The Analyst in the Inner City: Race, Class and Culture Through a Psychoanalytic Lens (Book Review)

Author:  Altman, Neil E. 
Publisher: Analytic Press
Reviewed By: David L. Downing, Summer 2001, pp. 56-58

I greeted the advance notices regarding The Analyst in the Inner City with enthusiasm and anticipation. This stemmed, in part, from my own long-standing interest in working with underserved populations. Furthermore, as a professor and director of clinical training at a school of professional psychology, I am keenly aware of the many state hospital and community mental health center internships and externships that offer varying degrees of structured programming for our professionals-in-training. These placements are often intense, disquieting; yet simultaneously very formative for students. The treatment populations are typically urban, multi-ethnic, often suffering from severe psychopathology, and of the lower social classes. There is a wealth of material written with regards to the application of psychoanalytical principles as applied to a broad range of psychopathologies, but a remarkable paucity regarding their application within particular contexts.

Finally, I was very keen to read this particular book because of my earlier reading of this particular author’s work. Dr. Altman wrote a masterful paper, “Psychoanalysis and the Urban Poor” (1993). This, as well as the accompanying article by Dr. Rose Marie Perez-Foster, which appeared in the Psychoanalytic Dialogues, represented for me very real breakthroughs for a theory and mode of treatment that had become increasingly esoterized, and disconnected from the often stark clinical realities experienced by most practitioners, psychoanalytical or otherwise. These articles have ever since been staples within a year-long psychotherapy practicum seminar I conduct, as well as my section of our program’s introductory course on psychoanalytical theories and psychotherapy. Other psychoanalytically-oriented faculty members have also found these works to be very evocative and have adopted them. But most striking has been the interest of faculty not especially psychoanalytically-oriented in their conceptual frame at all.

Chapter One, “Clinical Experiences from a Public Clinic” is largely a recapitulation of Dr. Altman’s excellent Psychoanalytic Dialogues piece. The book boasts a fine lay-out of topical chapters, including “Race, Culture, and Class” (Chapter Three), “A Psychoanalytic Look at the Bifurcation of Public and Private Practice” (Chapter Four), and “Psychoanalyzing the Context: Psychoanalysis in a Public Clinic” (Chapter Five). However, Dr. Altman’s synthesis and integration of his project’s many (too many?) ambitious and important (one could even say, necessary) agendas, as revealed in the book’s subtitle, is, unfortunately, often wanting. In particular, we really come to learn very little about the application of psychoanalytical constructs to diverse, often sorely stressed, and psychologically ill inner-city patients, as reported by this distinguished and highly experienced psychoanalyst. What too often obtains instead, are admittedly erudite and scholarly essays on the history of psychoanalysis, cultural anthropology and the psychoanalytically-informed political-economic-social theories of Eric Fromm, Marcuse, and others. Furthermore, an important subtext seems to be an indictment of capitalist political economies and an attempted rapprochement of psychoanalytical and Marxist thought.

While interesting, thought-provoking, and laudable projects on their own, to this reviewer at least, these lengthy, fairly derivative reviews seriously undermine the purported central focus of this book; as well as the creativity, originality, and voice of its author. Instead, we are given synopses of often arcane, obtuse writings that are quite difficult to so summarize; and treated to the trend, now in currency, of denouncing so-called Western-European/American political, philosophical, and psychological theories in perhaps too-strident tones. Now, it is abundantly clear that Dr. Altman is a fine scholar--and the well-researched bibliography alone is well worth the price of admission--but the philosophical concerns alone that he articulates and distills from these tomes requires far more lengthy, detailed expositions for adequate resolution than are delivered in The Analyst in the Inner City’s pages.

Also, these concerns occlude philosophical and, especially, practical matters of greater import and relevance. I am referring, for example, to the relatively brief and far too global discussion given over to the community mental health movement in the United States. There is a wealth of material available on this subject, including this movement’s use of walk-in centers, paraprofessionals, etc., that attempted to de-stigmatize mental health care, and make treatment more accessible and relevant for members of communities. We are now further away in time from the inception and halcyon days of this laudable, if flawed, experiment in mental health care, and attempting to reach new generations of mental health practitioners. Psychoanalytical and milieu models were often more the norm (or at least a valid equal “partner” amongst other treatment methodologies), rather than the exception. A more elaborated description of this attempt at community care that has been changed beyond recognition in its latest incarnations would thus be essential to impart.

Dr. Altman’s application of psychoanalytical principles to the understanding of clinical and organizational phenomena is noteworthy. For example, the discussion, à la Fairbairn’s endopsychic structure, of the excitatory and rejecting elements of the community mental health center helps to illuminate core dynamics that are often manifested on the stage of organizational life. That is, the agency (and/or psychotherapist) can be viewed as gratifying certain need states and wishes (for example, through the provision of transit tokens, snacks, helpful evaluations to receive disability income or public assistance); or withholding (Altman, 1995, p 6, 10). He offers cogent ways in which to consider and interpret the often daunting vicissitudes of working in such settings, replete with numerous pressures on the clinician for “billable hours,” made problematic by frequent failed appointments, crises, and so forth. Under such circumstances, maintaining a treatment “frame” or “holding environment” cannot be taken for granted. Dr. Altman’s attention to the symbolical, psychodynamic elements of organizational culture and life, can be helpful to consider even for the more seasoned practitioner; but is especially helpful and “containing” in establishing and adhering to a psychotherapeutic focus for the professional-in-training, new post-doctoral clinician, and so forth.

In relation to the above, there is also a striking lack of discussion regarding the many efficacy or outcome studies that helped to guide and inform community mental health programming and was part of the broader deinstitutionalization movement of the mid-to-late 1970’s in the United States. Furthermore, as exhaustive as Dr. Altman’s research certainly was, the seminal (and highly relevant here!) work by Hollingshead and Redlich (1958), Social Class and Mental Illness is given terribly short shift, and so unfortunately does little to help illuminate the important findings of their undertaking: “Academic Sociology tends to discuss social class in terms of income, occupation, and residential address” (Hollingshead & Redlich (1958), cited in Altman (1995), p. 80). Sociologists and anthropologists have consistently paid more attention, earlier on, to cultural variables and incorporating psychoanalytical theories in their research/analyses than have psychoanalysts (at least until recently). And, they have often done a better job of it, as well.

Dr. Altman does cite two important studies related to broadening the scope of psychoanalytical treatment. One, in 1963, was undertaken by the William Alanson White Institute, in collaboration with a local of the United Auto Workers Union. Interestingly, group and family treatment predominated, and patients came for an average of sixteen sessions. A later attempt at replication in the early 1990’s was undertaken at the NYU Post-Doctoral Program in Psychotherapy and Psychoanalysis. But this project had “much less success in attracting patients from the union and in finding therapists to see them” (Altman, 1995, p. 54).

Fortunately, community mental health projects and outcome/efficacy studies outside of the New York City-area do have some not-insignificant, mostly positive findings to report. Amongst others, the Michigan State Psychotherapy project is noteworthy. As reported in Karon & VandenBos (1981), Psychotherapy of Schizophrenia: The Treatment of Choice, patients included in the study were schizophrenic and were exposed to different forms of intervention. As their title would suggest, psychoanalytic psychotherapy was found to be more efficacious than the combined medication-psychotherapy approach, or pharmacotherapy used alone. Even more perplexing regarding the omission of their work from The Analyst in the Inner City are the specific results, intervention guidelines, and theoretical implications the authors relate to working with urban, minority populations.

Again, this can cause the reader to feel a bit confused in reading Dr. Altman’s book because of its relative lack of focus and depth regarding the application of psychoanalytic paradigms to diverse, inner-city populations, per se. Also, one detects, in the “New Wave” of psychoanalysis, the so-called “post-modern,” “social-constructivist,” or “relational” models, a tendency to obfuscate relatively straightforward principles with overwrought, arcane language that tends to have the opposite effect of the one I believe Dr. Altman espouses and has endeavored to communicate. Indeed, in Chapter Six, “On the Future of Psychoanalysis,” he rightly decries some of our profession’s “exclusivity and elitism” (Altman, 1995, p. 159). Also, by posing something different, as opposed to something altogether new, Sigmund Freud is often ignored within these schools, or marginalized regarding his sensitivity to the vicissitudes of class, culture, historical time, etc. To his credit, Dr. Altman does not accept uncritically this biased and skewed view of Freud, quoting from, amongst other works, Freud’s famous call to action on the part of the society-at-large:

...[T]he conscience of the community will awake and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neuroses threaten public health no less than tuberculosis... (Freud, S., 1919, p. 167; cited in Altman, 1995, p 30).

That is, while psychoanalytic training is now disconnected from the monopolistic and intellectually stifling, monolithic medical establishment of yore; and while this means that bona fide psychoanalysis is now being practiced more broadly across patient demographic groups and professional disciplines, the field continues to impress as elitist, exclusionary, and defensive. In short, along with these trends, there has been a corresponding trend to make our theories, our interventions, and our language (the way we psychoanalysts talk with one another--and our patients, too) more impenetrable than ever. No wonder students, faculty/professional colleagues, and patients already too-often negatively predisposed to psychoanalysis are “resistant” and quick to change the channel. Especially with regards to working with the exigencies of our patients who exist in poverty, or come from cultures other than the American “majority” (whatever that is), it is curious that Dr. Altman and other contemporary authors communicate their ideas in such esoteric ways.

Chapter Six, “On the Future of Psychoanalysis” remains a short, but elemental reading. Dr. Altman presciently discussed a number of, by now, time-worn issues, e.g., around so-called managed care; and the increasingly oppressive, brutalized society that spawned this “rationed” model of “care” (Miller, 1996). However, this does not make them any less important or relevant. Additionally, by recommending that psychoanalysts get out of their private practice settings once in a while, he offers the possibility of serving as consultants. This has especially taken root, not only in theory, but in academic programs (I teach a required core course in Consultation and Supervision in our program--an area of competency increasingly mandated by the National Council of Schools and Programs in Professional Psychology) and practice (see for example, such books as W.M. Czander, The Psychodynamics of Work and Organizations: Theory and Application; M.A. Diamond, The Unconscious Life of Organizations: Interpreting Organizational Identity; L.F. Stapley, The Personality of the Organisation: A Psycho-Dynamic Explanation of Culture and Change).

With so much focus on so-called “diversity issues” in academia, and our professional conferences, it is again seductive to view The Analyst in the Inner City as something more than what it is: a sound overview of some of the extant literature on race, class, and culture, one that could benefit from more reporting on the author’s clinical work with his patients. The book at times veers in the direction of cultural relativism, i.e., at risk of assigning too much valence to cultural variables. One potential outcome of this is, in essence, to negate observed psychopathology or reduce “culture” to a catchall repository for unaccounted variance. If we erred in the past toward minimizing cultural variables, we must be cautious and not inflate their contribution now. If we look at the impact of culture, which we surely must, examining this as a more complex variable is an absolute. For example, Anthony Wallace, back in 1961, wrote about the role of culture in the epidemiology of mental illness. This included a delineation of culture as being a direct or indirect pathogenic influence.

In a more purely psychoanalytic vein, I found it striking that Winnicott could write so evocatively of culture in its relation to early infantile experiences and interactions with the environment. Thus, he keeps us, paradoxically, in a more culturally sensitive frame of reference by keeping his discourse quintessentially psychoanalytical! How metaphoric for what the “New Wave” of psychoanalysis really does not explicate, psychoanalytically, by addressing more concretely the “thing” itself--in this case, culture. In his paper, “The Location of Cultural Experience,” Winnicott (1971) delineates a number of essential things about this problematic question. For him, culture is a derivative of play. He asserts that:

“[T]he place where culture is located is in the potential space between the individual and the environment (originally the object). The same can be said of playing. Cultural experience begins with creative living first manifested in play” (Winnicott, 1971, p. 100).

This echoes, for me, André Breton’s famous reply to the question about poetry: “Poetry? It isn’t where you think. It exists outside of words, of style, etc.” Post-modern theorists and psychoanalysts tend to take themselves very seriously. That’s certainly part of the problem here, as I hope to suggest via my use of Winnicott; and Breton, the titular founder/leader of Surrealism. But, such serious and concerted activity as evidenced in The Analyst in the Inner City is also the good news as well. Still, I should recommend Dr. Altman’s book only as a point of embarkation. As always, the marker of a sound theory or exposition is its ability to stimulate further theorizing. Such has been the case in the intervening years since its publication. More recently, we have, again from Psychoanalytic Dialogues, an excellent “Symposium on Race,” with contributions from numerous psychoanalysts, including Dr. Altman.

References

Altman, N. E. (1993). Psychoanalysis and the urban poor. Psychoanalytic Dialogues, 3, 29-49.
Czander, W. M. (1993). The psychodynamics of work and organizations: Theory and application. New York: Guilford Press.
Diamond, M.A. (1993). The unconscious life of organizations: Interpreting organizational identity. Westport, Connecticut: Quorum Books.
Fairbairn, W. R. D. (1952). Endopsychic structure considered in terms of object relationships. In Psychoanalytic Studies of the Personality. London: Routledge & Kegan Paul, pp 82-136.
Freud, S. (1919). Lines of advance in psychoanalytic therapy. Standard Edition, 17 :157-168. London: Hogarth Press.
Karon, B. & VandenBos, G. (1981). Psychotherapy of schizophrenia:The treatment of choice. Northvale, NJ: Jason Aronson.
Miller, I.J. (1996). Time-limited brief therapy has gone too far: The result is invisible rationing. Professional Psychology: Research and Practice, 27, 567-576.
Perez-Foster, R. M. (1993). The social politics of psychoanalysis. Psychoanalytic Dialogues, 3, 69-84.
Stapley, L. F. (1996). The personality of the organization: a Psycho-dynamic explanation of culture and change. London: Free Association Books.
Various Authors (2000). Symposium on race. In Psychoanalytic Dialogues, 10.
Wallace, A.F.C. (1961). Culture and personality. New York: Random House.
Winnicott, D.W. (1971). Playing and reality. New York: Routledge.

Reviewer Note

David Downing is a psychologist who teaches and works in Chicago, and is the president of a local chapter, Chicago Open Chapter.

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