THE SYNTHESIS OF SELF. VOLUME 2 IT ALL DEPENDS ON HOW YOU LOOK AT IT Development of Pathology in the Cohesive Disorders

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1 THE SYNTHESIS OF SELF VOLUME 2 IT ALL DEPENDS ON HOW YOU LOOK AT IT Development of Pathology in the Cohesive Disorders

2 THE SYNTHESIS OF SELF Roy M. Mendelsohn, M.D. Volume 1 THE I OF CONSCIOUSNESS: Development from Birth to Maturity Volume 2 Volume 3 IT ALL DEPENDS ON HOW YOU LOOK AT IT: Development of Pathology in the Cohesive Disorders BELIEVING IS SEEING: Pathology of Development in the Noncohesive Disorders Volume 4 THE PRINOPLES THAT GUIDE THE IDEAL THERAPIST

3 THE SYNTHESIS OF SELF VOLUME 2 IT ALL DEPENDS ON HOW YOU LOOK AT IT Development of Pathology in the Cohesive Disorders ROY M. MENDELSOHN, M.D. PLENUM MEDICAL BOOK COMPANY NEW YORK AND LONDON

4 Mendelsohn, Roy M. The synthesis of self. Library of Congress Cataloging in Publication Data Contents: v. 1. The I of consciousness-v. 2. It all depends on how you look at itv. 3. Believing is seeing-[etc.] Includes bibliographies and index. 1. Self. 2. Psychology, Pathological. 3. Psychotherapy. I. Title. [DNLM: 1. Consciousness. 2. Personality Disorders. 3. Psychoanalytic Theory. 4. Psychoanalytic Therapy-methods. WM 190 M537s] RC455.4.S42M ISBN-13: e-isbn-13: DOl: / Plenum Publishing Corporation Softcover reprint of the hardcover 1st edition Spring Street, New York, N.Y Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical. photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

5 To my teachers: my family who taught me to love, Missy who taught me about autonomy, Rebel who taught me about life, and my patients who taught me what to write

6 Overview of The Synthesis of Self This series consists of four volumes. Volume 1 addresses healthy development, moving from the earliest, most primitive stages to the most advanced stages, culminating in a picture of the genital character. The therapeutic progress of an autistic child is presented to illustrate the various developmental steps negotiated during the course of his treatment, supplemented by clinical material from others demonstrating similar points. Volumes 2 and 3 address the pathological consequences of an inability to negotiate specific developmental tasks, moving from those with the most advanced psychic organization to those with the most primitive, culminating in a description of the autistic disorders. There was a natural division into two volumes owing to the crucial significance of cohesiveness for determining the conditions necessary to facilitate constructive growth. Some clinical material from Volume 1 is used to bring out the full picture of the pathology, which had only been alluded to in the earlier volume because of its focus on healthy processes. Volume 4 addresses the basic principles of psychoanalytic treatment and their applicability across the broad spectrum of pathology, moving from the most primitive autistic disorders to the most advanced hysterical disturbances, to explicate the essence of the principles and their evolution into a classical psychoanalytic posture. Some clinical material from Volumes 1-3 is included to demonstrate the effects of the therapeutic relationship-when guided by the basic psychoanalytic principles in accordance with their essential nature-on both healthy and pathological processes. vii

7 viii OVERVIEW The use of several patients' psychic productions throughout the series of four volumes illuminates the interweaving of healthy and pathological forces operative in a given individual, highlights their significance in guiding a therapist toward conducting a growth-promoting therapeutic relationship, and provides a thread of continuity connecting health, pathology, and treatment. St. Louis Roy M. Mendelsohn, M.D.

8 Preface The oedipal situation involves much more than an instinctual attitude toward a prohibited object giving expression to unconscious wishes. It introduces a whole new way of perceiving the internal and external world and an entirely different orientation to the myriad of life's experiences. A great deal of structural development, requiring the negotiation of a sequence of early developmental tasks, has to have taken place before it is possible to encompass the complex demands of an oedipal attitude. When these early steps are not negotiated, although genital instinctual impulses may be manifested, the structural alignments necessary to enter into an oedipal position cannot be effected and the intrapsychic conflicts it engenders are not encountered. The thrust of early development has made it essential for a narcissistic perspective to be adopted toward all stimuli and all relationships in order to enable continuing self-expansion. All attachments must of necessity be based upon the narcissistic supplies they contain, which ultimately lead to increasing levels of independence, self-differentiation, and individuation. It is precisely when the component instincts are consolidated into a genital drive that a narcissistic orientation can no longer incorporate the representation of experiences needed for the full realization of self-potentials. Were stimuli to only possess significance in regard to their narcissistically enhancing attributes, the resulting dependence upon the external world would run counter to the thrust for independence and autonomy. The transition from narcissism to object relatedness is equally a transition from needing to be loved by an object to developing the capacity to be en- IX

9 X PREFACE hanced by loving an object. This places separateness and autonomy on a more solid and independent basis, allowing greater freedom in object choice and a more complete realization of dormant mental functions. The oedipal situation presents a potential pathway for fulfilling this developmental task by organizing a new level of psychic structuralization that enables the unseen dimensions of experience to be represented, adding richness to love relationships and broadening the autonomous functions of the ego. The hysteric and obsessive have been able to manage the transition to object relatedness with an inordinate degree of conflict, leaving infantile attachments that if unchanged will interfere with continuing progression. The phobic remains fixated in the transitional phase, with the oedipal situation representing an overwhelming demand. This volume presents an in-depth study of psychological disturbances in the cohesive personality, signifying that the self- and object systems of representation are structurally united and differentiated, continuity of experience is established, and repression proper functions as the major ego defense. The effects of a lack of synchrony in stage and phase specificity during the pregenital period are explored, and the pathology manifested with the formation and lack of resolution of an oedipal conflict is explicated. The relationship of character defenses to character pathology in the obsessive and hysteric is defined, and the significance of symptom formation illuminated. Discussion of the phobic disorders is particularly relevant because it clarifies an area clouded with uncertainty. Through an exposition of the nature of the unstable structures maintaining cohesiveness, the shifting positions, from exhibiting threats to self integrity to representing instinctual dangers are explained, reflecting the difficulty in negotiating the transition from narcissism to object relatedness. The role of the fixation points in creating distortions when defensively maintained is delineated, highlighting the foundation on which pregenitally determined character attitudes and defenses against the transference are constructed. The pathological consequences of an inordinately conflicted oedipal situation are revealed in the overdeveloped incestuous fantasies expressive of defense transferences, the dangers associated with primal scene fantasies expressive of the transference, and the immature level of superego

10 PREFACE Xl consolidation expressed through harsh prohibitions and a polarization of functions. The differences between hysteric and obsessive configurations are portrayed, and the relationship of character pathology to symptom formation is described. The phobic disorders are referred to as narcissistically determined and object related; they are the equivalent of cohesive, narcissistic personality disorders and exist on a fluctuating continuum of pathology. The underlying basis for the phobic attitude toward the influences of a bad object and toward instinctual overstimulation is presented. The hysteric, obsessive, and phobic disorders have all advanced sufficiently to move toward an object-related orientation, but this orientation has been unsuccessful to a greater or lesser degree in mastering its demands. St. Louis Roy M. Mendelsohn, M.D.

11 Contents Introduction... 1 The Genital Character... 3 Hysteria... 4 The Obsessive Disorders The Narcissistically Determined, Object-Related Disorders: The Phobias Chapter 1. The Cohesive Disorders... : 35 Introduction A Definition of Cohesiveness The Significance of Object-Related Perceptions The Development and Function of Fixation Points The Object-Related Neurotic Disorders: Hysteric and Obsessive Pathologies The Narcissistically Determined Object-Related Disorders: Phobic Pathology Chapter 2. Hysterical Symptom Formation and Hysterical Character Pathology: Preoedipal Determinants Introduction: Symptom Formation The Fixation Points in the Development of the Hysteric.. 54 The Grandiose Self and Ego Ideal in the Hysteric The Nature of Reaction Formations xiii

12 XIV CONTENTS The Preconditions for a Genital Organization and Their Effects upon the Oedipal Conflict The Defensive Significance of Hysterical Symptoms and of Hysterical Character Pathology Chapter 3. Hysterical Symptom Formation and Hysterical Character Pathology: Oedipal Determinants Introduction: Castration Anxiety and the Oedipal Conflict 67 The Influence of Early Development upon the Structure of Castration Anxiety and the Oedipal Conflict The Oedipal Conflict in Hysteria The Defensive Organization in the Hysteric The Status and Significance of Object-Related Perceptions in the Hysteric The Effects of Hysteric Development upon Thinking, Perception, and Adaptation Some Implications for Treatment Depression in the Hysteric Chapter 4. Hysterical Symptom Formation and Hysterical Character Pathology: Clinical Material Clinical Material Discussion The Structural Foundation of Thought in Hysteria The Structural Foundation of Thought in Other Disorders 102 Chapter 5. Obsessive Character Pathology and Obsessive Symptom Formation: Preoedipal Determinants.... Introduction-The Role of Aggression.... Early Influences in the Development of the Obsessive.... The Differentiating Structures Maintaining Cohesiveness The Fixation Points in the Obsessive The Nature of Reaction Formations The Effects of the Obsessive's Development upon Thinking, Perception, and Adaptation

13 CONTENTS XV Chapter 6. Obsessive Character Pathology and Obsessive Symptom Formation: Oedipal Determinants Introduction-The Anal Influence in Obsessive Disorders 119 The Preconditions for the Oedipal Conflict and the Structure of Castration Anxiety The Oedipal Conflict in the Obsessive The Oedipal Conflict in the Male The Oedipal Conflict in the Female The Significance of Obsessive Character Pathology The Significance of Obsessive Symptoms The Significance of the Defensive Organization of the Obsessive Depression in the Obsessive Chapter 7. Obsessive Character Pathology and Obsessive Symptom Formation: Clinical Material Clinical Material Discussion Behavior as a Reflection of Character: A Comparison with Hysteria The Structure of Thought in the Obsessive Chapter 8. The Narcissistically Determined Object Related Disorders: The Phobias. Pregenital Determinants Introduction Early Influences in the Development of the Phobias The Grandiose Self and Ego Ideal in the Phobic Separation-Individuation, Cohesiveness, and the Formation of Differentiating Structures The Effect of the Absence of Reaction Formations The Composition of the Self- and Object Representational Systems in the Phobias The Fixation Points and Their Relationship to Phobic Symptoms

14 XVI CONTENTS Chapter 9. The Narcissistically Determined Object Related Disorders: The Phobias. The Significance of the Oedipal Situation Introduction: The Conditions Necessary for a Shift from Narcissism to Object Relatedness The Preconditions for Object Relatedness in the Phobias The Status of Internal Regulation in the Phobias... " 175 The Relationship of the Fixation Points to a Genital Consolidation The Nature of the Oedipal Conflict The Threat of Loss of Cohesiveness Depression in the Phobic Disorders Chapter 10. The Narcissistically Determined Object Related Disorders: The Phobias. Clinical Examples and Discussion Introduction The Object Phobias The Self-Phobias The Combined Self- and Object Phobias Summary The Structure of Thought in the Phobic Disorders Chapter 11. The Cohesive Disorders: A Comparison The Self-Representational System The Genital Character The Hysterias The Obsessives The Phobias The Object Representational System... " 215 The Genital Character The Hysterias The Obsessives The Phobias Self-Object Need

15 CONTENTS xvii The Genital Character The Hysterias The Obsessives..., 219 The Phobias The Nature of Anxiety and Repression The Genital Character The Hysterias The Obsessives The Phobias The Conflict-Free Sphere The Genital Character The Hysterias The Obsessives The Phobias Transference The Genital Character The Hysterias The Obsessives..., 224 The Phobias The Conscious and Preconscious Systems The Genital Character The Hysterias The Obsessives The Phobias Drive Development The Genital Character The Hysterias The Obsessives The Phobias Regression in the Service of the Ego The Genital Character The Hysterias The Obsessives The Phobias..., 228 Reality Testing (The Fixation Points) The Genital Character The Hysterias The Obsessives The Phobias

16 xviii CONTENTS The Ego (The Process of Play) The Genital Character The Hysterias The Obsessives The Phobias The Id (Processes of Love) The Genital Character The Hysterias The Obsessives The Phobias The Superego (The Process of Work) The Genital Character The Hysterias The Obsessives The Phobias Conscious Motivation for Treatment The Genital Character The Hysterias The Obsessives The Phobias Unconscious Motivation for Treatment The Genital Character The Hysterias The Obsessives The Phobias Complaints The Genital Character The Hysterias The Obsessives The Phobias References Index

17 Contents of Other Volumes Volume 1 The I of Consciousness: Development from Birth to Maturity Introduction Chapter 1. Body Ego Experience and the Nuclear Self: The Onset of Unconscious Perception Chapter 2. The Qualities of Perceptual Experience and Object Impressions: The Self- and Object Representational Systems Chapter 3. Libido as Object Seeking and the Mechanism of Splitting: An Integration of Libidinal and Object Relations Theory Chapter 4. Separation-Individuation: The Formation of New Psychic Structures Chapter 5. The Onset of Cohesiveness: The Formation and Function of the Grandiose Self and the Ego Ideal XIX

18 XX CONTENTS OF OTHER VOLUMES Chapter 6. The Pregenital Phases of Psychosexual Development: The Evolution of Focused Perceptual Functions and Boundaries and the Preconditions for the Establishment of an Oedipal Conflict Chapter 7. The Oedipal Conflict as a Psychic Organizer Chapter 8. The Resolution of the Oedipal Conflict: The Consolidation of the Superego into an Independently Functioning Agency and the Process of Alteration in the Fixation Points Chapter 9. Significance of the Latency Period Chapter 10. Relinquishing the Attachment to Primary Infantile Objects and Their Replacement with New Objects Chapter 11. The Final Step to Maturity: The Genital Character References Index Volume 3 Believing Is Seeing: Pathology of Development in the Noncohesive Disorders Introduction Chapter 1. The Borderline Personality: The Inability to Negotiate Separation-Individuation Chapter 2. The Borderline Personality: Differentiation in the Absence of Cohesiveness

19 CONTENTS OF OTHER VOLUMES xxi Chapter 3. The Borderline Personality: Distortions in the Structural Foundation of Character Chapter 4. The Schizophrenias: The Inability to Negotiate a Psychological Symbiosis Chapter 5. The Schizophrenias: The Three Stages of Pathology Chapter 6. The Schizophrenias: The Significance of the Basic Schizophrenic Process Chapter 7. The Schizophrenias: The Significance of a Schizophrenic Break, the Ensuing Process of Repair, and the Fate of Splits in the Self Chapter 8. The Autistic Disorders: The Difficulty in Negotiating an Entry into a Psychological Symbiosis Chapter 9. Chapter 10. The Autistic Disorders: Primary and Secondary The Noncohesive Disorders: A Comparison References Index Volume 4 The Principles That Guide the Ideal Therapist Introduction Chapter 1. The Basic Principles of Psychoanalysis and the Holding Environment Chapter 2. The Basic Principles of Psychoanalysis and the Transference

20 XXll CONTENTS OF OrnER VOLUMES Chapter 3. Chapter 4. Chapter 5. The Autistic Disorders The Schizophrenias The Borderline Personality Chapter 6. The Narcissistically Determined, Object-Related Disorders: The Phobias Chapter 7. Chapter 8. Chapter 9. Chapter 10. The Neuroses The Obsessive Neuroses The Hysterical Neuroses An Overview References Index