BRIEF

Am

COMMUNICATIONS

with Sernyl, LSD-25, tention, motor function, try 1:651-656, 1959 10.

Ban tions

TA, Lohrenz of Sernyl-a J 6:150-157, 1961

When BY JESSE

the 0.

ii, new

HE:

Observations on drug. Can Psychiatr

the acAssoc

thinking.

JR.,

M.D.,

AND

JEAN

Arch

G. SPAULDING,

Curry

(6),

and

Waite

(7),

fall

between

these

stated

that

‘

‘

racial

differences

suggested

that

is Associate

Professor

of Psychiatry,

same

fears

Lucifer, Curry

two

may

be represented

or Judas. implied

be used

Medical Center, and Chief of Psychiatry. Veterans Administration Hospital, Durham, NC. Dr. Spaulding is Resident in Psychiatry, Duke University Medical Center and Veterans Administration Hospital, Durham, NC. Address reprint requests to Dr. Cavenar at the Veterans Administration Hospital, 508 Fulton St., Durham, NC. 27705.

1084

0002-953X/78/0009-I084$0.45

and not

that

1978

this

When

Curry

dif-

working-

that i.e., unre-

become

cathexis

of a reality

the

with

situation,”

blackness, an insurmountable that precludes treatment and fective interracial psychotherapy if proper attention is directed

American

Psychiatric

Association

issue

formation

becomes

a

it is because of these anxiety generated by

that

interlaced

reaction

to the

racial

therapist, and the

transference,

by Satan,

pre-transference resistance

concluded

conflicts

transference, ©

and

in mythology

as an effective

of a transference.

University

The opinions expressed in this paper are those of the authors those of the U.S. Veterans Administration.

important

lated to the individual’s past life and are therefore not transference phenomena per se. Curry suggested, as have other authors, that “black” may unconsciously represent bad, evil, darkness, and inferiority. These

between

Duke

are

resistance,

does in reality have a characteristic unconscious fears and fantasies, These fears and fantasies may be

the fantasies. Cavenar

1962

there

transference,

point of attack on the unconscious fantasies Dr.

6:395-401,

‘ ‘

may (8)

(9)

in the

the therapist can mobilize black color.

extremes. Fischer

Psychiatry

through process when the therapist is black. He neferred to a complex set of issues he termed “pre-transference. This pre-transference is due to the fact that

‘

Kennedy

Gen

M.D.

ferences

on psychoanalysis and psychotherapy when the therapist is black and the patient is white is very meager. There are markedly divided opinions as to the effect this variable may have on the treatment process. Oberndorf (I) suggested that interracial therapy cannot be effective due to the psychological biases that are present and implied that such treatment should not be attempted. However, Schachter and Butts (2) stated that racial differences ‘may have a catalytic effect upon the analytic process and lead to a more rapid unfolding ofcore problems.” Other reports in the literature, such as those of Bernard (3), Calnek (4), Gnier LITERATURE

(5),

1978

analyst and patient involve issues of unconscious meaning at many levels. These issues and meanings must be recognized and utilized, for there are serious hazards in either overestimating or in ignoring them.” Fischer further suggested that the black-white difference is a visible structure on which infantile fantasies may be projected. He concluded that “to ignore the manifest black-white issue is to avoid a piece of the patient’s and therapist’s everyday reality. To become overly invested in this apparent interracial content, however, represents an effort to deny and negate the deeper intrapsychic conflicts.”

The authors present a case report ofa white neurotic man treated in long-term psychoanalytic therapy by a black woman psychiatrist. The defense mechanism of reversal-the therapist was white in the patient’s early dreams-was evident not only in this patient but in several other white patients treated by the black therapist. The authors suggest that, contrary to the opinions ofafew other authors, the reality issues of racial differences can be dealt with successfully in this kind of interracial psychotherapy.

THE

September

Is Black

Psychotherapist CAVENAR,

135:9,

11. Cohen BD, Rosenbaum G, Luby ED, et al: Comparison of phencyclidine hydrochloride (Sernyl) with other drugs. Simulation of schizophrenic performance with phencyclidine hydrochloride (Sernyl), lysergic acid diethylamide (LSD-25), and amobarbital (Amytal) sodium: II. Symbolic and sequential

and amobarbital (Amytal) sodium: I. Atand proprioception. Arch Gen PsychiaLehmann psychotropic

J Psychiatry

ifthe “the

i.e.,

patient’s patient’s

the

own hyper-

therapist’s

resistance may form leads to acting out. Efis thus possible only to these complex preand resistance issues.

Am

J Psychiatry

135:9,

We became

September

interested

in this

psychoanalytic

term

male

patients

racial

variable

been

female

a clinical

in long-

involving

white

psychiatrist.

as to whether dream by the racial differences.

It has long

BRIEF

psychotherapy

and a black

also curious be affected

1978

We were

productions

observation

would

in psychother-

apy and psychoanalysis that the patient’s dreams frequently disguise a white therapist as a black person. This is most commonly noted in the early and middle phases of treatment as a defensive maneuver and usu-

ally

ceases as the man (10) reported

patient’s a dream

defenses are lowered. Altin which a white analyst

was disguised as a black person via condensation, displacement, and symbolization. We wondered whether the same defensive maneuvers would apply when the therapist is black; that is, would the black therapist be represented as white in an attempt to disguise transfer-

ence feelings? The purpose

of this

white male neurotic therapist in which

paper

is to report

patient treated these variables

ment

and dream

productions

This tients trated

case is representative treated under similar the same principles.

a case

by

a black of interracial

could

be studied

of several conditions;

of a female treat-

in detail.

long-term all cases

paillus-

was

indicated

in a dream reported in the 10th hour: “I was of the university for a summer field trip. We go to the athletic field for the field trip; one half of the class are girls, and a woman instructor is there. I felt good during the field trip; after the class broke up, the instructor suggested to me that we have a separate meeting that night. Suddenly I didn’t want to be there: I became concerned about

on the campus

urination.

I saw

and they and

packed

my

instructor.

The

patient

was

a 25-year-old

for anxiety, multiple phobias, and an inability to urinate in public places. He had been born and raised in a small southern town: his parents were from the middle class. He was the second of a set of nonfraternal twins and had one sister who was two years older. He described his father as a sadistic, angry man who was emotionally distant from the children and his mother as a seductive woman who frequently walked around the house and yard nude in view of the children. She bathed the patient until he was in early adolescence. When the patient was 13 years old his mother and father separated briefly. The mother took only the patient with her when she left; he slept with her until they returned home. The father accused the patient of having seduced his mother, and his inability to urinate in public places dated from that experience. evaluation

sonality

with

hysterical

single

because

We felt that the patient

of

phobic

of affect, reaction Psychoanalytic

judged

of choice.

The feelings densation,

patient

treatment

presented

who

came

free-floating

features.

fenses were isolation sion, and displacement. the

man

marked

had an obsessive-compulsive and

the

white

hour.

full

snow

had

been

of snow

pants.

and

again

walked

there

were from

dream

in which race-in

the first

for

ahead

down

to the

any

by

mention the therathe 27th

in the basement of the hospital, on my way to work in the morgue. While waiting for the dcyou and two other people about 20 feet away. I and you appeared to be agitated and angry with ‘I’m here to work in the basement,’ and you

do electrical vator, I saw felt anxious, me. I said,

shook hands with tal. Some windows gressive

I saw outside, to the had been broken, and Somebody is pretty sorry. ‘ I saw a and confident: I felt that was the

be.” Two

weeks

dalism.

fight

I went no blacks;

to distract

undisguised-except

“I was

in a snowball

into their

seems

presented

appeared

me.

later

the patient

brought

back of the I thought,

man

who

way

hospi‘Van-

was ag-

I wanted

the following

to

dream:

‘1 was going to my parents’ home in the country. I walked by a house where blacks lived: children were playing in the yard. All the black families have ten kids where I am from.

His

formations, psychotherapy

permain

de-

represwas

dream

in hour

about the therapist were well displacement, and symbolization.

6. His early

disguised He

by conreported,

‘The dream occurred at a place I had never been before. It seemed to be a church and I went to a classroom with 15 other people. I knew no one: it was a class on vectors. There was a girl to my left, two seats down from me; she looked ‘

over and smiled. It made me feel good, and I had a sense of well-being. After the class I walked by a restroom, and I knew I could go in and urinate without any tension.” The girl

of the

evolving

transference

family

greeted

me: they

always

seemed

to like me.

Their house had garbage around it: most oftheir houses do. I was surprised when I got to my house, because it was an old shack, too, like the house in which the blacks lived. “ This dream occurred 5 weeks before any verbalized recognition by the patient of the fact that the therapist was black. In the 37th hour, the patient reported another dream: ‘ ‘I was lying on a couch with a woman. She was making sexual advances; she was affectionate, and snuggled up to me. It was not in a motherly way. Her husband came upstairs and I was concerned that he might notice this. She was black and

had

long

black

hair

that

I stroked.”

He had

ciating to this dream material and stated any black women. The patient persisted

difficulty

asso-

that he did not know in his denial of any

knowledge ofa black woman. When the therapist finally fronted him with the fact that she was black he reacted denial, waiian-’

anger, and ‘anything

Over

attempts to make but black.”

the subsequent

dressed

hours

He had

intensified.

in dirty,

many

torn

cerned janitors and as a servant or slave

for

several

open

his first

in the dream was white. The strongly erotic nature

pants

of black. The patient pist

who

snow

In this dream

“

contrast,

men

to shove

‘

REPORT

psychiatric

two

started

The black CASE

COMMUNICATIONS

hours.

discussion

the patient’s dreams

clothing,

and

servants. The in relationship

After of his

her

this,

the

prejudice

Vietnamese

many

or Ha-

castration

of unshaven

other

anxiety black

men

dreams

con-

patient described to his supervisor

material toward

himself at work

switched black

conwith

to an

people.

Fol-

lowing openly

a lengthy period of examining his prejudice, he cried and said, “It’s unjust for me to be prejudiced and to let it influence any feelings I may have toward you. You’re the first black person with whom I’ve ever discussed race. I’ve looked for things about black people to be prejudiced about. If one did something that I felt was improper, I would generalize to all black people. I don’t like the way I am. I don’t like myself, I guess.” As the projections by the patient were gradually worked through, it became clear to him that he actually felt inferior, downtrodden, oppressed, and in other ways similar to his .

perceptions

of blacks.

This

phase

of the

treatment

.

.

is best 1085

BRIEF

Am

COMMUNICATIONS

illustrated by the following ment hour: “I went to this A picture of your mother does look black after all. and I were sitting around more

black

than

‘

dream, reported in the 74th treatblack woman’s house. It was you. was there. I thought, ‘Her mother Then my mother, father, brother, a table. It was as though we were

white.”

Over the following 18 months, ence neurosis developed. This

an intense transference

erotic transferneurosis was

through as any other would be; no alteration of techwas made necessary by the racial differences. The patient experienced good symptomatic reliefofhis phobias and urinary problem and a marked lessening of his anxiety. He began to date girls for the first time in his life, his relationships with both black and white authority figures and peers improved, and he began to take several courses to further his education. At the end of 3 years of therapy the patient began to bring typical termination dreams. One such dream was the following: ‘I was standing on an island and the water began to rise. I needed shelter, so I went to a nuclear fallout shelter. You

dreams tent

even

were

there

with a group

of people.

I needed

to urinate,

but

there was a man occupying the bathroom. I needed to go and find my own bathroom. I went into the woods to urinate: I wasn’t uptight at all. I saw a woman in the distance, and I knew I could talk with her. We felt that this dream was like those presented by Oremland (11) in which the therapist, undisguised, is involved with an initial symptom that brought the patient to treatment. The dream appears to indicate resolution of these symptoms. This patient’s psychotherapy went on to a successful conclusion several months later; no additional resi stance was encountered. ‘ ‘

COMMENT

The

case

reported

here

is one

psychoanalytic

psychotherapy

enced

the therapist

was can

in which white. be as

We believe productive

of several

cases

was

black

that interracial as any other

we

long-term have

and

expeni-

the patient

psychotherapy psychotherapy.

Certain different features must be recognized and dealt with accordingly. The dreams ofa white patient will be different in that the black therapist may be disguised as white. The defense mechanism involved is reversal, and it appears to work in the identical manner as when the therapist is white

and

disguised

as black.

Clearly

certainty. Our in the patients

if it did

not

occur.

In our

whom

sufficiently experience,

therapist

was

anxiety. mechanism

When

dreams,

overt

1086

disguised

patients

this

to dream of him or her. the dreams in which the

as white

revealed

the reversal disappears and blacks first appear

anxiety

is most

often

we have

it is our esteem, stricted with the

The

little

re-

the

when

white blackness.

treated

white

say with

therapist

is

any degree

of

have

the

the therapist

patient All

done

or

than

anxiety

is black

to ovenidentify of the patients

this

to some

degree;

impression that patients who have low selfare passive, and feel oppressed and conintrapsychically ovenidentify more readily black therapist.

ovenidentification

with

the black

therapist

may

have many meanings. Most often, in our experience, it is a hostile identification, a way ofappearing compliant and complacent but expressing hostility. In some patients, what appears to be an ovenidentification is not an identification at all but a massive projection of the patient’s unconscious conflicts. The patient merely identifies with what he or she believes the black therapist’s plight or station to be, when in fact it is totally distorted.

Although the same conflicts through in this kind of interracial

must therapy

be worked as in any oth-

en treatment, the sequence of the unfolding of the conflicts may be altered by racial issues. The differences in race may serve as a scaffold for multiple projections by the patient. Projections pertaining to race must be dealt with early in the treatment by helping the patient to appreciate that these are unconscious conflicts that the patient is experiencing. Our experience suggests that once this is accomplished the transference neurosis will develop as it does in any other treatment pnocess and the patient can proceed to a satisfactory working through and termination. Although other authors

have

reported

that

ferences cannot tients, we suggest the case.

1. Oberndorf chiatry

the

reality

be adequately from our

2.

Schachter interracial

3.

Bernard Am

4.

C: Selectivity 110:754-758,

issues

dealt experience

of

racial

dif-

with in some pathat this is not

black

overt

Calnek therapist 1970

M:

In the

WH:

Psychiatry

8.

Transference J Am Psychoanal

Assoc

Racial and the

6. Kennedy 7.

H:

V: Psychoanalysis

Psychoanal

5. Grier

and option

Am J Psy-

and

countertransference Assoc 16:792-808,

and members 1:256-267,

of minority

When process.

the therapist Am

J: Problems

posed

15:313-327,

is Negro:

J Psychiatry

in 1968

groups.

J

1953

factors in the countertransference: black client. Am J Orthopsychiatry

Waite R: The Negro Psychol 32:427-433, Fischer N: transference

for psychiatry.

1954

J, Butts analyses.

treatment

as a defense undisguised in

present.

is greater

however, is that was greaten.

finding

con-

anxiety

when

the

in the manifest

REFERENCES

versal has continued to appear in dreams until a sufficient number of the conflicts have been worked through to permit the therapist to appear undisguised in dreams. A transference of sufficient intensity must also have formed; in the absence of this transference there would be little intrapsychic reason to cathect the therapist In our

common

is the tendency of with the therapist’s

1978

threatening,

we cannot

impression, we treated

September

hostile,

the

situation,

of as black,

Another

large,

Whether

usual

135:9,

be noted

being

it is an attempt

of the dream work to deal with anxiety. In our experience, it is common for reversal to occur in dreams; in fact, we would be concerned about the integrity of ego functioning

may

blacks

murderous. the

,

‘

the

dreamed

worked

nique

this anxiety by

in

J Psychiatry

the black 40:39-46,

some effects

123:1587-1592,

in the analysis

on the

1967

of Negro

patients.

1952 patient

and

clinical

theory.

J Consult

Clin

1968

An interracial significance.

analysis-transference J Am Psychoanal

Assoc

and counter19:736-745,

Am

J Psychiatry

135:9,

September

1978

BRIEF

1971

9. Curry A: Myth, transference, and the black psychotherapist. Psychoanal Rev 51:7-14, 1964 10. Altman L: The Dream in Psychoanalysis. New York, Inter-

Psychiatric

Training

Gynecologist

for

the

national Universities Press, 1969, p 54 11. Oremland JD: A specific dream during the termination successful psychoanalyses. I Am Psychoanal Assoc 302,

Primary

phase of 21:285-

1973

Care

Obstetrician-

Resident

BY PRISCILLA

DAY

BOEKELHEIDE,

M.D.

The author describes a modelfor the psychiatric training ofobstetrics-gynecology house staff members who serve as primary care physiciansfor women. By integrating psychiatric skills with specialty training, the psychiatrist can enhance continuity ofpatient care for the resident during his transition to the role of primary care obstetrician-gynecologist.

house three

staff included residents, two

students. tnibuted cology shaped

a teaching-attending interns, and one

WELL BEFORE THE 1975 position statement by the American College of Obstetricians and Gynecologists and the American Board of Obstetrics and Gynecology on the role of the obstetrician-gynecologist in the primany care ofwomen (1), I was invited to share a woman’s point of view with the obstetrics and gynecology house staff of a large inner city nonprofit hospital who viewed themselves as total physicians offering comprehensive continuity ofcare to women. The house officers already recognized that they were often the first medical contact for their patients, that their responsibility should not be limited to acute illness, and that normative life crises required diverse skills such as marital, pregnancy, and sexual counseling, menoparsal care, and supportive therapy for the cancer patier1t. The keys to their development as primary cane physicians were their eagerness to learn and to accept the role and the use of a peer collaborative psychiatric consultant on their team. In addition to the senior psychiatric consultant, the

is Assistant Professor of Psychiatry, University of School ofMedicine, Chapel Hill, NC. 27514. At the was done, she was a psychiatric resident, Mt. Zion Francisco, Calif.

The author gratefully acknowledges the supervision of Drs. Haskell Bazell and Thomas Stein, Department of Psychiatry, and Dr. Fred Berman, Department pital, San Francisco,

of Obstetrics Calif.

and

Gynecology,

0002-953X/78/0009-I087$0.35

Mt.

Zion

Hos-

physician, on two medical

No grant or special external incentive conto the program, and most obstetrics and gyneteaching situations could rather easily be toward the same goals. My acceptance into the

program

was

a fellow

resident

probably

enhanced

but

also

College of Obstetricians The mutual academic

Dr. Boekelheide North Carolina time this work Hospital, San

COMMUNICATIONS

by my being

a Fellow

of the

and Gynecologists. goal was training

not only American

for better

pa-

tient care by increasing understanding and skills; the focus was often broadened to include the patient’s panents, her husband or boyfriend, her children, and even grandparents and neighbors if necessary.

METHOD

The tools were the staff’s medical background, their empathy, and their eagerness. Through weekly informal discussion and demonstration we studied the following areas over a period of 20 months: I) interview techniques, 2) selection and use ofpsychotropic drugs, 3) personality diagnosis, 4) psychosocial aspects of the patients’ everyday lives, and 5) health care rather than

medical

illness.

This

focus

obstetrician-gynecologist

practice

preventive

consideration and on the

Balint

offered as

mental

a unique

view

a specialist

health

who

care

(2). The

was on the doctor-patient chief drug, tincture of doctor,

of the should

overall

relationship described

by

(3).

The psychiatric consultant guided the sessions in an air of mutual inquiry. As early as feasible the psychiatnist helped to sort out the majority of patients whom

the staff advised stances

could handle as necessary. there

was

themselves In most

joint

and supervised of the remaining

observation

and

few

patients

were

referred

for further

tion.

When

staff

anxiety

was

© 1978 American

Psychiatric

Association

high

and in-

discussion.

direct or

when

A

consultaspecial 1087