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¹Philadelphia, USA

Correspondence to: Dr Deborah Luepnitz, 4247 Locust St., Apt # 817, Philadelphia, PA 19104, USA. E-mail: dalue@webtv.net

This essay describes the author's experience as a pro_bono psychoanalyst/consultant at a residence for homeless women in Philadelphia. She has found most cogent to that work the ideas of Donald Winnicott (e.g., the holding environment, projective identification, countertransference) and those of Jacques Lacan (e.g., desire, the jouissance of the symptom, the insistence of the signifier). The article points to the interplay between social class and desire and suggests that the analyst's position may be that of a good-enough saint.

Psychoanalysis, Culture & Society (2005) 10, 328-334. doi:10.1057/palgrave.pcs.2100058

homelessness; Lacan; Winnicott; capitalism; Insight for All

The more saints, the more laughter; that's my principle, to wit, the way out of capitalist discourse - which will not constitute progress, if it happens only for some (Lacan, 1990, p 16).

In Down and Out in Paris and London, Eric Blair, writing for the first time as George Orwell, described the 4 years he spent living as a "tramp" in order to expose the egregious conditions of Europe's underclass. Orwell's use of tramp - a word derived from Victorian vagrancy laws requiring the poor to keep moving or "tramping" along - dates the book, as do a few other observations. (For example, he is shocked to come upon a female tramp). But Down and Out is remarkable mainly for its enduring relevance to the problem of homelessness, and for the author's ability even at the age of 25 to speak as capitalism's unsparing conscience.

Although Orwell had no interest in psychoanalysis, his lament in the book's final pages makes one wish he had:

Some day I want to explore that world more thoroughly. I should like to know people like Mario and Paddy and Bill the moocher, not from casual encounters, but intimately; I should like to understand what really goes on in the souls of plongeurs and tramps and embankment sleepers (Orwell, 1933, p 213).

To refer to the inner life, Orwell uses "soul" which translates "psyche" - the very word Freud had chosen to name his science of the unconscious. In a speech given 14 years before the publication of Down and Out, Freud had addressed the issue of poverty and the importance of universal access to care. With confidence, he predicted a day when public clinics would offer psychoanalytic treatment:

¼so that men who would otherwise give way to drink, women who have nearly succumbed under their burden of privations, children for whom there is no choice but running wild or neurosis, may be made capable, by analysis, of resistance and of efficient work. Such treatments will be free (Freud, 1919, p 167).

My own interest in homelessness grew out of a psychoanalytic therapy with "Emily Green", who had lived on the streets first of Chicago and later, Philadelphia. By the time we met, she had moved into a grimy, noisy shelter with her 4-year-old daughter, whom she feared she would abuse. Given Emily's history (orphaned in adolescence, molested by a priest, abandoned by everyone she'd loved) I doubted that she'd even return for a second appointment. She did return, and we worked in a fairly rigorous treatment for the following 14 years. At the time of termination, she had recovered from a serious depression, held a job, and was sending her deeply loved daughter off to college.

The framework of my training had been object relations theory, and my main inspiration, Donald Winnicott. Without a way of thinking at the level of the pre-Oedipal, without his insights about hate in the countertransference and the value of depression, I don't know if I could have withstood Emily's envious attacks. She was extremely demanding, constantly testing my survivability. Reading Winnicott provided enough structure for me, a rank beginner, to sustain a holding space in which to convey a sense that her pain was bearable and had meaning. One must do this for every patient, of course, but if - to borrow a Winnicott (1986) title - "home is where we start from" - then we can't be surprised to find enormous challenges working with those for whom home and its meanings have been so ruinous.

Winnicott was not embarrassed about having to adjust classical analytic techniques to treat people who were extremely ill. For certain phases in such work he used the word "management" borrowed from his pediatric practice of helping patients manage (rather than cure) conditions such as diabetes and asthma. On at least one occasion, he took a patient into his home in order to help the young man control what was experienced as uncontrollable (Winnicott, 1947). I was never tempted to take Emily home with me, but I was able to keep a place for her in my mind and ultimately to convey something that he had once told a patient directly, that is, "You too have a good breast" (Guntrip, 1975, p 462).

Object relations theory proved necessary but insufficient to the work, and my reading of Lacan and my second personal analysis introduced concepts that helped substantially. Nowhere in Winnicott's work is there anything comparable to Lacan's emphasis on the insistence of the signifier and his movement of analytic telos in the direction of le bien dire (the capacity to "say it well" Lacan, 1990). Working with Lacan's texts refined my ability to allow the patient access to the interpretation of her dreams and to the meaning of her names (Lacan, 1954/1955; 1960/1961). Emily landed on the signifier "sin eater", which proved pivotal in moving her misery beyond the real of her symptoms to the registers of the imaginary and symbolic. (This case is described at length in Luepnitz, 2002.)

Availing oneself of Lacan's insights does not require a repudiation of Winnicott and the Middle Group. I have found it increasingly difficult to think about patients without an appeal to both analytic traditions. Moreover, what strikes me as a growing interest in working with both Winnicott and Lacan raises the question of whether we are about to see the emergence of a new paradigm - a kind of third way or "new Middle Group" - a question I have raised elsewhere (Luepnitz, 2005).

Project H.O.M.E.

In the mid-1980s when Emily started treatment, there were 25,000 people per year living on the streets of Philadelphia. The main cause of homelessness in America is not psychological; it is the unavailability of affordable housing. Federal money for low-income housing has dropped 90% since the 1970s, according to the Joint Center for Housing Studies at Harvard (Egan, 2002).

Philadelphia's homeless population has decreased dramatically to 1000 in 2005 - a change due largely to the efforts of two remarkable women friends: Mary Scullion, a sister of Mercy, and Joan Dawson McConnon, an accountant. Moved by sheer outrage at the plight of the poor in the world's richest nation, the women opened a makeshift shelter for homeless men in an abandoned recreation center in 1985. In their hands, this ultra-modest beginning has grown into a blooming project of unparalleled success including 11 residential facilities that homeless people never have to leave, two community centers that house afterschool and adult learning programs, 18 gardens, and three successful businesses run by homeless people. Private and public funding sources now make up its 40-million dollar budget, and the mayors of San Francisco, New York and Denver have sent teams to find out how Philadelphia performed this "miracle" (Boldt, 2000; New York Times, 2003; Fagan, 2004).

Project H.O.M.E. stands for Housing, Opportunities, Medical Care, and Employment. It offers the very poor not only social services, but also a chance to get involved in the democratic and political process. For example, while only 58% of Philadelphia's general population votes in any given national election, roughly 95% of Project H.O.M.E. residents vote, and they themselves have succeeded in registering 8000 new voters in our area (Scheffer, 2004). Moreover, every demonstration for social justice in the city in the past 15 years has included a significant Project H.O.M.E. contingent.

I got involved with the organization by doing outreach, which means driving around in a van to places homeless people gather and offering a place to stay. Even in this front-line work, psychoanalytic theory was useful. Like most people who grew up indoors, I once believed that only a heartless conservative could say that not every homeless person wants help. Encountering refusals of shelter even on freezing nights was disconcerting, and concepts such as impingement, desire, and the jouissance of the symptom were never far from my mind. An offer of help to someone who has never been cared for can indeed be experienced like what Winnicott described as an "impingement" - something coming at him or her. And Lacan reminded analysts throughout his career about the "aggressivity" that underlies the impulses of the missionary and the reformer. When, during an outreach shift, my frustration ran high, I was able to bring to mind the accomplished professionals in my practice whose eating problems lead them to starve, binge, and take hundreds of laxatives with the unconscious goal of re-enacting a childhood trauma. Those homeless men and women who develop frostbite rather than leave their familiar spot on the corner are hardly alone in living beyond the pleasure principle. Clinicians are simply more accustomed to interpreting the neurotic behavior of the middle class. Thus, the analytic question in this context is not, as some have asked me, "What is the psychology of homelessness?" but rather In encountering the very poor, can we bear to listen for desire?

As I began to form ideas about volunteering as a clinician at Project H.O.M.E., I asked to meet with the now nationally recognized Sister Mary Scullion, a woman of enormous personal power. In the 1980s, when people in the neighborhood of one of her first shelters requested that she live on the premises to ensure their safety, Sister Mary agreed, and for a decade she shared a residence - and a bathroom - with eight homeless men. One senses in her not the jouissance of the martyr who thrills to deprivation, but rather the high spirits of someone totally engaged with her community. She is tireless and funny and hates being called a saint by major US news outlets or anyone else. ("If I'm a saint, we're all in trouble.") Imagine a computer literate Jane Addams with a neat bob and Philly phonemes tinged with "atty-tood."

When Sister Mary asked me what psychoanalysis was, I said that psychoanalysts believe in the transformative power of relationships and of language. I let her know that the talking cure had allowed me to survive a disabling depression, and that I'd helped others do the same in my 20 years of practice. I didn't hesitate to mention that the "psyche" in psychoanalysis translates "soul," and that Freud had hoped the future would see his work available to all.

I gave her a first draft of Schopenhauer's Porcupines, my book of case stories, then waited nervously for her reaction. The case of the homeless woman I call "Emily" happens to include a coming-out story. Emily ended up in a satisfying relationship with a woman after working through her internalized homophobia and an unconscious fear of being bitten and devoured by a woman during oral sex. What was a nun going to think of me and this work?

We met at the White Dog Café one night to continue our conversation. Sister arrived with my manuscript in tow, and said she loved what she had read. Not a word was said about my references to sexuality, birth control, or abortion. However, a glance through her copy revealed that she had crossed out with clean pen-strokes every foreign language phrase in the manuscript - bête noir, doppelganger, modus operandi - saying that they would "make it harder for ordinary people to read." I fought her for "petit mal seizure" and won.

What about my idea of running a group at the Project H.O.M.E. residence for mentally ill homeless women called "Women of Change"?

"Go for it," she said, and since that night, has given me, well, carte blanche.

One thing I had noticed during my first year of activities at Project H.O.M.E. was that the best predictor of a homeless woman moving forward in her life - keeping medical appointments, going to job interviews, resisting the crack house - was the quality of her relationship with her onsite case worker. The turnover of case workers, however, was high - sometimes 100% in one year. (I had worked 60-hour weeks on an adolescent inpatient unit in West Philadelphia for 6 years, where burnout was a well-known job hazard.) I offered the staff the chance to meet with me weekly for what we simply call "Group." For the past 4 years, they have used Group to talk about difficult problems with the residents, dust-ups with each other, and not infrequently, personal troubles. I keep firm time boundaries and don't disclose much about myself. I listen. But I also answer questions, for example (1) How can we think about Doreetha, the woman with Elephant Man's disease? She's bright, and sometimes very coherent, but she gets furious when she hears the gargoyles on the buildings downtown badmouthing her. (2) Tawanda finally moved indoors after living 10 years on the street. She wears clean clothes now, but keeps a filthy piece of gauze on her head like a baby bonnet. What could it mean, and how should we talk to her about it? (3) Can you explain these words we read in hospital reports, like: "splitting," "projection," "borderline?"

One learns a lot trying to explain the buzz words of one's profession to people outside it - in this case, people who may have no college experience. My favorite example of a successful teaching moment came from borrowing a remark by R.D. Laing - a great admirer of Winnicott - in order to discuss projection, introjection, and projective identification. Laing had mused:

You are a pain in the neck.
To stop you giving me a pain in the neck
I protect my neck by tightening my neck muscles,
which gives me the pain in the neck you are.
(Laing, 1972, p 30)

Word about Group got around Project H.O.M.E. and case workers in other residences began asking, "Why can't we have a psychoanalyst come listen to us once a week?"

The answer: I'm working on it. An analyst working pro_bono in each of the 11 Project HOME buildings is part of my 10-year plan.

The rest of the plan includes offering psychoanalytic treatment to every interested resident and staff member (many of whom were themselves once homeless). I have also been searching for a psychoanalyst willing to run groups for parents at Rowan Homes - Project H.O.M.E.'s cutting edge facility for homeless families.

The problems we've had so far are those that have been reported for years by analysts involved in the inner city (see especially Neil Altman's 1995 classic). When a homeless person calls for a therapist, there is often no one with time to spare. Conversely, an analyst may call, generously offering an hour or a whole morning, and the people who were on the list have lost interest or fail to show. The occasional triumph keeps hope moving. For example, Cynthia, a battered woman whose husband managed to gain custody of their children, became homeless in her 40s. Connected to a talented analyst, she resumed the art work she had had to abandon, and now paints beautifully, teaches art classes, and has even shown her work locally. She has also been able to re-connect with her children.

Last year, my colleagues at the Women's Therapy Centre Institute in New York - the only institute for feminist psychoanalytic treatment in the world - decided to take up this work in their own community. Knowing that at least 80% of homeless women have been victims of domestic violence, the Women's Therapy Centre contacted the director of a local safe haven for battered women. The director said that many women who have found the strength to leave abusers - to get restraining orders and other legal aid - often fall into crisis as they leave the shelter. Contrary to what one hears about the anti-therapy bias of the shelter movement, this director asked the WTCI to provide psychotherapists for these women. The WTCI was able to obtain a grant to help orchestrate the program they devised together.

I am currently using the acronym IFA (Insight For All) to refer to the patchwork of efforts in Philadelphia and New York to make psychoanalytic services available to the formerly homeless. IFA's motto - not as lofty as Lacan's - is "Iffa this project lasts, it will be great."

I think of it each time I see the motto of Sister Mary Scullion and Joan Dawson McConnon, which is now inscribed above the archway of their main building:

None of us is home until all of us are home.

Altman, N. (1995). The Analyst in the Inner City: Race, Class and Culture Through a Psychoanalytic Lens. Hillsdale, NJ: The Analytic Press.

About the author

Deborah Anna Luepnitz is on the Clinical Faculty of the Department of Psychiatry at the University of Pennsylvania School of Medicine. She is the author of The Family Interpreted: Psychoanalysis, Feminism, and Family Therapy (1988) and Schopenhauer's Porcupines (2002). She was a contributing author to the Cambridge Companion to Lacan. Dr. Luepnitz has worked at a residence for mentally ill homeless women for 5 years, and maintains a private practice in Philadelphia. She is interested in the development of a "new Middle Group" between Winnicott and Lacan.