Is Therapy a Luxury?

My boss is something of a therapy purist. Having explored various schools of practice, he settled upon Lacanian psychoanalysis as his theoretical orientation. Although he doesn't get to do analysis as an administrator at our agency (he does it on the side), he supervises from that foundation.

A core feature of his approach is that neurosis and psychosis are inherently different, and should be treated in very different ways. Grossly oversimplified, the therapist invites projection and transference when treating neurotic clients, and tries to avoid contaminating the therapy by allowing his/her own ego (self) to be felt by the client. However, if this approach is used with psychotic clients, it may trigger a psychotic break. Instead, the therapist allows him/herself to be more present in therapy, providing more feedback, support and direction to facilitate consolidation of the client's ego. Incorrectly using the latter approach with a neurotic client causes less damage than the reverse error, but detracts from the efficacy of treatment (according to this psychoanalytic perspective).

A problem with this conceptualization of treatment is that it fails to consider the psychosocial (rather than intrapsychic) factors contributing to the so-called "neurosis." In an urban clinic where most clients are insured by Medicaid and/or Medicare, many of my clients find the impetus to seek treatment not because of an underlying mood or anxiety disorder (although those are present), but because they are overwhelmed by the struggles they face to meet their basic needs. If I were to follow the treatment dichotomy described above, I would provide tangible support for my psychotic client who has no financial resources and one change of clothes, but not for my neurotic client who was deemed ineligible for housing assistance after fleeing domestic violence. I fear the latter client would find my withholding of support invalidating and out-of-touch - the product of my own socioeconomic privilege.

Psychologist Abraham Maslow argued that human needs can be arranged on a hierarchy; people do not move on to a higher level until the needs on the level(s) below it have been adequately met. Thus, one cannot give one's full attention to psychological needs without having met basic needs such as food, clothing, shelter, and physical safety.

If we think about my "neurotic" and homeless client, I suspect that providing the psychoanalytical treatment appropriate for neurosis (i.e., not responding to her lack of shelter and security) would interfere with the efficacy of treatment just as much as "incorrectly" providing a more supportive response. It seems to me that ego restructuring is a luxury that just doesn't matter if you're hungry, preoccupied with where you're going to stay tonight, or where you're going to find bus fare to get to the clinic in the first place.

What do you think?

For more information on Lacanian theory and practice, see  Fundamentals of Psychoanalytic Technique: A Lacanian Approach for Practitioners For information on Maslow's Hierarchy of Needs, see Hierarchy of Needs: A Theory of Human Motivation