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An Appreciation and Critique of PDM-2’s Focus on Minority Stress Through the Case of Frank

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Abstract

In this article, Dr. Drescher presents a case of a sexual-minority patient treated by a sexual-minority therapist. The discussant, clinical psychologist and psychoanalyst Malin Fors, uses the case to reflect on the benefits and limits of the new section of the Psychodynamic Diagnostic Manual, 2nd Edition , called “Nonpathological Conditions That Could Need Clinical Attention” (minority stress).
An Appreciation and Critique of PDM-2’s Focus on Minority Stress
Through the Case of Frank
Jack Drescher, MD
Columbia University
and New York University
Malin Fors, MSc
Finnmark Hospital Trust, Hammerfest, Norway
In this article, Dr. Drescher presents a case of a sexual-minority patient treated by a sexual-minority
therapist. The discussant, clinical psychologist and psychoanalyst Malin Fors, uses the case to reflect on
the benefits and limits of the new section of the Psychodynamic Diagnostic Manual, 2nd Edition, called
“Nonpathological Conditions That Could Need Clinical Attention” (minority stress).
Keywords: minority stress, PDM-2, psychoanalysis, homosexuality
In June of 2017, coinciding with the publication of the Psychody-
namic Diagnostic Manual, 2nd Edition (Lingiardi & McWilliams,
2017), this paper’s authors presented at the PDM-2 Conference in
New York City. On a panel entitled “PDM-2 and Non-Pathological
Experiences That May Require Clinical Attention,” Dr. Drescher
presented a case of his psychoanalytic treatment of an older gay man
followed by a discussion of the case by Dr. Fors.
Frank
Frank is a 50-something American-born gay White Jewish man
who was in a three-times-a-week, 9-year psychoanalysis following
a year of once-a-week psychotherapy.
1
Frank contacted me at the
recommendation of Dr. A., a psychiatrist who had been seeing him
and his life-partner, George, in weekly couples treatment. Frank
and George had been together 18 years. Dr. A. had been seeing
George individually for several years, treating him for a disabling
depression of more than 10 years’ duration. Frank described the
couples treatment as “helping me cope with George’s illness” and
helping with communication. At the initial visit, Frank’s stated
reason for entering individual treatment centered around com-
plaints of what he called “free-floating anxiety,” which had started
a year earlier. “I am negative about a lot of things—the glass of
water is half-empty. I’m very critical.” However, the most salient
feature of Frank’s presentation was his being entirely caught up in
trying to take care of George. He described himself as “following
George’s moods,” by which he meant that if George was de-
pressed, Frank felt depressed. If George felt better, Frank thought
that he felt better as well. Frank also reported a great deal of
anxiety about the demands of running his consulting firm; his
primary source of income came from consulting to one major
client. “I’m never able to relax and enjoy the business.” Nomi-
nally, he and George were equal partners in the business, which
they had started together. However, because of George’s disability,
Frank essentially did all the work.
Concerns About Money
The business did provide them with enough of an income to live
“moderately”— but not a great deal of savings. Because of the
nature of their business, they often got first-class service or “spe-
cial treatment” at a discounted price. Frank would repeatedly, and
proudly, report an occasion when a chef would send out a special
dessert after a meal or a hotel would upgrade his hotel room. The
close relationship between special treatment and whether one had
to pay for services was a recurring theme in Frank’s analysis. For
example, Frank immediately expressed concerns, in the initial
consultation, about the cost of treatment. He was already paying
for George’s two weekly visits with Dr. A. Furthermore, as he
would elaborate in our second meeting, his individual treatment
with a previous therapist had ostensibly floundered over financial
issues.
A year before our initial consultation, Frank had been seeing
another analyst, Dr. B., “on and off” over a 1.5-year period. He
described Dr. B. as “unresponsive” and unwilling to answer direct
questions; he would instead respond by asking, “Why do you want
to know that?” Frank also intensely resented Dr. B.’s policy of
charging for missed sessions, particularly if the absence was “not
my fault.” He cited the example of being stuck in a subway for 40
minutes as inciting a major disagreement over where the financial
responsibility rested between the two of them. Dr. B. charged
Frank for the missed session, saying, “This is my policy.” Frank
told himself he would leave treatment with Dr. B. if “something
1
A more extended presentation of work with this patient has been
previously published (Drescher, 2009). The clinical material here is re-
printed with permission of Taylor & Francis (http://www.tandfonline
.com).
Jack Drescher, MD, Department of Psychiatry, Columbia University;
and Department of Psychotherapy and Psychoanalysis, New York Univer-
sity; Malin Fors, MSc, Finnmark Hospital Trust, Hammerfest, Norway.
Correspondence concerning this article should be addressed to Malin
Fors, MSc, Finnmark Hospital Trust, Mian 4 F, 9601 Hammerfest, Nor-
way. E-mail: malin.fors@mac.com
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Psychoanalytic Psychology
© 2018 American Psychological Association 2018, Vol. 35, No. 3, 357–362
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357
like this happened again.” Then, on a day he was feeling ill to start
with, the subway taking him to this session was delayed. Frank,
arriving to the session late and preoccupied about having to pay for
it, felt he had already spent too much time worrying on the subway
and left. The therapist called him a few days later and told Frank
that if he felt so strongly about it, he did not have to pay for the
session.
Rather than experiencing this as a gesture of conciliation, Dr.
B.’s reversal only intensified Frank’s feeling that the therapist was
more of a problem in his life than a helpful force. I told Frank I
also charged for missed sessions if they occurred without 2 weeks’
notice.
2
I said he raised an interesting question regarding where the
financial responsibility should lie when an unexpected event pre-
vents a patient from getting to a session. However, I told him I was
not willing to take financial responsibility for delayed subways and
would charge him on those occasions. Recognizing the inevitabil-
ity of such therapeutic arrangements no matter what analyst he
saw, Frank agreed to the therapeutic contract.
Family and Developmental History
Frank’s four grandparents were Russian Jewish immigrants who
eventually settled in an East Coast city in the United States where
both his parents and Frank were born. He grew up closer to his
mother’s side of the family and knew little family history on his
father’s side. His maternal grandparents had had a pushcart busi-
ness and sold dresses. Apparently they did well, because Frank’s
mother and father would later open a women’s dress shop with
financial help of his maternal grandparents. Frank’s parents lived
above the shop, as did the grandparents. The shop was in a
working-class Irish Italian neighborhood, and Frank recalls anti-
Semitic taunting during this period of his childhood. The family
later moved, when Frank was about 10, to a suburb he described as
“a gilded Jewish ghetto.” He remembers his preadolescent years
there as “a happy time for me.”
His maternal grandfather died before that move, when Frank
was 8 years old. His grandmother lived independently, and then
with his cousin for a few years, but she had a disabling stroke when
Frank was 11 and was taken in and cared for by Frank’s father and
mother. Her presence in the home was one of several sources of
friction between his parents. This grandmother died at age 80,
when Frank was 14. She had diabetes, as did his maternal grand-
father, his mother, and one of his other grandparents. During one
of his initial visits, Frank expressed the belief that he, too, would
one day become diabetic, and in fact, a few years later, he did.
Frank was the eldest child, born during World War II while his
father, in the military, served overseas. The father returned home
after the war when Frank was 4 years old. He remembers this as a
difficult time because he had previously had all of his mother’s
attention and believes his father resented the closeness that had
developed between Frank and his mother during his absence.
Frank described her as “a smothering Jewish mother” who “made
me a homosexual.” She had two miscarriages after his birth, and a
second child, a boy, was born 4 years after Frank. Another brother
was born when Frank was 7. In contrast to Frank’s relationship
with his father, which he described as one of “love– hate,” the
father adored the second boy. That brother died at age 8 (when
Frank was 12) from complications of mumps. When Frank was 14,
his father had a severe myocardial infarction that left him unable
to work. He died 5 years later, when Frank was 19. When Frank
was 28, his youngest brother, then 21, committed suicide. Mother
died 4 years later of a stroke. His only living relative with whom
he has occasional contact is a woman cousin, 12 years older.
Growing up, Frank remembers that disagreements about the
children were an ongoing source of contention between his par-
ents. Tragically, the parents blamed each other after the death of
their second child. They argued constantly, saying to each other
things like, “You’re killing me. You’re giving me a heart attack.”
As to arguments about Frank, “In my mother’s eyes, I could do no
wrong. I was the smartest. I had piano lessons, Hebrew lessons. I
was her child prodigy.” His father was constantly critical of Frank,
saying he would pay for school only if Frank became a doctor.
Frank attended a premed program when he started college. When
his father had his first heart attack, doctors told him he could not
work. This, too, became a source of contention between the par-
ents. His mother severely denigrated her husband for not working
or supporting the family. Frank’s father did not work for the 5
years leading up to his final, fatal heart attack.
Frank recalls his adolescence as a troubled time. “I was homo-
sexual—attracted to boys.” “I was overweight, self-conscious,
kind of a mama’s boy.” He recalls some sexual experimentation
(mutual masturbation) with other boys in camp and shame about
being found out. When he went to an Ivy League college, he lived
in the dorm. Frank said he was “shocked” to learn “that there are
smart Christians and that they also control the world.” He saw the
school as divided between “smart public school kids and privi-
leged private school kids,” with “conflict between the two groups.”
It was in New York, New York, away from his family, where
Frank eventually came out “as a homosexual.” Before coming out,
he did have some dating and sexual experiences with women.
While in graduate school, he impregnated a girlfriend, who had an
abortion. Yet despite living in relative anonymity in the gay
enclave of New York City’s Greenwich Village, coming out was
a complex task that took many years. As a college student, he
could not allow himself to go to gay bars in New York. He would
fly to Fort Lauderdale, Florida, because he was afraid of being
known as a homosexual. After going to bars in Florida, he felt a
little more comfortable, and eventually started going to New York
bars in a more direct way. However, all his relationships were
“purely sexual. No socializing, no speaking.” His primary sexual
interest at that time was “trade,” by which he meant ostensibly
“straight” men who were “not really interested” in having sex with
other men, but who would do so under certain conditions— either
if they were drunk or for money. These included off-duty military
personnel. He described several episodes where sexual encounters
with such men, whom he would bring home, almost turned violent.
The Relationship With George
Frank’s strategy of avoiding interpersonal intimacy changed at
age 29 after he met George in a gay pornographic movie theater.
At the time, Frank, who had been a film major in college, decided
he was not going to be a “great” filmmaker and became a public
school teacher. When they met, George was doing consulting
work. They decided to work together and gradually built up a small
2
I did not charge, however, if the patient was ill enough to have to see
another physician on the day of a scheduled appointment.
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358 DRESCHER AND FORS
business. Initially, George was the public face of the business.
When George had a severe depressive episode, however, he be-
came completely withdrawn and “nonfunctional.” They saw innu-
merable couple therapists, with each therapist offering a different
prescription, but all of them basically suggesting what Frank could
do to make things easier for George. For example, because one
therapist thought it would be good for Frank to take George out of
the city for the summer, they rented a beach house. Frank noted
with some irony that interactions with other vacationers and chil-
dren in the resort area were extremely stressful, and George got
more depressed.
Their couples therapy at time of consultation felt, to Frank, like
another repeat of those past experiences. After Dr. A. saw George
individually for several years, they began weekly couples treat-
ment. Dr. A. would listen to a report of their most recent argument
and then turn to Frank and ask what he thought he could do
differently to prevent George’s upset. There never seemed, at least
to Frank, any suggestion that George might do things differently.
He believed strongly that if he did not try and make George’s life
easier, George would kill himself. He believed this was a possi-
bility despite the fact that George had never attempted or threat-
ened suicide. Early in analysis, he linked the possibility of George’s
committing suicide to his brother’s successful suicide. Later, how-
ever, Frank came reluctantly to acknowledge the interpretation that
concerns about suicide represented an unconscious expression of
his wish that George be dead. Over the course of treatment, Frank
told Dr. A., in private, that he resented the position of “being the
solution” to George’s difficulties and managed to pull back from
that role. At the same time, Dr. A. moved in to fill the gap.
Just as he had to provide an “ideal” environment for George,
Frank often evoked in me a feeling that I was obligated to do the
same for him. Inevitably, my office was either too hot or too
cold, and I would be asked to turn down the heat or turn up the
air conditioning. Frank would often induce in me the feeling
that he was being unreasonable for asking, although there was
nothing overtly unreasonable about the request. Despite my
complying with his request, Frank nevertheless left me with the
feeling that he was dissatisfied; nothing I did felt like it was
enough.
Frank describes George as a rather critical individual. He ad-
mitted that George reminded him of his own father, for whom
Frank could do nothing right. George is easily and routinely
offended, has a low tolerance for other people’s needs or behav-
iors, and seems incapable of compromise. Although Frank shares
many of these qualities, and was able to reluctantly admit their
presence in himself, he has greater resilience. His capacity for
tolerating adversity increased during the course of analysis. Both
Frank and George share an inordinate need for “perfection,” as
exemplified by “the perfect vacation,” “the perfect dining experi-
ence,” “the perfect aesthetic experience.” As a result, they have
few friends: Most of their old friends have succeeded in offending
either one or both of them, and they have not been able to make
new friends to replace them. During the course of analysis, Frank’s
capacity to tolerate George’s anger greatly improved, and he came
to feel less responsible for the latter’s outbursts. He also came to
recognize that controlling his own angry feelings was a significant
issue for him, and that he often operated under the irrational
fantasy that if his own anger could be controlled, so could
George’s.
Self-Esteem
A great deal of treatment revolved around issues of self-esteem.
For example, despite his successes, Frank always felt like “a
phony.” He believed when his business clients eventually realized
how inauthentic his credentials were, he would be publicly em-
barrassed and humiliated. Although Frank was very ambitious,
he was also uncomfortable with his own competitive feelings. He
linked them to his envy and aggression, other feelings that he
found intolerable. Although he is not “in the closet,” Frank is not
quite comfortable about his gay identity. He considers himself a
member of the pre-Stonewall generation, guided by the principle
of “don’t ask, don’t tell,” and he initially expressed mixed feelings
about the openness of subsequent generations.
This issue came to the surface at the beginning of his second
year in treatment, when he saw me march with the gay physicians
group in the New York City Gay Pride Parade. Although he had
gone to see the parade, he would never consider marching in it. On
the one hand, he spoke of his admiration and envy for people of my
generation who appeared to feel differently (I am ten years
younger than George). But he also spoke of his disapproval and
contempt for those who engaged in public displays like parades.
He had always kept his homosexuality a secret from his family and
managed to live as a gay man by either living away from, or
cutting off anything but the most superficial of contacts with, his
mother’s extended family. During the course of his analysis, he
came to recognize his lack of acceptance of being gay played a
major part in his self-presentation. As he owned up to his own lack
of acceptance, he gradually, and paradoxically, became more ac-
cepting of his gay identity.
Themes about being Jewish also repeatedly surfaced in treat-
ment. There was a strong parallel between being “openly gay” and
being “openly Jewish.” He thought his parents were “too Jewish”
and felt inadequately prepared by them to confront a gentile world.
He recalls a skiing trip during college with a WASP friend and
being advised by the friend not to tell people his last name. Frank
has an obviously Jewish family name and has worried about
appearing “too Jewish,” or “too New York Jewish,” by which he
meant being “too pushy” or “too aggressive.” George is not Jew-
ish. Frank’s acknowledged Jewish anti-Semitism, however, abated
during the analysis as he spontaneously seemed more comfortable
using Yiddish expressions in sessions.
Malin Fors
Thank you, Dr. Drescher, for presenting this vivid case. While
I was reading it, several issues came to mind. This case is an
intertwining of context, time, and psychopathology and raises a lot
of questions in many different layers. Before coming back to Frank
and the case, I wish to take a small detour.
The historical battle for minority people to be seen as healthy
has been long and thorny. The injustice of pathologization has
historically been done to, among others, masturbating women,
escaping slaves, poor people, transvestites, and gay and lesbian
individuals (e.g., Drescher, 2015;Johannisson, 1994;Lingiardi &
Capozzi, 2004). Fanon (2008) has described the effects of coloni-
zation and symptoms of minority stress for Black Africans that
were often talked about as pathology of the Black population.
These battles for empowerment were not without effort or brave
people. In the United States, the empowerment battle included a
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359
DIALOGUE ON CULTURAL AND MINORITY ISSUES IN PDM-2
very brave gay psychiatrist, Dr. Fryer, who in 1972 attended the
American Psychiatric Association meeting disguised as Dr. Henry
Anonymous, to speak in favor of depathologizing gay and lesbian
people (Drescher, 2015;Scasta, 2002). In my home country,
Sweden, the political work included employees protesting antigay
prejudice by telephoning their workplace and the Swedish Social
Insurance Agency. They called in to say they could not come to
work because they were gay and, therefore, officially ill. It also
included major demonstrations on the stairs of the Swedish Na-
tional Board of Health and Welfare.
Thus, I see the Psychodynamic Diagnostic Manual, Second
Edition (PDM-2; Lingiardi & McWilliams, 2017) as a historical
contribution: a diagnostic manual that is not just assuming health
for previously misunderstood minority groups, but one that takes it
even further to name and address their ongoing cumulative trauma
experiences (Khan, 1963), invalidation, harassment, and microag-
gressions striking not only gays and lesbians, but also all other
minorities (e.g., Pierce, 1970;Sue, 2010). What an empowering
contribution!
Frank
Returning to Frank, is he masochistic, passive–aggressive, and
somewhat paranoid? Is he greedy and obsessional about money?
Or do his inner and outer worlds collude with discrimination in a
way that makes a contextual understanding of him a little bit less
pathological? Paul Wachtel (2009), in discussing “the chicken or
the egg,” described the root of psychological problems as both
inner and outer at the same time. In this case, there are at least three
factors that greatly affect both Frank’s outer circumstances and his
inner world: heterosexism, antisemitism, and classism. Frank has
been harassed for being a Jew; he has experienced the homophobia
that kept him in the closet for a long time, and he also names what
I would call the exploitation of prodigy children from lower
socioeconomic classes, citing the unfairness between “smart public
school kids and privileged private school kids.” He is neither
Black, nor disabled, nor female. But otherwise, minority stress and
lack of privilege have affected him, although they seem not to have
been fully named, or thought about, either in life or therapy. For
example, all three therapists in the case—Dr. A., Dr. B., and Dr.
Drescher—are male, gay, and Jewish. Yet the meaning of that is
little explored in the case history presented.
I find it amusing that the pseudonym picked for this patient is
Frank, when there is nothing really frank or direct about him.
Everything in his life seems to be a paradox and addressed in
indirect ways. Everything seems to be displaced. Life should be
perfect, and still nothing in his life is even close to perfect. He
wants special treatment, first-class status and upgrades, the perfect
vacation and the perfect dinner experience. The problem is not
only that he cannot handle the realities of imperfection, but that he
also makes no effort to increase his chances of getting what he
wants. Even a planned vacation, after suggestions from Dr. A.,
turns out to be a nightmare at a location prized by heterosexual
nuclear families, including a lot of noisy children. How could he
self-sabotage in that way? A common gay and lesbian skill when
going on vacation is to first check out how to avoid noisy hetero-
sexual families with loud kids splashing in the pool.
Repeatedly, Frank is stuck with the experience of being ex-
ploited or having second best. He is worried about the fee for his
own analysis, but seems not to worry about the cost of his partner’s
treatment, nor the fact that he is getting very little out of a couples
therapy that has a strong bias toward seeing problems through his
partner’s eyes. The current couples therapist is not even the cou-
ple’s own; he is inherited from his partner’s individual therapy.
Nor does he seem upset over the fact that his life partner is not
working. But he is angry with Dr. B. for insisting he needs to pay
for his session even if the subway is late, holding Frank respon-
sible for a late subway himself. Nobody else seems to have to take
responsibility for the unfairness happening to them, including his
depressed boyfriend. So why should Frank always be the one
responsible for life’s unfairness? Couldn’t the burden of life’s
unfairness be spread around a little bit more?
It is a fair question, even though it is not attuned to psychody-
namic realities about the therapeutic frame. Frank might be angry
and envious toward his therapists, who manage to insist that they
are not affected by unfairness despite the fact that they also share
the minority position. They, of all people, should understand
unfairness. And they act as if they do not! So when Dr. B. says, “if
you feel so strongly about it, you don’t have to pay,” it makes
Frank feel worse because Dr. B. is still not acknowledging the
unfairness.
I find myself wondering whether acknowledging that it really is
unfair that Frank suffers because the subways are late, but empha-
sizing that life itself is unfair, might have been more helpful to
Frank. He seems to be stuck in a position of repeating all kinds of
unfairness and doing a lot of self-sabotage. He seems to be
enacting some kind of success neurosis (Freud, 1916/1957,1936/
1964), a self-defeating pattern, and a lot of passive–aggressiveness
about the dissatisfaction that comes with that. Dorothy Holmes
(2006) addressed experiences of societal discrimination:
. . . one is haunted by one’s essential “crime”—not by a fantasized
oedipal or preoedipal one, but by a crime that our society indicts and
condemns even more. Namely, if one is not in the right racial group-
ing or social class, one is extremely negatively valued, and this
valuation often becomes a highly malignant, introjected reality that
one should not aspire to success on any level. (p. 219)
Frank experienced a lot of trauma and losses. In addition, the
parents had numerous arguments that never were constructively
addressed or resolved. They disagreed on the upbringing of chil-
dren, and Grandma’s living with the family was a source of
chronic irritation between them. Their middle son’s death was a
source of attacks on each other, and the fact that his father could
not work created friction. Frank seems to have been idealized by
his mother and harshly treated by his father, by whom he felt
unseen. His family history was full of losses, unresolved para-
doxes, and tensions.
It is not strange that for a long time, he tried to disconnect his
sexual interest from a gay identity. Everything could be denied.
Why not this? And for some reason, I find it most sad that he
sought sexual pleasure not from gay men, but from heterosexual
men who made an exception to their putative sexuality while they
were drunk. This is an internalized version of homophobia, acting
out by valuing straight-acting men more than gay men (Bergling,
2001;Eguchi, 2009;Weinberg, 1972). Frank wants special, first-
class treatment, and yet he seems to go for the second-best again
and again. It seems that life offers Frank only leftovers. He cannot
live fully. The glass is indeed half-empty.
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360 DRESCHER AND FORS
The paradoxes continue. Frank is taking care of the presumably
weak and depressed George, who he worries will commit suicide.
Yet he gives him so much power that George bosses him around
and rules him. His work follows the same pattern. He wants
success there, but he seems not to dare to work for what he wants
and fears his own competitive sides. It is easy to assume that
Frank’s lack of access to his feelings of competition and anger
simply mirrors his fear of being like his father. Frank is always the
undeserving underdog, self-defeating and passive–aggressive.
He does not accept being gay. He does not accept being Jewish.
He finds Jewish people too aggressive and too pushy, and he does
not want to have those qualities. It is possible that he projects the
image of a bad, greedy Jew on to his Jewish therapist, Dr. B., as
well. Being able to stand up for oneself could easily be interpreted
as being pushy and entitled. So it may be that his own internalized
anti-Semitism is projected onto the therapist. Frank’s sabotaging
his own success; his annoyance about his therapists’ self-confident
billing and shameless pride-parade marching fits this ambivalence
and envy. He does not deserve this himself. Why would they? And
as minority people, how do they dare?
3
PDM-2
Coming back to the PDM-2 (Lingiardi & McWilliams, 2017),
despite its empowering voice and potential, I find parts of it still
stuck in privilege blindness. I will give a few examples. First, the
PDM-2 assumes the therapist is a majority person. In the section
describing ethnic minority issues, the pronoun they is used. The
description of common countertransference reactions while work-
ing with minorities assumes that the therapist is in a majority.
4
Mirroring this case, where a minority person meets a minority
person, the PDM-2 gives no extra help for the distortions of envy,
internalized subordination in both parties, countertransference,
idealization, disappointment, and unspoken wishes to be better
understood by someone on whom we can project sameness.
The most striking example of privilege blindness in PDM-2 is a
case example featuring the struggles of a 16-year-old Pakistani
Muslim who had frequent school absences after being teased about
his religion’s traditions and rules with respect to food. Although
the case example does not say where the boy lives, it is unlikely to
be Pakistan or Asia, because Pakistani food is seen as foreign by
his schoolmates. The implicit assumption is that he lives in the
United States or Europe. Although PDM-2 has a worldwide,
universal approach, a Western context and living in the West are
taken for granted and implicitly seen as the norm.
In the chapter on children, in the section on nonpathological
experiences that may require clinical attention, only gender incon-
gruence is acknowledged as a minority issue. The suffering of
lesbian and gay children is not acknowledged. That may be taken
as implying that childhood sexuality is always heterosexual.
5
I
think the child section is missing other minority issues as well, for
example, ethnicity and religion.
Privilege Pathology
My third objection might be utopian, but still relevant. Accord-
ing to Young-Bruehl (1996), prejudices are social defenses. If so,
why is the pathology that comes with privilege not named? No-
body seems to bear, embody, or be responsible for racist, hetero-
sexist, classist, or ableist structures and norms, and yet some
people are hurt by these attitudes. And if there is a nonpathological
way to describe minority stress and cultural mistreatment due to
experiences of cumulative minority trauma, why is the flip side not
acknowledged? The PDM-2 addresses the effects of internalized
homophobia in gay people but not internalized homophobia or
internalized heterosexism in heterosexual people. The PDM-2
assumes victims but no offenders.
There is much empirical research showing that privilege invites
narcissism and dissociation from weakness and vulnerability. Piff
and colleagues (Piff, 2014;Piff, Stancato, Côté, Mendoza-Denton,
& Keltner, 2012) found that higher social class predicts both
narcissistic traits and unethical behavior. In social psychology
experiments, rich people steal more candy from children, lie more,
and are more likely to break traffic laws (Piff et al., 2012). In
addition, upper-class people in Western cultures tend to attribute
social differences to their own choices, autonomy, and hard work
(Kraus, Piff, Mendoza-Denton, Rheinschmidt, & Keltner, 2012). It
has been shown (e.g., by Galinsky, Magee, Inesi, & Gruenfeld,
2006;Kraus et al., 2012, among others) that privilege correlates
with a tendency to not consider others’ perspectives. Grijalva et al.
(2015) have even suggested that, for this reason, men as a group
are more likely than women to have narcissistic features.
Having privilege throughout the life span could also actually
mean suffering connected to privilege: For example, in the PDM-2
section on the elderly, the authors write movingly of the grief or
anger that can strike people with gender dysphoria and can affect
gay or lesbian individuals who come out late in life. Grieving all
the opportunities one missed, chances are lost. But here is the flip
side: Following the extensive empirical research suggesting that
privileged wealthy people tend to become narcissistic and self-
entitled (e.g., Piff, 2014), several issues arise about, for example,
aging. How can one come to terms with aging and the limits of life
if one feels entitled and if one is accustomed to fixing one’s life by
money, important friends, or status? Facing illness and death, no
one can buy an eternal life.
In Scandinavia, where everybody has access to publicly fi-
nanced health care, a new problem has been recently articulated:
Many older men who have narcissistic, authoritarian, sexist, and
racist attitudes now need the care of immigrant nurses from the
local public health service for activities such as showering, helping
them with medication, and bringing them food. The public system
is not overtly racist nor sexist, and even if some of these elders
have tried to ask for Scandinavian personnel, they cannot choose
who cares for them (e.g., Gustavsson, 2017). So many of these
racist people are now stuck unhappily with young immigrant
female caregivers from Eastern Europe, Asia, or Syria. More
consequentially, dedicated, skilled female and often immigrant
3
I suspect that a patient’s struggles with guilt or self-sabotage about
success would be even more likely to be explored as an intrapsychic
conflict than framed as a societal poisoning of the subordinate’s superego
if the therapist is a majority person.
4
This is quite offensive, not only to assume that minority persons are
exceptions in the field, and to assume that the majority needs a manual to
understand the other, but to imply that all minorities are in some way alike
and need no further explorations on countertransference issues.
5
A lot of children know from a very early age that they are gay, lesbian,
or bisexual, but they find no validation in the society for that.
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361
DIALOGUE ON CULTURAL AND MINORITY ISSUES IN PDM-2
caregivers are stuck with narcissistic racist patients who devalue
them.
Yet another problem of privilege occurs in PDM-2’s child
section: Should not clinicians and parents worry about the ages
between 3 and 5 when privileges and prejudices seem to become
internalized? Davids’ (2011) work suggested that age 3–5 is when
we all internalize an unconscious inner racist structure; that is, the
same age range named by Freud (1905/1953) as the time when we
internalize an oedipal structure. Several feminists and antiracists
(e.g., Chodorow, 1989;Davids, 2011;Swartz, 2007) have sug-
gested that internalization of Oedipus is in reality also internaliza-
tion of sexism and racism.
This concern recalls the research of Bronwyn Davies (1989),
who found, in an entertaining and striking study in which feminist
fairy tales were read to Australian preschool children, that small
boys could not handle their feminist narrative. When asked to retell
the story, its structure seemed confusing, and boys changed the
stories into gender-stereotyped narratives. For example, they
would make Rita the Rescuer into a boy. So, why is there not a
paragraph in the child section of the PDM-2 for this? “Warning,
this is the age when children commonly internalize sexism, het-
erosexism, and racism. Watch out that your child does not do that.”
Instead, there is just a section on children with gender incongru-
ence, one that does not address the other side of the coin. What if
the children really are gender stereotyped? Or become heterosex-
ist? Or racist? Would that not be a worry?
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362 DRESCHER AND FORS
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