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In a recent issue of Psychoanalytic Dialogues, Lewis Aron (1992) states, “Much of the tradition of clinical psychiatry and psychoanalysis has been that the clinician sees himself or herself as healthy and mature and looks down subtly or blatantly at the patient as sick and immature” (pp. 182-183). Later in the same paper he refers to Ferenczi, who believed that analysts tended to blame their failures on their patients by pointing to their resistances or to their unanalyzability. Aron says:
Ferenczi was a devoted healer who placed primary emphasis on helping patients and was less concerned with building a theoretical system…. He believed that an analyst should try to help any patient willing to come for analysis and that failure points not to the patient's resistance exclusively but to our own inadequacies and personal and theoretical limitations [p. 183].
When we treat patients from impoverished backgrounds, we must face not only our own personal and theoretical limitations, but also the limitations of a health system that does not give us the necessary freedom and time to work effectively. This dilemma is very well illustrated in “Psychoanalysis and the Urban Poor,” where Neil Altman shows in some detail how the health system works against the therapeutic process. For example, when Medicaid does not pay for missed sessions and thereby