PSYCHOANALYSIS IN THE COMMUNITY

I am not yet an analyst. I am a pediatrician for urban public schools and state-regulated behavioral health facilities. In my current capacity, I address the medical needs of hundreds of minority kids and families who are excluded from traditional psychoanalytic culture but who could deeply benefit from this healing art. Every day, I witness both the need for psychodynamic applications on a programmatic scale and imagine possibilities for public health partnerships to enable this process.

Working as a civil servant for underserved populations forces me to think largely and collectively. The resources are limited, and the racial/cultural/ethnic disparities are painfully present. The mental distress can be as immense as the socioeconomic obstacles are formidable. Every encounter, every patient, every family represents thousands more in the system. Though the details may be personal, the needs are the same and can be multiplied exponentially. All are seeking a way toward a better future. This recognition of shared humanity is the basis for developing compassion.

Compassion lets me feel for other human beings. And empathy allows me to identify with their distress. These allow deep human connection. My supervisor describes the connection as a bidirectional effort, requiring investment from the analyst as much as the analysand to sustain the healed reality that can be co-created with this model. It transcends all our perceived differences. It allows us to truly see who sits before us.

As an analyst in training, I discuss these perceived differences of race, class, disparity, and economics and the role they play in making psychoanalysis inaccessible to the larger Black and Brown culture. The conversations revolve around privilege and identification—my patients do not have the means to engage in psychoanalysis, and its private-practice system at large is not set up to accommodate them. And there are cultural divides that are bidirectional barriers to care beyond the monetary issues. Yet I understand the benefit of this treatment modality, both in my work with patients and through my own training analysis. I wonder how this compassionate healing space can expand beyond our private offices and be made accessible to the wider underserved community. With COVID-19, telemedicine has already brought mental health services into nontraditional spaces, so we can begin to consider how psychoanalysis might seize this momentum for greater equity. But are we prepared to do the work needed to ensure a culturally informed, welcoming environment for anyone who would need to access what psychoanalysis has to offer?

The how is the hard part.

Recently, I sat through a series of talks aimed at cultivating compassion for the self. In these stressful times of pandemic isolation, economic and political uncertainty, and deep racial division, learning to also be compassionate toward the self is a necessary survival skill. The notion that we could build up our personal reserve of compassion so much that eventually we have enough to turn this compassion and empathy outward was my takeaway. If we focus on doing the inner work, the compassion and empathy can radiate toward the Other.

Other in psychoanalytic terms generally implies something or someone that is “not me.” Often, the other is assigned all the qualities that we do not wish to see in ourselves. Othering can explain how we view those of different races, social classes, or ideological perspectives. It is the opposite of compassion, the antithesis of empathy. Othering strips the humanity from the patient before us until we no longer see them as we see ourselves.

But othering is a construct, in part, of our internal reality; it does not really make the other different. It has taken me half a lifetime to understand this. I remember the exact moment a colleague introduced me to this concept so many years ago. After a particularly contentious and difficult encounter with a patient, she came into the office smiling and left me something on my desk. The reward for my frustration? On a small scrap of paper, she had scribbled:

Remember, you are everyone you meet.

It is fair to say that my entire career has been spent in the service of marginalized populations and the socioeconomically disenfranchised. When I work with Black and Brown patients and their families, we reflect each other. Perhaps this is because I am a Black clinician. Perhaps this is because I am, in many ways, other too. Somehow, we know each other without knowing. And often, late at night when responding to episodes of crisis, we share the bond of our mutually lived experience as persons of color, navigating the world of mental health services on both sides—me as provider, they as patients, wondering how we all got here. I recognize in these encounters that there is no true other. I must apply my inner compassion outwardly and with empathy. I define these aha moments of connection, when othering is flipped and I am fully engaged, as “psychoanalytic compassion.” This can be applied to any patient. It transcends race. It transcends class. It transcends disposition so long as one is willing to accept and practice the mind-blowing concept that we are all, on some level, the same. The adopted lens of psychoanalytic compassion changes my outlook from “this is not me” to “this is also me,” in order to contextualize whatever is happening with whatever piece of myself that can understand it.

There has always been a fear on my part of diving in too deeply with patients and ending up in a place where we are both lost. But perhaps my year of psychoanalytic training or the turbulent times we are living in are compelling me to notice more, process what I observe, reflect in the space that this psychodynamic outlook opens. Finding a place in the patient’s story where there is familiarity and commonality allows the tensions to ease. In the depths of anger, of spewing rage, I now listen for rich, unconscious, useful content. Perhaps in those immediate minutes, I cannot be effective. But sometimes, later, when the moment allows, we revisit. We go deeper. We discuss. We connect.

Compassion to counter othering

We all have particular populations and persons we are uniquely skilled and trained to work with. And we all have room for growth and expansion. Just as my public health and clinical work are now informed by psychodynamic practice, so too can psychoanalysts consider how to apply the healing value and principles to the larger population. What I would hope is that we would all consider how to extend our talents to whatever groups can benefit from what we have to offer. But we must also ensure we have cultivated compassion within ourselves in order to begin to see ourselves reflected in the other of all our patients, however they present.

We are at a crossroads in history. Every mental health provider is needed to deliver services as the weight of current times levies its effect on the general public. We are also in a space of collective professional self-reflection. As members of a discipline that is examining the individual and collective thought processes that have led us to this moment of social change, we have a responsibility to share the results of our painful but necessary and honest self-analysis. And this applies to all of us. We all have “others” we view differently.

The countless roundtables, discussions, and conferences I have attended over the past months show that we are exploring the psychoanalytic field to expose our own resistances, our own blind spots, our own defenses and rationalizations that have allowed us to partake in the larger racialized system—an example of the othering we wish to expose and address. We can offer solutions once we have thoroughly done our own internal work. We can examine collectively who we have othered if we ask our questions with both a critical eye and with deep analytic honesty. And as we rectify, we can direct efforts outward to include the communities we have not reached.

I argue that psychoanalysis is a powerful tool that has been kept within exclusive circles. We have a responsibility to learn how to bring it to a larger community that has not had ready access to deep psychodynamic work. As a discipline, we can turn our compassion outward and export this knowledge, skill, and training. Let us name this outward expression and inclusive application of these principles toward needy communities the “psychoanalytic compassion model.” Let us commit our psychodynamic expertise to the communities that have thus far been omitted. 

I continue to look for and often find myself in everyone. It is a rather elementary yet useful paradigm that informs my work and helps me cope. I must look for myself in the face of every patient to do this, to not other—perhaps to like, perhaps only to tolerate. This takes compassion for the patient and self-love to overcome my own ability to exclude, to other. Twenty years of practice have shown me that it is both that simple and that complicated. ▪