PSYCHOANALYTIC WORK WITH HOMELESS ADULTS: An Interview with Deborah Anna Luepnitz Dr.

Deborah Anna Luepnitz delivered a paper at the Division 39 Meeting in San Antonio, TX on psychoanalysis with homeless people in Philadelphia. Her paper addressed many preconceptions and issues related to this work, and tied the work to Freuds analysts in Red Vienna of the early part of the last century, who opened free clinics and demonstrated a brave commitment to social justice. Dr. Luepnitz is also the author of The Family Interpreted (1988) and of Schopenhauers Porcupines (2002). She can be contacted at babette@webtv.net. The following interview with Dr. Luepnitz highlights aspects of her Division 39 paper and her remarkable clinical work. VAPS: Please tell us about your project. DL: The project is called I.F.A., Insight for All. At first, it was just me, running groups and consulting pro bono at an institution for formerly homeless women. About five years ago, I was able to interest a small group of psychoanalytic therapistseight in Philadelphia and eight in New Yorkwho shared my commitment to providing insight-oriented treatment to the very poor. VAPS: Was there something that drew you, personally, to the problem of homelessness? DL: I have lived and worked in West Philadelphia for thirty years, treating individuals, couples and families who are underserved. My interest in homelessness per se came from the experience of treating a woman (Emily) who had been walking the street with her 4-year-old daughter by day and sleeping in a squalid city-run shelter at night. She was at the end of her rope and often imagined hurting the child or just leaving her at the shelter. Fortunately, she knew enough to ask for help, and through a comedy of errors, ended up assigned to me at our clinic at the very moment in the mid-1980s when I had decided to start seeing a few private patients to help my finances. Our meeting seemed so star-crossed. After she told me her story of neglect and abuse, I didnt imagine shed return for a second appointment. She did return, however, and we ended up working in a fairly rigorous psychoanalytic therapy with several sessions per week, for the following 14 years. When we said goodbye, her little one was on her way to college. She was bright, engaging, and feisty, with a generous disposition. I wrote about this patient and her daughter at length in my book, Schopenhauers Porcupines. I called her chapter, The Sin Eater, based on an image she chose for herself. VAPS: A long relationshipwere you always convinced of a positive outcome? DL: No. For the first five years, she was very demanding, often paging me during the day to ask me something. I felt she had invaded my life and Id never be rid of her. I often imagined running away from home with no forwarding address. Winnicotts idea of identifying and accepting our hate in the countertransference was very helpful. I was young at the time and decided to get an hour of supervision just to help me care for this patient.

VAPS: In your current project, how do the other therapists cope with the challenges of these encounters? First of all, they arent young and inexperienced as I was back then. I decided to accept only experienced clinicians into IFA. The idea of students practicing on poor people is an old one, with obvious drawbacks. Also, IFA members meet to discuss our work and give each other a lot of support that way. They also know that, as director of the project, Im always available for consultation. To answer your earlier question about the origins of IFA, it was after Emily terminated treatment with me that I felt I wanted to know more about homelessness locally and nationally. I learned that 1.6 million Americans spend some time homeless during a given year. That includes people living on the street as well as in temporary shelters. It does not include people doubled up with friends or relatives after a foreclosure. Most are homeless for days, not months, at a time. Within this group, the smallest but most resource-consuming are the chronically homeless who suffer from mental illness and substance abuse. Given my experience with my patient, I wondered if there was something that experienced analysts with a willingness to do some free work could do to end homelessness. VAPS: You mention Sister Mary Scullion in your paper. Can you tell us about her, and how you met? DL: When I decided I wanted to know more about homelessness, someone said, You must meet Sister Mary. As a 25-year-old nun, she and her best friend decided they wanted to solve what was then an egregious homelessness problem in our city. When they started, there were 25,000 people sleeping on our streets. That number is now closer to 1,000. These two idealistic young women had no money. They took over an abandoned roller skating rink and invited a group of homeless drug-addicted men to come in for the winter. People heard about this makeshift project and began to volunteer time and resources. Then, someone offered them a grant, and the city and state got involvedreluctantly at first. What is now called Project H.O.M.E. has an annual budget of 8 million dollars, and they are celebrating their 20th anniversary this year. Over 8,000 people have cycled through Project H.O.M.E., and an amazing 95% have not returned to the street. Sister Mary is the holiest person Ive ever met, and also one of the funniest. One of Project H.O.M.E.s big donors happens to be the rock star, Jon Bon Jovi. He said, in an interview, Mary is the only nun [I know] who swears and spits. Asked about it on camera, she said, I dont spit. What makes Project H.O.M.E. different is that its goal has been not simply to warehouse people, but to offer permanent solutions. To that end, residents receive medical care, job training, help finding employment, art classes, and the chance to get involved in community development and political activism. To me, the residents of PH had access to all the necessities of life with one exception: psychoanalysis.

VAPS: So, how did you introduce the idea? DL: I relied on etymology, for starters. I said that the word psychoanalysis comes from two Greek words: psyche, which translates soul, and analyein, which means to loosen or untie. I told Sister Mary that psychoanalysis is about untying the knots of the mind or soul, and I also mentioned that Freud had wanted this work to be available to everyone, regardless of ability to pay. VAPS: Havent some analysts would argue that Freud stated that paying a fee helped the patient feel invested in the treatment? DL: Absolutely. In 1910, Freud made that argument, but he changed his mind over time. In 1918, at the congress in Budapest , he predicted that at some point, the conscience of society will awake and reveal that rich and poor alike were deserving of this kind of [psychoanalytic] healing. The last sentence of that eloquent speech is, Such treatment will be free. I used to quote the speech to show that Freuds heart was in the right place. Then, in 2005, Elizabeth Danto published her eye-opening book, entitled Freuds Free Clinics [see discussion of the book, this newsletter]. It turns out that between 1918 and 1938, ten free psychoanalytic clinics sprang up in seven European countries. They treated farmers, factory workers, servants, the unemployed, and poor students, who presented with the usual things: depression, psychosomatic problems, substance abuse, etc. The early analysts were keen to volunteer. This beautiful chapter of our history ended in 1938 when the Nazis took over the clinic in Berlin, throwing out the Jews and replacing the word psychoanalysis with The New German Psycho-therapy. Everything that had to do with sexuality was discarded as degenerate. Patients had 3-6 sessions to get better; those who failed vulnerable to euthanasia or deportation to a camp. Its really chilling stuff; it gives an eerie feeling of the past as prologue! In any case, Sister Mary trusted my explanation enough to give me permission to launch I.F.A., and she has remained extremely supportive of us. VAPS: Why do you think more people dont know about the free clinics, and why do many think of psychoanalysis as a treatment designed for the wealthy? DL: Many of the early analysts fled Hitler, and good number came to the U.S. Here, they encountered a strange development. Whereas Freud had said that medical training was the worst possible training for an analyst, the American Medical Association decided that medical school would be the only route to being an analyst! Its one reason Freud called America itself a great mistake. Those migr analysts wanted to be accepted in their new country and to assimilate as best as possible. They were glad to have survived the genocide and to land good jobs here. Given the long-standing fear of communism in the U.S., it wouldnt have served them well to say, By the way, in Europe we felt strongly about having lay analysts, and we also did this work for free. The medicalization of psychoanalysis also meant the de-feminization of it, by the way, since as late as 1963, only 6% of doctors were women. What had begun in Vienna as a radical project meant to contest bourgeois social and sexual norms became in the U.S. a conservative medical specialty geared to helping people adapt better to social codes. The high fees meant that only the wealthy would have access to the couch.

The point I would like to make is that my little project is not some bold, new application of psychoanalysis. Its a return to Freuds original intent, which was realized in the free clinics. Even most analysts dont know their own history. I feel we have a responsibility to educate ourselves first, and then the public. Think of the vast sums that the drug companies pump into advertising their medications on network television! VAPS: In your paper, you mention that what holds us as clinicians when we dont have regular supervision is a capacious theory. Can you elaborate? DL: Yes. For me, the two great psychoanalytic originals after Freud were Donald Winnicott and Jacques Lacan. People who study psychoanalysis seem to latch onto one of them and then studiously avoid the other. They are the yin and yang of psychoanalytic theory and practice. They knew and respected each other, much more than their followers do. Winnicott gives us so much that has helped in my work with formerly homeless patients. I already mentioned abiding hate in the countertransference. Other crucial concepts are: the holding environment, the danger of impingement, the true and false self, and the importance of environment. We try very hard to provide that secure experience of containment for our patients, while being very mindful about boundaries, so that we arent creating impingement. Weve found that in many cases, its essential to hold sessions on-site, rather than expect the person to leave the safety of their PH residence to come to our office. Lacan felt that there was too much emphasis in Winnicott on the mother, the pre-Oedipal, and the imaginary register. He wanted to return to words, language, and the symbolic to the place Freud had assigned them. This is very important in working with the formerly homeless. They have emotions, but so little ability to verbalize them. Many of them have enormously complex family histories, but typically have told their story to no one. Even if they have been in therapy at some point, chances are that the work focused squarely on the mother. When you think with Lacan, you need to understand any form of psychological symptom in the context of at least three generations. This is the clinical significance of working in the symbolic. When the patient I described to you earlier called herself a sin eater, it was tremendously liberating. She had watched some episode of The Twilight Zone or Night Gallery on TV, and learned about this particular practice in every village in Wales: having a poor person come to funerals to eat food spread out on the corpse to absorb its sins. Her suffering in the family had been immense and ineffable. She felt she had absorbed the transgressions and violence of the family. Finding words to describe what had been vague and corrosive was a big step to healing. Its the reason that Lacan once defined psychoanalysis as the cure of the Real by the Symbolic. Anyway, as you know, Ive worked on bringing these two traditions together, and recently published an article in the IJP called, Thinking in the Space between Winnicott and Lacan. It has been said that Winnicott introduced the comic tradition into psychoanalysis, whereas Lacan sustained Freuds tragic/ironic vision. Both are crucial to working with all patients, I think, including the homeless and formerly homeless.

Another French analyst Ive found helpful is Didier Anzieu, whose notion of the skin ego is fairly well-known. The first home we all inhabit is the mothers body, and under good-enough conditions, mother and baby create a skin ego which is precursor to the ego as we know it. Disruptions at this early stage make it difficult for the individual to ever really inhabit his or her own bodywhich makes it impossible to inhabit other spaces. Many homeless people end up sleeping in doorways, i.e., unable to exist either inside or outside a dwelling. Not everyone in I.F.A. is interested in the French tradition; many of our members identify most closely with the American relational school. They think in terms of intersubjectivity, authenticity, and self-states. Neil Altman is a relational analyst whose work with inner city populations over many years has informed our work. He points out, for example, that although we analysts love to be the good object for the traumatized patient, the really transformative moment occurs when we agree to be the bad object for the patientand then refuse to retaliate as the original bad objects did. VAPS: You referred in your paper to groups in both Philadelphia and in New York doing this work DL: Yes, we started around the same time. The NY group consists of eight or nine members of the Womens Therapy Centre Institute. I have been a faculty member there since 1997, and when I presented the case of Emily, and described my ideas for I.F.A., these N.Y. colleagues said, Why cant we start our own branch here? They have done some really inspiring work. Both they and we have patients who havent missed a session in 2-3 years, and who have used the treatment to really move forward in their lives. We like sharing our ideas with people in other cities who are considering starting their own homeless project. VAPS: The jobless rate clearly risks turning more Americans homeless. Do you see cause for optimism? DL: I do. President Obama has shown that he understands the problem of homelessness, by endorsing the solutions advocated by the National Alliance to End Homelessness: above all, prevention and affordable housing. We met with Sean DonovanObamas homeless czarlast month and were very impressed with his grasp of the problem. What the Reagan and Bush years destroyed in terms of affordable housing, the new administration may be able to repair. At the same time, we psychoanalysts can contribute by listening deeply to people who have never been listened to before.