Here I explore how the dynamics of therapy relationships may be inflected by class, based on my own research and the contemporary writings of others. Dimen argues that class has powerful unconscious resonances such that: ‘The fault lines of class and other hierarchies show up systematically in transference and countertransference’ (Dimen, 1994: 79). Whitman-Raymond describes how fraught with anxiety the elucidation of class in clinical work can be. She asks: ‘How can clinicians begin to talk about the pain of our class limitations and class exploitation as they are experienced, and at times replicated, in the clinical setting?’ (Whitman-Raymond, 2009: 440). This chapter provides many diverse examples of how therapists do often do this, within various class permutations, and sometimes fail to do so. I show how different therapists conceptualise and work with class issues, and the barriers to this.
I asked the therapists in my study (Ryan, 2006/2013) to describe in some detail their clinical work with two patients, one working class, and one middle class, as this was perceived by the therapist and/or in accordance with patients’ self-ascriptions where these were present. They were asked to select cases where they were aware there were class issues, either for their patients or for themselves in relation to these patients, or both. It became apparent that prior preparation for this part of the interview was advantageous, and I sent guidelines to all subsequent interviewees outlining possible topic areas and questions. This is unusual in qualitative research but reflects the reality that to ask therapists to talk in detail about their clinical work does entail thought and preparation. They were asked to provide some general background to their descriptions of their work with each patient, their understandings of class issues for that patient, and any class-related aspects of the transference–countertransference that they perceived. I would at times ask for more elaboration, or sometimes suggest links to other parts of the interview, if appropriate. The interviews were psychoanalytically informed, in the sense that all parties were experienced in psychoanalytic modes of self-reflection and thinking, and the topic was clinical work.
Most therapists readily located examples of work where they felt class was an issue of some kind. The exception was K, who said of her NHS work: ‘I did obviously have working-class patients there, but I don’t think class is what I was thinking about, and I don’t think I’d have mentioned it in an assessment.’
Many of the interviews were highly charged, and it was as if we had embarked on unusual discussions. The therapists’ accounts were a mixture of what they were felt were class issues for particular patients, and also of how they felt class played out in the interface between the two of them. B asked: ‘Does the social class appear in the transference and how would the analyst hear it?’ – a highly pertinent question that puts the onus as much on the therapist as on the patient. Here I illustrate some class-related transferences and how these therapists heard and responded to them.
In what follows, the data from the interviewees from lower middle-class backgrounds is combined with the data from those from working-class backgrounds, as much of their material, both biographical and professional, contained similar concerns and was distinctively different from that of the middle-class interviewees. This generated four possible pairings of therapist and patient as regards class: two with a class difference and two with a similarity. I did not start out with any assumption about dividing the research material up in this dichotomised way, but the subsequent analysis of the transcripts did suggest that with the two possible pairings with class differences there were distinctive themes, and there was almost no overlap between these. That talk about class can readily default to the binaries of working class and middle class, the ‘haves’ and ‘have-nots’, or ‘us’ and ‘them’, indicates the intensity of emotion and projection at play and the powerfulness of social divisions and inequality, even if this does not always correspond to more complex or differentiated realities. Class issues of many different kinds were reported in all combinations. Here I have selected some detailed accounts and described others more briefly.
There were several accounts of middle-class patients’ apparent contempt, disparagement and arrogance, ‘being put in your place’, which either overtly were, or were felt to be, class-related. Attacks and negative transferences can happen in any therapy, focused on many seeming issues, but it is striking that, when questions are asked about class, this was only described in this combination and not in any of the other pairings. The following example illustrates these themes.
H said of her patient, whose mother owned a very successful business in the ex-colonial country she had come from: ‘She was part of the elite, she spoke in this incredibly posh way, and was very, very aware of class. I started to feel uncomfortable with her early on, and I was aware of it being all my stuff about class, and she said to me in the second or third session: “I don’t know, I have to say this because it’s bothering me, I’m wondering if you are going to be any good, because you sound quite working-class. ” It was awful, it felt like she’s got right under my skin.… It set off these feeling of am I good enough?… Can I be a good therapist because I don’t speak in the right way? and a sort of anger towards her. I thought, who does she think she is? I’m very very aware of all that, and that I mustn’t retaliate, but what I felt then was: I’ve got to work harder to show her I’m good, I’ve got to see behind all this and not get caught up in my own stuff and see what it’s about for her.… Which I was able to do, but only by going back into therapy myself… because nobody had actually said that to me before… and it confirmed my worst fears.… I managed with her to turn it around, so I was able to get her to see that she was projecting onto me her own feelings of inadequacy, that although she was posh, she was still black, and… she still felt she didn’t belong… and we did some very good work… based on that she was always trying so hard to prove herself.’
This illustrates one of the many intersections of ‘race’ and class that surfaced in other accounts. Further exploration suggested what ‘working class’ signified for this patient: ‘It meant for her to be black, very black, both metaphorically and in reality.… To be working class was to have no culture.… The rejected … she was desperately trying to be the kind of person her mother had said she should be but all the time she actually felt like the disparaged people that her mother would talk about, those ordinary black people, “not like us”, so it’s all sort of mixed up there with race.’
Asked how she addressed this, H said: ‘It was a real struggle because it all could have failed because I could have got very retaliatory… or/and I could actually have become totally inadequate and become the useless working-class therapist that she thought I was going to be.… I’m aware of it when I see other patients… and again it’s always the accent I go for, and I feel I have to prove myself a little bit more, because I don’t speak the same way as them, and that they will pick this up and think, “Well, is she any good, is she educated?”’ Here, the explicitly class-related attacks had the potential to re-traumatise the therapist, to evoke old class wounds, illustrating the powerfully injurious impact of earlier class experience, and the considerable psychic work required to retain an analytic position.
The potential for feelings of class-related inferiority to be stimulated is also illustrated by A, working with a rich woman with a high professional status: ‘I felt instantly crushingly inadequate.… She placed me instantly, she knew exactly like Henry Higgins just where I came from, what my wealth was… this came out later. She complained about the chairs, wrote to the manager about the smell in the room, we moved to a different room. This was a measure of the command she felt she had.’
Other therapists also experienced being the target of contempt. F said: ‘It was in her attitude and some acting out she did, it wasn’t just contempt, it related to class.’ Asked about how she approached this: ‘I think I have struggled with my own prejudices… it’s probably my own values and beliefs about human beings and equality that ground me when I’m struggling with how little she’s been paying for years and years and how much she’s now earning now she’s going.… I have to challenge these things in myself… partly you realise through the work everybody whatever their class is human… her family was just hell, that modifies all those fantasies about how wealth would just make life easier.’
F’s statement about human equality occurs alongside her acute awareness of the significance of class difference, keeping them both in productive tension. It differs from the more usual class-blind assumption of the equality of individuals, for which F had previously criticised her analyst (see p. 112). F used her belief that wealth cannot buy happiness to overcome her feelings of envy and resentment. A also felt huge envy of his patient’s wealth and reflected how he had had to live quite a long time to understand that money cannot buy love: ‘I felt genuinely valued but as someone from below stairs… just the sadness about divisions between people that she genuinely felt.’
Several therapists described what they saw as middle-class bluff and bluster, a false confidence, which ‘gets them through some situations’. B said: ‘Middle-class people sometimes seem a bit naïve, take things for granted easily, which seems a bit silly.… I take it that confidence is on the side of the ego some place and it can be strangely oddly very fragile… it seems self-confident but not as clever as it seems.’
Class contempt as an aspect of transference exposes what is often kept politely or defensively hidden: attributions of inferiority and superiority according to class. It illustrates the middle-class use of class as a defence, to create an illusion of superiority and confidence, or to exert power. It shows the powerfulness of the social world in the construction of classed psyches such that working-class or lower middle-class past experiences and fears of inferiority and humiliation render them vulnerable to middle-class disdain or arrogance.
The impact of class and wealth in the transference–countertransference matrix is also evident in Bodnar’s (2004) work with a rich upper-class woman, which she prefaces by an account of her own upwardly mobile trajectory. Bodnar observes how initially boundaries were drawn around her working-class and the patient’s upper-class identifications, such that she found herself defer-ential to the patient’s fear of exploitation or being without means, a contract that she suggests has long characterised tensions between the working classes and the upper middle classes. She only began to question her own complicity in this, in not charging the patient adequate fees, when the patient purchased an expensive apartment and repeatedly emphasised the cost of unwanted gifts from her mother with whom she had an antagonistic relationship. Bodnar expressed astonishment at the lavish spending, and questioned the patient’s portrayal of her mother (as the rich-bitch) that she had previously gone along with. The patient’s furious and contemptuous response of ‘How dare you?’, revealed previously unaddressed aspects of the transference: coming to therapy was ‘slumming it’; her unspoken awareness of the analyst’s class background made it exotic; the analyst was like the nearly invisible household servants of her childhood, who silently witnessed her exaggerated entitlement, akin to the hired help who neglected her own needs.
Bodnar questions her own sense of moral superiority over such lavish spending, as part of her hidden but enacted working-class identifications, which meant she didn’t ‘stoop’ to charge the patient a full fee. She describes an ‘untouchable contempt’, the defensive disdain between herself and the patient, held in place by a class hierarchy that allowed a disconnection from the underlying emotions. It was through enactments, in not charging the patient an appropriate fee and then in expressing astonishment at lavish spending, that aspects of class were first hidden and then revealed. The subsequent deconstruction of the class issues in their relationship revealed the role of intergenerational transmission of unspoken trauma and loss in the patient’s family.
These accounts illustrate how the intensity of the analytic encounter can reveal class-based anxieties and projections, and exposes the viciousness at the heart of class, much of it described in psychosocial work. The rawness and forcefulness of these denigrating projections were intensified by the injurious legacies of these therapists’ own class experiences. Most therapists found ways of surmounting and working reflectively with such projections, and also with their own envy, but the personal demands of this were often great. They drew on their own values, their understandings of class forged through experience, and their professional skills, to meet these challenges. They successfully crossed ‘the boundaries of inequality’ (Sennett, 2003), despite the lack of wider psychoanalytic recognition of these significant conjunctures.
The potential for contempt in the transference, previously described, finds an echo in a fear of being denigrating that some of the middle-class therapists with working-class patients expressed. Several also described being stuck when they encountered class-related anger, which they felt unable to sufficiently take up or explore.
J, working in a low-fee organisation, described a man in a skilled manual occupation from a working-class family, referred because of an apparently psychosomatic complaint. She felt that she had helped him put into words his angry feelings: ‘… all related to his bosses who earn lots of money, had big cars and used him as a skivvy. You could see he resented being in the position he was, violently… he was in a sort of conflict situation with them, which of course repeated some of his earlier experience, and also repeated something in the therapy with me, because there I was, middle class, with a little warm consulting room, with the loo at the back.… I think it was very difficult for him to articulate anything about my position. I couldn’t help him do that… I mean, it was there in the transference, obviously, but you wondered whether with this man you should be trying to pursue or open this up. It might have been because there was a very violent part to him and in the countertransference I think I knew that.… I never did feel fear with him… it’s possible that there was more around than I was able to deal with, he was talking all about these men with big cars, and mine isn’t a big car, but that must have been there.’ Earlier J had spoken about her class embarrassment at having a fairly posh car, which sometimes she hid from her clients, suggesting a subliminal level of fear about envy.
J said overall the therapy was successful although she was still left with a sense of untouchable areas: ‘He had a grievance about his upbringing, but he wanted to hang on to that.… There was so much grievance because it had all been so bad… there was so much reality factor that it was difficult to go into it, there was very little to work on.… I don’t know if there was a countertransference that made me feel nervous of doing that, because of what might have been an outcome.… I felt there was something a bit untouchable.’ Here there is an appeal to ‘reality factor’ as contrasted with the assumed concerns of analytic work – a recurrent theme but one used to limit the work, as if exploring the ‘reality’ factors was somehow intrinsically unanalytic. This further constrains analysts’ ability to think about and work with patients who come from backgrounds of social and economic deprivation.
M also felt inhibited in taking up some aspects of the transference with a working-class upwardly mobile patient: ‘There is clearly a very ingrained sort of class issue for him and power differential and things like that.… There’s a sense that anybody in the upper class has more power and can afford to be ill, and I’m sure that includes me in the transference.’ M wondered whether his hesitation in exploring this further was to do with his perception of the patient’s paranoia and having to be especially careful of what he said to him, or whether it was: ‘a class thing, a kind of reversed snobbery.… It is difficult to challenge him, because of the sense that he would perceive it as dismissing his realities.… I suppose in the countertransference, I’d like to challenge him.… I don’t think it’s all about class, but you could see him stuck in that sort of grudge, he’s very much stuck there.’
The references to ‘grudges’ and ‘grievances’ is a significant use of language that suggests the complexities of this conjuncture between social circumstances and unconscious processes, and of the emotional politics of class, to use Skeggs’ term. The relevance of this to wider political concerns is suggested by the psychosocial work of Paul Hoggett and others. The authors identify the centrality of grievance, resentment and stuck victim positions to conditions of divisive social policies and political disempowerment, in the absence of political movements giving voice to real injustices. They suggest a structure of feeling whereby: ‘ressentiment occurs where grievances become blocked and turn in on themselves, leading to something more socially toxic’ (Hoggett et al., 2013: 5), providing ‘the affective basis’ for antagonisms between people. Such a perspective might enable the framing of ‘grudges’ and ‘grievances’ in wider terms.
In the present study, the language reflects therapists’ sense of frustration at what they felt they could not work further with, and maybe their own sense of powerlessness as regards the inequalities of social circumstance. They found it difficult to make further use of their probably correct perception of how self-defeating this angry stuckness had become. This pinpoints the difficult line that therapists may have to tread between the recognition of justifiable anger at social circumstances and the ascription of personal agency, something which can run the risk of appearing not to think the anger is warranted. Some therapists (see p. 127) did find ways of negotiating this. It is also a complex clinical judgement as to how and when to address rage without incurring undue destabilisation or fragmentation. Nonetheless it is striking that class-inflected anger of the kinds described could induce a kind of retreat or drawing back on the part of some therapists.
Another therapist, N, in work with a patient from a working-class background, had many struggles with the perceived differences between them, and the transference–countertransference dynamic. N felt guilt, and fear of being denigrating: ‘She immediately made me feel guilty about my privilege, not only my privilege but also my friends’ privilege.’ N felt, unlike with other issues, she could not ‘see the projections as well as own the reality… it has been difficult for me to speak about her family of origin… the work has been about unconsciously separating from them, as well as consciously. My guilt has meant that I am constantly aware of not wanting to denigrate them, even now I hesitate to describe them as a disturbed family.… I do think the class difference has been there, all through the work.’ She linked her difficulties with this patient to her early acute awareness of class differences (see p. 114), which she felt had not been helpfully addressed in her own analyses.
These excerpts illustrate Sennett’s description of what happens when the ‘boundary of inequality’ is not crossed, namely, silence, caution and fear of giving offence (Sennett, 2003). It shows the powerfulness of class in creating distance and withdrawal. Such anxious awareness of the potential for denigration of the working-class other suggests how deeply the culture-wide valuations of class permeate the psyche, whatever the conscious beliefs otherwise. My own experiences, as a middle-class therapist with many upwardly mobile patients, resonates with many of these descriptions, and was part of the spur to these investigations. With some, I felt acutely the discrepancies in our socioeconomic circumstances, especially as regards childhood, but often found myself unable to think when the work demanded that I explore the particular meanings of class, especially within the dynamics of the relationship. My anxiety and fear of anger and envy inhibited me in taking up any transference that touched upon my relatively privileged status.
Some therapists cast the impasses they felt in terms of ‘reality factors’, and the assumed opposition between the exploration of these and an analytic stance. P however did not use the language of grudges and grievances in describing his work with a working-class man ‘who was defiant and proud about it but who was carrying a lot of hatred and envy’. Coming from a very economically and emotionally deprived background, the patient described himself as a football hooligan. He had, P said, ‘a terrible anger’, and a determination never to be so impoverished. P was seen both as the ‘toff’ and as the immigrant who had made good and who tried to conceal himself with his accent. P described a threat of violence at times during the analysis, which he managed to contain. He also described the patient’s huge hatred against ‘the system’ that led him into extensive fraud: ‘All his endeavours had been to get at somebody.’ P said that at the end of a long intensive analysis: ‘He was still as angry and emotional but the language had changed, he had an ability to look at things that would worry him.’ He had also made many positive changes in his material and professional circumstances, an example of how it is possible to move out of repetitive stuck positions but not lose very justifiable anger at social circumstances, something which many people fear therapy will lead to.
The interview data suggests that P’s ability to work productively with this working-class white patient was linked to P’s experiences of being subject to racism, and also having felt well understood in his own analysis in relation to issues of ‘race’ and class (see p. 114). P’s account does not suggest fear or guilt in the face of intense class-related anger. He was able to work with the intertwinings of social realities with intra-psychic issues, rather than seeing them as opposed. Previously P had criticised the notion of ‘reality factors’ being used to limit psychoanalytic interest. This suggests how much can be learned psychoanalytically from those subject to social oppressions and discriminations of various kinds, as the following examples from working-class therapists also show.
Janine Puget, in her re-theorising of the psychoanalytic representation of social reality, observes that one barrier to recognising how the social field has its effects is that analyst and patient often live in the same social and cultural world. She suggests that ‘the unconscious link’ with the social field is easier to recognise when something alien is experienced (Puget, 1991). My research corroborates this in that there was greater wealth of clinical detail evident with class differences than with similarities. However, with working-class pairings some salient aspects of class were reported, as the next examples show.
Anger, feelings of inferiority, shame and envy within a class context were identified in clinical work with working-class patients, as well as the complexities of blame and responsibility. F described a woman who had huge conflict about the professional training she was pursuing, in that she felt she had to become middle class to do it: ‘She had so much anti-feeling about being middle class, she was really really ambivalent about it and we worked quite a lot on whether she could be black and working class and a professional (my substitution here), and make it her own and that was a very powerful issue in the therapy.… It was a real eye-opener to her that she could own the material she was developing… it didn’t belong to the middle class and she didn’t have to become one of them, she could actually take these things that she had learned and use them in her own way.’ In this passage, fundamental questions about the dominant culture and the social ownership of skills and ideas are touched upon, and led to F commenting: ‘Well, the middle class don’t own psychoanalysis, they don’t own course materials.’
F described some of the psychic fragilities and defences she felt this patient was struggling with in relation to her social circumstances: ‘For this woman to own that she had anything valuable… of having something good inside her… that counteracts feelings of envy, but I think if there’s a narcissistic wound that’s being defended against, then it’s very hard to think you’ve got anything at all. And when everything externally is reinforcing that, then it’s really hard to challenge that and find a place where you can take responsibility for what you haven’t got. If you feel resentful, not having had it for external reasons, then to take responsibility for your own deprivation in order to do something about it, whether internally or externally.… If you take responsibility… are you letting people you do blame off the hook?… But are you going to remain in this victimised place where you can’t take any responsibility because you are a victim? And it was very complicated with this woman because she was a fighter… she was doing extraordinarily well but at enormous cost, it was just unbelievable, and for her to do that in a different way, from a place of confidence rather than defensiveness, was just extraordinarily difficult.… The shame she felt about revealing her vulnerability… she had to be so defended against any emotional vulnerability.’
This passage suggests how F trod the ethical and therapeutic tightrope of addressing stuck and self-sabotaging anger that had a formative basis in stark inequalities. It brings out the immense psychic, as well as other forms of, labour that someone from a working-class background of economic deprivation and also subject to racism has to undertake to exist and succeed without unsustainable conflict in a middle-class environment.
F had been seen by this patient as middle class within the transference, which she had found difficult: ‘It touches on my prejudices about “them”.’ Because she was quite confident she was not middle class, she could take up this powerful transference: ‘and be the middle-class illusion’.
Other therapists felt they used their own class experiences to understand their working-class patients, although all were aware of the dangers of over-identification. C commented that some working-class patients may be ashamed of feelings of inferiority in a supposedly egalitarian society. He described his sense of identification with how his patient’s background ‘tended to be glossed over, a romantic notion of it being presented at first’. He continued: ‘I felt angry on his behalf, the way he had been intimidated by people of a different class, and sometimes made to feel ashamed of his background, his shame was very buried.… I identified with that a lot, not having a voice and finding it.’
This was echoed by E who described how, with a patient from a different working-class background from her, nonetheless she felt that she could understand something about the ‘poverty and basic things about class, how to speak in a public arena… I think my class background has enabled me to make links with her, I’m not saying a middle-class therapist wouldn’t have been able to… It wasn’t an easy fit, more I had a kind of trajectory or understanding of where she might be able to get to.… I had to wait for her to find her voice.’ E had earlier emphasised her own feeling of not being entitled to speak or have a voice, part of the low self-esteem she felt was connected to class.
H described a working-class patient from an extremely deprived background who felt huge shame and humiliation about her childhood. H could identify with ‘wanting to hold your own in a world where everyone appears to be more privileged than you, that sense of shame’. Whitman-Raymond (2009) describes using her identification with a working-class patient over a matter of hygiene that was felt as deeply shameful, and the consequent enriching of the clinical work. In my own clinical work, I learned how resistant class-related shame can be, in extensively stalling or making exceedingly painful the exploration of adverse childhood circumstances. The imperative earlier in life to hide family circumstances and dynamics felt as hugely shameful, and the precariousness of such a defence, means that subsequent exploration in therapy can be feared as unsurvivable exposure, to both the assumed gaze of the other (the therapist) and to buried, often unverbalisable and overwhelming emotions. Holmes is one of the few analysts (see Chapter 8) to address the traumatic aspects of class. In the final chapter, I explore the centrality of shame to class experience.
A however described disidentification and lack of empathy, at times amounting to hostility, towards a patient he saw as ‘lumpen proletariat’. She was, he said, always complaining and blaming everyone for her circumstances. He became quite confrontational which he said was not successful. He related this to how: ‘I used to have a phobia of the really poor, of slipping back into the id, my family has always worked, clawing themselves out of the grime and poverty of the East End.’ A had ironically described himself as a poacher turned gamekeeper, suggesting the need of those who feel only precariously different from the (despised) underclasses to radically distinguish themselves. A did not feel any fear of giving offence but rather enacted some class-based contempt.
The implicitly middle-class culture and frameworks of psychoanalytic therapy were cited by H as causing difficulties for work with some working-class patients, as did the writers about psychotherapeutic work in poor urban communities (see Chapter 4). She raised the question of impulsiveness within a class context, something Reich in his work in the free clinics had observed. H thought that delaying gratification was an attribute engendered by middle-class upbringing, the belief ‘that if you work hard you will get rewards later… it must be quite hard to have that if you really don’t think there’ll be any rewards later… so if something good comes your way you grab it now’. She saw this as reflecting the very different employment options for working- and middle-class people. I asked her about the clinical implications of this. H said: ‘I was aware I had to prove myself to them from the very first meeting, which probably meant I was working in a less analytic way, more like counselling, more immediate.… I would talk more… it was very important to establish the empathy because I would feel they wouldn’t expect me to understand and therefore I had to work much harder in showing them I could understand.… It was absolutely crucial I could get that across quite early on… it’s obviously important with all patients, but I was more aware of it.’ Such flexibility in approach has been argued for by many other writers on psychoanalytic work in poor communities.
These therapists’ capacities to work with class issues were not only matters of identification, understanding and empathy. Rather, they mostly appeared able to take up and work with stuck positions of victimhood and blame, and the accompanying entrenched powerlessness. Such ability came not from any wishful denial of social reality but rather the reverse, a huge understanding of what that could mean and also a commitment to what therapy could do. Their understandings of poverty and class, while born of their own experiences, is something that could be available to other therapists, from the sociological, psychosocial and autobiographical literature, should they so wish (see Chapter 5). The skilfulness of these therapists is also testimony to the psychic work that they themselves had done in their own upwardly mobile paths, addressing the impacts and insidious internalisations of class that affected them, to reach the thoughtful positions they were able to articulate and use.
Unsurprisingly the class issues in these dyads were less salient. The economic, social and cultural resources that make psychoanalysis accessible and attractive mean that assumptions of shared class status, values or lifestyles may go unquestioned. N described a strong sense of identification and engagement with a patient with similar social circumstances. While aware of the dangers of over-identification, she also acknowledged her relief to be working with someone from a similar background, having previously described the difficulties she had felt with a patient from a working-class background: ‘I feel a good therapist with her at a superficial level… it’s much less demanding superficially than working with someone from another class background… (it’s) an enormous trap, collusion in the symbiotic sense.’ She also felt money and fees were easier to address. M also mentioned that with a middle-class patient he had a sense of ease relating to her educational and social background: ‘It doesn’t get in the way.’ However he emphasised how relatively unimportant this was compared to the psychotic aspects of her disturbance.
In some instances downward mobility was also encountered. P said he was aware of patients who attacked their privilege and wealth, sometimes self-destructively. He described a patient, unable to sustain his very successful career, who was very ashamed of his upper middle-class background. He had had a breakdown, during which time ‘he was wandering around with a suitcase and two cardboard boxes’ wanting to shed all his social attributes and identifying strongly with the dispossessed. P described how the patient’s acute sense of shame was located in early experiences of his poorer peers being barred from his family’s exclusive enclosed property, and from forming friendships with him. This created an enormous sense of betrayal that he felt he had to make up for, and a strong but troubled identification with the excluded. P, at times, felt the temptations of the demand from this patient to label his upper middle-class privileges as utterly wrong. The patient saw P’s education and training as having enabled P to think, whereas his had only been to produce, a comment perhaps of the drive of the privileged to reproduce their class status through their children. The patient eventually found a viable compromise for himself, in work that used his professional skills in ways he found morally acceptable and not too demanding.
K described a patient who pursued fame and celebrity status, but with feelings of inauthenticity: ‘He’s got enormous social confidence, and it makes him utterly miserable how good he is at it, because he feels it is just a complete sham.’ K acknowledged her own feelings of fascination and envy. The issue of therapist fascination with rich or famous patients, which N reported she experienced with her own analysts, also occurs in writings about money and psychoanalysis (see Chapter 9). It reflects the social power imbued in elite status, that can be unreflectingly enacted by therapists of lesser means, for example in feeling important or gratified by having a rich patient, as Altman, in the next chapter, describes. Or it can create no-go areas as N’s experiences illustrate, and Bodnar (earlier) describes.
The thoughts of these therapists and also those writers cited indicate the many kinds of concerns that surface when class within clinical work becomes an explicit topic of discussion. Their testimonies suggest that class issues may be especially salient or cause most unease where there are differences between patient and therapist (as apprehended or imputed); nonetheless they can and do operate where there is seeming similarity. This is an important corrective to the common trope that it is only where there are differences that social and cultural issues need to be thought about. Similarities of middle-class status may obscure class issues, reflecting the cultural hegemony of middle-class mores within the profession and also the unconsciousness with which privilege may be lived or enacted.
The transference–countertransference issues often bore a strong relationship to the class background of the therapist, in combination with the (putative) class of the patient. They bring out what is often kept hidden or felt to be unacceptable in relation to the class other, especially the judgements, fantasies and projections of inferiority and superiority that are embedded in the psychic living of class. That the influence of biographical factors was so salient raises important questions in a professional setting. It seems that here the influence of trainings was minimal. The previously reported absence of discussion about class on trainings or in most post-qualification contexts meant that therapists fell back on their own experiences, formulations and values in their clinical work, with varying effects. This gap in psychoanalytic education is also suggested by the references to ‘reality factors’, invoked as imposing limitations to the therapy with these particular working-class patients. Such a notion was not used in relation to middle-class patients, nor within the working-class dyads. The implication is that ‘reality’ could not be thought about psychoanalytically, nor incorporated into clinical work with the patient. This in effect fences off the impact of aspects of social experiences into a no-go area. It indicates how most psychoanalytic education and discussion does not embrace contemporary writings on working psychoanalytically in poor communities, for example those cited in Chapter 4. It illustrates the wariness that Puget and Sanville (2000) argue psychoanalysis has towards social reality. Thus are understandings of inequality and class within psychoanalysis marginalised, to the potential detriment of clinical work.
One therapist, B, in asking how the analyst would hear class in the transference, implicitly raises the question of whether anything different is needed from ordinary analytic listening. Many of the present accounts indicate how class issues can be facilitators of transference, leading on to further productive work, if adequately taken up. In opening up the idea of transference beyond that of individuals or families to include more socially based attributes, we might ask if this widens the more usual understanding of transference, or whether it represents a more fundamental change. None of the therapists interviewed here suggested that radically new approaches or entities were needed. Laurence Spurling (2016) discusses whether incorporations of the social world into therapeutic discourse are to be seen as enlargements of the frame of the therapy, or as enactments. His review of the wider clinical literature that includes explicit references to social or political issues, often initiated by therapists, suggests, as might be expected, every possibility at play in this respect. If there were enactments involved in the work reported here, they were rather failures to adequately pursue and understand class concerns and dynamics that were being expressed, seeing them as ‘too much reality’, beyond the scope of the therapy. Bodnar (2004) however does see her displacement of her moral disdain about wealth into undercharging her rich patient, and also her subsequent introduction of money and class into the clinical dialogue, as enactments, albeit ultimately fruitful ones. Those interviewees who did productively integrate their understandings of class into the therapeutic dialogue did not suggest these were any kind of enactment, apart from one, A, who acknowledged that he had enacted some class hostility. Rather, their accounts suggest that ordinary analytic listening amplified by reflective sociocultural understandings, an ability to work with class in the transference, to maintain the tension between social and intra-psychic considerations without closing down either, and also a flexibility of approach, are all required.
Bodnar, S. (2004) ‘Remember where you come from: Dissociative processes in multicultural individuals’, Psychoanalytic Dialogues 14: 581–603.
Dimen, M. (1994) ‘Money, love, and hate: Contradiction and paradox in psychoanalysis’, Psychoanalytic Dialogues 4: 69–100.
Hoggett, P., Wilkinson, H. and Beedell, P. (2013) ‘Fairness and the politics of resentment’, Journal of Social Policy 42: 1–19.
Puget, J. (1991) ‘The social context: Searching for an hypothesis’, Free Associations 2: 21–33.
Puget, J. and Sanville, J. (2000) ‘Social reality’, International Journal of Psycho-Analysis 81: 998–1000.
Ryan, J. (2006/2013) ‘“Class is in you”: An exploration of some social class issues in psychotherapeutic work’, British Journal of Psychotherapy 23: 49–63. Reprinted in F. Lowe (ed), Thinking Space: Promoting Thinking about Race, Culture and Diversity in Psychotherapy and Beyond. London: Karnac.
Sennett, R. (2003) Respect. London: Allen Lane.
Spurling, L. (2016) ‘Transference and the psychosocial’. Unpublished paper presented to the Psychoanalysis Working Group, Birkbeck, University of London.
Whitman-Raymond, L. (2009) ‘The influence of class in the therapeutic dyad’, Contemporary Psychoanalysis 45: 429–43.