The Mind in Disorder

Psychoanalytic Models of Pathology

John E. Gedo

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780881630688
• eBook ISBN: 9781134878574
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Anchoring his schema in the belief that nonorganic disorders are disturbances in adaptation explicable within a depth-psychological framework, Gedo posits two broad categories of functional disorder: "apraxias" that represent any failure to learn adaptively essential skills, and disorders of what her terms "obligatory repetition." Within both categories of disorder, Gedo avers, the vicissitudes of mental functioning are understandable in terms of regression to relatively archaic modes of function and the reversal of regression and return to expectable modes of adult function.

It follwos from Gedo's understanding of how and why the mind becomes disordered, that diagnosis utilizing psychoanalytic principles can only be based on the succession of transference constellations encountered in treatment, since these constellations invariably pinpoint the developmental impasses in which maladaptive repetitive patterns and the failure to learn basic psychological skills are rooted. For purposes of understanding a variety of apraxic and repetitive disorders, Gedo equates such basic skills not only with the three major psychobiological attainments he has invoked in the past, but with the development of adequate perception, cognition, affectivity, and communication skills.

Beautifullu organized, lucidly written, and richly illustrated with case vignettes, The Mind in Disorder is not only the thoughtful yield of an outstanding clinician's three decades of experience. It is also the first psychoanalytic book since Otto Fenichel's masterwork of 1945, The Psychoanalytic Theory of Neurosis, to take the issue of how we conceptualize psychopathology as its central focus.

Chapter 1
Nosology and the Therapeutic Goals of Psychoanalysis

I

When Sigmund Freud began his therapeutic activities exactly 100 years ago, his treatment efforts were intended to eliminate a variety of somatic symptoms loosely linked under the rubric of hysteria (see Breuer and Freud, 1895). Freud’s first independent psychological discovery (1894) was the possibility of grouping a number of hitherto unconnected syndromes, hysteria among them, as the “neuro-psychoses of defence.” The focus of his attention was thereby shifted from manifest symptoms to intrapsychic processes, a change soon reflected in his adoption of the term “transference neuroses” (1914b) to designate conditions wherein either mental or somatic symptoms reflect the transfer of the intensity of unconscious libidinal processes across a repression barrier (see Freud, 1900, p. 553).

Between 1895 and 1920, give or take a few years, Freud differentiated two classes of psychopathology from the transference neuroses. In making these distinctions, he established the first psychoanalytic nosology, albeit one that did not entirely fulfill his aspiration to enunciate comprehensive theories. Starting with his paper on “anxiety neurosis,” Freud (1895b) attempted to subdivide neurotic syndromes into those produced as a result of intrapsychic conflict and others that had no specific psychological meaning but, in fact, constituted somatic processes triggered by various kinds of “psychical insufficiency” to manage adaptively the libidinal economy (1896b, p. 195; see also 1898, pp. 266-70, 178-80). He called syndromes of the second kind the “actual neuroses,” denoting that they were the consequences of current problems, rather than legacies of the past, like the “neuropsychoses of defence” (1896a).

The second nosological distinction was introduced when Freud (1914b) modified his metapsychology by formally adding the concept of narcissism to his theory of the libido. This new concept permitted him to propose a category of “narcissistic neuroses,” which included entities such as psychoses (see esp. Freud, 1911a; Abraham, 1908), homosexuality (Freud, 1910), melancholic depression (Freud, 1917), and other disturbances of character wherein objects are not invested with lidibo. Freud (1914b) attempted to push the nosological system he had developed on the basis of the libido theory to its ultimate limits in postulating that hypochondriasis might be an “actual neurosis” based on psychic inability to process narcissistic libido.

No sooner had Freud completed this first psychoanalytic nosological schema than he began to consider certain disorders of character that he could not understand in terms of libidinal vicissitudes: as early as 1916, he described personality types distinguishable by the mode of operation of their conscience. Not only did this finding compel him to develop a more complex nosology than his initial one, it also made necessary the revision of his contemporaneous theory of mental function-to go beyond mental topography and the vicissitudes of libido. Freud’s ultimate conceptual proposals-the structural theory (1923) and the repetition compulsion “beyond the pleasure principle” (1920)-were intended to accommodate the gamut of mental functioning, in health as well as in maladaptation.

These theoretical innovations initiated a revolution in psychoanalytic thinking. As early as 1924, Ferenczi had grasped that these conceptual developments outmoded existing theories of pathology and of treatment technique: he pointed out (in Ferenczi & Rank, 1924) that henceforth psychoanalysis could not confine its therapeutic aims to the elimination of isolated symptoms or of dynamic “complexes”; it had to address itself to the personality in all of its aspects. Thus was psychoanalytic characterology born (see also Reich, 1930).

In the era of ego psychology that followed, perhaps more emphasis was placed on the issue of what kind of ego structure made analyzability possible (or proved to be disadvantageous) than on fine nosological distinctions among character types (see, however, Ross, 1960). It gradually became clear that absence of analyzability could not be tightly correlated with the phenomenological criterion of “psychosis” or even with the degree of the patient’s “narcissism.” As a consequence, an ill-defined borderland between unequivocal psychoses and analyzable transference neuroses was tolerated for more than a generation (see Rangell, 1955; L. Robbins, 1956).

In the mid-1960s, as a result of efforts to “widen the scope” of psychoanalysis as a treatment procedure beyond the transference neuroses (Stone, 1954), there was a renewal of interest in narcissistic personality disturbances (see A. Reich, 1960; Kohut, 1968, 1971). Although some of the pioneers in this development subsequently formed the dissident school they call self psychology, the early proposals of Kohut to conceive of nonpsychotic but narcissistic character problems as a distinct nosological entity have found wide acceptance among psychoanalysts. In the opinion of some, these narcissistic disturbances are equivalent to the cases formerly considered “borderline”; others, like Kernberg (1975), distinguish psychoses, borderline conditions, and narcissistic character pathology as separate entities.

II

In contrast to the all but universal psychoanalytic preference for such well-defined nosological categories, each characterized by structured mental dispositions, I am convinced that most people have at their disposal a complex repertory of alternative psychological patterns (Gedo and Goldberg, 1973; Gedo, 1979a). I have found that every analysis ultimately provides clinical examples of dramatic shifts from one set of structural arrangements to another-startling changes the significance of which challenge all existing theories of psychopathology. Skepticism about the value of these theories is also supported by the low reliability of diagnoses based on them. To illustrate this assertion, I shall briefly review the case of a young man who, when I first encountered him during his college years, met the usual criteria of borderline pathology.¹ A relatively brief psychotherapy was followed by a hiatus in our contacts of some 15 years; the patient then returned for an analysis with a narcissistic disturbance within a better structured personality.

I am confident that my assessment of this patient (for whom I now have a 25-year follow up!) was accurate on each of the occasions I encountered him. When he first consulted me, he was maximally regressed, but his condition was not an acute illness. The regression to a borderline status had been precipitated several years earlier by a breach in his relationship to a nurturant stepfather. On the basis of the clinical evidence I obtained through a successful analysis lasting about four years when the patient was a philosophy professor in his mid-30s (described in greater detail in Gedo, 1981a, ch. 11), I am convinced that the 50-odd sessions of psychotherapy when he was in college undid this regression and stabilized the patient at his premorbid level of functioning, one that had characterized his latency years.

This mode of adaptation was fraught with a variety of narcissistic illusions that wore thin under the impact of a marital disappointment, but only at the climax of the iatrogenic regression induced by the analysis was the patient’s ability to function in a more archaic manner reconfirmed once more. The history of this long-term treatment is also a useful reminder of the fact, familiar to most clinicians (but see Gedo, 1964), that major and lasting shifts in many patients’ characteristic levels of functioning are often possible as a result of relatively short therapies, quite different from the analytic treatment espoused by most serious contributors to the literature on character disorders. If such gratifying results do not occur too frequently, the reason is the enormous difficulty of finding the proper set of interventions to bring them about (see Gustafson, 1984, 1986).

As my therapeutic experience has grown, I have learned, empirically, that to have a reasonable chance to assist people with problems stemming from early phases of development, the mutual security of a psychoanalytic framework provides the optimal setting. From a theoretical perspective, however, we must never forget that the entities hitherto regarded as psychopathological categories are in actuality successful, albeit sometimes inconvenient, adaptive maneuvers that may be rendered irrelevant by relatively minor changes in life circumstances.

Just as we should be prepared for the reversal of alarming states of regression, either by means of appropriate therapeutic interventions or as a consequence of fortuitous improvements in the patient’s life, so must we keep in mind the ever present possibility of unprecedented regressive developments in patients who do not provide prior evidence of such vulnerability. The reversibility of acute schizophreniform or depressive episodes should have taught us by now that it is no more sensible to label people permanently as schizophrenics or depressives on the basis of a time-limited sample of their behavior than it would be to think of them in perpetuity as fevered or convulsed because they are capable of having fever or convulsions. I suspect that the same principle applies to the conditions we label as neurosis or borderline state, despite the fact that many individuals seem for long periods to be stuck in such conditions.

Let me restate my principal point in still another way. The standard literature (cf. Kernberg, 1985) proposes a schema of personality diagnoses ascending a maturational ladder to heaven: psychotic personality organization, borderline, narcissistic, and neurotic personalities, with normal personality organization as the implicit apex of the series.² I look upon the various modes for the organization of behavior presented by the foregoing labels as more or less universal developmental possibilities. The more primitive variants are usually superseded by those of later origin, but this progressive development does not mean that the earlier alternatives have been permanently lost-whenever they might present adaptive advantages, former modes of organization may come into use once again. My conceptualization (see Figure 1) implies that every potential patient must be expected, sooner or later in analytic treatment, to function within the therapeutic milieu in accord with each of the modes of behavioral organization that person has traversed in the course of prior development.

My conception of the hierarchic possibilities of mental organization has the seemingly paradoxical consequence that I am simultaneously maximally optimistic about the recovery potentials of severely disturbed patients and much more skeptical about the value of elucidating the conflicts of the infantile neurosis than analytic traditionalists have tended to be. On the basis of completing some 50 analyses by mutual consent, I have concluded (Gedo, 1979b; 1984, ch. 2) that successful outcomes are most likely to follow the amelioration of problems stemming from the earliest phases of development. In this respect, my views seem to converge with those of Melanie Klein (1984). I have found that analyses focused exclusively on derivatives of the Oedipus complex, that is, on a relatively late phase of childhood development, tend to be therapeutically ineffective in the long run. This turns out to be so because, in the vast majority of instances, vicissitudes of development earlier than the conflicts of the oedipal period are equally implicated in pathogenesis (see Firestein, 1978; Gedo, 1980; Schlessinger and Robbins, 1983).

III

Insofar as psychoanalysis is the “depth psychology” far excellence, its therapeutic goals necessarily call for the elucidation of personality structure and its origins in the service of altering mental dispositions as far as possible in the direction of free choice in regulating behavior. Such a program does not mean the abandonment of internal guiding principles in favor of ease of adaptation in difficult circumstances, as some hostile critics of American psychoanalysis allege; rather, it signifies mastery of that obligatory repetition of preexisting behavioral patterns that constitutes the psychopathology. People seek psychological assistance when these patterns of behavior prove to be too costly or painful. In fortunate life circumstances, these same behavioral dispositions may cause so little loss of pleasure or profit that the affected person may have no incentive to alter them. Conversely, the degree of displeasure produced by a given pattern of behavior is codetermined by social pressures-not only the immediate reactions of family or friends, but even the mores of the community within which the person tries to function.

What are the principal types of behavior for which psychological assistance is likely to be sought? Obviously, these patterned responses may usefully be classified in a number of different ways, including the prevalent nosological distinctions among transference neuroses, narcissistic syndromes, psychotic disorganizations, and the like. For heuristic purposes, however, I should like to call attention to a more fundamental distinction-that between behaviors produced by the repetition of certain response patterns established in infancy or early childhood and other maladaptive or troublesome types of conduct that result from apraxia-failure, for whatever reason, to acquire essential psychological skills. Although the fundamental patterns that characterize a person’s core identity-patterns I have named the “self-organization” (Gedo, 1979, pp. xi, 10-12, 176-78)—must be ceaselessly repeated if a sense of personal continuity is to be maintained, specific aspects of these archaic patterns may become unacceptable in the course of development, giving rise to perpetual intrapsychic conflicts.³

Let me first try to demonstrate these actualities and the necessity to account for them within a comprehensive psychoanalytic psychology by means of a pair of highly condensed clinical examples. Both clusters of problems will be discussed in detail in subsequent chapters. My first illustration describes some aspects of a person whose pathology consisted for the most part of a series of intrapsychic conflicts.⁴

Case 1

The patient was a professor of linguistics approaching the age of 40. He desperately sought assistance because he was unable to tolerate his unfortunate marriage, nor could he leave his wife, whom he regarded as fragile and utterly dependent on him. He and his spouse were locked in a struggle of mutual provocation, contempt, and rage-manifested, on his part, through guilt-ridden infidelities, acts of savage depreciation or pervasive condescension, and refusal to gratify the wife’s wish for a child. He had married her, without love or respect, about six years previously, when both were engaged in lengthy psychoanalytic treatments in another city. The patient justified his absurd decision to enter the marriage on the ground that his analyst had implicitly endorsed it at the least by failing to prohibit this piece of acting out. On the other hand, he was unable to explain his utter disregard of the prophetic warnings of his beloved and admired mother, whose wisdom was beyond dispute, about the predictable consequences of his preposterous behavior.

As might be expected, the consultation with me soon threatened to bog down into fruitless arguments about my opinion that nothing short of a second analysis was likely to resolve the dilemma-arguments, moreover, in which his mother did not hesitate to participate. This impasse was dramatically broken by the sudden death of this formidable dowager-a contingency that was more of a surprise to me than to my patient, who later realized that he had decided to reopen the question of analysis, against his mother’s wishes, precisely because he was preconsciously aware of the onset of her terminal illness. And his decision to concur in my recommendation to resume analysis was made because the death of his mother left him in a state of bewilderment, and not for the reasons we had discussed some months before.

If the details I have provided thus far sound like the performance of an endless song with a repetitive refrain, I probably need not stress that the situation proved to be parallel, in ways not far short of uncanny, to certain events in the patient’s childhood. I soon learned that, when he was five years old, his mother had, over the objections of his father, arranged for him to enter treatment with a psychoanalyst because of his overt anxiety. As he recalled it, his anxiety was partly attributed to the threatening anger of his father, whose views and attitudes were treated with condescension by all concerned. At the same time, his mother was at the end of her tether because the patient ceaselessly pestered her to promise that she would marry him when he grew up. He still recalled with pride, mixed with wonder at his own boldness, how he persisted in provoking his mother by refusing to accept her explanations about the impossibility of his plan-for he understood well enough the significance of her failure to indicate a lack of interest in his offer! But these scenes would ultimately end in a tantrum on his part after his mother had finally lost patience.

His relatively brief analysis at the age of 5 seemed to have dissipated his castration anxiety. From his scattered recollections of these events, it became apparent that he had soon developed an erotic transference to his female analyst (who, not so incidentally, happened to be an old friend of mother’s) and was given interpretations about his phallicexhibitionistic wishes. In this context, the reality of his relative inadequacy vis-a-vis an adult woman became instantly clear to the child-he decided he had no wish to show the lady what his penis was like, his acute conflict abated, and the treatment was soon terminated, to the general satisfaction of the other participants. The story helped us to understand his reasons for concealing from his mother his decision, around the age of 30, to enter analysis in order to overcome his feeling that none of the women he had met could interest him as much as she continued to do, despite her loss of sexual appeal in late middle age. Incidentally, this early obstruction to the process of repression seems to have eliminated fantasies of castration from the patient’s mental repertory.

It was much more difficult to grasp what had happened in the course of the futile analysis that led to my patient’s marriage. Perhaps it was no more than one in a series of endless provocations directed at his mother, for he failed to get her approval for this move. Needless to say, she could not be kept in the dark about it for long and was highly disturbed about it. In this sense, the treatment was probably terminated because the patient’s marriage was a much more effective provocation than his inconclusive analysis. Because the patient’s mother silently but unmistakably disapproved of any effort on his part that excluded her-even his choice of a scholarly career!-the second...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• Acknowledgments
• Introduction
• 1 Nosology and the Therapeutic Goals of Psychoanalysis
• 2 Masochism and the Repetition Compulsion
• 3 Epigenesis, Regressive Disorganization, and Reversibility
• 4 Developmental Arrest and the Borders of Integrated Functioning
• 5 Disruption of the Self-Organization as an Inability to Repeat
• 6 Regression, the Psychosomatic Barrier, and the Capacity to Symbolize
• 7 Repetitive Enactment as Symbolization and Self-Healing
• 8 Transitional Relationships, Adaptive Skills, and Autonomy in Behavior Regulation
• 9 Character, Dyadic Enactments, and the Need for Symbiosis
• 10 Transference Neurosis, Archaic Transference, and the Compulsion to Repeat
• 11 Intractable Character Pathology as the Convergence of Repetition and Apraxia
• 12 Apraxia and the Inability to Learn: A Reprise of Previous Work
• 13 Disorders of Communication: Language, Affects, and Vegetative Signs
• 14 Disorders of Thought: Magic and Obsessions
• 15 The Conundrum of Sexuality
• Epilogue: The Art of Psychoanalysis as a Technology of Instruction
• References
• Author Index
• Subject Index