PATHWAYS OF PLEASURE

This article describes a mode of transference relationship in which the analysand has to contend with a psychic mobilisation that results from exchanges with the analyst-object and is related to the activation of pleasure in his/her own mental functioning. The patient's ego feels the internal and external excitations that stem from this mobilisation to be dangerous because of the anxieties about threatening intrusions that they raise. These anxieties arise along the contours of narcissistic flaws that give resonance to early traumatic experiences. The ego protects itself from the danger by organising narcissistic defences that oppose the impulses towards the analyst-object and foster a stagnation of the psychic work. The author puts forward the hypothesis that the patient's ego, not tolerating exposure to drive-related dangers, retracts into a mode of primary anality that is imprisoning and restrictive, setting up a fantasy of narcissistic nidification in which a part of the ego merges with an omnipotent primary object. The purpose of this strategy is to neutralise the excitations - as far as possible - while nevertheless maintaining the element of the drive excitation that forms the basis of the fantasy. The dynamics and the economy of the defensive organisation are examined in detail, as are the questions that these raise. A clinical case illustration is presented.     

Mutilation of self and object: the destructive world of the paranoid-schizoid patient and the struggle for containment and integration

Using case material, I have described the three overlapping phases of treatment that occur with some borderline, narcissistic, or psychotic patients. These patients are dealing with paranoid-schizoid experiences of the self and the object. In this part-self, part-object world, many shifting, opposing, and contrary states of feeling and thought occur. Acting out is the first phase of analytic treatment. This is an externalization of persecutory anxiety, primitive guilt, and phantasies of annihilation. Projective identification, splitting, and denial are common and tend to make for difficult transference and countertransference problems. During the middle phase of treatment, pathological superego states and manifestations of death instinct color the analysis. The death instinct reacts defensively to the sadistic superego. Technically, the destructive internal conflicts created by these two elements must be clarified and interpreted in the transference. Flexible analytic management and containment are crucial supplements to ongoing interpretation. If these chaotic patients are able to stay in treatment for a period time, the acting out and the superego/death instinct phase gradually give way to phantasies of loss. This is still a paranoid-schinoid perspective of loss, making it persecutory experience. Although depressive anxieties do enter the picture, these still involve pathological anddestructive states of guilt and all-or-nothing threats of abandonment and attack. A case was presented in which the patient managed to continue into the third stage of analytic treatment, long enough to benefit frominternal, structure change. In this final stage, the patient "O" was able to acknowledge, work through, and integrate her prior feelings and phantasies of loss, persecution, and abandonment anxiety into more manageable and reality-based depressive functioning.     

Psychotherapy of an adolescent presenting a mystical delusion: an illustration of splitting processes and their consequences

The paper discusses the psychotherapy of an adolescent who, during a psychotic breakdown, developed a mystical delusion on a religious theme. Splitting processes and the narcissistic defences that accompany them are illustrated. After showing how the patient had recourse to splitting and how the split-off parts of the ego took refuge inside an internal object, the ego's efforts to make contact once more with these split-off aspects and to reintegrate them are highlighted. With the help of certain concepts developed by, for example, Rosenfeld and Meltzer - specifically those relating to the organization of internal groupings or 'gangs' and their destructiveness and the compartmentalization of internal objects - the author shows how certain particularities of the patient's internal world can be understood in terms of these splitting processes. In addition the clinical material presented raises several technical questions, in particular those relating to dissociative processes and delusion or delusional theories as they become manifest in the treatment.     

SOME DIFFICULTIES IN THE ANALYSIS OF A WITHDRAWN PATIENT

The author discusses some difficulties that arose in the analysis of a seriously disturbed patient who found talking about himself extremely problematical. He defended against awareness of conflicts, ideas and affects while being tormented and overwhelmed by them. He seemed to have acquired an inhibited character that was not, however, schizoid. He related to others in a wary, quarrelsome, yet passive way. It became apparent that his sense of identity was confused. Attention to archaic fantasies led to the uncovering of a parthenogenetic unconscious fantasy involving identification with his mother and the attempted eradication of the mental function of his father. Experiences of differentiation led to extreme anxiety including risk of failure of ego functions with the arousal of latent psychotic anxieties. Interpretation of the content of sessions became possible only after several years: until then interpretation of defensive processes aimed at preventing contact or change predominated. Disclosure of 'unofficial' communications by the patient, expressed as lapses of vigilance by his severe superego, revealed his crises and feelings. These idiosyncratic, muted appeals for help became a vehicle through which interpretation of content and its transference meaning became possible. Some confusing transference and countertransference experiences in the analysis are described.     

Phallic narcissism, anal sadism, and oral discord: the case of Yukio Mishima, Part I

Thus far I have explored Mishima's traumatic childhood and the experiences leading him toward misogyny, phallic narcissism, and the drive to murder his own weakness and sexual vulnerability. Mishima suffered the extraordinary trauma of being separated from his parents and sequestered to the sickroom of a psychotic grandmother for the first twelve years of his life. Intense rage over abandonment and impingement engendered a disgust for femininity and the need to escape feminine messiness through homosexual pursuits. Mishima's entrenched feelings of shame and weakness gave rise to phallic narcissistic tendencies, as he idealized powerful men and eventually strove to become a powerful and beautiful male. In pursuing this erotic masculine image Mishima continued to fantasize about murdering his weak and shameful self-image, and commingled this sadistic impulse with fantasies of sexual merger with murdered love objects. Finally Mishima was the murderer erotically eradicating his sexual vulnerability as both subject and object. His suicide was a repetition of this erotic sadistic fantasy. In a further article I will continue the discussion by examining Mishima's fantasies of murdering beautiful and abandoning love objects. I will also address the complex nature of his ritual suicide as fantasy of rebirth, sexual merger, the murder of toxic introjects, and escape from death, decay, and regression to helpless infancy.     

The early appearance and intergenerational transmission of maternal traumatic experiences in the context of mother-infant interaction

The paper describes the case of a girl of 8 weeks, referred by her mother because of 'intolerable hysterical attacks' triggering maternal impulses of abuse. Maternal perception of her infant was distorted to the extent that the mother was re-experiencing encounters with her own intrusive and traumatizing mother in the face of her screaming child. She also perceived the infant's motor impulses as physical attacks on herself and expressed intense anxieties about her daughter's future aggressive potential. The infant was viewed by her mother as extraordinarily and dangerously greedy. Even neutral infantile vocalizations were perceived as manipulating and sadistic. She tried to ward off these anxieties by employing a rigid scheme of rules and obsessively controlling the father's and grandmother's interaction with the child. The mother feared being overwhelmed by the infant's needs if she were to yield to them in a flexible way. The mother's background of early neglect and trauma is described, in the light of recent literature about the early intergenerational transmission of traumatic experiences, in order to demonstrate possible treatment modalities and the need to consider both protective and risk factors.     

The internet and its role in the escalation of sexually compulsive behaviour

As increasing numbers of patients present with problems of compulsive use of internet sex and internet pornography, psychotherapists are challenged to develop models that address the powerful, and potentially disturbing effect of this stimulus. Internet sex does not just facilitate access to sexual materials but can act as a catalyst, affecting established defences and ego and superego functioning. Escalation in sexually compulsive behaviour, which affects a small proportion of those accessing online sex, may be thought of as a series of transitions: from casual to compulsive use, from compulsive use to illegal use, and from use of illegal pornography to contact offending. Drawing on clinical experience and the available research evidence, psychodynamic processes associated with movement through these transitions are considered. Internet sex has the potential to fuel manic defences, invites narcissistic and part-object relating, provides a vehicle for the expression and disowning of sadistic impulses and can potentially undermine superego functioning. The combined effect of these processes may lead to a breakdown of ego controls in vulnerable individuals.     

Level and form of psychopathology and the structure of group therapy

Drawing upon concepts derived from ego psychological and object relations psychoanalytic theories of individual development and from a depth group psychology, the present empirical study, a naturalistic field investigation, explored hypothesized relationships between aspects of patients' psychological boundaries and structural features of inpatient therapy groups. More specifically, patients were assessed in terms of their level (i.e., psychotic vs. borderline organization) and form (i.e., anaclitic vs. introjective) of psychopathology. Their perceptions of themselves and of their therapy groups were measured following participation in two kinds of small group treatment designed to differ in terms of degree of internal structuring. Findings, generally supporting the hypotheses, showed the anaclitic borderline patients, in particular, to be most sensitive to structural variations and most adversely affected by an impersonal and highly structured treatment climate. Theoretical and practical implications of these findings were discussed.     

Two modalities of manic defences: Their function in adolescent breakdown

The aim of this paper is to explore two different modalities of manic defences and their specific underlying anxieties. I will describe the relation between these defences and the role of the superego and their specific function in adolescent breakdown. While one type of manic defence operates by the ego’s identification with a sadistic superego the other one operates via evacuation of a guilt-inducing superego. I will illustrate the proposed ideas with clinical examples from the analysis of two adolescents. This paper stresses the specific differences between these two modalities and the clinical importance of both identifying and addressing the enactment in the transference of the unconscious phantasies and anxieties (paranoid and depressive) that give rise to these two types of defences.     

Superego formation, adolescent transformation, and the adult neurosis

The superego is heir to the Oedipus complex but has a much larger developmental legacy which includes preoedipal precursors and the influence of latency and adolescence. The superego continues to change in function and content throughout life, and radical transformation in adolescence may result in developmental discontinuity as well as core developmental continuity. A case is discussed in which adolescence was overlooked in previous analysis and in which adolescent superego modification had a major impact on the patient's character and his adult neurosis. The developmental significance of adolescence experienced under conditions of social isolation and rejection with forebodings of the Holocaust was unrecognized in sanctioned silence and shared analytic denial. These repeated earlier experiences of silent submission and stifled protest, and the silent suffering of the patient and his family, were an integral part of his humiliating and emasculating adolescent experiences. The intimidated adolescent, threatened from within and without, identified with the aggressor as well as with the victim. Identification with the aggressor and glorified victor contributed to a final adolescent structuralization of a punitive, sadistic superego and a rigidly perfectionistic ego ideal. As an adult, he tended to passive masochistic compliance with diminished self-esteem and unconscious self-denigration. He was prone to shame and guilt, self-criticism, and hidden hypercritical attitudes toward others. The adolescent internalization of aggression, intense castration anxiety, and pervasive narcissistic mortification led to retreat from resolution of revived oedipal conflict and to concomitant detrimental superego alteration. These issues were of major importance for analytic understanding and therapeutic progress.     

The unreachable object? Difficulties and paradoxes in the analytical relationship with borderline patients

The author investigates the main difficulties the analyst encounters in borderline patient analysis, focusing on the specific way in which such patients put the analyst's mental functioning to the test and highlighting the most salient elements of the transference-countertransference dynamic. The author picks out several of the paradoxes that characterize the analytical relationship with these patients, who are constantly seeking contact with the object, which is inevitably traumatic for them. On the basis of highly detailed clinical material, the author demonstrates how - no matter which theoretical-clinical model is adopted - a specific technical problem with these patients is how to manage their intense destructiveness. With these patients, countertransferential difficulties are inevitably predominant because of the looming threat of the destruction of the analytical relationship. Maintaining a balance between the recognition-legitimization of primary narcissistic mirroring needs and the recognition-control of narcissistic demands and attacks on the analytical link is as crucial as it is complex. The paper examines the most important therapeutic and anti-therapeutic factors, highlighting the importance of countertransference analysis and self-analysis as ways of accessing as yet unrepresented elements of the patient and analyst respectively. Particular attention is given to the role played by the analyst's subjectivity and to the enactment.     

Thoughts on Interpreting

In this paper I examine the value and contra—indications of interpreting. I point out the specific danger of interpreting when patients suffer from a weak ego as is the case in narcissistic personality disorder and borderline psychosis. I highlight the danger of premature interpretations of the shadow. Reference is made to the analyst's counter—resistance to interpreting and to his interpreting being motivated by his psychopathology. The paper contains clinical material to illustrate these views.     

Attention deficit hyperactivity disorder (ADHD): An affect‐processing and thought disorder?

In the literature on child and adolescent psychoanalysis attention deficit hyperactivity disorder (ADHD) is described as complex syndrome with wide‐ranging psychodynamic features. Broadly speaking, the disorder is divided into three categories: 1. a disorder in early object relations leading to the development of a maniform defence organization in which object‐loss anxieties and depressed affects are not worked through via symbolization but are organized in a body‐near manner; 2. a triangulation disorder in which the cathexis of the paternal position is not stable; structures providing little support alternate with excessive arousal, affect regulation is restricted; 3. current emotional stress or a traumatic experience. I suggest taking a fresh look at ADHD from a psychoanalytic vantage point. With respect to the phenomenology of the disorder, the conflict–dynamic approach should be supplemented by a perspective regarding deficits in α‐function as constitutive for ADHD. These deficits cause affect‐processing and thought disorders compensated for (though not fully) by the symptomatology. At a secondary level, a vicious circle develops through the mutual reinforcement of defective processing of sense data and affects into potential thought content, on the one hand, and secondary, largely narcissistic defence processes on the other. These considerations have major relevance for the improved understanding of ADHD and for psychoanalytic technique.     

Denial in fantasy and hypomania: an exploration

There is a spectrum of normality and psychopathology in which we see the presence of denial in fantasy, action, and word. The underlying ego distortions, such as the overuse of a denying fantasy in reality testing, will determine the clinical appearance of this mechanism. Traumatic experiences in the first 18 months are a determining factor in the development of these ego distortions. Clinical material is presented that supports a theory of elation put forward by Lewin (1950) who suggests that denying elations are repetitions of childhood dreams with their adult elaborations. In Mrs. A., the denying elations occurred particularly when experiences of castration anxiety or object loss became intolerable.     

Evidence for the criterion validity and clinical utility of the Pathological Narcissism Inventory

In this study, the authors evaluated aspects of criterion validity and clinical utility of the grandiosity and vulnerability components of the Pathological Narcissism Inventory (PNI) using two undergraduate samples (N = 299 and 500). Criterion validity was assessed by evaluating the correlations of narcissistic grandiosity and narcissistic vulnerability with established indices of normal personality traits, psychopathology and clinical concerns, and pathological personality traits. Overall, the pattern of correlations supported the convergent and discriminant validity of grandiose and vulnerable conceptualizations of pathological narcissism as measured by the PNI. Clinical utility was assessed by evaluating the extent to which clinicians without specific training in pathological narcissism as well as clinicians with expertise in pathological narcissism could accurately predict the correlates of PNI grandiosity and vulnerability with normal and pathological personality traits and psychopathology. The r(contrast-cv) coefficient provided a global index of accuracy in clinicians' predictions that was more fully elaborated by examining systematic discrepancies across groups. Overall, novice and expert clinicians were generally able to predict criterion correlations, with some exceptions (e.g., counter to predictions, pathological narcissism was negatively associated with treatment resistance). These results provide further evidence regarding the validity and utility of the narcissistic grandiosity and narcissistic vulnerability constructs as measured by the PNI.     

Three visits to eternity: Freud, Wiesel, and Patient X

Freud's experience on the Acropolis is reviewed and reappraised. Also, the experience of Elie Wiesel at the Wall in Jerusalem and Patient X's reaction visiting an Egyptian temple are examined. Carl Jung's wish to go to Rome and his inability to do so are noted. The aim of the paper is to offer deeper understanding about intense reactions many sensitive and creative people experience over travel to special places. These places are treated as idealized and ambivalently loved transference objects. Normal anticipatory pleasure prior to the trip is impaired and reality pleasure at the site cannot be enjoyed. When these spots are reached, ego regression is initiated by the intolerably intense narcissistic pleasure mobilized by the gratification of fantasies that were felt to be unrealizable. The fantasies can be conscious or unconscious and from oedipal as well as preoedipal and postoedipal developmental levels; however, they always involve the fulfillment of overwhelmingly powerful wishes. The deep ego regression, archaic fantasies, and the complex defenses mobilized are frightening since there may also be concern about ego dissolution or irreversible transformation. One highly adaptive solution which helps master these conflictual and developmental experiences is creative ego activity. While maintaining integrity for the individual ego and enhancing the self, creative work and accomplishment also enrich and advance the cultural process.     

克恩伯格边缘性人格组织理论述评

边缘性人格组织是人格障碍的内在结构。克恩伯格主要从非特异性自我虚弱性、现实检验、原始防御机制、病理性的内在客体关系以及身份认同紊乱五个方面阐述了边缘性人格组织理论。该理论弥补了DSM-Ⅳ中人格障碍诊断标准的无理论化倾向的缺陷,并为深入理解人格障碍的心理病理学提供了一个系统框架。     

Contributions of psychopathic, narcissistic, Machiavellian, and sadistic personality traits to juvenile delinquency

The aim of this study was to assess the relative contributions of psychopathic, narcissistic, Machiavellian, and sadistic traits to delinquent behaviors in adolescents. Participants were 615 high-school students who completed self-report questionnaires. Psychopathic, narcissistic, Machiavellian, and sadistic traits were moderately correlated suggesting they may be overlapping but distinct constructs. Hierarchical multiple regression analyses were conducted to control for other socio-familial or psychopathological risk factors. Psychopathic and sadistic traits were independent predictors of delinquent behaviors in boys only. These findings suggest the importance of studying the role of sadistic traits in juvenile delinquency.     

The exclusion of the other2

The author begins by noting that the subject of obsessions and obsessional neurosis seems to have fallen out of favour with the analytic community in spite of the important part it played in the formation of Freud's theories, and notwithstanding the significance of its mechanisms in the maturation of the ego. He then discusses some theoretical considerations regarding the development of the taboo on touching and, by extension, contact. Attention is drawn to the parallels with autistic functioning emphasised by other authors. Particular importance is attached to the distinction between internal and external reality that arises during the anal‐sadistic phase and that leads to polarisation and splitting in obsessional neurosis. Following a discussion of the transference' countertransference situation with obsessional patients and of their concretistic experience in the treatment situation, as also featured in the literature, an extensive case history exemplifies the author's contentions and shows how the patient concerned developed during the course of his analysis. After pointing out the importance of the avoidance of identifications as a mechanism of obsessional defence, the author concludes the paper with a brief comparison of obsessional and hysteriform functioning and a characterisation of the obsessional defence as the excessive recourse to perverted thought functions so as to ward off paranoid anxieties.