CBT is often framed underestimates the individual’s intelligence. Not to mention that one of the primary benefits of individual therapy is allowing the patient to space to discover personal truths rather than educating people about what works and what doesn’t. Also, CBT doesn’t really understand or address transference something that I think is pretty important. I absolutely agree that 12 weeks is woefully inadequate for successful treatment. Given that most CBT studies eliminate anyone with more than the the symptom under focus (excluding multiple determinants such as substance abuse, suicidal thoughts, psychotic symptoms, etc.), I suppose they only treat individuals with neat and isolated problems. I have yet to meet this mono-symptom person in the public sector.
Tuesday, October 23, 2012 at 7:34 am
Adam, yes that does not surprise me. People never stop to examine how the expectations of the person providing the service (therapy, education, etc) might over-determine the performance of individuals receiving the service.
Tuesday, October 23, 2012 at 7:50 am
I’m not sure I know what Daniel is saying with his comment.
Tuesday, October 23, 2012 at 9:32 am
I think it was an attempt at a “gotcha comment” but it added nothing to the post and probably deserves to be trashed.
Tuesday, October 23, 2012 at 10:01 am
Firstly, as a matter of history, it’s patently false to say that ‘intelligence’ has ‘always been’ a class construct. If you mean that given that many forms of intelligence relate to certain kinds of cognition that are, of their essence, dependent on certain forms of iintepersonal nteraction, then there must be an intersubjective element in the assesment of some forms of intelligence, then I agree. But, as a matter of even the fuzziest logic, the inability to say where a line is being drawn does not free us from the commitment to the notion that a line can be drawn. You see how this makes a difference?
Now, given the status of the above as ‘local assumptions’ (just for the time being), it’s also true that in the tediously egalitarian world of the Statues and Britain, CBT is of course (like all the bowel-clenching horror of the ‘personal effectiveness’ end of the spectrum – cf. Landmark Forum) not going to allow for a more societal model of how people should be, precisely because of its functionalist, suffering-free model of what counts as success. Personality disorder is not a diagnosis, it’s a criticism.
Someone less bored can myself and who respects the author of this hand-wringing inelegant rubbish can fill in the banks between a temporary grating of the second paragraph and seeing how there might actually be some merit in ‘class-based’ shortcuts in certain flavours of insight psychotherapy.
Tuesday, October 23, 2012 at 10:03 am
I wrote too quickly: let me quickly apologize for the two obvious aberrancies of orthography in the last paragraph.
Tuesday, October 23, 2012 at 10:14 am
Wow. Productive discussion ensues!
I think Daniel’s stumbling block may be that the implicit distinction between class-based ways of measuring intelligence (SAT) or class-based prejudices about intelligence and some common-sense notion of “real” intelligence is not made explicit. Hence an inattentive or uncharitable reader might assume that Jeremy, in claiming to be an adequate judge of intelligence, is actually claiming class privilege and “reinscribing” all those hurtful prejudices, etc.
Before this heats up too badly, I would encourage you to reread the post with the implicit distinction between two ways of using the term “intelligence” in mind and also perhaps keep in mind the author’s own broadly left-wing commitments. Then maybe we could start over and pretend your first comment and your overly defensive and harsh second comment never happened!
Tuesday, October 23, 2012 at 11:33 am
Adam clarified what I should have made more explicit. I agree with Daniel’s comment about personality disorders, although, to be fair, there is a serious price to pay for not adapting to society (even if adaptation should not be the goal of treatment).
One should also be clear that even modern measures of intelligence such as the WAIS (not college achievement or predictive assessments like the ACT OR SAT) is highly dependent upon vocabulary which is certainly impacted by class and the quality of education one receives (which is invariably influenced by economics).
I really had no intention of having a discussion about the history of how intelligence has been mesaured or the historical relationship between class and intelligence. I’m really more interseted in distinguishing between common-sense notions of intelligence and contrasting it with psychological mindedness or insight. I merely meant to say that our notions of intelligence do not necessarily correlate with insight although the way treatment is provided to the majority of people receiving psychotherapy continues to treat uneducated and poor people as if they cannot handle more searching and insight-oriented approaches. This is a tragedy and it is bullshit.
I would like to redirect the discussion to the psychotherapy side of things as this was the main focus of my post.
Friday, October 26, 2012 at 6:06 pm
Adam, the aberrancy (ab-errancy, as your Heidegger would doubtless have it) that the internet encourages has resulted in my looking at your home site and work. How are you finding UC? A friend of mine teaching in one of your interdisciplinary programmes found his students scabrously apolitical.
Back to intelligence. Jeremy, unless you’re going to strip intelligence of its capacity to reflect upon itself, and its intersubjective embodiedment in such a way as produce coherent, if evanescent, propositional content, then vocabulary is always going to matter. For these tools (and vocabulary exists merely at one end of a spectrum of such instruments, albeit an important end) are not ‘mere’ tools, but they themselves pose and suggest levels of problem, thought, and subtle relation which are the nub of what one calls intelligence. Of course, it is of the nature of subtlety that it depends upon a hard-to-build-in-five-minutes deep web of mutual understandings, at once social and linguistic, which what we, prereflectively, call ‘civilised’ environments allow, and which displays a ‘necessary though not sufficient criterion’ relation to certain levels of free time and access to inner reflection, which not all socio-economic arrangements foster. My next door neighbours, refugees from Mogadishu (forgive the Montaignesque obliquity), are illiterate. With the exception of the pleasingly quiet and reflective younger daughter, who finds the very noisy environment difficult, because she doesn’t read. She says she grew up in a culture where nobody could read, and that people were forever ‘interacting’ (note the verb) in ways that I would find rather invasive.
After a while, after all, it’s not the ‘car-crusher’ powerful “man shall not live by logical relation of propositional content alone” flavor of cognitive ability that we tend, as humans, most to value. Sure, the hard flame of rationality and logic should shine its light everywhere, but we value that ability most when it knows how to apply its firepower relevantly to the knowledge-domain in question. This is ineradicably societal, and rightly so. But not perhaps in the way that you want, Jeremy. Rather, certain kinds of socio-economic arrangement promote the kinds of intelligence that we value more than others. Indeed, it is rather the commodification of intelligence (something rooted in the various drives for the West’s current evil, ‘social mobility’, and a highly geographical mobile labour market) that has caused the development of snapshot measurements of something that is itself best appreciated in non-snapshot ways. There is a connection here with the vile proliferation of personality disorders. I am currently based for a while in Transylvania. Being sociable and of a high sex drive, I meet lots of guys. One really notes the effects of the internalization of this language of personality disorder here, by its absence. Just as (now I’m really moving too quickly, and I apologize), one can see the teenage cult of the Vampire in the states as the last gasp of the false ego-driven drama of identity politics.
Saturday, October 27, 2012 at 6:43 am
Where are you getting that I’m at UC?
Saturday, October 27, 2012 at 7:19 am
Also, good grief — Jeremy’s basically saying above, “Class bias leads people to think lower-class people are dumb, but that’s not my experience.” That’s it. None of what you are saying is relevant or helpful.