Juan, now 38, left Mexico with his younger brother to pursue a better life, hoping to escape poverty and the childhood traumas of living with an alcoholic and aggressive father. He crossed the border illegally with the help of coyotes, passing through very dangerous areas. He remembers losing his Mexican ID card during the trip and now must keep a fake ID.
Juan has come for therapy sessions three times a week since 2015.
Elsa, a 59-year-old Honduran woman, is in this country with temporary protected status (TPS), ending this year. She is tired, melancholic and appears older than her age. She has been depressed since the death of her mother in November 2015. The last time she saw her mother was eight years ago. She has lost most of her front teeth, probably why she covered her mouth during the beginning of the intake session.
The St. Louis Psychoanalytic Institute shares with other institutes the imperative to expand our engagement with the community and increase our relevance and accessibility to all members of our society. This imperative is driven by multiple forces ranging from the need to engage socially minded donors to the wish to attract and retain students who are often younger, from diverse backgrounds, and want to take their work into nontraditional settings. This has been a challenging new direction that has required innovative strategies to overcome institutional resistance. Practically, we, like many institutes, are small and thus have limited human resources to devote to activities beyond the basics of our analytic and psychotherapy training programs. Collaboration and creativity along with efficient leveraging of faculty wisdom and effort are required. We wish to share our pilot program for training psychotherapists who are equipped to serve a Spanish-speaking immigrant population in St. Louis, specifically, our collaboration with Casa de Salud, an agency that provides high-quality clinical health care to uninsured immigrants.
The institute’s interest in this collaboration emerged from the general effort to partner with a variety of agencies and organizations that serve the mental health needs of children and adults in the city. These partners help us expand the reach of our community education programming and raise the profile and awareness of institute clinical and educational activities. Our executive director, Cathy Krane, and various lay board members, simultaneously were pushing for more diversity and engagement with the community. We became aware of the work of Casa de Salud, and their efforts to
provide psychotherapy services to a long waiting list of Spanish-speaking patients. As in many cities, the availability of well-trained bilingual psychotherapists is quite limited. Most therapy, provided by an occasional student from a local university, or others donating time, required a translator. While translators are helpful in general medical treatment, their participation in a meaningful psychotherapy is problematic. Casa de Salud had the organizational structure to connect patients with medical care but was not in the business of training or supervising psychotherapists. Casa de Salud also had energetic and visionary leaders who saw the need to create consortiums to produce momentum to solve challenging social issues. Our institute, on the other hand, is not principally a service provider, but is good at training psychotherapists. Collaboration in a pilot program to train bilingual psychotherapists thus seemed to be a promising possibility.
A track for such training fit nicely into our existing low-fee clinic. The Schiele Clinic provides high quality, unlimited sessions of in-depth psychotherapy at a fee based on the client’s ability to pay. This clinic, at its founding staffed by part-time therapists, has evolved into a sought-after training clinic. Graduate and postgraduate level students of clinical programs for master and doctoral degrees in social work, psychology, or counseling are immersed in a 12-month practicum program, with the benefit of gaining hands-on experience through direct patient contact, and participation in supervision and case conferences. Most also enroll in our two-year Advanced Psychodynamic Psychotherapy program, and some extend their work for a second year in order to obtain licensure hours. A major asset of the clinic has been the ability to have our students on-site, as well as at off-site locations serving many populations.
In 2015, the Schiele Clinic and Casa de Salud began a pilot project to see if bilingual practicum students of the institute could be retained in the St. Louis area by having them provide psychotherapy to Spanish-speaking patients referred by the Casa de Salud system. Serendipity provided our first bilingual clinic student, an immigrant neurosurgeon from Brazil, at the time in a faculty teaching and research position at a medical school, working towards analytic candidacy. He was polylingual and had the professional and academic skills needed to help us document the community need and then to begin devising the protocols for accepting and evaluating referrals for treatment. Evaluations were conducted at the Casa de Salud facility in downtown St. Louis, near St. Louis University Hospital. Our second practicum student, also an immigrant, born and educated in Chile, and working to obtain licensure in the States, took over the evaluation process and maintains a large caseload of patients, all seen at our institute clinic offices in a St. Louis suburb. Additionally, this student came with research skills and is working on a project with the Casa de Salud population.
In February of 2018, the pilot program officially grew into a Mental Health Collaborative, with several partner-providers from diverse theoretical perspectives offered rent-free office space in a newly renovated facility. We have been disappointed that we have yet to identify additional bilingual, Spanish-speaking psychotherapy trainees, but have been able to place one of our students at the site who is growing a caseload of English-speaking immigrants. This student is fluent in French and we are actively attempting to engage the French-speaking immigrant population. Our search for more students is active as it is clear and obvious to all that the level of training provided makes a difference. Those at Casa de Salud who provide the treatment referrals are quite aware that our skilled and sensitive student therapists hold onto patients and engage them in a healing process.
When the pilot project began we had a couple of concerns. For one, would immigrants feel comfortable traveling to the institute to seek treatment? Ladue, where the Institute is located, is one of St. Louis’s wealthiest and predominately white suburbs. Another concern was, would it be an issue if the analysts who supervised the students were not bilingual?
Fortunately, positive outcomes outweighed our worries. Of course, some clients initially had apprehensions about coming to our location, but many have found our office to be accessible and safe. It especially helps that our students’ professionalism and awareness of cultural barriers contribute to a warm and welcoming environment. Additionally, the commonalities and differences among students and the analysts who supervise them has led to a beneficial and reciprocal learning experience. Ironically, to some undocumented immigrants, our site is less threatening than the Casa de Salud offices that would be an obvious place for immigration authorities to look for them. We translated into Spanish all our signage and forms and added a Spanish option to our phone messaging service.
Included in our pilot project was a plan to host monthly bilingual case conferences with not only psychoanalysts, but therapists in the community who do not have any psychodynamic psychotherapy training. The bilingual case conferences provide a space for dedicated therapists to sit at the table to learn from each other and offer support. The clients being served have suffered from significant episodes of trauma, before, during, and after immigration, trauma that also affects the therapist. Therapists in the community find it helpful to have a place to talk about their therapeutic experiences and to experience firsthand how dynamically trained analysts and therapists relate to them, respect them, and support their work. We, in turn, learn much from those working on the front lines with individuals who rarely have access to our private offices.
Beyond expanding our network of diverse therapists, the St. Louis Psychoanalytic Institute has been fortunate to connect with psychoanalysts from across the nation with expertise working with patients from diverse backgrounds and cultures. Several psychoanalysts remotely teach courses or come to the institute to guest lecture. One of our student therapists and a research fellow, Alicia Naveas, has been mentored throughout her project by Chicago psychoanalyst
Gabriel Ruiz. We hope this research, and other research projects we envision, will help us document and learn from this effort.
It has been, for many of us, a rich experience building relationships with other psychoanalysts, psychotherapists, and like-minded agencies in the Mental Health Collaborative. Significantly, efforts such as the Bilingual Psychotherapy Training track, have deepened the commitment of our lay board to support such outreach efforts. Substantial funds are needed to underwrite the Schiele Clinic and the board feels justified in allocating those funds to programs that are aligned with a recently developed strategic plan that prioritizes expansion of educational and training efforts to the wider community. The institute is continuously thinking of ways to highlight the exceptional skills of our well-trained psychotherapists and the value of psychoanalytic research and ideas to community efforts to improve the emotional well-being of children, families and adults.
The world is changing, so change within our institute is inevitable. Flexibility and creativity have allowed us in St. Louis to pilot programs which share important goals and strategies common to institutes around the country. Some of the goals and strategies we have highlighted include:
Make high quality psychodynamic psychotherapy more accessible to various populations;
Meet the needs of students whose chosen populations can greatly benefit from psychodynamic psychotherapy;
Innovatively think of ways to grow the population of people who study psychodynamic psychotherapy.
As psychoanalysts and psychotherapists, we have much to offer and much to learn from widening our engagement with the many and varied individuals and groups in our communities for whom obstacles to thoughtful care take so much effort to overcome. We belong on the frontlines of these efforts.
We welcome inquiries regarding our efforts and look forward to input and advice other institutes can provide to us. Feel free to contact Stuart Ozar, , or 314-725-2828.
Funding for the St. Louis Psychoanalytic Institute’s partnership in the Mental Health Collaborative has been provided by the American Psychoanalytic Foundation through the American Psychoanalytic Association.