by Beth Kita, Francisco Gonzalez, Mia Maturen, Rachael Peltz, Ryan Parker

At the April 2015 meetings of Division 39, Section 9 featured an en vivo presentation of Reflective Spaces Material Places (RSMP). RSMP is a thriving community of Bay Area clinicians interested in psychoanalysis and community mental health. It’s name very much describes what the founders sensed was needed — to carve out space, both within our minds as clinicians and within our places of practice, to reflect on our work and connect with one another.

Since the spring of 2012, mental health practitioners from a variety of settings — jails, parole, schools, private practices, family agencies, child welfare system, etc. — have met to discuss their work. Our model  emerged as an intervention in and of itself, and has given rise to a thriving community of people for whom psychoanalytic thinking and community practice are integrated.  In addition to the support that it provides for practitioners, the dialogues that emerge at RSMP give voice to issues that are crucial to both psychoanalysis and community practice.  In that sense, RSMP has provided the Bay Area with one form of a Community Psychoanalysis.

The following sections contain summaries and excerpts of the presentations made by members of RSMP as part of the Section 9 program at Division 39’s Spring 2015 meetings.

En vivo Presentation Gathering:

Ryan Parker:

The five RSMP members whose voices you will read below, had been planning our en vivo presentation for months. We were thrilled by Section IX’s invitation to present at Division 39, and were able to build important relationships through our collaboration. As the day approached, some of us feared that no one would come, others were confident that they would. The day had arrived, and we would soon find out.

In usual RSMP fashion, the chairs were in motion as we began to transform the conference room in San Francisco’s Palace Hotel to resemble what has become a hallmark of RSMP gatherings — whoever is able and willing is called on to help us create a circle of chairs. Those who arrived first chose their seats, only to have to get up again to make space for the over 50 people who poured into the room. I believe that over time, these experiences of working together to transform our physical space so that all feel included and valued, has been an important part of our building relationships and community. This was our first conscious enactment–to give people a sense of what RSMP is like. It’s cooperative and collaborative. It really does matter that everyone sits in a circle.

Introduction to RSMP and Section 9

Rachael Peltz:

We are really thrilled to introduce you today to the work of RSMP. The members here with us will introduce themselves and will offer a live example of an RSMP event. This is a model we are hoping will spawn similar groupings in mental health communities around the country. It’s been a privilege for me to work with my new friends and colleagues in this group. It really is a breath of fresh air that reminds me of the our radical history both in psychoanalysis and other political movements — a grassroots community grouping that strives to generate a safe place for discussion and difference.

I have some thoughts about how the formation of RSMP reflects a changing atmosphere regarding the role of psychoanalysis in the world, generational shifts, and the current world we live in.  If I were to give this changing atmosphere a title I would call it “Community psychoanalysis in motion.”

Psychoanalysis in the consulting room

Psychoanalysis in the clinic

Psychoanalysis in the schools

In the prisons

In the university

In the body politic

In the cybersphere

Like spokes on a wheel, we are reaching out to the places and people less likely to have the benefit of the sanctuary and support a psychoanalytic approach can offer.  And, then, returning to our center for collective reflection, planning, and recharging. In our call for the creation of free clinics and a “psychotherapy for the people,” as we approach the 100^th anniversary of Freud’s address to the Congress at the IPA in Budapest, we are reminded of the earlier vision of psychoanalysis as a progressive social movement, eager to bring the spirit of psychoanalysis to people and places that would not ordinarily have access to it.

This protean shift in our current psychoanalytic culture comes at a critical moment.  The press of intensified human need coupled with growing limits on available resources dominate our cultures and societies. It is also a time in which a creative explosion within psychoanalysis is not matched by a corresponding attraction of young professionals reaching for traditional psychoanalytic training in institutes.  Nor are psychoanalytic modalities deemed valuable in the public sphere. Psychoanalysis is subject to the same social forces that buffet the individual, struggling as a discipline in a society in which key psychoanalytic tenets do not reflect significant cultural trends. Today, the emphasis on scientific objectivism, information processing, and profitability in the world places little value on the key tenets of psychoanalysis — helping people to live more fully and find meaning in the subjective experiences contained within their lives.  These tenets are deemed unscientific, undisciplined, and thereby diminished. Psychoanalytic treatments are rarely supported by either public or private sources of funding, as diagnostic terminology and corresponding drug treatments abound. Psychoanalysis remains as one of the last bastions that honors the human need to derive meaning out of one’s experiences. Psychoanalysis must therefore make the case for itself in these times and engage the tensions that exist within the discipline in order survive intact and with integrity as it responds to the pressures of contemporary life. We are thus called upon to take stock of what is happening around and within us and exercise our moral imaginations — to visualize how to create new ways of thinking and acting that matter.

Engaging in such an imaginative process requires that we scrutinize our own history and practices and consider their implications as we approach our future relationships to analytic institutions and surrounding local, national, and global communities.  I think we have begun to address a legacy of unresolved and restrictive tensions that have existed within our psychoanalytic culture and metapsychology, including the tensions between the internal and external, the psychic and social,  the individual and the group, insight and support, depth and surface, objective and subjective, analyzable and un-analyzable, civilized and primitive,  exclusive and inclusive, psychotherapy and psychoanalysis, hegemonic and counter-hegemonic norms.  Through this thoughtful engagement we have begun to re-imagine the definition and scope of a contemporary social-psychoanalytic vision and turn our attention to how to best approach the struggles around us — and with whom.

Imagine for a moment analytic institutes that allow candidates to substitute one of the required control cases for more intensive involvement in a community institution, agency, or clinic in order to expand the scope of psychoanalytic practice into the community and help generate innovative psychoanalytically-informed community practices.

One of the ways we have begun to expand the ways we think about our analytic identities in our communities is by giving more attention to the good that can come out of collaborative working groups. The notion that personal fantasies are inextricably linked to effective social action is a radical statement we may want and need to consider.  I think if one were to develop that notion further in psychoanalytic developmental terms, it could lead to the positing of a “post-depressive position,” in which a form of relating occurs that extends beyond the triad of the Oedipal (whole objects) to communal groupings and society at large. The capacity of effectively locating oneself in relation to a social grouping could be considered a developmental achievement along with its concomitant attainments and respective regressive anxieties — for example, respecting difference, maintaining separateness, assuming responsibility for group members – as well as its concomitant fears of disappearing, competitive anxieties, and so on.  Bion (1961) described the various dynamics possible within group life. Gerard Mendel and Elliott Jacques, among others, applied some of Bion’s ideas to institutional group life.  But, apart from some of Erikson’s writings, I don’t believe psychoanalysis has sufficiently recognized the need for effective social/political life within the context of the developmental continuum.

RSMP is grounded in a belief in the generativity of groups. We are interested in developing a model of community building and containment grounded in the creative potential and authority of collaborative working groups — group-mindedness in which we have room for difference, attention to power dynamics, awareness of class, race, and generation, to name a few.  We are a group of clinicians from different disciplines, working in a variety of private and community settings, from different ethnicities, classes, and age groupings. We are interested in honest conversations, innovative thinking, and social justice and how to best use ourselves as analysts and citizens. We are interested in a “shake-it-up” mentality.

Now, we will all meet each other in the RSMP way.  Then, Beth Kita and Mia Maturen will tell us about the history of RSMP and the RSMP model. Ryan Parker will initiate the RSMP introductions, Francisco Gonzalez will offer his clinical presentation, and Ryan will moderate the discussion with all of us. We will make sure to leave time for questions and discussion of the entire experience before ending.

History

Beth Kita:

Thank you so much for inviting us to be here with you today.  I think that one of the most exciting aspects of RSMP is how much we all love it, so I’m so pleased to have a chance to share our experiences of this organization with all of you.   I’m going to spend just a few minutes talking about the history of RSMP, and then I’ll hand things over to Mia who will describe the model that has emerged.

In 2011, three local organizations — NCSPP (Northern California Society for Psychoanalytic Psychology, the Northern California chapter of Division 39), Access Institute (a local psychodynamic training clinic), and PINC (Psychoanalytic Institute of Northern California) — got together to “do something on community mental health and psychoanalysis.”                   Representatives from each — Lani Chow, myself, and Francisco Gonzalez,  respectively — met to try to figure out what that “something” might be. Our early conversations focused on how we had all found psychoanalysis to be so invaluable to our work in community mental health, because it helped us to think, not only about our clients but also the systems in which we worked with them.  Immediately emergent was how excited we were to have found each other — kindred spirits who saw psychoanalytic theory and community mental health as totally linked and invaluable to one another.

The three of us met over the course of a few months, and finally settled on planning a day-long conference.  For a while, we were more aware of what we did not want to do than what we did want to do. We knew that we did not want to create a top-down model that would feel colonizing, recapitulating many of the dynamics that we sought to deconstruct with psychoanalysis.

What we did want, we eventually figured out, was to create an opportunity for people in community mental health to come together to think psychodynamically about the vicissitudes of that work.  We knew from our own experience that working in a community setting was full of nuances that psychoanalytic theory helped us to think about, and we also knew that the experiences that we had in community practices were ones that could deepen and elaborate psychoanalytic theory.  We wanted to embody the recursiveness between the two in which we firmly believed, and worked hard to represent that at our event.

To that end, we took care to meet with various people in various positions — case managers, therapists, agency directors — and also relied on the diversity within our own practices and positions (MD, social worker, psychologist — parole department clinical case manager, analyst, training director) to create a vision for our event.   We also kept in mind the local terrain — what were training institutes, agencies, and other organizations already offering?  Who were they including and excluding?  What needs weren’t being met, and how might we meet them? Various guiding questions emerged, such as:

• How do we represent the intersection of the psychic and the social in which we all believed?
• How do we present material in such a way that it was relevant to both analysts and community mental health workers?
• How do we bring an analytic perspective without it seeming top-down?
• How do we own the precision of psychoanalytic language without potentially excluding others who were unfamiliar with it?
• Or, do we take pains to not use psychoanalytic language and potentially lose the utility it provides us in thinking about our work?
• How can we structure an experience that feels inclusive to a diverse audience?
• Are we trying to sell community mental health to analysts — or sell analysis to community mental health?
• Who do we invite and what does that communicate?  What was backgrounded and what was foregrounded — and what did that mean?
• How do we frame our event, and what would we delimit and define as a result?
• Perhaps most importantly, how do we plan a conference when we don’t even know if anyone would come — and who they would be if they did?!?

We did our best to hold all of those (and a million more) questions in mind, and decided to focus on creating just what we all needed the most:  reflective spaces that also considered our material places.

We moved forward with our first day-long conference in March 2012. We felt strongly that we wanted to center the community, and made sure to hold the event at an agency in the Mission in San Francisco (versus at a

training institute or other venue).  We kept the cost as low as we could (and actually had some really interesting discussions about how to keep the event affordable while not devaluing what we were offering).  We structured the day according to a format that we thought would encourage community and relationship-building:  the first part of the day involved case material presentations and a large group discussion while the second part of the day focused on small group meetings before the large group resumed.

Much to our relief, people did indeed show up!  (About 90 people, to be exact — case managers, therapists, analysts, psychologists, social workers, and psychiatrists — all from different agencies and practices all over the city.) The conference completely sold out, and the feeling of the day was very similar to how the three of us had felt:  OMG, there’s more like me!!

Probably one of the smartest things we did at that initial event was to print and post a sign-up sheet for anyone who was interested in meeting again.  We didn’t really know how this thing was going to turn out, but we figured that on the off-chance we had something good going, perhaps we could capture that energy and keep this RSMP idea moving.  (Our sign-up sheet said something like, “Want more RSMP? Join us on [date].”)  Amazingly — with no follow up phone calls, advertising, or anything — two months later, about 50 people showed up on a Saturday afternoon at Instituto Familiar de la Raza.  Everyone was so excited and it was incredible to hear these amazing conversations taking place about the intersection of psychoanalysis and community mental health, the psychic and the social, and the private and the public. All we did was create the space — and of course, the place — and from that emerged the RSMP you’ll be learning about today.  It was clear then that the need was there and very much shared, just waiting for a space and place to be expressed.

In the three years since that initial event, RSMP has been meeting bimonthly, save for summers, on Saturday afternoons at Instituto.  At each gathering, the presenter offers material as a stimulus for the group discussion.  We’ve focused on a variety of topics germane to community mental health — working in parole, losing clinics/places, practicing in high schools, navigating race and racism, complex trauma, countertransference, analyzing agencies, etc. We’ve not only created opportunities for group members to learn from each other, but to provide a holding environment for each other:  I know that my experience is not unique, and when I presented at RSMP it was the first time in my life that I didn’t have to explain one half of my presentation or the other.

Our community has steadily been growing. We tend to have between 40-50 participants at each event. Notably, there is consistently a mix of brand new folks, and those that attend every event.  The group is somehow the same and different each time.   It always features a combination of folks practicing in a variety of community settings, those in private practice, some doing a hybrid of both.  The group is unified by its interest in this “intersection” between the internal and external, and in our hunger for spaces in which to explore it.

In terms of infrastructure, our organizing committee is tasked with planning the bimonthly meetings, maintaining contact with our sponsoring organization, and reflecting on the growing edges of the group and figuring how to respond to them.  That committee has expanded from Lani, me, and Francisco to include five additional members:  three people from each sponsoring organization, and two people from community mental health agencies.  Over the past couple of years, Ryan, David Cushman, Rachael, and Mia have joined us.  Each of us takes turns in being the primary facilitator of each event.  (You’ll hear the word “emergent” a lot from us and it is code for we-basically-figure-things-out-as-we-go-along-and-do-everything-last-minute-and-with-the-least-amount-of-structure-necessary.)  But in all seriousness, part of why this group has worked in because 1) we all love and care about it; 2) we are willing to meet regularly, following each event and between them; and 3) we trust the group to grow as it needs to and we trust our capacity to be responsive to it.

When we set out to plan our second conference, held last Spring, we also formed an additional planning committee that comprises eight members.  That group is now planning our third conference, slated for this September (and featuring Lynne Layton).  Out of our second conference emerged a study group on race, and from that group we will be launching “RSMP Reads!” — a “book club” in which we will identify a book that lends itself to a psychoanalytic read on race/oppression and then facilitate discussion meetings. We also developed a website at some point that acts as a means of communication and contact, but also as a living document for the history of our group.  We also maintain a Google group (consisting of approximately 200 people). In addition to our regular meetings, we’ve also held a gathering following the Eric Garner murder and Black Lives Matter movement, and have also co-sponsored an event with a visiting scholar from PINC.  Currently, we are working on a writing project, further developing our model, and figuring out how to continue to maintain this method we’ve stumbled upon that seems to work — the facilitation of an organic and emergent process — with a little bit of intentionality and purposiveness from each of us — that allows our little group to grow.

RSMP Model

Mia  Maturen:

Reflective Spaces/Material Spaces was born out of an emergent and creative process. The model, like the space we aim to create, comes from and responds to a specific moment and to the specific needs in our community. Our model has developed out of our history and remains a work in progress. We do our best as organizers to follow the group’s lead, adding infrastructure as needed. Since the contours of RSMP have developed democratically and organically by the participants, the methodology can be replicated, but the specifics are variable. We imagine that if created in other areas, what emerges would have its own local flavor and might be quite different from what has occurred in the Bay Area.

There are several “rituals” or traditions that have taken hold in our meetings. We meet at a local agency in the community that you will hear more about from Francisco in the experiential portion of our presentation. We meet the second Saturday of every other month from 2-4pm. This time was intentionally chosen to allow people who work in community mental health agencies M-F from 9-5 pm to attend. We sit in a circle and everyone briefly introduces themselves. By doing so we discovered that this creates a greater sense of community, giving us an opportunity to get to know one another. It also challenges traditional formats where only the presenters and discussants, positioned as the holders of power and knowledge, are named.

The material presented is offered as raw material that functions as a catalyst for the group. These presentations often include the dyadic interaction in the clinical encounter, but also explore the contexts where the work takes place. There are discussions of the community in which the clinic or institution is located as well as discussions of the internal structure and politics of the clinic itself. We always have a mix of newcomers and regulars, but the environment has developed a culture that seems to carry through from month to month. Fundamental to this process is a strong ethic that values difference. The group strives to treat one another and the clients being presented with dignity and respect. Without a formal discussant, the group is our discussant. The decision to have the group as discussant is based on a notion that the group can offer containment that is different than the containment of an individual or dyad. This is especially notable when working together to metabolize traumas and experiences that occur at the intersection of the psychic and the social.

From the beginning of this project, there has been an emphasis on letting structure and ideas emerge from the collection of people present, rather than acting from a premise in which there was an assumed pre-existing (psychoanalytic) knowledge base that would be disseminated to those (community mental health workers) who didn’t know. Community-based practice requires and offers opportunities to translate some of our familiar concepts such as thinking, holding, and reflecting into physical, material, and action-based terms. We saw a need for spaces where the intrapsychic, interpersonal, cultural, systemic, and political can be thought about simultaneously and collectively.

Through the creation of a physical space for reflection, we challenge an understanding of our work as located solely in the individual, in the dyad, or in the office and recognize our work as occurring within social hierarchies and structures. We critically examine how psychoanalytic theory and institutions, in spite of their radical origins, continue to exclude people and remain conservative in approach and practice. We continue to struggle to create an inclusive space for those who are culturally alienated by psychoanalysis and are actively working to expand our community.

RSMP functions as a group mind for many clinicians who often feel lonely and isolated in their work. Community mental health practitioners are under enormous pressure to deliver more services with fewer resources. Through aiming to provide meaningful interventions that address the social, psychic, and material demands of those who struggle the most, there is an even greater need to carve out spaces, both within our minds as clinicians and within our places of practice, to reflect on our work and connect with one another. The need for new kinds of spaces does not only belong in the trenches, but is felt by many who work in private settings as well.

Some who have left community mental health — for different reasons — still feel committed to community values and social justice and are eager to find ways to become more engaged. Others are increasingly aware that delinking the material and the symbolic or the psychic and the social creates false dichotomies and delegitimizes very important aspects of our embodied lives. We are all, in many ways, working and living in the milieu and have found that in a group environment we are able to hold experiences that cannot be contained by one, two, or three.

Clinical Presentation

Francisco J Gonzalez:

I joined the staff of Instituto Familiar de la Raza in 1997 as a psychiatrist, and have been there ever since in various capacities, serving at times as medical director, as a team leader for a multidisciplinary treatment team with a focus on HIV-infected individuals, as director of a yearlong cultural training program for providers, and as the leader of a psychotherapy consultation group that has met twice a month for some 15 years. Instituto is an independent community-based social services agency serving indigent and working class Latinos, most of whom are immigrants or from immigrant families (with varying legal status: from completely undocumented to asylum seekers, residents, and citizens). About 95% of our clients are monolingual Spanish speakers, but there is a growing community of Yucatec Mayans, who speak Spanish only as a second language.

Instituto is located on the main street of the Latino community in the city. Walking down Mission Street you pass Casa Guadalupe grocers with their bins of chayote, cactus tunas, and plantains; Gallardos Party Favors, with everything you could need for a quinceañera, but also a locavore pie shop that serves organic coffee and a The Fizzary, “an urban menagerie of soda,” evidence of the hipster-ification of the Mission. The clinic was started by a group of Chicano activists and mental health providers, who raised the initial $300 seed money by selling tickets on the corner of Harrison and 20th Street in August of 1978 for a home-cooked Mexican food plate. The agency now has a budget of about $5 million, owns its own building, and has a staff of over 80 employees, almost all of whom are bilingual and bicultural.

One of the tenets of Instituto’s philosophy is “la cultura cure” — that culture heals — and IFR has made clinical use of cultural ritual, integrating curanderos — indigenous folk healers — into conventional mental health practice, for example, and celebrating cultural events like Dia de los Muertos ceremonies, Tonantzin (a coming of age ritual for adolescent girls), and the Mayan new year.

Let me now give you a snapshot of one short day in my clinical life there. By condensing a great deal, a snapshot can produce its own sort of overwhelm. But perhaps this is not a bad depiction of life at a community mental health agency, where the time to unpack the density of experience is often a luxury. Reflection is always constrained materially — it’s just easier to see this working in the community.

A few weeks ago, I start the day with a patient I’ll call Moisés (the names of all the patients in this presentation have been changed). He is a second generation Caribbean immigrant and one of the very few patients I have who use English in our sessions — though it’s sprinkled with Spanish phrases and pronunciations. HIs name operates in the inverse: he is adamant that he be called Moses, and when any of the staff happen to use the Spanish pronunciation Moisés, his first order of business is to correct them emphatically. In the recent past this had been followed by a stream of ricocheting associations, impossible to follow in any detail, but with themes involving his spiritual powers to heal with his hands, sexual innuendo, his communications with god, splintered references to his grandmother and sleeping on the streets, private jokes which strike him as hilarious but other people don’t really get, and demands for housing or sleeping pills. His psychosis has been florid. He clearly needs a great deal of help, and seems to want it, or wants something, but it takes weeks of hit-and-miss appointments, drop-in visits with the case manager, follow up calls, and outreach before he can make it into a session to see me.

In the first session he was generally affable, but completely disorganized in this thinking wanting — only valium, which I prescribed. It’s been a few months since that first encounter and he is now taking antipsychotics and living in a dual-diagnosis residential program. He enters today with a boxed pastry from Dianda’s, the Italian bakery down the street, and tells me it’s a gift for me: “I really appreciate everything,” he says. I thank him and leave the box on the desk. He is polite, respectful, groomed and neatly dressed. Maybe we have been playing something of a seduction game all along: pastries for valium. But there is a great deal more.  He has been massively disorganized, but unrelenting in his desire to get help. Today he makes full sense for the first 10-15 minutes of the session talking about his program, but when he starts associating to his past, things fall apart. And yet, through his delusions of magical healing powers, a bizarre emphasis on his bilingual name, shattered references to his grandmother, and his repeated insistence that he was actually born here in San Francisco, a multigenerational story of displacement and loss is starting to emerge. For the first time, I hear about his absent, drug-using, womanizing father, once loved, now lost, a displaced man, who shuttled back and forth to his Caribbean homeland. Moses, it seems, was to deliver the family, but something failed. “You are going to grow up to be just like your father,” grandmother would say.

He wants therapy today, and seems like he might be cohered enough to actually start making use of it. But we have a waiting list, the interns are completely full, and one of the therapists is leaving the clinic for a higher-paying job in a private hospital. We will have to place all of her patients with the overworked therapists that are left. Moses, though, needs a containing relationship now, to see him through the transitions from one residential program to the next — he cannot wait.  He agrees to increase his antipsychotic just a little, and I can arrange to see him in two weeks.

My next patient, Javier, is more depressed than his usual. He has just come back from an extended stay with the wife of one of the men he crossed the border with. Fifteen years ago this couple and he waded out into a chilly Pacific Ocean at night and slipped from Baja California to San Diego. The man just recently died of cancer. Javier had been lost and miserable in native Nicaragua.  A closeted gay man who was teased for being a sissy as a child, he joined an evangelical church as refuge and escape, entombing a vital part of himself in fervent religion. When the couple announced they were leaving the country for political reasons, Javier decided to go with them. He was secretly in love with this man, he realizes now, though no one, perhaps least of all himself, could know it then.

After moving to the US, he came out, but lost his church community in the process.  He found a partner, a gringo, and they lived together for almost 10 years, until the partner died of AIDS, and Javier was left alone and HIV-positive. The widow of this old friend and a group of friends he knew from that time now know about his being gay and being HIV-positive.  They accept him well enough. And the time together allows him to unfold a layered mourning, but only to a small extent. “The house where they live is way up in these hills,” he is telling me, “it’s not anywhere near a town or anything; it’s pretty, but so cut off, so far from anyone or anything.” I realize he is telling me about himself, his immigration, his losses, his depressive isolation. He seems to feel a little better when he leaves, and I a little sadder.

After the session with Javier, it is time for the consultation group with the therapists. The therapist presenting today, Susana, is a vibrant young woman from Venezuela, who plunges us almost immediately into her latest therapy hour with a 14-year-old girl she describes as smart and recalcitrant, doubtful that anyone can help her, withdrawn and angry by turns. Actually the session really starts the day before with a call from the mother, who wants Susana to tell her why her daughter wants to go to a summer residential internship week from an academic program. Va hacer demasiado peligroso — it will be too dangerous — the mother is saying, and goes to pound on the door of her daughter’s room — “your therapist is on the phone, she says you have to tell me whether you are going to go or not,” screaming through the door. Susana is trapped on the line, a pawn in the game. Other therapists in the group recognize the family: one person did an intake for the mother, another recognizes them from interactions in the waiting area, someone did support groups for another of the youth in the family. The presentation and subsequent discussion moves back and forth between English and Spanish, associationally, reflecting the complexities of biculturalism in the family and staff. We work together on developing interventions in the transference: trying to find ways to figure the closed doors and barricades erected against intrusions, the therapy room as prison, as refuge, and protected permeable enclave, as summer internship.

We talk about being a therapist to the field, finding ways to integrate the interventions of multiple providers with various family members and in different venues (school, youth program, therapy room). But also how the field acts as therapist — not one individual therapeutic object relationship, but a relationship between the 14-year-old girl (or even the whole family) and the collective of providers, a one-to-many or many-to-many object relationship. It is a lively group, and the animated exchanges and camaraderie are refreshing.

The next patient slot is open for administrative work. I need to write a letter of support for a former patient. I had closed Delia’s chart just a month ago. She had presented for the extended psychiatric evaluation required to obtain sexual reassignment surgery. She had been living as a woman and taking hormones for over a decade, had had top surgery, and was now ready for complete surgical reassignment. We met for months and she had been forthright and open in describing her story. I had a hard time imagining that she had ever been other than a woman. I had written a lengthy evaluation supporting the surgery and we had terminated and closed the case. Now, she had contacted the case manager requesting I write a letter to use in a U-Visa application. A U-Visa grants legal status to individuals who have been a victim of a crime while immigrating to the United States. We had not discussed any such traumatic incident. I felt very fond of Delia, and could well imagine her obtaining legal status would be beneficial, but had nothing to go on for a U-Visa. I felt a little trapped between a failed national immigration policy and professional ethics. I write a generic letter, describing her time in treatment with me and a therapist, but make no reference to the U-Visa, feeling a little guilty.

My next patient fails to show, and I am worried about him. I call his number but get no answer, and there is no way to leave a message. I shoot off a message to the case manager to see if she has heard anything about him and make a mental note to bring him up at the next team meeting.

The last patient of the morning is Juan Carlos. I have only seen him twice before. He had a chip on his shoulder and was extremely guarded. He used methamphetamines occasionally, but was getting worried about what it was doing to his mind. He had crossed over from Mexico about six years ago, was assaulted and badly beaten. In the first session, I was acutely aware of his vigilance. Juan Carlos could sense the smallest inflections of my demeanor and was quick to call me out on anything that had the slightest tinge of falseness. I had been impressed by his directness and we made a good bond. But last week I was called by an emergency room psychiatrist, who told me that he had been brought in drunk. The psychiatrist repeated several times how belligerent and difficult he had been, uncooperative and disdainful. He tells me today he knows he was in the wrong about a number of things and is contrite for some of his actions, but also that he was enraged because of what he perceived as racial discrimination. The triggering event set him off, and he can make good use of my interpretations describing a powder keg of past injuries and injustices and the match of the interaction that lit the fuse this time. I am thinking of a recent viewing of the video released on PEP, “Black Psychoanalysts Speak.” An analyst is describing the number of black men that have said to her, “don’t take my rage away from me, doc, it’s what’s kept me alive.” I empathize with his anger, and this makes it easier for us to talk about how such explosions are harmful to him. He has just started working with an intern therapist at the clinic, and I am glad that he feels a good connection with him. I tell him that I think we will be able to help him, in great measure because I can seen how sincerely he is struggling with his demons. “Tenga paciencia conmigo, doctor — be patient with me, doc,” he says on his way out. “Don’t worry, Juan Carlos,” I say, “pasito a paso” (“little by little”) — and pat him on the back on his way out.

I touch many of my patients at Instituto, it’s not uncommon for me to lightly put my hand on their shoulder as they are leaving. And never in my private practice — not even my Spanish-speaking patients. It’s interesting to me how the whole ambience of the clinic makes for a different mode of interacting. It’s palpable on walking through the door: there are prominent elements, like the mural of Jose Marti behind the reception desk (Martí

was a Cuban poet and patriot, and I’ve never quite understood what he is doing there — the mural was already in place when we moved into the building) and of course the altar, decorated with candles and flowers, where someone from the staff burns sage in the mornings.  But more than these iconic cultural symbols, which carry import for some staff and patients, and not at all for others, what I feel most is the people: there are usually a few staff, the executive director, and the transgender advocate, a couple of therapists, chatting in Spanglish around the reception desk, sometimes with patients, or patients are talking with each other while they wait. It’s the familiar in Instituto Familiar de la Raza: both something having to do with family and with familiarity. A different order of social space and psychological boundary than in my downtown office — a great cultural holding environment, perhaps, and one that makes certain things possible — certain kinds of understanding, or capacities to open deep wounds or almost unimaginable traumas to possible transformations.

When I leave the building into the bustle of Mission street, a one of my patients is coming up the steps, maybe to see a therapist or case manager, and gives me a big smile, “Hola doctor, como está?” “Super bien” I smile back, feeling a little like a small-town doctor.

Summary of Group Discussion

Ryan Parker:

Now we will open up the conversation to the group, and use this opportunity to think together. What came up for you as you listened to us talk about RSMP and heard Francisco’s clinical material? The room fell silent for a moment, but soon the group took up a conversation similar to many many we’ve had at RSMP meetings.

The first comments were focused on Francisco’s clinical material and the moving stories he shared about his work with patients and co-workers at Instituto Familiar de la Raza. There was a sense of longing for the kind of contact that Francisco described that can only happen in a community clinic. Responding to the theme of the group discussion, Beth offered the idea of what she calls the melancholia of private practice, the longing to find a way to return to the “community” that many who have left it, for whatever reason, feel. This is one gratification that RSMP often provides those who once worked in community mental health, but now work in private practice — contact with those parts of themselves and their work that they miss, and a way to access and rekindle those parts through their relationships and participation in RSMP.

The conversation soon found its way to the voices of those currently working in the trenches. People talked about their sense of isolation, and feeling overwhelmed and overworked. People expressed how much they long for spaces to reflect on their work and connect with others under similar pressures who are interested in psychoanalytic thinking and who share their values and experiences.

A resounding theme during the conversation was: But how can we create something like this in our communities? With a mix of hopefulness and anxiety — participants chimed in with the barriers they envisioned, others shared the ideas and plans that were beginning to take form in the moment. However frustrating, the RSMP presenters continued to speak to the idea that any RSMP-like group would, by necessity, be unique in each community. That RSMP had emerged through a conscious and ongoing responsiveness to the needs of its participants–as a community. We spoke to the power of a group to help make the ever increasing pressures of community mental health more manageable, to help us metabolize the trauma and pain and reflect on our work with those who suffer the most among us. It was said, as has often be said among RSMP members, that the intervention is the group itself. Sharing space, both physical and mental, as we think together.

And then our time was up, with so much more say…

References

Bion, W. R. (1961) Experiences in Groups. Tavistock.