Thursday, June 14, 2012

Nicaragua on the Couch - The Reluctant Psychoanalyst Reflects on Lessons Learned

Understanding a person or a culture from the outside is both easier and much, much more difficult than from the inside. Alexis de Tocqueville, a french nobleman, spent 11 months in the US when he was 25 and wrote a reflection on his travels in 1835. The resulting book, Democracy in America, is still used as a standard - both for proto-sociological writing, and for understanding America itself. But this work is far more the exception than the rule. And certainly as an analyst, to immerse oneself in another's world - even with the remarkable access that we were afforded on this trip - for one week and to pretend to understand them is hubristic at best. I often think that I "get" a patient's motivations early on - and it is only over time that I realize just how much more complicated his or her internal world is than I initially imagined. Even if my initial, crude, understandings are more or less on target, they miss the quality and subtlety of the person's lived experience.

Despite the limits of knowledge at the beginning of an engagement, we make decisions based on an initial assessment. In psychoanalysis, the question is: can this individual be successfully analyzed? Is he or she stable enough to withstand the rigor of honestly evaluating and owning those parts of themselves that they have disowned? Can he or she engage in an intimate dialogue with another over a long period of time and retain a reflective quality while he or she does this or is he or she likely to become caught up in the intensity and act on - more than reflect on - the powerful feelings that are stirred? I think that we have moved away from an either/or position on this question as we have become more flexible in our technical approach to analysis - like not insisting on the analyst being out of visual contact at all times, that can exacerbate difficulties that patients are having. But we still assess, talk about, and conclude whether or not to work together analytically.

A consistent observation above - that we can't know another's experience at first blush - is a message that resonates with what we heard over and over throughout the trip. Too often foreign agents enter, diagnose what the problem is, and provide a solution based on their own frame of reference. Ask what is needed, don't tell. Try to understand what the situation is by listening and by engaging in a cooperative dialogue, don't impose an understanding and the resulting conclusion. These wise and useful psychoanalytic perspectives (sometimes honored by analysts more in the breech than in practice) are echoed by citizens, successful interventionists, and representatives of various business and governmental interests.

By the way, though we (the US) are the most egregious at doing this, I think that Daniel Ortega, the despot ruling the country, and the unrepentant incest offender, is, both by his actions towards his child and his actions towards his country, enacting the dynamic of the paternalistic one who knows best for the other. He has decided what is best, he believes himself to be a champion of the poor, but he is imposing his will on them, not working with them. I think imposition of power feels no better when it is done by someone within the country than by someone outside (If anything, in molestation, being molested by a family member is more damaging). Curing the country of this will not come by having us (the US) impose regime change - that is simply enacting the same dynamic again, and telling those within the country that it is OK to meddle in this way - but this will change as the country takes responsibility for its own government - as it did during and after the revolution. Hopefully it will not take another armed revolution, but rather a psychological revolution that will lead to true empowerment of the people - something that will undoubtedly happen - as Dora Maria Tellez states - through meandering, not in a direct route.

Kids having fun at Fe y Alegria School
In the heart of the barrio of Managua

I think it is also the case that my approach to being in the country was one that was filled with intellectual understanding, and was woefully short on visceral engagement. Many of my fellow travelers were more visibly and immediately moved by the plight of the people in this country. My curiosity about birth control, or about the incest of the country's leader, while reasonable, may also have been serving a defensive function. The night I returned home, I was visited by a case of the turistas - traveller's diarrhea - in the middle of the night. Even though I was back home, in my own bed, with air conditioning, indoor plumbing, and medicine, I was uncomfortable - alternately too hot and too cold, I couldn't sleep soundly, and my dreams were patchy and disturbed. I think I could finally feel the profound sense of disquiet that being immersed in poverty brought me as I tried to imagine what it must feel like to live as a poor person in a country with no safety net and no viable economy for most of the inhabitants. To live in a city of over a million people with no sewer plant. To live in a House - a shack really - with no running water and a latrine - within the city limits. The people we saw somehow managed to stay clean, despite the incredible heat - heat that only minimally abated at night. But I did not appreciate the intensity of my visceral reaction to the living conditions of those around me until I was safely removed from the situation. I think it is hard to appreciate - and I can't pretend to know - how it must be to have all that as one's only reality. Certainly the happy - nay, ecstatic - children at Fe y Alegria school would suggest that these conditions do not over ride the joy of being alive and being human. But there must be a toll, even for those, unlike me, unused to having creature comforts. As the director of the center responsible for the Cuidad Sandino medical clinic said, the majority of the prescriptions are for analgesics - pain killers - because life here is hard.

I have also learned that, just as interpersonal relationships and the psyches of the persons who engage in them are much more complex than they seem at first glance, that this is true on a macro level as well. Both the relationships between countries and the internal socio-cultural landscape of a particular country are more complex than I would have, naively - and in perhaps a very American way - ever imagined. It is a privilege to be able to travel to the interior of another country. To talk to leaders of various entities of that country. Would that I could sit down with my patient's ego and have a conversation! It is also nice that the rules of a country are articulated in various documents including a constitution. Of course, I don't know if the written traffic laws allow using stoplights as stop signs in Nicaragua, but that is certainly the usage law, and I'm sure there are many other usage laws. But wouldn't it be nice if our clients, and we ourselves, came with a rule book? We observe, we listen, and we infer the underlying rules and laws - the written laws and the rules of usage - but the written laws are not written in a language that we can decode directly, we can only infer them.

Finally, I think I have learned that other nations, just as other individuals, have their own integrity. This country, as foreign and disturbing and different as it is, is a country of individuals who are bound together. It is a country whose inhabitants recognize that a rising tide raises all ships - and one whose individual members can forget that and become overcome by greed when they are presented with an opportunity to individually profit. But the country as a whole wants to move forward - on its own terms.

Interestingly, then, it is a country divided. Granada - one of the traditional seats of government - could not be more different from Managua - and probably from Leon - which we did not visit, but which was the other traditional seat of government before Managua became the compromise - split the difference - solution. But these divisions pale compared to the Atlantic vs Pacific Divisions. The Atlantic coast, peopled primarily by indigenous groups and creoles, apparently has a much more Caribbean feel, though it may be even more communal than other Caribbean cultures. In any case, the two Eastern regions enjoy relative self determination after being reclassified as autonomous regions - in distinct contrast to having been oppressed in many ways by the West - often with the help of the US Marines.

So, this country has integrity and also divisions. Unlike people, it could cleave - the East could become a separate country, I suppose. Even if it did, there would still be divisions - haves and have nots, men and women, rural and urban, Catholics and Evangelicals. These divisions are dynamic, interwoven, developing, and constantly creating a stable but mobile entity that remains connected to its roots but open to new possibilities. It is not infinitely flexible, far from it, but might be much more progressive - open to progress - than other countries, like the US, that pride themselves on Freedom and development.

So, would this country be a good candidate for a psychoanalysis? It seems to me to be quite psychologically minded - meaning that it is aware of itself, its inner workings, its strengths but also the areas of challenge, many of which are considerable. It is rich in resources - human, mineral, plant, and location - that could contribute to a variety of developmental pathways. It is filled with internal conflict and contradiction, as any human seeking analysis/treatment/growth is. And it is worldly wise. It knows a thing or two about authority and corruption and how allies can become bullies and how leaders can become corrupted. I agree with Dora Maria Tellez that this remarkable land harbors much to be hopeful for and about.

To access a narrative description of other posts on this site, link here.   For a subject based index, link here.

Additional posts about this trip to Nicaragua can be found here:
Anticipating Travel to a Third World Country  Preparing for Nicaragua
Fear and Loathing in Nicaragua First day in Nicaragua
In The Hall of the Incest King Daniel Noriega and Day two in Nicaragua
Mass in Nicaragua Day three in Nicaragua
Dora Maria Tellez Day four in Nicaragua
Talking with Peasants about Birth Control Day Five in Nicaragua
Talking Business in Nicaragua Day Six in Nicaragua

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