I work in a municipally run general hospital located in Queens, New York, in the outpatient clinic (also called Ambulatory Behavioral Health Services) of the Department of Psychiatry.
The surrounding community is one of the most culturally and ethnically diverse areas in the country, and includes immigrants from Africa, Europe, Asia and Central and South America. This provides a diverse patient and staff population and adds a strong multicultural dimension to our experience.
Last year alone the 3rd year residents in Psychiatry were from Turkey, Spain, Ecuador, India, Mexico, Egypt Colombia, Bangladesh, Pakistan and Nigeria. More than 160 languages are spoken in the area and the Hospital offers services in 20 different languages and more interpreters of other languages are available through the phone. Recently I used an interpreter for a patient coming from Burma. I can provide services in English, French and Spanish. I have been working here for 17 years.
My responsibilities include individual, couple and group psychotherapy, intake process, supervising psychiatric residents and psychology interns and participating in didactic seminars. I have worked with the medical population and also with victims and survivors of torture and asylum seekers.
My hypothesis is that the particular setting of the Hospital with the diversity of languages, cultures and ethnicity of patients and staff provide a fertile ground for the practice of psychoanalysis of Lacanian Orientation.
Not being a homogeneous population, it is not possible to apply one model to all, a universal protocol applicable to all.
The principles of Lacanian Psychoanalysis: such as, the not-all, the way we approach the symptom and the sinthome; knowing how to do with it; the one by one of each case; and the respect for the singularity of jouissance of each one have allowed me to maintain a serious and sustainable practice.
The model used is based on Lacan’s proposition of Psychoanalysis applied to the Clinic. Psychoanalysis can be conceived as a powerful desegregation identification tool, if we privilege the one by one, instead of working towards group identification and ideals. I run 3 groups of Hispanic women suffering from anxiety and depression. Spanish is the common trait but each one comes from a different country of Central and South America with different cultures and especially different symptoms. The tendency to constitute a homogenous group excluding the difference is always present. Remarks about the other ethnicities of the neighborhood are common: the Chinese this (even if they can be from Korea,) or the Indians that (mixing Pakistanis, Afghans, Indians in the same package). When I apply this logic to their own ethnic group, for instance the Colombians or the Mexicans, just to mention some, they are able to perceive how they use and apply the same logic they complain about.
Using and being aware of the contingency is very important. In one group there is a Muslim Puerto Rican woman who wears a niqab in public, which she removes in the group. This has allowed to demonstrate that not everything is what it seems and not everything is appearance. It introduces the time of a pause before passing judgement.
According to Wikipedia, Evidence-based practice is the integration of the best available research with clinical expertise in the context of patient characteristic, culture and preferences. I think that Lacanian psychoanalysis provides a wide and rich source of learning through the systematic rigorous clinical and theoretical research as demonstrated in events such as this Pipol 9 and the Congresses and Study Days happening in the World Association of psychoanalysis.
This is not to describe utopia or to idealize a particular clinical setting because there are requirements, bureaucracy, policies and protocols that constantly threaten the quality of the clinical work. That is why our practice has to be dynamic – innovating and maneuvering with subtlety. We can’t fall on the repetition, – falsely considered the scientific method. Our interventions should be on the side of the unexpected – the witz.
A very important aspect to maintain this orientation consists in keeping constant dialogue and conversation with colleagues of other disciplines: psychiatrists, social workers, and case managers. We need to use a language that allows us to exchange, not imposing our “lacanian dialect.”
This year the psychology interns asked me to teach a yearlong Lacanian Seminar. One of the concepts they struggled with was the concept of jouissance. One of the interns that co-leads a group with me, told me in supervision she had finally grasped “in vivo” what jouissance is and had happily shared it with the other interns. This is the vignette: A woman whose husband was assassinated in front of her for political reasons and who sought asylum in the USA, says in the group that she likes to listen to this particular music, but that it makes it her very sad and she cries. Her daughter has told her not to listen to the music if it puts her in such a state. But despite the suffering she likes to hear the music and has to listen to it.
The clinic of generalized foreclosure and ordinary psychosis are also an invaluable compass to guide our interventions and to deal with delicate moments of disruptions of jouissance and fragile transferential moments. The analyst operates on the jouissance substance without standards.