39: The Dread to Repeat: Comments on the Working-Through Process in Psychoanalysis Anna Ornstein, M.D. ABSTRACT

Transcription

1 (1991). Journal of the American Psychoanalytic Association, 39: The Dread to Repeat: Comments on the Working-Through Process in Psychoanalysis Anna Ornstein, M.D. ABSTRACT This paper focuses on the process of working through in psychoanalysis. Reemphasis of the centrality of the empathic listening perspective and discovery of the selfobject transferences made it necessary to reconceptualize various aspects of the analytic process from the perspective of psychoanalytic self psychology. With the help of a clinical vignette, the paper illustrates the manner in which archaic defense organizations and newly developing psychic structures find a compromise solution in a transference symptom. Such symptoms can serve as nodal points in the process of working through; they represent a transitional phase between the old automatic responses to narcissistic injury and an increased capacity to use signal anxiety. The psychopathology that became illuminated in this process can be described phenomenologically as a selfdefeating personality disorder. IN EVERYDAY PRACTICE, psychoanalysts do not concern themselves with a descriptive diagnosis based on generalizations. There are at least two reasons for this. The first and more obvious is that, in order to make a psychoanalytic diagnosis, the structure and the genesis of the psychopathology have to be ascertained by analysis of the transference. Once we make a psychoanalytic diagnosis, based on the nature of the transference and not on the descriptive characteristics of the illness, we recognize that no two people suffer from exactly the same disorder. The second, equally important reason is that what emerges as transference and resistance does not depend on the nature of the psychopathology alone. This also depends on the analyst's verbal and nonverbal responses, determined by his or Professor of Child Psychiatry, University of Cincinnati College of Medicine. Accepted for publication December 12, This vignette was presented at the panel, "Sadism and Masochism in Character Disorder and Resistance," at the Fall Meeting of the American Psychoanalytic Association, New York, December 16,

2 her personality and theoretical orientation: what emerges as transference, how and in what form resistances become manifest, is codetermined by both participants in the analytic process. However, in the process of analysis the nature of certain personality features become illuminated in ways that correspond to particular descriptive diagnoses in general use. The patient's psychopathology in the clinical vignette 1 reported below would, phenomenologically, best be described as a Self-defeating Personality Disorder. D.S.M. III R. (1987) no longer uses the diagnosis of "sadomasochism." The Personality Disorder that previously had been so designated is now being labelled as Self-defeating Personality Disorder with the justification that the essential feature in this disorder is a pervasive pattern of behavior that is self defeating. The Diagnostic Manual had abandoned the label "masochism" in order to avoid the historic association of the term with the older psychoanalytic views on female sexuality and the implication that a person with this disorder derives unconscious pleasure from suffering. In reviewing the psychoanalytic literature on masochism, Glick and Meyers (1988) state that "the relationship of overt sexual masochism and characterological masochism is controversial and complex. Clinically, the two do not with any consistency necessarily coincide. It was Freud's theoretical presumption of the ubiquity of unconscious sexualized beating fantasies as the source of masochism that would lead to the therapeutic focus on uncovering these fantasies in the curative process of psychoanalysis. This was to be a challenge to be taken up by his followers" (p. 9). This challenge is still in existence, as there is no general agreement as to the nature of the pathogenesis of this disorder. Conceptually, in the structural model of the mind, the close link between masochistic behavior and pleasureseeking has been

3 maintained, and masochism has ben viewed via compromise formation as an expression of the sexual and aggressive drives. Unconscious guilt played a particularly important role in this formulation since masochistic behavior was conceptualized as permitting, simultaneously, the gratification and the punishment for forbidden incestuous sexual impulses. However, once sexual and aggressive drives are no longer assumed to be the primary motives of all forms of psychopathology, a different view of this disorder emerges. In psychoanalytic self psychology, for example, analysis of selfobject transferences would indicate that the motivating forces in this disorder are related to efforts to "extract" validating and affirming responses from an environment that is being experienced as either indifferent, critical and/or withholding. Self psychology is not alone in postulating the genesis of self-defeating behavior (masochism) outside of drive psychology. Not only object relations theorists, but also many analysts who otherwise have given the dual drive theory primacy in the pathogenesis of other forms of psychopathology, have explained this particular character problem in terms of disturbed early parent-child relationship (Berliner, 1947), (1958); (Bergler, 1949); (Cooper, 1988); (Eidelberg, 1959). Whether the disorder has been conceptualized in terms of drive vicissitudes, that is, as an id and/or superego phenomenon (Fenichel, 1945); (Brenner, 1959); (Loewenstein, 1957); (Gero, 1962); (Bak, 1946), an ego defense and/or as a disturbed early object relationship (Berliner, 1947); (Menaker, 1953); (Bernstein, 1957); (Reich, 1933), determined the way the function of suffering as a characteristic of masochism was understood. Those who remained faithful to Freud's original formulation, prior to his introduction of the death instinct (Freud, 1920), explained the motive for the pain and suffering as a condition for the attainment of pleasure (Freud 1905), (1915), (1919); (Reich, 1933); (Reik, 1941) a view that preserved the pleasure principle as an important aspect of the libido theory. Authors who stressed the significance of early object relations, on the other hand,

4 understood the exhibitionistically displayed suffering to be either the function of a harsh superego (Bergler, 1949); (Cooper, 1988), or an appeal for love from a current love object, who is a transference stand-in for the originally frustrating or abusing one (Berliner, 1947), (1958). There appeared to be general agreement on one point only in the literature, the one made by Brenman (1952) when she demonstrated, with the help of a single but thoroughly analyzed case, that sadomasochistic behavior served multiple functions and that any one explanation fell short of the understanding of this very complex clinical picture. The agreement is obviously related to the fact that regardless of theoretical orientation, psychological symptoms can best be understood as final common pathways for a variety of anxieties. From a self-psychological perspective, such anxieties include the fear of enfeeblement, depletion, fragmentation, and disintegration. From infancy on, in response to various sources of anxiety, defensive reactions become progressively integrated into increasingly complex psychological structures; newly developing cognitive patterns and other psychological functions are drawn into this final common pathway. These complex defense organizations will employ whatever possibilities cognitive and other psychological functions afford for warding off threatening intrapsychic dangers (Wolff, 1960). The distinction between "pathological" and "adaptive" defenses had become blurred over time. From clinical observation and theoretical considerations, formulated primarily by Schafer (1968), Gill (1963), and Rapaport (1957), it would appear that, to the degree to which the defense organizations are automatic, unconscious, and walled off from the rest of the psyche, they should be considered pathological, but that, to the degree that they attain secondary-process attributes, they are adaptive and not different from other psychic functions. Though there is a fundamental difference in the way psychoanalytic self psychology conceptualizes the motives for defense, the theory of multiple functions

5 in relation to symptom and character formation is being maintained here as well. Here, too, symptoms and character pathology are viewed as becoming established by the clustering and layering of various defenses in response to various kinds of anxiety. When viewed from within the patients' perspective, these defense organizations perform the crucial function of holding a vulnerable and/or fragmentation-prone self together, albeit at the expense of considerable mental suffering, restrictions, and interpersonal difficulties in the patient's life. Defense and Resistance from the Patient's Perspective Kohut reaffirmed the central significance of empathy as the analyst's primary mode of listening and responding (Kohut, 1959) and placed this into the center of his subsequent theorizing (Kohut, 1971), (1972), (1977), (1980), (1984). Empathy, as a mode of observation attuned to the patient's subjective experiences first led him to the recognition of two new transference constellations, the idealizing transference and mirror transference (Kohut, 1971). The emphasis in these transferences is on the patient's experiencing the analyst as a selfobject: the recognition that the manner in which the analyst responds (or fails to respond) deeply affects the patient's momentary self-states. What becomes revived in these transferences are phase-appropriate developmental needs for affirmation, validation, and idealization. Selfobject transferences are not considered to be only repetitions, but to represent a need to resume a thwarted (derailed or arrested) development as well. The compulsion to repeat, here, is replaced with the dread that the old self-defeating patterns will be repeated and the analysis will not provide a chance for a "new beginning" (A. Ornstein, 1974). It is in the analytic process that the revived developmental needs and the habitual defenses related to them undergo the necessary transformation from their archaic to their more mature forms by being accepted, understood and explained, that is, interpreted and worked through

6 The reemphasis of the central significance of the analyst's empathic immersion in the patient's subjective experiences, and the recognition of new transference constellations, has implications for the conceptualization of defense and resistance analysis. In self psychology, defense organizations (and their behavioral correlates) are not viewed as constituting resistances against the uncovering of repressed infantile drive wishes. Rather, as indicated earlier, they are viewed as performing the crucial function of protecting a vulnerable self from further depletion and fragmentation. Kohut (1984) gives a detailed exposition of the self-psychological approach to defense and resistance analysis. He distinguishes this from the traditional approach in which defenses are interpreted as isolated mental mechanisms governed by the pleasure principle and interfering with the analyst's efforts to make the unconscious conscious. "Defense activities," he states "are undertaken in the service of psychological survival, that is, as the patient's attempt to save at least that sector of his nuclear self, however small and precariously established it may be, that he has been able to construct and maintain despite serious insufficiencies in the developmentenhancing matrix of the selfobjects of his childhood" (p. 115). Defenses here are viewed as protecting a defective self that will continue to develop from the time its development was interrupted. What Kohut does not say, but to him must have been self-evident, is that the defense organizations established in relation to infantile and childhood traumatic experiences become the foundations for the development of later psychopathology and appear in the analysis as aspects of the transference. With this view of the function of defenses, we have to ask ourselves: what forms will resistances take, and how do we interpret the unconscious defense elements which, on the one hand, were established to protect a vulnerable self and, on the other hand, constitute the most powerful obstacles to change? In traditional psychoanalysis, the view related to resistance has also undergone changes. When the aim of analysis was to

7 lay bare the infantile wishes that gave rise to symptoms, everything that interfered with this aim was considered resistance. Therefore, the defenses related to the repressed infantile wishes had to be overcome by all means. It was soon recognized, however, that the very effort of "removing" the defenses tended to increase the resistances against the work of the analysis. The ascendancy of ego psychology after 1923 and cumulative analytic wisdom ushered in a new period in psychoanalysis, that of "resistance analysis." However, since resistances were considered to be defenses as they became manifest in the analysis, they were interpreted primarily in their intrapsychic meaning. In other words, though resistances appeared in the context of the analytic relationship, their manifestations were still seen as being relatively independent of the vicissitudes of that relationship. This view of resistance has been challenged by Gill (1982). Because of its implication for technique, Gill has stressed that while defense is an intrapsychic concept, resistance is an interpersonal one. The view that resistances are codetermined by the analyst's verbal and nonverbal communications (by the analyst's tone of voice and by the phrasing and wording of the analyst's responses) can readily be shared by a selfpsychologically informed psychoanalyst. Specifically, when the analyst inadvertently repeats a genetically significant trauma, even in a relatively well established transference, disruptions may occur. It is at times of such disruptions that the patient's anxieties and the defenses related to them are particularly well exposed. Interpretations under these circumstances are most effective when they encompass both, the dynamic (here-and-now) as well as the genetic (there-and-then) sources of the patient's specific vulnerabilities and the defenses related to them. The reconstructive interpretations of the repeated and unavoidable disruptions serve various purposes: they facilitate the reestablishment of empathic attunement, deepen the analytic process, and provide insight

8 Since the selfobject transferences are established in relation to developmental arrests, the working-through process is not restricted to the attainment of insight. It also has to include the acquisition of psychic structures structures that are to increase self cohesion so as to make habitual defenses and symptomatic behavior less necessary. Kohut (1971) describes the impact of interpretations offered in relation to disruptions in the transference thus: "The meaningful recall of the relevant childhood memories and the ever-deepening understanding of the analogous transference experiences converge in giving assistance to the patient's ego, and the formerly automatic reactions become gradually more aim-inhibited and more under the control of the ego [This] working-through process leads to the accretion of psychic structure, just as happens in the transference neuroses as the result of analogous analytic work" (pp ). The Nature of Psychopathology as it Emerged in the Course of an Analysis The patient was a forty-two-year-old professional woman who was working in a management position at a large firm. She was married and had three teenage children. On the telephone, she sounded soft-spoken and somewhat hesitant, though she was quite definite that what she wanted was a psychoanalysis. Although she was in a responsible position with a very good salary, her appearance was strikingly modest: a simple cotton dress, worn-out shoes, no makeup. The patient decided on psychoanalysis because now that she had finally gotten a position she wanted and one that she liked, she realized she was totally incapable of experiencing contentment. She was chronically angry and chronically anxious. She usually started a project with enthusiasm, but sooner or later she became disillusioned and angry with everyone around her. She was a workaholic, which she thought of as an escape, since she was very unhappy in her marriage. She got up at five every morning, did not get home until eight at night, spent very little time with her children, and rarely ate a meal with them

9 Many hours were spent on the description of her work situation. These were, I thought, particularly revealing of the way in which she attempted to maintain relative stability in her personality organization. She would take on a great many assignments, would not ask for help, but deeply resented her colleagues for not offering to help. In business meetings she would rarely speak up; she sat in the background and listened to the discussions with contempt. When she did speak up, she felt that her ideas and recommendations never got proper attention. She considered her colleagues mostly incompetent and ill-willed. She was asked to leave three previous jobs because of her attitude and "failure to cooperate." These were incidents in which she would angrily expose her colleagues publicly for "mistakes" they had made. In describing these incidents, the patient spoke with poorly veiled rage in her voice and a great deal of indignation, "justifying" her attitude with her superior understanding of the issues at hand. What I heard in her descriptions was the shrill voice of a little girl who was not all that sure of herself, who feared her peers' judgment and was enraged at them for failing to reassure her and to appreciate her. But the patient could not listen to herself as yet; there was no evidence of self-reflection. Rather, she was eager to impress me with the injustices she suffered wherever she went, and the efforts she was making to please others without ever feeling appreciated. The complaints were repetitious and predictable, and I found myself resenting her efforts to have me join her in suffering for being an innocent victim in a cruel world. At such times, I was conscious of my effort to conceal my irritation. On the whole, however, I was able to maintain a fairly consistently empathic listening perspective. My responses, rather then being made in the form of repeated questions or categorical statements, were made in the form of open-ended statements that had a tentative quality. This facilitated the patient's capacity to get hold of nuances and subtleties of her subjective experiences. We

10 referred to this mode of communication as speaking in the "interpretive mode" (Ornstein and Ornstein, 1980), (1985). From the beginning, I hoped to convey that I was searching for an ever deepening understanding of the unique features of her subjective experiences, and that she was an active participant in this search (Schwaber, 1984). Feeling understood (or experiencing the analyst as making an effort to understand) enhances self-cohesion which permits the exploration of hitherto repressed or disavowed affects. Generally, this mode of communication, where the emphasis is on conveying understanding, facilitates introspection and appears to be optimal for the exploration of the unique and specific meanings patients give to their own behavior, and that of others. The unconscious elements in such an exploration appear to emerge relatively effortlessly as the interpretive work proceeds from within the patient's perspective, without confrontations. When the patient eventually asked herself: "Why am I toxic to others?", the question indicated that she felt safe enough to ask herself some questions, that she felt safe to be introspective. Sandler (1960) discusses the nature and origin of "background safety" in psychological existence. He suggests that it is the gradually increasing acuity of perception and reality testing that, in the course of development, "reduces anxiety, and thereby contributes to a background feeling within the ego, a feeling which can be referred to as one of safety or perhaps as security" (p. 353). "The feeling of safety," says Sandler, "is not connected a priori with ego boundaries or with the consciousness of self, but develops from an integral part of primary narcissistic experiences " (p. 354). The patient's increased sense of safety was indicated by her increasing ability to speak about some of the most painful aspects of her childhood. She spoke about her parents' heavy drinking and her mother's violent temper when drunk: "I really didn't know how bad it was when I was a child Mother always conveyed to me that there was something horribly wrong with me I never felt that I could be attractive My aunt

11 said I was an okay-looking kid. I saw pictures of myself, and I really did not look bad. But I struggled with this question all my life: who is the bad one? I always ended up feeling that it was me. I should have just cut her off, but I ended up protecting her " The patient was the oldest of three children; she had a sister and a brother. She remembered her mother pulling her hair when she did not clean the house to mother's specifications. She had one outstanding memory when her mother, in one of her drunken rages, locked the patient in the basement and, when she pounded on the door to be let out, mother pushed her down the stairs. She did not remember hating her mother as much as fearing her. She was a "good child," always did what was expected of her, except for one incident. Once, when her mother was systematically destroying some furniture, the patient pulled out a kitchen knife and was ready to attack her when her father intervened. The patient was a very good student. She thought that her scholastic achievements had sustained her through grade school and high school. In college, her grades dropped some because of what she now believed was a fairly severe depression. Most of the time, the patient entered the office with her head down, not looking at me. She would literally slide onto the couch. She came either exactly on time or a few minutes late, and frequently appeared out of breath. She rarely gave the previous hours any thought. Toward the end of the first year of analysis, in response to a relatively brief disruption, she commented that she was pleased she had missed me; it meant that "these hours" mattered to her. Should anything happen to me, she would not see another analyst; she would have to consider that as the expectable continuation of her "bad luck" in life. In the second year of the analysis the patient began to come later and later to her appointments. As I mentioned earlier, she never came early and always appeared in a hurry. This time,

12 however, she would be more than five minutes late, escalating to ten, and at times fifteen minutes. In her associations, she first focused on her difficulty in extricating herself from her work, later, on her fear that she would leave something undone and her colleagues or her customers would find fault with her this she feared above all else. It was this association, the fear that others would find fault with her, that alerted me to the possibility that being late was a response to her having perceived irritation in my voice. The irritation in my voice could well have represented a repetition of her mother "finding fault" with her and, possibly, her rages at the patient as well. The exploration of this possible reason for her lateness proved to be most fruitful. Yes, she said, she thought I was irritated with her; I must be angry, and disappointed in her. What scared her was her response to this: the impulse to leave the analysis. This, she said, would have been a repetition of her old pattern of behavior. With sadness in her voice, she added: "If I get mad at you too, there isn't much left." Was this a resistance against the repetition in the transference against uncovering the rage at her mother-analyst? Or was she dreading to repeat the old self-defeating pattern of behavior, should she experience rage? Her associations and her affect indicated the latter possibility. The lateness was not simply an expression of resistance against experiencing and expressing a negative affect. Rather, it appeared to be an unconscious solution to a conflict that was created by the analytic situation. This was a conflict between the archaic defense organizations (retaliating in response to a narcissistic injury in order to reestablish psychological equilibrium), and the relatively newly acquired capacity to reduce anxiety which had enabled her to delay action that, in the past, the patient experienced as imperative. Since such a conflict is specific to a particular analysis, its solution can best be conceptualized as a "transference symptom." Such transference symptoms are nodal points in the process of working through, as they contain elements of the

13 archaic defenses as well as the newly acquired psychic structures. Transference symptoms indicate changes that are taking place in the analysis; they represent a new beginning. In contrast to traditional psychoanalysis where working through has been viewed as a "wearing-away process," the time required to overcome fixations because of the "adhesiveness of the libido," and "the tendency to repeat" (Freud, 1914), the working through here is viewed as a process during which the newly developing psychological capacities enable patients to reduce anxiety, and thereby overcome symptomatic behavior. In traditional psychoanalysis, the desired changes in the course of analysis are expected to come about because " under the pressure of the positive transference and the synthetic function of the ego, the patient is motivated to seek new pathways of instinctual discharge which represent a modification of the earlier drive aims" (Stewart, 1963p. 487). In order for such changes to take place, the patient has to have reached the oedipal phase of development when the ego can be expected to have sufficient strength to bring about the desired changes once the pathogenic conflicts have been analyzed. However, in analyses where selfobject transferences are mobilized in relation to developmental arrests, newly developing psychic structures enter the working-through process: the simultaneous presence of the old and the new creates a conflict that finds a temporary solution in a transference symptom. In this case, the capacity to experience signal anxiety enabled the patient not to respond in her characteristic manner, more or less automatically, to narcissistic injury a response that, in the past, assured her of continued functioning, though at the expense of considerable mental suffering. This is, I believe, what Kohut (1984) meant when he said that "defense activities [are] undertaken in the service of psychological survival, that is, as the patient's attempt to save at least that sector of his nuclear self, however small and precariously established it may be, that he has been able to construct (Kohut, 1984p. 115)

14 At this time in my patient's analysis, an archaic selfobject transference was well established, and my analytic functions (acceptance, understanding, and explaining) had begun to be transmutedly internalized (Kohut, 1971), which brought about relative stability to her psychological equilibrium. This was still a transitional phase however, which, rather than reducing, had increased my importance to her. (See analogous developmental experiences discussed by Tolpin, 1971.) Perceiving irritation in my voice, and my failure to pay attention to her coming late for a while, filled her with dread; she dreaded the reexperiencing of the rage that could lead now, as in the past, to the permanent severance of the relationship. In my responses to her, I tried to address both aspects of her dilemma. I said that although she had been feeling better and appeared to be increasingly safer with me, that very sense of safety brought with it new fears: will these good feelings continue or did something happen here that could spoil it all? Coming late seemed to solve the problem for her, at least temporarily. Yes, she said, she has been feeling better, but thinking about the irritation in my voice made her very cautious, and she really could not trust me completely. She wondered whether she could ever trust anyone. "What does trusting someone completely mean to you?" I wondered. Her answer came swiftly: "Trusting means acceptance. I cannot see how you could accept me I hear you to be understanding, but that may well be your analytic attitude. You must have an opinion, and that cannot be good." Trusting someone, she said, meant to feel accepted as one is, not to be questioned and not to be corrected. How could anyone accept her that way when she could not accept herself: "If I wasn't what my mother wanted, how could I be what you may want or anybody else may want? My efforts to please others know no limits, but I never feel the job I do is good enough. I resent that I know that these are my expectations, but I still want others to recognize that I am doing a good job." She remembered how after she finished washing the dishes, her

15 mother would come and inspect them. If she found anything wrong with them, she would not say a word, but push the patient away from the sink and wash the dishes herself. I now heard the patient wondering more clearly how I or anyone could accept her unconditionally. I could better appreciate her deep conviction that I could not possibly accept her as she was after all, she experienced herself as an angry, anxious, and disagreeable woman. This was why she thought I would not resent but welcome her lateness: "I thought you may enjoy not having to see me You may feel relieved when I am not here This feeling goes along with my not feeling wanted by anyone, any place This is the feeling that makes me feel alone. Did I want to get you angry with me? I can't feel that But I thought that what I am doing here is not right That I am not right I expected you to say that the way I do the analysis was not getting us anywhere and that I ought to quit." After some thought, she added: "Should that actually happen, if you did become really annoyed with me and asked me to quit, I would be outraged, but then I would no longer know that I had provoked that in any way." The patient's associations here are significant as they reveal the most painful aspect of her emotional life: a deep sense of inferiority, the feeling that there was something profoundly wrong with her; that in her very essence, she was unacceptable and unlikable. The behavior that defensively accompanies such feelings (haughtiness and a chronic sense of indignation for being wronged) ordinarily provokes either rejection, criticism, or indifference from the environment. In traditional psychoanalytic theory, this pattern of behavior has been understood to be in the service of securing punishment for unconscious guilt. Since sadism was considered to be primary in this disorder, it was postulated that unconscious guilt was created by turning sadism inward and through complexly layered beating fantasies to give rise to masochism. As a compromise, masochism was considered to be the final common pathway for the expression of incestuous sexual wishes as well as for the original sadistic fantasies of the young child

16 Based on the analysis of selfobject transferences, in psychoanalytic self psychology such behavior is understood as protecting a vulnerable self from retraumatization, fueled by a deeply repressed need for unconditional acceptance, affirmation, and validation. These transference needs, and the peremptory, retaliatory nature of the rage that accompanies their actual or anticipated frustration, renders patients oblivious to the impact their behavior may have on others. Expectedly, in her everyday interactions, the patient was frustrated repeatedly in her attempt to exact recognition and praise for her business skills. Rather, the opposite would occur: the disguised manner in which she expressed narcissistic rage over the frustration of these expectations had alienated many of her coworkers and had resulted in her dismissal from several jobs. It is the rage associated with the actual or expected frustration for unconditionsl acceptance that Berliner (1958) describes as "the aggressive attitude" of the masochist, which he considers to be a highly disguised expression of sadism. This sadism, Berliner states, is secondary to the masochist's "bid for affection of a hating object in a transference situation" (Berliner, 1958pp ; italics added). It is also my view that sadism in this context is not the product of the unmitigated aggressive drive, but the expression of chronic narcissistic rage for being repeatedly frustrated in relation to a transference need to be accepted, valued, and appreciated. "The aggressive attitude" has two simultaneous functions. On the one hand, it is a demand for acceptance and appreciation, not different from a child's angry demandingness when the environment is not spontaneously responsive to these developmental needs. On the other hand, anticipating the frustration of these transference needs, the aggressive attitude is also retaliatory in nature. Narcissistic rage is characterized by an imperative need for revenge (Kohut, 1972); "holding grudges" and "collecting injustices" are another way of expressing the unrelenting demand "to right the wrong," to undo the

17 psychic pain caused by the present-day transference objects' failure to express their appreciation for who one is and what one does. For example, I understood my patient suddenly and unexpectedly exposing her colleagues' incompetence publicly as such an unconscious sadistic act, an act of revenge for feeling unappreciated and dismissed by them. In the analysis, the revenge is a response to feeling misunderstood, dismissed, or to the analyst's irritation or indifference. This is a prime example of an effort to turn a passively endured childhood experience into active mastery in adult life. In this case, the irritation in my voice and that I had not noticed her lateness threatened to reactivate the patient's habitual ways of reacting to narcissistic injuries. Coming late to the appointments constituted a compromise: by controlling the level of interaction between us, she was able to avoid experiencing the need for revenge and thereby permanently sever the analytic relationship. In the context of working through the meaning of the transference symptom, the patient began to take a closer look at other aspects of her life, including her reasons for working up to hours a day and not leaving any time for some longed-for recreation. As we examined the function this work schedule had in the maintenance of her psychic equilibrium, her memory went back to her school experiences when her sense of mastery and good feelings about herself were derived almost exclusively from successfully accomplishing a particularly challenging task. She felt very much the same way now when she was able to solve a difficult problem on her job. She asked me: "Can you believe that as miserable as I feel, and as much as I wish to change, I am also afraid to change? If I don't work so hard there would be nothing that could make me feel good about myself." Since the patient's self-esteem depended almost exclusively on her accomplishments in her work, any change in the compulsive manner in which she tried to excel constituted a threat to the precarious maintenance of her self-esteem

18 With the clarification of the transference symptom, the clinical picture attained greater clarity. Sitting in the background in meetings and feeling angry and unappreciated, staying away from her family and staying away from the analyst, had a common root: they all expressed the same fear that her need for recognition and unconditional acceptance would not be met, that she would then feel the same anger and disappointment she had always felt, that her rage would eventually surface and find expression either in exposing "the frustrating other" in a subtle but cutting manner, or that she would withdraw in rage and indignation. In either case, the imperative need to take revenge in order to "right the wrong" would result in the perpetuation of her characterological difficulties. Discussion The close link between development of the self and development of selfdefeating behavior disorder has been noted by others. Stolorow (1975), for example, considers "masochistic activities to serve as abortive efforts to restore, repair, buttress and sustain a self-representation that had been damaged and rendered precarious by injurious experiences during the early preoedipal era, when the self-representation is developmentally most vulnerable" (p. 442). I agree with Stolorow that the self "had been damaged and rendered precarious," and the patient's efforts at "restoring, repairing, buttressing and sustaining" her "self-representation" did not succeed. But I wish to stress that the chronic narcissistic rage and its behavioral consequences further undermine an already severely damaged self-esteem regulatory system. Bergler (1949) and Cooper (1988), too, consider masochism to be part of narcissistic development and therefore part of the "self-esteem system." They see the problem as related to the infant's frustration at having to give up omnipotence

19 (Bergler), and to the inevitable frustrations associated with separationindividuation (Cooper). Since these are aspects of normal development, these authors do not postulate that masochism and sadism are the outcome of "injurious" or untoward childhood experiences. In other words, Bergler and Cooper consider normal development as sufficiently hazardous in itself; they see no need to postulate injurious experiences that may be specifically pathogenic for the development of this form of psychopathology. Maybe "narcissistic-masochistic tendencies" are compatible with normal development, but I believe that, in the clinically significant forms, something had to go wrong developmentally to produce this clinical picture. Under optimal circumstances, the infantile narcissistic structures omnipotence, grandiosity, and exhibitionism rather than constituting the foundation of low self-esteem, self-abuse, repressed rage, and guilt, are the narcissistic infantile structures that can account for the development of the capacity to regulate affect and anxiety and to experience pride and pleasure in the self and its activities. The fate of these infantile narcissistic structures depends on the availability of an empathically responsive selfobject environment, an environment that is expected to be responsive to the infant's and child's developmental needs for affirmation and validation. When these needed responses are not forthcoming, or not reliably so, we witness the emergence of behavior that indicates the presence of low self-esteem, narcissistic vulnerability, poor impulse control, and other signs of a poorly consolidated self. Complex defense organizations as we see them in selfdefeating behavior are unlikely to become established in relation to the anger and guilt the child may feel toward the ordinarily frustrating parent. This is more likely to occur in relation to caretakers who fail to provide phaseappropriate selfobject functions functions responsible for the transformation of the infantile narcissistic structures. Phase-appropriate selfobject responsiveness assures the development of a well structuralized and cohesive self which

20 is capable of experiencing affects of various kinds with various levels of intensity, as well as use signal anxiety effectively. Hypothetically, the personality disorder we call sadomasochism or selfdefeating behavior in the adult can be related to two different but interrelated forms of childhood (strain) traumatic experiences. In one, the child experiences his emotional environment as indifferent; the child does not feel valued and appreciated for his uniqueness. Under these circumstances, little or no transformation of infantile grandiosity and exhibitionism can take place, leaving the individual permanently hungry for affirmation. In my patient's case, for example, infantile grandiosity (feeling superior to her colleagues) continued to exist side by side with her profound sense of inferiority. The clinical picture here was characterized by low self-esteem and narcissistic vulnerability, and the personality disorder that developed was predominantly "masochistic." The second form of strain trauma is one in which not only the developmentally needed selfobject responsiveness may be missing, but in which the patient as a child may have experienced mistreatment and abuse situations where the child experienced the emotional environment as unpredictable, volatile, and violent. The eventually developing clinical picture here is likely to be dominated by sadism. REFERENCES BAK, R Masochism and paranoia Psychoanal. Q. 15: [ ] BERGLER, E The Basic Neurosis, Oral Regression and Psychic Masochism New York: Grune & Stratton. BERLINER, B On some psychodynamics of masochism Psychoanal. Q. 16: [ ] BERLINER, B The role of object relations in moral masochism Psychoanal. Q. 27:38-56 [ ] BERNSTEIN, I The role of narcissism in moral masochism Psychoanal. Q. 26: [ ] BRENMAN, M On teasing and being teased: on the problem of moral masochism Psychoanal. Study Child 8: [ ] BRENNER, C The masochistic character: genesis and treatment J. Am. Psychoanal. Assoc. 7: [ ]

21 COOPER, A The narcissistic masochistic character In Masochism ed. R. Glick & D. Meyers. Hillsdale, N.J.: Analytic Press, pp EIDELBERG, L Humiliation in masochism J. Am. Psychoanal. Assoc. 7: [ ] FENICHEL, O The Psychoanalytic Theory of Neurosis New York: Norton. FREUD, S Three essays on sexuality S.E. 7 [ ] FREUD, S Recollecting, repeating and working through S.E. 12 [ ] FREUD, S Instincts and their vicissitudes S.E. 14 [ ] FREUD, S A child is being beaten S.E. 17 [ ] FREUD, S Beyond the pleasure principle S.E. 18 [ ] FREUD, S Inhibitions, symptoms and anxiety S.E. 20 [ ] Gero, G Sadism, masochism, and aggression: their role in symptom formation Psychoanal. Q. 31:31-42 [ ] GILL, M. M Topography and Systems in Psychoanalytic Theory Psychol. Issues, Monogr. 10. New York: Int. Univ. Press. GILL, M. M Analysis of the Transference Psychol Issues, Monogr. 53. New York: Int. Univ. Press. GLICK, A. & MEYERS, D. Eds Masochism Hillsdale, N.Y.: Analytic Press. KOHUT, H Introspection, empathy, and psychoanalysis: an examination of the relation between mode of observation and theory In The Search for the Self vol. 1 ed. P. Ornstein. New York: Int. Univ. Press, pp [ ] KOHUT, H The Analysis of the Self New York: Int. Univ. Press. [ ] KOHUT, H Thoughts on narcissism and narcissistic rage Psychoanal. Study Child 27: [ ] KOHUT, H The Restoration of the Self New York: Int. Univ. Press. [ ] KOHUT, H Summarizing reflections In Advances in Self Psychology ed. A. Goldberg. New York: Int. Univ. Press, pp [ ] KOHUT, H How Does Analysis Cure Chicago: Univ. Chicago Press. [ ] LOEWENSTEIN, R. M A contribution to the psychoanalytic theory of masochism J. Am. Psychoanal. Assoc. 5: [ ] MENAKER, E Masochism a defense reaction of the ego Psychoanal. Q. 22: [ ] ORNSTEIN, A The dread to repeat and the new beginning: a contribution to the psychoanalytic treatment of narcissistic personality disorders Annual Psychoanal [ ] ORNSTEIN, P. H. & ORNSTEIN, A Formulating interpretations in clinical psychoanalysis Int. J. Psychoanal. 61: [ ] ORNSTEIN, P. H. & ORNSTEIN, A Clinical understanding and explaining: the empathic vantage point Progress in Self Psychol [ ] RAPAPORT, D Cognitive structures In Collected Papers of David Rapaport ed. M. M. Gill. New York: Basic Books. REICH, W Character Analysis New York: Orgone Press. REIK, T Masochism and Modern Man New York: Farrar & Rinehart. SANDLER, J The background of safety Int. J. Psychoanal. 41: [ ] SCHAFER, R The mechanisms of defence Int. J. Psychoanal. 49:49-61 [ ] SCHWABER, E Empathy: a mode of analytic listening In Empathy Vol. 2 ed. J. D. Lichtenberg, M. Bornstein & D. Silver. Hillside N.J.: Analytic

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23 STEWART, W. A An inquiry into the concept of working through J. Am. Psychoanal. Assoc. 11: [ ] STOLOROW, R The narcissistic function of masochism (and sadism) Int. J. Psychoanal. 56: [ ] TOLPIN, M On the beginning of the cohesive self Psychoanal. Study Child 26: [ ] WOLFF, P. H The Developmental Psychologies of Jean Piaget and Psychoanalysis Psychol. Issues, Monogr. 5. New York: Int. Univ. Press

24 Article Citation [Who Cited This?] Ornstein, A. (1991). The Dread to Repeat: Comments on the Working- Through Process in Psychoanalysis. J. Amer. Psychoanal. Assn., 39: