Psychoanalysis in some public sectors
This chapter considers some of the ways in which psychoanalytic therapies have existed or do now exist within various public sectors, especially the third or ‘voluntary’ sector of community clinics. I address some of the cultural, economic and clinical issues arising when psychoanalysis engages with working-class clientele, and the challenges this creates for established practices. Some of the themes arising in the historic free clinics emerge in these different historical contexts. Issues of technique, cultural context and the structuring influence of social forces persist, added to by greater attention to the role of the therapists’ own attitudes and cultural awareness. I consider what we can learn from these different kinds of free and low-cost clinics and bodies of work.
The influence of Freud’s widely cited visionary speech about free clinics (Freud, 1918) lives on, in the inclusive spirit of many of the projects considered here. Strikingly, this speech is also quoted below the masthead of the UK Association for Psychoanalytic Psychotherapy (APP) in the NHS, whose psychotherapists have provided what they describe as ‘psychoanalytically informed care’ for more than a half century. However, the ambivalence (explored further later) also contained in Freud’s speech about the status of psychotherapy continues to negatively affect the recognition of the value of free and low-cost work. Thus the journal of the APP refers to work in the NHS as ‘applied’ psychoanalysis, with its implications of not ‘pure’. Here I argue that this contrast between the supposedly ‘pure’ forms of intensive private practice and the lesser frequency and shorter duration of those deemed ‘applied’ has dogged much of subsequent discussion and also the politics of the field. The exigencies of the present time demand a radical reevaluation of these hierarchies and binaries, which are predominantly matters of class and inequality, and which negatively affect the wider standing of psychoanalysis.
The idea of free or low-cost psychoanalytic clinics, available to working-class people, went into abeyance after the demise of the Vienna and Berlin clinics and in the wake of World War II. A much more conservative era in psychoanalysis ensued, especially in the USA, but also in Europe, oblivious to its previous history, a kind of Laplanchian ‘going astray’ that Stephen Frosh (2009) regards as a loss of moral valence. Harvey Taylor, in his assessment of where psychoanalysis now stands, describes this as the ‘truncation of the original broad vision of the pioneers’ (Taylor, 2013: 3). The post-war era was marked by an amnesiac blotting out of the politically radical aspects of the past, the adoption of socially conformist standards of mental health and gender roles and the extreme pathologisation of homosexuality (Lewes, 1989; O’Connor and Ryan, 1993/2003). The notion that working-class people were not ‘analysable’ gained widespread acceptance, confining them to physical and pharmacological treatments. There appears to have been almost no contemporaneous challenge to this distorted perception. Moskowitz (1996b) shows how the ghosts of ‘analyzability’ still linger, especially affecting ‘minority’ patients. Several contributors to a contemporary book about psychoanalysis in disadvantaged urban communities still saw the need to argue against this canard (Foster et al., 1996). More recently, analysts working with Latino populations in the USA have also argued against this still expressed prejudice (Gaztambide, 2014; Gherovici, 2016).
In the social ferment of the 1960s and 1970s, many reworkings of psychoanalysis took place, challenging its conformist aspects and harnessing its socially radical potential. These challenges critiqued the prevailing ideologies of psychoanalysis, especially in relation to women, gender and ‘race’. Some left and feminist groupings, alert to the importance of everyday life in political struggles, took on board the usefulness of psychoanalysis as a tool for understanding how the dominance of state power was underpinned by processes of individual repression, reproduced within the family. This has some continuity with the engagements of the earlier left psychoanalysts who saw psychoanalysis as an emancipatory tool at both the personal and social level. ‘The personal is political’ became a widespread motif. The notions of ‘internalised oppression’ and of ‘interpellation’ led to many advances in locating individual subjectivities within a wider social framework of political subordination. There was a resurgence of interest in some of Reich’s writings. The anti-psychiatry movement inspired by Laing and others developed forms of psychoanalytic practice for those deemed psychotic, who had otherwise been subjected to pharmacological treatments and hospitalisation.
Psychoanalytic therapy in the UK, following the 1929 settlement with the medical profession, was never fully integrated into state provision. However, within the NHS it grew considerably in the post-war period, concomitant with the development of the welfare state. It included adult and child psychoanalytic psychotherapy, group analysis, family therapy and therapeutic communities within hospitals. Although always limited in extent, and often contested, nonetheless, as Andrew Cooper and Julian Lousada (2010) describe, psychoanalysis did have a solid presence in the wider mental health world and also within mid-twentieth-century social work. Much of this is now attenuated, replaced by CBT and other therapies, or abolished.1 Sally Sales (2011), describing the political and theoretical contexts in which CBT has become so dominant, argues that working-class people especially are increasingly being consigned to brief manualised forms of treatment, an increasing concern also with campaigning organisations.2
However, in the UK, many psychoanalytically trained clinicians and trainees do still work in primary and secondary care in the NHS and in child psychotherapy departments. Recent evidence submitted by the umbrella bodies to the UK Parliament estimates that 25 per cent of registered psychoanalytic therapists work in the NHS, in some way.3 Such work also continues in the public hospitals and clinics of the USA, as well as in various community settings. This means that many psychoanalytic therapists do encounter patients from a diversity of class and ethnic backgrounds. Although the detailed clinical work of NHS psychoanalytic psychotherapists has a predominant place in the APP’s journal, Psychoanalytic Psychotherapy, a cursory survey suggests that discussions of class and ethnicity are infrequent, and cited, if at all, as ‘background’ factors. It is surely timely for the public sector work described in this journal and others to be given a higher profile as to its social and clinical importance. As Paul Wachtel (2002) argues, there is a need for a conceptual framework and reflection on what public sector and community work may throw up for psychoanalysis, some of which I put forward later on. In what follows I mainly consider psychoanalysis within community and third-sector clinics of various kinds.
The reworkings of psychoanalysis did not remain at the level of ideology alone but also led to a plethora of innovative practical community projects, providing socially conscious forms of psychoanalytic psychotherapy, accessible to those previously excluded financially or put off by mainstream elitism, bias and prejudice. The extent of this field was and is huge, and deserves more extended research. Broadly speaking, there are three overlapping categories of such projects: those with an explicitly emancipatory agenda, that seek to combine therapeutic and political forms of struggle; those whose aim is to contest and remedy mainstream psychoanalytic bias and ideologies that exclude or wrongly pathologise groups identified by, for example, gender, ethnicity or sexual orientation; and those whose main aim is to extend access to psychoanalytic psychotherapy to those excluded from it by financial or other factors – a social justice agenda. Many projects occupy more than one of these categories but by far the largest number are those with a social justice agenda. All such projects tend to be precariously funded by a mixture of state (local authority, central government) and charitable sources, and often have sliding scales of charges.
Here I consider the issues that are raised by the transposition of psychoanalysis in its explicit engagements with class and poverty. Within a very broad definition of psychoanalytically informed therapy, the diversity of such projects, both past and present-day, is extraordinary4 and is testimony to the continuing concern and desire of many psychoanalytic practitioners to remedy the exclusive nature of psychoanalysis. However, the available literature is scant and scattered; in-depth accounts of most projects, let alone an encompassing survey, have as yet to be written. Much useful information is probably hidden within the funding applications and annual reports that organisations produce. The kind of documentation on which Danto (2005) was able to draw was due to the priority that the early left psychoanalysts gave to outreach work, to popular writings and to the publication of their detailed records. The issue of the accessibility of psychoanalysis to working-class people is no longer part of mainstream psychoanalytic consciousness in the way it was then. Thus the knowledge that such engagements can bring is neglected, and the work of such diverse clinics does not gain the understanding or recognition it merits. Here I attempt to identify the main issues, using some of the available literature and my own experiences.
There are many different motivations for working in public or voluntary-sector clinics. In the case of politically radical clinics, the motivations may be explicit. I have devoted considerable space to these, as they, unlike most other projects, are often written about. Many of the issues identified apply to work in other more numerous but less documented settings.
Marie Langer, who trained in pre-World War II Vienna and subsequently in Buenos Aires, embodies many of the ideas of the historic free clinics, albeit in a different environment and historical period. She is a transitional figure, making reference in her writings to Reich’s Sex-Pol, which she regarded as before its time, and also incorporating aspects of the Kleinian theory of her training. Much of Langer’s work, from the 1950s onwards, took place in the context of conflicts within and splits from the Argentinian Psychoanalytic Association. Increasing state repression and terror led to her eventual exile and psychotherapeutic work in Mexico and Nicaragua. Langer’s accounts of work in disadvantaged communities foreshadow many of the themes in later projects.
Langer, in her various journeys through psychoanalysis, Marxism and feminism, impressively maintained a necessary dialectical tension between clinical work and political activity, and between theory and practice. She challenged the demands of classical psychoanalysis as untenable in practice: ‘[T]he placing of social reality “in parentheses” during treatment and the supposed “objectivity” of the psychoanalyst. Both are unsustainable.’ (Langer, 1989: 156). She further argued that an object-relations approach, as opposed to one based solely on drives/instincts, allowed more possibility for embracing the social, an argument also made by a later radical pioneer, Sue Holland.
Langer addressed issues of clinical practice that have since become familiar. She argued that it is important to distinguish between aspects of the analytic frame that are necessary for clinical reasons and those that are ideological or useful for the analyst. She and her colleagues adapted the psychoanalysis of their training to provide less frequent sessions, face-to-face rather than on the couch and dialogue with the patient rather than analytic silence. They also addressed the importance of countertransference as a ‘working tool’ rather than an obstacle. This is now common within most theoretical orientations but was then being pioneered, partly through the work of another Argentinian psychoanalyst, Heinrich Racker. All contemporary discussions of practising psychoanalysis in poor communities emphasise the importance of these factors.
Langer also critiqued the notion of neutrality, the idea that analysts can be completely ideologically neutral and not influenced in their work by their own political and moral commitments. Like Langer, the pioneers of contemporary feminist approaches to psychotherapy argued that supposedly neutral stances unquestioningly reflect the status quo (Eichenbaum and Orbach, 1982). Langer also queried the then common view that the fee was an important part of the treatment, regarding this as more to do with the economic needs of the analyst, and maintaining that any resistance or idealisation connected to free treatment could be addressed within the therapy. Furthermore, she strongly disputed that working-class patients could not verbalise sufficiently well to undertake psychoanalysis. Rather, they understood the interpretations offered and had as good or as bad capacity for insight as ‘bourgeois’ patients in private practice. Many working-class patients:
who were very deprived, really needed that hour in which they had the right to listen and to be listened to. That someone was interested in their fate and was witness to it, was much more unusual and therefore more appreciated and therapeutic than it is for our private patients.
(Langer, 1989: 176)
This is a powerful observation also made by some of the therapists I interviewed (see Chapter 7).
Reflecting subsequently, Langer said:
In our therapeutic work we remained faithful to our psychoanalytic technique of interpreting unconscious conflict. While we refrained from offering advice, suggestions or didactic interventions, our interpretations of our working-class patients’ discourse included a critical perspective of the class and gender determinants of their unconscious pain and rage.
(Hollander, 1997: 76)
She also described how the economic and social circumstances of the patients were taken into account: time constraints, cost of transport, domestic demands, childcare, all might mean that deep regression was to be avoided.
Langer noted how commonly unconscious guilt feelings and self-blame would derive from a conviction that individuals were the only ones responsible for their ‘failures’, an ideology that has been intensified in the current era. The aim was to help such patients to discriminate between their responsibility for aspects of their personal history, and that of their family and of society. Class-consciousness was part of Langer’s aims, achieved through work in groups that built on insights into individual problems, to place these in a wider social context, and also to forge bonds of solidarity, and a sense of belonging, something also embodied in Holland’s model, described later.
Strategies for combining therapeutic and political forms of struggle are also put forward by Paul Hoggett and Julian Lousada, describing a project, Battersea Action and Counselling Centre (BACC), where I also worked (Hoggett and Lousada, 1984). They argue that to offer a therapeutic service for working-class people it was necessary to understand both the fragmentation of everyday life within capitalism and also how the therapeutic/helping professions were experienced by the community at large. This latter included people’s experiences of psychiatry and social work as an aspect of social control, of the widespread prescription of psychotropic drugs, of the perceived stigma of mental illness, and the fear of being seen to be receiving therapeutic help. Whereas, for the practitioners involved, psychoanalytic therapy might seem an undisputed good, this was not necessarily so for the intended clients, an issue that surfaces in many other accounts. Rather, the cultural resonances and the social codes implicit in its practices can seem alien, unwanted and sometimes coercive. Beverley Skeggs argues that the reflexive, knowing, inner self is a specific historical production, enabled through different practices: ‘[F]orced telling for welfare for the working-class, and authorial exhibitionism for the middle-class’ (Skeggs, 2004: 119).
Such factors can lead to justified suspicion towards an invitation to take up counselling or therapy. Daniel Holman (2013), in an appraisal of the role of class in taking up talking therapy for depression and anxiety, identifies several factors. He uses Bourdieu’s theoretical schemas (see Chapter 5) to argue that the underuse of such services by working-class people can be understood in terms of cultural dispositions structured by social conditions. Clinical encounters, where ‘institutionally sanctioned ways of talking, thinking and feeling are especially apparent’ (Holman, 2013: 12), can constitute ‘a form of symbolic violence over working-class lives’. Simon Charlesworth, in A Phenomenology of Working Class Experience, emphasises the ways in which the interview situation itself constitutes a form of cultural domination, leading to inhibition, self-negation and apparent inarticulacy, in which the ordinary expressiveness of everyday speech is lost, felt as worthless (Charles-worth, 2000).
Other notable features of BACC were a full-time nursery and crèche, a small advice service, and a vegetable co-op, as well as psychotherapy. In this way the centre embedded itself in the local community and tried to address some of its material needs, lessening suspicion, as well as distinguishing itself from state interventions. This came from an understanding that whereas it might be very difficult to approach a mental health service openly, it was perhaps easier to talk about practical difficulties. This might then lead on to talk about issues for which therapy could be offered.
Freud himself in his 1918 speech suggested that psychoanalysis with working-class people might necessitate some attention to their material needs. Some of the contributors to Foster et al. (1996) describe how addressing practical or advocacy needs can enable a better comprehension of the patient’s experiential and material world, which may be very unfamiliar to the therapist. The question of how this impacts on the therapeutic work and its frame is one many practitioners in such settings tussle with. An argument can be made that such provision facilitates confidence in the therapist’s understandings and commitment, and thus sustains the therapeutic work, despite the departure from usual practice. Ruth Fallenbaum (2003, see Chapter 8) provides an example in which after much reflection she agreed to an advocacy role.5 Economic insecurity and deprivation can thus be felt to invade the clinical frame, and disturb the usual setting; but none of this is beyond analytic reflection within the work. Taking psychoanalysis out of its private practice location, where the social world does not impinge so intrusively, demands that the space for and of psychoanalytic therapy is protected but without resort to rigidity or lack of realism.
The attempt at BACC to address some material needs within a therapeutic centre reflected the understanding of how interconnected these needs are with emotional ones, rather than bracketing off the latter into a completely separate sphere. However, there was also a clear recognition that the spheres of private and public life should not be conflated or reduced to one another, but that the dynamic tensions between them should be sustained. Reductionism could take the form of psychologising political involvements, interpreting rebellion as Oedipal protest, for example, a then common psychoanalytic trope, or of seeing emotional issues as unimportant and self-indulgent compared to material ones, to be overcome by political activity, at the time an attitude typical of many left groups.6 These considerations all illustrate the complex position that such projects inhabit in attempting to encompass both politics and therapy. Some of the earlier left psychoanalysts did see psychoanalysis as having a socially liberating role. However at BACC we were clear that any emancipatory change through therapy was not itself to be seen as a form of political action, although it might lead to that through a reorientation to aspects of reality and a different self-evaluation.
Hoggett and Lousada also emphasise the central role of language in articulating mental distress: the frequent unavailability of a vocabulary other than a medicalised one, and the lack of people who are able to listen without overly entangled responses. The desire to share some therapeutic knowledge, including enabling a language of the emotions, led BACC and the subsequent Lambeth Mental Health group (Banton et al., 1985) to offer counselling skills courses and workshops to people in the community. These empowering efforts proved very popular, and are an echo of Freud’s and Ferenczi’s recommendations for psychoeducation in working with disadvantaged groups (Gaztambide, 2012).
When a Tory council gained power, BACC was immediately closed down, illustrating the precarious position that radical mental health projects occupy in the wider political arena. BACC reflected an era in which the welfare state was seen by the left as an aspect of social control, and not, as now, as an essential service, free at the point of use, embodying an ethic of collective support while being under virulent attack from neo-liberalism. However, the ‘therapeutic’ interventions of the current welfare system may still embody aspects of social control – witness the ways economically disadvantaged families are now being renamed ‘troubled’ ones.7
One of the main initiators of BACC was Sue Holland, who set up a much more enduring project on a large working-class estate in White City, London. Holland’s psychoanalytic approach was based on Ronald Fairbairn’s form of object relations, which she saw as providing a potentially more social view of the individual than classical Freudian theory. This she combined with Paolo Freiere’s notions of conscientisation. Holland and Holland (1984) outline how they saw global forces transformed into intra- and inter-psychic relations:
[A] comprehensive therapy must include not only a recalling of repressed “rejected” part-objects and part-self representations, but also “conscientisation”… concerning a people’s own historical roots through which, for example, a mother’s failing and rejection can be understood in its political and economic context.
(Holland and Holland, 1984: 100)
Interestingly, some US community activists are now using Freiere’s ideas in combination with psychoanalysis (LeRoy, 2016).
In White City this meant providing initial one-to-one psychotherapy to address the familial and intra-psychic aspects of depression and to lessen the need for medication, and then a transition to groups which allowed hidden and shared histories to be unravelled. This enabled not only a recognition of commonalities of suffering and loss, but also of collective strengths, with possibilities for action to bring about desired changes. Holland described this dialogical and intersubjective process as moving ‘through psychic space into social space and so into political space’, with participants having the choice to exit at any point (Holland, 1995). One of the notable features of the long-lived White City project is how the integrity of the project’s political values were sustained alongside its dependence on state funding and also through significant shifts in wider political rhetoric.
The necessity for understanding history as it impinges on an individual, as well as intra-psychic dynamics, is a theme that runs through these politically inspired projects. Strong arguments for this are also made by those working clinically with people exposed to social traumas of various kinds, for example, Barbara Fletchman-Smith (2003) in the case of the legacies of slavery, and Francoise Davoine and Jean-Max Gaudillière (2004) with reference to wars and genocide. Valerie Walkerdine (2015), building on her psychoanalytically informed work in a working-class community subjected to the devastations of deindustrialisation, argues that such an approach is essential in understanding how class is transmitted through generations. Recognition of historical and social frameworks gives depth and meaning to experiences otherwise felt to be entirely individual, or else not explicable; ‘small’ histories carry echoes of ‘large’ ones. This constitutes the restoration of the ‘social link’, the fore-closure of which, Davoine and Gaudillière argue, can lead to psychosis. Such attention to history is part of the framework needed when psychoanalysis is practised outside its usual contexts, and indeed within them.
Many projects and clinics situate themselves in economically deprived areas with the inclusive aim of increasing access to therapy. They are informed by an assumption of psychoanalytic therapy as an undisputed good, unfairly distributed, even if, as sometimes, in need of revision.
Such conscious sociogeographic placement means that many factors arise concerning the cultural interface between the profession of psychoanalytic therapy, its staff and the intended clientele. Some of this has been recorded in several American books, which provide the greatest detail about contemporary psychoanalysis in such localities (e.g. Altman, 1995/2010; Foster et al., 1996). As Altman and also Rendon (1996) record, the US community health movement made important contributions to challenging and changing the prejudice against working-class people being offered psychoanalytic therapy. The growth of a socially conscious relational psychoanalysis has also provided many practitioners with the frameworks to work in these settings. We thus have a considerable body of literature which does not repeat the prejudices of the past but looks more openly, critically and dynamically at what may be involved.
Many of these writers are emphatic that working in disadvantaged working-class communities presents a challenge to the cultural embeddedness of psychoanalysis, and to some of its values and practices. In their view, the problems derive not from the fundamental nature of psychoanalytic theory but with its implementation. They pay particular attention to the pre-existing perceptions, attitudes and professional identities that therapists may bring to such engagements, as well as to how the stimulation of particular subjective reactions may impede useful work. They eschew what Foster refers to as ‘condescending’ alterations in technique, but argue strongly for a more pluralistic, socially well-informed approach in which both analyst and patient are regarded as mutual participants in the therapeutic relationship. Many authors advocate a less rigidly interpretive approach, in favour of an exploratory dialogic one, in which the analyst is more open to how a patient may convey his or her realities, and less inclined to impose theory on a patient. In part, the authors are taking issue with the dominance of classical and ego psychology forms of psychoanalysis, and advocating a turn to a more relational approach, although not, as Altman does, dispensing altogether with classical psychoanalysis. Moskowitz (1996a) indeed argues that the recognition of the primacy of love and aggression gives psychoanalysis the potential to transcend cultures, and advocates for the integration of both schools.
From Fanon (1952/1967) onwards, it has been a basic argument of culturally aware approaches to psychoanalysis that the familial structures and relationships to power implicit in Freudian theory may not obtain in other cultures. This is especially so in those cultures which are subjected to historical forces of domination, exploitation and racism. Individual autonomy, separation and independence may be valued very differently in poor urban and immigrant communities, where the family plays a different role in relation to the state, compared to that of the indigenous bourgeois nuclear family. Foster (1996) gives several clinical illustrations of how a less theoretically driven interpretive mode seeks to understand the specific social formations of families, and the importance of family solidarity in the face of oppressive conditions.
Gaztambide (2014), in a commentary on a conference held to discuss psychoanalytic work in poor Latino communities in the USA, amplifies this further. In one particularly salutary passage, citing another participant’s contribution, he illustrates the importance of:
[B]eing exquisitely attuned to the patient’s metaphors, cultural symbols, and ways of thinking. Padron’s presentation implicitly raised the question of what is “concreteness” but a metaphor we have yet to connect to, a symbol we have not yet deciphered, a language we have not learned to speak? A very moving aspect of Padron’s work was the way in which his interpretations of Antonio’s [the patient’s] conflicts contained a “both/and” rather than an “either/or” quality in relation to sociopolitical themes in the patient’s life.… He holds both psyche and culture as sources of meaning, while at the same time searching for psychological depth, adding another dimension of psychological meaning to sociopolitical realities.
(Gaztambide, 2014: 34)
This argument, that ‘concreteness’ is a mode of expression that needs more deciphering, rather than always being a block to psychoanalytic understanding, is important. It is a challenge to any facile writing-off of some people as unsuitable for psychoanalysis, as well as to creative analytic skill. The question of ‘analysability’, the allegation that working-class Latinos are ‘too concrete’, not psychologically minded enough, and have too weak ego strength to engage with psychoanalysis, thus becomes a question of analysts’ perceptions and desires, their capacity to understand and communicate. This is a very important reordering of perspective, putting the emphasis more on the abilities and interests of the analyst, rather than on the alleged deficits of the analysand.
Likewise, Foster emphasises that where there are large cultural or class differences between analyst and patient, work is needed on both parts for some joint understanding. Disparate social worlds may give rise to ‘mutual subjective arousal’ (Foster et al., 1996: 15), inhibitions and anxieties, and these can limit therapeutic work unless they are addressed. Part of what is needed is for the therapist to be able to recognise and process her own subjective reactions to what she learns or perceives of the circumstances of a patient’s life. One common reaction I have noticed in my supervision experience is the despair and hopelessness that can be generated in the practitioner when faced with the weight of accumulated deprivation and adversity borne by many working-class and otherwise disadvantaged patients. Lee Whitman-Raymond (2009) also comments on how trainees, who often work with the most economically deprived patients, may feel overwhelmed by their circumstances, compounded by feelings of shame at feeling this, and by the difficulty of acknowledging or addressing the huge social differences involved. This puts particular demands on the capacity to find and enable the space for psychoanalytic work.
Diane Reay (2000) argues that the ‘complex self-hoods’ of working-class children have not adequately influenced psychoanalytic theorising, and that a more sophisticated understanding is needed of social jealousy, fear, denial, longing and envy, an understanding which she provides in much of her work. Javier and Herron (2002) also argue that ‘the poor person’ has not been well understood by psychoanalysis: ‘Thus for most analysts who find themselves working with a patient who is economically deprived, there is a sense of confusion’ (Javier and Herron, 2002: 151). Substantial inequalities of wealth and circumstance are not differences that most analysts will have been trained to think about, unlike gender differences, for example. These authors see the consequences of poverty as liable to create a distancing between the economically disadvantaged patient and the better-off analyst, with the potential to lead to unsatisfactory outcomes if these intersubjective dynamics are not available for reflection. Javier and Herron suggest:
Possible attitudes by analysts are to feel sorry for the patient and in turn emphasize the social reality of poverty to the exclusion of personal responsibility, or to reverse the process and blame the patient.… (T)he analyst is also faced with a fear of revealing an offending attitude.
(Javier and Herron, 2002: 160–1)
They also see the challenges in such work as arising from the virulence and schisms of class divisions and differences, which all participants in the encounter are subjected to and which make the development of a working alliance especially complex. They illustrate the complexities for the therapist of maintaining the tension between realistically seeing the patient as subjected to adverse social circumstances and seeing him or her as having agency in their predicaments, while not colluding with any tendency to excessive self-blame, an echo of Langer’s injunction, and also something which some of the therapists I interviewed (see Chapter 7) wrestled with.
In psychotherapeutic work with women in a deprived urban environment, Pamela Trevithick (1995) describes how low confidence about articulating thoughts and feelings, stemming from a lifetime of negative experiences, may make the beginning of any therapeutic process extremely difficult. She notes how the inhibition of curiosity, resulting from chronic low self-esteem and adversity, can block helpful experiences and learning. She argues that explanations of personal intersubjective and wider cultural processes, as well as positive affirming input, are all needed to facilitate the take-up and taking-in of therapy. This chimes with the arguments that recognition and understanding of historical and current cultural contexts are necessary as part of any therapeutic enterprise with oppressed and poor populations, as is some relevant psycho-education. In a further article, drawing on Winnicott, she argues that recognition of present-day failures of the environment, and the provision of adequate holding and sometimes of material help, are all necessary (Trevithick, 1998).
Similar conclusions, framed in different theoretical terms, are found in Miriam Rosa and Ilana Mountain’s (2013) account of what they term ‘clinical listening’ with socially excluded young people in Brazil. Their work derives from a Lacanian perspective combined with Bourdieu’s notion of symbolic violence. It is a relatively unusual attempt to engage with extremely marginalised ‘street kids’. Whereas the previous writers make an appeal for the ‘subjectivity’ of working-class patients to be more adequately recognised, these authors argue that their intended clientele should be recognised as desiring subjects, rather than subjected to discourses that disenfranchise them, for example, those which see them as unanalysable or which reproduce existing power relations.
Rosa and Mountain see social marginalisation as a form of symbolic violence, where there is domination through communications in which the domination is disguised. This collective reification can result in ‘blind submission, autistic closure, or irruptions of violence’ (2013: 13) on the part of the young person. It creates ‘discursive helplessness’ (i.e. having no recognised voice) and thus no ‘appeal to the Other’. Such desubjectivisation is traumatic. The authors emphasise how their analytic work takes place in precarious conditions, where there is often huge need, lack and urgency. Clinical listening requires ethical and political positioning, whereby the webs of domination and exclusion are made more apparent without any attributions to the supposed characteristics of the subject. In this way their approach has much in common with the overtly political approaches described previously.
Just as Foster et al. (1996) and Altman (1995/2010) emphasise the importance of understanding the countertransferential responses of analysts in work with disadvantaged clients, so too these authors delineate the kinds of resistances that may occur when clinical listening becomes unbearable. These include too hasty onward referrals; too much focus on the social situation, something Whitson (1996) also mentions; and only seeing subjects as victims. Conversely, analysts can assume unrealistic possibilities of choice, similar to the bifurcated thinking that Javier and Herron (earlier) describe. Analytic resistances also include too much adherence to theory and mistaken diagnoses; too much emphasis on differences, which can entrench stereotypes and distance. Listening can become unbearable for the analyst, because of the extremity of pain and deprivation involved and also because of the potential for feeling complicit in the social order that produces these circumstances, by reason of being more privileged. This I suggest is an insufficiently acknowledged source of therapist confusion and dysfunction.
Clinical listening, according to Rosa and Mountain, involves not the repetitive recounting of trauma, but rather, by supposing the ‘desiring Other’, a witnessing, a rescuing of memory and a recognition of desire in the transference, by which they mean the desire to be heard and understood, and have meaning attributed to experiences. Such listening can undo the suppression of subjectivity. It is ‘transgressing in relation to the bedrock of the way society is organised, and it implies rupturing the tie that institutionalises a refusal to listen to the subject’ (Rosa and Mountain, 2013: 14), a way of describing one main function a therapist may be able to perform in socially oppressive conditions.
Compared to the elaboration of their theoretical positions, Rosa and Mountain’s description of their clinical work with particular clients is somewhat brief, albeit very moving. They note how the children initially regarded psychoanalytic listening with distrust, one more strategy of domination over them, even though their participation was voluntary, something which may well have felt compromised by their compulsory institutionalisation. The therapist gained their confidence by ‘giving room to the symptom’, recognising the subject’s defences that, necessary for psychic survival, are engendered by being in the position of a ‘leftover’ in the social structure. This counters any tendency to over-hastily interpret or even attack defences in socially marginalised people, something which can occur. By meeting the ways in which the subjects present themselves, even the most traumatic circumstances can be given meaning and context. This restores ‘desire in the transference’.
The advantage of this theoretical position is that it does not deal in any supposed psychological characteristics of socially excluded people, and therefore does not run the risk of inadvertent pathologisation or othering, which a more psychologised approach, however well intentioned, can do. By seeking to understand the position of socially excluded subjects discursively it attempts to create an egalitarian, they would say, ethical, approach. This egalitarianism is reflected in how they see the process being one of clinical listening rather than therapy, with all that the latter might imply about the goals and professional knowledge of the therapist setting the agenda. Although the benefit of their approach for their intended clientele remains to be shown more definitively, I would argue that for an analyst struggling with work in a poor inner city and assailed by the many emotions this can stir up, their approach could well be helpful. It can help the analyst think not so much in terms of the personality characteristics that extreme social exclusion might create (and that might be thought to render participation in analysis problematic) but of the ways in which the social order can exclude and disenfranchise certain subjects from access to any inclusive process of recognition and understanding, rendering their often traumatic experiences devoid of meaning or context. This puts the emphasis much more on the value of the process of listening and the establishment of an other who wants to hear. Furthermore, the authors are, to my mind, appropriately realistic about how, on the one hand, clinical listening can have modest mutative effects for the subject but, on the other, they recognise that radical social change is needed. This can help counteract any omnipotent tendency or its sequel, despair, by the analyst confronted with extreme poverty.
Patricia Gherovici, an analyst in inner-city Philadelphia, also concurs with this Lacanian emphasis, enjoining therapists to understand how ‘concreteness’, passive relation to authority and a focus only on the present are all symptoms of structural violence rather than supposedly inherent cultural attributes (in Gaztambide, 2014). Latinos, she avers, are certainly capable of psychoanalytic work and rather than consigning them to non-analytic or directive therapies, a ‘strict and untendentious’ (à la Freud) analytic approach would entail listening to clients as desiring subjects, thus facilitating ownership of their own subjectivity. Gherovici (2016) argues strongly that ‘real’ problems do not mean people are unanalysable: ‘It is like saying poor people do not have an unconscious.’
It can be argued that all these recommendations are simply aims that any good psychoanalytic therapy would pursue: openness and less rigidity in using theoretical ideas, cultural and other self-reflections on the part of the analyst, some degree of social understanding and exploration of how the patient might perceive both the analyst and the therapeutic enterprise. This, although true in some ways, neglects the question of why this has been and still is hard to achieve with working-class and ethnic-minority patients in poor urban communities. It denies the specificity of the issues at hand, the historical injustices and sources of pain involved, and concomitantly the need for analysts to undertake serious reflection on their own attitudes, emotional responses, social understandings and theories, any of which may hinder therapeutic work in poor communities.
The divisions within the psychoanalytic field, especially those between psychoanalysis, psychoanalytic psychotherapy and psychodynamic counselling, are transparently class divisions. The inequality of access is barely mitigated, and certainly not rectified, by the limited availability of lower-cost or ‘affordable’ longer-term private psychoanalytic therapy with trainees, or with those analysts and therapists who donate their time to low-cost clinics or who have sliding scales.8 How widespread these often-cited practices are, or how far these scales slide, is currently unknown, since the role of money in the discipline is seldom debated, as Chapter 9 discusses further.
This situation has led to an insidious and perverse dynamic, whereby psychoanalytic work under the most difficult and challenging circumstances receives the least recognition and esteem and tends not to be carried out by those with most experience. This has structured the psychoanalytic field from the beginning, despite the best efforts of the early pioneers. The ambivalence at the heart of Freud’s (1918) statement on the need for ‘a psychotherapy for the people’ runs through most discussions on providing psychoanalytic therapy outside private practice settings. Freud wrote that any ‘large-scale’ application of ‘our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct suggestion; and hypnotic influence, too….’ He continued: ‘But, whatever form this psychotherapy for the people may take, whatever the elements out of which it is compounded,… its most effective and most important ingredients will assuredly remain those borrowed from strict and untendentious psycho-analysis’ (Freud, 1918: 167–8, my italics).
These passages serve a double function of both exclusion and inclusion. They drove a wedge between psychoanalysis and the assumedly lesser form, psychotherapy, suitable for those who cannot pay. Gaztambide (2012) argues that this laid the ground for the restrictive development of the notion of analysability, which led to many working-class and minority clients being excluded from the ‘pure gold’ of psychoanalysis. This reflects a historic process whereby those excluded on economic, educational and cultural grounds are then perceived to possess the very characteristics that would seemingly justify their exclusion – a way in which the fundamental inequity of the situation is elided and disowned, and the idealisation of ‘pure’ psychoanalysis is not challenged for what it contains and conceals – namely, a defence of privilege.
Aron and Starr (2013), in their arguments for a progressive and less divided psychoanalysis, also suggest that the way Freud drew his distinction between psychoanalysis and psychotherapy has had far-reaching and adverse effects in how this difference has continued to be seen, with the concomitant idealisations, denigrations and misunderstandings. As is well documented, Freud was always concerned to radically differentiate psychoanalysis from any association with hypnosis or suggestion. Because Freud linked the difference between psychotherapy and psychoanalysis to the assumed role of suggestion (which he was at pains to repudiate as any part of psychoanalysis), psychoanalytic psychotherapy has been wrongly seen as necessarily involving something akin to this, as being more directive and supportive, not ‘properly’ analytic. This is far from the reality of most psychoanalytic psychotherapy, something not sufficiently recognised by those who make this disparaging judgement. There is a largely inconclusive literature on where and how to draw the distinction (e.g. Frisch et al., 2001), a symptom of the disavowal of the underlying status and economic forces at play. The second part of Freud’s assertion, that ‘psychotherapy for the people’ will, to be effective, use the approach of ‘strict and untendentious’ psychoanalysis, has been frequently ignored. And yet this is exactly what those working at lesser frequencies aspire to and do often provide, in both private and public settings.
Aron and Starr argue that ideology, economics and professional insecurity all affect where and how the boundaries between psychoanalysis and psychoanalytic psychotherapy are drawn. This creates a binary emptied of the social and economic factors that structure it. In the heyday of American psychoanalysis, post-World War II, the distinction and distance between the two was at its greatest, at a time when psychoanalysis was most in demand, most lucrative and most conservative. It was also the period when the idea that working-class clients were not analysable was at its height, cementing the economic, cultural and symbolic capital of psychoanalysis. There was thus a marking out of territory by the psychoanalysts, an assertion of identity related to social hierarchy and a disdain for any other use of psychoanalysis. In the UK, despite the influence of the social justice ideology of the welfare state, and the presence of psychoanalysis within this, the hierarchy between ‘pure’ psychoanalysis and allegedly ‘applied’ psychoanalytic psychotherapy prevailed, as it still does today. Such hierarchical territoriality contributed in the 1990s to the splitting of the newly established umbrella body for psychoanalysis and psychoanalytic psychotherapy into separate organisations, eliding their common usage of psychoanalytic theories and practices.9
Cooper and Lousada (2010), in their critique of the resistance of psychoanalytic institutes to adapt to social changes and to the diminished market for psychoanalysis, comment on the attitudes of ‘hubris and arrogance’ with which psychoanalytic institutes view other therapeutic practices. Their explanation of this lies in several factors: the ways in which psychoanalysts may see themselves as part of a cultural establishment, the clinging to tradition and the uncritical belief many have of their uniqueness. They also see the dynamic features and anxiety inherent in the psychoanalytic situation as rendering analysts vulnerable to the imputed judgement of the ‘analytic super-ego’. Cooper and Lousada argue that psychoanalysts:
depend for their continuing self-esteem and hierarchical dominance upon being able to successfully project inferiority or weakness into psychoanalytic psychotherapists, who in turn do the same for ‘counsellors’. But the projections also operate both ways, since the supposedly persecuted groups may fiercely criticise the ‘analytic arrogance’ of the supposedly dominant.
(Cooper and Lousada, 2010: 36)
Their description of ‘excess hierarchy’ in the psychoanalytic field captures well the often difficult relationships between those trained at certain organ-isations and other psychoanalytic practitioners, and also in the restrictive practices as to eligibility for particular roles, such as those of training analysts. It surfaces in the battles fought about who can legitimate whom, and who has the entitlement to various labels or trade descriptions – who can call themselves or be recognised as a psychoanalyst, for example.10 These are all struggles over symbolic capital, underpinned by economic capital, although seldom recognised as such. Cooper and Lousada go on to argue that the task facing psychoanalytic institutions now, in the face of the many external changes taking place, is to hold on to the unique skills and capacities that a psychoanalytic education can confer in understanding unconscious processes and unconscious communication, without the assertion of the moral superiority or cultural arrogance – gold versus copper – that they critique.
These arguments do not deny that there are often important differences, rather it is a question of how these are valued, and what they are taken to mean. Psychoanalytic therapies inherently take time – that is part of their value and importance – and within capitalism time is money. Frequency and duration are the main poles of distinction commonly drawn between psychoanalytic psychotherapy and psychoanalysis,11 and also between what is possible in private practice settings and in community or public sector ones. It is inherently a class issue, because of the economic factors involved and also because of how less frequent, for example, once weekly, work is often seen as of lesser value and given much less recognition. Quantity, as Teresa Mulvena (2004) in her review of the issues surrounding frequency points out, becomes quality. This is a process that Marxists have long ascribed to the workings of capitalism.
Most practitioners who work with the limits imposed by funding or other constraints will have experienced the frustration of not being able to work for longer or more intensively with many particular clients. Often, although importantly not always, more is felt to be better, by both patient and therapist. Time limits may sharpen therapeutic efforts, and a theoretical understanding of the timelessness of the unconscious does allow for the possibility of rigorous and intensive psychoanalytic work under more limited circumstances. However, this does not address those aspects of therapeutic efficacy that depend upon the open-endedness, duration and consistency possible under better-resourced conditions and sustained relationships.
The available literature on outcome research in relation to frequency (for example, Frosch, 2011) suggests that more frequent work is often better, in terms of outcome, although not invariably. It is also widely acknowledged that other factors, such as the emotional quality of the analytic relationship, the experience of the analyst, and the degree to which he or she is inter-nalised by the analysand, can all be crucial whatever the frequency. And it is also true that unduly long-term psychoanalysis can sometimes be harmful, in perpetuating a stultifying dependency, as opposed to a useful one. Further, conflicts of interest can be created in the open-ended nature of private practice with well-off patients, whereby the analyst stands to gain from prolonging the treatment, as several writers on money and psychoanalysis have argued (see Chapter 9).
The situation is also structured by how most psychoanalytic trainings require a particular frequency of sessions, both for the therapist’s own analysis, and for working with patients. They mostly do not train people to work at a lesser frequency or for fixed short-term durations, despite the availability of accumulated knowledge and experience, a shortcoming that Taylor (2013) and many others see as having had serious consequences in limiting the contribution psychoanalysis makes within the public sector. Yet this is often the situation in which psychoanalytic practitioners find themselves, in private practice as well as in public sector work. Aron and Starr cite studies that show that in the USA most graduates of psychoanalytic institutes, despite their training in high-frequency work, see most of their patients once weekly, and only a few more frequently, who are often themselves trainees. It is widely recognised that this is true in the UK too. Inevitably, without relevant training or support, this is felt as inferior, and practitioners, haunted by the ideal of intensive open-ended work, can feel deskilled and despairing. Cherry et al. (2012), based on surveys of analytic practice, suggest that trainings need to change to recognise the lower-frequency work that most analysts commonly do, and also their use of additional techniques. Some trainings now do recommend (although do not require) that their trainees gain experience of less frequent work.
Alloys of course can be superior to pure metals, in their greater strength or fitness for particular purposes, even if, unlike gold, not of such great market value. Cooper and Lousada ask what the psychodynamic counsellor has to teach the psychoanalyst about the practice of therapy and the nature of unconscious processes, a politically astute question.12 They suggest that this question is neither surprising nor contradictory, just because such counsellors are more likely to work in ‘the complex messy world of front-line mental health services’ (2010: 44). There is much that can be learned by practice at this interface, especially in respect of ‘race’, ethnicity and class. It is important for the future of psychoanalysis, as well as for the benefit of patients, that such work is better recognised, understood and valued, without denying its limitations. Some of the writings cited in this chapter, as well as the arguments of this book, could contribute to that, were there the political will.
Freud also suggested that the ‘new conditions’ of free clinics would require psychoanalysts to adapt their techniques. The considerations of this chapter, and also of Chapter 2, have shown that the innovations made in these settings are far from being ‘suggestion’ or ‘dilution’, but rather additions to and enhancements of psychoanalytic practice more generally. As with the historic free clinics, and as with Ferenczi’s technical recommendations, engagement with a wider clientele in diverse settings has driven new creative approaches (see e.g. Lemma and Patrick, 2010). Notably, the most recent innovations in psychoanalytic therapy have come from public sector work. Much of this is researched, evidence-based and responding to the needs and challenges of mental health institutions, although also felt by some to be unwarranted adulterations of the ‘pure gold’ of psychoanalysis. These innovations, which are beyond the scope of this book, include Mentalisation-based Therapy, Dynamic Interpersonal Therapy (DIT), Parent–Infant Psychotherapy (PIP) and psychoanalytic consultations and supervision for mental health staff. Psychoanalytic interventions and consultation can take many forms (see e.g. Campbell, 2006; Carrington et al., 2012; Evans, 2016) and are a particularly effective way of extending psychoanalytic thinking to a variety of situations, as are Balint groups, which have a continuing life. My own experience, as a supervisor/consultant to an NHS inpatient unit, is that many staff, not least nurses, are very receptive to psychoanalytic input, if it is presented in succinct ways that are of immediate relevance to their work (e.g. Land, 2004; Evans, 2016).
All such innovations and adaptations are based on core psychoanalytic concepts but extend psychoanalytic technique and sometimes integrate other approaches. Such readiness to engage with the social world is essential to the survival of psychoanalysis, and to any considerations of social justice and fairness. Taylor (2013) makes a strong plea for the broadening out of what is comprised by ‘psychoanalysis’ to include diverse uses of psychoanalytic theory, with equivalent value accorded to each, in the interests of a ‘new settlement’. If all the many scattered and committed individual efforts and projects within the various public sectors could gain greater collective existence and recognition, it would create a more effective political pressure for the value of psychoanalytic work within our mental health institutions.
This chapter has illustrated the diversity of thought and practice that psychoanalytic practice in many different free or low-cost contexts has given rise to. It has emphasised the importance of sociopolitical histories in the lives of both analysands and analysts. What stands out, apart from the overriding issue of funding, is the absence of much mainstream interest, recognition or teaching of such work. This reflects the divisiveness inherent in the internal politics of psychoanalysis, its lack of reflection on its own social status and also its separation from the wider world of modern mental health provision. If psychoanalysis as a profession could become more socially aware and inclusive in its trainings and social locations, and encompass the many diverse uses to which it is put, it would not only do justice to these many efforts, but also garner itself more public acceptability – an enduring argument since the earliest days.
1 The extent of these changes is hard to assess, as no survey exists. The therapeutic communities of the Henderson and Cassel Hospitals no longer exist.
2 Such as the Alliance for Counselling and Psychotherapy: https://allianceblogs.wordpress.com
3 Evidence from UKCP and BPC to the Public Accounts Committee Inquiry into IAPT services. Available on BPC website, June 2016.
4 Within a small part of London alone I know of or have known of the following: Red Therapy, Battersea Action and Counselling Centre (BACC), The Barefoot Psychoanalyst, Open Door Young Person’s Consultation Centre (Haringey), The Women’s Therapy Centre, The Maya Centre, City Road Youth Counselling, The Brandon Centre, Off Centre (Hackney), Nafsiyat Intercultural Therapy Centre, The Fanon project, PACE – therapy for LGBT people, The Blues project (CAPP), the Lambeth Mental Health Group, The Lorrimore Centre, White City Mental Health project, The Inner City Centre, various Mind centres. There are many more in other areas, and countries, and also ones I will not have heard of. Some of these listed projects are now defunct.
5 A common contemporary example is therapists being asked by patients to provide detailed evidence of mental health difficulties for entitlements to benefits.
6 The slogan ‘Don’t break down, break out!’ was typical of this attitude.
7 The recent suggestion that obligatory counselling should be enforced as a condition of unemployment benefits is another worrying example.
8 This practice is similar to the much-vaunted UK practice of private schools offering subsidised fees or free places to poor ‘bright’ children, which props up rather than changes the inequitable system.
9 It is only recently that the three main regulatory bodies have opened formal talks about how they may cooperate in facing issues that they all have in common – a belated recognition of their similarities and the necessity to find joint ways of engaging with the changing political landscape.
10 Some practitioners who work psychoanalytically and have trained outside the main IPA organisations do call themselves psychoanalysts – a development that challenges the hegemony of the ‘elite’ organisations.
11 Even though there is little consensus about whether there is a fundamental distinction and what it might be based on (e.g. Frisch et al., 2001).
12 It is interesting to note that the British Psychoanalytic Council, which Lousada has been chair of, now accredits psychodynamic counselling courses – a recognition of core similarities, even if the symbolic hierarchy is preserved.
Altman, N. (1995/2010) The Analyst in the Inner City: Race, Class, and Culture through a Psychoanalytic Lens. New York: Routledge.
Aron, L. and Starr, K. (2013) A Psychotherapy for the People: Towards a Progressive Psychoanalysis. New York: Routledge.
Banton, R., Clifford, P., Frosh, S., Lousada, J. and Rosenthall, J. (1985) The Politics of Mental Health. London: Macmillan.
Campbell, J. (2006) ‘Homelessness and containment – a psychotherapy project with homeless people and workers in the homeless field’, Psychoanalytic Psychotherapy 20: 157–75.
Carrington, A., Rock, B. and Stern, J. (2012) ‘Psychoanalytic thinking in primary care: The Tavistock psychotherapy consultation model’, Psychoanalytic Psychotherapy 26: 102–20.
Charlesworth, S. (2000) A Phenomenology of Working Class Experience. Cambridge: Cambridge University Press.
Cherry, S., Meyer, J., Hadge, L., Terry, M. and Roose, S. P. (2012) ‘A prospective study of psychoanalytic practice and professional development: Early career interviews’, Journal of the American Psychoanalytic Association 60: 969–94.
Cooper, A. and Lousada, J. (2010) ‘The shock of the real: Psychoanalysis, modernity, survival’. In Lemma, A. and Patrick, M. (eds) Off the Couch: Contemporary Psychoanalytic Applications. London: Routledge.
Danto, E. (2005) Freud’s Free Clinics: Psychoanalysis and Social Justice 1918–1938. New York: Colombia University Press.
Davoine, F. and Gaudillière, J.-M. (2004) History beyond Trauma. New York: Other Press.
Eichenbaum, L. and Orbach, S. (1982) Outside In… Inside Out. Harmondsworth: Penguin.
Evans, M. (2016) Making Room for Madness in Mental Health. London: Karnac.
Fallenbaum, R. (2003) ‘The injured worker’, Studies in Gender and Sexuality 4: 72–92.
Fanon, F. (1952/1967) Black Skin, White Masks. New York: Grove Press.
Fletchman-Smith, B. (2003) Mental Slavery: Psychoanalytic Studies of Caribbean People. London: Karnac.
Foster, R. (1996) ‘What is a multicultural perspective for psychoanalysis?’ In Foster, R., Moskowitz, M. and Javier, R. (eds) Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Lanham: Jason Aronson.
Foster, R., Moskowitz, M. and Javier, R. (eds) (1996) Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Lanham: Jason Aronson.
Freud, S. (1918) ‘Lines of advance in psychoanalytic therapy’. In Strachey, J. (ed) (1955) The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 17: 157–68. London: Hogarth.
Frisch, S., Hinshelwood, R. and Gauthier, J. (2001) Psychoanalysis and Psychotherapy. London: Karnac.
Frosch, A. (2011) ‘The effect of frequency and duration on psychoanalytic outcome: A moment in time’, Psychoanalytic Review 98: 11–38.
Frosh, S. (2009) ‘Where did class go? Psychoanalysis and social identities’, Sitegeist 3: 99–116.
Gaztambide, D. (2012) ‘“A psychotherapy for the people”: Freud, Ferenczi and psychoanalytic work with the underprivileged’, Contemporary Psychoanalysis 48(2): 141–65.
Gaztambide, D. (2014) ‘Melancolia bajo un palo de mango: A review and critique of “Psychoanalysis in El Barrio”’, Division Review 11: 33–6.
Gherovici, P. (2016) ‘A poor brain is as worthy as a rich brain: Psychotherapy faces a privilege problem’. Available at: http://gu.com/CMP=Share_iOSApp_Other. Accessed 9 June 2016.
Hoggett, P. and Lousada, J. (1984) ‘Therapeutic intervention in working class communities’, Free Associations 1: 125–52.
Holland, S. (1995) ‘Interaction in women’s mental health and neighbourhood development’. In Fernando, S. (ed) Mental Health in a Multi-Ethnic Society: A Multidisciplinary Handbook. London: Routledge.
Holland, S. and Holland, R. (1984) ‘Depressed women: Outposts of empire and castles of skin’. In Richards, B. (ed) Capitalism and Infancy. London: Free Association Books.
Hollander, N. (1997) Love in a Time of Hate. New Brunswick: Rutgers University Press.
Holman, D. (2013) ‘What help can you get talking to somebody? Explaining class differences in the use of talking treatments’, Sociology of Health and Illness 35: 1–18.
Javier, R. and Herron, W. (2002) ‘Psychoanalysis and the disenfranchised: Countertransference issues’, Psychoanalytic Psychology 19: 149–66.
Land, P. (2004) ‘Thinking about feelings: Working with the staff of an eating disorders unit’, Psychoanalytic Psychotherapy 18: 390–403.
Langer, M. (1989) From Vienna to Managua: Journey of a Psychoanalyst. London: Free Association Books.
Lemma, A. and Patrick, M. (eds) (2010) Off the Couch: Contemporary Psychoanalytic Applications. London: Routledge.
LeRoy, M. (2016) Urban liberation and psychoanalysis: Free associations at the grassroots’, The Psychoanalytic Activist, online newsletter, 30 March. Available at: https://psychoanalyticactivist.com/2016/03/30/urbanliberationandpsychoanalysis/. Accessed August 2016.
Lewes, K. (1989) The Psychoanalysis of Male Homosexuality. New York: Quartet.
Moskowitz, M. (1996a) ‘The social conscience of psychoanalysis’. In Foster, R., Moskowitz, M. and Javier, R. (eds) Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Lanham: Jason Aronson.
Moskowitz, M. (1996b) ‘The end of analyzability’. In Foster, R., Moskowitz, M. and Javier, R. (eds) Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Lanham: Jason Aronson.
Mulvena, T. (2004) ‘Once-weekly work: Less of the same or something different’. Unpublished Paper.
O’Connor, N. and Ryan, J. (1993/2003) Wild Desires and Mistaken Identities: Lesbianism and Psychoanalysis. London: Karnac.
Reay, D. (2000) ‘Children’s urban landscapes’. In Brewer, S. (ed) Cultural Studies and the Working Class. London: Cassell.
Rendon, M. (1996) ‘Psychoanalysis in an historic-economic perspective’. In Foster, R., Moskowitz, M. and Javier, R. (eds) Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Lanham: Jason Aronson.
Rosa, M. and Mountain, I. (2013) ‘Psychoanalytic listening to socially excluded young people’, Psychoanalysis, Culture and Society 18: 1–16.
Sales, S. (2011) ‘The making of docile working class subjects: CBT, class and the failures of psychoanalysis’, Journal of Psycho-Social Studies 4: 126–38.
Skeggs, B. (2004) Class, Self, Culture. London: Routledge.
Taylor, H. (2013) UK Psychoanalysis: Mistaking the Part for the Whole, British Psychoanalytic Council Discussion Paper. London: BPC.
Trevithick, P. (1995) ‘Cycling over Everest’, Groupwork 8: 5–33.
Trevithick, P. (1998) ‘Psychotherapy and working class women’. In Seu, B. and Heenan, C. (eds) Feminism and Psychotherapy: Reflections on Contemporary Theories and Practices. London: Sage.
Wachtel, P. (2002) ‘Psychoanalysis and the disenfranchised: From therapy to justice’, Psychoanalytic Psychology 19: 199–215.
Walkerdine, V. (2015) ‘Transmitting class across generations’, Theory and Psychology 25: 167–83.
Whitman-Raymond, L. (2009) ‘The influence of class in the therapeutic dyad’, Contemporary Psychoanalysis 45: 429–43.
Whitson, G. (1996) ‘Working-class issues’. In Foster, R., Moskowitz, M. and Javier, R. (eds) Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Lanham: Jason Aronson.