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Psychoanalytic concepts of the etiology of severe mental illness.

In this paper I challenge some prevalent psychoanalytic concepts of the etiology and pathogenesis of severe mental illness which I believe to be in need of revision. There is insufficient evidence to conclude that the etiology of the two major adult psychoses, schizophrenia and manic-depressive illness, can be attributed to failures in development or fixations during the earliest years of life. Furthermore, I believe it incorrect to ascribe these failures of development to deficiencies in the early maternal environment. I base my disagreements on three main considerations: the misinterpretation of the etiological significance of regression, the relevance of new biological data, and erroneous conclusions drawn from lack of diagnostic distinctions. I also challenge the generally held concept of etiologic phase specificity which proposes that failures during various early phases of development can be correlated with different kinds of adult psychopathology. In calling this concept into question, I argue that current psychoanalytic concepts of the etiology of the borderline group of disorders also need to be reevaluated.

Bipolar Disorder↗

Aggression and love in the relationship of the couple.

In this paper I examine the interplay of love and aggression in a couple's emotional relationship. I explore the activation of dominant repressed or dissociated object relations with the parental figures, and the unconscious collusion of both partners to enact these past relationships in the present. I then examine the couple's relationship as determined by differences in male and female development, as well as the counterpart of these differences--unconscious moves toward "twinship" and complementarity. Unresolved oedipal conflicts are explored as a major cause of invasion of the couple's sexual boundaries, and a vehicle for the expression of dissociated aggression from many sources. Perversity--the "recruitment of love at the service of aggression"--as a threat to the basic fabric of a couple's love life is one alternative to the normal channels for elaboration of aggression in their relationship. Protective functions of the couple's interaction with their social network are examined in the context of their elaborating and integrating aggression with love.

Aggression↗

The psychoanalytic treatment of a preschool boy with a gender identity disorder.

A three-year, nine-month-old boy began analysis by wishing he was a girl and pretending he was a superheroine. Over the course of almost five years, the cross-gender defense against fear of loss of the object, anal loss, and castration by the object reorganized in all libidinal phases through early latency. Developmental arrests seemed to occur during the anal rapprochement and oedipal phases that led to observable cross-gender strivings by two and a half years of age. The role of early childhood illness, narcissistic vulnerability, mother's childhood wish for a sister, the mother's adult wish for a daughter, a shared fantasy between mother and child, identification with the perceived power and beauty of mother and grandmother, pathological sibling rivalry that influenced identification with his sister, were demonstrated in his play during sessions. Interwoven in the background was the impact of an emotionally absent father, a dying grandfather, and an accident-prone uncle. This paternal matrix seemed to discourage budding masculinity and encourage feminine identifications. The analyst's approach and the child's responses to interpretation of the transference manifestations, cross-gender behavior, fantasies, and play are presented. Finally, the gradual resolution of the conflicted wish to be a girl was supplanted by the emergence of appropriate gender identification. A two-year followup appeared to confirm his postanalytic gender stance and continuing consolidation of stable gender development.

Anxiety, Castration↗

Sadomasochism in the perversions: some thoughts on the destruction of reality.

The author summarizes and develops some of her viewpoints on the perversions (outlined in several of the books and articles she has written). For her all the perversions, whatever their content, develop against an anal sadomasochistic backdrop. Their aim is to destroy reality. Reality, from a psychosexual perspective, may be defined as resulting from the existence of the father separating the mother and the child. This may be formulated in another way: reality is recognition of sexual and generational differences. Or, yet again: mother and father have a procreative sexuality, whereas the child does not. This leads to the idea that the destruction of reality is equivalent to destruction of the paternal universe. Clinical case illustrations are provided, one of which centers on the assassination of an old man who, besides representing a paternal oedipal image, also represents reality itself. This case illustrates in concrete form the murder of the father, and hence of reality, accomplished by the pervert when he eradicates the paternal dimension of psychosexuality by regressing to the anal sadomasochistic dimension.

Fantasy↗

The real person of the analyst and his role in the process of psychoanalytic cure.

This paper focuses on the real relationship with the analyst in the psychoanalytic situation as an aspect of the therapeutic process that leads to change. The role of free association, clarification, and interpretation of the transference are taken for granted as major activities of the analyst, and the real relationship with him is seen as a complementary but important ingredient for change. In particular, his emotional availability determines the climate of analysis. The concepts of neutrality, anonymity, and abstinence, though of importance as guideposts in the conduct of an analysis, have conceptual limitations that not infrequently bind the analyst in a stance that is not useful for the progress of the analysis. On occasion, confirmation by the analyst of the verity of an experience in the patient's early life facilitates the analytic process. This occurs particularly in situations of early trauma, but at times may include chronically traumatic early life experiences. An important motivating force in analysis is the patient's unconscious wish to find the ideal parent absent in early life experience, a wish that is experienced and ultimately analyzed. This is to be distinguished from a defensive idealized transference. Psychoanalytic developmental psychology contributes to our understanding of how the real person of the analyst, his emotional availability, his responsiveness at particular times, his attitude toward action and progressive change in the patient, affect the therapeutic process that leads to change.

Adult↗

The absence of the father.

The author discusses the role of the father in early development through the concept of triangulation. Three male patients are presented who seemed to lack images and memories of their fathers and experienced them as absent, despite their physical presence during childhood. In these men, the oedipal phase appeared skewed and a dyadic relationship with the mother dominated the material. They reported a lack of a sense of masculinity and a phobic concern about the dangers of male violence, along with feelings of specialness and grandiosity. Analytic data suggested that the image of an absent father reflected a process akin to splitting of the ego, in which the significance of the father was disavowed and the patients fantasized a special role with their mothers; via projection, the fathers reappeared as dangerous intruders. It is proposed that this structure derives from a specific developmental situation in which a disturbed parental relationship has impaired the father's position as a "third" in the early triangle. The child's sexual and aggressive tensions cannot be contained in his fantasies of the couple and must be projected outside. The absent father returns in the transference, where the analyst is reexperienced as useless and absent and as a threat to the specialness of the dyad, thereby recapitulating the predicament of the child.

Adult↗

Postoedipal transformations: latency, adolescence, and pathogenesis.

There is a tendency in psychoanalysis to seek ever earlier determinants of pathology. One effect of this search is to relegate adult memories of latency and adolescence to serving mainly a defensive screen function. Psychoanalytic material from child and adolescent cases is used in this paper to illuminate postoedipal developmental transformations. These findings are applied to the understanding and technique of work with adults. Alertness to latency elements can affect the timing of interpretations, the understanding of neurosogenic factors, and the forces for health available in the patient's personality. Alertness to adolescent phenomena highlights the adult patient's difficulty in integrating adolescent realities with childhood fantasy solutions to preoedipal and oedipal conflicts. We conclude that no one phase has preeminence over others, that earlier is not necessarily more important, and that there cannot be pure recapitulation, revival, or "reanimation" (Freud, 1925) of the past in the present. However, knowledge of the transformations appropriate to each phase in the past gives us additional access to the determinants and functions of the patient's pathology in the present, increases the specificity of genetic interpretation, and gives both patient and analyst greater conviction about the accuracy of the essential analytic work of reconstruction.

Adult↗

Oedipal sibling triangles.

Sibling triangles exist independent of parent-child triangles and undergo parallel development into constellations bearing significant formal and dynamic similarities to the standard parent-child oedipal relationships. They may exert definitive effects on the individual's identifications, adult object choices, and patterns of relating. Recognition of such constellations and their outcomes is often crucial to successful therapy. A developmental line is delineated with emphasis on the recapitulation throughout development of oedipal sibling issues. Speculations are offered about the possible factors responsible for pathological outcomes of oedipal sibling triangles, and about why, in many cases, oedipal sibling experience may be more influential in development than oedipal parental experience.

Adolescent↗

Oedipus and the sphinx: triumph and catastrophe.

The downfall of Oedipus in Sophocles' most famous play, Oedipus Tyrannus, is the reversal of his triumphant entry into the city of Thebes 17 years earlier. The oracle at Delphi has told the Thebans that the plague will end only when the murderer of Laius is identified and punished. The unconscious collusion between Oedipus and the Thebans to ignore the unsolved murder breaks down. Told by Teiresias that he is the culprit, Oedipus begins a desperate effort to find evidence to refute this accusation. When other witnesses come forward, his cause is lost. The effect of Oedipus's collusive interaction with the Thebans is balanced in Sophocles' account by the story of the riddle of the Sphinx. The Sphinx is a goddess of discontinuity. She represents the unconscious forces at work both in Oedipus's personal fantasies and in the collective fantasies of the Thebans. The tragedy results from the interaction of these fantasies in the government of the polis. Sophocles' play thus exemplifies the intricate intertwining of the child's innate wishes and the reaction they evoke from the environment during the oedipal period. The neurotic patient's illusion of sexual triumph over his or her father or mother as a child can be best understood through the interaction of these factors.

Defense Mechanisms↗

The preconceptual organization of emotion.

The suggestion is made that emotions organized on a preconceptual level are psychic constructs different in kind, as well as degree, from emotions organized on a more abstract conceptual level. For many people the regressive alteration in ego functioning that gives rise to these emotional constructions represents a characterological way of handling conflict. Emotions organized on a preconceptual level and rigidly maintained through primitive defenses ward off a host of fears ranging from castration to dedifferentiation. The shift from the preconceptual world of sensation to the conceptual world of abstraction complements the resolution of oedipal themes and is essential for free and easy movement between reality-based interactions and the imaginary experience of both self- and object representations in the transference. Structural and dynamic aspects of these emotional constructions are discussed and their relation to a person's experience of reality is explored through transference material taken from different points in an analysis. The problem of the analyst's use of concepts to refer to preconcepts is also discussed, as is the issue of enactments.

Adult↗

"Someday ..." and "if only ..." fantasies: pathological optimism and inordinate nostalgia as related forms of idealization.

Fantasies whose core is constituted by the notions of "someday" and "if only" are ubiquitous in human psyche. In severe character pathology, however, these fantasies have a particularly tenacious, defensive, and ego-depleting quality. The "someday" fantasy idealizes the future and fosters optimism, and the "if only" fantasy idealizes the past and lays the groundwork for nostalgia. The two fantasies originate in the narcissistic disequilibrium consequent upon the early mother-child separation experiences, though the oedipal conflict also contributes to them. Both can be employed as defenses against defective self and object constancy as well as later narclssistic and oedipal traumas. This paper attempts to highlight the metapsychology and behavioral consequences of these fantasies as well as their unfolding in the treatment situation. It suggests six tasks to be especially important for analytic work with such patients: (1) providing and sustaining a meaningful "holding environment"; (2) employing "affirmative interventions"; (3) helping the patient unmask these fantasies and interpreting their defensive, narcissistic and sadomasochistic aspects; (4) rupturing the patient's excessive hope, analyzing the effects of such rupture, and facilitating the resultant mourning; (5) reconstructing the early scenarios underlying the need for excessive hope; and (6) paying careful attention to countertransference feelings throughout such work.

Countertransference↗

Cloacal anxiety in female development.

Contemporary psychoanalytic theory about feminine genital anxieties has shifted our focus away from some essential developmental realities of the little girl prior to the oedipal phase. Anal phase experience has recently been reemphasized as contributing significantly to the girl's developing body image, her mastery modes, and her psychological experience of gender. This paper proposes that associated with this phase is a specific anxiety described as the girl's fear that her genital is dirty, messy, and repellent to the love object, and that her sexuality is out of control and dangerously explosive. This is an important anxiety for the girl, a specific feminine version of anxiety around loss of love and approval. It derives from her bodily experience and is typically incorporated into the feminine genital anxieties of the oedipal period.

Adult↗

Oedipal dynamics in panic disorder.

Both research and clinical work have revealed factors that can lead to the onset and persistence of panic disorder. Preoedipal conflicts intensify the danger of oedipal longings for panic patients. Competition with the same-sex parent is linked with angry preoedipal fantasies and associated fears of disruption in attachments. Fantasies or actual successes can thus trigger panic episodes. Regression to a helpless, dependent state such as panic defends against the danger of aggressive, competitive fantasies and actual achievements. However, the regressive state can also be experienced as dangerous, and can be linked with frightening homosexual fantasies. A reactive aggressive oedipal stance can sometimes result, triggering escalating turmoil. The panic episode serves a series of compromise formations in dealing with these conflicted wishes.

Adult↗