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What does culture and race have to do with psychoanalysis?

by Ruth Lijtmaer, PhD.

From a clinical viewpoint, culture and race play a role in etiologies of disorders, diagnosis and the therapist's approach to treatment. Therefore, the clinician comes to the consulting room with a set of predetermined ideas about the characters of the respective patients. For example, a clinician reading an intake of a Hispanic mother of six children living in a poor neighborhood and on public assistance might immediately have the expectation that she physically abuses her children, is probably incapable of real intimate connection with her children, and is probably incapable of any intimate connection with an adult partner. Or, a therapist who is sought for a clinical consultation with an upper middle class professional family might promptly entertain the assumption that children are emotionally unattended, and dysfunctions in the family system are compensated by lavish material (Perez-Foster, 1999). With these examples I suggest that the clinician's cultural assumptions may be correct or incorrect; however, to think that the clinician is neutral or "culturally free" is inaccurate. For those cultural assumptions will quickly serve to guide the clinician's judgments about such things as the patient's human values, likeability, personal threat, amenability to treatment, capacity for insight and change, and other judgments that will influence the course of treatment.

Culture can be defined as a composite of beliefs about the purpose of life, symbolic rituals, concepts of time and space, causation of events, the individual's responsibility for those events to occur, and how mind and body work. Certain ideas included in this definition of culture can have different meanings in different cultures. Think of the dichotomy East/West, dependence/independence. How do you explain to medical personnel that a 70 years old Japanese man with cognitive deficits, who lived his entire life within traditional Japanese family roles, and has never dressed himself, cooked or cared for his home, is not confused or noncompliant with his treatment when he refuses to do certain tasks because the treatment may be irrelevant to him? Or that to "save face" from a burdensome injury, a "samurai" male believes suicide is a noble choice? This individual defines independence in beliefs and actions far differently than the treating cultural beliefs of the Western health care system.

Considering this, culture can be viewed as having defensive hierarchies that result in cultural patterns and ethnic characters. There is a commonality of defenses and conflicts that are both provided and facilitated by a particular culture. Anxiety, depression, defense mechanisms, dreams are present in people of all cultures. Nevertheless, their modes of expression may differ in diverse cultures.

Likewise, racial difference and similarity in the treatment relationship highlight the question of what is real and apparently psychological in the different racial experiences of patients and therapists (Hamer, 2002). Race as it is lived in America is used stereotypically so much of the time that we have oversights that go unacknowledged. Particularly because the ideas that created them are so unconscious or so accepted as reality, that the perspective is lost. For example, in the early 70's the questions about the treatment of black people were: did they have sufficient ego strength to participate in psychoanalysis; or were their problems so clearly the result of oppression, that they were not psychological in nature. This has not been a discipline that has been receptive to black people (Lijtmaer & Thompson, 2007).

Therefore racial stereotypes exist as cultural constructions, influence associations to people colored differently, and they define not only the other but also the sense of self (Altman, 2000; Schacter, & Butts, 1968; White, 2002; Yi, 1998, in Lijtmaer, 2006).

Intrapsychic meanings of race exist in the borderland between the body and the social contexts within which the body is recognized and constructed. Sameness or difference in a few body features (e.g., skin color, hair texture) can serve as the basis for a myriad of constructions which, like anatomical differences between the sexes or generational differences, assume psychological significance for different reasons and at various moments of urgency. Skin color difference may arouse anxiety about difference that is psychologically quite primitive, emerging out of our earliest efforts to define the sense of self along the represented features of the body, among them, the colors of the skin of the primary caretakers (Hamer, 2002). Significant psychodynamic papers on race indicate how race can be included in the therapeutic dialogue as an organizer of the therapeutic experience and the clinician's racial and ethnic guilt (Altman, 2000; Blue & Gonzalez, 1992; Constantine, M. G., & Sue, D. W., 2007, Holmes, 1992; Laungani, 1997; Leary, 1997, in Lijtmaer, 2010). The findings of these works suggest that prejudice and biases are aspects of our internal objects that can be acted out when the therapist is working with someone ethnically and racially different. These cultural introjects, which are values, attitudes and conventional ways of behaving, develop from early life experiences, and influence our world-view (Schechter, 1992).

Bearing these comments in mind, I suggest the possibility that a professional may misjudge the behavior and the verbalizations of the patient, attributing the patient's behavior only to pathology while neglecting the cultural background. The clinician's personal biases about his/her own ethnic identity and about other ethnic groups can pose a problem in identifying what is pathological and what is not.

When therapists work with patients of different race and culture, they are likely to be influenced by three overlapping viewpoints: their culture of origin, the culture of their metapsychology and the dominant culture as it is reflected in the patient's communications and responses. Therapists living in this multiethnic society require humility in accepting that we are and we are not the same. Whether working with somebody ethnically similar or dissimilar, therapists have to explore their motives for responding to the patient in particular ways as issues of sameness and betrayal can lead to failure of empathy as powerfully as issues of difference. Color blindness and politically correctness inhibits the practitioner's ability to question, and the patient's ability to disclose, placing constraints on the therapeutic relationship.

References:

Hamer, F.M. (2002). Guards at the gate: Race, resistance, and psychic reality. Journal of the American Psychoanalytic Association, 50, 1219-1237

Lijtmaer, R. (2006) Black, White, Hispanic and both: Issues in Bi-racial Identity and its effects in the transference-countertransference. Chapter10. In: Moodley, R. and Palmer, S. (Eds.) Race, Culture and Psychotherapy: Critical Perspectives in Multicultural Practice. London: Brunner-Routledge. ISBN: 1583918493

Lijtmaer, R. & Thompson, C. (2007) Race and Psychoanalysis. New Jersey Psychologist, 57(2), 19-20.

Lijtmaer, R. (2010). 2nd Annual Conference on: 'Integrating Traditional Healing Practices into Counseling Psychology, Psychotherapy and Psychiatry.' Pre-conference Papers: "Diversity and Multicultural Counseling in USA"; "Race, Culture and Psychotherapy". Conference paper: "Integrating Latin American traditional healing into counseling and psychotherapy". July 22 - 23, 2010, University of Kwazulu-Natal

Perez-Foster, R. (1999). An intersubjective approach to cross-cultural clinical work. Smith College Studies in Social Work, 69(2) 269-291

Schechter, A. (1992). Voice of a hidden minority: Identification and countertransference in the cross-cultural working alliance. The American Journal of Psychoanalysis, 53(4), 63-81.