Inside Out and Outside In: Psychodynamic Clinical Theory and Psychopathology in Contemporary Multicultural Contexts [5 ed.] 9781538125458, 9781538125465, 9781538125472

Citation preview

Praise for the previous editions “Inside Out and Outside In is a rare and stellar example of how to make an outstanding textbook even better. This exceptional classic work has been updated for the DSM-5, is inclusive of a wide range of diagnostic categories, provides rich examples representing all aspects of diversity, and showcases the application of contemporary psychodynamic theories at their finest.” —Carole Tosone, New York University Silver School of Social Work, editor-in-chief of Clinical Social Work Journal “In this era in which clinical training is experiencing such significant pressure, this is an indispensable, accessible book, connecting contemporary generations of social workers to key aspects of our theoretical and conceptual legacy and knowledge base, while underscoring and honoring our profession’s historical focus on social justice and intersectionality.” —Caroline Rosenthal Gelman, Silberman School of Social Work at Hunter College, City University of New York “This volume’s continuing attention to our inside lives, ‘outside’ lives, and the interplay of the two is enhanced by its ever-increasing attention to multiple dimensions of diversity. Written for helping professionals, it is the best and most accessible resource I know of for learning about the major lines of psychodynamic thinking from its origins to the present, with case examples from practice throughout.” —Jeane W. Anastas, New York University Silver School of Social Work, past president of the National Association of Social Workers “Comprehensive in its breadth of clinical theories, with meaningful critique and application of the cross-cultural dimension, this work is invaluable to clinical training and education. It is not only useful for the beginning clinician but also an important reference for the more seasoned professional.” —Mario L. Starc, Sanville Institute for Clinical Social Work and Psychotherapy

Inside Out and Outside In Psychodynamic Clinical Theory and Psychopathology in Contemporary Multicultural Contexts Fifth Edition

Edited by Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz

ROWMAN & LITTLEFIELD

Lanham • Boulder • New York • London

Acquisitions Editor: Mark Kerr Assistant Editor: Courtney Packard Sales and Marketing Inquiries: [email protected] Credits and acknowledgments for material borrowed from other sources, and reproduced with permission, appear on the appropriate pages within the text. Published by Rowman & Littlefield An imprint of The Rowman & Littlefield Publishing Group, Inc. 4501 Forbes Boulevard, Suite 200, Lanham, Maryland 20706 www.rowman.com 6 Tinworth Street, London SE11 5AL, United Kingdom Copyright © 2022 by The Rowman & Littlefield Publishing Group, Inc. Fourth edition copyright © 2016 by Rowman & Littlefield All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without written permission from the publisher, except by a reviewer who may quote passages in a review. British Library Cataloguing in Publication Information Available Library of Congress Cataloging-in-Publication Data Names: Berzoff, Joan, editor. | Flanagan, Laura Melano, editor. | Hertz, Patricia, editor. Title: Inside out and outside in : psychodynamic clinical theory and psychopathology in contemporary multicultural contexts / edited by Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz. Description: Fifth edition. | Lanham : Rowman & Littlefield Publishing Group, [2021] | Includes bibliographical references and index. | Summary: “The fifth edition of ‘Inside Out and Outside In’ is an up-to-date and essential resource for mental health professionals and students practicing in today’s increasingly complex environment”— Provided by publisher. Identifiers: LCCN 2020054182 (print) | LCCN 2020054183 (ebook) | ISBN 9781538125458 (cloth) | ISBN 9781538125465 (paperback) | ISBN 9781538125472 (epub) Subjects: LCSH: Psychodynamic psychotherapy. | Personality development. | Psychoanalytic interpretation. | Psychology, Pathological. Classification: LCC RC489.P72 B47 2021 (print) | LCC RC489.P72 (ebook) | DDC 616.89/14—dc23 LC record available at https://lccn.loc.gov/2020054182 LC ebook record available at https://lccn.loc.gov/2020054183

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Contents

Acknowledgments

vii

  1  Why a Biopsychosocial Context? Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz

1

  2  Drive and Beyond: Freud’s Psychoanalytic Concepts Joan Berzoff and Gerald Schamess

14

  3  Ego Psychology Gerald Schamess and Robert Shilkret

47

  4  Psychosocial Ego Development: The Theory of Erik Erikson Joan Berzoff

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  5  Object Relations Theory Laura Melano Flanagan

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  6  The Theory of Self Psychology Laura Melano Flanagan

125

  7  Relational and Intersubjective Theories Joan Berzoff

152

  8  Attachment Theory Cynthia J. Shilkret and Robert Shilkret

169

  9  Neurobiology, Attachment, and Trauma Janet Shapiro

188

10  Psychodynamic Theories and Gender Joan Berzoff

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Contents

11 Psychodynamic Contributions to Understanding Racism: Implications for Clinical Practice Brian Rasmussen and Ann Marie Garran 12  The Bridge: From Theory to Practice Patricia Hertz, Laura Melano Flanagan, David S. Byers, and Joan Berzoff

217 233

13 The Psychoses, with a Special Emphasis on Schizophrenia Spectrum Disorders Patricia Hertz

247

14 Personality Disorders, with a Special Emphasis on Borderline and Narcissistic Syndromes Patricia Hertz and Meg Hertz

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15 Mood Disorders, with a Special Emphasis on Depression and Bipolar Disorders Joan Berzoff, Teresa Méndez, and Daniel Buccino

312

16  Anxiety and Its Manifestations Joan Berzoff and Susan Pasco

346

17  Trauma Theories and Disorders Kathryn Basham

371

18  Some Final Thoughts Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz

404

References

407

Index

435

About the Contributors

443

Acknowledgments

This fifth edition of Inside Out and Outside In has been a pleasure to write, largely because of the very enthusiastic responses of so many students and colleagues around the country and because the three coauthors who have coedited and coauthored this book have shared such similar clinical, social, and theoretical sensibilities with one other, and with you, the reader. We have enjoyed the ongoing process of trying to make this work even more biopsychosocial and hope that this edition surpasses the first four in doing so. With each edition, we have added new psychological social and biological content, and have been especially committed to doing so in this time of so many disenfranchised voices being raised, including those from the Black Lives Matter movement. The person who deserves my greatest thanks is Lew Cohen, my husband, dearest friend, co-parent, and co-grandparent. He has been a steadfast and loving support, whose prodigious accomplishments have taken us all over the world: to lecture, to write, and to travel. Somehow, from the beginning of this book in 1989 to the present, we have raised two wonderful children, now men, all the while wondering, “What did we do right?” Those children, now parents, are sources of inspiration, pleasure, and humor, and their childhood experiences serve as models of development interwoven into the pages of this book. As men, Zeke is a city councilman and Jake an educational consultant. Both are leaders, activists, and educators who are joyful, creative, and kind. Zeke brought us Reena Ardeshna, a funny, loving, and wise psychiatrist, and together they are wonderful parents to the outrageous and spirited Maya and Elias. Jake has brought us Libby Longino who heads the political arm of a foun­ dation, and is smart, savvy, and funny. They are the parents of Micah Cohen, a magical little boy. My two nieces, Sarah and Kate Shapiro, and my nephew, Zach Shapiro, have taught me so much about loss and about living. They are also my children. Together we all share the blessings of Hannah Bea and Jonah Bussler, whom I am proud to claim as grandchildren. I have been blessed with friendships as well. Jaine Darwin has given her love, her heart, and her undying loyalty to every chapter of my life. Merry Nasser has offered wise counsel and been steady ballast. Wendy Salkind, another old friend from birth on, has provided me continuity and an abiding sense that from our roots, somehow, we could create good children and good work. Elly Winniger, another best friend from birth on, has held my own vii

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memory for me, being the longest-term friend, dating from in utero. Anne Lown and Patricia Kates remain lifelong friends. I am indebted to my sisters-in-law, Toby Tider and Felice Grunberger, and my brotherin-law, David Noah Cohen, who have always allowed my wackiness to be a part of their families. Their children have become dear and wonderful nieces, nephews, and friends; and my great nieces and nephews contribute invaluably to our lives. I also want to acknowledge four people who are no longer with us but very much within me: Sydney Berzoff, my father; Barbara Shapiro, my sister; Myra Berzoff, my mother; and Vera Cohen, my mother-in-law. I thank my colleagues at the Smith College School for Social Work, and my new colleagues at the Institute for Clinical Social Work (ICSW), for their intellectual stimulation and support. And I cannot thank my students at Smith and ICSW enough, both master’s and doctoral, who have offered so many insights, case experiences, questions, probes, and ideas. I also thank Judy Levin for her thoughtful and sensitive copyediting and Melissa Henry for her outstanding organizational and technical skills without which this truly would have been impossible. Finally, we want to acknowledge two colleagues whom we have lost. Gerry Schamess died in 2019, after a long illness, as we were writing the fifth edition of this book. His contributions were innumerable: as a teacher, a scholar, a writer, a passionate clinician, a man of endless curiosity and wit. We are deeply grateful to him for his wisdom, his contributions to our knowledge, and his help on all of the earlier editions. Cynthia Shilkret also died this year. A gifted teacher, a consummate and gifted clinician, with an incisive mind and a droll sense of humor, Cynthia brought so much of herself to his book. We truly miss her. Joan Berzoff Northampton, Massachusetts It has been a great privilege to coauthor and coedit Inside Out and Outside In yet again. It has been our hope from the beginning to produce a book about the enduring usefulness of psychodynamic theories in clinical practice. In these troubled times when oppression and injustice are becoming ever more apparent, it is especially important to understand how outside forces get inside and to expand our knowledge and skills of how to help people heal and grow and have better lives. Although twenty-four years have passed since this book was first published, my acknowledgments have not changed that much because I  am fortunate to have a core group of people who support me in my learning and my work. Starting closest to home, I  owe Judy Levin the same debt of gratitude that I  still cannot fully articulate in words. She read, she typed, she listened, she sent and received innumerable e-mails, she edited brilliantly, and she was a major part of this process from beginning to end. Without her special insight into the material and her consistent, loving encouragement, I would not have been able to persevere. Her unswerving belief in all of us made the book better. I thank my wonderful sons, Michael and Brian. They are now fully embarked on their own meaningful, productive, loving lives. As of this edition, they have enhanced their lives and mine by choosing beautiful partners in Michelle and Julie and by adding the joy and wonder of a new generation to the family—my beloved, sparkling grandchildren Emily and Nicole, Wyeth and Maris. Last time, I thanked my sons for their patience and forbearance during the lengthy process of writing the first version of this book. This time, I thank them for graciously ignoring altogether the fact that this book (“The Book,” as they call it) was being rewritten yet again. What remains true is that I continue to learn invaluable lessons from the steadfast and courageous ways they pursue their own hopes and dreams.

Acknowledgments

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Although my mother, Maria Melano, has died in the interim, I still owe her my profound thanks for having been a great enabler of my teaching and writing, both through her financial generosity, which bought me precious time, and by the example of her vibrant, active life. I am still inspired by the memory of how at eighty-five, two weeks before her death, she still traveled alone by bus to audit classes at her alma mater, Barnard College. To my dear friends, thank you for having the grace and the kindness to stop asking, “Why in heaven’s name are you writing that book again?” while at the same time lovingly encouraging me to continue. At the Smith College School for Social Work, I am forever indebted to Ann Hartman and Joan Laird for pushing, prodding, and coaxing me to expand my thinking about sociocultural concepts. That stretch has enriched both my teaching and my contributions to this book. My thanks also go to Michael Hayes, who was with us for a while as an author, is still with us as a teacher, and whose inspiration has endured. His ability to combine a sophisticated grasp of the fine points of psychodynamic theory with a loving, gentle application of that theory to practice helped me retain the belief that this theory is indeed worth teaching. Continued thanks go to Dennis Miehls, also at Smith, who became the coordinator of the courses on which this book is based and managed that arduous task in a skillful, nurturing, and energizing way. His deep knowledge of theory and his clear vision of how to make use of it to help people heal infuse much of my new work. We have been lucky with each edition of this book to have had stellar assistants and copyeditors to thank. This time it is Melissa Henry’s turn. Her talent with technology (and endless patience with my dread of it), her spirit of helpfulness, and her steadfast support have made it possible for me to work on these revisions. Many, many thanks. My deep gratitude still goes to Joan Berzoff and Pat Hertz—colleagues, collaborators, dear friends. There were moments when I thought we would not survive the writing of this new edition, but somehow one of us always came up with the enthusiasm, vision, sanity, or commitment to help the others out. What I said twenty-four years ago remains true today: the path we walked to create this book has been joyful, arduous, exciting, frustrating, fun, and sometimes infuriating, but ultimately we walked it together. Finally, and most importantly, my thanks go to my patients and students who have sustained me, challenged me, and taught me more than I ever thought possible during all my professional life. Laura Melano Flanagan Brooklyn, New York Over the course of the twenty-four years this book has been in print, life has brought joys and challenges and a perspective that only time can provide. My immersion in the world of mental health, coupled with the COVID pandemic and societal and political upheaval, has informed my writing and thinking about the ways our theories of practice both enrich and fall short in providing the compassion and care so many need. Nonetheless, I feel incredibly fortunate to have found a professional home in the mental health field, one that brings great meaning and purpose to my life and affords me an opportunity to make a bit of a difference in the lives of others. As I  thought about my acknowledgments, I  realized that they have remained relatively consistent over these many years. I continue to feel enormously grateful to the many people who have helped me sustain my passion for the clinical work that we do. I am indebted to my patients who generously and courageously let themselves be known—to themselves and to me—in the deeply personal and hopefully transformative work in which we engage. I am

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grateful to the many students whose inquisitive minds force me to articulate why I think and do what I do, and continually remind me of what I have yet to learn. My colleagues at Smith College School for Social Work trusted me to teach long before I knew I had something to offer. I “grew up” professionally with an amazing staff at the “old” Revere Community Counseling Center alongside of whom I learned to work with many of the patients whose stories fill the pages of this book. The social workers and psychologists at Beth Israel Deaconess Medical Center and the Dana Farber Cancer Institute allow me to learn from them in my role as their clinical consultant, and inspire me with their commitment, compassion, and dedication to patients and to professional growth. I am particularly indebted to the director of the Social Work Department at BIDMC, Barbara Sarnoff, for her unwavering commitment to staff development, and for giving me an opportunity to work with her talented staff for so many years. And last, the clowns in the Laughter League at Children’s Hospital, who help me dance on that fine line between laughter and sadness, lightness and suffering. I want to thank those who have been so close to me personally, who may not have read every draft of these chapters, but without whom I could never have sustained the energy to complete this project. The love and support of my friends and family have made me what I  am today and have helped give me the voice that is captured in many of these pages. This includes my ninety-three-year-old mother, Marilyn, whose steady patience, love, and common-sense vision continue to guide me in my life; my incredible sisters Meg, who after editing too many versions of my updated chapters, cowrote one of them and continues to accompany me in all parts of my life, and Marcia, who always offers a wonderfully wise older sister alternative perspective and who continues to provide us with literal and figurative sustenance; my nephews Seth, Aaron, and Josh, who warm my heart with their kindness, sense of family, ability to find their own paths in life, and, as an added bonus, their prodigious knowledge of sports trivia; Heather (like family) who gives new meaning to the concept of “twinship” even to someone who is a twin; and my trusted and wonderful community of friends who have sailed smooth and turbulent waters with me and keep showing up. I remain indebted to my coauthors Joan and Laura for their collaboration over these many decades. Through five editions of the book, through harmonious as well as difficult conversations, we have continued to find a common language and a shared vision about the issues that matter most to us in clinical practice. I am deeply grateful to Judy Levin, both for her friendship and for her gifts as an editor and writer whose voice has so improved our work. Finally, I want to thank Melissa Henry, who, with good humor and patience, formatted yet another edition of our book. My greatest gratitude is to my daughter Sofia, who has taught me more about courage, compassion, and perseverance than anyone in my life. Her quiet and unwavering empathy, deep sensitivity and kindness, lively spirit, remarkable intuitiveness, and gift in giving to those in need have continued to nurture, center, and inspire me. This one is, yet again, for you. Patricia Hertz Brookline, Massachusetts

1 Why a Biopsychosocial Context? Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz

In this book, we try to maintain that every human life is shaped by the interplay of forces that arise from both within and without, from nature as well as nurture. We introduce the reader to psychodynamic theories of psychological development, which help us understand the inner world of a person, and we enrich the usefulness of those theories by trying to integrate the biological and social aspects that these theories often lack. Psychodynamic theories do not purport to be all-inclusive. Each looks through its own rather narrow lens deep into an individual’s inner psychological world. And yet to know a person more fully, or to do any kind of clinical work, the lens has to include the biological and social factors that interweave throughout any client’s life. This is why we so strongly believe in what is called the biopsychosocial approach to clinical practice. Each newborn arrives in this world with certain individual physical characteristics—green eyes or chocolate-colored skin or big feet or sweetly shaped ears. Even these seemingly “outside,” objective, concrete characteristics are deeply formative, because they would be viewed and valued in vastly different ways in different cultures and by different races, thereby shaping the inner world right from the first moment of life outside the womb. And what of gender? Mary is a girl. John is a boy. These simple statements seem to describe objective facts, and yet they belie enormous complexity. Mary may, in fact, later identify as a male or John as a female. Either may come to identify as non-binary, preferring the pronoun they to she or he. Gender is not immutable either but is socially constructed. Cultures, religions, social classes, even locales have different definitions of what it is to be a boy or to be a girl—as does each different individual and family. When Freud (1925) noted that biology is destiny, he meant that anatomical and biological differences sometimes shape goals, wishes, and personality traits. He was somewhat right but also very wrong. Gender is one of dozens of social variables that will shape a life, but only one. The more correct statement would be “everything is destiny”: every factor—biological, psychological, and social—makes its impact. Every baby is born with innate, highly individual, idiosyncratic inner characteristics, some of them biologically based. These traits—a quickness to anger, an easy smile, a way of being calm or fidgety, a lively curiosity, a tendency to melancholy—are not so easily visible, are much harder to get to know, and ultimately are always somewhat mysterious. Yet they, too, 1

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Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz

play a crucial, complex role in shaping the course of a person’s life. And the web grows. All babies with their own inner and outer socially constructed characteristics are then born into the greater outside world with specificities of its own: time, place, class, race, family, community, country, ethnic group, religion, political climate. Even to be born a white, middle-class girl of European descent in New York City in 2020 is to be born into a different world and a different life than a white, middle-class girl of European descent born in New York City in 1940 or 1911. Years ago, at a breakfast honoring a diverse group of young women in their twenties who had achieved rising-star status in the business world, the New York Women’s Agenda organization also honored women in their eighties and nineties who had not been able to become stars in their fields simply because of when they were born. Many of the older women were in tears, speaking about the pride in the young women’s achievements, but also of the envy and loss they felt listening to the opportunities being made by and for the younger women today, opportunities they had not been offered simply by virtue of their birthdate and their gender. And these are only small examples of the variable of time. Every other variable is just as powerful. An African American baby and a Korean American baby and the baby of an undocumented immigrant mother from Mexico, all born on the same day in the same hospital in Kansas City, will each be strengthened or assaulted by very different outside economic, political, and cultural forces, all of which will intersect in complex ways. Understanding their interplay is what is now referred to as intersectionality. As the name suggests, we are constructed not just by our races, classes, sexualities, genders, or psychologies but also by their intersections, including how they interact within the institutions in which we are embedded (whether in the family, in a hospital, in the military, in a prison, in a school, or in a nursing home). In fact, we believe strongly in holding a balanced, comprehensive biopsychosocial view of assessment and treatment, valuing each of the components equally. We hope in this book to challenge some of the false dichotomies and try instead to teach the subtle and ever-changing intersecting of all the factors, the relative weight of which can change from moment to moment.

WHAT IS PSYCHODYNAMIC THEORY? Since this book is written to focus predominantly on the psychodynamic part of the biopsychosocial matrix, we need to explain what we mean by the word psychodynamic. Webster’s Third New International Dictionary (1963, p. 711) defines dynamic as “pertaining to energy or power in motion . . . the motive and controlling forces, physical and moral, of any kind; also, the study of such forces,” and “characterized by continuous change, tending to produce change.” Psychodynamic is defined by Webster’s (p. 1833) as relating to “the science of dealing with the laws of mental action” and “motivational forces, especially unconscious motives, and relating to or concerned with mental or emotional forces or processes developing especially in early childhood and their effects on behavior and mental states.” The many theories that fall under the term psychodynamic, then, have to do with inner energies that motivate, dominate, shape, and control people’s behavior. These are based on constitutional factors, past experiences, and present realities. We use the term psychodynamic because it is broad enough to encompass any theory that deals with psychological forces that are out of conscious awareness and underlie most human behavior. But psychodynamic theories are often about self and identity. And neither self nor identity has any meaning without an understanding of the social contexts in which both develop.

Why a Biopsychosocial Context?

3

We also wish to distinguish psychodynamic theory from psychoanalytic theory, although this is by no means easy to do. The two terms are often mistaken for one another. Some clinicians use them interchangeably. Others insist they are vastly different. There is disagreement even among psychoanalysts as to what the term psychoanalysis encompasses—some reserving the term for the Freudian theory of unconscious conflicts about drives and desires, others including all theories that deal with anything in the unconscious. There continues to be, in psychoanalysis, a sharp debate about its nature, purposes, and goals. Some, as Freud did, describe it as a branch of natural science and others, such as Lacan, as a form of hermeneutics—of deep interpretation—in which personal narrative, not objective data, is the subject of interest. We see it as both: as a form of evidence-based work and as way of understanding the self and others through narrative and interpretation. Richard Chessick (1993), in A Dictionary for Psychotherapists, says the following about psychoanalysis: Psychoanalysis is in some ways very simple to define and in other ways very difficult. All psychoanalytic models have the same conceptual base, the dynamic unconscious, although they may differ in certain fundamental ways. All deal with transference and countertransference and use the method of free association. All view infantile and childhood experiences as crucial and stress preoedipal and oedipal factors to one degree or another. All in various ways and to varying degrees emphasize repetition, the role of the analyst, and the importance of interpretation. (p. 306)

Many of the theories presented in this book go beyond these psychoanalytic concepts, including attachment theories, neurobiology, object relations, self psychology, relational theories, trauma theories, race, and gender theories. So we are not calling this a book on psychoanalysis: We are including social dynamics that are also often unconscious, and we want to pay more attention to biological, social, and cultural forces. We view psychodynamic as a much broader, more inclusive term and psychoanalytic as having a more limited focus. To go back to the dictionary definition, psychodynamic applies to all forces at play in shaping the personality. In this book, we use it to mean any forces, internal or external, that have an impact on mental and emotional development. Our hope is that this book will be useful and relevant for a wide range of mental health practitioners, including those who work in settings where transference issues or unconscious conflicts are NOT the main focus of treatment, either because of time constraints or due to the needs and goals of the clients. One does not need to work in an outpatient mental health setting to make use of psychodynamic ideas. Those working in, for instance, case management, or with hospice patients, with clients recovering from substance abuse, or with children in schools or adults in group homes, in homeless shelters, or in foster care settings can still use psychodynamically informed practice while also addressing cultural struggles, issues of oppression, and concrete and reality-based needs. In this fifth edition of Inside Out and Outside In, we attempt to explain the complexities of human psychological functioning and human suffering from multiple perspectives. Many schools of psychology, counseling, and social work, however, have turned away from the idea that the psychological lives of individuals, families, or groups can be understood from the “inside out.” These schools no longer attend to how the unconscious motivates human behavior but, joining with current managed care practices, argue that only what can be observed, measured, fit into a manual, and empirically tested is of clinical value. Solution-focused, short-term treatments, cognitive and behavioral therapies, and biological treatments that are quantifiable and empirically grounded are at times preempting the use of psychodynamic approaches, even when these approaches may be equally effective either on their own or in conjunction with other forms of treatment.

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Fortunately, in 2010 Shedler published an extensive meta-analysis titled “The Efficacy of Psychodynamic Psychotherapy.” He began by outlining the problem: There is a belief in some quarters that psychodynamic concepts and treatments lack empirical support, or that scientific evidence shows that other forms of treatment are more effective. The belief appears to have taken on a life of its own. Academicians repeat it to one another, as do health care administrators, as do health care policy makers. With each repetition, its apparent credibility grows. At some point, there seems little need to question or revisit it because “everyone” knows it to be so. (p. 98)

Instead, the results of the most recent and methodologically rigorous evaluations of psychodynamic psychotherapy reveal a very different picture: “Especially noteworthy is the recurring finding that the benefits of psychodynamic psychotherapy not only endure but increase with time, a finding that has now emerged in at least five independent meta-analyses” (Shedler 2010, p. 102). Psychodynamic psychotherapy has been demonstrated, empirically, to be effective. Another intense debate has been going on about the relative importance of biological etiologies and biological solutions in the treatment of mental illnesses, due in part to our improved diagnostic tools and in part to the problems of financing mental health services. With mandates to cut costs by reducing the access to and frequency of mental health services, the treatment of mental illness and psychological suffering has been increasingly dominated by shorter-term managed care; a heavier reliance on the use of medications; and brief, even single-session, therapy. This, in time, exerts pressure on many clinicians to turn away from theories that try to describe and understand the mysterious internal forces that shape human behavior. We believe that the failure to teach psychodynamic theories ultimately results in a disservice to clients simply because a knowledge of psychodynamic forces can illuminate what is going on in any human interaction or communication, no matter how brief it is. If Cymbalta is prescribed for five people, it will have a different meaning for each, and the meaning—relief, insult, hope, failure, care—will have been shaped, at least partly, by psychodynamic forces and will affect both compliance and outcomes. If two men on Social Security disability are given carfare for clinic appointments, one may accept the money gratefully as a sign of concern and care, while the other may feel belittled and ashamed. Again, the meaning of the benefit is radically different because of each man’s internal and external life experience. At the time of this writing, most schools of social work have dropped psychodynamic theory and practice in favor of evidence-based practice. And at the same time, the Council on Social Work Education, which accredits all schools of social work, has required that every educational objective taught in social work have a measurable behavioral result. One outcome is that clinical education begins to mirror current practice in the field: only that which can be observed behaviorally valued. This is in stark contrast to the nuanced clinical psychodynamically oriented practice, which includes history, psychology, sociology, anthropology, philosophy, critical theory, gender and racial studies, and postmodernism, all of which call into question the value of teaching only “objective” and formulaic treatments. We have always firmly believed that a person who is “behaving” or “functioning” well may still not be feeling well and may be in need of counseling, therapy, or some other kind of psychological care. When behaving becomes the only criteria for success, many people who are suffering will be left to suffer alone. Over the combined decades of our years of practice, we have seen hundreds of clients who have gallantly forced themselves to “function” even as they struggled with a variety of painful feelings such as anxiety, depression, envy, addictions, rage, low self-regard, or suicidality. To quote Shedler (2010) again, “As noted earlier,

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the goals of psychodynamic psychotherapy include, but extend beyond, alleviation of acute symptoms. Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility” (p. 107). Many schools, then, have turned away from ideas that individuals may be driven by desires or fears that they do not understand, that people may act out of conflicts about which they are unaware, or that they may be compelled to enact old relational templates. They fail to look at the psychic costs of trauma or the messy and often complex understanding of what constitutes a person’s psyche, which after all is the Greek word for soul (Bettelheim 1983). They have turned away from developmental models and even from relational models that focus on the importance of the therapeutic relationship for change. Ideological battles over whether to emphasize the importance of social factors or psychological factors are also legion. Even in the school in which these authors teach, there is no longer consensus about whether a master’s-level practice teacher needs to be able to teach about the value of the unconscious in determining behavior. The current field of clinical practice is dominated by splits—long term versus short term, behavioral versus intrapsychic, biological versus social—that we believe to be false dichotomies. How can we understand and hold the complexity of our clients’ lives if we are compelled to see their concerns through only one lens? We believe that clinicians must not be limited to viewing problems as embedded exclusively in the external environment or as biological vulnerabilities to be addressed only on the concrete or manifest level. Nor should they be limited to paying attention only to the inner, sometimes unconscious world of their clients. To work therapeutically with another human being, we must use multiple lenses, simultaneously, and address external realities: the social contexts of races, classes, genders, ages, abilities, cultures, and sexual orientations; the biological influences of genes and brain chemistry; and the complexity of a person’s inner world. In this edition, we attempt, albeit not always successfully, to hold ourselves to this standard of care as we invite the reader to share these lenses with us. Why, then, do we dichotomize so much? Melanie Klein (1882–1960), the British psychoanalyst who made important contributions to psychodynamic theory, tells us it is very hard to maintain psychological complexity, especially when we feel helpless or afraid. As clinicians, we often feel helpless. Klein tells us that little children are drawn to seeing the world in black-and-white terms, where there is only right and wrong, or good and bad. Klein tells us that it is a developmental achievement, in fact, to realize that different and even opposing points of views can be “held.” Klein calls this the depressive position, because it is depressing to realize that there is no one hold on truth. It’s hard to hold complexity. It is easier to split. We believe that a knowledge of psychodynamic theory is invaluable, whether a clinician is treating someone in long-term psychotherapy or conducting diagnostic evaluations, making a hospital discharge plan, or completing a housing application. Clinical knowledge grounded in psychodynamic theory is one of the most powerful means we have to look inside someone’s heart and mind. Without it, we are almost blind, limited to the surface, the concrete, the manifest. Let us give two examples of why this is so. One of our authors taught in a post-master’s program for advanced clinical social workers for over ten years. The students in the program had all received master’s degrees in social work from fine schools, but schools that no long­er taught psychodynamic theory. All of the students had been in practice for several years and many were still receiving supervision in their places of employment, which included hospitals, family service agencies, mental health clinics, addiction programs, prisons, and schools. The students were very knowledgeable and highly skilled in understanding and

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changing systems (including family systems), in helping clients get necessary services, and in empowering groups whose voices were not being heard. They were, in fact, expert at working from what we would call the “outside in.” Yet they all applied for additional training, citing a painful and frustrating dearth of knowledge about what was going on in the inner world of their clients. They felt that they had never been taught to work from the “inside out” and that this lack greatly limited and hampered their clinical work. In one particular case discussion, a student described trying to work with Michael, a twenty-fouryear-old Latino man who was living in a halfway house after psychiatric hospitalization. His history revealed severe and persistent abuse at the hands of his stepfather and abandonment by his mother, who had fled from the home and left him with cousins when she herself was abused by the same man. Michael’s main emotional problem was that he had divided himself into three parts, which he had named Good Michael, Bad Michael, and Middle Michael. Because of the fragmentation within him, members of the psychiatric team argued about his diagnosis. Some thought he was schizophrenic, others believed he suffered from multiple personality disorder, and still others saw him as having a borderline personality. The post-master’s student assigned to be Michael’s clinician did excellent work helping Michael to adjust to life outside the hospital and get started in a sheltered workshop. But he was mystified about the meaning of the three different Michaels and uncomfortable when the patient referred to them. The student felt he had no vocabulary and no tools to understand the reason for the nature of the fragmentation, especially because Michael seemed at times to be very pleased to have these selves and other times to be in great pain because he was “so messed up.” A psychodynamically informed view of Michael’s inner world ultimately allowed his therapist to enter into and understand Michael’s separate selves. Michael spoke nervously about how his family held very strict Catholic views that he felt were almost impossible to reconcile with some of their own behavior and with the appeal of the drugs and sexual activity so easily available in his neighborhood. At home, he heard that giving in to the Devil would lead to an eternity in Hell, while on the streets his peers tried to lure him into drugs and sex. Early in his life, Michael became overwhelmed by these confusing and conflicting forces that were both outside and inside himself, for he wanted to be good and close to God and his family, but he also wanted to experience the pleasure and power of the streets. Hence, he unconsciously created three Michaels to reflect and embody these disparate, seemingly irreconcilable parts of himself. When the therapist truly understood Michael’s need to divide his inner experiences into parts, as well as the risks of integrating them, he was able to help Michael begin to weave the parts of himself together.

Another example is that of Martin, a twenty-eight-year-old Black Haitian man, who came seeking mental health treatment because he could not stop worrying about what was to befall him next. His anguish had caused him to drop out of graduate school, he had lost his part-time job, and his marriage was in deep emotional trouble. Martin, the son of a policeman, had grown up in a Caribbean Catholic culture with a father who expected his son to bring honor to the family. At age twenty, Martin had emigrated to the United States to pursue an advanced degree, and was by all standards doing well. One evening he attended a party in a racially mixed part of the city that was rife with racism. The party became loud, and the police were called. Martin, although quiet and soft-spoken, was physically large, and the officers who arrested him placed him overnight in jail. White prisoners assaulted him with racial epithets and doused him with buckets of urine. When released (with no charges), he was unable to function or concentrate. He lost considerable weight and could not stop dwelling on the humiliating experience. He berated himself and felt that somehow he deserved the punishment. He began having trouble in his marriage, alternately withdrawing from, or becoming angry with, his wife, who herself then became frightened, confused, and depressed.

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While the postgraduate student did an excellent job of connecting Martin to legal services and advocating on Martin’s behalf educationally, she was bewildered about why Martin remained emotionally immobilized despite the resolution of his legal and educational concerns and his taking psychiatric medication. The student lacked the theoretical tools to understand that Martin had experienced the external racial assaults internally, and now the oppressive environment, which was once outside, had come to reside inside of him, continuing to cause Martin tremendous anxiety and self-reproach. He believed he was horrible and weak. The student was confused that Martin was yelling at his wife rather than turning to her for comfort. Without a knowledge of psychodynamic theories and the consequences of trauma, the student did not know that because his assaults were now internal, Martin might feel ashamed and unworthy of comfort. For Michael, and for Martin, as perhaps for all clients, there is often no more profound experience than being heard, understood, and accepted. This requires that the clinician have the capacity for empathy—the ability to project oneself into the experience of another. Empathy requires knowledge and skill. In this book we hope to tackle the first element of this formula, showing how knowledge about a client’s inner life helps us enter into the client’s whole experience. We hope to demonstrate how an understanding of internal psychological factors, as they intersect with external factors of culture or individual biology, helps us understand the tapestry that becomes an individual self. It is from this perspective that we begin to learn how the outside comes to be inside a person, and, in turn, how the inner world shapes a person’s outer reality.

WHO IS THIS BOOK FOR? This book has been written for beginning clinicians who are about to make the long and challenging journey into clinical work. It is also written for those more experienced practitioners who may never have had a comprehensive understanding of psychodynamic theories and their uses in a multicultural world. It is for all students who want to understand how internal life is conceptualized within biological and social contexts, and for those practitioners and continuing students who want to learn to thoughtfully critique these theories. It is written for those practitioners who are challenged by the limits of managed care and who want to understand how what is inside and outside an individual comes to be metabolized as psychological strengths and disturbances. For many, we hope that it will serve as a useful review. There are many psychological texts that discuss drive theory, ego psychology, life cycle theory, trauma theory, object relations, self psychology, attachment theory, relational theory, and intersubjective theory. There are many texts about culture, race, and ethnicity. In this book, however, we try to combine a psychodynamic understanding of individuals with an understanding of how they function within their social contexts. To our knowledge, this is one of the few attempts to look at the inside and the outside concurrently, which is difficult to accomplish because most psychodynamic theories are more heavily weighted toward the inner world. For years, as teachers, we would become defensive when those more interested in teaching about external realities and oppression would tell us that what we said about race, class, gender, and culture was always “just tacked on at the end.” What we finally realized is that it sounded tacked on because it was. That is why in this book we hold an intersectional perspective. It is a social justice perspective. It is one that holds that any person’s behavior is shaped by a kaleidoscope of structural issues: who holds privilege and power, for example, and who does not. An intersectional

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approach always considers inequalities, based in categories such as race and gender. An intersectional approach takes into account many forms of oppression based on political and economic forces. An intersectional approach challenges binaries: male/female, Black/white, gay/straight, and demands greater complexity. We may, for example, be socioeconomically challenged but still carry white privilege. We may be white and have male genitalia, but be transgender, therefore likely to be reviled, hated, and at risk of violence. As clinicians, then, we are always aiming to see individuals from a multiplicity of perspectives: where culture, class, sexualities, races, ethnicities, age, and places in the social structure impact self and identity (Havinsky 2014). We know that starting with Freud, through Erikson, to Greenberg and Mitchell to Layton et al. (2006), Benjamin (1988), and Samuels (2001), theoreticians have been aware of and interested in the role of culture, class, race, and gender in how they shape unconscious life (Altman 2000; Chodorow 1991; Dalal 2002; Layton et  al. 2006; Moss 2006; Perez-Foster et al. 1996; Roland 1996; Wachtel 2002, 2008). Similarly, there are many books that review the characteristics of different psychopathologies. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013; hereafter DSM-5) remains an atheoretical, descriptive text of objective criteria for mental illnesses. The Psychodynamic Diagnostic Manual (PDM Task Force 2006) is the first to try to offer a developmental understanding of each of the psychological disorders. Some other texts offer an understanding of emotional disturbances by looking at them through a biological, cognitive, or psychodynamic lens alone, or by critiquing the current explanations of the etiologies of the disorders. In the second half of the book, then, we attempt, once again, to hold biological, psychological, and social lenses concurrently as we look at several, somewhat arbitrarily chosen, diagnostic entities that include the psychoses, personality disorders, mood disorders, anxiety disorders, and trauma. Here too, we try to resist the tendency toward polarization by exploring the contributions of psychodynamic, biological, and social factors in the development of emotional difficulties. Once again, while acknowledging that equal weight is not always given to each of these factors, our commitment is to demonstrate the relevance of both external and internal forces in shaping the lives of individuals and the mental disturbances that plague them.

A CRITICAL THINKING STANCE In this book, we study psychodynamic concepts and theories of psychopathology from the perspective of human behaviors. Psychodynamic theories represent approximations of human experience, metaphors that have developed within particular cultures, during particular social times, and with particular social values. As such, we state and restate our conviction that every theory is a social construction. By this we mean that all theories are, of necessity, products of their time and place and culture. No thinker, writer, or practitioner lives in a vacuum. Every theoretician is inevitably influenced by all the experiences of his or her life and, therefore, constructs theories out of the raw material of those experiences. However, many theoreticians find it difficult to acknowledge that their ideas are socially constructed and culture bound. They often fall prey to the rather grandiose notion that their theories are universal and apply to all people at all times. And so, as we study each theory and pathology, we try to ask: Who created this theory? What dominant ideologies does the theory represent? Who is not represented? What biases are embedded in the theory of psychopathology? Does this theory apply to all people at all times? Because many psychodynamic theories have been silent about issues of race and gender, while other theorists have openly devalued oppressed groups such as women or people of

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color, we provide a gender and a racial critique of psychodynamic theories. Many students and their professors are tempted, when a theory is biased, to throw out the baby with the bath water. We are critical of some of the psychodynamic theories for their biases or omissions in terms of race or gender, for their devaluation of oppressed groups, and for whom they include and exclude in the theory. But we also see how psychodynamic theories are invaluable in helping us understand how people experience oppression psychologically, and we wish to make use of what is helpful in “old” theories, even while acknowledging their biases.

THEORY AND CULTURE As we present psychodynamic theories and psychopathologies throughout this book, we want to remind the reader that definitions of health and pathology are always culture bound. In predominantly white Western cultures, for example, considerable value is placed on autonomy and individuation as the psychological developmental goal. Many Eastern, African, and Hispanic cultures, however, define health as the achievement of interdependence. This was brought home to us in the description of a class on normal psychological development that was held in Iran in 1984. Iranian psychology students were asked to observe two mother–child dyads: one American and the other Iranian. The American mother brought her toddler to class dressed in a T-shirt, jeans, and sneakers. Within minutes, the toddler was wandering among the students, eating the candy they offered, straying far from the mother, who smiled as her daughter wandered from student to student. By contrast, the Iranian baby was beautifully groomed and dressed, and she and her mother never left the elegant rug that her mother had so carefully set down. While the Iranian baby sat silently on her mother’s lap, the students were asked to assess the psychological health of the dyads. Uniformly, the first mother–child pair was diagnosed by the Iranian students as highly pathological given the mother’s “neglect” and the child’s obvious “lack of attachment.” The second pair was seen as normal and healthy because the child and mother were so tightly bound. American observers would have arrived at opposite conclusions. They would have seen the Iranian baby as too passive, dependent, and enmeshed; the American baby as healthily active and independent. Whereas in predominantly white Western cultures, the baby is viewed as a dependent creature needing to begin the healthy journey toward independence and autonomy, in Iranian culture, the baby is seen as already too separate and distinct, needing to be bound to the community. In this book, we take the stance that normality is always in the eyes of the observer. Consider another cautionary tale about the errors that can ensue when a well-intentioned clinician is unfamiliar with cultural traditions and therefore defines mental health in her own terms. Two years after receiving her MSW, the clinician was working in a large city hospital, assigned to the inpatient unit of the department of psychiatry. She had been working with the parents and young wife of a medical student who had become psychotic. The patient was suicidal and had been hospitalized on the very ward where he had been a promising and successful intern. The social worker had been seeing the parents together and the young wife alone for over six months. Despite being medicated and having a staff member with him at all times, the medical student managed to commit suicide by throwing himself off the roof of the hospital. The task of notifying the family fell to the social worker. After spending some time with each shocked and grieving family member, the social worker was asked if she would pay a call to the parents’ house the next evening, which she agreed to do.

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Feeling quite shaken, she arrived promptly at 6:00 PM and observed the following: the door was propped open, the mirrors were covered with what looked like burlap, and several women were sitting on wooden crates. The women wore no makeup and their hair was uncombed; the men wore suits, but their feet were in sneakers, and they wore ties that looked ripped or cut up. Despite coming from a bicultural, bilingual family and living in a multicultural city, the social worker saw only strangeness and unfamiliarity, and instantly diagnosed the entire family as suffering from a simultaneous psychotic break. She remained frozen in the doorway while actually beginning to count the number of people in the room in order to tell 911 how many ambulances to send! The mother of the dead medical student, however, was able to assess the clinician’s predicament and very gently said, “No, it’s not what you think. We have not all gone mad. We are sitting shiva and this is our way of mourning. Come in and let us explain it to you.”

The importance of this vignette is that it illustrates how the clinician’s own anxiety caused her to see pathology in what was, in fact, cultural strength—the strength of a family to use their beliefs and rituals to engage in the process of grieving. This book attends both to the cultural relativity of our theories and our diagnoses and to the ways different groups have of coping with, and finding solutions to, what others may define as pathology. An essential part of making a diagnosis and of ensuing clinical work is the capacity to identify strengths—of the individual, the family, the community, and the culture. No matter what degree of disturbance we encounter in our clients, there will also be in them sources of joy, ideals, flexibility, humor, ambition, and hope that give them strength, solace, and the potential for growth. These must be elicited, heard, respected, and understood with the same vigor we use in pursuing the deficits, developmental arrests, and maladaptation that characterize their psychopathology.

HOW THIS BOOK IS ORGANIZED First, a word about language: We originally tried to write this book using the female pronoun she exclusively, in order to correct the centuries of books written only about he. Eventually, this came to sound as stilted as any book written using only the male pronoun. We then tried he or she, and she or he, and even s/he, but these combinations sounded forced and unnatural. What we finally settled on is our own idiosyncratic combinations of she and he, while also understanding that these two pronouns are not sufficient to capture the complexity of gender identifications that exist and that are increasingly being recognized and honored, including that of people who are transgender. In the first half of the book, the authors examine and illuminate core concepts drawn from psychodynamic theories: drive theory, ego psychology, life-cycle theory, object relations, self psychology, attachment theory, relational theory, and intersubjective theory. Each of these theories offers different lenses, many complementary and some contradictory, for understanding how the self develops in many contexts. We study these concepts historically and in terms of their applicability to clinical practice. In chapters two though eight of this book, we learn how each theory developed within its unique social context and is therefore a product of that milieu. We also learn how each theory was revised by internal critiques within the theory itself and by external critiques, and how those critiques led to development of new theories. We especially attend, in separate chapters, to the approach (or lack thereof) to race and gender in psychodynamic theories. Thus, we have two separate chapters on race and gender that critique psychodynamic theories while also appropriating those theories to illuminate how social structural issues may be seen as impacting the psyche and the soul. In

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summary, the first half of the book examines different ways in which psychodynamic theories have conceptualized human problems and strengths from the inside out. Because we believe that psychodynamic concepts help us understand people in different social contexts, we have chosen to use cases drawn from our own practices in multicultural settings. Many books on psychodynamic theory illustrate their concepts using white and privileged, middle-class clients who may be shielded from discrimination, poverty, homelessness, disabilities, discrimination based on sexual orientation, and severe and persistent mental illness. Our intent is to show how psychodynamic concepts are usefully applied to populations that are not so privileged. Hence, we have chosen cases for their variations in race, class, gender, culture, and sexual orientation. In the second half of the book, we use the theories and concepts discussed in the first half to understand five major psychopathologies. We do not study all of the diagnoses in the DSM-5. Rather, we have chosen to study those diagnoses for which a knowledge of psychodynamic theories seems to be the best way to help the clinician into the internal world of the client. These five broad categories are the psychoses, personality disorders, affective disorders, anxiety, and trauma. With an increasing appreciation for the importance of neurobiology in understanding psychopathology, we introduce those concepts as they relate to each of these diagnostic categories. Again, we repeat that psychodynamic explanations alone do not account for all of human suffering. Social and biological influences are also factored into the study of each of these disorders. As is true in the first half of the book, when we study the psychopathologies, we continue to ask: How does the diagnosis reflect the dominant values and ideologies of the social times in which it developed? Who does it privilege? Who does it marginalize? What biases are inherent in the diagnosis? In addition, as we study each of these five major psychological conditions, we attend not only to the experience of the client but also to the experience of the helper. We try to remember that not only are definitions of psychopathology socially constructed, but beliefs about health are culturally bound as well.

MYSTERY In this book we hope to convey some appreciation for the mysteries of another person’s humanness. Respect for the mysteries inherent in clinical work can be particularly difficult when one is trying to learn a theory and its application. The developmental theories we study here are by nature causal and linear. They often postulate that if certain experiences occur during certain stages of development, certain results are likely to follow. Sometimes they do, but often they do not, which we must always remember in order to keep ourselves honest, open, and alive to the sense of wonder with which human phenomena must be clinically approached. There is a passage in Mary Gordon’s novel Men and Angels (1985) that expresses how little can really be known about the relationship between a traumatic event in childhood and its effects on personality development. A  mother, stunned after she has discovered the dead body of their babysitter, who has committed suicide, holds her sleepy children in her arms. She thinks about the kinds of trauma that mothering sometimes inflicts and about how much we don’t know about its results. She muses: And what could you say of it [mothering] that was true? She used to think it was of all loves the most innocent, but now she knew she had been wrong. There were mothers who loved their children in a way that cut the children’s breath and stopped their hearts; there were mothers

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who, in a passion of love, took the children and pressed them to their bosoms and in the next moment threw the children screaming from them, covering them with blows. There were mothers for whom the sight of their children meant nothing; no love stirred, no part of their heart lifted. There were mothers who hated their children from the moment of their births; who hated the first touch of flesh on flesh and went on hating. There were mothers who loved their children but could not love them, for they bent to kiss the children’s flesh and felt the flesh stop in their mouths and make them fear for their next breaths. And children throve or starved, and no one knew why, or what killed or saved. (p. 238, italics added)

“And no one knew why”: what a frightening, yet freeing, statement for a clinician, and what an excellent reminder that theory cannot possibly explain everything. There is, then, always mystery in clinical work. It is crucial that when we learn developmental psychodynamic theories, we are careful not to define the person’s pathology by a specific deficit or trauma that occurred in one particular stage of development (e.g., there was a trauma when the client was two years old; therefore, he must have difficulties in separation and individuation and must carry the diagnosis of borderline personality disorder). Instead, in every case, we need to know how the individual emotionally, constitutionally, and socially comes to be who she is and to explore the subtle, complex interplay between who the person is and what her environment provides. This is why a biopsychosocial approach to diagnosis offers the best chance for understanding a person in all her fullness. Thus, we believe it is always necessary and important to consider both nature and nurture when trying to understand and treat any human being.

OUR PURPOSE This fifth edition has many purposes. In it, we hope to convey an appreciation for the value of psychodynamic theories as students try to learn how to enter into something as unique and complex as the inner life of another human being. We hope to show how a person takes in her environment and acts upon her environment based upon both her strengths and her weaknesses, which she has developed from a complex web of experiences, relationships, innate abilities, biological endowments, and social conditions. We hope to articulate what motivates human behavior and some of the life experiences and healing environments that promote psychological growth. We want to stress the importance of social factors—culture, class, race, gender, sexual orientation, and the physical surround—on experiences of self and identity. We also want to emphasize how social work and counseling can powerfully contribute to or undermine optimal development. We want to add new knowledge from biology—genetic, neurobiological, hormonal—that also explains human behavior. In addition, we hope that students will think critically about the theories they use and about the social, political, and economic contexts in which those theories always develop. While there are other theories that are useful and valuable, such as humanistic and existential theories, which approach understanding human beings as striving to be the best that they can, and seeking to find meaning in life events, in this book we hope to help clinicians to recognize that all the theories in the world are not sufficient to explain everything about a person’s feelings, strengths, or weaknesses. As Hamlet says to Horatio, “There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.” We hope readers will keep an open mind and heart to many philosophies as they enter a client’s world from the inside out and the outside in.

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REFERENCES Altman, N. (2000). Black and white thinking: A  psychoanalyst reconsiders race. Psychoanalytic Dialogues 10(4):589–605. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM-5]. Arlington, VA: American Psychiatric Association. Benjamin, J. (1988). The Bonds of Love: Psychoanalytic Feminism and the Problem of Domination. New York: Pantheon. Bettelheim, B. (1983). Freud and Man’s Soul. New York: Knopf. Chessick, R. (1993). A Dictionary for Psychotherapists: Dynamic Concepts in Psychotherapy. Northvale, NJ: Jason Aronson. Chodorow, N. (1991). Feminism and Psychoanalytic Theory. New Haven, CT: Yale University Press. Dalal, F. (2002). Race, Colour and the Processes of Racialization: New Perspectives. Hove, UK: Brunner-Routledge. Freud, S. (1925). Some psychical consequences of the anatomical distinction between the sexes. Standard Edition 19. Gordon, M. (1985). Men and Angels. New York: Random House. Havinsky, O. (2014). Intersectionality 101. San Francisco, CA: Institute for Intersectionality Research and Policy, SFU. Layton, L., Hollander, N. C., & Gutwill, S. (2006). Psychoanalysis, Class and Politics: Encounters in the Clinical Setting. New York: Routledge. Moss, D. (2006). Mapping racism. Psychoanalytic Quarterly 75:271–95. PDM Task Force. (2006). Psychodynamic Diagnostic Manual [PDM]. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Perez-Foster, R., Moskowitz, M., & Javier, R. A. (1996). Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Northvale, NJ: Jason Aronson, Inc. Roland, A. (1996). How universal is the psychoanalytic self? In Cultural Pluralism and Psychoanalysis: The Asian and North American Experience, pp. 3–21. New York: Routledge. Samuels, A. (2001). Politics on the Couch: Citizenship and the Internal Life. New York: Karnac/Other Press. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist 65(2):98–109. Wachtel, P. L. (2002). Psychoanalysis and the disenfranchised: From therapy to justice. Psychoanalytic Psychology 19(1):199–215. ———. (2008). Relational Theory and the Practice of Psychotherapy. New York: Guilford Press. Webster’s Third New International Dictionary. (1963). Springfield, MA: G. & C. Merriam Company.

2 Drive and Beyond: Freud’s Psychoanalytic Concepts Joan Berzoff and Gerald Schamess

We said in our introduction that we live in a world in which mental health practices are being evaluated almost exclusively through the lenses of quantifiable goals (i.e., the reduction of measurable symptoms, but not necessarily the improvement of the quality of a person’s life). It is an era in which empirical validation trumps a more philosophical, imaginative, or interpretive way of understanding human behavior. While some schools of social work still teach psychoanalysis, they often devalue psychoanalytic theories, either caricaturing them as endless navel gazing or favoring theories and practices that are empirically based, manualized, and measurable. Why have so many schools abandoned psychoanalytic theories and practices? Perhaps one reason is that we do not like to view people as conflicted within themselves, nor are we comfortable admitting that our clients’ inner worlds, let alone our own, may be full of hate, sexuality, desire, rage, envy, aggression, or other passions of which we are largely unaware. We may not welcome the idea that early loss shapes our subsequent behavior in ways that we may live out, often destructively, in unconscious relationships within ourselves and with others. We may not like the idea that our everyday dream life, slips of the tongue, or behaviors have meanings of which we are largely unaware and may even reveal our frailties or vulnerabilities. We may not welcome the thought that difficulties at one stage of development may have lasting effects on our character, relationships, and sense of the world and of others. We may not want to acknowledge that we have an unconscious life that may propel us to act in ways that are irrational, not in our best interests, or even contrary to our own ideals. We may not like to think about the sensual or sexual lives of children. We may not want to confront the ways in which our minds disavow unpleasant truths. We may not want to embrace a psychological view that is inexact, messy, and ambiguous. While the zeitgeist of Freud’s time forced him to try to make his work a science, a more postmodern view of Freud holds that he, like Karl Marx, was trying to alleviate human suffering, alienation, and conflict, based in a humanistic view that people who remained unaware of the origins of their suffering were unlikely to be able to change them. Take, for example, Paul White, a fifty-year-old white, cisgender, working-class, computer technician who came for help because he was actively suicidal and unable to work after 14

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having hacked into his wife’s computer and learning of her affair. The affair had been going on for the last two years. She would not come to treatment with him and told him that she was not interested in ending the affair either. Paul envisioned hanging himself, using a computer cord to do so. Paul soon revealed that he had grown up in a home in which he felt powerless in the face of an economically and emotionally impoverished single mother, who was sixteen when he was born. She often told him that he had destroyed her childhood and conveyed her rage and disappointment about her difficult life by withdrawing from him. His solution was to enslave himself to her, and in the face of her distance and their terrible economic circumstances, he learned to do whatever was asked of him. He became compliant, even servile, taking on all the household chores from folding laundry to cooking meals. He was not allowed to leave the perimeter of his yard, though he longed to be with other children on his street. When he was ten, his mother married a white man, bearing two more children, whom he felt both parents treated preferentially. Paul felt that his parents expected him to be a “man,” as they increased his responsibilities to include taking care of his siblings. When his mother later divorced her husband and abandoned the family, she left Paul in charge of his younger half-brothers. At eighteen, Paul left his half-brothers behind and joined the army, where he thrived on its order and discipline. He had long planned to marry his high school sweetheart, until his mother interfered, encouraging his girlfriend to end the engagement, which she did. Soon thereafter, Paul took up with a single mother who, at age sixteen, had had her own child. Unmindful of her likeness to his own mother, he set about rescuing her from a life of poverty, paying for her divorce, and buying her a home. During their twenties, she engaged in many extramarital affairs while he supported her. Now he was ready to kill himself, largely unaware of how his present repeated his past. It was Freud who first unlocked a way of looking at Paul’s life and behaviors, and who offered some understanding of what drove Paul, what motivated his behavior: how his rage might have been turned inward rather than outward, how early traumatic events had shaped his character, and how his old modes of relating failed to work for him in the present. It was Freud who wrote the first set of concepts about psychic life that explained the power of the unconscious mind, the ways in which early experiences are repeated in the present, and the ways in which psychological conflicts shape human development. Freud saw the relationship between past and present as a part of something he called an unconscious life. Psychoanalysis has been interested in understanding our inner lives ever since. Freud’s work is often maligned because he is perceived to have been pseudo-scientific, distant, neutral, omniscient, and sexist. Yet Freud was intimately involved with his patients, seeing them many times a week, often in unorthodox treatments, experimenting with and trying to understand what motivated their behaviors. Bruno Bettelheim (1983) argues that Freud wrote of psychoanalysis not only as a science but also as a cure through love, a way of taking the work personally and not at a safe distance of anonymity and neutrality. He thought that Freud chose the symbol of psyche, for psychoanalysis, from the myth of Psyche, the goddess of love, who had to enter the dark underworld in order to better understand herself. He argued that Freud’s work was truly about pathways to self-discovery, and that the German word that had been translated into English as “psychoanalysis” should have been translated as the “analysis of the soul.” Bettelheim also tells us that Freud admonished his readers to know themselves. If we could really face our hateful feelings, and our loving feelings, Freud thought that we might not be compelled to act in ways that are destructive, narcissistic, or self-defeating. It is through self-awareness that we may change the ways in which we act unconsciously, helping us up to love and work more freely.

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Freud, then, was among the first psychological theorists to posit that human beings are literally driven by powerful, instinctual, biological forces of which they are largely unaware. These forces—of love or hate, of sexuality and aggression—express themselves differently in each individual, and ultimately shape how each person develops. In his fifty-three-year career, Freud developed a psychology of the mind in which he identified how the drives (both sexual and aggressive) seek expression and result in characteristic ways of being and living. He posited that the drives influence the development of symptoms and relationships with others. In his evolving view of human behavior, Freud viewed humans as bestial in their natures (Mitchell 1988), fueled by forces, fantasies, longings, and passions beyond their control. He hypothesized that most psychological problems occur when the drives are opposed by other forces in the mind. His theory was the first to suggest that powerful forces, urges, and wishes are perpetually in conflict with the self and society. He organized those ideas into a system of human behavior. This chapter introduces many of Freud’s core concepts that are still relevant to clinicians practicing today. We begin our study with Freud’s first insights into the nature of psychological symptoms, using the case of Anna O. This is really the first trauma case, and we look at the disagreements the case generated, the methods Freud developed for “curing” people, and the absolute importance he placed on the therapeutic relationship for producing psychological change. As his career developed, Freud came to appreciate the importance of the therapist’s self-knowledge as essential to being able to understand the passions and yearnings that might exist in the client. In our study of his ideas, we examine how Freud used both his self-knowledge and his clinical mistakes to revise his theories when the clinical data did not fit. Continually changing one’s theories when data do not fit takes creativity and courage. Who among us are willing to forsake our favorite ideas because they may be flawed? Freud developed many therapeutic methods, such as the analysis of transference/resistance, free association, and the analysis of dreams, as ways of gaining access into the psyches of his clients. Freud also evolved a theory of how drives differ at each stage of childhood development, and this psychosexual theory explained distinct kinds of character traits, relationships, and potential problems that may emerge in normal child development. Freud also posited economic ideas theorizing that when psychic energies are bound up in one part of the mind, they are depleted for other functions. Freud also had topographic ideas—that there are layers in the mind, which need to be excavated to be understood. Finally, Freud developed a structural theory: the idea that there are enduring parts of the mind that are always in conflict with each other. Each of these are discussed in this chapter. Although Freud used scientific and empirical language, his clinical theories were deeply grounded in the actual lived experiences of his patients. In his clinical practice, he listened with what he came to call evenly suspended attention, trying to be open to hearing what his clients said in ways that allowed his theories to evolve from the data.

INTELLECTUAL TRADITIONS Freud was a physician and a scientist interested in the investigation of the psyche. Many disciplines influenced his thinking. Because Freud was a neurologist, he conceptualized the mind in terms of neural excitations that were stored and needed to be discharged or tamed. The neurology of his time also influenced his belief that psychological functions occur in discrete or separate parts of the brain. Thus, he envisioned each function of the mind as interdependent and acting upon the others. Physics had a profound influence on Freud, leading him to view human behavior as a function of predetermined and predictable forces. Physics also contributed a hydraulic metaphor to Freud’s thinking—that there were energies in the mind that flowed from one part of the mind to others. Archaeology and geology

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influenced him as well. He saw the mind as having a prehistory that needed to be excavated to be understood. Freud’s scientific leanings were also leavened with a love of art, literature, religion, and philosophy, all of which contributed to his appreciation of the symbolic aspects of human behavior. Shakespeare influenced the romantic elements of Freud’s thinking especially about human tragedy and suffering. From Judaism emerged other strains: deep pessimism about the human condition, cultural prescriptions about the value of an individual life, and deep meaning assigned to the value of the nuclear family. Judaism also influenced the mystical side of Freud that probed deeply into the inner workings of the soul.

SOCIOCULTURAL INFLUENCES Throughout this book, we will emphasize that every theory can be understood as a social construction emerging from the unique economic, cultural, religious, and political forces of the times in which it is developed. Thus, to understand Freud’s earliest psychoanalytic concepts, we have to look at how his culture informed his thinking and how the social times in which he lived contributed to his worldview. Freud was born in 1856 in Freiberg, Moravia (now a part of the Czech Republic), to the family of a wool merchant. When he was four years old, Freud moved with his family to Vienna. At the height of the Victorian era, this city was considered to be the seat of licentiousness and sexuality in all of Europe. There was a facade of control and repression of sexuality within a largely upper-middle-class Catholic culture; yet men routinely went to prostitutes, and women had lovers. Women in Victorian Vienna were viewed either as sexual property, among the working classes, or, among wealthier women, as sexless objects with carefully prescribed, and limited, social roles (Lerman 1986). In either case, women rarely were expected to fulfill their potential for full human experience. Furthermore, the absence of reliable and affordable contraception made the expression of sexuality in all social classes a dangerous enterprise. Thus, Freud grew up in a cultural context of sexual contradictions. It was within this social context that the concept of repressed sexuality, so central to Freud’s thinking, emerged. It is also important to note that as a Jew in Vienna, Freud was the victim of rampant antiSemitism, which marginalized him professionally and impeded his professional recognition. Many of his ideas remained outside mainstream medicine. Some of his views reflected his own experiences of oppression so that by the end of his career, when he was forced to flee from Vienna in the face of Nazism, he came to believe even more fervently that aggression was a central force, not only in human development but in national development as well. His views on the essentially aggressive and even bestial aspects of humankind were borne out by a regime that sought his—and all Jews’, gypsies’, and homosexuals’—extinction. Lastly in any discussion of Freud’s work, it is important to know about Freud’s deep commitment to populations at risk. A  little-known fact about Freud and his followers was the development of the ambulatoria: low-fee analytic clinics for those who were poor and most at risk. Freud was central to the developing of these low-fee clinics in Berlin, Budapest, Vienna, London, and Frankfurt. It was only the rise of Nazism that ended his free clinics (Danto 2005).

FREUD’S EVOLUTION OF A THEORY AND METHOD FOR UNDERSTANDING HYSTERIA AND TRAUMA Freud completed medical school in Vienna within three years and went on to study with Charcot, a Parisian neurologist who treated women suffering from hysteria. Charcot’s female patients had many symptoms. These included paralyses and blindness for which there was

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no known organic cause. At that time, it was thought that the symptoms these “madwomen” suffered had a particularly female etiology. Indeed, the very word hysteria in Latin meant “wandering uterus,” and so it was common in those days to attribute a sexual etiology to certain kinds of mental illness. Charcot experimented with treating hysterical symptoms and used hypnosis, applying pressure to sensitive spots, such as the ovaries. Freud studied hypnosis with him and began to suspect that hysteria was not solely a woman’s disease and that hysterical symptoms were not simply fabrications of women’s minds (Brill 1921). Freud made enormous intellectual leaps, however, when he went from hypnotizing women in Charcot’s clinic in Salpêtrière to discovering key concepts in psychoanalysis that are still alive in our practices today. Let us then turn to one of the cases in which he discovered so many of these concepts. Anna O.: The Case in Which Freud Conceptualized Free Association, Symptoms as Disguised Wishes, Transference, Countertransference, Resistance, and Repression In 1882, early in Freud’s career, his colleague Josef Breuer consulted with him about a woman who came to be called “Anna O.” This was a difficult case that had ended badly. Anna O. was an extremely intelligent and willful twenty-one-year-old woman whose symptoms included a nervous cough, difficulty swallowing, anorexia, suicidal ideation, sleepwalking, rages at her governess, tics, squints, paralyses of her arms and neck, temporary blindness, an inability to speak in her native German, and episodes of changed consciousness. The patient was from an upper-middle-class Jewish family. Yet the choices available to young women of her social class in her day were to marry, become a governess, or tend to the sick. For such a creative and gifted young woman, these options were particularly oppressive. When her father fell ill of pneumonia, Anna was charged with his care. After nursing him until his death, her symptoms became so overwhelming as to affect every aspect of her waking life. These symptoms continued for over two years. Anna O. also had a family history of psychological instability among her more distant relatives and also had had two siblings who had died. She was therefore predisposed to some significant vulnerabilities. Her internist, Josef Breuer, was a handsome, middle-aged physician who began treating Anna’s physical symptoms by hypnotizing her in the late afternoons at her bedside. He visited her three to four times a week and held her hand as he invited her to enter into a hypnotic state. When he asked her about what may have caused a particular symptom, she would say whatever came to mind, without censorship. Often, she would not recognize him, and would drift into trances, or following his visits, fall into deep sleep, or what she called her “clouds.” During these late afternoon meetings, she spoke freely (Freeman 1979). It was Anna O. who called this a “talking cure” and likened telling everything on her mind to “chimney sweeping.” In fact, Breuer and Anna O. were actually developing a method that would become central to psychoanalysis, that of free association, in which patients can access hidden or forgotten feelings, memories, and wishes through saying, without censorship, whatever came to mind (Freeman 1979). In the course of Breuer’s work with Anna O., many ideas became a part of the field of psychoanalysis. Breuer thought that by letting his patient speak freely and in a hypnotic state, she could revisit the traumatic events of the past two years, and abreact, or rid herself, of those memories. Without any formal training in psychoanalysis, without even the existence of such a field, Breuer intuited that her fantasies might be texts that could unlock secrets about how and why her illness had developed. Until his collaboration with Freud, however, Breuer still had no way of making sense of the many fantasies Anna O. produced. For example, in his paper with Freud, he wrote:

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In July 1880, while he [Breuer] was in the country, her father fell seriously ill of a sub-pleural abscess. Anna shared the duties of nursing him with her mother. She once woke up during the night in great anxiety about the patient, who was in a high fever. . . . Her mother had gone away for a short time and Anna was sitting at the bedside with her right arm over the back of her chair. She fell into a waking dream and saw a black snake coming towards the sick man from the wall to bite him. . . . [In reality, she had been recently frightened by actual snakes behind her house.] She tried to keep the snake off, but it was as though she was paralyzed. Her right arm, over the back of the chair, had gone to sleep and had become anesthetic and paretic; and when she looked at it the fingers turned into little snakes with death’s heads. . . . When the snake vanished, in her terror she tried to pray. But language failed her: she could find no tongue in which to speak. . . . The whistle of the train that was bringing the doctor whom she expected broke the spell. (Freud & Breuer 1893, pp. 38–39)

Imagine a woman reporting such a hallucination! Without a preexisting theoretical model, how would any of us make meaning of the symbol of the snake or make sense of her paralysis and muteness? Freud and Breuer began to hypothesize that this “waking dream” contained some kind of conflict. Today we might speculate that Anna O. might have wished her father’s suffering to end and, hence, wished for his death. Perhaps Anna O. was angry at being left to care for her father and wished that snakes would kill him. However, such aggressive wishes, especially at her own hands, would have conflicted with her conscious desire to care for him and so would need to be kept out of consciousness. Perhaps, having nursed her father in the most intimate of circumstances, alone and at night, separated from her mother and deprived of any opportunities to be with men her own age, Anna O. felt sexual feelings toward her father. The snakes, which came out of her own hands, not only might have a biting and aggressive component but also might represent forbidden sexual wishes that she had for her father, or perhaps masturbatory impulses. Since these sexual feelings might have been unacceptable to her, they might have been out of her conscious awareness. It is even possible, given the nature of her episodes—her difficulty swallowing and her anorexia—that she was the victim of sexual abuse and that the snakes might have represented memories of previous sexual trauma at the hands of her father and that these memories were reactivated in caring for him and his body, at night, by his bedside. But all of these ideas were to follow later with the development of drive theory. At this time in history, what Anna O. consciously experienced was paralysis and muteness. Freud would later hypothesize that her physical symptoms expressed and condensed her sexual and aggressive wishes as well as their prohibitions. Was it possible that physical symptoms were internal psychological conflicts that were converted into physical pathways? He later called these kinds of symptoms conversion hysteria, and they are currently classified under the general rubric of somatoform disorders today. As Anna O. and Breuer continued their work, many of her conversion symptoms began to have some association to previous trauma. Her difficulty hearing seemed related to her father having asked her in vain for some wine. Her squint appeared related to a time when she couldn’t see her father because of the tears in her eyes. Her cough seemed related to wishes to be elsewhere than with her dying father. Each symptom seemed to have some association with wishes or feelings that were consciously unacceptable and had been transformed into physical states. As the associations were examined, and understood, many of her symptoms abated. Over time, a close relationship developed between Anna O. and her doctor. When he went on vacation, leaving another physician to look in on her, she went into a deep depression, becoming paralyzed and mute again. As she had been paralyzed under the weight of feelings toward her father, some of her intense feelings now appeared to be occurring within

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her current relationship with her physician. This experience of bringing feelings, wishes, and assumptions from past relationships to the therapeutic relationship was the phenomenon that we now refer to as transference, although neither Freud nor Breuer named it as such. This takes place in all relationships but is a particularly useful tool for understanding the internal and unconscious aspects of clients’ inner lives as they are lived out in the treatment process. As episodes from the previous year in which she tended her sick father were repeated, remembered, and talked through, Anna O. seemed to improve, and Breuer attempted to terminate the treatment. To his great dismay, however, he was summoned to Anna O.’s bedside in the middle of the night to find her in the midst of a hysterical pregnancy. As she screamed and groaned in labor, she accused Breuer of being the father of the baby. Breuer was unaware of and certainly unprepared for the intensity of Anna’s feelings toward him. Given that he had no theoretical model in which to conceptualize her sexual feelings for him, he hypnotized her a final time and is reported to have left for a second honeymoon, never to see her again (Jones 1953; Freeman, 1979). What Breuer could not know, and what Freud would discover, was just how powerful, real, and urgent Anna O.’s sexual feelings were. These powerful transference feelings had flourished during their regressive late afternoon sessions. Anna O.’s sexual and aggressive fantasies had been transferred to her therapist and were experienced as if they were actually happening in their relationship. Because those feelings were not acknowledged consciously, they became represented in her hysterical pregnancy. And because Breuer did not recognize his own feelings in himself, he wrote of his beautiful patient, “The element of sexuality was astonishingly undeveloped in her” (Freud & Breuer 1893, p. 21). A therapist’s own sexual and aggressive fantasies and feelings toward the client are called countertransference reactions. Breuer’s unawareness of his own countertransference reactions probably resulted in his disavowed attraction to her and in the premature termination of her treatment. Today, we know that denying, avoiding, or repressing countertransference feelings interferes with the therapeutic process. In fact, the patient’s growing conscious awareness of feelings for the therapist and the therapist’s awareness of feelings for the patient provide some of the most useful data that there are in clinical work. This process—in which the client examines her own feelings, fantasies, and reactions to the therapist, and the therapist does the same toward the client, either inwardly or in supervision—requires honesty, vigilance, and self-knowledge (see chapter 7 on relational and intersubjective theories). When these intense feelings are recognized, Freud thought, they could be controlled. But when they are denied, resisted, or avoided, as Breuer did, they can negatively affect the course of treatment. Freud initially thought that transference should and could be avoided, but he would shortly discover, in the case of Dora, that transference was an unavoidable part of the talking cure. Later, he came to see transference as the major vehicle for psychoanalysis, rather than an impediment. Anna O. did not do well immediately after her treatment with Breuer. She was hospitalized and addicted to morphine for a time. But she later became a great feminist social worker, advocating on behalf of women who had been exploited—prostitutes, unmarried mothers, and young girls in the white slave trade or what we today call forced prostitution. Perhaps her commitment to working with women oppressed by men had its roots in her unequal relationships with her brother and her father, as well as with Breuer. We do know that she did not value psychoanalysis for her own clients and that she appeared to have never forgiven Breuer for “not knowing.” (Freeman 1979)

Yet the irony is that, because Breuer did not know, and because he dared to explore an inner world that neither she nor he could understand, he unwittingly demonstrated the

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phenomena of transference and countertransference. Because he did not know, and because he dared to share his clinical errors with Freud, Freud was later able to use this case to begin to develop core concepts still used in psychodynamic practice today.

THE BEGINNINGS OF CONFLICT THEORY Let us now examine several of the concepts from this case that led Freud to develop his theory of the mind. First, the case of Anna O. led Freud to think that by free-associating, by reliving the past, and by verbalizing repressed feelings, past trauma could be worked through, and some symptoms could be relieved. Second, this case illustrated that traumatic experiences, when repressed, sought expression through physical symptoms. Freud would later show that by freely associating in the context of a trusting relationship, clients could gain access to powerful sexual and aggressive wishes. Freud also began to discover in his work with other hysterical women that their wishes and urges that sought release were always opposed by counterforces in the mind that resisted coming into consciousness. This was the essence of his idea of a conflict theory; it was a dynamic theory: that unconscious sexual and aggressive wishes seek expression but are kept out of consciousness by other forces in the mind. Freud envisioned a censor in the mind that resisted unacceptable thoughts, feelings, and wishes. Later, he identified the central mechanism for keeping unacceptable thoughts, urges, and feelings out of conscious awareness as repression: the defense that keeps us from feeling or knowing that which is too painful, shameful, or dangerous. The idea that there might be forces in the mind that keep unbearable feelings out of consciousness began to account for why hypnosis alone did not bring enduring relief of symptoms. Bringing unconscious material to light was not enough. Clients need help in overcoming their resistances and their repression in order to work through what is unconscious, dreaded, and feared. Psychological conflicts, Freud began to realize, were an inevitable part of psychic life. In Freud’s earliest cases, then, were the precursors to many critical concepts: free association, freely reporting whatever comes to mind; resistance, the forces that oppose the striving toward recovery (Freud 1912); repression, the unconscious mechanism that keeps unacceptable wishes and feelings out of consciousness; symptom formation, the nature of symptoms as symbolic, unconscious expressions of conflicts; conversion, the transformation of aggressive or sexual wishes into somatic pathways; transference, thoughts and feelings for a therapist that have their roots in earlier relationships and in subsequent emotional experiences with others; countertransference, thoughts and feelings and reactions to the client rooted in the therapist’s own history and current world; symbolic content, fantasies, hallucinations, and dreams containing symbols, which may convey many wishes and feelings; and unconscious conflict, unconscious wishes and fears that seek expression but meet with repression and last, a dynamic view of the mind, as always in conflict with itself. Each of these concepts remains a vital part of psychodynamic clinical work today. Early in his career, Breuer and Freud (1895) reported on another case, that of Katerina, certainly one of the very shortest-term cases in the annals of psychoanalysis! Katerina was a waitress at a restaurant in the Alps that Freud frequented. She asked for his help because of a feeling of severe heaviness in her chest. Freud encouraged her to free associate and to report whatever came to mind. Over the course of one afternoon, she was able to link the heaviness in her chest to an incident of incest that she had witnessed. The memory had been out of her consciousness, but she now recalled witnessing a sexual encounter between her cousin and uncle. Remembering the trauma and verbalizing it lifted her repression and led to her symptom relief. However, in a footnote, Breuer and Freud tell the reader that it was not her

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uncle who had sexually abused her cousin, but rather Katerina’s own father who had abused her! Thus, the role of sexual trauma was established in the development of physical symptoms that have no organic basis, even if only in a footnote then!

THE EVOLUTION OF FREUD’S UNDERSTANDING OF PSYCHOPATHOLOGY While Freud initially continued to hypnotize hysterical patients, he found that much of the same material was also accessible via free association in the analytic setting. In Studies in Hysteria (1895), he began to evolve a number of theories drawn from patterns in the hysterical women he treated. Now he began to write that their symptoms, such as dissociation, amnesia, and conversion disorders, seemed related to real sexual traumatic events that these women had experienced as children. Memories that could not be consciously expressed emerged as symptoms. The cure for hysteria involved gaining access to unconscious memories through free association. The talking cure became a way to allow strangulated affects, or feelings, to be discharged through speech. The cure involved remembering the sexual trauma, making it conscious despite resistance, repeating it in the transference, and working it through in the context of a therapeutic relationship. It should be noted that Breuer held a complementary but different view from Freud about Anna O.’s symptoms. He suggested that, after a trauma, her affects or feelings had been dissociated and showed up in hypnoid states. What ensued was a splitting of the mind, and the role of hypnosis was not so much to lift repression but to integrate these dissociative states. This view underlies much current trauma theory today (see chapter 17). However, between the publication of Studies in Hysteria in 1895 and its reception in 1905, Freud retracted his view that all hysterical women had suffered from real sexual trauma. He was under great pressure to deny rampant sexual abuse within his conservative medical society and as an outsider, he recanted. Instead, he began to view sexual seductions in childhood as wishes produced by his female patients’ own desires. That a real event should so simply be disclaimed as a fantasized realization of a wish was problematic then, and it remains a difficult part of the theory now. Indeed, discriminating memory from fantasy continues to be a raging debate in the trauma literature today (Loftus & Ketcham 1994). But Freud’s abandonment of the seduction theory led to many decades in which the importance of real trauma was minimized and denied (Masson 1984). To review, then, Freud came to see hysteria as a function of a patient being traumatized, and later experiencing forms of excitation that could be painful. The traumatic memories also represented something that was unacceptable to the person’s mind, and thus the unacceptable idea or feeling was repressed (or dissociated). The excitation then took a somatic (physical) pathway so that what was left in consciousness was only a symbol. If the traumatic memory could be brought to consciousness, then the painful affects (feelings) could be released and the patient would be less symptomatic. We can see this somatization in the following example. Gloria, a single, forty-year-old, middle-class Polish Catholic alcohol counselor, came to treatment having heard one of the authors give a talk about dissociative identity disorders at a national conference. She said that she had been stirred up by the talk but stated in the first session that she was very skeptical of ever having experienced sexual abuse. She complained of low energy, constant headaches, and a lack of memory or focus. She lived at home with her eighty-year-old father; her mother and four brothers had moved out of the home ten years before because of her father’s chronic alcoholism and physical abuse. Her sister had married at eighteen and had left home for good.

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Now she took care of her father, providing his meals and shopping and cleaning for him, with a very limited life outside of her work and home. He mostly sat in the dark, in his easy chair, watching television, bitter and depressed. She described herself as still sleeping at night, fitfully, with the sheets wrapped around her like a mummy, as close to the wall as she could get. She had slept this way throughout her adolescence and young adulthood. In about the sixth session, Gloria brought in a hard plastic doll whose ears and feet she had literally chewed off in childhood. Talking about the doll and wondering why a child might chew something so hard led her to wonder about what she might have been feeling as a child. She then recalled a memory of a man in the doorway, smoking a cigarette. In the memory, all she could see was the red dot of the flame of the cigarette. This memory unleashed a flood of other memories, which were extremely painful and which she would alternately and tentatively accept and then dismiss. But as the memories began to surface, she remembered hearing rustling in the bed closest to the door which her sister occupied. She recalled knowing and not knowing that her father was in her sister’s bed, and only later was able to remember that her father had made advances toward her as well. But Gloria resisted bringing memories to consciousness because they were too painful to bear. Her need to know and not know at the same time was further compounded by her having experienced some excitement, as well. Remembering those feelings provoked guilt and self-reproach. When Gloria was able to feel and empathize with what a child must have felt: the terror, the confusion, and even the excitement of a parent in her bed, she regained some of her energy and began making plans to bring in a housekeeper and move out of her family home.

Freud began to conceive of traumatic events (or fantasies) producing a conflict in the mind. One part of the mind seeks to keep such memories from conscious awareness (repression); another part of the mind resists the fantasies or memories becoming conscious because they are too painful, and so what is left in the conscious mind is some excitation that is incompatible with the conscious mind. Usually, the symptom represents the conflict. Freud’s view was that hysterics suffer from reminiscences, or from memories that produced dammed-up or strangulated affects (feelings). The goal of treatment is to remove symptoms by accessing and recovering repressed memories and verbalizing them with the associated feelings. This, too, is fundamental to trauma theory today. Furthermore, with these insights, Freud was beginning to see symptoms as compromises between repressed memories and the conscious mind. While the conscious mind struggles to keep what is painful out of consciousness, symptoms emerge because of strangulated affects that cannot be extinguished.

THE ANALYSIS OF DREAMS Freud continued to investigate the internal lives of individuals through free association and through exploring their dreams (1900). He began to theorize that dreams were actually like symptoms. He noted that under the relaxation and regression of sleep, dreams express unconscious fantasies or wishes, which are often encoded in symbols that express desires in disguise. Every dream, he thought, expresses a wish or an impulse, some of them infantile. What we often see in dreams is that wishes are condensed, or symbolized, so that the wish is disguised. What is consciously remembered from our dreams is called the manifest content. Dreams occur in the unconscious but undergo a secondary elaboration as they make their way through the censor of the mind and into consciousness. Like symptoms, but in a more everyday way, dreams allow for the discharge of sexual and aggressive drives, wishes, and impulses. The work of dream analysis, then, lies in making connections between the manifest content of a dream and latent or symbolic content, which includes

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urges, impulses, and feelings that are unacceptable to the conscious mind. Dreams provide access into some of the fragmentary, early, shameful, secret aspects of unconscious life. Freud believed that by following patients’ associations to dreams, we can help them to decode their meanings. Freud also continued to remain aware of a censor that keeps the forbidden meaning of dreams out of consciousness. During sleep, the censor relaxes, permitting the instinctual impulses of childhood to be expressed without regard to the concerns or controls that operate in conscious life (Freud 1900).

THE REPETITION COMPULSION In 1920, Freud introduced another new and startling idea about human behavior in Beyond the Pleasure Principle, which he named the repetition compulsion. Here he was trying to understand how we are driven to repeat that which we often cannot understand. Salman Akhtar (2009) describes this phenomenon in his eminently useful Comprehensive Dictionary of Psychoanalysis: Freud suggested that there might be a self-destructive “daemonic force” at work in them [some people]; this force worked in opposition to the “pleasure principle.” It is as though these individuals never comprehend the futility of their repetitions; often, they are unaware of their role in it and regard themselves as a victim of “bad luck.” Freud argued that the force underlying “repetition compulsion” was aligned with a fundamental attribute of the mind, which involved a search for reduction of all excitation to quiescence, even to the extent of reducing the organism to its previous, inorganic state. “Repetition compulsion” thus reflected the conservatism of instincts in general and the operation of the “death instinct” in particular. (p. 245)

Like so much of Freud’s work, this insight illuminates what, on the surface, seems like totally illogical behavior. For why would anyone repeatedly seek out the same kind of people and situations that have hurt them terribly in the past? It does not seem to make any sense, but Freud thought that doing the same negative thing over and over again might also be an expression of rage turned against the self. The old-fashioned foot-stomping childhood chant, “Nobody loves me/Everybody hates me/I’m going to go eat worms,” comes to mind; it captures perfectly the fierce anger that makes one want to make a bad situation worse because at least that means one can both relish it and have some control over it at the same time. Later theoreticians, such as Edward Bibring (1943) and Hans Loewald (1971), suggested that along with anger, there can be hope and longing for a better outcome in those who are caught in the grip of a repetition compulsion, which is usually, but not always, unconscious. A Vietnamese, working class, cisgender man who applied to an outpatient psychotherapy clinic mentioned at intake that he was worried about making the same mistake again. He had married and divorced two alcoholic women and was about to propose to a third. When asked why he would want to do such a thing, he answered with great vehemence, “Because I want it to come out right this time.” He then disclosed that he had had an abusive alcoholic mother, whom he hated but also loved dearly, and said, “I’m only interested in alcoholic women because I want to find the one who will give up drinking because she loves me so much.”

Here we see an example of the repetition compulsion containing both the rage and the hope that kept this man firmly entrenched in the internal relationship with his mother, rather than being able to live his life in the present. Freud surmised that in order to have

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new and better relationships and a better life, the patient would need to go through the process of mourning the fact that he was not loved in the ways he wanted to be the first time around. Only then could he be more conscious about not repeating the past. Perhaps because it so negative and frightening—and takes the concept so far—few current clinicians believe in the existence of the death instinct, but working with the repetition compulsion remains a cornerstone of practice when clients present with the same behaviors, over and over, the unconscious roots of which they do not understand.

THE ROLE OF SELF-KNOWLEDGE Freud continued to maintain that the way to understand unconscious life was through understanding, insight, and self-awareness. While he continued to refine his methods of free association through analysis of his own and his patients’ dreams, he was not satisfied to look at the passions of others only from the safe distance afforded the clinician toward the client, and so, he undertook his own self-analysis. He began to identify within himself some of the passions and conflicts he was finding in his patients. He remembered, for example, his own shame as a boy at seeing his once powerful father humiliated by an anti-Semitic attack. He remembered his arousal at seeing his mother’s naked body, and his guilt for having these feelings. What Freud uncovered in himself were his own repressed sexual feelings for his mother, wishes to be rid of his father, and fears of retribution or punishment for his incestuous wishes. Referring to Oedipus Rex by Sophocles, Freud conceptualized these themes as being oedipal in nature. From his own self-analysis, he began to develop a theory that there were universal themes of sexuality and aggression, as well as their prohibitions, at different levels of child development.

A GENETIC THEORY OF PSYCHOSEXUAL DEVELOPMENT Up until now, we have looked at a beginning conflict model, or a dynamic model, for understanding symptoms and psychopathology. But now Freud began to use the word genetic to refer to the ways in which early history is laid down and unfolds over time. He was not using the word as we do now, but rather to express the way certain patterns are innate, like how an acorn can only become an oak. He evolved a model for understanding how normal child development is shaped by the two powerful drives of sexuality (or libido) and aggression. He understood these drives to be biologically based phenomena that seek discharge or expression. There are many drives: hunger, sleep, and other biological regulatory functions. Freud postulated that the drives arise in the body, that their derivatives are unconscious, and that they become conscious as they seek expression. Toward the beginning of his career, he emphasized sexuality as the major drive and an important factor in psychopathology. Later, he introduced the importance of the aggressive drive. Freud proposed that sexuality and aggression seek expression in the everyday lives of children. That children were sexual was a radical idea. That their sexual and aggressive drives evolve and become increasingly complex with their physical and psychological maturation was a substantive and creative leap. Freud’s theory about the developmental course of the drives united embryological and developmental theories with neurological concepts of drives that seek discharge. Freud’s theory of infantile sexuality, or psychosexual development, as he called it, was epigenetic. It held that everything that grew had a predetermined ground plan. Developmental

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periods require that the individuals meet and surmount critical tasks at the proper time and in the proper sequence. Development is hierarchical, invariant, and sequential. Each new stage of psychosexual development depends on the preceding stage. Within this paradigm, there are regressions (or returns) to earlier stages of functioning, and there can be fixations (a getting stuck) at each stage of development, which may form the basis for pathological relationships or character traits in later life. According to psychosexual drive theory, each phase of child development is shaped by an erogenous zone (a physical zone of sexual pleasure), a drive, an object (usually a person) toward whom the drive is aimed, the psychosexual issue that the individual faces at that stage of development, the cluster of character traits that emerge at each juncture of childhood development, and the kinds of symptoms that might occur at each stage of development. Freud began to articulate a model of child development that viewed childhood as governed by internal sexual and aggressive urges, by physical maturation, by the passage of time, and by events in the real external world. Thus, his psychosexual drive theory synthesized the concept of children’s erogenous zones as being associated with the kinds of relationships and attachments, symptoms, character traits, and psychological preoccupations they face at each stage of development. Freud divided childhood psychosexual development into five stages: infancy, toddlerhood, the phallic or oedipal stage, latency, and adolescence (the genital stage). Let us consider each of them individually. Before doing so, however, we want to issue a caveat: This theory about psychological stages often sounds vastly oversimplified—and it is. For example, descriptions of the oral stage make it sound as if the infant is simply one big mouth with no other interests and experiences. To focus on the fulfillment or frustration of oral needs, nothing else is described, which gives a very limited and distorted picture of that particular time in life. In reading about any particular stage, it is important to remember that many other things are going on and that what happens developmentally also depends on the individuality of the person and all the other factors influencing his or her life. Fred Pine (1990) offers the term developmental moments to replace the more rigid, monolithic idea of developmental stages. We find this concept useful because it is much more fluid. The oral stage can then be understood as having many oral developmental moments, and perhaps more oral moments than at any other time in life, but room is left to imagine the infant as a multifaceted, complex little person. The Oral Stage Freud proposed that at the oral stage (birth to one and a half years of age), babies experience pleasure and aggression primarily through their mouths, the first erogenous zone. Babies stimulate themselves by sucking on a breast, fingers, or toys. Their needs, perceptions, and pleasurable and painful feelings all seem expressed principally through their mouths and tongues. Babies will scream to be fed. They will derive great pleasure from sucking, and they will be satiated through their mouths. There are aggressive aspects to orality. Babies use their mouths to spit, to bite, or to chew. Some aggressive feelings can be pleasurable as well. Babies depend on relationships with their parents, their caregivers, or others to regulate their tensions, and to soothe, feed, and comfort them. Freud thought that, to the degree that babies can love, their love is invested in themselves. Other people are valued as the parts that serve the baby as need-fulfillers or neglecters, as breasts or bottle carriers rather than as persons in their own right. The central psychosexual issue at this stage is to get basic needs met and to satisfy oral drives, both loving and aggressive. The healthy character traits that may emerge include the capacity for trust (Erikson 1950), self-reliance, and self-esteem.

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When oral issues are unresolvable, they show themselves in adult problems. Let us look for some of the oral themes that emerged with a patient in therapy. William, a thirty-one-year-old white cisgendered male graduate student, came to treatment complaining of “glaring at people,” something which he felt he could not stop. He described a fantasy life populated by alligators. He imagined these vicious animals in a moat protecting him from the intrusions of others—anyone who tried to get close would be devoured. William had been an only child, born to two middle-aged parents. He described his own mother as excessively dependent on his grandmother, who lived with them until her death when he was eight years old. His father was described as a rigid, removed, and distant military man. Neither parent was seen as reliably comforting. When William’s grandmother died, he gained about forty pounds. He remembers that neither parent noticed. He grew up feeling chronically empty, hungry, and lonely. When it came time to apply to college, William had his mother write his applications, including his autobiographical statement. She chose his college, and her choice reflected her own conservative values rather than William’s radical political values. Throughout college, his mother baked sugar cookies and sent them to him. He would reciprocate by sending her his laundry halfway across the country, believing that he could not do it for himself. He described a worldview of relationships summed up by “I’ll feed you if you feed me.” True reciprocity was impossible, and his relationships were often marked by rage when he felt any deprivation. For example, when his landlord raised the rent, William threatened to pour boiling oil through the pipes. When a girlfriend became pregnant with his baby, he ended the relationship because her plan for an abortion was simply, as he saw it, an attempt to kill a part of him. At work, he expected immediate rewards. When, during a blizzard, a piece of copy he had written could not be read immediately, he became irate and careened through the icy streets, endangering himself and others. Often William would give presents, but then would become disappointed by the lack of immediate payback, and so would demand them back. Like the oral child who bites and rages when his needs are unmet, William was not able to see relationships in any terms but his own. Over the course of treatment, a gulf of loneliness and unfulfilled needs emerged. Often, he would bring a knapsack filled with bananas and milk and eat them in sessions as he recounted incidents of his emotional hunger. In fact, one of the more notable gains in treatment came when he was able to delay and anticipate his hunger and discuss with his therapist the ice cream cone he would like to have after the session. The ability to delay eating and, ultimately, to feed himself took many years. After four years of treatment, William was able to get the recipe for sugar cookies and actually bake them for himself. He stopped sending his laundry home, and he even entered into a work situation where he could be admired while not having to work closely with people. His interpersonal relationships remained distant, but he was less driven by the intensity of his hunger, dependency, and rage. He was more able to express his anger in terms that were socially acceptable, becoming an activist whose protests were appreciated by others. William had serious difficulties tolerating his own oral needs: to be loved, to be satisfied, or to be appropriately gratified. Because his basic needs had been both overly gratified and not gratified enough, he could not see himself or others as whole. He had difficulty with empathy, with mutuality, and with love. In drive theory terms, William struggled with excessive and unneutralized oral drives—biting, hunger, oral greed—coupled with a need for immediate gratification. This resulted in his prominent character traits of narcissism, dependency, envy, and rage.

The Anal Stage By the second year of life (ages one and a half to three), the capacity to walk and climb gives a toddler some degree of autonomy. Toddlers, however, are notable for their selfcenteredness and limited capacity for reason. They do not see value in waiting to cross the

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street.  They have not developed internal controls that prevent them from hanging from a light cord, putting a knife into an electric socket, kicking, biting, screaming, or lying down in a crowded airport or supermarket. Almost all of their behaviors seem aggressively intensified and directed toward testing the boundaries of what is acceptable and what is not. Toddlers must learn not only what is prohibited but also how to internalize the prohibitions of others, thus making them their own. Their psychosexual tasks, then, are around the development of internal control. This usually manifests itself around toilet training in Western cultures in which there is indoor plumbing. Ultimately, toddlers must begin to manage their anal struggles over independence and autonomy by internalizing parental wishes and prohibitions. What motivates children at this stage to accommodate to social demands, Freud thought, is shame and the fear of loss of the parents’ love. The erogenous zone identified with the anal stage is, as the name implies, the anus. Freud hypothesized that there was both erotic pleasure in and heightened aggression over the production of excrement. Two-year-old children, for example, show anal eroticism by delighting in, and expecting caregivers to equally applaud, the products of their bowels or bladders. They may show equal curiosity and delight in caregivers’ toileting behaviors, following them to the bathroom, and discussing or insisting on inspecting their caregivers’ excrement. Toddlers may show anal aggression in retaining, expelling, or even smearing their feces or urine. They may express these feelings through play with dump trucks, puddles, play dough, or finger paint. Freud thought that both the loving and the aggressive drives in the anal stage are aimed at trying to gain control, first, over their sphincter muscles, and then, over the important objects (people) in their lives. Relationships at this stage involve two people; that is, they are dyadic in nature. The quality of their relationships is marked by struggles over self-control. Take, for example, Martin, whose account of himself when he was a child indicates that at age five he was still fixated at the anal stage. His father was a naval officer, and Martin’s favorite form of play was floating his toy boats in the bathtub and torpedoing them. Both parents had become frustrated with Martin because he consistently expelled his feces in his pants and not in the toilet. In desperation, they offered him twentyfive cents for every bowel movement he made in the toilet. Martin soon calculated that it was not in his best interest to become toilet trained, because to do so would mean that he would ultimately lose money. Instead, he would use the toilet for three days to earn the money. But the only way to keep the money flowing was to lose control periodically, and this he would do at home or at the homes of his friends. One day, Martin’s best friend’s mother insisted that, at her house, he use the toilet. There, she overheard him muttering to himself about Napoleon’s battles. When he came out of the bathroom he informed her, “I’m Napoleon, and Napoleon shits wherever he pleases!”

For Martin, toileting had become the battleground to control and dominate others. Not surprisingly, some of Martin’s adult character traits were shaped by his early anal fixation. He had difficulty completing his master’s thesis because he could only write “in spurts.” He tended to have difficulty interpersonally, especially in control struggles with his advisors and in close relationships. Other anal character traits that Freud identified include excessive cleanliness, hoarding, or frugality. The Phallic Phase By ages three to five, children have entered an exciting world of fantasy, imagination, and budding romance. Suddenly, their preoccupations are no longer around “poop” or “pee.” Rather, they may begin to express romantic feelings and sexual fantasies, often directed toward their parent or parent surrogate of the opposite sex. Children at this stage are just beginning to discover their own genitals. As pretend princes and princesses, kings and queens, girlfriends/boyfriends, oedipal children become cognizant of sex roles and play

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out games of love and marriage on the playground and in the nursery school. One nursery school-teacher reported that when she would instruct boys and girls to put their hands on their heads, on their toes, or in the air, some little boy inevitably would call out, “Put your hands on your penis!” This preoccupation with genitals as the erogenous zone at the oedipal stage is natural and normative. It may be hard to imagine a three- to five-year-old as sexual, or as having sexual feelings, but they often have longings for an adult of the opposite sex. Often, they play out their fantasies in which there is some sort of retribution from the parent or parent surrogate of the same sex. For example, a colleague described this conversation with her four-year-old son, which took place in the bathtub: Son: I love you so much even my two arms can’t show you enough. Mother: I love you so much my arms can’t show it either. Son (said with a little discomfort): And Daddy too. Mother: And Daddy too. Son: You’re so beautiful. I’d like to marry you. You know, Daddy could live down the street in a smaller house. In fact, you know, I’ve noticed lately that sometimes Daddy smells. Have you? Mother: You know, sweetie, as much as you love me, and I love you, you really can’t marry me. I’m married to Daddy. But I bet that when you grow up, you’ll marry someone even more beautiful than me. Son (now fondling his genitals): Do you really think I’ll ever be bigger than him anyway?

Another mother described her son admiring her as she dressed to go out. He said, “You look lovely, my princess bride. May I suggest that you wear this [pointing to a necklace] to go out with me.” Indeed, in a wonderful poem by A. A. Milne (1924, 1952), a little boy is described at the height of oedipal longing: James James Morrison Morrison Weatherby George Dupree. Took great Care of his Mother Though he was only three. James James Said to his Mother, “Mother,” he said, said he, “You must never go down to the end of the town if you don’t go down with me.” (p. 521)

A third mother remembered this event between her daughter and her husband: Four-yearold Lilly, who had been dressed for bed, suddenly began to take off her nightgown in a kind of striptease before her father, saying, “Bosom dance. Bosom dance.” Her father responded, “Lilly, put your nightgown back on! What are you doing?” Lilly replied, “Daddy, you know I’ve been thinking that a three-year-old couldn’t marry you, but I bet a four-year-old can!” For the oedipal child, Freud theorized that the penis or the vagina becomes the erogenous zone. According to drive theory, the oedipal child’s world is not made up simply of dyadic relationships of the self and another but includes triadic relationships. The oedipal child’s

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world now requires reconciling sexual feelings and aggressive feelings that involve three people: the child, the mother, and the father (or parent-substitutes because it is not necessary to have a nuclear family to have oedipal feelings). In most societies and cultures, children have to come to terms with “thirdness,” which has to do with renouncing one’s own desires and finding ways to manage envy and aggression. This may be expressed through conflicts with deities and gods as in some Asian cultures or Native American cultures, but all children have feelings that go against social norms and which need to be renounced and are ultimately repressed. Freud thought that children were motivated to give up their erotic feelings for their object of desire because they feared retribution coming from the person who is their rival. Often, this is represented as some physical harm that may come to the child. Freud called this castration anxiety and saw it as a precursor to guilt. It is important to mention that the threat of castration as a punishment was not uncommon in Freud’s era. Castration anxiety later becomes an extremely important concept in Freud’s understanding of guilt and the superego. While he viewed boys as fearing castration, he saw girls as feeling already castrated. (See chapter 10 for a fuller explication of Freud’s views on women and why, as a theory that explains heterosexuality and homosexuality, these ideas fall short.) Freud hypothesized that children ultimately resolve their oedipal conflicts by developing a conscience. Through the process of identifying with one parent and by taking on the attributes, values, and ideals of the rival parent, a child’s gender-role identity is solidified. At the same time, by identifying with parental injunctions of right and wrong, a child at the oedipal stage develops an internalized set of moral principles. No longer motivated only by fears of loss of love, children at this stage are now motivated by guilt. This is a feeling that emerges when internal moral prohibitions are violated. It is an internal feeling within the child, not an external prohibition. With the development of a conscience, or what Freud called a superego, morality for the oedipal child now becomes an internal concern. No longer governed by external prohibitions only, the oedipal child now experiences the unpleasant feeling of guilt when she or he encounters sexual and aggressive longings that violate internal moral injunctions and social prohibitions. Hence, one important goal of the oedipal period is to establish, through identification, both a gender-role identity and a conscience. Many kinds of neurotic disturbances derive from fixations at the oedipal stage. These include excessive competitiveness, emotionality, over-sexualization, inhibition, and a sense of inadequacy or inferiority. While pathology may emerge as a result of a fixation at this stage, children’s incestuous and aggressive wishes toward parents and parent surrogates are not, in and of themselves, pathological. Brenner (1955) has written of oedipal feelings that “the most important single fact to bear in mind about the Oedipus complex is the strength and force of the feelings which are involved. It is a real love affair. For many people it is the most intense affair of their entire lives. . . . The description that follows cannot begin to convey what the reader must keep in mind as he reads this: the intensity of the tempest of passions of love and hate, of yearning and jealousy, of fury and fear that rages inside the child” (p. 106). Selma Fraiberg (1959) adds, “Yet this is a dream which must end in renunciation and reconciliation” (p. 204). Oedipal children are often drawn to fairy tales because these stories provide in fantasy both oedipal wishes and their resolutions. In the fairy tale “Jack and the Beanstalk,” Jack is a young boy left alone to care for his widowed mother. Already, this fact contains an oedipal boy’s wish to have his mother exclusively. Jack trades in his mother’s cow (Milky White—an oral image) for three beans. Jack brings the beans to his mother, but she rejects these signs of his manhood, and throws the beans out the window. To Jack’s phallic delight, up sprouts a large beanstalk, which he climbs three times (three being a symbol of triadic relationships) to do battle with a giant ogre (his rival and competitor, who is bigger than he) so that he can

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support his mother. While Jack is (in some versions of the story) saved by the ogre’s wife, and regresses by hiding in her oven (womb), he is finally betrayed by her and must climb down the ogre’s beanstalk. At the bottom, he looks up to see an image many oedipal boys experience when they view their own naked fathers—that of a giant man with a beanstalk (phallus) through his legs. Jack is terrified of being hurt, even devoured, by the giant, who will punish him for trying to steal what is not his (the golden harp). And so Jack chops the beanstalk down with an axe, steals enough gold to provide for his mother, and marries a princess of his own. “Jack and the Beanstalk” has a moral tale to tell the oedipal child. Jack must come to terms with his wishes to have his mother exclusively, with his aggressive feelings toward a symbolic father (the giant), as well as with his fears that the giant will harm him. To deal with his forbidden sexual wishes toward his mother, he both takes on the manly attributes of the giant (or father) and tries to kill him. Jack has expressed a universal oedipal fantasy of coveting what is not his. But by identifying with the giant’s manly strengths, he ultimately gets rewarded by having a princess of his own. Bettelheim (1983) has proposed that Freud’s choice of the Oedipus myth as a guiding metaphor for psychoanalysis was not accidental. The myth of Oedipus is, in fact, the tragedy of a boy who kills his father due to a metaphorical blindness. He kills his father because he does not know himself. The story of Oedipus tells of a boy born to the king and queen of Thebes, who are warned by an oracle that their son will murder his father. To avert that tragedy, they send him away to be killed; however, he is instead adopted by the king and queen of Corinth, whom he believes are his real parents. When he consults an oracle, he is told that he will slay his father. To avoid that fate, he leaves Corinth, only to meet and murder a stranger on the road. Of course, that stranger is his true father. Oedipus, a seeming hero, then answers the riddle of the sphinx and is made king of Thebes, where he marries the queen, unaware, of course, that she is his real mother. When a plague befalls his city, he tries to discover its source and, in the process, uncovers the truth: by not knowing himself, he has, in fact, murdered his father and married his mother. In his grief and despair, he blinds himself, and his mother kills herself. Bettelheim (1983) writes: This is a crucial part of the myth: as soon as the unknown is made known—as soon as the secret of the father’s murder and the incest with the mother are brought to light and the hero purges himself—the pernicious consequences of the oedipal deeds disappear. The myth also warns that the longer one defends oneself against knowing these secrets, the greater is the damage to oneself and to others. The psychoanalytic construct of the Oedipus complex contains this implicit warning too. Freud discovered both in his self-analysis and in his work with patients that when one has the courage to face one’s own unconscious patricidal and incestuous desires—which is tantamount to purging oneself of them—the evil consequences of these feelings subside. Becoming aware of our unconscious feelings—which makes them no longer unconscious but part of our conscious mind—is the best protection against an oedipal catastrophe. (p. 15, emphasis added)

In trying to develop a corollary theory about the oedipal situation for girls (or homosexuals), Freud’s own self-analysis was not helpful. Indeed, both Freud and his female patients were embedded in a culture and a social milieu that devalued women. Within this culture (and his patients gave him plenty of evidence for his theory), he postulated that girls viewed their genitals as “inferior” and as evidence of having already been castrated. He believed that girls were angry with their mothers for having given them an inferior organ and that they envied boys; that they turned to their fathers as heterosexual object choices because they wanted a baby as a compensation for their disappointment and anger with their mothers,

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and that because girls saw themselves as already castrated, and hence inferior, they developed penis envy and the character traits of passivity, receptivity, narcissism, and masochism. Freud’s mistake was not in seeing penis envy but in minimizing its cultural sources. We discuss the phallocentrism of this theory extensively in our gender critique in chapter 10, but that Freud’s theory was phallocentric is incontrovertible. It also failed to allow for a homosexual object choice as a healthy outcome of this period. Freud’s articulation of different psychological development for girls and boys has provoked reactions from women, gays, lesbians, and transgendered people that have lasted over a century. Again, a discussion of these issues can be found in chapter 10. Latency Freud thought of latency (six to eleven years of age) as a time in which the sexual and aggressive drives are relatively quiescent. In latency, sexual and aggressive energy is no longer directed toward parents. The recently intense oedipal passions of romance, longing, and rivalry of the oedipal child are now transformed into behaviors that are calmer, more pliable, and directed toward peers (Noshpitz & King 1991). As school-age children move beyond the bounds of their nuclear families and into the world of school, their sexual and aggressive energies are expressed as a drive to gain mastery of physical skills and cognitive learning. In latency, one sees games, classrooms, and neighborhood configurations organized around same-sex segregation. These games often involve fantasies of superheroes, good guys, and bad guys. For boys, there can be endless delight in being Toxic Crusaders, Superman, or Power Rangers; for girls, being Barbie may express their identification with the culture’s same-sex ideals. What captivates the literary imaginations of latency-aged boys and girls are myths, legends, or mysteries, such as The Knights of the Round Table, the Hardy Boys, or Nancy Drew. All of these stories incorporate themes of adventure and rescue. Peter Pan might be considered the quintessential latency-aged boy. Peter Pan lives with a tribe of lost boys in Never-Never Land, a world characterized by endless battles and chases made up of same-sex peers. In this story, Peter enlists Wendy and her two brothers to leave the real world and join him in his adventures involving pirates and Indians. But when Wendy expresses mildly romantic feelings for Peter, he is willing to lose her forever and even to forsake his tribe of lost boys so that he can continue to live in a same-sex world of exploits and rescue. Sadly, for Peter, Wendy returns to the real world of sexuality where she grows beyond the pleasures of latency and can never rejoin Peter. When Peter returns to find her, he discovers Wendy living in a world that has advanced developmentally beyond him. In latency, aggression is freed from within the bounds of the nuclear family and is expressed through competition with peers. Children at this age define their identities by virtue of their place among their peers—in spelling bees, team games, and sports. Loving and sexual feelings, once directed toward the opposite-sex parent, are often turned into idealizations of the same-sex parent or surrogate (teachers, coaches, etc.). Often latency-age boys and girls will insist that their fathers or mothers and coaches or counselors are the strongest, bravest, and best in the world. Because sexual and aggressive drives tend to be transformed into activity, the latency-age child is notable for exploring, skill building, learning, and socializing beyond the bounds of the nuclear family. This is a stage where children will collect rocks, stamps, baseball cards, bottle caps, dolls, models, and so forth. These sorting and exploring activities, Freud hypothesized, were purposeful behaviors to defend against unacceptable sexual and aggressive impulses.

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Unlike the exhibitionistic phallic child, the latency-age child tends to be modest about his or her body. Now the child’s body becomes a means for achieving in sports, for acquiring skills, and for developing muscles for games. When there are difficulties in body mastery, in learning, or in social interactions, there can be the potential for long-lasting character traits of inferiority, failure, and defeat. Freud also thought that some of the obsessive behaviors of this stage could lead to lifelong character traits marked by rigid thoughts and behaviors. The Genital Stage (Adolescence) Freud proposed that, in contrast to latency, during which the sexual drives are quiescent, adolescence is a tumultuous stage of biological changes in which there is an upsurge of aggressive and sexual impulses. With rises of sex hormones and resultant physical maturation, boys and girls become keenly aware of their bodies and those of the opposite sex. Boys develop facial and pubic hair, their voices change, and they experience nocturnal emissions. Girls develop breasts and pubic hair and begin to menstruate. These physical changes affect cognition, emotion, and fantasy. In the cognitive realm, adolescents may be flooded with sexual and aggressive feelings that may interfere with learning. At the same time, this affective flooding may enrich their curiosity and creativity. Adolescents tend to be highly emotional and often regress to earlier oedipal themes of grief, unrequited love, rage, longing, desire, and revenge. Sudden hormonal changes may cause their mood swings to be intense, confusing, and overwhelming. Given the sexual transformations in their bodies, adolescents gravitate toward peers who can help them develop norms around sexuality. They voraciously seek out literature, movies, music, and other forms of popular culture that are sexually and aggressively explicit. For the adolescent, the world now becomes filled with sexually charged feelings about siblings, teachers, coaches, and peers. Whereas oedipal feelings and fantasies were repressed in latency, they are revived in adolescence. Since one of the goals of adolescence in Western cultures is to separate from the family of origin, sexual attraction to peers promotes disengagement from the family. Adolescents also experience grandiosity and invulnerability in their thinking and judgment, believing that they have all the answers in contrast to their “over-the-hill” parents and teachers. But it is important to note that separation in adolescence is not necessarily the goal in many Asian, Latino, or some African American, Caribbean, or Middle Eastern cultures, and that there can be considerable cultural conflict between less Westernized parents and their more Westernized children at this time. As the objects of their sexual drives shift, so, too, is aggression redirected. Adolescents are known for their acting out and rebellious behaviors, their political and ethical stances that are in opposition to those of their parents, and their devaluation of authority in general. All of these expressions of their aggression, Freud suggested, are in the service of the goal of adolescence—that of separation from the family of origin. Adolescence is also a time for the consolidation of a conscience and of aspirations and goals. Adolescents may go through an ascetic phase characterized by rigid morals and ideals. Their idealizations of idols, music figures, and saints present them with opportunities to experiment with new values and new kinds of ideals. Janna’s white cisgender middle-class parents called the community counseling center alarmed by the changes in their daughter’s behavior. They reported that the school principal had suspended Janna that day for cutting class with her boyfriend and for smoking pot. Her parents lamented that their once responsible, sweet, cooperative girl had turned into a sullen, uncommunicative, and angry fifteen-year-old. Whereas she had once returned from school filled with stories to tell her family, she now spent most of her time at home barricaded behind a closed bedroom door, talking on the phone with friends. She plastered her bedroom walls with posters of the rock

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group Metallica. She wore a nose ring, ripped jeans, and tattered shirts. She spent most of her spare time with her leather-clad boyfriend. In the initial session, her father described how his daughter had been his “special girl,” but how he refused to talk with her now while she was dating “that bum.” Janna responded to the clinician’s questions with shrugs and monosyllabic replies, her gaze transfixed on a tree outside the office window. She said that she just wanted “space . . . to live my own life and make my own decisions.” Janna’s white Western psychological goal was to separate from her family and to define her separate identity. Her sexual and aggressive acting out was her unconscious effort to deal with revived oedipal feelings. Freud would maintain that the way she expressed, modulated, and sublimated her aggressive and sexual drives would ultimately affect the course of her adult personality integration. Were she to remain fixated at this stage of adolescent development, some of the pathological character traits that might emerge might include violations of social norms through acting-out behaviors, a lack of neutralized aggressive and libidinal drives, and a lack of age-appropriate identifications.

It must also be remembered that we now know that the task of each of these stages is not only biologically and psychologically determined but also culturally and socially constructed. Environmental influences always advance or assault personality development. While this idea will be more fully addressed in our discussion of Erikson’s life-cycle theory (chapter  4) and in our chapters on gender and racial theorizing (chapters  10 and 11), Freud’s psychosexual theory did provide a way, albeit culturally narrow, of viewing development as both biological and psychological.

ECONOMIC THEORY Freud evolved another way of thinking about the aggressive and sexual drives: as forces in the mind that, when excessively tied up, left little energy for others. Using economics as a model, he thought that there were finite amounts of psychic energy, which, if used in one place, would be depleted in another. This was a more quantitative way of understanding human behavior (Brandell 2004) than some of his other theories. In his trying to understand the two phenomena of narcissism and depression, his economic theory was at play. Freud understood narcissism as a form of excessive self-love, which did not leave room for the love of others. Based on the myth of Narcissus, who fell so in love with his own image that he drowned, Freud saw the problem of narcissism as that of having too much libido (or love) invested in the self (1914). When we are ill, when we are in mourning, even when we are asleep, we often withdraw our energy from the outside world and invest that energy in ourselves. That is considered healthy narcissism. But when too much energy is invested in the self, there is not sufficient energy for connecting to others, and this may leave the self, impoverished. When Freud considered depression, he again used the lens of economic theory. He believed that in mourning (as with a profound loss), a person turns inward, investing her energy in the work of grief while also hypercathecting (holding on to) the memories of the object or person she has lost. Under the best of circumstances, slowly and with time, one decathects (divests) one’s energy in the loved person and begins to experience energy for new love and for work. For the person who is depressed or melancholic, however, energies that are bound up in the “lost object” are harder to free up. Because we experience ambivalence in every relationship, Freud thought, when there has been a loss, there is also always anger at the person who is gone. But when this anger or aggression is disavowed or entirely denied, then the unconscious aggression toward

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the person who has died or left can be turned inward, and the disavowed hatred toward the other can be turned against the self. This can result in lowered self-esteem, or even in self-hatred. (For a fuller explanation, see chapter 5 on object relations and chapter  15 on depression.) We can see in the case of William, whose early needs were so unmet, how he was more cathected, or bound, to himself than anyone else. We all work with people who have suffered losses and whose energies are so tied up with repressed feelings about those who have died that there is little left energy for the living.

TOPOGRAPHIC THEORY Freud’s archeological roots were never more obvious than in his first understanding of the mind as layered. Freud envisioned the mind as a map. Given his interest in archeological and geological principles, he began to think of the mind as consisting of layers: an unconscious, a preconscious, and a conscious mind. According to this model, the unconscious mind is governed by the pleasure principle. The unconscious is the unruly part of the mind not governed by the constraints of reality; it is the part of the mind in which wishing will make it so. It operates according to primary process thinking. This phrase refers to the chaotic, disjointed world James Joyce so eloquently described in Finnegans Wake. It is a world of free association and fantasy, minimally governed by logic or reality. It is the world in which dreams express fantastical desires, wishes, and urges. The preconscious mind is that part of the mind that can be brought to awareness but that is largely out of consciousness. Jokes and slips of the tongue are evidence of preconscious processes. The conscious mind is governed not by pleasure but by the reality principle. The conscious mind is comprised of the logical, orderly, rational, cognitive operations of everyday waking life. Within the conscious mind is the capacity for self-evaluation, reason, judgment, and delay. It uses a logical and sequential kind of thinking that Freud called secondary process thinking. Freud envisioned the conscious mind as striving to reduce excitation. He proposed that these parts of the mind try to achieve homeostasis, whereby excitement is neutralized. These ideas became central to his understanding of hysteria. They also contribute to the idea of a mind that is always in conflict with itself. It reinforces the basic Freudian idea that unconscious processes always underlie and motivate conscious thinking and behavior.

A BRIEF REVIEW So far, we have considered a number of Freud’s ideas. We began with Freud’s trauma theory. Here Freud thought that trauma was repressed, but its feelings were not. Though the memories were unconscious, when they were awoken by a sound, a smell, or some memory that evoked them, they led to strangulated affects. Through abreacting memories and in the context of a relationship, clients could begin to link their memories with feelings and with words and experience symptom relief. We moved to an analysis of the mind through free association, the investigation of transference, countertransference, and dreams. We considered how we are bound to repeat (the repetition compulsion) that which we do not understand. We considered the absolute value of self-knowledge. We discussed a theory of psychosexual development in which symptoms, character traits, and pathologies may emerge at different moments of development. We discussed an economic theory of development where too much bound-up energy bound up in the self or in the loss of the other may lead to depleted energy and result in narcissism or depression.

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All of these concepts have focused attention on the essential role that unconscious mental processes play in both pathological and normal mental functioning. Freud’s insistence on integrating the past and the present into a unified theory of mental functioning established a compelling agenda to which contemporary students of the mind must refer, whether they agree or disagree with his specific formulations. While contemporary therapists tend to talk about developmentally early desires such as wishes or passions, Freud and his colleagues always used more forceful terms, especially in their early writings. They referred to sexual and aggressive wishes as drives, impulses, or instincts, biologically based words that emphasize that the wishes actually motivate thought, feeling, and behavior. This view argues that we are often driven by psychological forces that we do not understand and, therefore, cannot control through conscious thought. When viewed from this perspective, Freud’s drive theory advances the ideas that both sexual and aggressive impulses seek expression but are in conflict with reality and with society. Drive theory ultimately led to his development of a theory of the mind as being one perpetually in conflict with itself. Freud termed these ideas as structural theory.

STRUCTURAL THEORY Structural theory as first articulated in Freud’s “The Ego and the Id” (1923) supplements and expands classical drive theory. It addresses a number of difficult theoretical and clinical issues that had been recognized during the first twenty-five years of psychoanalysis. The theory is called structural theory because it refers literally to structures—the three structures that Freud believed make up the human psyche: the id, ego, and superego. Structural theory presents us both with great contributions to the field and with problems. On the one hand, it is clear and lucid in its explanatory power. On the other hand, it is too concrete and rigid to explain anything as complex and fluid as the inner workings of a human being. The solid, architectural metaphor of the self as composed, indeed constructed, like a building out of three interrelated parts works well, but not fully. This new theory affirms Freud’s view that unconscious sexual and aggressive drives motivate most, if not all, human behaviors. At the same time, however, it directs our attention toward the central role that the ego plays in organizing and synthesizing mental functioning. At its core, structural theory calls attention to the processes through which the ego regulates unconscious wishes that are morally and/or socially unacceptable. In their original form, such wishes are repugnant to the adult self and, in addition, violate the norms of ordinary social interaction. By emphasizing the ego’s central role in organizing and balancing conflictual forces that arise within the mind, the structural hypothesis markedly expands the range of human behavior that can be explained by psychodynamic theory. Over the course of the first twenty-five years of psychoanalytic practice, Freud began to recognize that his original ideas did not adequately explain his patients’ psychological problems. The clinical data were particularly confounding in regard to two emotional states: depression and anxiety. Freud was keenly aware that, at best, these states are quite distressing, and, at worst, they disorganize mental functioning in extreme ways. Depression presented a particularly serious theoretical problem because Freud’s first theory of unconscious mental conflict did not provide a reasonable explanation for why aggression might be directed against the self. Since guilt and self-hatred are the hallmarks of depressive illness, the lack of a viable explanation was quite disconcerting to patients and therapists alike. Anxiety was also problematic because the early theoretical formulations suggested that it arose as a consequence of unsatisfied sexual desires. This formulation suggested that anxiety would

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disappear when clients uncovered the unconscious wishes they had previously repressed. While these ideas seemed reasonable from a theoretical perspective, it gradually became apparent in the clinical situation that a significant number of clients became more, rather than less, anxious when they began to recognize their unconscious desires or experience the danger of aggression against the self. The theoretical and practical importance of these problems can best be illustrated by a case example (Hayes 1991, personal communication): A therapist reported the treatment of a nine-year-old African American girl, Shovanna, who suffered from episodic rages accompanied by the temporary loss of well-established psychological functions such as the capacity to speak. These difficulties had severely disrupted her life both at home and at school. Shovanna had seen her mother shoot and kill her father when she was four years old. Prior to the killing she had regularly witnessed violent fights between her parents. During a play therapy session, she had her doll shoot an adult doll and then begin to drown a baby doll in a sink of water. As the play progressed, she panicked, screaming as if she were being killed. Quickly she became even more disorganized, perspiring profusely, wetting herself, and speaking incoherently. When the therapist realized what was happening, he intervened to “save” the baby doll from “drowning.”

An early drive theorist would explain Shovanna’s disorganization in terms of unconscious wishes or memories breaking through the repression barrier into consciousness. This explanation would assume unconscious content related to either repressed aggressive wishes directed toward one or both of her parents or repressed memories of a traumatic event she had actually lived through. However, neither of these formulations explains why she would turn her aggression against the baby doll after shooting the adult doll (it seems likely that, in fantasy play, the baby doll represented herself), or why she so quickly regressed to an almost infantile level of functioning, wetting herself and losing the capacity to speak coherently. Certainly, her anxiety did not decrease or disappear as she became aware of her aggressive wishes, nor were her depressive feelings ameliorated by her expression of anger (in the play situation) against the adult caregiver (doll). Later in this chapter we will see that Freud’s structural theory provides a more useful explanation of such dilemmas by postulating an unconscious conflict among the different agencies (id, ego, and superego) of the mind, with the ego mediating between the opposing forces. In chapter 3, we will see that ego psychology suggests still another explanation by emphasizing the study of defense mechanisms and the importance of overall ego functioning. Although drive theory, structural theory, and ego psychology complement one another, each framework advances a somewhat different explanation for the same clinical problem. As we will see over the course of this book, the most useful explanations, from both the therapist’s and the client’s perspectives, are the ones that best consider the client’s level of emotional development, internal (psychological) organization, and capacity for object relations, as well as the social/economic and political contexts in which the client lives. If we now return to the case vignette, we can probably agree that regardless of the theoretical perspective utilized to understand Shovanna’s terror, “remembering” the wishes and/or events she had previously repressed initially made her worse. As her defenses crumbled, she was immediately overwhelmed by a combination of anxiety and terror. When she could no longer repress what had been unconscious, she became younger and younger in her emotional functioning in a desperate effort to reestablish her psychological equilibrium. By regressing to a more and more infantile level of functioning, Shovanna clearly communicated her need for a caring adult who would protect her against the memories, feelings, and wishes she had worked so hard and so long to “forget.” Since her

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emotional response made it clear that she was incapable of managing the terrifying inner world she had thus far concealed from both herself and the world around her, the therapist acted quickly to support her ego by rescuing the baby doll, at which point Shovanna was able to pull herself together. We will discuss the concept of ego support in more detail in chapter 3. Freud addressed the theoretical problems related to depression, anxiety, and symptom formation in three major publications: “Mourning and Melancholia” (1917), “The Ego and the Id” (1923), and “Inhibitions, Symptoms and Anxiety” (1926). He was sixty-one when he published the first of these papers and seventy when he completed the third—quite an accomplishment for a man of his age. In these works, Freud proposed a new and more complex model of the mind that has come to be known as structural theory. He also markedly revised his views about the nature of depression and anxiety, and about the roles these powerful emotions play in mental functioning.

TERMINOLOGY Before discussing structural theory as it is currently conceptualized, we want to revisit what we said earlier in this chapter. Bettelheim (1983) contends that many of Freud’s original concepts were seriously distorted to make them seem more scientific, and therefore more acceptable to the American medical profession. He notes that in “naming” the structures of the mind that we now call the id and the ego, the origin of the words id, ego, and superego was actually rooted in the everyday language of German children. Das es, German for the id, referred to that which is irrational, uncontrolled. Das ich, German for I, actually referred to the self, to the idea of me. Both the id and the I were imbued with feeling and meaning, which, when translated to the Latin, became cold, mechanistic, and technical. No word has greater and more intimate connotations than the pronoun “I.” It is one of the most frequently used words in spoken language—and more important, it is the most personal word. To mistranslate Ich as “ego” is to transform it into jargon that no longer conveys the personal commitment we make when we say “I” or “me”—not to mention our subconscious memories of deep emotional experience we have when, in infancy, we learned to say “I.” (Bettelheim 1983, p. 53)

Bettelheim goes on to explain that in choosing the term superego the translators rendered that concept even more sterile. The term Freud chose was uber Ich, and again he used it as a noun. In English, it would be the “over I.” In German, uber Ich not only conveys the notion of mature conscience but also carries the feel of the tyrannical persecutory, immature inner forces that can be inappropriately self-blaming. Superego, not even being an English word, has no such resonance for us. This commentary should be kept clearly in mind when studying structural theory. While the theory in its (mis)translated form has considerable explanatory power, Bettelheim is right in saying that the “scientific” language we currently use objectifies the intimate, emotionally powerful mental processes that define who we are as individuals, and what each of us shares with humanity at large. In the process, it distances therapists from both their own and their clients’ inner lives. For these reasons, it is especially important to balance a thorough cognitive understanding of mental structure and organization with a keen appreciation for the personal meanings and the intensity of feeling that vitalize our inner lives. One way to stay as close as possible to Freud’s original meaning is to remember the colloquial, childlike evocative words that he so purposely chose.

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STRUCTURAL CONCEPTS: THE ID, THE EGO, AND THE SUPEREGO Structural theory postulates that all mental activity is organized around the interaction of three relatively stable and enduring structures or agencies of the mind: the id, the ego, and the superego. Each of these structures has a set of unique functions. Although the structures are interdependent, their aims and functions frequently conflict. As a result, their interaction within the mind generates considerable dynamic tension, or what is known as intrapsychic conflict. By studying their interaction, therapists have come to understand unconscious mental conflict, particularly as it leads to neurotic symptom formation (hysteria, phobias, compulsions, etc.). In addition, therapists have learned that the processes that synthesize inherently incompatible wishes and fears also lead to healthy adaptation, even among individuals who have been severely traumatized. Finally, structural theory has taught us to empathize with the unconscious struggles that our clients experience, even when the clients themselves know nothing more than that their symptoms make them feel utterly miserable. Let us now turn to a fuller description of each of the three psychic agencies. The Id The id is described as the source and repository of sexual and aggressive impulses, the seat of all desire. It is the part of the mind that wants what it wants when it wants it. It is also the part of the mind that makes sure there is hell to pay if the gratifications it seeks are either delayed or denied. It is governed by the pleasure/unpleasure principle, the concept that the whole aim of all mental activity is to seek pleasure and avoid pain. It is not directly influenced by reality, morality, logic, or social convention. Classical drive theory assumes that its contents do not change after adolescent development has been completed. In spite of this formidable description, it is assumed theoretically that id impulses can be contained, rechanneled, or transformed as a result of ongoing interaction with the ego. Substantial evidence drawn from clinical practice supports that view. The id is thought to be rooted in physiological processes that cannot be represented in the conscious mind. Accordingly, only derivative expressions of id aims and objectives reach conscious awareness. When derivatives become conscious, they do so in the form of sexual and aggressive fantasies (and/or impulses to act), and this allows dynamically oriented practitioners to make inferences about the influences the id is exerting on mental processes at given moments in time. A forty-four-year-old African American, working class, divorced woman who had been in treatment for six months told of a dream in which she had watched her highly respected and admired minister argue vehemently with his wife. At the height of the argument, he turned to the client saying, “Let’s go off together. I’m fed up with my wife and I’ll be a lot happier with you than I ever was with her.” The dream ended with the client and the minister going off happily together while his wife receded noisily into the background. Not surprisingly, the client felt considerable shame and guilt as she described the dream. Even though this dream comes close to conveying the underlying id wishes, it is derivative in that the “real” objects of the client’s passion, competition, and disdain are still disguised. As treatment progressed, she revealed that her mother had been seriously ill when she was an adolescent, and that she had spent a great deal of time trying to care for her alcoholic father. She imagined that she would be able to convince him to stop drinking, and she remembers thinking when she was thirteen or fourteen that she could have been a much better wife to him than her mother ever was. Over time the underlying oedipal dynamics became quite clear, as did the fact that the minister and his wife were stand-ins for her father and mother.

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Freud’s (1940) formal definition states that the id “contains everything that is inherited, that is present at birth, that is laid down in the constitution—above all therefore, the instincts which originate from the somatic organization and which find a first psychical expression here (in the id)” (p. 145). Earlier, Freud (1933) had described the id as “the dark inaccessible part of our personality. We approach the id with analogies: we call it a chaos, a cauldron full of seething excitation” (p. 73). Since Freud never modified his view of the id, it is worth emphasizing that the concept of the id, over and above its usefulness as a theoretical paradigm, reflects a philosophical view of basic human nature—no exceptions and no apologies, at least not from Freud. The Superego The superego is conceived of as a relatively enduring organization of moral beliefs and prohibitions within the mind. Although psychodynamic practitioners tend to think of it as conscience (in the adult sense of the term), it also represents developmentally early, punitive, and persecutory tendencies. In essence it tells us how we ought to think and act, and how we may not think or act. It “sets up and maintains an intricate system of ideals and values, prohibitions and commands. It observes and evaluates the self, compares [the self] with the ideal, and either criticizes, reproaches and punishes . . . or [conversely] praises and rewards” (Moore & Fine 1990, p. 189). While the superego can represent morality and civilized behavior, it can be as demanding and unreasonable as the id is in the pursuit of pleasure and vengeance. Depending on how and when moral expectations and prohibitions are internalized, the superego may or may not demonstrate an appreciation of moral complexity. In early childhood, it tends to be harsh, rigid, and punitive, often reflecting the principle that an eye for an eye and a tooth for a tooth is the only possible and right form of justice. If development progresses reasonably well, such persecutory fantasies diminish, and the superego gradually becomes more flexible, more reasonable in its expectations, and better able to appreciate realistic constraints on moral behavior. As this occurs, the punishments it demands become less harsh, and within broad limits it becomes more tolerant of moral ambiguity. A ten-year-old may believe that it is “never, ever, ever okay to tell even the teeniest lie,” while an adult may realize that sometimes it is appropriate or even necessary to tell a fib to protect or spare someone. In performing its functions, the superego may diminish or enhance self-esteem, often in extreme ways. In the psychodynamic literature it is frequently described as an internal authority or judge that functions below the level of conscious awareness. Typically, individuals do not recognize the ongoing mental processes of self-evaluation that so acutely affect how they feel about themselves. However, derivatives of these processes regularly become conscious in the form of fluctuations in self-esteem. When, as frequently happens, these fluctuations occur without apparent cause, individuals experience good or bad feelings about themselves that seem unrelated to anything happening in their day-to-day experience. Similarly, individuals may punish or endanger themselves in serious ways, without any conscious awareness that they are doing so. A  thirty-seven-year-old white cisgender divorced man from an Evangelical Christian family entered treatment because of depression and the feeling that he could never develop a positive relationship with a woman. He had grown up in a very religious family with an abusive, alcoholic father and a resigned, long-suffering mother. His mother never acknowledged her husband’s drinking or his abusive behavior. Although the client expressed a great deal of anger toward both his mother and his former wife, he maintained the view that he had been mostly, if not

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entirely, responsible for the breakup of his marriage and for the problems in his subsequent relationships with women. Well into the second year of therapy, he acknowledged, with enormous shame and guilt, that he had been sexually involved with prostitutes during his senior year in college. Although he had renounced his family’s religious beliefs many years previously, he still felt strongly that his “unclean” sexual activities in college made him unfit to be with a “decent” woman. In the course of discussing these feelings and memories, he acknowledged for the first time that some of his recent sexual encounters with women had bordered on sexual harassment. It occurred to him that such encounters not only confirmed his view that no decent woman would want him but also endangered his career. It was only then that he became conscious that if he had been sued and/or fired from his job, he would have finally succeeded in punishing himself as he thought he deserved to be punished (“ruined forever”), for his “sinful” sexuality. It had never occurred to him that the behavior that for so many years had kept him at the edge of ruin might be related to guilt, shame, or a need to punish himself. Since sexual harassment is a very serious problem rooted in social inequality as well as individual psychology, this psychodynamic examination of this client’s behavior, while accurate for him, does not constitute a general explanation for harassing behavior, nor does understanding these dynamics in any way excuse it.

Freud first proposed the concept of the superego in his 1923 monograph, “The Ego and the Id.” In that work, he attempted to solve a number of theoretical problems related to guilt, self-hatred, and the workings of an internal conscience. Freud thought that the superego came into existence through identification with the parent of the same sex during the resolution of the Oedipus complex. He also thought that, once the superego had been established, its contents remained relatively constant throughout life. In the psychoanalytic literature, identification is viewed both as an ego defense and as a process that contributes to intrapsychic structuralization—the creation and maintenance of psychic structure. In this second meaning, identification involves taking in selected aspects of a beloved person and incorporating those aspects as functional parts of the self, without conscious awareness of their origins. Contemporary theorists think that the contents of the superego change throughout the life cycle. In addition, they view the ego ideal as a functional part of the superego. In structural theory, our ego ideals play a significant role because who we want to be contain representations of the attributes we value most in the people we love. Our ego ideals function as the repository of our most cherished ideals, strongly influencing how we wish to lead our lives and whom we want most to emulate. Who we want to be, how we want to live are all influenced by our ego ideals. The Ego Structural theory starts by postulating that, within the mind, the aims of the id and the superego are diametrically opposed. If structural theory is to work as a general explanation of personality organization, it must then postulate the existence of a third structure. This third structure is needed to mediate the conflicts generated by the two structures that oppose each other. Without a third structure, the mind would be constantly divided against itself, and it would be impossible to conceive of a coherent functioning personality or of cohesive individual identity. Structural theory, then, postulates the existence of the ego. If we think about the theory as a model of the mind in conflict, we recognize that the ego functions as a kind of internal gyroscope. Its most important task is to maintain psychological cohesion and stability in the face of the powerful, conflictual forces that arise when id, superego, and/or external reality

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clash—that is, when people experience a combination of wishes, moral demands, social expectations, and fears that are inherently incompatible. Technically speaking, the ego is described in terms of a relatively stable group of functions that organize, synthesize, and integrate mental processes. In the early formulations (Freud 1923), its central role involved mediating between the conflicting demands of the id, the superego, and external (social) reality. Contemporary theorists have markedly expanded its functions to include: (1) perceiving the physical and psychological needs of the self as well as the qualities and attitudes of the environment; (2) evaluating, coordinating, and integrating perceptions of the self and external reality, so internal demands can be adjusted to better correspond with external requirements; (3) finding ways of achieving optimal gratification of the sexual and aggressive wishes that are compatible with moral constraints and social norms; (4) repressing or rechanneling those wishes that offend or defy social norms; and (5) preserving a reasonable level of self-esteem by maintaining good relations with the superego. To accomplish these tasks, the ego must be as sensitively attuned to the demands of the physical world and social reality as it is to the demands of the id and the superego. Note that the first four ego functions listed above place as much emphasis on the ego’s relationship with external reality as they do on its relationship with the other structures of the mind. Over the course of psychosexual development, the ego develops a characteristic defensive organization that protects the self from what it perceives as internal and external danger. Different defense mechanisms operate below the level of conscious awareness and are brought into play automatically whenever the ego begins to experience feelings of anxiety. Anxiety, as Freud reconceptualized it in 1926, is engendered when the different psychic structures come into conflict either with each other or with external reality. Generally speaking, defense mechanisms assist the ego in its efforts to resolve mental conflict. When a specific conflict cannot be resolved, the defense mechanisms work to encapsulate the conflict and reduce its effect on overall mental functioning. We will describe the defense mechanisms and their effect on functioning in some detail in chapter 3.

COMMON MISINTERPRETATIONS The concept of enduring mental structures can be quite misleading since it is easily misinterpreted. The first common misinterpretation is based on the idea that the id, ego, and superego are physiological entities located in specific areas of the brain. This idea leads practitioners to talk about the composition, contents, and functions of the various mental structures as if they were organ systems that can be isolated, mapped, and manipulated. The second misconception proceeds on the assumption that the structures of the mind are homunculi (imaginary, diminutive people) who live inside the brain where they perform specific tasks and fight with one another when their aims or functions conflict. When this way of thinking predominates, as it often does, even among knowledgeable clinicians, discussions of intrapsychic conflict take on the quality of battlefield dramas in which opposing armies attempt to defeat or dominate each other (e.g., a powerful id that overwhelms a poorly defended ego and a weak superego in the pursuit of sexual gratification). In considering this problem, it is important to recognize that Freud and his colleagues deliberately used metaphors to convey complicated ideas about mental functioning that did not lend themselves to ordinary methods of exposition. For example, structural theory draws on architectural and/or anatomical metaphors. Conflict theory evokes images of warfare, while topographical theory, which we described earlier, is rooted in the concepts and methods originally developed for the study of archeology and embryology. In spite of

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their usefulness, metaphorical explanations can be problematic. They lack precision and they mean different things to different people. As a result, they are interpreted in a variety of idiosyncratic ways. For that reason, if for no other, it is essential to remember that when we talk about structures of the mind, we are describing very complex mental processes in an evocative rather than a precise way. In using the concept metaphorically, we are encouraged to imagine how our own and our clients’ mental lives might be organized. Such acts of imagination make it possible to temporarily enter the minds of our clients, and they are thus beneficial to both therapists and clients. That is, they are beneficial as long as the therapist remembers that the structures of the mind are metaphors not metropolises or organ systems. The following case example demonstrates how structural theory may be used to explain unconscious mental conflict and neurotic symptom formation. It describes how the ego reduces conflict within the mind by creating symptoms that are both pathological and, within the context of an individual’s life history, adaptive. This paradox is intrinsic to the theory and is intentional. Freud believed that neurosis is the price human beings pay for civilization. A caveat is in order: Freudian theory, especially structural theory, can sometimes sound like a parody of itself. With its metaphors of pipes and dams and eruptions, it easily lends itself to ridicule and has been the butt, as it were, of many jokes. It is attributed to Freud that even he said a cigar is sometimes just a cigar. In the following case, it just so happens that structural theory was the most useful tool to illuminate and alleviate this client’s suffering. Mr. Johannson, a fifty-seven-year-old married cisgender Caucasian man of Scandinavian descent, requested treatment for compulsive symptoms and obsessive thoughts that interfered with his normal functioning and caused him considerable mental distress. He worked alone on the night shift as a technician in a hydroelectric generating plant, a responsible, well-paying job that he had held for almost twenty years. His final task was to turn off fifteen valves that controlled the passage of water through the turbines that generated electricity. He was supposed to complete this task at 1:00 AM, the time of day when electricity demand was at its lowest point and his work shift ended. In describing himself, Mr. Johannson recognized that he had always been a very “careful” person and a conscientious employee. In the past years it had taken him approximately half an hour to shut off and check the valves. That was twice the time it took the technician who relieved him on his days off. However, it was important to him that he do his work “correctly,” so he was wanting to take the extra time. For six months prior to his request for treatment, he had been spending more and more time turning off the valves. The night before his first therapeutic appointment, it had taken him almost three hours to shut down the generating station. As a result, he got home well after 4:00 AM. In addition to his concerns about the extra time spent on the job and about getting home to his wife so late, Mr. J. said that he was consumed with anxiety about making a mistake. He felt that if he made an error in shutting down the plant, he would cause a massive flood that would injure people and destroy property. “Rationally” he knew this could not happen. Nonetheless, the prospect made him so anxious that he would return to the beginning of the sequence twenty or thirty times a night to make certain that he had not left a valve open. For example, he said, no sooner had he closed valve six, then he began to worry about whether he had fully closed valve two. This made no sense to him because even if he did leave a valve open, the only consequence would be that water would continue flowing through the turbines, drawing down the reservoir and perhaps reducing the amount of water available to produce electricity the next day. In fact, one of the weekend technicians had done just that and had received a mild reprimand from the supervisor. But this compulsive symptom was making Mr. J. miserable. He complained that it interfered with his relationships with his wife and grown children, as well as with the daytime activities he enjoyed. However, he felt he had absolutely no control over the symptom and that, in fact, the

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symptom was controlling him. He had begun to dread going to work, a feeling that was extremely distressing to him since he had always enjoyed his work. Over the first three months of treatment Mr. J. explored how his symptom had affected relations with other family members. He remembered that the compulsion had begun at about the time he found he could not maintain an erection when attempting sexual intercourse with his wife. This had happened on two or three occasions, for the first time in his life. He had no idea of why he might have experienced this difficulty and was extremely upset by it. He had consulted his family physician, who assured him that occasional impotence was not unusual for a man of his age and that there was no reason for him to be concerned. He had not been reassured by the physician’s advice. As he continued to talk about his feelings, he realized that, in fact, he had been avoiding sexual relations with his wife because he feared being impotent again. He also recognized that his compulsion at work reduced the opportunities for sexual relations with his wife, who in the past had waited up for him until he returned from work but could not wait for him until 4:00 or 4:30 AM. She worked during the day and needed a reasonable amount of uninterrupted sleep, a need Mr. J. accepted without question or complaint. As treatment progressed, he gradually recalled that his impotence had first occurred at a time when he and his wife were having a serious disagreement about how much financial support to offer a son who had lost his job. It was unusual for Mr. and Mrs. J. to have serious disagreements, but in this instance, he felt his wife was being too indulgent. At one point he found himself secretly wondering whether his wife preferred his son to him, a thought he was quite ashamed of. In spite of his angry and jealous feeling, he had decided to “give in” to his wife’s wishes because he remembered how stern and ungiving he felt his own father had been when he was growing up. In discussing these feelings and memories, he recognized how hurt, angry, and upset he had been, both about his wife’s attitude and his son’s “inability to take care of himself.” When the therapist suggested that these feelings might have contributed to his impotence, he expressed considerable interest in the idea. He decided to discuss his feelings with his wife and promptly did so. She had been unaware of how strongly he felt and was quite concerned about his hurt feelings. Over the next six months, his compulsion gradually disappeared and his relationship with his wife improved markedly. His fears about being impotent diminished, and he was able to resume a mutually satisfying sexual relationship with his wife.

As this case suggests, it would be possible to explain Mr. J.’s compulsion by applying Freud’s first theory—that is, that his frustrated sexual impulses had been transformed into anxiety and symptomatic behavior. Yet the clinical material in its fullness required a more complex explanation. Using structural theory, Mr. J. and his therapist came to understand that the initial incidents of impotence stemmed directly from a conscious attempt on Mr. J.’s part to control his angry feelings (aggressive impulses) toward his wife and son. While this attempt was overtly successful, it had serious consequences at the level of unconscious mental functioning. The first consequence appears to have been his impotence, which was accompanied by guilt and a profound loss of self-esteem, as his superego “reproached” him for being so angry with his wife and son. Concurrently, his sexual desires were frustrated as a result of his impotence, and to make matters worse, his self-esteem (ego ideal) was injured when he was unable to live up to his own standard of masculinity. His ego, faced with a serious disruption of intrapsychic equilibrium, an upsurge of libidinal and aggressive impulses, and a significant loss of self-esteem, automatically instituted defensive measures. We will discuss the specific defenses he employed in chapter 3. Suffice it to say at this point that the ego’s work so far (note the anthropomorphism) kept Mr. Johannson’s aggressive feelings toward his wife and son outside the realm of conscious awareness and prevented him from acting on them. However, the ego had not addressed the sexual frustration and loss of self-esteem that accompanied his impotence. His inability to maintain an erection threatened Mr. J.’s

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ideal image of himself (ego ideal) and interfered with the id’s demand for genital orgasm. In attempting to provide the id with some measure of substitute gratification, the ego offered a compromise that involved regression to an earlier stage of psychosexual development (the anal stage). In doing so, it temporarily diverted the id from its original aim (genital orgasm). With sadness and relief, Mr. J. realized that his fantasies were expressed symbolically through his fear of opening a giant pipe and causing a destructive flood. At this point in the process of symptom formation, the ego was attempting to work cooperatively with the id to provide the best form of gratification that could be achieved within the context of superego and reality constraints. As the foregoing analysis indicates, the process of symptom formation involves both effort and creativity on the ego’s part. Often a symptom is a compromise formation, combining, in symbolic form (so that different elements will not enter conscious awareness), a forbidden impulse, a threatened punishment, and a solution that attempts to reconcile the conflicting forces. Even when, as in Mr. Johannson’s case, the solution is problematic and creates a great deal of psychological misery, it constitutes the best compromise the ego can devise at a particular moment in time given the client’s idiosyncratic psychosexual history and the environmental context in which he functions. When symptoms successfully perform the function the ego intends, they encapsulate a troublesome intrapsychic conflict without unduly disrupting overall psychic functioning. For example, a mild handwashing compulsion will, for some people, stabilize unconscious conflict over forbidden sexual or aggressive impulses, without seriously interfering with the individual’s day-to-day activities or relationships. In Mr. J.’s case, however, the symptom did not perform this function effectively, as evidenced by his increasing level of anxiety and the fact that, night by night, it was taking him longer to complete the ritual the ego had devised to deal with the conflict. A  therapeutic relationship was thus necessary to help Mr. J deal more adaptively with this conflict: to recognize his anger at his wife, to reflect upon how it may have been turned against himself, to explore why he was so harsh with himself, to find ways to express his desires that were less conflicted, and to resolve his dilemma with his wife, which took the form of feeling, and being, impotent. The case discussion illustrates the usefulness of structural theory in studying and understanding complex mental processes, especially those that lead to symptom formation.

OVERVIEW AND EVALUATION In creating structural theory, Freud viewed the mind as an arena in which inherently incompatible forces contend with each other for primacy. He viewed the ego as a crucible in which wishes, fears, moral demands, and social expectations are synthesized. The structural hypothesis is thus a theory that explains how the mind is organized and how its different parts interact with one another. It is also a philosophical treatise that proposes a thought provoking, but not entirely satisfactory, view of the relationship between individuals and the societies in which they live. Structural theory, like drive theory before it, made a significant contribution to understanding human suffering as a result of intrapsychic conflict. It utilized and expanded drive theory but gave more primacy to the role of the ego over the id, and eventually laid the groundwork for psychology of the ego. In this one chapter, we have considered Freud’s genetic, topographic, dynamic, economic, and structural theories. We have looked at key technique ideas including free association, transference, countertransference, trauma, symbolic meaning, manifest and latent content, the repetition compulsion, and the role of self-knowledge.

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What an incredible feat for one man to have developed, refined, and elaborated so many complex ideas! Let us now turn to the development of ego psychology to understand more fully the role the ego plays in maintaining healthy and adaptive functioning.

REFERENCES Akhtar, Salman. (2009). Comprehensive Dictionary of Psychoanalysis. London: Karnac Books. Bettelheim, B. (1983). Freud and Man’s Soul. New York: Knopf. Bibring, E. (1943). The conception of the repetition compulsion. The Psychoanalytic Quarterly 12:485–519. Brandell, J. (2004). Psychodynamic Social Work. New York: Columbia University Press. Brenner, C. (1955). An Elementary Textbook in Psychoanalysis. New York: International Universities Press. Breuer, J., & Freud, S. (1895/1950). Studies in Hysteria, ed. A. A. Brill. Boston, MA: Beacon. Brill, A. A. (1921). Fundamental Conceptions of Psychoanalysis. New York: Harcourt-Brace. Danto, E. (2005). Freud’s Free Clinics: Psychoanalysis and Social Justice 1918–38. New York: Columbia University Press. Erikson, E. (1950). Childhood and Society. New York: Norton. Fraiberg, S. (1959). The Magic Years. New York: Scribner. Freeman, L. (1979). Immortal Anna O. New York Times Magazine, November 11, pp. 30–38. Freud, S. (1900). The interpretation of dreams. Standard Edition 4/5:1–626. ———. (1912). A note on the unconscious in psychoanalysis. Standard Edition 12:255–67. ———. (1914). On narcissism, an introduction. Standard Edition 14:67–102. ———. (1917). Mourning and melancholia. Standard Edition 14:243–58. ———. (1922). Beyond the Pleasure Principle. Trans. by C. J. M. Hubback. London, Vienna: International Psycho-Analytical. ———. (1923). The ego and the id. Standard Edition 19:3–66. ———. (1926). Inhibitions, symptoms and anxiety. Standard Edition 20:75–175. ———. (1933). New introductory lectures on psychoanalysis. Standard Edition 22:5–182. ———. (1940). An outline of psychoanalysis. Standard Edition 23:144–207. Freud, S., & Breuer, J. (1893). Psychical mechanisms of hysterical phenomena: Preliminary communication, in “Studies in hysteria.” Standard Edition 2:1–48. Hayes, M. (1991). Personal communication. Jones, E. (1953). The Life and Work of Sigmund Freud, Vol. 1. New York: Basic Books. Lerman, H. (1986). A Mote on Freud’s Eye: From Psychoanalysis to the Psychology of Women. New York: Springer. Loewald, H. W. (1971). On motivation and instinct theory. The Psychoanalytic Study of the Child 26:91–128. Loftus, E., & Ketcham, K. (1994). The Myth of Repressed Memory. New York: St. Martins. Masson, J. M. (1984). The Assault on Truth. New York: Farrar, Straus & Giroux. Milne, A. A. (1924/1952). When We Were Very Young. New York: Dutton. Mitchell, S. (1988). Drive theory and the metaphor of the beast. In Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press. Moore, B. E., & Fine, B. D., eds. (1990). Psychoanalytic Terms and Concepts. New Haven, CT: Yale University Press. Noshpitz, J., & King, R. (1991). Latency. In Pathways of Growth: Essentials of Child Psychiatry, Normal Development, Vol. 1, eds. J. Noshpitz and R. King. New York: Wiley. Pine, F. (1990). Drive, Ego, Object Self. New York: Basic Books.

3 Ego Psychology Gerald Schamess and Robert Shilkret

Structural theory was forged in the aftermath of World War I, a cataclysmic event in human history. Between 1918 and 1936, Freud and his colleagues witnessed one unthinkable disaster after another: the war itself, the widespread destruction left in the aftermath of the war, the deadly flu epidemic of 1918, the dismemberment of the Austro-Hungarian Empire, the Great Depression, the rise of Nazism, the beginnings of the Holocaust, and the preparations for World War II. Deeply pessimistic about human nature at its core, structural theory teaches practitioners about the “primitive” desires that drive human experience, about archaic codes of justice and retribution, and about the uniquely human struggle to transform amoral childhood wishes and fears into civilized adult behavior. In contrast, ego psychology began to take shape in Vienna and England toward the end of the period between the two world wars, and it was elaborated after World War II, mostly by European expatriates who emigrated to the United States to escape Nazi persecution. Buoyed by their newfound political freedom and encouraged by the optimism that characterizes American society, they were considerably more hopeful in their fundamental view of human nature and more pragmatic in their approach to understanding mental processes. They shared certain beliefs with the Freudians about the powerful forces in the id, but were far more interested in the ego, which they saw as the preeminent psychic agency. For the most part, they studied and theorized about how the mind accomplishes particular tasks. Filled with optimism about their newfound land, many focused on mastery, competence, and strengths. Ego psychology also encourages practitioners to think about developmental processes across the life cycle, the unfolding of human capacities in response to the interaction between environmental influences and inborn developmental potentials, the internal forces that propel individuals toward ever more complex and goal-directed patterns of organization, and the ways individuals either adapt to their social and physical environments or modify those environments to make them more compatible with personal needs and wishes. Because ego psychology focuses attention on the mind’s development in interaction with the social and physical world, it provides clinicians with a theoretical framework for (1) repairing the 47

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effects of arrested, incomplete, or distorted psychosocial development, and (2) facilitating a better fit between the psychological needs of the individual and the normative expectations of society. It also attends to the “fit” between individuals and their environments.

CONCEPTUALIZATIONS OF THE EGO The ego has been conceptualized in different ways over time. Freud’s (1923) original formulation was, simultaneously, the most elegant and the most constricting. In its relation to the id [the ego] is like a person on horseback, who has to hold in check the superior strength of the horse; with this difference, that the rider tries to do so with his own strength while the ego uses borrowed forces. The analogy may be carried a little further. Often a rider, if he is not to be parted from his horse, is obliged to guide it where IT wants to go; so in the same way the ego is in the habit of transforming the id’s will into action as if it were his own. (p. 25)

In this quotation, Freud emphasizes the ego’s relative lack of strength in relation to the id. He notes that the horse (id) has most of the energy and power, and that the rider (ego) must depend on the horse’s power if he hopes to arrive at his chosen destination. The metaphor suggests that most of the time, but not always, the ego is capable of harnessing the id’s energy toward its own purposes. Eloquent though the imagery is, Freud’s view of the ego’s relationship to the id and to the external world does not adequately convey how the ego is organized or how it functions. Because the metaphor assumes that the ego’s fundamental job is to regulate id impulses, it does not recognize that other ego activities such as perception, cognition, judgment, reality testing, and affect regulation also play vital roles in helping individuals achieve their chosen objectives—that is, if we wish to preserve Freud’s imagery of directing the horse where the rider wants to go. In other words, the metaphor does not recognize that the rider has strength, knowledge, goals, and a range of inborn capacities that contribute to his effectiveness in regulating the horse’s behavior. Contemporary conceptualizations focus on the ego’s executive and synthesizing functions. The conceptualizations assume that the ego performs a variety of different tasks that, when combined, allow it to organize and manage mental experience and functioning. The ego attempts to stabilize mental equilibrium, in much the same way as a gyroscope orients and stabilizes the path of a rocket in flight. Since each individual gradually constructs an idiosyncratic style of ego organization over the course of his/her psychosocial development, each individual’s ego has idiosyncratic strengths and weaknesses. These particular strengths and weaknesses reflect the techniques and processes the ego utilizes to manage internal and external stimuli. Over time, the ego organizes the techniques into a stable, repetitive pattern called character structure. This pattern makes it possible for individuals to think, feel, and act in predictable ways throughout the life cycle. Conceptualizing the ego in terms of its organizing and synthesizing functions focuses attention on the large number of specific tasks that must be accomplished, which people take for granted as they go about their day-to-day lives. The most important of these are: 1. perceiving, filtering, and selectively remembering the enormous amounts of information that originate both inside and outside the mind; 2. organizing (editing) the filtered information in ways that allow individuals to think, feel, and act coherently;

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3. finding socially acceptable ways of satisfying the conflicting demands of the id and the superego; 4. facilitating all of the routine mental activities (loving, learning, playing, acquiring new skills and capabilities, etc.) that characterize human experience; 5. mastering the developmental and social challenges that arise normatively over the course of the life cycle; 6. developing capacities that make it possible to deal adaptively with the ordinary stresses of everyday life; and 7. finding ways of minimizing the disruptive effects that trauma has on overall functioning. While a number of specific ego functions are listed in the section that follows, it is important to keep in mind that the concept of ego cannot be understood simply as the sum of its component parts, or even as the sum of its many functions. Contemporary ego psychologists assume that the ego has successfully accomplished its organizing and synthesizing functions when individuals experience themselves as coherent, functional human beings with an enduring sense of personal identity. When viewed from this perspective, the concept of ego closely resembles Erikson’s concept of ego identity (see chapter 4) and Kohut’s concept of the self (see chapter 6). The following vignette illustrates adaptive, synthetic functioning under stress: A forty-seven-year-old divorced woman of Bulgarian descent moved to a new job in a new community where she had no friends or family. Her twenty-two-year-old son, an only child, had decided to pursue his career in their hometown, several thousand miles away. The woman was the oldest child in a large family that had always celebrated Christmas with ceremony and enthusiasm. The Christmas following her move she decided not to go home, fearing she would realize how lonely she was in her new community. To cope with her loneliness, she invited a number of acquaintances to her home for Christmas dinner. She chose people she knew who did not have other plans for the holiday. The dinner was potluck, and she advised her guests to bring one present to be given to another guest after dinner. When the time for gift giving arrived, she stipulated that none of the guests could open a gift until they had answered a personal question asked by another guest. Her guests, many of whom barely knew each other, were delighted by the game and enthusiastically engaged in asking and answering questions. By the end of the evening the party had generated considerable good feeling, much to the hostess’s delight. The lively interaction and good cheer temporarily overcame her loneliness and reminded her of the family gatherings she had enjoyed so much. She also realized that she had gotten to know quite a lot about her various guests. Although she still missed her son and siblings, she felt she had begun to make a place for herself in her new community.

EGO FUNCTIONS The ego’s ability to organize and synthesize mental activity is based on the interaction of a number of interrelated capacities called ego functions. The most important of these are described below. A working understanding of ego functions is enormously helpful both in evaluating clients’ strengths and weaknesses and in predicting how they are likely to respond to different therapeutic interventions. In addition, periodic review of a client’s ego functioning provides the therapist with a systemic way of evaluating treatment progress.

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Reality Testing This function involves the individual’s capacity to understand and accept both physical and social reality as it is consensually defined within a given culture or cultural subgroup. In large measure, the function hinges on the individual’s capacity to distinguish between her own wishes or fears (internal reality) and events that occur in the real world (external reality). The ability to make distinctions that are consensually validated determines the ego’s capacity to distinguish and mediate between personal expectations, on the one hand, and social expectations or laws of nature, on the other. Individuals vary considerably in how they manage this function. When the function is seriously compromised, individuals may withdraw from contact with reality for extended periods of time. This degree of withdrawal is most frequently seen in psychotic conditions. Most times, however, the function is mildly or moderately compromised for a limited period of time, with far less drastic consequences. The following vignette describes someone whose reality testing was severely compromised: A young volunteer entered a locked, padded, seclusion room in a state mental hospital. The room was occupied by a ten-year-old boy who crouched, trembling, in a corner. An aide explained that the boy had become violent that morning, attacking everyone who approached him. Having placed him in seclusion, the staff thought it might comfort him if someone kept him company. Since the boy conveyed nonverbally that he did not want to be approached, the volunteer sat quietly in the corner furthest away from him. After an hour, the boy asked why the volunteer was there. The volunteer answered frankly and asked if the boy was frightened. The boy asked why the volunteer wasn’t afraid of the snakes. Startled, the volunteer looked around the room. The boy volunteered that the room was crawling with poisonous snakes that were trying to kill him. The only safe place was where he was sitting, since he was saying “magic words.” However, he didn’t see any snakes where the volunteer was sitting and asked how the volunteer kept the snakes away.

A second example describes a less severe loss of reality testing: A young professional white woman, Mary, had been living with her aged mother, who died suddenly. The estate was not large, and the will divided the assets equally among Mary and her siblings. Mary mourned her mother intensely. In addition, she needed money desperately since she had not worked during the years she lived, rent free, with her mother. She had cared for her mother and, with her mother’s approval, had pursued an interest in painting. Among her mother’s possessions was an heirloom chest that the siblings decided to sell to raise cash. Citing her knowledge of antiques, Mary estimated the chest’s worth. Much to everyone’s surprise, two professional appraisers evaluated it at half of Mary’s estimate. For the next six months, Mary refused to accept the professional evaluations, thereby making it impossible to sell the chest. It was only after her grief had moderated and she had found a full-time job that she accepted the “realistic” appraisal and allowed the chest to be sold. Her temporary loss of reality testing was a result of her ego’s depletion in the process of mourning her mother.

Judgment This function involves the capacity to reach “reasonable” conclusions about what is and what is not “appropriate” behavior. Typically, arriving at a “reasonable” conclusion involves the following steps: (1) correlating wishes, feeling states, and memories about prior life experiences with current circumstances; (2) evaluating current circumstances in the context of social expectations and laws of nature (e.g., it is not possible to transport oneself instantly out of an embarrassing situation, no matter how much one wishes to do so); and

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(3) drawing realistic conclusions about the likely consequences of different possible courses of action. As the definition suggests, judgment is closely related to reality testing, and the two functions are usually evaluated in tandem. We have placed the quotation marks around “reasonable” and “appropriate” because sound judgment is a social construct. Clinicians who understand the contextual nature of judgment think carefully about their own cultural values, as well as about the particular social and cultural contexts within which their clients live. For example, the “appropriate” response to a schoolyard threat from peers is quite different for middle-class, suburban high school students than for inner-city students. The middle-class students would, at worst, have to consider the possible implications of being drawn into a fistfight. The inner-city student with good judgment would have to consider the possibility of being shot. The “appropriate” action for the two teenagers would be quite different, and would depend not only on their internal (psychological) organization but also on the realistic dangers they face and the social norms that characterize their particular communities. On a day-to-day basis, judgment plays a central role in deciding whether one has drunk too much to drive safely; whether one is adequately prepared to pass a test at school; whether the man or woman one has fallen in love with is likely to be a loving, reliable partner; or, at the most basic level, whether one is dressed warmly enough to go out in the cold (you and your mother might disagree about whether you are properly dressed).

Modulating and Controlling Impulses This function is based on the capacity to hold sexual and aggressive feelings in check without acting on them until the ego has evaluated whether they meet the individual’s own moral standards and are acceptable in terms of social norms. Adequate functioning in this area depends on the individual’s capacity to tolerate frustration, delay gratification, and tolerate anxiety without immediately acting to ameliorate it. Impulse control also depends on the ability to exercise appropriate judgment in situations where the individual is strongly motivated to seek relief from psychological tension and/or to pursue some pleasurable activity (sex, power, fame, money, etc.). Problems in modulation may involve either too little or too much control over impulses. A group of adolescent male gang members were on a therapeutic camping trip and were cooking shish kebab for dinner over an open fire. Having delayed preparing the fire until they were famished and desperate to eat, they were only able to cook the meat until it was lightly browned on the outside before they tried to eat it. With each bite, they yelled and cursed, blaming the counselors because the meat was raw. This sequence was repeated again and again because the boys could not control their appetites long enough to cook the meat adequately. The only gang member who enjoyed his meal was a boy accurately nicknamed “Joe Fats” because of his love of food. Of all the boys, he alone listened carefully to the counselor’s instructions and waited patiently until the meat was cooked. He feasted royally while his friends cursed. An intellectually precocious eight-year-old boy, who was also discussed in chapter 2, was referred for treatment because he regularly defecated in his pants. During a treatment session that opened with a discussion of his inability to control himself, he began to talk about his interest in Napoleon’s military campaigns. Recognizing his admiration for and identification with Napoleon, the therapist asked whether he thought Napoleon “pooped” in his pants. He fixed the therapist with a withering stare and said, “Napoleon pooped anytime and anywhere he pleased.” The interchange highlights the boy’s unwillingness to exercise age-appropriate control over his bowel functions.

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Therapists who work with eating disorders regularly see problems that arise from excessive impulse control. A common but extreme example involves the anorexic teenager who, on eating half a carrot, feels compelled to exercise for several hours to burn off the calories she has consumed. Clients who are severely anorexic may have great difficulty in tolerating any kind of oral pleasure, feeling that food will make them fat and ugly, and that they have to punish themselves severely whenever they eat. Modulation of Affect The ego performs this function by preventing painful or unacceptable emotional reactions from entering conscious awareness, or by managing the expression of such feelings in ways that do not disrupt either emotional equilibrium or social relationships. To adequately perform this function, the ego constantly monitors the source, intensity, and direction of feeling states, as well as the people toward whom feelings will be directed. Monitoring determines whether such states will be acknowledged or expressed and, if so, in what form. The basic principle to remember in evaluating how well the ego manages this function is that affect modulation may be problematic because of too much or too little expression. As an integral part of the monitoring process, the ego evaluates the type of expression that is most congruent with established social norms. For example, in many white American cultures it is assumed that individuals will contain themselves and maintain a high level of personal/vocational functioning, except in extremely traumatic situations such as the death of a family member, very serious illness, or terrible accident. This standard is not necessarily the norm in other cultures. For example, when Arabic women mourn the death of a loved one, their culture expects them to scream and wail publicly, tear their garments, and pull out their hair. Women who do not publicly express intense grief are viewed with suspicion. Their restraint is thought to be inappropriate, suggesting they may not have really loved the family member who died. Compare the Arabic norm for mourning among women with the vignette cited below, which describes an American man who is mourning his mother’s death. In doing so, keep in mind the gender differences within American culture; men who mourn are expected to behave differently from women who mourn. Using a cultural standard, the behavior described in this vignette would have been even more problematic had the client been a woman. This first vignette illustrates constriction in the expression of affect: A white Anglo-Saxon man calmly told his therapist that he was relieved about his beloved mother’s death. He noted that she had suffered greatly from a degenerative neurological illness during the last years of her life. He added that his religious beliefs assured him that she has passed on to her “just reward” in Heaven. During the memorial service and funeral he did not shed a tear, and after the service he disposed of her household possessions without the slightest conscious awareness of grief. Some weeks later he entered treatment. He was perplexed about the reasons for his reduced work effectiveness and for his difficulty concentrating, even on such simple tasks as reading the newspaper.

The second example involves excessive and inappropriate expression: A middle class man with Greek origins, a photographer, felt his supervisor had unjustly reprimanded him. Consumed with anger, he told the supervisor, “You’re not fit to be a pimple on a real photographer’s ass.” He told friends about this incident, who worried about his future, yet he was the only one surprised when he was fired. On being asked to reflect on this behavior, he

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commented that he had every right to be angry and to express it openly. His only regret was that the remark overestimated his supervisor’s competence.

In evaluating this man’s overall ego functioning, it would be necessary to consider not only his capacity to modulate affect but also his reality testing, judgment, and capacity for impulse control. As the example illustrates, all of these functions were seriously compromised. Object Relations This function is discussed as a separate theory in chapter  5. For now, it is sufficient to say that this function involves the ability to form and maintain coherent representations of others and of the self. The concept refers not only to the people one interacts within the external world but also to significant others who are remembered and represented within the mind. Adequate functioning implies the ability to maintain a basically positive view of the other, even when one feels disappointed, frustrated, or angered by the other’s behavior. Disturbances in object relations may manifest themselves through an inability to fall in love, emotional coldness, lack of interest in or withdrawal from interaction with others, intense dependency, and/or an excessive need to control relationships. Self-Esteem Regulation This function involves the capacity to maintain a steady and reasonable level of positive self-regard in the face of distressing or frustrating external events. Painful affective states, including anxiety, depression, shame, and guilt, as well as exhilarating emotions such as triumph, glee, and ecstasy may also undermine self-esteem. Generally speaking (and this is a generalization), in white American culture a measured expression of both pain and pleasure is expressed; excess in either direction is a cause for concern. White Western cultures might tend to assume that individuals will maintain a consistent and steady level of self-esteem, regardless of external events or internally generated feeling states. A thirty-five-year-old professional white man of Lithuanian descent who had grown up with rejecting parents had always assumed that his wife sometimes ignored him because she didn’t love him. His perception caused him enormous emotional pain and confirmed his private view that he was less than fully human. His idea that he was basically a “loathsome” creature reflected his serious problems in self-esteem. After discussing his feelings in treatment, he asked his wife whether she was avoiding him, and if so, why. To his surprise, he discovered that during childhood she had suffered from a serious learning disability, and still had difficulty focusing her attention when she felt “over-stimulated.” Since she knew that she loved him and he loved her, she had always assumed he would understand if she was sometimes inattentive. He responded to these revelations by further examining his reasons for viewing himself as a person “with whom no one would voluntarily associate.” Thereafter, he found it easier to maintain a positive sense of self-esteem, even when his wife was distracted and temporarily unavailable to him.

Mastery When conceptualized as an ego function, mastery reflects the epigenetic view that individuals achieve more advanced levels of ego organization by mastering successive developmental

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challenges. Each stage of psychosexual development (oral, anal, phallic, genital) presents a particular challenge that must be adequately addressed before the individual can move on to the next higher stage. By mastering stage-specific challenges, the ego gains strength in relation to the other structures of the mind and thereby becomes more effective in organizing and synthesizing mental processes. Freud expressed this principle in his statement, “Where id was, shall ego be.” An underdeveloped capacity for mastery can be seen, for example, in infants who have not been adequately nourished, stimulated, and protected during the first year of life, in the oral stage of development. When they enter the anal stage, such infants are not well prepared to learn socially acceptable behavior or to control the pleasure they derive from defecating at will. As a result, some of them will experience delays in achieving bowel control and will have difficulty in controlling temper tantrums, while others will sink into a passive, joyless compliance with parental demands that compromises their ability to explore, learn, and become physically competent. Conversely, infants who have been well gratified and adequately stimulated during the oral stage enter the anal stage feeling relatively secure and confident. For the most part, they cooperate in curbing their anal desires and are eager to win parental approval for doing so. In addition, they are physically active, free to learn, and eager to explore. As they gain confidence in their increasingly autonomous physical and mental abilities, they also learn to follow the rules their parents establish and, in doing so, win parental approval. As they master the specific tasks related to the anal stage, they are well prepared to move on to the next stage of development and the next set of challenges. When adults have problems with mastery, they usually enact them in derivative or symbolic ways. Over a two-year period, prior to each of her therapist’s three vacations, an intelligent, well-­ educated, Latina client from an upper-class family cancelled the last appointment prior to the therapist’s departure. She had been abandoned repeatedly by her parents and other caregivers during childhood and had unconsciously established a pattern of leaving relationships before the person she cared about could leave her. Well in advance of his next planned vacation, the therapist pointed out the pattern of missed appointments. She was surprised by the therapist’s comment since she was totally unaware both of what she had done and of the feelings connected with her behavior. As a result of the interpretation, she kept all her appointments, including the last one before the therapist left. After the therapist’s return she commented that it had taken her more than two years to believe he would actually come back. Moreover, in his absence she realized she had never believed he would want to see her again, even if he did return. The interview material suggests that, over the course of treatment, she had begun to master the separation anxiety that had, until then, interfered with her attempts to establish intimate relationships. From that point onward she could talk more openly about her fears of loss and abandonment. Over time, her attention gradually turned to issues of sexuality and intimacy and the absence of parental love and extended family that she had experienced.

THE USE OF DEFENSE MECHANISMS Up to now we have discussed the ego in terms of the specific functions it performs. In doing so, we have paid particular attention to the superordinate functions that involve organizing and synthesizing mental processes. We now consider the ego’s role in protecting the self from both real and perceived danger, along with the methods (defenses) by which it fulfills that task. Defense mechanisms are among the most important of the ego functions.

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The ego requires protection from four kinds of danger: (1) conflict among the different agencies of the mind (id, ego, superego); (2) conflict in interpersonal relationships; (3) conflict in relation to social norms and institutions; and (4) the disruption of psychological equilibrium that occurs in response to trauma. Conflicts among the agencies of the mind arise when there is a clash between developmentally early, unconscious, sexual, and aggressive wishes (emanating from the id) and the ethical and moral standards represented by internalized conscience (emanating from the superego). Interpersonal conflict arises when an individual’s unconscious wishes and fears are incompatible with the behavioral expectations and needs of caregivers, family members, friends, and/or lovers. Social conflict arises when unconscious wishes or fears and the behaviors associated with them challenge consensually accepted social norms. Trauma occurs when psychological equilibrium is disrupted (at least temporarily) by an inescapable need to cope with terrifying external events. When faced with one or more dangers, the ego uses defense mechanisms to protect the self. Defense mechanisms automatically and unconsciously modify the individual’s perception of and/or reaction to danger. The specific mechanisms that are employed reflect the ego’s evaluation of perceived danger and the level of psychosocial development the individual has achieved. Ego psychologists believe that the conscious self feels threatened whenever it becomes aware of unconscious wishes and fears, regardless of whether they originate in the id or superego. Every defense mechanism is designed to keep unconscious content from entering conscious awareness. However, each defense mechanism accomplishes the task in a different way. While defense mechanisms protect the self from perceived danger, they do so at a certain cost. The cost varies, depending on the mechanisms employed. As one would expect in a hierarchical theory that emphasizes the mastery of stage-specific developmental tasks, it is assumed that individuals employ defense mechanisms that are congruent with their achieved levels of ego organization. At the lower levels of ego organization, the ego uses defenses that significantly interfere with reality testing. Defenses such as denial and projection interfere with overall ego functioning even though they protect the self to a limited degree. At intermediate levels of organization, the ego employs defenses that interfere with impulse control and judgment, turn wishes and fears into their opposites, redirect feelings away from their original objects, impede cognitive functioning, and/or undermine memory. Defenses such as acting out, reaction formation, displacement, and repression interfere less with overall functioning and usually provide the self with better protection. However, the cost of utilizing them may still be considerable. At higher levels of organization, the ego uses defenses (e.g., sublimation and humor) that protect the self quite well and enhance rather than interfere with overall functioning. Although the distinctions between the defenses used at higher and lower levels of ego organization are important, clinicians should remember that individuals always use the most adaptive defenses available to them. The unconscious use of a defense or set of defenses depends on the individual’s developmental history, the nature of his/her significant relationships, and the stresses and supports inherent in his/her social environment. Within that context, the defenses reflect the best choices that the individual is capable of making. Descriptions of defenses in the literature and in the classroom often sound pejorative, almost as if the person employing them were doing something bad or weak. Nothing could be further from the truth, since defenses are always attempts (often gallant attempts) to preserve psychic integrity and survival under the pressure of stress and fears. It is important for clinicians to remember this principle when deciding how they will deal with specific defenses that interfere with overall functioning.

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Anxiety and Defense Mechanisms Before listing and describing the defense mechanisms used by the ego, it is important to explain how they relate to anxiety. Defense mechanisms are automatically triggered when the ego becomes conscious of anxiety, an inherently distressing emotion that individuals experience along a continuum ranging from mild discomfort to intolerable panic. Unpleasant though it is, anxiety serves a necessary and useful function in regulating mental processes. In much the way that pain alerts us to problems that are likely to affect our bodily functions, anxiety alerts us to problems that are likely to affect our emotional well-being. It is effective as a warning precisely because most people find it so painful and unsettling. When the ego perceives anxiety, it responds by mobilizing the defense mechanisms available to it with the aim of preserving emotional well-being and limiting the degree of functional impairment. In his monograph “Inhibitions, Symptoms and Anxiety,” Freud (1926) identified five steps of anxiety. Each type is associated with a particular stage of psychosexual development and with a normal developmental task that must be mastered if the individual is to progress to the next, more advanced developmental stage. Freud thought that the first and most overwhelming kind of anxiety was experienced in early infancy, particularly during the initial twelve months of life. He named it automatic anxiety to distinguish it from signal anxiety, which he viewed as developmentally more advanced. Automatic anxiety arises in response to excessive levels of frustration, such as hunger, or threatening kinds of stimulation, such as fever, loud noises, or noxious odors, which the infant can neither escape nor modulate. When faced with such painful stimulation, infants have no recourse except to cry, kick, and flail about. Fortunately, they can usually be consoled by an attuned caregiver, even when they are extremely distressed. If outside help is not forthcoming, they can only cry until they exhaust themselves and fall asleep. By doing so, they shut off both outside stimuli and internal mental processes. Contemporary ego psychologists assume that infants experience these terrifying moments at the level of excruciating organic distress, accompanied by inchoate fears that overwhelm them. If this type of anxiety is reevoked in adulthood, it frequently leads to psychotic decompensation. However, some traumatized individuals are able to limit the degree of decompensation, even when so stressed, by utilizing dissociation as a defense. Dissociation, which also shuts off internal and external stimulation, has serious but far less drastic consequences (see chapter 16 on anxiety disorders). Because this type of anxiety threatens the total loss of ego functioning, contemporary theorists refer to it as annihilation anxiety, a term chosen in an attempt to capture the depth of the overwhelming, disorganizing terror involved. A second, developmentally more advanced level of anxiety often referred to as “fear of loss of the object” is originally experienced during the second and third years of life. It involves the fear of being abandoned by a primary caregiver. Since young children depend on adults both for survival and for emotional well-being, abandonment anxiety is quite terrifying. In spite of the degree of terror that the threat of abandonment evokes, therapists should remember that abandonment anxiety is an important marker of developmental progress. Abandonment anxiety can occur only when normal development has progressed far enough for the child to recognize that the primary caregiver exists separately in the world, and therefore is not under the child’s omnipotent control. Generally speaking, if this kind of anxiety is reevoked in adults, it is enacted through intensely dependent and/or clinging behavior, or through acting out, which may be antisocial in nature. Acting out unconsciously asserts that the individual does not need a caregiver, is not anxious, and is capable of taking perfectly good care of himself without any assistance from anyone else.

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A third level of anxiety, called “fear of loss of the object’s love,” is associated with the threat of losing the caregiver’s love and esteem. Children ordinarily become aware of this danger during their third and fourth years of life. It is evoked by their attempts to (1) curb childhood sexual and aggressive desires and (2) accept the behavioral rules and constraints their parents endorse. This type of anxiety is allayed when children can maintain a stable internal representation of the caregiver (object constancy) and are willing to change their behavior in order to win the caregiver’s approval. At a still more advanced level of development, we see an anxiety that is specific to the phallic and oedipal stages of development. This type of anxiety, unfortunately still often referred to as castration anxiety, involves a fear of retribution, bodily harm, or the loss of an essential, highly valued physical or mental capacity. It is based on the child’s projected fear of retribution for hostile wishes against a parent. Adults who reexperience this kind of anxiety tend to use neurotic defenses and to function at a neurotic level of intrapsychic organization (see chapter 16). In spite of the psychic pain associated with castration anxiety, its appearance indicates that the individual has successfully mastered the previous stages of psychosocial development and has achieved a high level of ego integration. And finally, during latency, children may selectively experience anxiety associated with any or all of the earlier stages of psychosexual development (annihilation, abandonment, loss of the caregiver’s love, retribution, bodily injury, and/or loss of valued capacities). Different levels of anxiety are evoked because the internalized parental representation, the superego, has assumed responsibility for making moral judgments and meting out punishment. In this role, the superego threatens the ego with phase-specific punishments, based on how it views particular wishes, feelings, and memories. Ego psychologists believe that after latency, if development has progressed reasonably well, the superego will be less punitive in responding both to forbidden wishes and to situations that threaten its moral standards. The mature superego’s increased flexibility reduces pressure on the ego, thereby making it possible for the ego to consider a greater range of options in attempting to resolve intrapsychic and interpersonal conflict. Since contemporary theory states that the ego continues to mature during latency and thereafter, people who have mastered the developmental tasks intrinsic to the oral, anal, phallic, and genital stages of development tend to experience anxiety in more transient ways, to employ healthier (higher-level) defenses, and to become less dysfunctional in the face of perceived psychological danger. Defenses are activated by anxiety in the following way: When the ego perceives anxiety, it responds automatically, first by evaluating the nature of the danger, and second, by reviewing its repertoire of defenses. It employs a defense or set of defenses that had been effective in managing a similar threat earlier in life. Since all defenses are unconscious, individuals do not ordinarily recognize either the danger they are defending against or the protective mechanisms that have been activated. The activation of defenses happen unconsciously, totally outside the individual’s conscious awareness. If defenses work as intended, anxiety disappears from conscious awareness. However, if the defenses fail and do not eliminate (or at least diminish) the threat of danger, anxiety increases and additional defenses are called into play. Generally speaking, the most threatening perceived dangers are those that reevoke real and/or imagined childhood fears. To illustrate how this process works, it is useful to reconsider Mr. Johannson, the power plant engineer who was discussed in chapter 2. Mr. J. obsessed endlessly over whether he had actually turned off the water outtake valves he was responsible for turning off. During treatment he remembered that he had been very angry at his wife because she had sided with his son in a family disagreement. With considerable shame, he also remembered his feeling that his wife preferred his son to him. This incident reevoked

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childhood experiences of his own with an indulgent mother and a stern, punitive father. When, some months later, he became impotent for the first time, his childhood anxieties returned. Unconsciously, he viewed his impotence as the punishment he had feared when he was five— castration. In thinking about his impotence, he was consciously aware of concerns about his sexual functioning but not of his childhood memories or anxieties.

In attempting to deal with both the current and historical threats to his manhood, Johannson’s ego employed several defense mechanisms that had previously protected him from similar dangers (the defenses italicized here are explained in more detail below). When his anger at his wife threatened his childhood defense of repression (he remembered nothing about his childhood oedipal wishes and fears), he regressed to a developmentally earlier level of psychosexual organization, replacing the wish for genital intercourse with a compensatory wish to exhibit his phallic prowess by creating an enormous flood. (There is a wonderful description of similar fantasy in Rabelais’s [1532] classic book Gargantua and Pantagruel, 1946 edition, pp.  41–43.) Realizing that the compensatory wish was also unacceptable, he defended against it through reaction formation and undoing; that is, in his conscious mind he was determined not to cause a flood (reaction formation), even if he had to turn the valves on and off for hours at a time (doing and undoing). Given the strength of the wish and the intensity of his castration anxiety, the combination of defenses available to him did not work adequately. His levels of anxiety and functional impairment increased, and he finally entered treatment. Defense mechanisms are easy to understand once their unconscious content is revealed. Before the client has recognized and acknowledged unconscious content, however, the underlying meaning of any given defense mechanism is, by definition, unclear. In fact, there is no way a therapist can be certain that a defense mechanism is being utilized until the client acknowledges the defense in some fashion. For example, if the client does not remember an event or a feeling (repression), how can the therapist know that the patient is not remembering something? Similarly, if a client says she loves her mother, how can the therapist determine whether she does, in fact, love her mother or whether she unconsciously hates her mother (reaction formation)? While it is useful for therapists to develop hypotheses based on other information the client has presented, it is important to remember that hypotheses are no more than informed speculations, until they are confirmed or disconfirmed by the client. This way of approaching the unconscious material encoded in defense mechanisms encourages therapists to be respectful of the protective role that defenses play and to remember that clients voluntarily (albeit unconsciously) give up defenses when they feel it is safe to do so. From an ego psychological viewpoint, patience, respect, and careful observation are the crucial elements that permit clients to feel safe enough to recognize the underlying meaning of the defenses they employ.

A HIERARCHY OF DEFENSES We can now consider specific defense mechanisms and how they operate. Of the twenty or more defense mechanisms identified by Anna Freud (1936) and George Vaillant (1992), we will present eleven. In doing so, we will follow the well-established tradition of categorizing defenses hierarchically. Vaillant (1992) classifies defenses as developmentally early/ psychotic, immature, neurotic, and mature/healthy. These categories parallel the stages of psychosexual development that have been discussed previously. Note that the classification

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reflects a continuum. It begins by describing defenses that drastically impair functioning, continues with defenses that are less disruptive, and ends with defenses that enhance functioning. Although we will use Vaillant’s classification system, we do so with a proviso. Vaillant contends that people who function at the higher levels of ego organization always employ higher-level defenses, the ones he classifies as neurotic or mature/healthy. In contrast, clinical reports suggest that highly functioning clients actually employ a wide range of defenses, including some that are categorized as developmentally early or immature. It seems likely that the ability to call on, as needed, a wide range of different defenses is an indication of emotional health. Vaillant’s hierarchical system seems slightly more reliable in describing clients who function at lower levels of ego organization. Such clients seem to have fewer defenses available to them, and therefore rely almost exclusively on developmentally early and/or immature mechanisms; however, clinicians have seen many examples of clients with poor ego organization who also have a rich array of defenses at their disposal depending on the level of anxiety they are experiencing. Developmentally Early/Psychotic Defenses Denial The ego ignores or disavows a painful event or the meaning connected with it. When denial is operating, the ego simply does not acknowledge the existence or implications of threatening aspects of external reality. In its most extreme forms, denial contributes to the development of psychotic delusions and hallucinations. However, in most instances it simply blocks out specific events or stimuli that are overwhelmingly threatening to the ego. Denial is ubiquitous among alcoholics and drug abusers who, even in the face of overwhelming evidence, refuse either to admit their addictions or to acknowledge that the addictions interfere with their functioning. For example, in an inpatient alcohol rehabilitation program, it was customary to videotape the original intake interview with every client. Two weeks later, when the clients had “dried out” and regained their health to some degree, they were shown their own videotapes. Approximately a third of them insisted they were not the person who appeared in the videotape. They could not or would not believe they had ever looked so desperate, so down-and-out (Rohan, personal communication about the alcohol treatment program at the Northampton, Massachusetts, Veterans’ Administration Hospital, 1984). Like every other defense mechanism, denial can be adaptive under certain circumstances, especially in realistically dangerous situations where there is no means of escape. Soldiers in combat use denial adaptively to minimize their terror and to keep fighting. Patients suffering from slow, debilitating, and fatal illnesses often use adaptive denial to sustain their will to live. People with impaired hearing who communicate through sign language will, sometimes, when they don’t want to understand what is said to them, simply close their eyes. Projection The ego deals with unacceptable impulses and/or terrifying anxieties by attributing them to someone in the external world. In this defense, individuals do not experience or acknowledge the projected impulses or anxieties as their own. The feel victimized by some other person who, inexplicably, wishes to injure them, or who blames them for

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some terrible deed. In its most extreme form, projection dominates the mental life of psychotic or paranoid clients whose relationships with external reality may be seriously compromised. Even when it is utilized by healthier people, projection can be a startling and disconcerting defense. For example, a white recreation worker tells of having to restrain a six-year-old African American boy who had been throwing pool balls around the game room. When the boy had finally been carefully restrained, he turned around, spat in the worker’s face, and said, “You black boogie bastard.” The worker, who was quite fond of the child, later told his supervisor, “I  was near tears. I  don’t know much psychology, but I do know that if one of us sees himself as a ‘black boogie bastard,’ it’s not me.” Because projection can have such a profound, negative effect on the people toward whom it is directed, it is important to emphasize the important constructive role it plays in everyday human interactions. Projection makes it possible to fall in love, to care for children, and to empathize with people whose inner lives and cultural experiences are different from our own. All of these quintessential human activities are based on the ability to put one’s own thoughts and feelings into someone else’s mind and to retrieve them as needed. The process can be more or less healthy, depending on the degree to which the projected thoughts and feelings are congruent with the other person’s actual thoughts and feelings. Immature Defenses Acting Out This defense involves the direct expression of wishes, impulses, and fantasies through overt behavior. Immediate action makes it possible for individuals to avoid conscious recognition of distressing feelings they unconsciously experience as intolerable. “Acting out involves chronically giving in to impulses in order to avoid the tension that would result were there any postponement of expression” (Vaillant 1992, p.  245). Addicts who drink because they cannot tolerate depressive feelings, patients who engage in self-­mutilation because they feel unsure of whether they are actually alive, and the adolescent who steals a leather jacket because he can’t tolerate wanting but not having a jacket of his own are all using acting out as a defense. Dissociation In dissociation, a painful idea or memory is separated from the feelings attached to it, thereby altering the idea’s emotional meaning and impact. It is a core defense among incest survivors and among adults who were abused as children. A thirty-eight-year-old white working-class woman who had been sexually abused repeatedly as a latency-age child could remember the details of the abuse, but did not experience any feelings in relation to the abuse. She knew intellectually that she must have bad feelings, but could feel nothing. After a period of treatment she became aware that when she started to experience feelings connected with the abuse, she simply disappeared emotionally, even in the middle of a conversation. “I just go away in my head. Sometimes when I’m driving, I look around and realize I’ve lost half an hour. I don’t know where I am, how I got there, or what’s been going on in my head. I’ve just been gone, even though I’ve been driving the car. I get scared about that. I wonder whether someday I’ll have a serious accident.”

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Regression This defense involves a retreat to an earlier level of psychosexual functioning and/or ego organization. Typically, it appears when a specific developmental challenge cannot be mastered or when an environmental stressor creates high levels of anxiety. While it usually makes its first appearance as a defense during the anal stage of development, it is utilized throughout life regardless of the individual’s level of ego organization. In childhood, regression is frequently seen after the birth of a sibling. For example, an older child temporarily loses bowel or bladder control, even though control had previously been well established. In such instances, the regression is caused by jealousy of the new baby and by the older child’s fantasy that he would be equally loved and fussed over if he were a baby. Regression may also take place “in the service of the ego.” When adults become physically ill and need care, they frequently take to their beds, asking to be fed, bathed, and pampered. While such behavior reflects a transitory wish to be a baby again, it may also facilitate healing. When regression is temporary, as in this example, it enhances ego functioning by providing individuals with a moratorium during which they do not feel they have to act in mature and responsible ways. As a result, they are able to reassess their emotional problems, recover their strength, and return more rapidly to prior levels of functioning. When this occurs, stress on the ego is reduced, and the degree of functional impairment is limited. Under such circumstances, regression not only protects the self from danger but also enhances the ego’s adaptive capacity. In therapy, regression can be beneficial if it helps clients get in touch with their developmentally early wishes and fears and with preverbal bodily needs. Generally speaking, however, when regression continues over long periods of time, it significantly impairs ego functioning. The duration and degree of regression markedly affects the “cost-benefit” ratio and may make use of the defense counterproductive. Neurotic Defenses Repression This defense simply involves complete forgetting. Thoughts, memories, and feelings that are repressed simply do not exist in the person’s conscious mind. Repression protects the self from unwelcome knowledge such as the awareness of desires that defy moral standards, or fears that are too terrifying to contemplate, or disappointments that are too difficult to bear. One young, African American woman in treatment began talking about how much she had suffered in school from her serious, yet undiagnosed, learning disabilities. She described feeling not only stupid and ashamed but also alone and unprotected because no family member or teacher paid enough attention to help her figure out what was wrong. As the patient described those painful feelings and events, her white therapist was thinking rather smugly about how vigilant and active she had been regarding her own children’s learning disabilities and what excellent help she had gotten them. After the session, the therapist expected to feel compassionate toward the patient and pleased with herself and was therefore surprised when she felt very frightened and ill at ease. She was even more surprised during the next session when she sat there nervously, hoping the subject of learning disabilities would not come up. Her anxiety grew until several days after the second session she suddenly remembered that she, too, had struggled with learning disabilities

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as a child and that no one had been aware of her difficulties or helped her with them. Like her patient, she had learned to get decent grades by paying very careful attention in class and compensating in every way possible for her visual-motor impairment. She had repressed these painful memories because she had not wanted to recognize how angry and hurt she was at her parents for their neglect. During the first session, during which her client talked about learning disabilities, the therapist recalled how good she was with her own children, a reaction formation that, among its other functions, allowed her to forget the ways in which her parents had failed her. Her attempt at repression failed, however, when the patient’s story made her aware of the painful memories she had unconsciously banished. Reaction Formation This defense transforms an unacceptable wish into an acceptable one, a “bad” wish into a “good” one. When individuals employ reaction formation as a defense, the wishes of which they are consciously aware are the exact opposites of the wishes they actually want to fulfill. To understand this defense one must recognize that expressed love can conceal hatred, expressed mercy can conceal cruelty, and expressed obedience can conceal defiance. For example, parents who are very angry at their children will often be overly solicitous about the child’s health and well-being, sometimes to the point of emotionally suffocating the child. Similarly, people who feel sexual desire for an unavailable partner will often describe publicly, at great length, in very derogatory terms, how sexually unattractive the object of their desire is. Although such talk may be part of a conscious strategy to challenge and attract a partner, when the underlying attraction is unconscious, the negative comments serve a defensive purpose. Displacement In this defense, unacceptable sexual and aggressive wishes are directed away from one person and redirected toward another. Usually, wishes and impulses are directed away from a person who is perceived as inappropriate and/or dangerous and redirected toward a person who is perceived as appropriate and/or safe. A young therapist working in a mental health clinic was unconsciously angry at his supervisor. He was unaware of his anger, in part because he was afraid the supervisor would evaluate him poorly. During his supervisory meetings, he complained bitterly about the clinic administration. Even though he was expressing intense anger he was unconcerned about his supervisor’s response, since he knew she shared many of his negative opinions. He was quite surprised one day when his supervisor quietly asked him whether he might also be angry at her. At that point, he could no longer maintain the displacement, and he became consciously aware of his angry feelings for the first time.

Displacement occurs predictably and normatively during adolescent development. One frequently sees adolescents of both genders dating people who bear a distinct resemblance to the parent they had most loved when they were young children. Since one of the fundamental developmental tasks of adolescence is to find a partner, outside the family, toward whom one can feel passion, and with whom one can share one’s most private thoughts and feelings, the adolescent’s use of displacement is an essential and constructive component in his/her attempt to master this essential stage-specific task. Displacement is also

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the mechanism that takes place in transference and countertransference. Greenson (1965) described it best when he said that transference is “a new edition of an old relationship . . . an anachronism, an error in time. A displacement has taken place; impulses, feelings, and defenses to a person in the past have been shifted onto a person in the present” (p. 201). Undoing This defense involves acting in ways that symbolically or actually make amends for prior thoughts, feelings, or behaviors that one feels guilty about and/or that threaten punishment. Mr. Johannson’s inability to decide whether he had closed the water outtake valves at the power plant is a prime example of undoing. Having actually closed the valves, his unconscious wish to create a flood undermined his certainty about whether they really were closed. To make sure he had closed them, he had to reopen them. Having reopened them, he needed to close them again. On proceeding to the next valve, his unconscious wishes again made him feel uncertain about whether the last valve was open or closed, so it was necessary for him to start over again. As with Mr. Johannson, this process can go on for very long periods of time. Undoing is a defense most often seen in clients with obsessive-compulsive symptomatology (see chapter  16). When it operates to a limited degree, it can be quite adaptive. For example, accountants and computer programmers who are expected to make as few errors as possible are often praised for their use of doing and undoing, which is viewed by their supervisors as evidence of carefulness. When the defense gets out of hand, however, it disrupts ego functioning and relationships with others in profound ways. Mature Defenses Sublimation This defense involves a process in which the ego transforms asocial, sexual, and aggressive wishes into derivative behaviors that are socially acceptable or valuable. A gangly young white adolescent, who at fifteen is six-and-a-half feet tall and weighs a hundred and forty pounds, feels awkward, unattractive, and unlovable. He hates his peers, all of whom are better looking and more popular than he is. Three years later, he has learned how to dress, and by emphasizing his height, has made himself into a very handsome young man. He has worked on his coordination by studying dance and has developed some undiscovered talents as an actor. Instead of avoiding people and hiding in shame, he now participates in public theater performances and has become popular with his peers. He has quite literally transformed himself, and the self-hatred he thought he would carry to his grave has metamorphosed into a healthy, if somewhat exhibitionistic, appreciation of how wonderful he has become.

Another example shows how socially sanctioned behavior can demonstrate sublimation. Professional football players routinely display levels of aggression that, if enacted anywhere but in a football stadium, would quickly bring them to trial for assault and battery. As professional athletes, however, they are extremely well paid for their talents. As long as they follow the rules, they are encouraged to knock people down and run over them in a kind of controlled mayhem. If they are good at the sport, they become role models as well as sex symbols for a sizable percentage of the population. The kind of aggressive behavior that, under other circumstances, would cause them and society enormous trouble, has been transformed into a socially desirable activity.

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Humor This defense permits the overt expression of painful or socially unacceptable wishes and feelings without causing discomfort to the individual who is being humorous or (in most instances) offending the listeners. Like sublimation, humor frequently enhances overall functioning. An extremely intelligent African American seven-year-old boy whose parents were engaged in a bitter custody battle was referred for treatment because of problems with peers and poor schoolwork. On settling in for his first treatment interview, he asked whether the therapist had heard the story of the “Titchenstein monster.” The therapist had not, and the boy told the following story. Long ago and far away, nine children were playing on top of a high dam that was holding back a huge reservoir of water. Suddenly the dam began to crack, and the children realized they could not save themselves, since they had been playing in the middle of the dam. Their parents, half of whom were on one side and half on the other, could not reach them either. Just when they feared they were doomed, out of the water rose the Titchenstein monster, an enormous beast with red eyes, and flames coming out of his mouth. With one great, hairy claw he scooped up all the children, depositing half on one side of the dam, and half on the other. The children and parents were delighted to be reunited.

At this point the child stopped and asked the therapist if he had guessed the moral to the story. The therapist had not, and the child said, “You should have! . . . The moral is, a Titchenstein saves nine.”

THE AUTONOMOUS EGO FUNCTIONS Any serious discussion of ego psychology requires careful consideration of the work done by Heinz Hartmann. Among his other contributions, Hartmann (1939) articulated the view that a number of important ego functions are genetically programmed (inborn), and that these functions normally operate outside the sphere of intrapsychic conflict. This formulation made ego psychology into an independent, freestanding theory with important theoretical and clinical practice implications. When Hartmann first proposed it, the formulation was startling and innovative. It revised the prior view that at the beginning of life all psychic energy is concentrated in the id. The earlier formulation stated that it was necessary for the ego to acquire energy from the id, as id impulses were tamed during the course of psychosexual development. In that formulation, the ego’s capacity to influence mental life depended entirely on its ability first to neutralize id energy, and then to use that energy for its own purposes. In constructing the horse and rider metaphor cited earlier, Freud tried to show that the rider (ego) could pursue life goals only if he could control, direct, and manage the horse’s (id’s) superior strength and energy. By postulating an autonomous, conflict-free sphere of ego functioning, Hartmann revised Freud’s view, persuasively arguing that from birth onward the ego is endowed with energy and power of its own, allowing it to perform a number of essential mental functions, independent of id wishes or superego constraints. The functions that have primary autonomy include intellectual ability, perception, and motor activity (motility), as well as inborn capacities that facilitate the acquisition of language and make it possible to plan and initiate goal-directed behavior. Under ordinary circumstances, the autonomous

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functions are not affected by conflict of any kind. The ego is capable of maintaining and further developing these functions during the various phases of psychosexual development, except in instances where children are born with genetic limitations or have been subjected to severe and persistent mistreatment (neglect, abuse, rejection, or other trauma) early in life. In this context, Hartmann proposed the view that autonomous ego functions develop within normal limits if the infant’s genetic endowment is adequate, and if the infant’s caregivers provide an “average expectable environment.” Because the infant is totally dependent on its caregivers, normal development unfolds in the context of a human environment that recognizes and meets the infant’s basic needs for nurturance, protection, care, and stimulation. Hartmann suggested that the “fit” between an infant’s inborn temperament and the caregivers’ ability to understand and address the infant’s idiosyncratic ways of conveying need states is crucial in determining the infant’s subsequent developmental course. The concept of an average expectable environment assumes that when there is a reasonably good fit between infant and caregiver, and the caregiver provides the infant with a reasonably protective and gratifying environment, the infant’s physical and psychological capacities will develop within what are consensually considered to be normal limits. As noted above, however, in instances where the child’s genetic endowment is compromised, or when the social environment is less than average and expectable, even autonomous ego functions can be disrupted. When this occurs, children experience significant distress and suffer from serious functional impairments. Shovanna, the nine-year-old African American girl who had seen her mother kill her father when she was four years old (see chapter 2), had well-developed language ability for a child her age. However, when her spontaneous play unexpectedly reminded her of her father’s murder and of her overwhelming fear for her own and her mother’s safety, she instantaneously lost the capacity to speak coherently. She could say nothing about what she was experiencing and began to make the sounds an infant would. Because the killing occurred when Shovanna was four, her capacity to use language had developed adequately before the trauma occurred. When the trauma was re-experienced, however, she temporarily lost the function, even though it had previously been well established. Had the original trauma occurred at an earlier age, she might well have become mute, an outcome that could have permanently compromised her language development. Without language, her overall ego functioning would have been seriously, and perhaps permanently, impaired.

In considering the concept of the average expectable environment, consider how children are affected when they grow up poor, ill-fed, ill-housed, ill-educated, with inadequate medical care, and with little or no protection from the violence that permeates their communities. Shameful though it is in a society as rich as ours, this litany of deprivation describes the average expectable environment for the substantial number of American children (25 percent) who grow up in poverty. Consider how parents are affected when they face the reality that they cannot provide adequate food and shelter for their children. Consider what it means when parents have to acknowledge to themselves that the environment in which they live not only deprives their children of adequate food, shelter, and health care but may also be life-threatening on a day-to-day basis. Given what we know about the effects of severe deprivation and trauma, it is remarkable that so many children who grow up poor and who are surrounded by violence throughout childhood and adolescence reach adulthood with their ego functioning intact. The capacity for adaptive functioning that we see in these children is a tribute both to their innate resilience and to the efforts of caregivers who, against all odds, somehow provide them

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with a human environment that is good enough to promote healthy growth. Certainly, the conditions under which they live do not provide them with an average expectable environment as defined by middle-class standards. And, just as certainly, the environment these children live in is not the one their parents would choose for them if their parents had a choice. Hartmann’s other major contribution to ego psychology was the concept of adaptation, a term that clinicians use regularly to describe behavior that allows individuals to cope advantageously with the environments in which they live. In Hartmann’s view, adaptation can involve alloplastic behavior, behavior through which individuals change the external environment to better fit their own wishes and needs. Adaptation can also be autoplastic in nature. In autoplastic adaptations, individuals change how they feel and act to better fit the demands and expectations of the external world. In either case, adaptation is desirable when it creates a more harmonious relationship between the individual and the external world. Clinicians assess adaptive capacity by evaluating the client’s ability to be productive in love and work, to enjoy life, to maintain mental equilibrium under stress, and, when change is called for, to change in ways that preserve an inner sense of ego integrity. Adaptive capacity is a fundamental attribute of healthy ego functioning. Successful adaptation is well illustrated by the parents and children described earlier who achieve high levels of ego integration in spite of dangerous physical and social environments that are unsupportive at best, dangerous most of the time, and deadly with disconcerting frequency.

MASTERY RECONCEPTUALIZED In a significant elaboration of the concept of autonomous ego function, White (1959, 1960/1971) proposes that mastery be viewed as a primary motivational force, equal in importance to sexuality and aggression. He argues that there is an inborn human need to master developmental, interpersonal, and environmental challenges. From his perspective, human beings work toward achieving higher and higher levels of competence for the sheer pleasure of doing so. People who study, learn, theorize, challenge themselves, overcome difficulties, and change their environments to conform better to personal wishes and needs are simply being true to their species-specific basic nature. White (1959) emphasizes that humans are born with a strong desire for effectance and competence. Those concepts can be understood in terms of “what the neuromuscular system wants to do when it is otherwise unoccupied or is gently (rather than intensely) stimulated by the environment” (p.  321). Through this definition, White emphasizes that as a species we are intrinsically motivated to do a great many things that are not directly or indirectly related to need states. When we are not actively seeking gratification or avoiding pain and punishment, we work, play, interact, explore, and learn things. In White’s view we engage in these different activities because we belong to an intelligent and curious species, which experiences pleasure in exercising and developing the capacities we are born with. White is eloquent in arguing for “effectance” as a basic motivating force. He states: The infant’s play is indeed serious business. If he did not while away his time pulling strings, shaking rattles, examining wooden parrots, dropping pieces of bread .  .  . when would he learn to discriminate visual patterns, to catch and throw, and to build up his concept of the

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object? . . . [Infancy is] a time of active and continuous learning during which the basis is laid for all those processes, cognitive and motor, whereby the child becomes able to establish effective transactions with his environment and move toward a greater degree of autonomy. Helpless as he may seem until he begins to toddle, he has by that time already made substantial gains in the achievement of competence. (p. 326)

CONTROL-MASTERY THEORY This chapter will conclude with an introduction to a late-twentieth-century development in ego psychology, an approach known as control-mastery theory. The approach was developed in the 1960s and 1970s by psychoanalysts Joseph Weiss and Harold Sampson, who began first to talk with each other about their clinical case observations and how those observations often did not fit with their traditional training. They began to include others in these discussions and to undertake research studies that would test out their ideas. Their approach can be seen as a further development of the changes Freud made in the 1920s, which emphasized the greater role of ego functions and defenses and initiated the development of ego psychology. But control-mastery theory can also be seen as a radical critique of drive theory. As a contemporary ego psychological theory, control-mastery assumes that we all have considerable unconscious “control” over our mental lives, in contrast with drive theory’s assumption that unregulated and unconscious sexual and aggressive drives are predominant. Second, rather than offering various resistances to change, it assumes that clients in treatment seek to master their conflicts. Drive theorists thought that resistances reflected the client’s desire to continue the compromise gratifications that were assumed to be the basis of psychopathological behavior. Closely related to Robert White’s assumptions about mastery, control-mastery theory assumes that the primary motivations are adaptation and survival. To survive, the human infant needs a great deal of help from caregivers, and attachment to early caregivers is thus assumed to be a primary motivation both early in life and later, because residues persist later in life. Adaptation involves not simply the development of confidence that basic biological needs will be met in reasonable ways (Silberschatz 2005a). It also involves the development of beliefs about how the world works, about one’s family and oneself in relation to the people important in one’s life. While many beliefs are conscious, some of the most important ones are not. For example, a child who has a parent who becomes upset whenever she expresses a desire to do things with friends may develop the belief that her parent needs her to be nearby (the unconscious component in this example), not simply that her parent is strict about friends (the conscious component). Control-mastery theory also assumes that behavior is regulated by judgments (often unconscious) about safety and danger. Traumatic experiences are examples of dangerous situations. The theory addresses obvious extreme dangers such as traumas (e.g., abuse or neglect), but it also includes more moderate, but ultimately pathogenic patterns of behavior in its concept of what can be traumatic. For example, if a parent has a pattern of becoming upset and depressed whenever the child expresses interest in developing friendships, the child might eventually renounce the developmental goal of wanting friends. On a conscious level, she would most likely simply experience a loss of interest in making new friends and perhaps a corresponding new interest in doing something that keeps her close to home. In this scenario, she would be unlikely to have the insight that her parent’s depression is related

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to her new interest (recall that often the most problematic aspects of a belief are unconscious). Unconsciously, the child judges the safety/danger of various possible actions on her part in terms of the parent’s reactions. The child will choose to do those things that reduce the danger and increase her sense of safety. Here, as in may formulations in this model, the danger is one that presents a threat to a loved one, the parent, who has the potential to become anxious or depressed in response to the child’s behavior. The child acts in a way that preserves the attachment to the parent or, in this instance, protects the parent from becoming depressed. Inferences such as these, often developed over considerable periods of time from the dense texture of everyday life, are called unconscious pathogenic beliefs when they result in behaviors that are not in the person’s best interest (e.g., renouncing a normal developmental goal). Because the theory emphasizes the attachment between child and parent, as well as motives such as empathy and concern for loved ones, particular emphasis is given to pathogenic beliefs that threaten these most important early relationships. Three kinds of such beliefs are distinguished. Separation guilt refers to the anxiety surrounding having different ideas, different values, indeed, a different life than one’s loved ones. This can occur when the person has come to believe that developing differently than the attachment figure(s) wants, threatens those loved ones. Thus, separation guilt is far more than guilt toward a parent, for example, about moving away from the parent; it involves guilt about leaving in a psychological sense rather than simply physically. A  college student may, for example, become very depressed about developing a new value (e.g., about his career plan) if he believes a parent would become upset by the new direction. The student may well not make the connection between his new value and his depression. Rather, he may become tired, study less, and begin to do poorly in courses that might prepare him for this new career as a way, interestingly, of sabotaging his own new interest. Survivor guilt comes from the child’s belief that he deserves the same fate as a loved one who is suffering or, if one has a better life than one deserves, the loved one suffers as a consequence (see Bush 2005 for a fuller discussion). For example, women incarcerated for nonviolent crimes (e.g., prostitution, drug offenses) often have families that directly and overtly elicit survivor guilt (e.g., the accusation “You think you’re better than us” when the woman tries to kick her drug habit), making improvement more difficult (Simone & Shilkret 2001). College students are vulnerable to survivor guilt when they have parents whom they perceive as weak or having difficulty with a life crisis (e.g., divorce), especially if they believe their successes in college will deprive the suffering or weak parent of their help (Shilkret & Nigrosh 1997). In such circumstances, a student might fail academically without being aware of the guilt-based dynamic of her loss of interest in her work or in doing well. Third, children often develop beliefs about themselves to comply with their parents’ beliefs about them. Such “compliances” can also be the basis of current and later difficulties. Parents who consistently are harshly critical of a child often have children who believe critical things about themselves. For example, it is not unusual for a parent with an alcohol problem to blame the child directly for this problem (“If you were easier to raise, I wouldn’t drink so much”). Often such beliefs are more subtle. Even negative views of a child held by the parent in a well-intentioned attempt to protect the child from failure can still be inaccurate and pernicious (e.g., the parent who concludes that a four-year-old will be bad at math because she, herself, was). It does not require direct statements for such beliefs to develop; children often make inferences on their own in an attempt to understand important relationships and to protect relationships with loved ones.

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Therapeutic Implications As a result of its view that people strive for adaptation and mastery, control-mastery theory assumes that clients enter therapy with a “plan” for the therapy, significant aspects of which may be unconscious. The plan consists of such elements as the client’s “goals” for the therapy and the “pathogenic beliefs” that have impeded her in everyday life. The therapist’s task is to understand what the client’s plan is. This discovery process is ongoing as therapy proceeds. It is useful in the therapist’s own thinking, however, to formulate the client’s plan very early in therapy, keeping in mind that the therapist’s understanding will be continuously refined as she learns more about the client. In therapy informed by control-mastery theory, therapist and client work together to disconfirm the client’s pathogenic beliefs (see Silberschatz 2005a for a fuller version of this description). A good deal of research has demonstrated that the process of disconfirming pathogenic beliefs is therapeutic. The therapeutic work is accomplished in three ways: First, the relationship with the therapist itself may be therapeutic. A client who has been routinely ignored by parents, for example, may find it quite therapeutic to have a therapist who pays careful attention. Second, the therapist’s interpretations, if they are congruent with the client’s plan, are therapeutic. Third, the client usually presents the therapist with certain tests; these tests usually arise as a result of earlier traumas, which may be repeated patterns of responses by parents or others of importance in the client’s past. Tests are particularly important in this treatment model and are of two kinds. Transference tests occur when the client acts with the therapist as she did earlier with a parent, in the hope that the therapist will not respond in the traumatizing way a parent did. For example, a client whose parent was highly critical even of very minor things, and needed to have his children do everything his way, and like everything he did, might engage in a transference test by committing relatively minor offenses, such as coming a bit late to appointments. If the lateness is a test, the client is particularly affected by the therapist’s response. If the therapist is unbothered or makes only a passing reference to the tardiness, the therapist’s response might be sufficient to disconfirm the pathogenic belief that doing things wrong will upset an important person. If so, the therapeutic work will deepen. The client will progress in making this particular issue clearer or might reveal more about the origins of this trauma. In such ways, the therapist continuously refines her inferences about what the client’s plan is. However, if the therapist focuses on the tardiness in a heavy-handed way, by, for example, offering a rapid, deep interpretation, the client may think the therapist was, indeed, upset by her lateness. The client’s narrative might become confusing; she might object to the therapist’s interpretation; she might shift the topic to something safer for her or to some other issue the therapist has handled more successfully. The second way clients test in therapy is called passive-into-active testing. The client above might test in this way, for example, by being highly critical of a minor mistake on the therapist’s part. Here, the client is acting toward her therapist in the way a parent acted toward her. Her hope, often unconscious, is that the therapist will not be as traumatized as she was earlier at the hands of her domineering parent. Again, by observing how she handles the therapist’s response to her criticism, the therapist can confirm (or disconfirm) the idea that this, indeed, was the dynamic between the client and her parent. Since many clients in therapy have had highly critical parents, there is a good deal of unreasonable criticism of therapists, and it is useful to think of much of this behavior as passive-into-active testing. That is not to say, of course, that therapists do not engage in

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behavior that is genuinely worthy of criticism! If a client’s criticism is truly a test, it usually is considerably greater than the therapist’s supposed or real transgression warrants. Further, even some positive behavior toward the therapist may involve passive-into-active testing. An example of this is the client who was seduced or sexually abused as a child, and who becomes seductive with a therapist, in the hope that the therapist will not allow herself to be seduced. Often, the therapist can use her own reactions to make the judgment about whether a client’s behavior is a test. But one cannot judge simply from whether the client’s behavior toward the therapist is negative rather than positive whether the behavior is or is not a test. Clients often have been traumatized in numerous relatively small ways over many months and years. Sometimes the process of testing in therapy, as well as the other ways therapy can be transformative (e.g., the therapist’s attitude; the therapist’s interpretations), may take a long time before the client finally comes to the conclusion that she is not as responsible for the misfortunes of others, for example, as she had originally thought. However, the control-mastery approach has also been very effective in shortterm therapy. If the client enters therapy knowing that time is limited, she then decides, often unconsciously, to work on goals and pathogenic beliefs that are more paramount at that moment for her. Control-mastery theory can be seen, then, as having important similarities with earlier post-Freudian developments in ego psychology as well as with more contemporary cognitive and relational approaches to psychotherapy. Unlike most psychodynamic theories, control-mastery theory is supported by a large research base as well as detailed clinical observations (see Shilkret & Shilkret 1993; Silberschatz 2005b for summaries of the research).

OVERVIEW AND SUMMARY Ego psychology markedly expands the range of psychodynamic formulations that attempt to explain motivation. While childhood sexual and aggressive wishes are still viewed as primary, ego psychology adds the autonomous ego functions and the desire for “effectance” to the list of variables thought to motivate behavior. This significant change encourages a fuller, more balanced view of human activity and provides support for assessments of human behavior that emphasize the importance of positive, growth-inducing capacities. In evaluating the problems that a client brings to treatment, cognitive capacities, goal-directed behaviors, and the desire to overcome difficulties are all viewed as indications of health. An appreciation of the client’s strengths and latent capacities makes it possible to approach treatment in an optimistic and respectful way without losing sight of underlying problems in ego functioning and adaptation. ­Control-mastery theory expands these theoretical developments and proposes a radically different explanation of basic human motivation, while still utilizing principles drawn from ego psychology. By focusing on specific ego functions, carefully examining defense mechanisms, and placing anxiety in a developmental context, ego psychologists emphasize the ego’s supraordinate role as the organizing and synthesizing agency within the mind. The ego manages what we think, what we do, and how we feel. This theoretical framework emphasizes that treatment is best directed toward strengthening the ego in terms of both its relationship to reality and its relationship to the other agencies of the mind. Ego psychologists thus reaffirm

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the complementarity between individuals and society. The concept of adaptation makes it unmistakably clear that individuals do not exit separately from their social and biological contexts. As a species, not only are we capable of changing our own behavior to suit a range of different environments, but we can also change the environments we live in to better suit the wishes and needs we bring to them. The theoretical changes outlined above have profoundly changed therapeutic practice. Instead of focusing on uncovering unconscious impulses, ego-oriented treatment emphasizes the importance of intervening in ways that strengthen ego functioning and thereby enhance adaptive capacity. Therapy based on control-mastery theory works from a notably different premise. It emphasizes the ways in which clients test their therapists as they attempt to fulfill their unconscious plans for the treatment. When therapists disconfirm the pathogenic beliefs that clients develop to deal with unconscious guilt and to preserve their attachments to primary caregivers, ego functioning is repaired and their capacity for healthy development is restored. The case example presented below reflects a traditional ego psychological approach to treatment. It focused on trying to repair object relations, strengthen reality testing, and enhance self-esteem. Some years into treatment Ms. R., a forty-seven-year-old white middle-class woman suffering from a serious depression, feelings of being “unreal,” and the conviction that she was “crazy” in spite of the “normal” façade she maintained at work and in her social relations, began to talk about how worried she was about the safety and well-being of her thirty-four-year old drugaddicted brother, Colin. Colin no longer was in contact with her or with any other member of her family, having disappeared at least a decade before after a violent argument with their father (who had abused him repeatedly). Although their father had long since died, Colin had not made any attempt to reunite with the family. Ms. R. had information that suggested that Colin was living in an impoverished neighborhood of a large city, and she often thought about visiting that city and walking through the “skid row” areas in the hope of finding and helping him. When Ms. R.’s male therapist commented on her love for and concern about Colin, Ms. R. continued for a time to talk about her plan to rescue him and then stopped in mid-sentence to stare intently at the therapist. After several minutes of silence, she continued by saying, “I don’t think I’ve ever talked to you about this. When I was thirteen, Colin was born. My mother stayed in the hospital for at least a week, and my father invited me into his bed to sleep with him. I don’t think he did anything overtly sexual, but I was very uncomfortable being there, and a night or two after my mother returned home, I told her about what had happened. She must have talked with my father that same day because the night after I told my mother, he told me that I needn’t come to bed with him that night. After that, my relationship with him changed drastically. Until then, he and I had always been close. From that time onward, throughout my adolescence, he criticized me constantly, calling me a slut and a whore. He would ask me, in front of the entire family, who I was sleeping with. Of course, as a good Catholic girl, I was hardly dating. I wasn’t kissing boys, let alone sleeping with them. My mother never said a word on my behalf, and as you know, by the time I  was seventeen, I  felt my survival depended on getting away from the family. When I left for college, I felt certain that both my father and mother were glad to see me go. Whenever I’ve tried to think about this time in my life, it was like stepping into a black, swampy pit where I would be sucked down and drowned. I don’t know why, but when I heard you say that I love my brother, I  suddenly imagined you would take my hand and walk with me into the pit, so I wouldn’t be alone anymore. I thought if you held my hand the pit would still be horrible and dangerous, but that somehow I would be able to get out alive; I wouldn’t drown. Looking back on all this, it seems strange. My mother was so exhausted after taking care of all my other sisters and brothers, that, being the oldest child, I raised Colin almost as if he were my own. I think that taking care of him made it possible for me to survive those awful years until I left home. During

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all of that time, I never knew whether my father’s accusations about me being a slut were true. Mostly, I think I believed him.”

This vignette is noteworthy because the client spontaneously remembered the traumatic events of her adolescence after she was convinced that the therapist understood and accepted the love she felt for her brother. That knowledge gave her hope that the therapist would stand by her during her worst moments of terror. The growing strength of her relationship with the therapist and the image she created in her mind—of his taking her hand much as a parent takes the hand of a frightened child—gave her the courage to remember that her father had not only invited her into his bed but also abused her psychologically throughout ­adolescence. In subsequent sessions, she could talk in a feeling way about how the changed relationship with her father and mother (who, she felt, had not protected her from her father) had affected her view of herself. She recognized that she felt crazy in the face of her father’s accusations and that she has felt crazy ever since, no matter how she tries to conceal it. Assessing Ms. R.’s functioning from an ego psychological perspective highlights her ego organization and adaptive functioning. Ms. R.’s social and vocational functioning was relatively intact in spite of her underlying view of herself as crazy. She experienced serious problems in maintaining self-esteem, as well as some encapsulated difficulties with reality testing, evidenced by her continuing uncertainty about whether she actually had been/still was a whore and a slut. Judgment, affect regulation, and impulse regulation were all intact, with some tendencies toward constricted expression. Her capacity for mastery was well developed in the intellectual, social, and vocational spheres. Under ordinary circumstances her primary anxiety focused on the dangers inherent in losing the love and esteem of a significant other, but when memories of her adolescent abuse were triggered, she briefly regressed to fears of annihilation. By the end of adolescence when she left home to go to college, her ego had regained its capacity for synthetic functioning and had successfully defended against the memories of abuse by repressing them. Ms. R.’s capacity for relationships was superficially well developed. On a deeper level, relationships were dangerous for her because she could only relate to people by molding herself to their expectations. This adaptation made it possible for her to avoid the danger of subsequent abuse but foreclosed the possibility of genuine intimacy. Her experience in treatment made it possible for her to imagine a relationship in which another person would be interested in and attuned to her needs and feelings, without exploiting her. As the treatment summary indicates, the ego psychological approach did not focus on uncovering her unconscious sexual and aggressive desires, but instead encouraged the development of a new relationship that strengthened her overall ego functioning. This is among the most important contributions ego psychology has made to contemporary treatment technique. It is no overstatement to say that the effects of that contribution are profound.

COMMENTARY Ego psychology adds complexity and nuance to Freud’s original formulations about drives and intrapsychic structures. In spite of its impressive utility, however, like all theories of mind, it has significant limitations.

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First, except for its emphasis on adaptation, it does not attempt to address fundamental issues about why people think, feel, and act in the ways they do. By utilizing drive theory explanations about basic human motivation, it ignores the limitations that have become increasingly apparent in those formulations. In recent years, control-mastery theory presents a theory of causality organized around the concept of pathogenic beliefs engendered in formative relationships with parents and/or other primary caregivers. Over time, it will be interesting to see to what degree that formulation proves compelling and useful to contemporary practitioners and theorists. Second, because ego psychology focuses on how rather than why the mind works as it does, it tends to encourage mechanistic ways of thinking about human behavior, a tendency that can be problematically reductionist. Third, although ego psychology recognizes that object relations and self-esteem are important aspects of intrapsychic functioning, it does not emphasize their centrality and developmental significance, an omission that was later addressed through the development of object relations theory and self-psychology (see chapters 5 and 6). And finally, therapists now know that people who utilize “mature” defenses, demonstrate high levels of ego functioning, and appear well adapted to their environments can nonetheless experience significant emotional distress and live lives they experience as unhappy and unfilled. That observation has spurred the development of theoreti­ cal models that attempt to understand and address ego psychology’s inherent limitations. The next chapter considers the work of ego psychologist Erik Erikson, who expanded the concept of the ego to include self and identity and who described how the ego develops over the course of life.

REFERENCES Bush, M. (2005). The role of unconscious guilt in psychopathology and in psychotherapy. In Transformative Relationships: The Control-Mastery Theory of Psychotherapy, ed. G. Silberschatz, pp. 43–66. New York: Routledge. Freud, A. (1936). The Ego and the Mechanisms of Defense. New York: International Universities Press. Freud, S. (1923). The ego and the id. Standard Edition 19:3–66. ———. (1926). Inhibitions, symptoms and anxiety. Standard Edition 20:75–175. Greenson, R. (1965). The working alliance and the transference neurosis. In Explorations in Psychoanalysis, ed. R. Greenson, pp. 199–225. New York: International Universities Press, 1978. Hartmann, H. (1939). Ego Psychology and the Problem of Adaptation. New York: International Universities Press. Rabelais, F. (1532/1946). Gargantua and Pantagruel. New York: Dutton. Rohan, B. (1984). Personal communication. Shilkret, R., & Nigrosh, E. E. (1997). Assessing students’ plans for college. Journal of Consulting Psychology 44:222–31. Shilkret, R.,  & Shilkret, C. J. (1993). How does psychotherapy work? Findings of the San Francisco Psychotherapy Research Group. Smith College Studies in Social Work 64:35–53. Silberschatz, G. (2005a). The control-mastery theory. In Transformative Relationships: The Control-­ Mastery Theory of Psychotherapy, ed. G. Silberschatz, pp. 3–30. New York: Routledge. ———. (2005b). An overview of research on control-mastery theory. In Transformative Relationships: The Control-Mastery Theory of Psychotherapy, ed. G. Silberschatz, pp.  189–218. New York: Routledge.

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Simone, R., & Shilkret, R. (2001, April). Attachment, guilt, and symptomatology among incarcerated women. Poster presented at the biennial meeting of Society for Research in Child Development (SRCD), Minneapolis, MN. Vaillant, G. E. (1992). Ego Mechanisms of Defense. Washington, DC: American Psychiatric Press. White, R. W. (1959). Motivation reconsidered: The concept of competence. Psychological Review 66:297–333. ———. (1960/1971). The core of personality: Fulfillment model. In Perspectives on Personality, ed. S. R. Maddi, pp. 85–146. Boston, MA: Little, Brown.

4 Psychosocial Ego Development: The Theory of Erik Erikson Joan Berzoff

In chapter 3, we considered the functions of the ego: to organize; to synthesize; to defend against unwanted impulses, feelings, and anxiety; and to adapt to internal demands and societal realities. We looked at how the ego tries to master the forces within the internal world and adapt to, or even change, the forces from without that are in the external environment. We considered some of the ways in which the ego functions independently of psychological conflict, and we saw how the ego provides many functions, not the least of which are mastery, coherence, and continuity to the self.

ERIKSON: THE EGO PSYCHOLOGIST Erik Erikson was a particularly unique ego psychologist who dedicated his career to the idea that the ego tries to maintain a coherent sense of self and identity over an average and expectable human life cycle. He theorized that the ego itself is shaped and transformed, not only by biological and psychological forces but also by social forces. In this way, he was the first psychodynamic theorist to develop a truly biopsychosocial theory, modeled on Freud’s model of psychosexual theory, and one that joined principles of ego psychology with Freud’s epigenetic principles from drive theory. Erikson also made a huge contribution to understanding of human functioning and dysfunction by developing a theory of human development that extended beyond childhood, through adulthood, and to old age. In his unifying theory, biology and ways of functioning were integrated so that the concepts of self and identity could be seen as influenced by the body and the mind, and the social contexts in which they developed. In this chapter, then, we examine how Erikson’s psychosocial perspective expanded Freud’s premise that all of psychological development occurs within the first fifteen years of life. Again, Erikson, unlike Freud, saw development occurring from birth to death, within the contexts of social relationships and social institutions that either foster or undermine ego development. 75

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How did Erikson define ego identity? He viewed identity as a sense of personal continuity and sameness, personal integrity and social status, which occurs as a result of the interactions between the self and the environment. He was the first psychoanalyst to articulate the absolute interdependence between any person and her environment and to consider the influence of culture and society on identity formation. Erikson was also the first life-span developmentalist to maintain that personality development was not fixed in childhood but was something that involved an unfolding of ego psychological developmental tasks over the life cycle. He wrote, “If everything goes back to childhood then everything is someone’s fault and trust in the power of taking responsibility for oneself is undermined” (Evans 1981, p. 27). Like Freud, Erikson’s theory of ego development was epigenetic. Each developmental stage unfolds from infancy through old age; each stage builds on previous stages and affects later stages. Development is invariant, sequential, and hierarchical. Every individual negotiates basic developmental tasks and basic biopsychosocial crises from birth to death in a predictable developmental sequence. Erikson clustered these tasks into “eight ages of man” [sic], which he defined as infancy, early childhood, play stage, school age, adolescence, young adulthood, adulthood, and old age. A Strengths Perspective As an ego psychologist, Erikson’s interest was not so much in pathology as it was in health, and so he identified the ego strengths (as well as vulnerabilities) that a person faces at each junction of life-cycle development. Erikson defined health in terms of the ways in which a person (1) masters her environment, (2) has a unified personality, and (3) perceives herself and her world accurately. In subsequent theoretical developments, especially in relational and postmodern theorizing, his ideas have come under attack, as the self is no longer seen as unitary or coherent, and instead is marked by discontinuity, multiple selves, and identities. But as someone writing in the 1950s, identity was as central to Erikson’s thinking as sexuality was to Freud’s. Erikson’s theories were, of course, very much a product of his own biography and identity struggles. Born in Frankfurt, Germany, in 1901, Erikson had been abandoned by his biological father, who was Danish and Jewish. He was raised by his mother, a German Jew, and his stepfather, a German-Jewish pediatrician, neither of whom told him about his biological origins until he was eighteen. In fact, his mother acted as if his biological father never existed, although Erikson clearly had some awareness of him based on his own sense of difference. As a child, then, Erikson suffered a series of identity crises. He was a blond, blue-eyed son of a Jew, thought to be Jewish by non-Jews and non-Jewish by Jews. His sense of not belonging, within his community or within his own family, became a central theme in his work. Interestingly, in adulthood he reinvented himself with a Danish name, that of the son of Erik, or “Erikson.” When he fled Germany in the 1930s to escape the Nazis, he first attempted to immigrate to Denmark. Refused entry there, he subsequently came to America, once again having had the experience of being a marginalized outsider who had been excluded from what he considered his real homeland. Erikson did poorly in school and, in fact, dropped out for a time. He would later conceptualize such periods as “psychosocial moratoria” during which adolescents temporarily suspend their identities to discover and redefine themselves before making adult commitments. During his own psychosocial moratorium at age seventeen, Erikson traveled around Europe as an artist. In 1927, he met Peter Blos, a later leader in ego psychology and adolescent development, who was then tutoring the children with whom analyst Dorothy Burlingham and Anna Freud were working. Erikson became a teacher in their Montessori school. Soon after, he was analyzed by Anna Freud. With neither a medical degree nor any formal training beyond high school, he was invited into the Viennese analytic circle. Without professional

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credentials, however, he continued to remain the identity of a marginalized outsider. Although his marginal identity was costly to him, it also afforded him a certain degree of flexibility within psychoanalysis and propelled him toward more interdisciplinary pursuits than his counterparts (Monte 1980). In 1933, taking with him the theoretical viewpoints from both ego psychology and drive theory, Erikson moved to Boston, Massachusetts, where he collaborated with anthropologists Margaret Mead and Ruth Benedict. This led to his rich cross-fertilization of anthropological, psychoanalytic, and ego psychological ideas. After teaching at Harvard and at Yale (without ever achieving a formal degree!), he traveled to South Dakota, where he worked with anthropologists in understanding Sioux and Yurok Indians from psychological, social, and cultural perspectives. It was in this collaboration that he began to articulate how identity development occurs as a biopsychosocial phenomenon. With these biographical footnotes as a backdrop, let us examine Erikson’s most lasting and important contribution: that of his theory of the eight ages of man [sic]. According to Erikson, there is a progression of development over the life cycle that is epigenetic. Each developmental stage is defined by an individual’s facing an age-specific crisis, at an agespecific time, with an age-specific concern. The past and the present always come together as new developmental tasks emerge. Each developmental stage can be seen as a crisis and an opportunity in which new development can emerge. Hence every developmental stage has the potential for new development, or for its opposite. Erikson (1964) wrote, “I’m not speaking of values; I am only speaking of a developing capacity to preview and abide by values established by a particular living system” (p. 113). This is indeed a strengths perspective. According to Erikson, each stage of development can be positive or negative, but Erikson also eschewed an overly binary way of seeing growth occur. Erikson cautioned against absolutism. “Actually,” he wrote, “a certain ratio of [positive and negative outcomes] is the critical factor. . . . [For example] when we enter a situation, we must be able to differentiate how much we can trust and how much we can mistrust in the sense of a readiness for danger and anticipation of discomfort” (Erikson 1968, p. 105). Although Erikson did not challenge Freud’s formulations, he changed the focus of attention, making each stage of psychological development about social values and emphasizing the adaptive, positive character traits that can emerge when particular psychological and social developmental tasks are mastered. He also expanded the original psychosexual model of development by adding ego psychological concepts (such as ego strengths, adaptation, mastery, and identity), and by emphasizing the importance of the person in her environment. He brought time as a construct into his theory and with it the idea that everyone relates to themselves and others at different stages of the life cycle in unique ways, depending upon their different intersecting life stages and identities. Most important, he brought social context into every aspect of psychological development so that social contexts of oppression, disenfranchisement, poverty, violence, war, discrimination, and natural disasters all interact with a person’s developing psyche throughout her life. This was a milestone in psychoanalytic theorizing and remains very important to this day. Let us turn now to his theory of psychosocial development to illustrate how ego identity emerges over the life cycle.

THE EIGHT AGES OF MAN Erikson’s psychosocial developmental timetable roughly corresponds to Freud’s theory of psychosexual development until adolescence. Whereas Freud thought that psychosexual development ended with adolescence, Erikson added three more important life stages that

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Table 4.1.  Erikson’s Epigenetic Stages Basic Stages

Psychosexual Stages and Modes

Psychosocial Crisis

Significant Relations

I. Infancy

Oral-Respiratory, Sensory Kinesthetic (Incorporative Modes)

Basic Trust vs. Basic Mistrust

Maternal Person

II. Early Childhood

Anal-Urethral, Muscular (Retentive-Eliminative)

Autonomy vs. Shame and Doubt

Parental Persons

III. Play Stage

Infantile-Genital, Locomotive (Intrusive, Inclusive)

Initiative vs. Guilt

Basic Family

IV. School Age

Latency

Industry vs. Inferiority

Neighborhood

V. Adolescence

Puberty

Identity vs. Confusion

Peer Groups and Outgroups/Models of Leadership

Intimacy vs. Isolation

Partners in Love, Friendship, Competition, Cooperation, Sex

VI. Young Adulthood

Genitality

VII. Adulthood

(Procreativity)

Generativity vs. Stagnation

Divided Labor, and Shared Household

VIII. Old Age

(Generalization of Sensual Modes)

Integrity vs. Despair

Mankind/My Kind

shape every person’s identity over the life cycle. He thus created a developmental theory that suggests that people grow, change, and develop throughout their entire lives, surmounting and overcoming new challenges (see table 4.1). At each stage of physical, psychological, and social development, there are psychological and social tasks to be mastered and conflicts to be negotiated. Like Freud’s psychosexual stages, Erikson’s early stages associate the tasks of ego development with dominant biological organs or zones of pleasure. But his genius lay in expanding biological timetables with the ways in which individual development took place in the context of interactions with larger social institutions, societal values, and social and cultural expectations. Once he went beyond adolescence and into adult development, however, he identified biological processes that shape psychosocial tasks and outcomes, but no longer defined them as erogenous because Freud conceptualized erogenous zones as ending with adolescence. Let us consider each of Erikson’s eight epigenetic stages. Infancy: Trust vs. Mistrust (Birth to Eighteen Months) In the first stage of infancy, a baby’s mouth is her source of nourishment as well as her medium for relating to caregivers. Erikson describes infants as social, interactive, and incorporative from the beginning. A baby drinks in her mother with her eyes and her skin. The baby comes to expect to be nurtured and taken in, as caregivers come to expect to give love and to be loved. Erikson views the infant as developing her identity in the context of a

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relationship in which she learns about being cared for and loved. The reciprocity that ideally occurs between the child and her caregiver ultimately forms the basis for basic trust. We saw in Freud’s description of a baby that the mouth is the central organ and the zone of pleasure, which is also true in Erikson’s epigenetic plan. By nature, infants also take in the outside world through their mouths. They bite, which reflects aggressive aspects of their interactions with caregivers. Ultimately, infants need to form relationships with caregivers in which they can manage both their incorporative and their sadistic modes. Sufficient trust in a caregiver’s recognition and affirmation leads to what Erikson calls “the virtue of hope.” Without sufficient basic trust, a child develops an enduring mistrust and pessimism. The challenge of this stage is to achieve some balance between trust and mistrust. If this development task cannot be mastered, the negative outcome can result in a person’s dependent, unthinking, rigid adulation of others, or its opposite, a pervasive mistrust of others. Basic trust forms the foundation for all other stages of development. To illustrate the relevance of Erikson’s theory of infancy, let’s turn to Frances, whose identity was shaped during her earliest years in ways that left her both dependent upon and mistrustful of others. Frances was a fifty-year-old white lesbian occupational therapist from a working-class background who could not develop even the most basic trust with others. While having gone on to complete many life-cycle tasks, including commitment to an adult relationship and a career, she felt a deep sense of hopelessness and mistrust. She described her relationship with her own mother as fraught with confusion. As early as she could remember, her mother, who was an alcoholic, would swear at her, break lamps, and “be crazy.” When her mother was finished with one of her outbursts, she would tell Frances that she (the mother) had a twin sister and that it was the twin who had been raging and not she, herself. Frances grew up with a very deep mistrust of others, which she tried to overcome by seeing those in authority as always being correct and as having her best interests at heart. When, however, her boss transferred her to another part of the hospital for what she thought were capricious reasons, she felt hopelessly betrayed. Incapable of mastering her own disappointment, and unable to reconcile the belief that her boss was watching out for her, and with the feeling that he had betrayed her, she became so mistrustful that she left her job and never worked again.

While Frances’s earliest childhood experiences of mistrust culminated in a profound psychological disorganization, Maxine, by comparison, also suffered great fear in early childhood, which resulted in a different outcome. Maxine was a sixty-one-year-old white Jewish heterosexual music critic and mother of two children. She survived World War II by being hidden in a cellar in Austria. For the first eight months of her life, she had little food or light and lived with a family that feared being sent to a concentration camp and killed. To this day, Maxine feels physical fear when faced with dangers on the subways or on the streets. In a visceral way, she is hypervigilant, noticing even a menacing look and always aware of acts of violence around her. While she does not have memories of what it meant to be cold, hungry, alone or in severe peril, she carries a bodily feeling of mistrust within herself. But given a life context peopled with family members, teachers, and mentors; given her strong and abiding spiritual faith; and given her community, in which physical, psychological, and social needs were met, her mistrust has evolved into a healthy skepticism that mostly serves her well in her life career as a critic.

Early Childhood: Autonomy vs. Shame and Doubt (Eighteen Months to Three Years) This second stage of child development corresponds with Freud’s anal stage. While Freud’s “anal” baby took sexual and aggressive pleasure in the retention and the expulsion of feces,

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Erikson’s toddler learns to master his or her sphincter muscles in relationship to others and to the social world. The toddler tries to respond to his or her environment by controlling caregivers and others in that world. Biologically, a toddler needs to negotiate two muscular actions: holding on and letting go. Children at this stage need to achieve a sense of independence over their own bodies, including some control and autonomy over what is inside and what is outside of them. This includes not only the ways a toddler retains or eliminates feces but also the ways in which toddlers hold on to and let go of toys, food, or other objects (in ways that often exhaust even the most patient caregivers). If a child experiences some autonomy in walking, exploration, and sphincter control, she may gain some confidence and pride, which becomes a part of her ego identity. If she experiences herself as overly controlled, or without any controls, she may feel excessive shame and doubt. Evan, a white twenty-six-year-old cisgendered plumber, was recently reminded by his parents of his initial delight in an especially large production of feces. At age two and a half, he had called his mother and father into the bathroom to examine and admire his opus. Both parents exclaimed with pride about its size and quantity. But when he called in his brother to look, the brother responded by saying, “That’s not very big at all. In fact, that’s one of the tiniest poops I’ve ever seen!” Evan’s mother also recalled preparing a family dinner when, as she watched in horror, two-and-a-half-year-old Evan peed all over the newly cleaned floor. His mother remembers her look of disgust and his of shame as he slinked away from her and hid in the bathroom. But given many other factors that supported his self-esteem—a sustaining day-care situation, a cultural milieu that encouraged the more playful and creative aspects of his willfulness—Evan developed an identity of willful independence rather than one of self-constriction, shame, and doubt. In fact, Evan chose a profession that encourages him to engage in fixing that which is stopped up for which he is well paid! His work still takes place in bathrooms and in kitchens where he keeps toilets and sinks from leaking, overflowing, or backing up.

Ideally, a child at this stage develops a sense of identity based on some social experiences of cooperation and self-expression without fear of retaliation. But a child who is filled with doubts will not feel autonomous; she will feel compelled by the will of others. Michael was the seventh child in a white low-income Irish Catholic family. Both of his parents were financially and emotionally overwhelmed. They were living far from extended kin, which increased their isolation. Michael’s father worked a day job as a security guard, and his mother cleaned office buildings at night. Michael had little sense of protection and little supervision. Michael remembers not being able to defecate until his mother returned home from work. As he grew older, he became concerned about encopresis (involuntary defecation). He would soil himself at school or worry that he would soil himself with friends. He felt exposed and without inner or outer control. These feelings became manifest later in a number of adult feelings and behaviors. As an adult, Michael chronically doubted himself. He felt potentially invaded by others and felt he needed to protect himself from others. Friends and family were barred from his apartment or his workplace. Any time he was in public places he felt exposed. He was unable to use the bathroom at his girlfriend’s house or at his workplace, as any toilets other than his own made him feel at the mercy of others, exposed and ashamed. These symptoms constricted his bodily, psychological, and social functioning. He also described how the rules of his family and church were so rigid that they only increased his sense of shame and exposure for breaking them.

The virtue at this stage is will: “The unbroken determinant to exercise free choice as well as self-restraint” (Erikson 1964, p.  119). Where Evan’s willfulness became transformed into a strong and determined will, Michael experienced himself as without good will or free will.

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Play Stage: Initiative vs. Guilt (Three to Six Years) Like Freud, who depicted an oedipal stage, Erikson noted how children between the ages of three and six enter into a period rich with imagination and creativity, ushered in by locomotion and language. This is a time of romance and of conflicts between what a child may want in fantasy and what she may have in reality. It is during the oedipal stage that Erikson saw children’s modes of action as “on the make, the attack and the conquest,” and it is within this stage that children face the ego-psychological tasks of identifying not only with their parents’ but also with their society’s values. In their social worlds, children who successfully negotiate both internal psychological demands and social expectations learn to plan and to discover. But they must also learn what they may and what they may not do or have. The virtue in this stage is the development of a sense of purpose—that is, “the courage to envisage and pursue valued goals uninhibited by defeat of infantile fantasy, by guilt and by the foiling fear of punishment” (Erikson 1964, p.  122). In this stage, Erikson thought, children begin to develop the ability to make enduring commitments. Raoul, age four, was a purposeful and delightful working-class Hispanic boy. At his day-care center, he’d initiate the building of enormous block structures, which he’d lead his friends in knocking down. On the playground, he’d boldly slide down the steepest slide, delighting in and conquering this scary structure. Each night he’d play a card game with his dad, who would often allow Raoul to outwit him and win. “I’m really good! I’m great,” he’d say.

Where Erikson’s theory has the most value is in considering Raoul’s sense of initiative in the context of his social environment. If he had been living in Iraq or Iran, seeing corpses hanging from lampposts or lying in the streets, the social surround might have had an impact on Raoul’s initiative. However, we would still need to know what protective factors—a father, a brother, a sibling—might have helped him achieve a sense of purpose. Likewise, what if Raoul had grown up in the Henry Horner Housing Project, only one of many notorious projects in South Chicago (Kotlowitz 1991)? By age five, virtually all children there have seen a shooting or have known someone involved in one. In fact, 30  percent of children in American inner cities have witnessed a killing by the time they are fifteen years old, and more than 70  percent have seen someone beaten. Yet Erikson would expect that there would be many children who would find ways to master those pathogenic environments, achieve relative safety, and maintain ego coherence. That is to say pathogenic environments alone do not create pathology in children. Rather, Erikson would assess Raoul’s ego strengths and their effects on mediating his environment for him. Therefore, it is important to remember that Erikson’s life stages, social conditions, and the potential for psychopathology do not have a direct correspondence. Without basic controls at the anal stage, socially and psychologically, a child may bring that experience of excessive doubt into all subsequent life stages, doubting himself as a learner, as a sexual partner, as a worker, parent, or friend. The child who feels excessively guilty will lack initiative not only in this stage but in all the stages to follow. School Age: Industry vs. Inferiority (Six to Eleven Years) This stage corresponds to Freud’s psychosexual stage of latency. As children enter school, their social worlds widen. Developmentally, they begin to reason deductively, to use adult tools to complete tasks with steady attention and with diligence. They are invested

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in making things and making them well. Children now move beyond the bounds of the nuclear family and develop play skills, cognitive skills, and skills about group life, including learning to express and integrate their own feelings. If a child’s efforts are thwarted (for example, by inhospitable schools or by social conditions such as racism or homophobia), then relationships with parents, teachers, or peers may be threatened, and an enduring sense of inferiority could become a feature of the child’s identity. But if a child has a community of others that help him and that foster his development, even under oppressive conditions, that child may develop an identity based on a sense of industry and achievement. The virtue that may emerge at this developmental stage is competence, which Erikson (1964) defines as “the free exercise of dexterity and intelligence in the completion of tasks unimpaired by intellectual inferiority” (p. 124). Learning disabilities or some other kind of developmental interference at this stage often present children with particular challenges in latency, where educational support from schools or lack thereof can make a profound difference. But parents or teachers who recognize the child’s challenges and work to keep her self-esteem intact while new strategies are found can make a profound difference. Eric was a wonderfully busy and industrious white middle-class eight-year-old boy. But when he was faced with the task of understanding the printed word at school, he was unable to comprehend or decode the symbols. He began to feel stupid in the classroom and to kick and hit other children. Whereas this behavior could have been defined as pathological in and of itself, his school recognized that his was not a behavioral problem, but a reaction to frustration in mastering reading tasks. With a tutor and resource room to provide some academic support, as well as with emotional support from his single mother, he was able to reenter group life easily, without his sense of competence with peers being undermined. Here the social milieu was necessary to counter his identity as an incompetent learner and to help him achieve a more positive identity as a growing master of his learning. Many children, like Eric, are not afforded the same resources as he was.

Other kinds of societal pressures can lead to a sense of inferiority unless counteracted by other supports and forces within the family and the community. Lucy was also an industrious and competent seven-year-old daughter of a divorced, white, lesbian mother who had been in a relationship with a female co-parent for six years. Her family lived in a politically conservative, working-class rural community. Lucy’s mother could not reveal her sexual orientation at work, in Lucy’s school, or to the larger community, as she was embattled in a custody case and feared losing her daughter if her sexual orientation were known. When Lucy broke her arm at school, her co-parent was invisible as a significant other. There was no place to identify Lucy’s second mother on the hospital forms. Only her biological mother was invited to attend parent conferences. Lucy was careful about whom she invited home. Despite the fact that there was no socially approved language to define the role of co-parent, and in spite of the homophobia Lucy faced when dealing with social institutions, her own identity as a competent student and friend was stable. This stemmed largely from her co-parents’ clarity about their own identities as well as the support her family drew from an extended friendship network of other lesbian families.

Here again, we see Erikson’s emphasis on how the social milieu mediates and supports an individual’s identity. Jake, age eleven, experienced much security in both his school and his home environments. He had few impingements psychologically, physically, or socially. Robust, endowed with a strong intellect, and very pleased with himself for graduating from the same school that he had attended

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since he was three, he wrote an alphabet journal about the school’s significance for him. Note his latency age language about conquering new material, of the importance he places on peers for his development, of the role of teachers, as he reflects on his development. “Q” stands for quest. I feel that the Campus School has been like a quest to me. It has obstacles and it has easy, wide-open roads. It has had its up and its downs, but altogether it turns out as a success. I have loved this school so, so much. “R” stands for reading. When I was younger and this may be due to the fact that I skipped Kindergarten, I couldn’t read well. Actually, I could barely read at all. But luckily, I had a good friend, Annie. She would go over the alphabet many times with me and then we would read words. My parents and teacher also taught me, but Annie was the one who really stuck with me. Now I consider myself to be an excellent reader and I would like to thank Annie so much for helping me. “S” stands for spelling and studying. I love spelling. Spelling came easily to me after I learned how to read. At the Campus School, they really stress studying for tests. I guess they do that at any other school but here if I get a bad score on a test, I feel awful. Not bad, but awful. I also feel bad if I don’t study. “T” stands for talent show. It is only for 6th graders and I remember going to the performance every year and wishing that I were the one on stage. This year I finally was. “U” stands for united. At the Campus School, teachers are united when it comes to bad language and such. They are always fighting a battle to rid the school of it. This is a losing battle. If a teacher catches you swearing you may be sent out of the room, given the hairy eyeball, or if it happens a number of times, you may lose your recess. Recess is really fun so you try not to lose it. “V” stands for visiting. I  visited many schools this year. I  felt this thrill because my life was totally in my hands. “W” stands for Ms. Wickles. She was our substitute teacher and she was really nice, for example, when she was done teaching she gave us gift certificates. She was also really strict, like one day she told us that all she wanted to hear was the scratch of the pencil on paper. After that, we all laughed. “Y” stands for year. This year we studied the Industrial Revolution and simple machines. It was a lot of fun and we had to make a project that, with the power of a hair-blower, would lift an egg. During all of this, we had been writing, reading, and learning. In math we learned distributive property, algebra, equations, fractions, decimals, and percents. Currently we are doing acid rain. Altogether, this has been an amazing year. “Z” stands for Zeke. He is my brother. He isn’t always a nice boy. We fight a lot but what do you expect brothers to do? I mean he plays with me. We joke around and he usually does not physically hurt me. Conclusion. Oh no, this essay is ending! Anytime you feel lonely, feel free to read this Alphabet book again. This essay has been very gratifying. I have had bundles of joy in writing it. It has taken time, energy, and a sharp mind to write all of this. I hope that you have licked up every last scrap of my school life and still have its delicious flavor on your tongue. Savor this. I won’t make another one. And finally, I thank my school for giving me six great years of a near-perfect life!

In Erikson’s view, Jake’s narrative about his life, his pleasure in learning, in mastering new skills, and in relationships, would look different had he had biological problems with learning, a social environment that was ill equipped to nurture his learning, or a set of family circumstances (major loss, severe family violence, trauma) that might have undermined his sense of mastery. Adolescence: Identity vs. Role Confusion (Eleven to Eighteen Years) Almost universally, adolescence is a difficult time. Adolescents face rapid hormonal changes. Their reference groups shift from parents to peers. They are deeply concerned with themselves. Erikson saw their efforts to fall in love, with other people or with ideas, as efforts

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to also define themselves. Adolescents engage in painful struggles over self-acceptance and acceptance from others. They are deeply concerned about who is “in” and who is “out.” Adolescence provides a time of achieving individual identity through a group identity. In Erikson’s schema, adolescence presents a crisis around the development of a sense of a personal identity. Adolescents are often in a state of suspended morality, as they begin to formulate personal ideologies based upon values that differ from those of their parents. Adolescent drug experimentation and sexual experimentation are attempts to construct individual values, based on group identity. The psychosocial task of this stage is that of identity versus role confusion. The task is to achieve a stable sense of self, which must fit with an image of the individual’s past, present, and future of larger possibilities. What must be achieved in adolescence is the accrued confidence that one’s identity might and will remain stable over time. Erikson did not set a standard for the development of a “healthy” identity. Again, he always argued that the meaning of an adolescent’s behavior had to be understood within the sociocultural and historical contexts in which the adolescent develops. In his studies of the Sioux Indians, for example, he demonstrated how an adolescent’s identity might be shaped positively in the context of a disenfranchised culture. Erikson was careful to state that simply because any individual was socially or economically disenfranchised, she should not be seen as lacking strengths. If adolescents, as was true for some Sioux Indians, engage in seemingly pathological behaviors such as truancy, alcohol abuse, or passive aggression, these may well be adaptive responses to the external disruption of their continuous identities and communities through discriminatory practices. Consider this poem by Rosario Morales, an adolescent, Latina immigrant, whose identity is being forged in a new culture, a new social class, and both Puerto Rican and Jewish ethnicities. She writes: I am what I am and I am U.S. American. I haven’t wanted to say it because if I did you’d take away the Puerto Rican but now I say go to hell I am what I am and you can’t take it away with all the words and sneers at your command I am what I am I am Puerto Rican I am U.S. American I am New York Manhattan and the Bronx. . . I love the sound and look of Yiddish in the air in the body in the streets in the English language . . . I am what I am and I’m naturalized Jewish-American . . . and its me dears it’s me bagels blintzes and all I am what I am Take it or leave me alone. (Morales 2002, pp. 12–13)

While Morales celebrates her identity for all of its discontinuities in ethnicity, class, and culture, sometimes an adolescent may develop what Erikson calls a negative identity. A negative identity may be forged around those “identifications and roles which at critical stages of development had been presented to them as most undesirable or dangerous and yet also as most real” (Erikson 1959, p. 131). Some adolescents even form socially deviant identities with groups that may be dangerous, such as antisocial gangs or cults. A negative identity may also develop in opposition to the excessive idealism of a parent. While an adolescent may turn to antisocial groups, cults, or gangs, or to terrorist groups, not all gang membership results in a negative identity. In fact, for some adolescents, gangs can provide community, fraternity, fidelity, and loyalty. Mark was a thirteen-year-old Chicano boy in an urban housing project who began to hang out with the Warlords. Their leader was a drug dealer who, under less socially impoverished conditions, would have been a positive role model in the community. Mark was drawn to the drug dealer’s savvy, strength, and leadership skills. His identification with the dealer had aspects that were both positive and negative, as he learned to assess his situation, to understand market economy, and to protect himself on the streets. These qualities later served him well in a business career.

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Erikson proposed that as adolescents struggle with who they are, they may need, as he did, a psychosocial moratorium, or period of time in which it may be adaptive to drop out and explore one’s identity without making premature commitments. But if adolescents are not supported in forming coherent identities through their personal strengths and societal supports, they run the risk of prematurely foreclosing on their identities or of losing themselves in fanatical or exclusive commitments or through negative identifications. But if an individual is able to emerge from this stage with something of a coherent identity, the virtue is that of fidelity, defined as the ability to sustain loyalties freely pledged in spite of differences in values. Young Adulthood: Intimacy vs. Isolation To achieve intimacy in relationships, a young adult needs a solid sense of identity. Intimacy involves mutuality, and mutuality, Erikson opined, requires the ability to lose oneself and find oneself in another without losing one’s own identity. When identity is shaky, attempts at intimacy “become desperate attempts at delineating the fuzzy outlines of identity by mutual narcissistic mirroring: to fall in love often means to fall into one’s mirror image” (Erikson 1964, p. 18). Without the capacity to share with loved ones, including friends, there can be a tendency toward isolation. In sociocultural times such as the 1980s and 1990s, when individualism was so highly valued and the narcissistic pursuit of self-­ gratification so socially sanctioned, isolation may have represented a socially acceptable feature of what, in fact, were poorly consolidated identities of many young adults. As part of intimacy, Erikson identified the role of genitality, which he defined as the capacity for orgasm with a partner who is loved, trusted, and competent, and with whom one is willing to regulate one’s work and play for the purposes of procreation. Real intimacy requires having ego boundaries that are strong enough so that one is able to temporarily suspend them in the service of connection to an intimate other. For people whose identities are fragmented, rigid, or brittle, the capacity for real intimacy may be limited or impossible. The virtue of this stage is love, which Erikson (1964) defined as “the strength of the ego to share identity for mutual verification of one’s chosen identity while taking from this supportive relationship the opportunity to be a separate self” (p. 129). It should be noted that Erikson saw intimacy as achieved in a partnership that was heterosexual, and that he privileged one form of sexual expression and commitment over others. This heterosexism, of course, mirrored the time and place in which he was writing, largely the 1950s. Adulthood: Generativity vs. Stagnation Loving and working adults need to feel concern for, and interest in, the next generation if they are to maintain their continuous identities. The abilities to extend interests within and beyond the home, and to establish and guide future generations is what Erikson referred to as midlife challenges. To be generative, however, does not mean that one must produce biological children. Consider the coaches, troop leaders, clergy, and teachers who serve and work in their communities. Then reflect upon the ways in which they have shared their interests, guided, organized community or church activities, mentored, cured, and showed concern for others. Generativity ultimately involves finding one’s place in the life cycle of generations. The opposite of generativity is stagnation and self-absorption, pseudo-intimacy or self-indulgence. In this developmental stage, Erikson saw the virtue as care. Care is “the widening concern for what has been generated by love, necessity, or accident” (Erikson 1964, p.  131). The guiding parent, friend, teacher, mentor, or even storekeeper needs to have the conviction that “I know what I am doing and I am doing it right” (p. 131). The opposite may be authoritarianism, self-indulgence, or insensitivity to the needs of others.

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Dorothy was a forty-two-year-old African American schoolteacher and single parent. The mother of two boys, she had worked since her sons were infants. In the school in which she taught, Dorothy spent long afternoons, evenings, and weekends with her students, working on community issues, giving freely of her skills by tutoring and by providing encouragement, guidance, feedback, and love. Her colleagues benefited from her effusive and generous nature. She wrote an important and widely used handbook on working with minority adolescents; she provided strong leadership in curricular development; and she was consulted widely and often. Her generativity extended far beyond her nuclear family, although her two children also thrived within the richness of her life.

By contrast, T. S. Eliot’s poem “The Love Song of J. Alfred Prufrock” (1915) captures some of the self-absorption, somatic preoccupations, self-consciousness, and stagnation of a midlife man who is not generative. It is interesting to note that Eliot wrote this poem when he was an undergraduate, containing within it his own concerns about a stagnant identity that had already begun in adolescence. J. Alfred Prufrock lamented: “Do I dare?” and, “Do I dare?”— Time to turn back and descend the stair, With a bald spot in the middle of my hair— . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do I dare Disturb the universe? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Should I, after tea and cake and ices, Have the strength to force a moment to its crisis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do I dare to eat a peach? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I have heard the mermaids singing, each to each. I do not think that they will sing to me. (Eliot 1915, pp. 131–35)

Here, we see how the difficulties in negotiating earlier stages (initiative, intimacy) contribute to Prufrock’s midlife experience of stagnation, fear, and a lack of capacity to care beyond himself. Old Age: Integrity vs. Despair Old age requires acceptance that death is an inevitable part of life. Whether having lived as a Sioux, African American, Irish-Catholic, Latino, Protestant, or Jew, the finality of death in old age is inescapable. Each culture mediates the meaning and significance of old age and death differently. Asian, Hispanic, and African cultures venerate the old and accord a great deal of respect and wisdom to people at this life stage. Many other Western subcultures respond to old age with fear and denial, warehousing old people in substandard nursing homes and isolating them from their communities and social supports. How a person negotiates this stage of life in the face of death is mediated by the individual’s ego strengths, the family, the culture, the historical time, and the social surround. In this stage, adults who have been cared for and who have cared for others may now care for themselves. In this last stage of life, integrity is the opposite of self-centered love. Integrity is a sense of acceptance that this is one’s only life. This is the time (and last time) for emotional integration. An infant first learns to trust herself as she trusts the world, and so

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in the beginning the infant depends on the integrity of her caregivers. With the achievement of integrity in old age, the life cycle is complete. Erikson wrote that healthy children should not fear life if their elders are integrated enough not to fear death. If, at the end, the life cycle turns back on its own beginnings so that the very old become again like children, the question is whether the return is to a childlikeness seasoned with wisdom or to a finite childishness. The old may become (and want to become) too old too fast or remain too young too long. Here only some sense of integrity can bind things together . . . and by integrity we do not mean only an occasional outstanding quality of personal character, but above all, a simple proclivity for understanding or hearing those who understand the integrative ways of human life. . . . [With integrity] there emerges a different, a timeless love for those few others who have become the main counter-players in life’s most significant contexts. (Erikson 1980, p. 46)

The virtue of old age is wisdom, defined as a “detached concern with life itself in the face of death itself.” The opposite is disgust and despair, which implies a sense of futility about one’s life, a meaninglessness, and ultimately an inability to care for oneself or for others. Consider the ways in which Mrs. Frank and Mrs. Grace approached the end of their lives. Mrs. Frank was an eighty-six-year-old white Anglo-Saxon Protestant woman who had lived in the same neighborhood most of her life. She had been married at twenty, was widowed at sixty, and raised two daughters who had families and careers of their own. Every week she attended a book group comprising women of different ages. She often had young neighbors in for tea and was deeply interested in their relationships and their lives. Local kin would be invited for Sunday dinner. She was still involved in social action and she attended musical events regularly. Although her children and grandchildren were geographically distant, she maintained regular contact with them. She even came to speak to a psychology class on Erikson’s final life stage and enjoyed her own presentation immensely! While Mrs. Frank was in relatively good health, save rheumatoid arthritis, she also recognized that her own life was nearly over. She had prepared for her home to be sold when she became unable to function independently and had arranged for residential care when necessary. She had decided which books she hoped would go to which grandchildren, and which furniture would go to which daughter, had been able to talk with her children about her life choices, advance directives, and impending death, and appeared to accept her death as an ultimate finality.

While Mrs. Frank was able to approach the end of her life with both wisdom and responsibility, integrating the many successful earliest resolutions of identity crises, Mrs. Grace, by contrast, met the psychosocial tasks at the end of her life with pessimism and despair. Mrs. Grace, also white Anglo-Saxon and Protestant, suffered many losses in her life. When she was a young child, her father was diagnosed with tuberculosis and the family had to move their home to be near a sanatorium, never knowing when her father would require institutional care, for how long, or when he would be well enough to come home. Her mother was absent and distracted and Mrs. Grace grew up with only the approval of the nuns at the Catholic school she attended, whose religion her family did not practice. Her father died when she was seventeen; she had difficulty leaving home and married as quickly as she could. While she geographically separated from her family, she was haunted by the fear that her husband would become ill and abandon her as her father had. In fact, her husband did become ill with cancer in his late thirties. While he kept his illness a secret from her for as long as he could, his disease progressed, and he died at the same age as her father had died. Mrs. Grace had three sons. When her husband died, she took to her bed and did not function for over two years, leaving her children, all in their teens, to fend for themselves. She made one suicide attempt. As each son left home, she made her anger at them for leaving her very clear. She expressed bitterness and envy when they married, had children, and had professional successes of their own. She was highly critical, read

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the obituaries daily, and delighted in reading about young men who had died. With her children and grandchildren, she was withholding, and her pessimism made it hard for each of them to feel close to her. In the rare instances when her children, now adults, needed her, she complained of feeling used and abused and could not generously respond because she felt so depleted. Her eldest son tragically also became ill with cancer in his early forties and died at the same age that her father and husband had.

As she aged, Mrs. Grace became more and more bitter about the ways in which life had cheated her. In old age she needed more care and moved to the town where her middle son resided. There she complained bitterly about feeling neglected despite his best efforts to care for his mother in ways he had not been cared for. She felt unloved and expressed regrets that she had not gotten a doctorate as her son had, that she did not live in a house like her son’s, that she did not have a living partner as her son did. As she faced death, she was frightened. Although she saw herself as a staunch advocate for assisted suicide and decried that she did not want any intervention were she to be hospitalized, each time her son left town, she became sick and was hospitalized, seeking the most aggressive treatments. As death approached, she was furious and despairing that her body had failed her as well. She died while her son was overseas, on a business trip, frightened and alone.

CRITIQUES OF ERIKSON Erikson made an enduring contribution to understanding human development in ways that incorporated culture, class, ethnicity, race, and historical oppression. He vastly expanded the idea that health and psychopathology are something that occurred within the nuclear family alone, and he came to identify the importance of strengths and impingements from the social environment. But over the past few decades, Erikson has been faulted for the gender biases in his theory of life-cycle development. For example, Erikson proposed that male and female life-cycle development differed in childhood, adolescence, young adulthood, and midlife, but in ways in which the differences often looked like girls and women were less developed than boys and men. In describing childhood, for example, Erikson identified gender difference in the spatial organization and play of boys and girls. He noted that boys’ play tends toward creating high towers and protrusions, and that their play was independent and aggressive. Girls at play tended to be preoccupied with interior, closed spaces, and their play was more receptive. Erikson understood these differences to be a result of the interface between anatomy, social roles, and psychosexual tasks. His underlying assumption of female passivity and receptivity, however, unwittingly reflected the sex-role stereotypes and expectations for women in the 1950s and early 1960s, the decades in which he wrote. Much like Freud’s describing the women he worked with as narcissistic and passive, Erikson could not step out of the social times in which he theorized. Erikson also proposed that, in adolescence, women lag behind men in the development of a gendered identity. In fact, he wrote that for a woman identity is not actually achieved in adolescence but rather occurs in early adulthood and is defined by the man she will marry, who will fill her inner space. This idea captures another gender stereotype—that women are defined by their relationships with men. His theory was both sexist and heteronormative. It also implied that female identity is less articulated and less differentiated than is male identity, with the disconcerting suggestion that this might result from a deficiency in women rather than from the unequal social world in which women are raised.

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In describing the state of generativity, Erikson suggested that female identity was defined by motherhood. Once again, the gender stereotype of a woman caring for children at home was viewed as a developmental achievement. If female identity in midlife is defined by motherhood, then why is male identity at the same stage not defined by fatherhood? As has been true in so many of the psychodynamic theories we have studied, then, male development was the prototype for all development, and female development was considered a deviation from the norm. Recall that Erikson postulated that normally (read “for men”) identity precedes intimacy. By the end of adolescence, a man has a sufficiently separate and bounded identity that he can form a relationship with a woman with whom he shares life’s pleasures and with whom he can lose and find himself. By contrast, Erikson posited, a woman’s identity occurs later. It is defined in early adulthood by the man she will marry and by the children who will fill her inner space. Hence, women were seen as less developed than men. Jean Baker Miller (1984) argued that Erikson’s theory neglected the role of relationships and attachments throughout the life cycle. In an effort to balance what she saw as an overemphasis on separation (with developmental goals such as autonomy, initiative, and industry), Miller proposed adding a relational component to each of Erikson’s eight stages of man. For example, in infancy, a girl develops not only trust but also a sense of herself in a relationship, giving her the capacity for emotional empathy. In the second stage of autonomy versus shame, Miller noted that a girl never becomes autonomous, instead developing a sense of her own agency within a community of relationships with others. At the oedipal stage, girls in Western cultures begin to learn about their mothers’ devalued place in society and to identify with them. For example, Lizzie, a six-year-old white middle-class girl, noticed that in her basketball games, boys tended to shoot the baskets while girls were trained to pass the ball. She went to her school principal to tell her what she had discovered. Her principal responded that this was the “normal” way that girls learn to be girls. In effect, her principal codified that gender inequality was a normal part of Lizzie’s development and that Lizzie should accept her devalued place in the game and in society.

In latency, Miller maintained, a girl’s relationships with female friends play an important part in self-definition. And yet it has been noted that when girls on the playground who are engaged with female friends are asked what they are doing, they invariably reply, “Nothing.” Clearly, girls in latency also learn to devalue, as their society does, their relational ties. By adolescence, Miller noted, girls begin to see their own needs as conflicting with the needs of others. Gilligan (1982) has also noted that in adolescence, girls begin to silence themselves academically, conforming to societal expectations to tend to the needs of men. In a similar vein, Franz and White (1985) criticized Erikson for his overarching emphasis on separation and individuation in his life-cycle theory. In fact, his emphasis on separateness unconsciously privileged male development. Franz and White suggested, as did Miller, that Erikson’s stages of development be viewed as two pathways: one of individuation and the other of attachment. For example, using Mahler’s ideas about separation and individuation, they noted that a two-year-old child becomes autonomous only when she masters the relational achievement of object constancy. As a child develops within Erikson’s stage of initiative, she develops greater relational complexity, taking the initiative to engage with others in play. By school age, a child develops the capacity for industry and also for collaboration with other children. Adolescence is a time when a child develops a separate identity, but it is also a time for interdependence. Thus, many of his stages, such as autonomy, initiative, industry, and identity, reflected the values of a Western, male-dominated, competitive,

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industrialized culture (Berzoff 1989). Miller, then, and Franz and White offered relational correctives to what they saw as an overemphasis on separation and individuation. The critique of Erikson elucidated a problem that every theorist has faced: all theorists are embedded in their unique culture and moment in sociohistorical time. Hence, when Erikson referred to intimacy, he referred only to heterosexual intimacy, which he defined as occurring through mutual, genital, heterosexual orgasm. But is this the only form of adult intimacy or love? We would argue emphatically that genital orgasm with a heterosexual partner is not the hallmark of intimacy, but that the ability to lose oneself and find oneself in another, in mutually regulated ways, constitutes the highest form of adult intimacy and love. We imagine that Erikson, who paid such close attention to cultural variance, would have been far more inclusive of variance in sexual orientation were he writing today. An additional critique comes from the current discourse in postmodernism (see chapter 10 on gender). Many theorists are beginning to question the value of stage theories such as Erikson’s, which are both linear and hierarchical. They question the validity of a continuous construct such as “the self” or “identity.” They ask whether a core self truly exists or whether we are constituted as multiple “selves” that continue to develop in the contexts in which we grow, live, and work. In this latter view, we carry multiple identities, in multiple situations (Mitchell 1993). Postmodern theorists note that in a technological and social world that requires multiplicity (Gergen 1991), we are students, and teachers, adults and children, social media profiles, email addresses, workers, siblings, bosses, parents, and so forth. We contain multiple selves in the instant when the telephone rings, the cell phone intrudes, or we step onto an airplane that within hours will transport us into an entirely different context that calls for different parts of ourselves and identities. In a postmodern world, the self is continuously oscillating, based on the many social and relational contexts in which it is experienced and expressed. Despite these critiques, Erikson was one of the first developmental theorists to add gender to the definition of identity. Erikson was also the first to emphasize the importance of a person’s location in the social structure and to recognize the degree to which a person’s identity was shaped by biology, culture, religion, class, and by social history, including oppression. His theory is more open to critique precisely because it is more inclusive.

CONCLUSION Despite many critiques, Erikson’s life-cycle model of ego development remains very valuable for psychodynamic practitioners. First, it brings child development out of the narrowly defined bounds of the nuclear family and into a social world in which developing children interact not only with parents but also with peers and teachers, with day-care providers and community members in the context of larger social and cultural expectations. Second, it provides a developmental framework that projects personality development beyond infantile sexuality and concentrates on development throughout the adult life cycle until death. Third, it focuses on identity, as opposed to sexuality, as a central determinant of psychological well-being. Fourth, it begins to unite ego psychology with object relations so that an individual is seen as increasingly mastering inner and outer reality as she moves through the life-cycle tasks, individual stages, and relationships crucial to the developmental tasks of those stages. Finally, Erikson’s theory is more psychosocial than Freud’s or that of any other ego psychologists. His theory is the first, and still the strongest, to expand the discourse on development by adding the variables of culture, race, class, gender, and time to how a

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person develops a coherent sense of identity. His theory is strength based relying on potential virtues that emerge through development. While Erikson was constrained by his own cultural constructs and values, by his era, and by a linear view of development, his work has provided us with a theory that takes biology, race, class, and gender into consideration far more than any previous psychodynamic theory. His inclusion of the sociocultural surround in which individual identity develops makes a profound contribution to clinical practice. While Erikson sought to explain the confluence of gender and identity, it is an ongoing task of our current and future theories to continue to articulate the ebbs and flows of separation and connection as they occur in the identities of girls, boys, men, and women in differing sociocultural contexts.

REFERENCES Berzoff, J. (1989). Fusion and heterosexual women’s friendships: Implications for expanding adult developmental theories. Women and Therapy 8(4):93–107. Eliot, T. S. (1915). The love song of J. Alfred Prufrock. Poetry: A Magazine of Verse 6(3):130–35. Erikson, E. (1950). Childhood and Society. New York: Norton. ———. (1959). Identity and the life cycle: Selected papers. Psychological Issues Monograph 1(1). New York: International Universities Press. ———. (1964). Insight and Responsibility. New York: Norton. ———. (1968). Identity, Youth and Crisis. New York: Norton. ———. (1980). Elements of a psychoanalytic theory of psychosocial development. In The Course of Life: Psychoanalytic Contributions toward Understanding Personality Development, Vol. 1, Infancy and Early Childhood, eds. S. I. Greenspan and G. H. Pollack. Washington, DC: National Institute of Mental Health. Evans, R. (1981). Dialogue with Erik Erikson. New York: Praeger. Franz, C. E., & White, D. (1985). Individuation and attachment in personality development: Extending Erikson’s theory. Journal of Personality 53(2):82–106. Gergen, K. J. (1991). The Saturated Self: Dilemmas of Identity in Contemporary Life. New York: Basic Books. Gilligan, C. (1982). In a Different Voice. Cambridge, MA: Harvard University Press. Kotlowitz, A. (1991). There Are No Children Here. New York: Doubleday. Miller, J. B. (1984). The development of women’s sense of self. In Essential Papers in the Psychology of Women, ed. C. Zanardi. New York: New York University Press. Mitchell, S. J. (1993). Hope and Dread in Psychoanalysts. New York: Basic Books. Monte, C. F. (1980). Beneath the Mask. New York: Holt, Rinehart. Morales, R. (2002). I am what I am. In This Bridge Called My Back, eds. C. Moraga and G. Anzaldua. Berkeley, CA: Third Woman Press.

5 Object Relations Theory Laura Melano Flanagan

Object relations theory continues the study of psychological development and contributes its own special lens with which to look into a person’s inner world. The focus of object relations theory is not on the forces of libido and aggression or on the adaptive functions of the ego. Rather, it is on the complex relationship of self to other. Object relations theory explores the process whereby people come to experience themselves as separate and independent from others, while at the same time needing profound attachment to others. Melanie Klein (1952) summarized the core tenet of this theory: “There is no instinctual urge, no anxiety situation, no mental process which does not involve objects, external or internal; in other words, object relations are at the center of emotional life” (p. 53). Or, as in the famous and enigmatic quote by Donald Winnicott (apparently uttered at a psychoanalytic society meeting in the early 1940s), “There is no such thing as a baby.” By this, Winnicott meant that there exists no such thing as a baby without another person.

WHAT IS OBJECT RELATIONS THEORY? Object relations theory is the term that has come to describe the work of a group of psychodynamic thinkers, both in England and in the United States. Although almost always written in the singular, object relations theory is not actually a theory, because it refers to the work of many writers, who did not necessarily identify themselves as part of any given school and who often argued and disagreed quite passionately with one another. Object relations theory is so called in order to distinguish some of its central tenets from those of drive theory, ego psychology, and self psychology. Object relations theory is based on the belief that all people have within them an internal, often unconscious world of relationships that is different and, in many ways, more powerful and compelling than what is going on in their external world of interactions with “real” and present people. Object relations theories focus on the interactions that individuals have with other people, on the processes through which individuals internalize those interactions, and on the enormous role these internalized object relations play in psychological life. The term 92

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object relations thus refers not only to “real” relationships with others but also to the internal mental representations of others and to internal images of self as well. While other theories have attended to how libido and aggression may seek discharge, expression, and satisfaction, or to how the ego copes with life stressors and adapts to conflicts between intrapsychic structures, object relations theory adds an inner mysterious world, with its own story, plot, drama, and, above all, cast of characters. When thinking about object relations in psychodynamic theory, it is important to remember that the term is not synonymous with the commonly used term relationships. Object relations does refer, in part, to the complexity of external relationships with others, but it also includes a whole internal world of relations between self and other, and the ways in which others have become part of the self. This can be seen in peoples’ fantasies, desires, and fears, which invariably include images or representations of other people. One’s internal world, then, includes the mental representations of self and other. When object relations are assessed in the process of diagnosis, it is important to examine not only the quality of real, external, interpersonal relationships but also the nature and quality of internal self and object representations. When confusing object relations with relationships, people may say, “Mr. Smith must have good object relations because he has been married twenty years” or “Ms. Jones must have poor object relations because she is not involved with anyone.” The mere fact that someone has been married for twenty years or that someone is not in a relationship does not necessarily tell the clinician much about object relations. For instance, Mr. Smith could have remained married for twenty years because his object relations are troubled, because he believes that everyone aside from his wife is bad or dangerous. His self-representation— meaning his view of himself—could be that of a weak man desperately needing the protection of one good object, his wife. Ms. Jones, by contrast, might have healthily and adaptively come to know herself as a person who prefers and benefits from solitude and separateness. Her self-representation could include a balanced view of both her strengths and her needs, and her internal world might be filled with benign object representations that keep her from being too lonely while not involved with an intimate other. The use of the word object to mean “a person” is traditional in psychoanalytic literature. This choice may seem odd, and is perhaps unfortunate, because object usually refers to a thing. Each of the authors has had the experience of giving a lecture on object relations to students and colleagues from other fields who eventually, incredulously, ask, “When she uses the word object, does she mean a person?” When the answer is yes, the response is always some variant of “What a weird choice of words for professionals who are supposed to be interested in people!” Object, when used in reference to a person, can sound depersonalizing and static, but, in fact, the word has been chosen to capture an important facet of human relations—that people outside the self can be many things, including objects of desire and fear, rather than simply the people they are. The word object is also chosen because it clearly differentiates object from subject. In this way, it becomes evident that the subject is the self and the object is the thing outside of the self that the self perceives, experiences, desires, fears, rejects, or takes in. Webster’s (1963) offers several useful definitions for the word object: “Something that is sought for.” “Something of which the mind by any of its activities takes cognizance, whether a thing external in space or time or a conception formed by the mind itself.” And, simplest of all, “what is aimed at” (p. 1555). In psychodynamic theory, the word object usually refers to people, but other things such as music, art, the weather, or even medications can become objects when they are deeply and symbolically connected to powerful object experiences in the inner world. An antidepressant being given to a patient may function not

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only as a pill but also as the symbol of care, nurture, and even feeding, since it is taken by mouth. In Freudian drive theory and in ego psychology, the term object is usually used in reference to people. Yet the word object in drive theory can be somewhat depersonalized. Even when drive theory refers to objects as people, it is referring to people as representing the targets of the drives, and as such they become the means or object by which a drive can be satisfied or frustrated. In contrast to Freudian drive theory and ego psychology, object relations theory fleshes out the relational aspect of the object. Object no longer refers to the person or thing outside of the self as the gratifier or frustrater of instinctual wishes, but looks more closely at how needs are met or not met in relationships. Object refers specifically to the person, real or internalized, with his qualities and his contribution to the interaction. In fact, this theory is the first to make a clear and important distinction between need and impulse, with need being understood as a far broader concept. D. W. Winnicott (1956), a major object relations theorist, believed that drives and impulses could be gratified or frustrated even by someone with whom the relationship is not all that important, whereas needs have to be met by a meaningful person, thereby placing the relationship at the center of the experience. For optimum development to take place, important needs have to be met, including the need to be seen and valued as a unique individual, to be accepted as a whole with both good and bad aspects, to be held tight and to be let go, and to be cared for, protected, and loved. Object relations theory postulates that human beings are incorporative by nature, both physically and psychologically. Just as the body takes in food and drink and then metabolizes it, the psyche takes in what it experiences with others and process it to become part of the psychological self. In the physical realm, what happens when a body takes in food depends in part on the individual body. So, too, in the psychological realm, there are individual variations in what happens to what is taken in emotionally. Ten people eating the same amount of salad or steak or chocolate cake will not gain or lose the same amount of weight or extract the same kinds and amounts of nutrients. What happens will be determined by each person’s complex physical condition at the time. Ten people being criticized or being given a hug will similarly take in the experience in ten different ways depending on the psychological strengths, vulnerabilities, past experiences, and social and cultural influences that have made them unique. When a clinician is getting to know a client and beginning to make an assessment, in any setting, no matter what service is going to be provided, it is useful, indeed necessary, for her to consider both the nature and the nurture of the person. We have always believed that it is important to look at both what the person has experienced from the outside and who the person is who is taking in those experiences. As clinicians we also believe that what is taken in from the outside are not just the personal experiences in a client’s life but also the social forces at play in her culture and society and the “intersection” of those forces. The term intersectionality was coined by Kimberlé Crenshaw (1989) to describe the way in which both feminism and antiracist policies fail to address the subordination of black women, who are at the intersection of two kinds of discrimination. Since then, intersectional theory has finally become central in the teaching of psychological development. Intersectionality addresses the way that people can be disadvantaged by multiple sources of oppression—including their race, class, gender identity, sexual orientation, and other identity markers—resulting in a cumulative marginalization and discrimination that is more than the sum of its parts. Oppression, prejudice, hatred, discrimination, being looked down on—all these messages get inside the internal world just as powerfully as

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interactions with immediate family members. Racism, sexism, ageism, heterosexism, ableism, classism—all the -isms in our society—need to be fought against not only as external evils but also because they get inside the people who suffer from them and then shape and color our internal worlds. Rose, a successful, professional, thirty-five-year-old, African American businesswoman, feeling ill, dreads the thought of asking her boss for some time off. She not only imagines the boss rejecting her request but also is convinced she will be shamed and humiliated. For several nights she dreams that she is “bleeding to death from the heart” on her boss’s desk while the boss chats and laughs with his white friends on the phone. When Rose actually asks for the time off, she is surprised and confused by the gentle, concerned manner in which she is encouraged to take a few sick days.

This example shows us how a person’s internal representations of object experiences from the past, coupled with discrimination and racism, can dominate the present inner world to such a degree as to render life painful and confusing by distorting present relationships. Rose is a person who often cannot tell what is inside and what is out, or even what is present and what is past. She was raised by a family that consisted of rigid, controlling, often sadistic grandparents, a schizophrenic mother, and a severely depressed father. The family lived in crushing poverty and therefore offered limited economic and cultural opportunities, which caused further frustration and despair to this bright, curious little girl. There was a great deal of illness as well, and Rose suffered as each family member was hospitalized for serious physical and emotional breakdowns. All of her caregivers were dead by the time she was twenty. Nothing ever seemed stable, clear, clean, or safe. Therefore, Rose now carries within her the expectation (what object relation theorists call “object expectations”) that bad things will come at her (fearing the boss’s rejection) and that this will result in life coming out of her (bleeding to death). Although Rose is keenly intelligent and has a quick, perceptive mind, which she uses successfully in her work, her reality testing and her judgment fail her when it comes to herself and her needs. Having taken in the badness around her, she still experiences herself as a neglected, invisible, and bad girl in that chaotic, racist, hostile, frightening world in which she grew up. Led by social work, which has always valued the biopsychosocial approach, the mental health disciplines have become more aware of the importance of looking not only at the person but also at the “person-in-situation.” The striking, invaluable contribution made by object relations theory is that it helps the clinician to look at the opposite phenomenon, which is the “situation-in-person” and to understand its power. In other words, what is “outside” often gets “inside” and shapes the way a person grows, thinks, and feels. In a brilliant paper by Kathleen Pogue White (2002) titled “Surviving Hating and Being Hated: Some Personal Thoughts about Racism from a Psychoanalytic Perspective,” she writes, “I also think that people learned lessons from being hated, which inform character development as surely as the events of family interaction that are more typically cited in theories of development” (pp. 401–22).

BEGINNINGS In chapter 2, we saw that Freud’s genius lay in his appreciation of the passions that “drive” humankind, passions both sexual and aggressive. However, he was also aware of the role that real objects play in development. In 1917, he published “Mourning and Melancholia,” a paper that for the first time addressed the role of the object as much more than simply the

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target of the drives and stressed the importance of the object in psychological development. Freud distinguished the process of normal mourning from that of melancholia. In mourning, the sorrow is about loss and, once the loss is worked through, the self remains basically unchanged or perhaps even strengthened through internalization of the lost “good” object. In melancholia, which looks like a mourning that does not end, harsh or negative feelings toward a lost loved one become internalized, are turned against the self, and actually change the self into a self-hating human being. This is the first time in psychoanalytic theory that change in psychic structure is seen as coming from an object relation rather than from the success or failure of the gratification of a drive. In the time immediately after someone’s death, the person in mourning is dejected, full of sorrow, and uninterested in present-day life. But that same person will often be passionately interested in memories of the dead person, who may seem more vividly alive and important than anyone else. The memory of the loved one’s voice or of her smile, of the way she loved spaghetti or woke up in the morning—all these details are present, sometimes unbearably so. Places become filled with meaning, beauty, and pain because of past experiences with the dead person. It is as if the mourner makes one last desperate attempt to keep the person alive, to defy and deny the reality of loss. In time, however, as each memory is seized and cherished, reality ultimately requires letting the object go, allowing the mourner to return to the present, to the self, and to new objects. Melancholia looks the same at first. There is the same dejection, the loss of energy and interest, but in melancholia these things do not pass. There is no sense of anything being worked through. The mourner remains in mourning, unable to move forward and, strikingly, in addition to being sad about the loss, starts to become full of complaints about the self. The mourner seems to be suffering from a disturbance in self-regard that often reaches the level of self-hatred. What accounts for this melancholia, this drop in self-esteem? Freud postulated that the complaints about the self were instead plaints about the lost person that have been turned against the self. In this condition, the loss of a significant other, occurring through death, abandonment, or emotional unavailability, is accompanied by strong feelings of ambivalence. To deny the guilt about negative feelings toward the lost object and to preserve a positive image of the other, the mourner takes in and identifies with the abandoning object, and then directs feelings of anger and disappointment toward the self. Self-reproach and self-punishment become ways of dealing with anger toward the ambivalently held other, as that anger is now turned against the self. Rather than letting the loved one go and creating inner space for new objects and experiences, the melancholic becomes consumed by this negative internal relationship and turns her energies away from the world. To explain this process, Freud (1917) wrote one of the most dramatic and beautiful sentences in all of psychodynamic literature: “Thus the shadow of the object fell upon the ego” (p. 119). Here we encounter for the first time the potent idea that the nature of the relationship with an object actually influences the nature of psychic structure. We can see how the mental representation of another is created in the self and how it serves to shape a person’s sense of self and ability to relate to others. The concept of the shadow of the object falling upon the ego, of something in a relationship beyond instinctual gratification or frustration profoundly affecting the structure of the self, represented an enormous expansion of psychodynamic theory and eventually became the heart of object relations theory. The process of how and why a person identifies with others, takes in others, and turns feelings about others into ways of feeling about the self is being examined, discussed, and debated about by object relations theorists to this day.

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BASIC CONCEPTS In the rich and varied field of object relations, there are several schools of thought or theoretical groups. From the beginning there has existed a lively tradition of dialogue, interaction, and even sometimes quite fierce arguments within and between the schools. The simplest division of the schools is into the British and the American traditions. Main proponents of the British school are Melanie Klein, Ronald Fairbairn, Harry Guntrip, Donald Winnicott, and John Bowlby. Chief among the Americans are Margaret Mahler, Otto Kernberg, Thomas Ogden, and James Masterson. Primary, Basic Attachment Object relations theory fundamentally addresses the absolute, primary need for attachment and the harm that can come if that need is not met. Several theorists have explored this concept through direct observation of infants and children. Bowlby (1969) concluded that attachment is a primary, biological, and absolute need in human beings, necessary for the survival of the species. Unlike the theoreticians who believe that the mother or primary caregiver becomes important because she takes care of the child’s needs, Bowlby believed that she is important from the very beginning in an absolute, built-in, biological way that is part of the “archaic heritage” of the human race. He argued that children can suffer true mourning due to loss of the caregiver, rather than merely frustration because wishes are not gratified, because the primary caregiver is crucial to their very psychological existence. Before Bowlby, Winnicott had already recognized the importance of not using the word gratify for the needs of the infant. It is instinctual wishes that are either gratified or frustrated. Real needs for object relations must be either met or not met. What Bowlby proposed from his extensive and voluminous study of behavior across many cultures is that attachment and relationships are absolute needs (see chapter 8 on attachment theory). Earlier still, Spitz (1946) published a study describing the psychological harm that can come to children who are deprived of adequate emotional care. He observed and filmed infants placed in orphanages and contrasted them with babies cared for in prison by their mothers. The foundling infants received excellent physical, medical, and nutritional care from the overburdened nursery staff, who were unable to hold and cuddle them as much as the babies in prison were by their mothers. Slowly but surely the foundling babies began to withdraw into themselves. They lost interest in and responsiveness to the world around them. A sizable proportion developed what is called anaclitic depression—a severe, total withdrawal from the environment, characterized by a turning away from objects, and a going inward somewhere so far away that there can be no return. They manifested the condition that is heartbreakingly known as “failure to thrive.” Suffering this kind of severe depression, some of the infants became anorexic and simply lay in their cribs, inert and drained of energy. A few of them actually died. The film is harrowing and extremely difficult to watch. Of those that were cared for and survived, many showed severe developmental abnormalities in the use of motor skills and language, even at eighteen months, and their depression lingered, in some cases, all of their lives. Attachment theory has become an integral part of developmental theory, and new theoreticians have emerged whose research has greatly deepened our understanding of attachment and illustrated its usefulness for clinical practice. Chief among these is Daniel Stern (1985), whose exhaustive research with infants demonstrated without a shadow of a doubt that babies have moments of intense awareness of, interest in, and attachment to others.

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A vignette from the treatment of a forty-five-year-old accomplished, successful professional woman illustrates the theory of the universal need for attachment and the enduring emptiness and sorrow that can result from a paucity of early and current attachment. Sandy, a forty-five-year-old African American, single, cisgender woman entered treatment complaining of an inability to take care of herself properly despite a seemingly successful and wellorganized life. She had a prestigious job and a small circle of friends but was at a loss when she was at home alone. The truth of the matter was that she almost never cooked for herself, rarely even went to the market, and was quite unable to clean her house or keep her clothes in order. Her dinner often consisted of eating barely warm frank and beans out of the can. She slept in her underwear and took quick showers in the morning, but only out of necessity. She had been left alone and neglected a great deal as a child, and the therapist correctly determined that she lacked self-parenting skills because of that deprivation. Together therapist and patient worked on helping her learn to market, cook, clean, and take long, luxurious baths. Despite good progress Sandy still seemed very sad. When asked what was wrong, she said, “I am really glad I have learned to take care of myself better. Every evening now I buy good food and cook it well and set the table with pretty things. I read a good book and bathe in my bath salts and powder myself and put on a soft nightgown, and nice face cream. And then I sit on the edge of my bed and cry and wonder when the grown-ups are going to come home.” Sandy had learned all about the comforts and joys of physical care, but still felt terribly and tragically lonely inside because of never having had enough secure inner attachments. Sandy was born to a sixteen-year-old single Black mother who was in many ways still a needy child herself. Her mother became clinically depressed and unable to care for the sixth-month-old Sandy. The child welfare system intervened, but, having neither the policies nor the resources to help keep mothers and babies together, the system placed Sandy in the first of a long series of foster homes. Sandy’s great-grandmother fought fiercely to be allowed to raise her, but was deemed “too old” at fifty-nine. Because of the systemic failure of the foster care system to understand the important role of grandmothers in Black families, profound connections were therefore severed that were not to be replaced in the foster homes where Sandy lived for varying periods of time, always feeling like the outsider despite what often was adequate care.

In object relations terms, we would say that Sandy’s inner loneliness was due to her lack of soothing introjects. Introjects are the result of what one has taken in from others. They are the inner people we all carry within us. Their quality and quantity can vary tremendously. They can be helpful or harmful or absent or any complex combination thereof. Sandy teaches us that attachment is necessary for more than simple physical survival. The fullness and quality of a person’s inner world is greatly influenced by the quality of early relationships, and Sandy had been left feeling too long alone and unattended to.

THE BRITISH SCHOOL OF OBJECT RELATIONS Donald Winnicott (1896–1971) We now turn to Winnicott’s contribution, which highlights the importance of the quality of relationships, and to how the nature of object experiences influences development. We will also evaluate the way in which his theory stresses the need to balance attachment with the capacity to be separate. Winnicott (1958b) was especially interested in the capacity to be together as a prerequisite for the ability to be alone and to enjoy solitude. His work explored the complex interplay between the need for attachment and the need for separateness in development. He realized that both needs are profound and that, because they are almost opposites, there is a

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tremendous amount of tension between the two. Louise J. Kaplan, in a book titled Oneness and Separateness (1978), captures some of the intensity of this basic dilemma: Where does the dialogue begin? In his first partnership outside of the womb, the infant is filled up with the bliss of unconditional love—the bliss of oneness with his mother. This is the basic dialogue of human love. The next series of mother-infant dialogues concern the way the infant separates from the state of oneness with the mother. All later human love and dialogue is a striving to reconcile with our longings to restore the lost bliss of oneness with our equally intense need for separateness and individual selfhood. (p. 27)

Regarding the “bliss of oneness,” Winnicott did place a rather heavy burden on the shoulders, or rather the bosoms, of mothers. He postulated that at the very beginning of life the infant thrives with a mother (we would say caregiver, not just mother) who can allow herself to merge into the kind of blissful union and total merger that, if it were not so healthy and fundamental to development, would be seen as abnormal. Winnicott (1956) calls it primary maternal preoccupation and, in fact, describes it as a “normal illness” (p.  302). By this he means that a healthy mother must allow herself to lose herself completely in her baby. The state described is akin to being totally, consumedly in love and, as such, eases the shock of the baby’s transition from the perfect state of oneness in the womb to separate, extrauterine life. In fact, Winnicott says that this merger with the baby ideally needs to start during pregnancy so that this almost totally safe surround is ready for the infant when she is born. The critique of this theory is that it is highly culture bound, placing at its center the idealized stay-at-home mother of the 1950s—a totally different world from that of 2019, when it is estimated that in the United States, 72  percent of mothers either choose or have to work outside the home. Taken too literally, it can sound as if the child’s healthy psychological development is doomed unless the child’s mother can achieve that state of primary maternal preoccupation. Taken in perspective, however, the value of this concept is that it can help the clinician appreciate the kind of closeness and attachment that needs to occur at least some of the time in early life, and, sometimes, later in treatment, for development to proceed well. In other words, it is probably true that all babies and all people need to feel some moments of complete safety, union, and love, provided by someone. It must also be remembered that it was Winnicott himself who qualified all his statements about mothers by saying that the mother does not have to be perfect for healthy development to occur. She just has to be “good enough,” and the most important quality the good-enough mother possesses is a capacity for attunement to the baby’s changing developmental needs, a daunting task in and of itself. This period of mother–child union shifts as the infant begins to recognize her separateness, and her individuality grows. Her sense of being in a good-enough “holding environment” continues to be necessary, but it must be subtle enough to be protective without being overly impinging or limiting. By holding environment, Winnicott did not mean only the literal holding but also the capacity of the mother to create the world in such a way for the baby that she feels held, safe, and protected from the dangers without and protected as well from the danger of emotions within. The concept of the holding environment is also an extremely useful one for the clinical encounter. Clients likewise need the therapist to construct a holding environment that creates a safe physical and psychological space wherein they feel both protected and free so that spontaneous interactions, feelings, and experiences can occur. As it is for children, that space must be created in such a way that clients benefit from it without necessarily being aware that it is being created for them. A therapist tells the touching story of being pleased when a very shy four-year-old boy, possibly on the autistic spectrum, whose trust he had worked hard to gain, came and sat on

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the floor near him and started to color. The atmosphere was calm and peaceful, and then the clinician made what he himself calls a treatment error. Out of his own kindness and his wish to acknowledge the closeness, he simply leaned forward and said, “What a pretty picture you have made, Steven.” And that was the end of that. Steven folded up his paper, put away the crayons, and went to sit at the far side of the room, from which he did not return for several weeks. What Steven had needed was to be allowed to keep the illusion that nothing was being given to him or being done for him. He needed to feel that he had the power and the efficacy to create the moment of closeness and peace. He did not need the therapist to point it out. The clinician admits that in this instance he forgot Winnicott’s nuanced and creative thinking, which posits that sometimes what seems like a good thing, such as the offering of love and praise, can actually take something precious away. Now that we have looked at the state of blissful attachment to the object, we need also to understand how the child moves toward a state of separateness. In looking at children’s strivings to reconcile these two needs, Winnicott observed that children often turn to the use of what he called transitional objects. The worn, scruffy teddy bear; the beloved, chewedup piece of blanket; the humming of Dad’s favorite tune—these are the things that children carry with them in order to begin to cross that great gap away from complete union toward the sense of self as a separate entity. These transitional objects offer ways for the child to hold on to the internal representations of others when she is not yet able to do so on her own. In other words, when the child does not yet have the capacity for internal representations, a separation can be experienced as a disappearance, as a ceasing to exist, as a permanent void. The transitional object then is literally the only bridge to the possibility that a person continues to exist even if absent. Clinically, the concept of transitional objects is extremely useful in helping those clients who have trouble holding on to the mental representations of others in their absence and cannot, like the healthy child, create a transitional object from within. When there are no internal representations of the therapist, vacations or even the time between sessions can leave the client with a sense of complete emptiness. The strengthening of the client’s capacity for internal representation during a separation from the clinician can often be achieved if the clinician offers the client a picture, an address, a postcard—anything that will represent the object of the clinician while she is away. The purpose of the offer is to create a bridge, a transition to the time when the object can be retained in its absence without the need for pictures or cards. One client tearfully reported that when her husband went away on a business trip, she “could not hold on to the idea of his existence.” The therapist suggested that she create a ­little booklet with pictures of him and a narrative of some of the things they like to do together and carry it with her at all times. This transitional object turned out to be so immensely helpful to her that she developed better object permanence and eventually said, “I don’t need the booklet any more. I can carry the picture of him inside me.” From a cultural point of view, it is interesting to note that the need for a transitional object to facilitate separation is by no means a universal phenomenon or a sign of emotional health. Not surprisingly, the phenomenon is found chiefly in groups that value independence and privacy and therefore encourage their children to tolerate being alone at a very early age. Jeffrey Applegate (1989) reports on several fascinating studies about the use of transitional objects that factor in such variables as sleeping arrangements, feeding patterns, and the extent of rhythmic physical contact. In one study, he observed Italian rural families, Italian city families, and Anglo-Saxon families living in Rome. In the rural group, 77 percent of the children slept in either the same bed or the same room as their parents and only 5 percent of them developed transitional objects. In the city group, almost as many children slept in

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the same room as their parents, but they were rocked and patted much less frequently, and 31 percent turned to toys or blankets for comfort. In the Anglo-Saxon families, only 17 percent of the children slept in their parents’ room and 61 percent developed attachments to transitional objects. Having reminded the reader of the inevitable ethnocentricity of theory formulation, Applegate urges clinicians to pay close attention to culture in developmental achievements. He recalls his training (which he later considered dangerously flawed) in which he was taught that the failure to develop transitional objects was a diagnostic indicator of probable developmental arrest and subsequent psychopathology. Winnicott (1958a) gave a great deal of thought to the capacity to be alone and wrote a beautiful essay on that subject. He came to believe that the ability to tolerate, enjoy, and make use of healthy solitude could be developed, paradoxically, only in the presence of another. The ideal situation would be a parent reading quietly while the child plays with her toys on the floor, and they occasionally smile at each other so that there is a lovely balance of connection and separateness at the same time. If separateness is experienced as too empty, separate, or bleak, it becomes unbearable. This can happen if a child has been left alone too much either physically or through misattunement to psychological needs. Aloneness and loneliness become synonymous. The inner world is not peopled with enough comforting figures. Conversely, it can also happen that aloneness becomes painful or intolerable if the inner world is too crowded with threatening, controlling figures who offer no safety, comfort, or peace. The ideal, then, is for the growing child to experience being near someone while also being separate and apart, to be allowed to simply be in the presence of someone who is neither too stimulating nor too frustrating. Regarding the quality of attachment, Winnicott (1960) made one additional important point. He believed that attachment needed to be flexible and genuine enough to nurture what he called the True Self, which is at the core of the personality. The True Self is the repository of individuality, uniqueness, difference. In relationships characterized by genuine attachment, the separate individuality of both persons is seen, respected, and encouraged to flourish. But if the child’s striving for separateness is thwarted, the holding environment can become a prison, a limiting rather than an expansive force. A True Self cannot emerge if the child feels she must be overly attuned to the needs of others in the family system and if she needs to behave in a certain way in order to be recognized and acknowledged. The highly individuated True Self will not emerge when the environment fails to be genuinely attuned to the child’s uniqueness. What happens instead is that the child may develop a False Self, one that seeks to suppress individuality and molds itself to the needs and rules of others. It is a safety operation, a defense to ward off disapproval, condemnation, or even dreaded abandonment. This False Self, unconsciously trying so hard to please and placate and pacify others, ultimately becomes rigid and overly compliant. Uniqueness, vibrancy, idiosyncrasy, and difference are all submerged. In this debilitating, constricting process, the energy, the power, the “wildness” of the True Self is lost. Adam entered treatment for chronic depression. His demeanor was rigid, joyless, and overly polite. A Jewish white man in his early forties who grew up in Atlanta, Georgia, he had created what he called a “seemingly perfect American life—a lovely wife, two great kids, and a successful career as a lawyer.” It turned out, however, after months of exploration, that Adam hated being a lawyer. He had never liked it. The aggression, organization, and linear thinking that are so useful in a law practice had always “felt foreign” to him. With encouragement and acceptance, he was able to come to know himself as a much gentler, more creative person. Also, vibrant, relaxed, funny, less polite—and much less depressed. He discovered/remembered that what he really wanted to be was a florist, but that such a wish could not even be “known” to him, much less mentioned, in his upwardly mobile family. Adam had to figure out ways to leave the law and eventually worked as a horticulturist. In treatment, he had come to understand that he had

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developed a False Self to comply with family expectations and to protect the family from disappointment if he did not realize their dreams.

K. P. White (2002) suggests another kind of False Self that can develop within oppressed groups: I find that black people develop a safety operation that I  call a “survival shell” in response to racial hatred that operates in encounters across the racial boundary. This is distinct from a falseself operation, as it is more or less conscious. In my work with black patients, I inquire about the level of consciousness of this maneuver, the amount of stress that it causes, and the degree of dissonance there is between the survival-shell operation and the true self. This gives them an opportunity to reflect on what the risk level is in living in a racially hating culture, and whether or not their survival-shell operations are collusive with racial hating. (p. 406)

White reminds us that people of color must adopt conscious false selves to survive in white worlds: having to speak differently, carry themselves differently, tone themselves down, behave differently. The cost to one’s authenticity and spontaneity can be considerable. This is also true for gay/lesbian people who may have to pass as straight, or for trans people who have to deny who they are. Women in the corporate, political, and professional worlds know all too well the self-erasure often needed to succeed. Shakespeare’s Cressida says, “I  wish’d myself a man,/ Or that we women had men’s privilege/ Of speaking first” (Troilus and Cressida, III.ii.124–29). Women often still feel trapped in that same position today. Financially drained or struggling people, who are often shamed in our society for not being rich and successful, often mute and hide their authenticity by being overly cautious in their behavior and language. Deaf people have had to fight to claim the right to live proudly as Deaf people: to use sign language, for instance, instead of lip-reading so as to appear “hearing.” Passing or having to fit in robs people of their true, idiosyncratic self and takes away the zest and deep connection to others. Melanie Klein (1882–1960) Melanie Klein, along with other theorists from the British School of Object Relations, including Ronald Fairbairn and Harry Guntrip, presents us with very specific and useful ideas about what the internal object world can be like. The internal world comprises representations of self and other, representations formed by experiences, memories, and ideas about the external world. A representation has an enduring existence, and although it begins as a cognitive construction, it ultimately takes on a deep emotional resonance. For example, memory images of a mother feeding, hugging, cooing, and so forth, coalesce into an object representation of the mother. Similarly, the various images of the self as they are experienced within—for example, “I am warm and loving” or “I am selfish and mean”—make up the self-representation. These representations are not observable and may not reflect the actual situation, but they are the content of the internal world and the building blocks from which relationships with the self and with others are ultimately formed. Although originally a drive theorist, Melanie Klein was most interested in the internal “relatedness” of infants from birth. She saw the drives as “inherently and inseparably directed towards objects” (Greenberg & Mitchell 1983, p. 136) from the earliest moments of neonatal life, not merely for the reduction of bodily tensions but also for fuller passionate relatedness to another person. In Freud’s view, no phantasy (this is the way Klein always spelled it) will take place if real gratification is available. Klein offered a radically different view. She did not see phantasy as a substitute for real gratification but as a basic characteristic of human beings. And for her, phantasies were always “peopled,” were always full of yearning for objects and object relations.

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Klein’s theory about the internal world was also developmental. However, unlike Freud, who postulated the oral, anal, phallic, and genital phases, Klein talked about internal “positions.” The term positions made it clear that she was not simply describing a phase or a stage to be passed through, negotiated, and resolved but rather internal states—ways of perceiving the world, ways of feeling—that can and will be experienced throughout the life cycle. The two positions presented by Klein are the paranoid-schizoid position and the depressive position. Each describes a state of object relations that occurs early in life but can also be present in adult life. Problems arise from the fact that developmental theorists from Freud onward use terms such as phases, stages, or positions, because they sound so fixed and static. One writer, Pine (1985), proposes the more fluid, more useful concept of “developmental moments.” If a child in the second year of life is said to be in the anal phase, does that mean that every moment of her existence is focused on anal issues of being clean versus dirty, of giving and withholding? Surely not. And what about the fact that age two is considered to be the separation-individuation phase by Mahler? How many phases or stages can a child be in at once? Surely more than one. Pine suggests the idea of moments to solve this dilemma, trying to capture the fact that during certain times in life there are periods of “peak intensity and peak developmental significance of certain phenomena” (p. 40). Therefore, although the socalled “anal child” has many other important things going on in her life, there are probably more moments at age two when issues of surrender and control are of compelling interest to her than at other times in her life. Pine’s concept of developmental moments is also useful as we look at Klein’s description of positions. The first position she defined, the earliest way of being, is the paranoidschizoid position. The name itself is frightening and describes the terrifying moments in the neonatal period that can be filled with feelings of fragmentation, surprise, and fear. Even the most cherished, protected, and nurtured baby cannot feel safe and connected all of the time, simply because it is so little, delicate, and dependent in a stimulating and startling world. The child in the paranoid-schizoid position lives in a land of shadows and pieces, of noise and light, of moments that feel blissful and moments of overwhelming discomfort. This may sound pathological, but it is not, since it is something that all of us go through as babies and even have moments of as adults. The main anxiety in this paranoid-schizoid position is that persecutory parts of objects will get inside the self, overwhelm it, and even annihilate it. Again, the possibility of a baby’s experiencing persecution is hard to understand, but if a baby gets very hungry, waits too long, gets panicky, and then gulps down the milk so fast as to choke, one can begin to understand how even something good from the outside can feel like an attack inside. Klein postulated that there was no such thing as a totally objectless autistic phase. The early world of the infant is full of impressions of “things out there” and “things inside” without clarity or accuracy of what’s where or what’s what. The things out there are not even remotely experienced as what adults can come to know as whole objects or real people, but they are nonetheless present and important. Klein’s name for objects as they are experienced in the paranoid-schizoid position is part objects, in order to capture the fragmented way the world looks when a person is, or feels, too little to perceive the whole. An eight-year-old boy away from home at sleepaway camp for the first time writes to his mother: Dear Mom I miss you. a lot of times I think about you I almost always cry. I wish you were here. Miss Flule always tries to kiss us good night so does miss lever. I wish you could kiss me good night. I’ll love you even blu even wen you’re spaced out. Oh if only I could just see a part of your face then I would be OK. Your son Brian Dantona Kelly.

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Under the painful pressure of separation, eight-year-old Brian is trying desperately to get enough comfort from the counselors’ good-night kisses, but it isn’t quite enough to soothe away the pain and fear. He then remembers some of the mother’s bad qualities (“blu” and “spaced out”) and declares himself capable of loving her even with faults—interestingly, faults of distance. Then, with the strongest cry from his heart, he states that he would be OK if he could just see a part of her face. By age eight, Brian has achieved some sense of the wholeness of others (which he demonstrates with the “I’ll love you even blu”). However, in his vulnerable state, he has regressed to the world and the longings of a much younger child. A whole, complex, real object is not needed—just a piece, a fragment, a part will do. During a subsequent camp visit, his mother asked him what part of her he would have liked to have seen. He pondered awhile and the answer did not come easily because at first he couldn’t decide between her mouth or her eyes, but then he said, “Oh, it doesn’t matter, any old tiny part would have helped.” Brian also makes sure that he signs his full name (as if his mother wouldn’t know who just “Brian” was), probably to reassure himself about his wholeness, his solidity, and his substance on this earth. He is trying not to fall apart into fragments. As we will see later in the chapter, this is a good description of a person trying to hold on to what Mahler called “self and object constancy.” In describing the second position, the depressive position, Klein tried to capture some of the sadness that can occur, paradoxically, just at the time when there is growth in the internal world. She saw the depressive position as starting when the toddler begins to have enough experience to realize that the good person who feeds him and nuzzles him and keeps him warm and the bad person who sometimes puts him down harshly or keeps him waiting for his food or his diaper change are one and the same. Perhaps even more upsetting is that the person, the self, who loves is also the person who hates. The loss that comes from this developmental step of seeing both others and the self as complex and multifaceted is basically a loss of innocence, a loss of the belief in the possibility of perfection. For many, this theory is disconcerting because the thought of a depressed eighteenmonth-old is not a particularly welcome one, especially when the depression comes from normal development itself, rather than from any misfortune. However, the developmental phases of infancy do include these intense feelings. Even for mature adults there can be pain in trying to reconcile being full of love and at the same time full of hate for the same person. It is a struggle and at times depressing not to experience oneself or an other as simply and totally good or bad. The clinical utility of Klein’s work lies in understanding that the eighteen-month-old is beginning to experience the first faint traces of one of life’s most difficult and enduring dilemmas—that of both wanting and fearing to be whole, which requires holding complex and contradictory feelings at the same time. Melissa is the white twenty-year-old daughter of a cruel and volatile alcoholic father. Her grandparents immigrated to New York from Ireland due to the harshness of their lives there, and alcoholism had been endemic in her family for generations. She describes vowing three things to herself as a little girl: (1) that she would always “totally and completely” hate her father, (2) that she would “always be utterly different from him,” and (3) that she would never need anyone and would never cry. With a grim face and great tension she reports that she has succeeded, but her presenting problem is that she is so tense and rigid that she feels “made of stone.” After a few meetings, when she is asked what would happen if she finds out that she does have some softness in her and does love her father a little, her answer is a terrible cry of despair: “First I would want to hit you and then I would get so depressed I wouldn’t be able to live.”

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Melissa is trying hard to keep her internal world very simple, to reduce everything to the seeming clarity of black and white. She is struggling to ward off the depression that would ensue if she had to face both goodness and badness in her father and therefore in herself. The only way she has found to survive and distance herself from the traumas of her home was to think of herself as totally different from her “bad” father. Until she entered therapy, she believed it would be too confusing, too sad, and ultimately too unbearable to face the complexity that she and her father were each both good and bad. Her conflict, as it is for all of us, is the dilemma inherent in wholeness. To be whole, one must give up the purity of ideal goodness or of total badness. Indeed, seeing the other as totally good can be equally problematic. After a great deal of therapeutic work on integration with a patient who idealized her husband as perfect and herself as flawed, a patient said, touchingly, to Melanie Klein, “With wholeness I have gained a lot. My life is better and more balanced. But some of the luster is gone.” Both patients eventually learned the benefits of wholeness, and Melissa concluded, “I can love myself as a real person with some faults as well as lots of goodness.” Her internal world, then, became peopled with images of self and others that were complex, full of goodness and badness, love and hate. This captures the essence of how the depressive position is mastered through the development of tolerance for an integrated sense of self and others. This concept is central to object relations theory. An important critique of Klein’s theory is that it collapses and condenses too many later feelings and experiences into the period of preverbal infancy and ascribes to babies clear-cut internal experiences that they probably do not actually have in the form or at the time that Klein postulates. While there is validity to this critique, Klein’s insights into the fears and desires, connections and disruptions at the beginning of life are both evocative and clinically useful. If a client is struggling with some of these feelings, it does not matter in exactly what month of their lives they first felt them or whether they have words to describe them. Again, it is important to remember that Klein is not giving diagnostic labels to these positions (although the terms chosen can sound pathological), but rather describing normal, universal states. Ronald Fairbairn (1899–1964) Ronald Fairbairn was trained at the British Psychoanalytic Society in London in the 1930s, but then returned to his native Edinburgh. There he lived and worked in relative isolation, treating shell-shocked soldiers, abused children, and psychotic patients, in addition to conducting his regular psychoanalytic practice. Perhaps because of these diverse experiences, he developed some of the most disturbing, useful, and controversial concepts in object relations theory. More than any of the other object relations theorists, Fairbairn believed that what is inside the self, what actually becomes part of the internal world and the structure of the self, is taken in from experience with “outside others.” He believed that the ego (the “I”) is present from birth and object seeking from the start, rather than pleasure seeking, as Freud had thought. In his view, our deepest longing is for contact, and our deepest fear is of rejection and therefore of separation and fragmentation. Fairbairn saw the ego, and therefore the self, as composed of many splits, or fragments. He believed that what is inside all of us are the following: a libidinal ego drawn to an exciting object, an anti-libidinal ego hurt by a rejecting object, and a central ego of everyday living. These somewhat awkward terms describe a complex self, composed of many parts, almost like shards, both conscious and unconscious. Fairbairn describes these parts of the self as

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splits in the ego and considers them to be schizoid phenomena. Using the word schizoid can be confusing to us nowadays, because schizoid personality disorder now appears in the Diagnostic and Statistical Manual as a mental illness. Fairbairn does not mean it that way; rather, he considers schizoid phenomenon as part of the human experience for everyone. He is using the word schizoid, as derived from the ancient Greek, meaning fragments or splits or divisions, and he believes that we each have these fragmented parts of ourselves in our internal world. Fairbairn’s internal world is made up of the following five parts or splits: (1) the libidinal ego, (2) the exciting object, (3) the anti-libidinal ego, (4) the rejecting object, and (5) the central ego of everyday living. The libidinal ego is primarily unconscious and is that part of the self that corresponds most closely to the Freudian id. The libidinal ego is seeking the exciting object and is attached strongly to it. The exciting object is always enticing and full of the promise of gratifying contact but actually rarely offers fulfillment. When the libidinal ego continues to stubbornly seek out gratification, it has similarities to Freud’s description of the repetition compulsion, wherein people keep going to the well, which is always empty. There is, however, some disagreement among clinicians today about whether the libidinal ego seeking the exciting object is only a negative force or a more complex part of the self with a range of functions. This author believes, along with Mitchell and Black (1995), that while the libidinal ego is at times filled with some of the compulsion, darkness, and primitiveness of the Freudian id, it is also “the part of the self that experiences perpetual longing and hope” (p. 120). This author has seen in her patients that it is better to be able to yearn and hope rather than to live in despair, because then there is at least a possibility of seeking out objects that offer true fulfillment. Freud’s famous image of the riderless horse as a symbol of the id comes to mind. We can see a riderless horse not only as a dangerous, unbridled creature that can bite or kick or even kill but also as a wild animal of great beauty, vast power, and vibrant energy. The anti-libidinal ego is even more deeply unconscious and is the repository of bad object experiences that have now been taken into the self. It is the agent by which rejecting and cruel object experiences from the rejecting object are now in us in very destructive ways. While libido is available to the libidinal ego, aggression is at the disposal of the anti-­libidinal ego, which Fairbairn sometimes referred to as the “internal saboteur.” Lavinia Gomez (1997) writes, The anti-libidinal ego is the split-off ego fragment that is bonded to the rejecting object. We can think of it as the “anti-wanting I,” the aspect of the self that is contemptuous of neediness. Rejection gives rise to unbearable anger, split off from the central self and disowned by it. (p. 163)

Instead of acknowledging neediness, this part of the self ensures that people neither seek nor get what they want. The anti-libidinal ego resembles the overly harsh Freudian superego in some ways, but it is not an entity in itself because it is a split-off part of the central ego and it has no moral significance. It is mean and attacking and destructive because it has taken in the qualities of the rejecting object and become part of the self. The central ego is the seat of self-observation and recognized self-experience. It corresponds in some ways to the ego described by the ego psychologists, made up of the many ego functions and defenses delineated in chapter 3. It is the part of the self that experiences the feeling of “this is me” or “I feel like myself right now.” It is still available for real relationships in the external world. The following dream of a client reveals how these different splits from internalized object relations live on inside of us.

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Carla, a shy twenty-nine-year-old heterosexual Dominican woman who works as an office manager, came in to treatment suffering from low self-regard and a pattern of unstable and chaotic love relationships. After a year of recognizing and working on various internal parts of herself, she is beginning to see herself as more competent and more whole. The following is a dream she reported: A woman is walking on “a dark and evil plain.” In the distance she sees a group of hobos sitting around a fire and at first she is drawn to the warmth and the light. As she goes closer, however, she realized that the hobos are engaged in a brutal task. They are roasting puppies (“adorable, innocent little puppies”) on the fire. Some seem already dead and some are still struggling. Controlling her fear and horror, the woman, whom Carla begins to recognize as herself, figures out how much money she has and begins to bargain with the hobos for the lives of the puppies that can still be saved. She does this with considerable mathematical skill, arriving at a precise amount per puppy. Even while still dreaming, Carla is quite impressed by her skill, because she has always considered herself to be a “weak moron at math.” As the dream ends, she is carrying a bunch of living puppies to safety.

Working with this dream transformed Carla’s therapy and has been an enduring metaphor for who she is and what she means to work toward. She understands all the characters in the dream to be parts of herself. The puppies were her “baby self” (libidinal ego), full of potential and yearning to be cared for, although tragically some were dead and some wounded. The cruel hobos (anti-libidinal ego), now within her, were introjected from her parents (the rejecting objects), who were, in her memory, extremely harsh and rejecting toward anything infantile, weak, or helpless. What was most useful, however, was not another reminder that she had experienced her parents’ rejection, but seeing that those rejecting objects are now part of herself and similarly cruel toward her own weakness and babyishness. Also of extreme importance is her new recognition of the brave and competent aspects of herself (central ego), which in her unconscious mind was capable of saving the weak parts of herself. Carla immediately understood the characteristics of the hobos because she had already explored with her clinician the fact that she was often passionately drawn to charismatic, narcissistic, rather cold-hearted men, hoping to coerce them into a loving tenderness toward her—exactly the kind of men who would never give a damn about vulnerable puppies or have any interest in saving them! Here again are echoes of the phenomenon of the repetition compulsion, in which people keep choosing friends or partners similar to those who have hurt and disappointed them, in the hope that this time those others will be different and willing to change because they love them so much. Carla’s healing and growth was stimulated by this dream, and she became much more aware of the times when she was harshly lacking in compassion toward her own vulnerability and neediness. She began to alter her relationship to herself at those times by saying, “My hobos are at it again.” This allowed room for true growth, and also enhanced the functioning of her more adult self (central ego of everyday living), which the dream had also revealed to be more competent than she had known. Her view of herself as a “weak moron at math” diminished as she joyfully began to acknowledge her skills and strengths. This case example shows us how potent the negative internalizations of others can be and how they can rule the internal world, but also how they can change through growth in consciousness and new object experiences. In conclusion, the clinical utility of Fairbairn’s ideas is that we can learn about and develop greater compassion for our clients’ internal worlds, which sometimes seem made up of schizoid shards of glass. Using the theory flexibly, we can offer the hope that with growth and healing, the shards of glass can eventually form instead into a beautiful mosaic.

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Harry Guntrip (1901–1974) Harry Guntrip, another theorist in the British School of Object Relations, was aware of, and intrigued by, Fairbairn’s schema of the internal world comprised of schizoid splits: the central ego, the libidinal ego attached to the exciting object, and the anti-libidinal ego attached to the rejecting object. His unique contribution about the internal world lies in the fact that he came to believe that there is another, final, split that occurs within the human psyche. This split he called the regressed ego. He understood the regressed ego to be the most deeply unconscious ego of them all because it is caused by an overwhelming fear of life itself. Interestingly, Guntrip tells us that he discovered this deeply regressed aspect of the self from work with his patients, not through theoretical thinking. Like Winnicott before him, who touchingly dedicated his book Playing and Reality (1971) “To my patients, who paid to teach me,” Guntrip learned about the regressed ego by listening to his patients’ dreams. At one point in his work, he was treating several people who had come to him after completing productive classical analyses. They had resolved many conflicts and achieved much insight but they still did not feel well. They often presented dreams of opening drawers or containers and finding frail babies within them. These dreams moved and intrigued Guntrip, and he eventually concluded that there exists yet another schizoid part of the self that many people struggle with. It is a limp, half-dead, barely alive self that feels too weak to be in the world of reality at all. With his customary poetic language, he named it “the lost heart of the self” (p. 86) and believed that this regressed ego resulted in an actual inability to love and, more importantly, to be loved. Guntrip believed that many people are terrified that their neediness, their hunger, indeed their greed for love, will paradoxically destroy them when they receive it. They need love so much, and yet they fear that they will allow themselves to be swallowed up and lose their identity if it is offered. Guntrip’s particular sensitivity was to the most vulnerable and weakened parts of the self. He described what he termed the struggle with “ego weakness” and the “regressed self” that takes place in everyone as they attempt to develop and thrive. Guntrip believed that “the core of psychological distress is simply elementary fear, however much it gets transformed into guilt: fear carrying with it the feeling of weakness and inability to cope with life; fear possessing the psyche to such an extent that ‘ego-experience’ cannot get started” (Guntrip 1968, pp.12–13). Much of the work done today on recognizing and healing the “inner child” comes from Guntrip’s attunement to this very young, very frightened self in all of us. Although not completely disavowing the drives as powerful factors in human motivation, Guntrip believed that they retained a central place in psychological theory only because people would prefer to think of themselves as filled with mighty instincts rather than face the greater universal truth of being tiny and vulnerable in a powerful and mysterious universe. He also came to the startling conclusion that people can become overwhelmed and undone when they finally receive the love they had been seeking. Just as it is difficult to accept the Kleinian notion about the depressive position, which occurs, paradoxically, with the developmental achievement of seeing people as whole (both good and bad), it is also painful to recognize that people can be so frightened and needy that they cannot bear love when it is present. It is much easier to think of a person suffering because care and love are not available to him or her. Experiencing terror because of being loved confronts us with a much more complex human dilemma. Tom, the son of Indian immigrants, was the forty-four-year-old CEO of a large corporation and came for therapy because he “couldn’t ever rest or be still.” A recent medical examination had revealed high blood pressure and a rapid heartbeat, and the physician had insisted on

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psychotherapy. Tom was by nature, personality, and culture the kind of person who exulted in “never doing just one thing at a time.” He was praised at work for his boundless energy, although his relationships at home were strained by his intensity and perpetual motion. He always rushed into sessions and then could barely sit in his chair. After many months, which were spent trying to help Tom calm down a bit, he was finally able to respond to the therapist’s request that he be still for a minute to see what that experience would be like. Since Tom had been pacing, he was standing at the time. When he remained still and closed his eyes, he began to rock ever so slightly and two silent little tears began to trickle down his cheeks. In a tiny voice he said, “I feel like a nerd, I feel just like a nerd.” The therapist was immensely moved by the sight of this powerfully built, well-dressed, self-described “captain of industry” revealing his suffering in such a poignant way. She was about to say something accepting and responsive when Tom added in a desperately tight tone, “And please, please, don’t be nice and loving to me because then I will be nothing, at all, no one at all.”

It took Tom a long time to accept and love the part of himself that, in the language of childhood, he called a “nerd.” When he was able to make peace with his “littleness” and his intense neediness, his behavior became much less driven. Eventually, he also became less terrified at the loss of strength and autonomy, the loss of self, the nothingness, which he used to believe would occur if he allowed someone to care. One of the greatest contributions of object relations theory has been a rethinking of independence and autonomy as developmental goals that for so long defined mental health and maturity. In the belief system offered by object relations theorists, connection is highly valued, whereas absolute independence is seen as unhealthy and not psychologically sound. Mature dependence, or “interdependence,” is considered to be the ideal. Having achieved mature dependence, a person could survive for a while without dependence on others, but would not actually want to. Development is understood to proceed from infantile (total) dependence to mature interdependence, but never to the independence and autonomy so beloved by the ego psychologists and some of the American object relations theorists, or so valued in Western ideals of mental health.

OBJECT RELATIONS DEFENSES In the chapters on drive theory (chapter 2) and ego psychology (chapter 3), we introduced the concept of defenses, defined some of them, and described the role they play in development. We will now turn to the contribution of object relations theorists to our understanding of the defenses. Since all the theorists discuss them, we will not present each author’s point of view but will look instead at the defenses that play the most important roles in object relations theory. Object relations theorists wrote extensively about the defenses, paying particular attention to how they pertain to relational issues. Because of their interest in the creation of the internal world and the processes whereby object relations are organized, they wrote most about the defenses that begin to be organized in the earliest months and years of life. These defenses, known as the primitive defenses, are introjection, projection, projective identification, denial, splitting, idealization, and devaluation. As the names themselves imply, all these mechanisms exist to ward off and cope with anxieties inherent in object relations. These processes serve to manage fragments and parts of the self and others—to keep them in, to get them out, to control them. Guntrip (1968) welcomed a mentor’s moving and thought-provoking description of the defenses as “the person’s most gallant attempt to survive” (p. 13).

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There are, however, problems in using the term defense, and, even more so, the term primitive defense, to define these processes. The term defense is most often used to describe the mechanisms that people develop within themselves to ward off anxiety. Yet when the words introjection and splitting are used, they simply refer to the way the infant is at the beginning of life. Babies and young children just do not have the capacity at first to know what is inside and what is outside, or even remotely to experience themselves or others as whole. They are too little and too new to do anything but live in a world of fragments and beginning impressions, so they are actually not warding anything off or “defending” against anything. With regard to the characterization of certain defenses as “primitive,” the word itself is problematic because in everyday language it has a pejorative ring to it. Indeed, in modern anthropology and folklore, care is taken not to describe cultures as “primitive” because the connotation is to that of something being crude, unsophisticated, or inferior; however, in developmental theory, the term is meant purely descriptively as “pertaining to the beginning or the earliest time” (Webster’s 1963). Primitive is also meant to elicit compassion for the young child trying to cope with a very complicated world by using simple inner mechanisms. These issues become important when we attempt to do a full biopsychosocial assessment. When, for example, an adult is observed to be “doing a lot of splitting,” we must assess whether we are looking at a developmental arrest (failure to progress, either fully or in part, to a more advanced developmental level) or a constellation of primitive defenses (regression under stress). It is an exceedingly difficult distinction to make since the words, feelings, and behavior of the client look and feel very similar. But there is, in fact, a huge and important difference between whether something is a defense or developmental arrest. One way of determining the difference is testing out whether the client welcomes or fears the possibility of integrating fragmented parts of self and others. For example, if it is pointed out to a client that the boss she is experiencing today as a “total devil” is the very same person whose kindness she was describing last week, and that observation is welcomed as useful, then one can speculate that the person was not previously helped to see others as complex and whole human beings, and that the splitting was a developmental arrest. If, however, suggestions that human beings contain good and bad aspects are not only unwelcome but actually rejected, one can begin to think along the lines of defense—that there is some reason why the person wants to keep various aspects apart and separate. There is a desire to avoid or control something. This is quite different from experiencing the world as being in bits and pieces. There is a real wish, often experienced as a need, to keep the pieces apart to avoid the suffering that comes from seeing objects as whole and therefore flawed or disappointing. As one client said to her therapist, “I don’t want to remember that the boss I  am hating today is the same person I  thought was nice to me last week. That would be too complicated to handle. I would prefer one strong feeling at a time.” The term deficit model applies to those instances when the dysfunction is understood as being caused by developmental arrest due to early failures in object relations that did not offer the opportunities for development. The term conflict model is used when psychological dysfunction seems to be caused by unresolved conflicts between desires and the defenses that are the prohibitions against them. We will now look in some detail at the contribution that object relations theories have made to our understanding of the defenses, seeing them as both part of a normative developmental process and mechanisms to ward off anxiety.

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Splitting Splitting is the term used to describe the process by which the good and bad or positive and negative aspects of the self and others are experienced as separate or are kept apart. The word splitting can be very misleading because it implies that something was once whole and was then split apart, but in object relations theory splitting can describe a way of seeing the self and objects prior to seeing them whole. It is central to the way in which infants first organize their world—into good and bad or frustrating and gratifying experiences. Infants make use of splitting to help order chaotic early life experiences. Splitting allows infants to let in as much of the environment as they can manage when they still lack the maturational ability to synthesize incompatible or complex experiences into a whole. When splitting becomes a defense it is an indication of an unconscious desire to keep things apart and separate, a desire to disavow something. Splitting roughly runs along the lines of good and bad, but is often a complex phenomenon and is not usually as simple as, for example, perceiving one’s mother as all good or all bad at different times. For some people, splitting is an enduring way of organizing the world, whereas, for others, it can be a temporary regression to a more simplistic, all good or all bad, way of looking at things during times of stress. This can apply to groups, or even nations, that are under stress as well. Jim, a thirty-five-year-old Black man, was sent to therapy by his supervisor at the Metropolitan Transit Authority where he worked as a subway conductor. His supervisor had noticed that he seemed chronically depressed and was having increasing difficulty getting along with coworkers. All went well for the first few sessions, despite Jim’s reluctance to “see a shrink,” and he told the therapist that she seemed like “a very good person.” However, this changed abruptly when the therapist told him that it might be useful for him to have a medication consultation. She had done so sensitively and compassionately, acknowledging that another referral might be difficult for him. The care she took in making this intervention did not matter. Jim instantly became furious, said that she was “no good after all,” and that he was sorry he had ever thought that she might be a decent human being. The therapist accepted his anger calmly, and in a spirit of inquiry, asked him what had happened inside him when she made the referral. Jim was then able to describe that this kind of thing happened to him all the time. “It’s like a switch going on and off and I can’t control it.” Now that she had been kind to him, he thought she was great again.

Jim’s history revealed that he had grown up in a very rough, working-class Brooklyn neighborhood in which there was a street-gang presence. He recalled that even as a little boy he was terrified that he could not “tell the good guys from the bad guys.” He gained the insight that his current difficulties, turning on people at work or feeling that they were turning on him, became much worse after the attacks of September 11 during which he was stuck underground in a subway knowing that people “really were trying to kill us.” After that day his capacity to evaluate people’s intentions toward him, already fragile, diminished. Exacerbated by the trauma of September 11, Jim presents us with an example of someone who needs to use splitting because he is unable to manage complex truths and feelings that are not easily integrated. Like all defenses, splitting has adaptive, useful functions. Splitting attempts to put some order into chaos. It is not surprising that children love fairy tales, in which good and evil are easily discerned. Splitting can be the basis for the adult faculty of discrimination and the capacity to differentiate good and bad. It is also needed as the precursor to the more developmentally sophisticated defense of repression, because it is a young way of keeping things apart, keeping away something that is feared as bad and unacceptable. It is also said that no one would ever be able to fall in love without being able to think, at least for a little while, that the other person is perfect.

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Incorporation, Introjection, and Identification Central to object relations theory is the belief that human beings are incorporative by nature. This means that we are constantly taking in from the world outside ourselves messages, ideas, attitudes, feelings, whole people, parts of people, and good and bad experiences. Psychodynamic theories propose various kinds of internalizations, the three main ones being incorporation, introjection, and identification. These are the dreaded I-words of psychodynamic theory exams, because these processes sound and, in fact, are quite similar. Do we take things in to hold on to them, to control them, to deny them, to remember them, to make them part of ourselves? Do we take things in out of love or hate or fear or need? These questions are still part of a lively debate to this day, and once again underscore how psychodynamic theories reflect the philosophic view each author holds about human nature and the human condition. The terms incorporation, introjection, and identification are often confused with one other, and they are used in many different ways by different authors. These processes can be understood to exist on a fluid continuum with introjection somewhere in the middle. Incorporation occurs when the distinction between self and other has only barely been achieved and when there is a sense of the object being swallowed in part or whole. It has the quality of an almost cannibalistic oral ingestion and is the earliest, most primitive form of taking in. A schizophrenic man who cannot tolerate being separated from his mother may say to his therapist that he has eaten her. Introjection describes the process of internalizing aspects of the object or whole relationships with objects. We can think of introjects, for example, as the taking into the self of the warmth of a mother’s joyful smile or the coldness of her angry frown. Introjection is a type of internalization that is more advanced than incorporation. Freud originally understood introjection as a process in which the lost object is taken in, in order to retain it as part of one’s psychic structure. In contrast, Fairbairn did not believe that good objects or object experiences need to be introjected because they can simply exist in memory. He believed that only bad objects need to be introjected in order to split them off from consciousness and to control them. Most theoreticians, however, believe that the mechanism of introjection is needed for both good and bad object experiences and that our internal world is filled with both. Object relations theorists have focused primarily on how introjection helps us master our experiences with painful and disappointing objects in our lives in order to be able to bear the anguish that the people we love and depend on can also at times be experienced as hateful to us. The “badness” of the other is “taken in” in an attempt to control and master the situation, in an attempt not to feel so powerless and to preserve the positive image of the needed other. This part of object relations theory is of great use clinically and helps explain why the victims of neglect, abuse, crime, or brutality often end up hating themselves rather than their abusers. It would seem much more logical that the person being hurt would be angry at the person doing the hurting, but that is often not the case. Children who are taken away from abusing parents almost always ask to be allowed to return home, claiming that they are the ones who are bad. Surviving victims of the Holocaust have often described being filled with self-loathing rather than hating their torturers. In A Taste for Death, P. D. James (1986) describes a character who shielded the object representation from possessing any “badness” at great expense to herself: Miss  Wharton had been taught to fear in her childhood, and it isn’t a lesson children can ever unlearn. Her father, a schoolmaster in an elementary school, had managed to maintain a

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precarious tolerance in the classroom by a compensating tyranny in his own home. His wife and three children were all afraid of him. But shared fear hadn’t brought the children closer. When, with his usual irrationality, he would single out one child for his displeasure, the siblings would see in each other’s shamed eyes their relief at this reprieve. They learned to lie to protect themselves, and were beaten for lying. They learned to be afraid, and were punished for cowardice. And yet, Miss Wharton kept on her side table a silver-framed photograph of both her parents. She never blamed her father for past or present unhappiness. She had learned her lesson well. She blamed herself. (p. 162)

To illustrate the power of introjection, Fairbairn (1952) wrote poignantly of how profoundly people needed to believe that “God’s in His Heaven—All’s right with the world,” of how crucial it is to feel that the world outside is good, even if the “badness” must be felt in the self in order to preserve that belief. At least then there is hope of redemption and love. A child can only survive believing that there are good objects because “it is better to be a sinner in a world ruled by God than to live in a world ruled by the Devil” (p. 66). In a world ruled by the Devil “the individual may escape the badness of being a sinner,” but the psychological price to be paid is very high because the world becomes a place without the possibility of hope, rescue, or salvation. With introjection, the power and influence of the real external object diminishes because it is now controlled in fantasy within the self. Often this compromise lies at the heart of depression—I dare not hate you, my parent; I will keep you as a good object but I will hate myself and therefore there will be no joy in life. Tragically, this phenomenon also sometimes explains why certain people do not get better in therapy—their need to protect their parents’ “goodness” prevents them from facing the truth and finding the goodness in themselves. As always, there are adaptive and useful aspects to introjection, beyond that of the warding off of anxiety. Introjection helps in the later, more sophisticated process of identification, as it is necessary to be able to take something in, in order to identify with it. Identification is a more sophisticated defense than introjection. It is not so reliant on splitting, and therefore less central to object relations theory. It is a much more selective process, wherein what is taken in are valued parts of another. An example of positive identification would be a man who chooses to work among street gangs in Spanish Harlem because his father was a Quaker activist in Latin America. In identification, selective and valued parts of another are internalized, but remain unconscious. In Freud’s view, the taking in of parental rules through the process of identification results in the formation of the superego. Mature identification is not merely a copying of someone else’s traits but actually making those traits uniquely a part of the self. We will hear distinct echoes and elaboration of this idea in Heinz Kohut’s use of the term transmuting internalization (yet another I) in the chapter on self psychology (chapter 6). Projection Projection refers to the process of expelling, sending outward, and getting rid of unwanted or bad feelings (parts of the self), and placing them in others. The purpose of projection is to disavow those aspects of the self and get rid of them completely. Projection is a defense that can cause a lot of trouble in a person’s life since it distorts reality. It is at the heart of illnesses such as paranoia, the classic example being the murderously angry patient who goes through the world thinking everyone is going to kill her. The aim of projection is to make the self feel all good, devoid of badness. This can make the outside world seem very dangerous. It can also leave the self feeling empty, depleted, and sterile.

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Projective Identification Projective identification is one of the hardest defenses to define and understand. A complex phenomenon, it has several parts and serves a variety of functions. It is, in fact, not just a defense but also the manifestation of a fantasized object relationship (Moore & Fine 1968). The projective part of projective identification is the same as in simple projection, in which the aim is to get rid of something within the self that we cannot bear, that is uncomfortable and unacceptable. But in projective identification the projector does not want to lose the projected part completely—hence the identification. Ogden (1979) offers some definitive work on the subject. He proposes that projective identification serves four functions and, as such, plays a large part in much of psychic life: 1. A defense to distance oneself from an unwanted part of the self, while in fantasy keeping the part alive in the recipient. 2. A mode of communication in which the projector hopes to be understood by making the recipient feel the same way. 3. A type of object relation in which the projector has achieved a certain degree of separateness but is still in some ways merged with or undifferentiated from the object. 4. An important pathway for psychological change and growth since the process is by no means static and the projector can learn much from the identification with the other (p. 56). The following are two examples of projective identification: A wife talks constantly with her friends about her husband’s intense anger and depression. She focuses in particular on the way he curses and then despairs when little things go wrong, such as the kids spilling their milk or a light bulb burning out, often screaming “God damn it—I can’t stand it.” In their arguments he always vehemently denies that he is depressed. In contrast, she describes herself as efficient, hopeful, and happy most of the time. A  month after the couple separates the wife finds herself shouting “God damn it—I can’t take it” over and over again as she frantically pounds the light switch to a bulb that has blown out. To her dismay, she realizes in that moment that she, too, is depressed, that she is behaving exactly the way her husband did, and that she had wanted to “place” all her frustrations and despair into her husband in order not to face them in herself. However, she had remained intensely interested in his depression by constantly thinking and worrying about it. In subsequent marital counseling after a reconciliation, both partners learned to acknowledge and accept their own anger and depression, and the projective identification was no longer needed as a defense. A client accuses her therapist of being a “greedy pig” when the therapist proposes a fee increase based on the fact that the woman’s salary has doubled after a job change. Rather than feeling greedy, the therapist is feeling quite virtuous because she has proposed only a moderate raise, despite having charged a very low fee for years. She thinks that the patient is greedy for not wanting to pay more now that she has more. The argument about who is greedy and who is not consumes a great deal of the therapy time and goes on for weeks. Only when the therapist’s supervisor points out that perhaps she is feeling greedy and secretly desires a much higher fee does the impasse begin to be resolved. The therapist can then talk with acceptance of her own greediness to the patient, enabling the patient to stop defending against that feeling in herself and to start exploring it instead. For the first time, the patient is able to recount how she felt growing up “on the edge of poverty” in a South American country where many of her friends and classmates flaunted considerable wealth. She had always hated “being a have-not among the haves” and now becomes conscious that she had “grown greedier and angrier every day”—hence her projective identification with the therapist’s request for more money.

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Both examples illustrate an important aspect of projective identification—that “it takes two to tango.” If no one in the dyad can take responsibility for the unwanted feeling, it will be thrown (sometimes hurled) back and forth between the two like a hot potato. When one person can comfortably “own” the feeling and no longer needs to disavow it, the pathway for psychological change can begin and the troublesome feeling can be integrated into both self and object representations. Another adaptive and useful function of projective identification is that of “staying in touch with” and “feeling with” the other person, capacities that later lead to the formation of mature empathy. Idealization Idealization is sometimes difficult to understand as a defense since the word itself has so many different meanings. For instance, we will see in the next chapter that self psychology views the capacity for idealization and the availability of objects to idealize as essential to the development of a vibrant, cohesive self. Idealization is a defense when, like all the defenses, it is used to keep painful and unacceptable feelings out of consciousness. The feelings that are troublesome are usually the same ones that people often want to deny: anger, disappointment, envy, sadness, desire, greed. Dawn, a white twenty-one-year-old, came to New York to study ballet with a renowned teacher. She had auditioned with him in the Midwest and had been impressed by his knowledge and his rigor. Even before leaving her hometown, she began to idealize her teacher as “the most wonderful ballet master in the entire universe.” At this point she was idealizing him because she was afraid of such a big move and had to convince herself and everyone else that it was a good decision to go because her teacher would be “perfect.” When she got to class in New York, she saw that the teacher had far too many students and was both unclear and sadistic in his way of conducting practice sessions. Because she could not yet face the painful truth of her disappointment, fear, and anger, she idealized him further, telling everyone that she admired his courage to be true to his art as he yelled at students and humiliated them. She spoke about the “purity of his standards.” Only when several students quit the class because of his cruelty was she able to begin to face the fact that his behavior was abusive and unacceptable. Eventually she was also able to leave and find a more helpful and creative class.

Idealization is particularly maladaptive when it is used as a defense against envy. When someone idealizes a person in an attempt not to feel envy toward him or her, the idealization can actually make the envy grow, because the more wonderful the person is perceived to be, the more there is to envy. Devaluation Devaluation is the converse of idealization and is used as a defense for the same purpose— to deny troublesome feelings such as neediness, weakness, insecurity, envy, or desire. Most people have at one time or another said, “I wouldn’t go out with him if he asked me,” or “She thinks she’s so beautiful, but she’s a snob and I  don’t want her,” when in fact they are very attracted to the other person but fear their advances would be rejected. If a person denies desire through devaluation, they end up feeling smug and superior but quite alone. In the previous example, Dawn might have begun to devalue her teacher in an attempt to feel “I didn’t want to study with him anyway,” thereby denying the pain of dashed hopes. Both idealization and devaluation, when used as defenses, rob people of connection to their authentic feelings.

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All of these defenses are also unconsciously employed in the dynamics of racism and the reader is guided to chapter 11, to explore them more fully.

THE AMERICAN SCHOOL OF OBJECT RELATIONS Thus far in this chapter we have discussed some of the most central concepts of object relations theory: the need for attachment, the importance of the quality of relationships with others, the nature of the internal object world, and the role of the early defenses. While we have not presented individual theorists’ definitions of these defenses, we will mention here that some of the most vibrant, incisive, deeply understood work on these primitive defenses and early ways of being can be found in the writings of Otto Kernberg (1975). Kernberg is described in various ways, either as a contemporary Freudian revisionist (Mitchell & Black 1995) or as an American object relations theorist. He is actually both, because in his system the drives do not exist at birth. Libido develops over time from experiences with good, gratifying objects, and aggression consolidates over time from experiences with bad, unsatisfying objects. His work with the defenses as correlated to developmental levels and subsequently to diagnosis is invaluable. Hence, more of his work will be presented in chapter 16 on borderline personality disorders. Margaret Mahler (1897–1985) Margaret Mahler preferred to think of herself as an ego psychologist, but we have included her in this chapter because her work emphasizes the development of self and object constancy so well, because her ideas fit snuggly with object relations theory, and because her work is often cited as a further elaboration of it. Mahler added to the study of psychological development a schema that explains how a child makes attachments to significant others, internalizes those attachments, and yet ultimately blossoms into a separate, autonomous individual. She called her developmental schema the process of separation-individuation. These are two different, but similar, interrelated and interwoven processes. She believed these led to the “psychological birth” of the human infant. Her work presents us with a Western, white, middle-class, male belief system of mental health. Autonomy and independence are highly valued and made synonymous with health and maturity. It is not a view of healthy development that would be shared by all cultures. We can harken back here to the example cited in chapter 1 of the Iranian students observing an Iranian and an American mother–child dyad. Mahler’s conclusions would be exactly the opposite of the Iranian students’. The American child would be seen as growing appropriately in autonomy, becoming comfortable with separateness and independence. The Iranian child would be viewed as overly “clingy” and dependent and headed for developmental trouble. Hence, Mahler’s image of the baby captures uniquely American themes. The baby, in Mahler’s theory, is seen as “an explorer of the New World,” even as “a conquering hero.” Surely pathology and normality are in the eyes of the beholder. Because of this very Western overvaluing of independence and autonomy and the shift to more relational theories, Mahler’s work is not as much in vogue as it was twenty years ago. Nevertheless, because patients routinely bring into treatment unresolved issues and problems stemming from the developmental challenges of Mahler’s various “phases,” her work has great clinical utility. Separation is defined as the process by which a growing child comes to experience herself as a separate, distinct entity who “stands alone,” so to speak. It is the process of moving away from union/oneness with the mother. Individuation is defined as

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the process of coming to experience oneself as the unique individual self one is. It includes very specific self-knowledge about the traits, qualities, characteristics, and idiosyncrasies that make one oneself and no one else. Mahler delineated phases in the separation-individuation process that she tied to specific moments of a child’s life and related to the physiological maturation of the child. Applied in too concrete a fashion, her theory can be linear and static. A similar problem can arise when particular pathologies are traced in a linear way to certain phases of development. Strict adherence to Mahler’s phases is not useful and can lead to “cookie cutter” diagnoses. It would be better, once again, to think of them, as Pine (1990) suggests, in terms of “developmental moments.” What Mahler describes does not happen in set phases or only in specific months, but it does happen. Here then is a description of Mahler’s phases of development. The Autistic Phase (Birth to Twelve Weeks) The autistic phase is postulated by Mahler (Mahler et al. 1975) as an objectless and, in fact, even self-less phase. If this phase exists, it would be a time of almost complete nonrelatedness and nonmeaning. Mahler correlates problems during, or regression to, this phase with the development of psychosis later in life, which is highly problematic, especially in view of the current state of knowledge about biological factors in the most severe mental disorders. Many theoreticians reject the idea of an autistic phase since they believe instead in the infant’s capacity to relate from the moment of birth. Mahler’s conclusions about this phase in particular are also the most challenged by current infant research (Beebe  & Lachmann 1988; Lyons-Ruth 1991; Stern 1985). This work reveals a subtlety and intensity of recognition, interaction, imposition of self, alertness, and relatedness in infants heretofore unknown. These observations refute that a baby is ever completely in an autistic or unrelated phase. Despite this, it must be remembered that some children do suffer from autism and seem to be living away from relatedness in a land of mysterious shadow. There are also certainly autistic moments of nonrelatedness experienced by all babies and adults. One adult patient whose diagnosis was generalized anxiety disorder would nevertheless at times be at such a loss for words that he would hesitatingly try to communicate by saying “and now for a translation from the autistic.” The Symbiotic Phase (Six Weeks to Ten Months) Mahler (Mahler et al. 1975) calls the symbiotic phase “the primal soil from which all subsequent human relationships form” (p. 48). Symbiosis is the term used to describe a time in life when caregiver and baby seemingly exist in one orbit. It is the time of the most complete union, of healthy merger. The holding environment is the most encompassing at this time and from it stems the feeling of being safe in the world. Symbiosis refers not only to the actual relationship with the caregiver in the first months of life but also to the perhaps universal fantasy of a time of total omnipotent union and bliss. In Mahler’s view, the hallmark of symbiosis is “omnipotent fusion with the representation of the mother and, in particular, the delusion of a common boundary between two physically separate individuals” (p. 450). In clinical terms, it is useful to listen for patients’ moments of longing for an impossible return to symbiosis, the desire for which is often at the heart of sorrow and depression. Having looked earlier in this chapter at Winnicott’s ideas about the quality of attachment, we can see how this phase coincides with his views about the need of the baby to experience “primary maternal preoccupation.” However, we also know that this is the same time in life that Klein saw as the beginning of the paranoid-schizoid position. Again, there are

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undoubtedly moments of each—when the baby experiences blissful oneness with another, but also when she feels alone and frightened, experiencing the seeming bigness, fragmentation, and chaos of the world around her. Separation-Individuation Proper According to Mahler, the baby begins to “hatch” out of symbiosis, entering what she calls separation-individuation proper. This includes the subphases of (1) differentiation, (2) practicing, (3) rapprochement, and (4) on the way to object constancy. Differentiation (Five to Twelve Months) This period is marked by the infant’s beginning separation out of the symbiotic unity. Growing interest in the world outside of the primary caregiver is stimulated by the new ability to crawl or creep or roll, and eventually to stand. The chief caregivers are still tremendously important, but they are no longer the center of the universe in the same way. Practicing (Ten to Twenty-Four Months) Practicing coincides with increased locomotion and ever-increasing bodily skills. Learning to walk is of enormous consequence, not just in terms of physical mastery but also because it ushers in the psychological correlates of being able to stand alone and walk both toward and away. This era of new cognitive and motor skills is often filled with elation on the part of the toddler. It is a time of triumph, exhilaration, grandiosity, omnipotence, and narcissism. “No” and “bye-bye” are often favorite words. The child feels like “the world is her oyster.” She is “the gleam in her mother’s eye.” Sometimes, though, that new world out there becomes frightening or tiring; it is then that the caregivers need to be there for emotional refueling. It is best for the child if the adults in her environment can accept with good grace her omnipotence and grandiosity in order that the child’s eventual disillusionment can be gradual and so that some of the power and exhilaration of this phase remains available throughout the life cycle. A family is walking toward the ocean with an eighteen-month-old boy. As they reach the top of the dune they are all struck by the roaring of the rough ocean waves that day. The little boy looks momentarily startled but then squares his shoulders, holds up his head, and in a very imperious manner proclaims, “Stop, waves.” He does it with such power that the adults almost expect the waves to stop. Naturally they do not. To really underscore the grandiosity of the toddler, he is not even fazed by his “failure.” Anyone else exerting such force to make something happen would be crushed, but not the child in this phase. He is perfectly happy with the power of the gesture and the fantasy, and so, ignoring the crashing waves, goes off contentedly to play in the sand.

Rapprochement (Twenty-Four to Thirty-Six Months) Rapprochement is probably the most complex and complicated of the phases for both parent/caregiver and child. This is because it is the time that the child has very opposing needs—the need to cling and be close, as well as the need to separate, to be off on her own exploring the world. Gone is the blithe exploring of the practicing days when separation seemed so triumphant. Yet the wish is not for total symbiosis either, because that would mean giving up too much selfhood. Because of this complexity of needs, this phase can often be the most trying for caregivers. A needy parent might cling too hard when the child

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needs to be let go, while an overburdened parent might push the child away too soon when she needs to be held close a little while longer. From this phase is derived the idea that the parent needs to be both optimally frustrating and optimally gratifying, another of those daunting-sounding tasks for parents. One of the developmental struggles of the rapprochement subphase is called ambitendency. This term in psychodynamic theory captures the tendency to swing between two intense wishes—the wish to be close and the wish to be separate—and the two enduring, intense fears—the fear of engulfment and the fear of abandonment. These twin fears arise most potently as challenges during rapprochement, but vestiges of this dilemma often remain present throughout life, and for some, ambitendency becomes central to their psychological problems and dysfunction. Ambitendency needs to be carefully distinguished from ambivalence, with which it is sometimes confused. Whereas ambivalence refers to a person’s mixed or contradictory feelings toward another person, ambitendency describes a person’s fluctuating states of desire for and fear of both merger and distance. In a state of ambivalence a person has simultaneous and opposite feelings, usually love and hate, about another. This can be difficult to bear and to come to terms with. Ambivalence causes discomfort because it represents the struggle to integrate good and bad feelings about another object. Ambitendency also causes discomfort, but it is the discomfort of an earlier time developmentally. In ambitendency, the developmental challenge is not to reconcile the positive and negative aspects of the other, but rather to overcome fears about the dissolution of the self. The developmental opportunity in ambitendency is to discover that one need not be engulfed and destroyed by closeness and that distance does not necessarily mean abandonment and unbearable aloneness. People often experience a resurgence of ambitendent feelings at the beginning of falling in love. This proved to be the case with Richard, who came for brief, focused therapy due to the wild, intense mood swings he could not control at the beginning of his relationship with Peter. Richard had felt ready for a serious, committed relationship for some time. He believed himself prepared to proceed wisely when he met Peter and realized that he liked him a great deal. He was dismayed when he soon “started acting like a nut case.” On one date Richard would feel very loving and close toward Peter and talk with him about the possibility of a long-term, committed relationship. On the next date he would be aloof and distant and talk about himself as a loner with little interest in engagement or closeness. Despite these shifts, which he could not control, Richard was having a wonderful time with Peter and recognized that he was learning to love him deeply. In therapy, Richard kept talking about his “ambivalence” about Peter, but he soon realized that he did not have mixed feelings about Peter at all. What he did have was deep fears about what degree of closeness and separateness he desired and could tolerate. He could not find a comfortable way of being that included a good balance of union and separateness. When he felt close to Peter he wanted to “merge with him forever,” but then that would scare him because he feared he would lose “all energy, individuality, and ambition.” Impelled by these fears he would distance himself, but distance too much, and then become frightened about having gone too far away and being too alone. Once Richard understood these fears he was able to confront them, realize how young the feelings were, and work on achieving a comfortable way of being with Peter in a long-term partnership. Over the years Richard has returned to therapy occasionally for short-term work on other issues—career changes, aging parents, and so forth. After twelve years he is still in a happy, fulfilling relationship with Peter. He states he still struggles occasionally with fears of engulfment and abandonment, but he recognizes what they are and works through them successfully.

In this example, Richard has worked out and grown beyond rapprochement issues. These developmental tasks will be revisited in chapter  14, where we talk about the borderline

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condition, since many of the developmental tasks and problems of rapprochement appear in people suffering from that disorder. On the Way to Object Constancy (Thirty-Six Months to the End of Life) On the way to object constancy is the name Mahler chose to denote the last subphase of separation-individuation. The fluid nature of the concept has been welcomed by many practitioners because it denotes that developmental achievements are not fixed and rigid but come and go depending on the various stresses and strains in different periods of a person’s life. Object constancy refers to the establishment in the psyche of a relatively stable, benign, and positive representation first of the parent, and eventually of others, that “holds” even in the face of absence, disappointment, or anger. It is a crucial capacity to develop in order to have an even reasonably healthy, mature psychological life. It is one of the most important cornerstones of mental health, but even those who have achieved it lose it from time to time, some more severely and enduringly than others. Hence the welcome “on the way.” Simply put, object constancy provides security and strength from the feeling that the self can endure and be well whether or not the object is meeting its needs at the moment. Object constancy is related to object permanence but is not the same thing. Piaget (1937) coined the term “object permanence” to denote a purely cognitive achievement—that is, the capacity to retain a mental representation of an object even when the object is not present. Object permanence has no affective coloration. Object constancy adds that affective dimension because its achievement introduces the capacity to retain belief in the goodness and love of the object even when it is not being gratifying in the moment. Many people struggle with weak object permanence and wavering object constancy. Clinicians hear this from clients who say, “I can’t even remember that you exist when I am not in the office with you” (lack of permanence) or “I can’t believe you are there for me and care about me if we disagree about something” (lack of constancy). In treatment the achievement of object permanence and object constancy are often worthwhile and attainable goals. Mary Lou, a white middle-class woman in her mid-thirties, whose parents had both suffered from extreme anxiety, suffered from shaky object constancy as well as from occasional lapses in object permanence. The world, therefore, was often an overwhelming and frightening place for her. If a friend or coworker became annoyed with her, she could not remember that the person basically liked her. Although she tried, she could not summon an image of the therapist to help her out internally when she was getting lost in the belief that no one cared about her. Mary Lou herself came up with the inspired idea that it might help her if she could call the therapist’s answering machine every day, not to talk and leave a message, but to hear the outgoing message. Mary Lou meant this quite literally and said, “Perhaps if I hear your voice on the outgoing message every day and remember that you exist and are basically a decent, courteous person, I will finally be able to grasp that there is someone out there in a constant relationship with me no matter what is going on.” Mary Lou called the machine daily for approximately three weeks and discussed the changes occurring within her in her weekly sessions. One day she stated simply, “It’s done; I’ve got it now, I don’t need to call any more,” and from that day forward felt transformed by her developmental achievement. For the first time in her life, she was able to form friendships and get along with supervisors, because she could retain the idea and feeling that (a) they still existed even when not present, and (b) that they liked her even when they were at odds with her.

In this vignette, it is literally the voice on the phone that illustrates the use of what Winnicott called the “transitional object,” which can serve as the bridge to a more solid permanent connection between self and other.

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A CRITIQUE OF OBJECT RELATIONS THEORY IN ITS SOCIAL CONTEXT It is important, as with all theories we study, to place object relations theory in its historical and cultural contexts. The heart of object relations theory was developed in England and in the United States during an era when belief in the existence and the value of the nuclear family was at its height. It is no accident, then, that the theory focuses with great intensity and specificity on the mother–baby relationship, assuming not only that mothers would want to be the primary caregivers but also that they would be able to stay at home during almost all of the early childrearing. Then, as now, the theory does not take into account the fact that many mothers and fathers who want to are not able to be home with their children because of financial inequities. Like any other theory, then, this theory must be understood to be limited by when and where and by whom it was constructed. One of the most important critiques to bear in mind is that object relations theory can sound like, or actually become, a potentially motherblaming theory. Since the vicissitudes of development are tied so closely to the quality of the mother–child interaction, there is a danger of interpreting this to mean that whatever goes wrong is primarily the mother’s fault. This does not seem to have been the intent of the theoreticians, but in paying such intense, microscopic attention to mother and child, they did at times lose the forest for the trees. The forest encompasses other relationships within and outside of the family—the social, cultural, religious, and economic forces at play, and the innate temperament, personality strengths, weaknesses (and therefore input) of the baby itself. When Winnicott said, “There is no such thing as a baby,” he meant that there is no such thing as a baby without a mother. We would say there is no such thing as a baby without a mother and/or father, siblings, grandparents, extended family, and, ultimately, a country, neighborhood, school, and religious and cultural affiliations. There is also no such thing as a baby who grows up without being profoundly influenced by the prevailing realities of and attitudes toward gender, race, ethnicity, sexual orientation, and class. A baby always grows up in a specific country within its political and economic system, and the values of that system have a profound impact on its development. Object relations theory can sound as if every child grows up in a traditional nuclear family consisting of a biological mother and father and a couple of kids. This resonates with what at the time was probably a romanticized fantasy within our culture of the perfect Father Knows Best, Ozzie and Harriet type of family. But many children do not grow up that way and it is not everyone’s fantasy, and so we must take those realities into account in our reading of past theories, in our future development of theory, and in our clinical work. Here are some facts, not fantasies, about current living arrangements of families in the United States. The U.S. Census Bureau (2019) reports: In 2019, 73.53  million children under 18 lived in households. The majority of these children (51.56 million) lived with two parents. Almost 4 percent (3.23 million) of children lived with two parents who were not married to each other. Of the 19 million children living with only one parent, 3.23 million lived with their father. 4.35 percent of children (3.2 million) had no parent present. Almost half of these lived with grandparents. About 2 million fathers were stay-at-home dads. More than 190,000 children lived with same-sex parents. Over 16 percent of children, almost 12 million, were living in poverty.

These figures begin to give us an idea of what complicated relational lives children lead. They remind us that object relations theory often describes an extremely limited family

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structure. Since the first edition of this book, published in 1996, the statistics show steadily increasing divergence from that nuclear family—and the statistics offered by the census bureau omit families with, for instance, same-sex caregivers until 2019. We’re a long way from Father Knows Best. Another limitation of object relations theory (and, in fact, of all psychological theories) is that it was developed largely by white, Jewish or Christian, middle- to upper-class clinicians treating patients primarily from the same racial, socioeconomic, and religious backgrounds as their own. These theories, then, are not derived by, or from, a study of the poor, the disadvantaged, or racial or religious minorities or non-Western cultures, and do not in any way capture the richness, heterogeneity, and diversity of the current population of the United States. For this reason, great care must be taken to evaluate what aspects of these theories are irrelevant or actually harmful to the care and treatment of specific individuals or groups within our society. In a New York Times Magazine article (Smith 1990) titled “Mothers: Tired of Taking the Rap,” a clinical social worker and mother writes poignantly of how a rigid, narrow adherence to the belief that mothers are responsible for everything can be misleading and damaging: As part of my work I have made many home visits to very poor women in housing projects. I witness the obstacles these mothers must overcome to arrange a day’s worth of juice and Pampers for their toddlers. They have no money, bad housing, no day care, no way to earn a living, no physical safety, few reliable relationships and no social support. But when their children are evaluated at mental-health clinics the all-too-common requiem for the mother’s effort is simply “neglectful and unmotivated.” The fact that mothers have had primary responsibility for raising children does not mean they have had the power and the resources to protect children from the world’s tricks and perils—nor from their own circumstances and limitations. Primary responsibility for raising children cannot be simply equated with primary responsibility for harming children. Such fantasy notions of the good mother harm all mothers and cause them to assume too much blame for damaging their children. Mothers imagine irreparable psychological consequences whenever they yell, stay late at a meeting, use the TV as a baby-sitter, forget to serve a vegetable, let a child share a bed, or leave a bad marriage. I cannot remember ever working with a mother—wealthy, middle class or poor—who did not have secret theories about how behaviors, or choices, or feelings of hers had deeply harmed her children. While some part of such worry and guilt is appropriate to the task of child-rearing, it is increased unfairly and exponentially by the pervasive and unremitting image of what a really good mother would have done in her place.

Finally, although early objects relations theorists were not thinking specifically about the social justice implications of their work, many of their concepts are now used to understand hatred and discrimination. As Lavinia Gomez (1997) says, “Object Relations offers an insight into the dynamics of prejudice in terms of Klein’s bad object, Fairbairn’s exciting and rejecting objects, and Bowlby’s insecure or avoidant attachment patterns. Demons are easily made when we identify with one side of a split” (p.  200, italics added). She described Black people demonized by white nationalists, racists demonized by white liberals, feminists derided by sexist men, immigrants hated by nationalist groups, and psychoanalysts looked down upon by humanistic clinical practitioners. But it is crucial to remember that hatred can always go both ways: some racists demonize white liberals, some feminists may condemn all men, and psychodynamic clinical social workers sometimes look down at CBT practitioners on one end of the spectrum and psychoanalysts at the other! The way object relations theory understands early defenses and the people who exist in our internal world reminds us that anyone can be the dreaded “other” until we can heal the damage taken in from harmful object experiences.

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CONCLUSION What, then, has object relations theory contributed to our knowledge of the client’s inner world? Most simply, it has provided a number of basic concepts for understanding psychological development. The first and most basic concept of object relations theory is that of the primary, absolute need of human beings for attachment. The second central concept is that the child’s inner world is shaped by internal representations of others. The third important concept is that human beings need to be both alone and with others, and that the struggle to balance and meet these seemingly contradictory needs lasts throughout the life cycle. Fourth, object relations theory looks at why we need others, how we take them in, and how we relate to them internally. It looks at the consequences of loss on the development of selfhood. It looks at the influences of relationships on the internal world. Being very much a theory about psychological processes, object relations theory pays particular attention to the earliest experiences and defenses—those that have to do with trying to distinguish between self and other, between what is inside and what is outside, and eventually with accepting and integrating both the good and the bad parts of the self and others. Object relations theorists have also given us a new way to look at the therapeutic encounter. One of the most useful tools for learning about a client’s early object relational experiences is the relationship that develops between client and therapist. Here the clinician learns in her bones about the client’s feelings about separateness; here the clinician comes to know (often through projective identification) how the client’s difficulties and strengths in relationships are reexperienced in the present. Here the client and therapist discover how in the transference, the client may hide true wishes while trying to conform to her perceptions of what the therapist wants the client to be. Here the therapist may experience the client’s fear that if the client is too distant or too close, the therapist will no longer care. Here the clinician and client can begin to understand the costs and gains of separation and individuation and what these may have meant and now mean for the client. Often the clinician cannot know and the client cannot express the complexity of her inner object world until both have experienced it together, in a relationship, over time. And although managed health care may push us toward solving problems using time-limited, intermittent treatment, it is ultimately object relations theories that remind us of the utter centrality of a relationship to psychological development and growth.

REFERENCES Applegate, J. (1989). The transitional object reconsidered: Some sociocultural variations and their implications. Child and Adolescent Social Work 6(1):38–51. Beebe, B., & Lachmann, F. (1988). The contribution of mother-infant mutual influence to the origins of self-object representations. Psychoanalytic Psychology 5:305–37. Bowlby, J. (1969). Attachment and Loss, Vol. 1, Attachment. New York: Basic Books. Census Bureau. (2019). America’s Families and Living Arrangements: 2019. Washington, DC: U.S. Census Bureau. Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A  black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum 1989:139–63. Fairbairn, W. R. D. (1952). Psychoanalytic Studies of the Personality. London: Routledge & Kegan Paul. Freud, S. (1917). Mourning and melancholia. Standard Edition 14:237–58.

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Gomez, L. (1997). An Introduction to Object Relations. New York: New York University Press. Greenberg, J. R.,  & Mitchell, S. A. (1983). Object Relations in Psychoanalytic Theory. Cambridge, MA: Harvard University Press. Guntrip, B. (1968). Schizoid Phenomena, Object Relations and the Self. London: Hogarth. James, P. D. (1986). A Taste for Death. New York: Warner. Kaplan, L. (1978). Oneness and Separateness. New York: Simon & Schuster. Kernberg, O. (1975). Borderline Conditions and Pathological Narcissism. New York: Jason Aronson. Klein, M. (1952). The origins of transference. In Envy and Gratitude and Other Works, 1946–1963. New York: Delacorte. Lyons-Ruth, K. (1991). Rapprochement on approchement: Mahler’s theory reconsidered from the vantage point of recent research on early attachment relationships. Psychoanalytic Psychology 8(1):1–23. Mahler, M., Pine, F.,  & Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books. Mitchell, S. A., & Black, M. J. (1995). Freud and Beyond. New York: Basic Books. Moore, B. W., & Fine, B. D. (1968). A Glossary of Psychoanalytic Terms and Concepts. New York: American Psychiatric Association. Ogden, T. H. (1979). On projective identification. International Journal of Psycho-Analysis 60:357–73. Piaget, J. (1937). The Construction of Reality in the Child. New York: Basic Books. Pine, F. (1985). Developmental Theory and Clinical Practice. New Haven, CT: Yale University Press. ———. (1990). Drive, Ego, Object, and Self. New York: Basic Books. Shakespeare, W. (1974). Troilus and Cressida, Riverside Shakespeare. Boston: Houghton Mifflin. Smith, J. M. (1990). Mothers: Tired of taking the rap. New York Times Magazine, June 10, pp. 32–38. Spitz, R. (1946). Anaclitic depression: An inquiry into the genesis of psychiatric conditions in early childhood. Psychoanalytic Study of the Child 2:313–42. Stern, D. (1985). The Interpersonal World of the Infant. New York: Basic Books. Webster’s Third New International Dictionary. (1963). Springfield, MA: G. & C. Merriam Company. White, K. P. (2002). Surviving hating and being hated: Some personal thoughts about racism from a psychoanalytic perspective. Contemporary Psychoanalysis 38(3):401–22. Winnicott, D. (1956). Primary Maternal Preoccupation. London: Hogarth. ———. (1958a). Through Paediatrics to Psycho-Analysis. London: Hogarth. ———. (1958b). The Capacity to Be Alone. London: Hogarth. ———. (1960). Ego Distortion in Terms of True and False Self. London: Hogarth. ———. (1971). Playing and Reality. London: Hogarth.

6 The Theory of Self Psychology Laura Melano Flanagan

Thus far, we have examined very different views of the self. In drive theory, the self is seen as a cauldron of seething impulses of sexuality and aggression. In ego psychology, the self is that agency of the mind that mediates among the drives, reality, and morality. In object relations theory, the self is made up of internal representations of relationships with others. This chapter presents the theory of self psychology, which pays exquisite attention to the kinds of life experiences that contribute to the formation of a mature, vibrant, and cohesive self. Self psychology focuses a different lens on how the self develops in the context of relationships with others. Throughout the history of philosophy, literature, psychology, and the social sciences, there have been many ways of defining and constructing ideas of the self, no two exactly alike. Indeed, all psychodynamic theories talk about the self in one way or another. What distinguishes self psychology (and the reason it is called self psychology) is its focus on understanding that the self has a separate line of development that should, ideally, lead to a creative, loving, and, especially, cohesive whole. Thus, the emphasis begins to shift toward a person’s subjective sense of cohesion and well-being, rather than on what was understood as the more objective functioning of various aspects or parts of the self, such as the id, ego, and superego, or self and object representations. Self psychology contributes, in its own useful way, to the understanding of the experience of self from both inside out and outside in. In Webster’s Third New International Dictionary (1963), there are many definitions of self. The three most congruent with self psychology are “the entire person of an individual,” “the union of elements (body, emotions, thoughts, sensations) that constitute the individuality and identity of a person,” and “the source of social adaptation and growth of the individual personality” (p.  2059). Heinz Kohut, who first developed the theory of self psychology, defined the self as “the I we recognize ourselves to be: a bounded entity with cohesion in space and over time” (Elson, 1987, p. 18). Heinz Kohut’s (1923–1981) main body of work was published in the 1970s and early 1980s. His work gave birth to what has become a separate and distinct school of thought and a specific way of conducting treatment. Self psychology has become one of what are 125

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known as the “four psychologies” (Pine 1990), the other three being drive theory, ego psychology, and object relations theory. In various ways, self psychology flows out of and incorporates some of the ideas of those theories, but it also, as so many subsequent theories do, critiques, rejects, changes, and modifies many tenets of the other theories and makes its own unique and creative contribution. It is also one of the psychodynamic theories that is most congruent with the current, serious attention that is being paid to the exploration of intersectionality, which is defined as “the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage” (Oxford University Press 2019). Although Kohut did not pay specific attention to phenomena such as race, class, and gender per se as they interface with the psychological development of the self, his theories enrich our knowledge about how these factors affect it. Whereas object relations added to our understanding of the impact of our relationships with people, self psychology can help us understand the impact of our relationship to almost any thing: a school, a police department, a place, a symphony, a beautiful day. Any of those things can be a help or a hindrance to the development of a cohesive, vibrant self. In Kohut’s view, we all need the outside world to offer us opportunities for validation, idealization, and twinship, in order for each of us to develop into a cohesive healthy self. He understood that anyone can be helped or hurt, not only by the people close to us in our lives but also by our communities, the opportunities and services we have access to, and the policies of our government. Thus, for marginalized groups, social injustice and oppression are taken in and become part of their very selfhood. The enormous, passionate Black Lives Matter protests that were taking place nationwide in June of 2020 can be seen as a manifestation of how harmful to the development of a calm, cohesive secure self a racist society can be. Kohut was born in 1923 in Vienna to a middle-class Jewish family. He showed intellectual promise early but was marginalized as a medical student studying neurology because he was Jewish. In 1939, he fled Nazi persecution to Chicago but had to bear the tragedy of several relatives dying in the death camps. He became a prominent, controversial member of the Chicago Institute for Psychoanalysis, where he did his groundbreaking work. Kohut began his career as a classical Freudian analyst and kept close ties throughout his life with Anna Freud and Heinz Hartmann. Kohut, who wrote in German, did not publish his first book until he was in his fifties, but then he challenged psychoanalytic tenets with his new theory of self psychology, which was one of the first significant psychoanalytic movements to originate in the United States. His theories were constantly evolving, and he was often at the center of controversy. Many in the classical establishment stopped thinking of him as a psychoanalyst altogether because he deemphasized the importance of the drives and of internal conflict. For instance, Slap and Levine (1978) stated rather harshly, “Although Kohut refers to it as a psychoanalysis, his therapeutic method depends on suggestion and learning, but not insight, conflict resolution, or making the unconscious conscious.” It is indeed true that Kohut (1971) formulated a radically different view of the unconscious, stating that people repress not the impulses and wishes of the id but rather “unfulfilled archaic narcissistic demands, related to the mother’s rejection of the child’s independent narcissism” (p. 185). Kohut also proposed new definitions of transference, naming them narcissistic transferences, which he understood as based on needs rather than on conflict. In terms of technique, he taught that interpretations are often not only unhelpful but even destructive. He believed that empathy was the best way to understand and relate to other human beings. Kohut’s work significantly changed psychoanalytic thinking for many clinicians, and the currently popular schools of intersubjectivity and relational theory flow out of his innovative work.

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Rather remarkably, and to the annoyance of many, Kohut did little to acknowledge the theorists who came before him. In his 2005 book on self psychology, Lessem titled his chapter on the thinkers who influenced Kohut “Theorists Who Anticipated Self Psychology,” explaining that he had to choose that name for the chapter because we can only deduce whose work Kohut built his own upon. Kohut himself did not tell us. Lessem names Ferenczi, Balint, Fairbairn, and Winnicott as “theorists whose work in important respects can safely be said to have anticipated Kohut’s, even though it is not known if they directly influenced him” (p. 221). Lessem also mentions that these object relations theorists were “particularly offended” because several of Kohut’s key concepts bear strong similarities to theirs. At first Kohut postulated that the development of the self coexisted with the development of the ego as a separate but equally important line of development. However, by the end of his life, he rejected classical structural theory altogether and placed what he called a tripartite self, with its own structure, at the center of the personality. In Kohut’s final metapsychology, the self is a supraordinate configuration that exists from birth. It is the source “for our sense of being an independent center of initiative and perception, integrated with our most central ambitions and ideals and with our experience that our body and mind form a unit in space and a continuum in time” (Kohut 1977, p. 177). We will see later in the chapter that this supraordinate self as described by Kohut has its own structure, needs, and driving forces. Id, ego, and superego are replaced by the concept of the tripartite self: a self that is driven by ambition, pulled by ideals, and needing to recognize itself in similar others. Also central to Kohut’s theory is the belief that the self can best come to be understood through empathy rather than through insight. Indeed, according to self psychologists, the self can only develop within a manageable empathic matrix of relationships that offer a combination of optimal empathic responsiveness and manageable empathic failures.

INTELLECTUAL AND CULTURAL CONTEXTS FOR SELF PSYCHOLOGY As was discussed in chapter 1, and as has been true of all the other theories we have looked at, the themes presented in any theory are always congruent with the cultural themes of the time in which they developed. In a review of Strozier’s (2001) biography of Kohut, Mark Edmundson (2001), a professor at the University of Virginia, writes: Kohut came to believe that he was reshaping psychoanalysis to respond to the cultural climate in which he found himself. Freud’s emphasis on the Oedipal complex might have been apt in a society that almost totally repressed sexuality and where many patients grew up in hothouse families, with three generations living under a single Viennese roof, along with a clutch of maids, nurses, manservants and other potential objects or initiators of seduction. But times had changed. In midcentury America the self was the central preoccupation, narcissism was the central pitfall, and analysts had to reset their instruments.

It is important to remember that the very concept of “self” is itself a social construct rooted in time, place, and culture. The value placed on the development of an individuated, autonomous, flourishing self varies widely from culture to culture. The notion of an enduring individual self has always been central in Western Judeo-Christian tradition and is still very much a part of the ethos of the modern, Western, largely male-dominated, industrialized world, which values autonomy over community. In Christian theology, the individual self and, therefore, the individual soul remain individual for all eternity and will be reunited with the individual body at the end of time. Many other major systems of belief, such as Buddhism, for instance, view the individuated self as an impediment to spiritual growth and

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enlightenment. In those religions the soul is always but a part of the whole universe, and if the belief system includes reincarnation, the soul returns not to become more individuated but to become a more evolved part of the whole. The historical era in which self psychology developed was the 1970s and 1980s, decades known for a fierce focus on individual self-definition, fulfillment, and well-being. This was a time of self-aggrandizement, overindulgence, and power-seeking, in which “perfecting” the self became its own goal. Magazines such as Self flourished; popular novels such as The Bonfire of the Vanities and movies such as Wall Street chronicled society’s preoccupations with power, individuality, and greed. Christopher Lasch’s The Culture of Narcissism (1978) describes Americans in that era as living in “a state of restless, perpetually unsatisfied desire” (p. xvi). The ascendance of self psychology coincides with the period when many people in the United States valued commitment to self-actualization above all else. Not surprisingly, the pathologies of the times became “self” pathologies: the empty self, the fragile self, the fragmented self, the overburdened self. Today, self psychology is considered to be a useful clinical theory precisely because it is open and positive in its view of human nature and because of its focus on the individual. There are fewer dark internal forces in self psychology since the self is viewed as having a tremendous desire and capacity to grow if its needs are met. There are no drives or unruly, disruptive impulses originating from within, but rather there is an innate, vigorous, motivating “push” toward health. Early in his career Kohut observed that he was treating a group of patients who were not helped by his interpretations of drive and conflict. They did not feel better about themselves, nor were their symptoms alleviated, even though they gained a certain amount of insight. Kohut suggested that many of these patients struggled with dilemmas of narcissism. On one hand, they were arrogant and aloof and felt superior to others; on the other, they seemed not to have achieved a sound, cohesive sense of self or healthy, balanced self-regard. In the transference relationship, these patients needed either to be admired profusely or to find perfection in the clinician or sometimes both. In examining his own countertransference, Kohut realized that these patients often left him feeling listless, bored, and disconnected. They were so wrapped up in themselves that the therapist could not feel useful or sometimes even real. They seemed not to need anyone at all and yet paradoxically seemed very fragile and prone to shame. Later, Modell (1975) was to write about narcissistic pathology as “the illusion of self sufficiency,” a phrase that poignantly captures the narcissistic struggle to appear strong and invulnerable while hiding tremendous neediness and lack of cohesion. Because of these observations, Kohut began to rethink the question of what constitutes a healthy self. Eventually, he abandoned the drives as the motivating force in growth and personality formation, and placed the impetus to become a cohesive self at the center of psychological development. He came over time to reject the Freudian notion that psychological structure is composed of the id, the ego, and the superego, and the idea that the resolution of intrapsychic conflict produces health. Instead, he came to believe that a healthy self is derived from experiences in which caregiving others, known as “selfobjects,” meet the specific needs of the emerging self. And a good selfobject can be anything at all in the outer world that serves as psychological nourishment to the inner world and contributes to the development of the self. Rage and aggression are no longer seen as intrinsic forces flowing from distinct, innate drives, but rather as reactions to unmet selfobject needs. Needless to say, this radically different view of human nature met with great opposition, and the discussion about whether aggression and therefore rage are innate forces or only occur as a reaction to life’s vicissitudes continues to this day.

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At first, Kohut believed that his new insights applied only to certain patients, those who suffered from narcissistic character problems. He still saw the validity of drive, ego, and object relations theories for problems of a neurotic nature. However, by the end of his life he believed that all psychopathology was based on flaws in the self and that “all these flaws in the self are due to disturbances of self-selfobject relationships in childhood” (Kohut 1984, p. 53). Here again we see the phenomenon that we discussed in chapter 1 and have pointed out already several times in the book: the apparently natural but unfortunate tendency of major theoreticians and their followers to come to postulate that their theories are true for everyone at all times. Again we reiterate our belief that this is not possible. Human nature is too complex and human experience too diverse for one theory to even begin to explain everything about development or psychological health and illness.

THEORIES ABOUT NARCISSISM Before turning to the actual building blocks of self psychology, it is necessary to understand the profoundly new and different view of narcissism offered by Kohut that lies at the heart of self psychology. Freud’s view of narcissism was drive centered, based on energetic concepts, and as such was both quantitative and linear. It was quantitative in that he believed that each person has a finite amount of libidinal energy. What loving energy was directed toward another must be taken away from the self. If a person has only a certain amount of libido to divide between self and others, then she will need to replace self-love and self-involvement with object love in order to move forward in development. It was a linear theory for related reasons. In Freudian psychology, healthy narcissism has only one line of forward development— from self-love to object love. Pathological narcissism occurs when too much libido remains invested in the self and therefore the shift to object love does not occur. Freud also differentiated primary narcissism from secondary narcissism. Primary narcissism exists in the earliest phases of life when all libido is attached to the ego. For the infant, this state is considered natural; it is the starting point of development. Secondary narcissism occurs later in life when the libido that has been directed toward others is withdrawn from objects back into the self due to thwarted growth opportunities, disappointments, illness, trauma, or the onset of old age, which are part of the human condition. Thus, in secondary narcissism an infantile state of self-involvement is recreated, and Freud considered this to be in need of clinical attention. Throughout Freudian theory, narcissism has a mostly pejorative connotation; it is something to be outgrown, avoided, or treated. Since Freud, debate and controversy have swirled around this subject. Many of the ego psychologists and object relation theorists have also described primary narcissism as a state of utter self-absorption and absolute infantile omnipotence to be modified or outgrown. But they are by no means in agreement with Freud or with one other about how, when, or why narcissism develops or what an ultimate, healthy resolution might be. To give just a few examples, Klein denied the existence of any period of primary narcissism whatsoever, ­while the Blancks, major ego psychologists, wrote about the possibility of “sound” secondary narcissism and defined this as the acquisition of healthy self-regard wherein self-representations are cathected with value (Blanck and Blanck 1979). In all these definitions, however, there still exists the implied belief that narcissism is something to be outgrown or modified in favor of a more adult interest in others. Kohut, however, eventually described narcissism in a less pejorative and more expansive way, differentiating between the crucial development of healthy narcissism and the pathology of narcissism. He postulated a separate and central line of development for

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normal, healthy narcissism. His view was less linear, polarized, and quantitative than that of the other developmental theorists. He did not believe that libidinal energy was finite. In fact, self psychology is based on the belief that the more attunement and love people have for themselves, the more they will have for others. Pathological infantile narcissism occurs only when insufficient love and attunement are received from others, thereby forcing the person to remain or to become overly interested and invested in his or herself. Anger and narcissistic rage occur only when a person is wounded by injuries that come from the outside world. Kohut did not view self love and object love as mutually exclusive. He did not posit object love or separation-individuation as primary goals of development or as important signs of health and maturity. On the contrary, he valued a much wider range of possible choices, seeing them as equally healthy and worthwhile ways of living. Kohut did not view independence from others as a hallmark of maturity, since he believed that we are all mutually dependent on others throughout life. His ideas offer the clinician new and different ways to think about narcissism as they might apply to a wide range of clients.

THE THEORY OF SELF PSYCHOLOGY Despite devoting a considerable amount of attention to the concept of narcissism, Freud began the first section of his paper “On Narcissism” (1914) with this modest and poignant statement: “The disturbances to which a child’s original narcissism is exposed, the reactions with which he seeks to protect himself from them and the paths into which he is forced in doing so—these are themes which I propose to leave on one side, as an important field of work which still awaits exploration” (p. 92). Kohut willingly took up the baton and it is to the exploration of these themes and this important field of work that he devoted his life, in his study of what he called “the science of the self” (1978, p. 752). He did not want to leave them to one side but rather placed them at the center of his life’s work. From his explorations, he concluded that the plight of “Tragic Man” was at the heart of the human condition. For Kohut, the term Tragic Man described the suffering that all individuals struggle with when empathic failures thwart their efforts to achieve self-cohesion and self-realization. He contrasted his view to what he called Freud’s notion of the pleasure-seeking “Guilty Man” who struggles with conflicts that arise between desires and prohibitions. Whereas Freud was interested in the phenomenon of guilt, Kohut turned his attention to the exploration of shame. Guilt occurs when a person feels he or she has transgressed against the prohibitions of society, usually contained in the superego, or against one’s ego ideal, which is contained in the ego. Guilt has to do with rules and codes of conduct and morality made by persons outside the self and brings with it fear of punishment. Once the rules have been internalized, guilt can be based on not living up to one’s own ideals. Shame is a much younger, nonverbal, less conceptual experience. It is not about being bad, it is about the feeling within the self of being inadequate, embarrassed, humiliated, pathetic, “less than.” It is felt more in the body than in the mind and often has somatic manifestations such as blushing, trembling, or crying. Shame often comes about from narcissistic wounding—“you’re a sissy boy,” “you’re a lazy slob”—which is one of the reasons why Kohut was so interested in it. Patients can often be helped to face and grow out of their shame if they can use the language of childhood comfortably while talking about it. They often describe the feeling as being “icky,” “puny,” “pathetic,” or “nerdy.” One client began to call his experience of shame “my slimy, little wormy feelings” and, once named and known, began to deal with them.

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Several new key concepts are central to Kohut’s understanding of psychological development: (1) the importance of empathy, not only as the main tool in clinical work but also as the matrix within which all growth takes place, (2) the existence and crucial role that selfobjects play in psychological development, and (3) the notion of the structure of the tripolar self. Each is described below. The Role of Empathy The role of empathy in development and in clinical work is not a new concept, but Kohut elevated it to a position of supreme importance and considered it to be the primary clinical tool. Kohut did not use the term empathy according to the current, lay usage of the word, which often includes notions of warmth, sympathy, or approval. He meant something much closer to the Webster’s (1963) dictionary definition of the word: “The projection of one’s own personality into the personality of another in order to understand him better: intellectual identification of oneself with another.” According to the dictionary definition, one could have empathy for an ax murderer, and that is precisely the way Kohut used it—to “understand” from within the experience of another, no matter what the experience. For Kohut, empathy is not a feeling. It is much more than that; empathy is a way of “knowing.” Empathy is not an affect; it is an action. It is not compassion, which is a feeling of sympathy for the plight of another. Nor is it attunement or kindness. Those feelings can flow from empathy, but empathy is the most direct road to understanding the separate, even very different, “other” in the deepest way possible. Kohut wrote a great deal about the use of empathy, or what he called vicarious introspection, as a powerful tool in clinical work. Using vicarious introspection means experiencing in one’s own imagination the feelings and actions of another, while at the same time paying attention to one’s own personal thoughts, feelings, and responses. He also described his belief that all human beings need an empathic matrix within which to grow and that only an empathic environment can provide the psychological nutriment and sustenance essential for mental health. Kohut did not envision the environment, however, as being always empathic. He knew full well that perfect empathy is impossible. Sooner or later human beings always disappoint or hurt or fail one other to some degree. What he did say was that there had to be an optimal balance of empathic gratification and empathic failure for the developing self to flourish and eventually experience itself as energetic and cohesive. Both in life and in clinical treatment, reactions to failures in empathy can be worked through if the disappointment and anger over unmet needs can be expressed and understood. This leads to a stronger and firmer sense of self. According to self psychology, empathic attunement is the necessary facilitator of development; repeated and chronic empathic failures without repair are the roots of disturbance and thwarted growth. A children’s book that always got a joyous response from youngsters was I Hate It When . . . (Preston 1969). The “when” refers to necessary parental endeavors such as “when you scrub my face” or “when you make me eat my spinach.” The book is full of such examples of empathy for children because it acknowledges the truth about the bad feelings children might have even when someone is doing something for their own good. The book does not say, “Because you hate it, I won’t scrub your face” or “You shouldn’t hate it when I  do necessary things for you.” It merely, through empathy, acknowledges what feeling is truly being experienced by the child and therefore validates and solidifies the sense of self of the child. Caregivers scrub faces and sometimes children hate it; that simple reality offers true empathy to both. In some ways this is akin to Melanie Klein’s beautiful point that if you can name troublesome, ugly feelings, you can begin to master and transform them, because

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you have a fuller, more accepting knowledge of all aspects of yourself. Empathy does not necessarily make a person feel good, but it does help people feel genuine and authentic. It is interesting to note that the book is no longer in print and that there is an ongoing discussion among theorists, therapists, educators, and parents about whether it is a good or a bad thing for children to be allowed to feel or name feelings such as hatred. Remembering that empathy is a tool for understanding the experiences of the other, a self psychologist would want to be able to see the hatred and then help the child own it, understand that there is hurt and vulnerability underneath it, and find expression for it in an appropriate way. Parenthetically, when kids were asked about the book, they loved it! The following example illustrates the inner impoverishment that can ensue when there is a lack of empathy for a developing child. Lisa, a thirty-seven-year-old, shy, anxious woman from El Barrio, a Latino section of New York City, joined a support group at a women’s center. The group decided to focus on each one of them identifying and healing their wounded “inner child.” Participants encouraged one another to remember and tell their painful stories of mistreatment and abuse. Lisa, who was the sixth child of an exhausted, struggling, poor single mother, became alarmed when she could summon no specific memories of her early childhood. Every time the group turned to her, she felt “gray, empty, and blank,” almost as if she did not exist. Surrounded by others, she nevertheless felt alone and anxious. She secretly feared that she had undiagnosed memory problems or that she was stupid. The therapist was beginning to worry that Lisa was dissociating. After many weeks Lisa began to realize, with great relief, that the gray, empty feeling was her memory. Her childhood had been characterized not by assaults but by an absence of empathy for anything at all about her—good, bad, or indifferent. She realized that her sense of herself was vague and diffuse, and lacked specificity. She had not been seen in any detail and therefore could not see herself. The group members also realized that it was not sufficient to help Lisa heal the wounds of overt neglect; rather, they had to help her see and explore with specificity what had not blossomed in her, due to years of inattention. The therapist understood that it was empathic mirroring that was most needed. Lisa flourished from the attention of the group and the therapist. They had empathy for her sadness and emptiness but also began to point out her quick wit and curiosity about the world, her occasional grumpiness, her love of nature, and other traits that she never knew in herself. For the first time, and with great reluctance and guilt, she began to feel anger towards her mother, and the group offered her profound understanding and empathy for her anger and the hurt beneath it. Having taken in that empathy, she was able to develop some compassion for her mother’s plight, which was in large part due to poverty, lack of services, discrimination, and social injustice. Now that she had been seen by others, she could see her mother more fully as well. Now that others had empathy for her plight she also had empathy for herself.

In a radical departure from previous theories, Kohut looked to the lack of empathy to explain narcissistic rage, which he believed to be the most destructive form of anger and sadism. He did not believe that anger was an innate drive but rather that it resulted from the intense, sometimes violent reaction to the kind of hurt that makes people feel powerless and ashamed and therefore vulnerable and weak. He considered narcissistic rage to be pathological because it emerges when the very fabric of the self has been injured by poorly met selfobject needs. Kohut (1977) called narcissistic rage a disintegration product because it occurs when a person feels he or she is literally falling apart and has returned to a state of primitive disorganization.

Selfobjects and the Tripolar Self As has already been discussed, when it came to defining the structure of the self, Kohut replaced the Freudian view that a person’s structure is made up of the id, ego, and superego.

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He postulated that, instead, the self is made up of three distinct poles, thereby introducing a major new piece of metapsychology. However, just as the Latin words id, ego, and superego were probably not the best choices to identify parts of the self in English (see chapters 2 and 3), so, too, the choice of the word pole for parts of the self is awkward and overly concrete. However, Kohut chose pole to refer to an aspect or a pathway of development within the self that has its own energy and needs. He initially identified two poles in the self—the pole of the grandiose self and the pole of the idealized parent imago—and thus labeled the self “bipolar.” Toward the end of his life Kohut added a third pole, the pole of twinship, and considered the developmental needs of this pole to be equal in power and necessity to the other two. Confusingly, some of the literature of self psychology still refers to the bipolar self. But the full structure that Kohut eventually envisioned was tripolar. Perhaps the best way to understand the tripolar self is to turn to Kohut’s concept of self­ objects, for it is selfobjects that are needed to meet the needs of each aspect or pole of the self. In A Dictionary for Psychotherapists, Chessick (1993) defines selfobjects as follows: An object may be defined as a selfobject when it is experienced intrapsychically as providing affect attunement, consensual validation, tension regulation and soothing, recognition of one’s autonomous potential, and restoration of a temporarily threatened fragmentation of the self through a variety of activities and comments. (p. 357)

Kohut believed that the formation, cohesion, and health of the self actually occur from the taking in of good psychological nutrients from selfobjects. Object relations theory talked a great deal about the influence and importance of objects in psychological development. Kohut introduced the term selfobjects to capture the process by which people take in everything and everyone around them. That is function of good selfobjects—to create a strong, vibrant self. The need is not simply to be seen or to have an ideal person to merge with or to have alter ego experiences, the need is to actually be created, to be made. Phyllis Greenacre perhaps put it best when she sent Kohut a thank-you letter after he had introduced her as a speaker. She wrote: Something happened to me with your introduction of me that Sunday. I have tried to think of what it was: I thought “I was greatly touched”—“No, I was moved”—and then it occurred to me that perhaps it was not so much one of these, as that I  was gently and reassuringly solidified. (Quoted in Cocks 1994, pp. 90–91)

“Gently and reassuringly solidified”—what a beautiful and evocative way to capture what happens when selfobjects function well: the self literally becomes more substantial. Self psychological theory postulates that selfobjects, understood as people or things outside of the self, are vitally necessary to every individual as sources of mirroring, sources of perfection and grandeur to merge with, and as similar selves to feel at one with. Selfobjects are needed to fulfill these functions throughout the life cycle and are called selfobjects because they stand not as separate objects to be related to, in and of themselves, but as objects that function to give the self what it needs in order to become and remain energetic and cohesive. Although selfobjects are most often people, it is important to realize that other things, such as art, literature, music, nature, spirituality, or sports, can also serve selfobject functions. For example, a client who is particularly attuned to the weather may experience it as a selfobject. Susan, whose sense of a well-functioning, cohesive self is very fragile, begins feeling “lost and panicky” if there are several rainy or cloudy days in a row. When the sun returns, she experiences a restoration of hope and well-being. For her, the sun is a symbol of the warmth and beneficence

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she needs to take in from the loving gaze of a selfobject. It is also a symbol of power, and her sense of merger with its warmth and light is one of the few sources of well-being in her life.

The psychiatric diagnosis called seasonal affective disorder (known as SAD) identifies patients whose brain function is affected by the shorter amount of daylight in the dark winter months. However, that biologically based diagnosis should not exclude the meaning of light and warmth in Susan’s internal world. This particular patient, who became quite attuned to the interweaving of psyche and soma, was helped immeasurably by the combination of light therapy and talking about what strengths blossom in her when she feels that the “light and warmth” in her relationship with the therapist are sufficient to nourish her energy and hope, and thereby make her sense of self more substantive. As part of healing she also had to mourn what she called the “golden warmth” that her family and community was never able to give her. Conversely, another patient, Matthew, often becomes depressed and agitated on bright, sunny days. To him the light seems piercing and harsh, and reawakens the pain of his mother’s blazing and intrusive gaze, which he experienced as fierce, critical, and oppressive. Sunshine, for Matthew, does not serve a helpful selfobject function because the person it evokes was harmful to the development of a strong, cohesive self, and made him feel more fragmented. The Tripolar Self To understand the main contribution of self psychology, we will now turn to the selfobject needs of each of the three poles of the tripolar self—the pole of the grandiose self, the pole of the idealized parent imago, and the twinship pole. Each one needs empathic responses from selfobjects in order to flourish and grow. Each is necessary for the development of a cohesive self. Each has its own selfobject transference based on the selfobject experiences needed in childhood by this part of the personality. Again, although the language of self psychology is cumbersome, the theory poignantly describes human needs and yearnings. The word pole sounds rigid, but what it is attempting to capture is not a fixed tripartite structure but rather the idea of a flexible, ever-changing, relational web of aspects or polarities of the self. The Pole of the Grandiose Self—the Need for Mirroring The first part or pole of the self described by Kohut, the pole of the grandiose self, needs mirroring selfobjects: people who will reflect and identify its unique capacities, talents, and characteristics. Some clinicians prefer to call this the pole of ambitions. The grandiose self is the self that wants to feel special and full of well-being. It is the repository of natural, healthy exhibitionism. It also includes a great deal of specificity about characteristics of the self, and therefore forms the core of identity and individuality. People with sound grandiose selves are vibrant, full of confidence, hopeful, ambitious, and productive. They don’t quite believe they can do anything, but they often have the courage and the vision to try. There are echoes here of Mahler’s “practicing child” crowing that the world is her oyster, being the gleam in everyone’s eye. There is also a similarity to Winnicott’s concept of the “True Self,” full of raw vitality, fantastic feelings, and fervent wishes. If we think back to the story of the little boy in chapter 5 who needed to feel he could stop the waves when he was frightened, we can see how harmful a lack of empathy for grandiosity could be. If the adults had said, “Don’t be silly—you can’t stop the waves,” he might have been deflated and therefore experienced his littleness or helplessness as overwhelming or shameful and humiliating. Empathic attunement to his need to feel powerful, however, allowed him to go off and play with a sense of wholeness and well-being.

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The concept of the grandiose self can best be illustrated in clinical examples where there has been an absence of delighted mirroring or an active thwarting of the child’s wish to shine on the part of the selfobject. For example: Mary, a forty-two-year-old white, middle-class woman raised in a Midwestern military family, was an usually quiet and reserved person. At the beginning of treatment, she was surprised, moved, and a little scared when her therapist reacted with delight to the way she described an event of the previous day. With a keen sense of observation and a twinge of humor, Mary had recounted how her meditation teacher, who had been sitting on the floor dressed in a sweat suit humming a mantra, suddenly jumped up, changed into an evening gown in front of the whole class, and went rushing off to meet her diplomat husband at a white-tie event for dignitaries of the United Nations. The therapist laughed at the humorous description and smiled warmly at Mary as she recounted this tale. With great appreciation, she pointed out Mary’s sense of humor and skill in describing the moment. She then observed that Mary seemed very stirred by this attention. Mary responded to this mirroring by stating sadly that no one in her family ever seemed to identify or care about any of her qualities, except if she was bad. No one had ever noticed or enjoyed her humor, her way with words, or her vitality. She then began to recount the story of her childhood in a very rigid army family. The standards of behavior for the children centered around silence and self-effacement. “Children should be seen and not heard” was actually embroidered on a sampler hanging in the living room. Grandiosity was not only seen as unhealthy but also feared as unruly, disruptive, and possibly leading to evil. Boasting and pride in oneself were “works of the devil”—traits to be tamed, controlled, and, if possible, rooted out. Naturally, through the course of her life, Mary had become a good listener, but she felt that she had lost herself in paying attention to others. She had entered treatment after reading a book on shamanism. “I can no longer find my soul,” she said. “The flame of my spirit was flickering out because no one recognized or cared what it was like.” Subsequent treatment revealed to Mary many specific qualities about herself that she now thoroughly enjoys: she is very funny, she can be sarcastic when she wants to be, she can even be angry, she has a true gift of imagery and a quirky take on the world. She sometimes would rather talk than listen, and she likes being the center of attention. Through the process of transmuting internalization, the empathic mirroring she received had made her more substantive and whole.

In 2010, at the Museum of Modern Art in New York City, there was a performance piece called “The Artist Is Present,” by Marina Abramovic´. It serves as a wonderful example of mirroring. As a MoMA publication described it: Seated silently at a wooden table across from an empty chair, she waited as people took turns sitting in the chair locking eyes with her. Over the course of nearly three months, for eight hours a day, she met the gaze of 1,000 strangers, many of whom were moved to tears. “Nobody could imagine  .  .  . that anybody would take time to sit and just engage in mutual gaze with me,” Abramovic´ explained. In fact, the chair was always occupied and there were continuous lines of people waiting to sit in it. “It was a complete surprise . . . this enormous need of humans to actually have contact.” (MoMALearning 2010)

One visitor, who returned twenty-one times, described sitting with the artist as “a transforming experience—it’s luminous, it’s uplifting, it has many layers, but it always comes back to being present, breathing, maintaining eye contact.” Ah, the power of mirroring! How a simple gaze from a complete stranger can make so many people start to cry! Kohut would be pleased. Because self psychology is not a drive theory, one still needs to ask about what energies or forces fuel the wish or need for a healthy, grandiose self. Kohut never fully offered a substitute for the drives but did speak of the pole of the grandiose self that is “driven by ambition.” This fits in with his general concept that there is something in each person akin to a biological growth force that pushes the individual toward the completion of maturational

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tasks. Kohut believed this inner motivation, or tension, to be the innate, embryonic push every individual has toward the development of a cohesive self. Anxiety is also understood differently in self psychology than in drive, ego, or object relations theories. As in relational theory (see chapter  7), anxiety is not seen as arising from intrapsychic conflict, but rather from loss of contact with the self or selfobjects. It is experienced not so much as tension or nervousness but rather as fear and dread. In the polarity of the grandiose self, there can be fear of loss of contact with one’s authentic self if grandiosity becomes too exaggerated and unreal. The authentic self needs to feel special or strong in a real way based on genuine qualities. A person who has become overly grandiose may feel so filled with energy and power that these become painful and frightening. The anxiety is akin to that experienced by people in manic states who feel they might burst or disintegrate. When Yvonne, a hard-working, talented Latina teenager whose family lived in poverty in a dangerous, under-served neighborhood, earned a full scholarship to a prestigious college, she received so much attention in her school and from the media that she began to feel “high and wild.” She no longer paced herself well in her studies, becoming obsessed with getting higher grades even though they were no longer necessary. She began to daydream about getting straight A’s in college and “becoming famous on campus.” With just a little help in therapy she realized she had become overstimulated by all the admiration. She also came to know that she was overburdened by both the responsibility and the excitement of carrying all the hopes and dreams of betterment for her family and her community. With the therapist’s support and gentle encouragement, Yvonne began to meditate as a source of needed self-soothing and within a period of weeks was considerably less anxious. She learned to pay attention to what she needed and wanted. Her therapist also offered useful empathy to her by sharing that as a white person raised in an upper middle-class family, it had been hard enough to go to college without all the added pressure and overstimulation Yvonne was experiencing. Over time, Yvonne was able to develop the mature qualities that develop when the needs of the grandiose self are met appropriately. These are enthusiasm over reasonable goals and the ability to pursue these ambitions with joy and self-confidence.

Kohut called the transference that occurs when the needs of the grandiose self have not been well met the mirroring transference. The client needs mirroring and the clinician must respond to this need, not by interpreting it but by meeting it. Mitchell and Black (1995) describe it in the following way: Some patients . . . establish a powerful attachment to the analyst based on the need for the analyst to grasp and reflect back their experience of themselves, their excitements, their perceptions, as well as their disappointments. Although the analyst may seem to be insignificant to the patient in the traditional way, she is actually essential as a kind of nurturing context (much like Winnicott’s “holding environment”) within which the patient can begin to feel more seen, more real, and more internally substantial. (pp. 160–61)

Of course, Kohut knew that no therapist could or should even try to gratify patients’ needs perfectly and, in fact, what he recommended for growth (not only for the patient but also for the developing child) was a balance of optimal gratification and optimal frustration. It is also important to note for clinicians that what should be mirrored are not only special qualities that the patient may have but also problematic ones so that the client does not feel that she has to hide or disavow “bad” parts of herself. In mirroring, we as clinicians try to reflect back the full complexity of who our clients are.

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The Pole of the Idealized Parent Imago—the Need for an Idealized Other The second pole that Kohut described is that of the idealized parent imago or, less awkwardly, the polarity of ideals. By imago he meant an internal, sometimes unconscious, object representation of an idealized other, usually from the early history of an individual ­(Chessick 1993). Again, the choice of words is unfortunate and misleading. First, the word imago is awkward, unfamiliar, and not used in common parlance. Second, calling it a parent imago is misleading because it implies that the experience is limited to childhood and that the representations are limited to early caregivers. The use of the word “parent” does not make clear that one of the strengths of self psychological theory is that it postulates that selfobject needs can and should be met by a variety of people and experiences throughout the life cycle. This includes the intersectional experiences of race, class, and gender in the social environment the person has been, or is living in. For example, a community can serve as a parent imago to soothe the child so that a community that upholds the value of racial pride can serve a helpful selfobject function. Conversely, a community whose institutions are racist would provide selfobjects that can be immensely destructive to a healthy, proud sense of self. Dorcas Bowles (1983) described the selfobject functions that Black mothers play for their children. In a larger world that is both discriminatory and oppressive, Black mothers need to mirror their children’s beauty, strength, and power, and reflect back to them their value and worth. They also need to provide a sense of calm along with a realistic sense of danger, without which their children are unprepared for some of the threats and painful experiences that await them. Without such mirroring, and without an idealized parent imago, the children’s development of self cohesion and sense of well-being are at risk. The idealized parent imago aspect of the self contains what Kohut proposed as the second, universal, selfobject need—the need to have someone strong, calm, and admirable to idealize and merge with in order to feel safe and complete within the self. Just as the pole of the grandiose self needs to feel that the beauty and the splendor within is mirrored by others, the pole of the idealized parent imago needs to see strength and wonder outside of the self, in others, in order to merge with their growth-enhancing qualities. The aspect of the grandiose self needs to be shown qualities within the self that are wonderful, while the aspect of the idealized parent imago needs to find qualities in others that are wonderful and strengthening to merge with and provide healthy idealization. Annie, a fifty-four-year-old white, cisgender, upper-class woman, came to treatment because of anxiety and depression so crippling she could barely function. The therapist had been highly recommended to her by a trusted friend and had been described as a caring, skilled practitioner. Annie was very pleased with the first meeting and said she experienced the therapist as “warm, important, and smart.” By the second session Annie was paying close attention to the therapist, gazing at her intensely in the hope of seeing something good in her, which because of her need (and because the therapist was a genuinely nice person) she found. By the third session she would start speaking about the therapist before even entering the office, while the therapist was still out of sight. Sight unseen, Annie would call out things like, “Oh, you look so pretty today. You look so calm. I feel better already,” or, “You’re so smart. I just know you are going to be able to help me today.” She always said these things with a piercing childlike sweetness and her whole being seemed filled with the hope of having found someone wonderful to merge with. Despite coming from a privileged background, Annie seemed to be suffering severely from a terrible lack of having had no one or no thing to idealize, almost a de-idealization. In speaking about her early experiences, she described a family she was ashamed of. Her father was an alcoholic tyrant and her mother a “wifty socialite with no substance.” They were gossiped about and looked down on by the community. Annie described her high school years as particularly

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painful because she knew, and was deeply ashamed of, all the nasty gossip about her parents. This made her very anxious. She longed to be associated with people she could be proud of. As her treatment progressed, Annie often remarked on what a difference it made to her that she now had “someone special who makes me feel that I  too can be calm, hopeful, and strong.” Annie asked and was told about some of her therapist’s professional accomplishments and was especially proud of her association with a prestigious college, because Annie had been forced to go to an elite “finishing school” for secretaries, despite having excellent grades. Her unattuned parents could not be bothered to help her with the more difficult application process for college and had no particular ambitions for her. After being encouraged to acknowledge her appropriate envy, and to understand what it meant about her deep need to have someone in her family to be proud of, she gained a sense of pride from working with her therapist. She learned how to feel good about herself and to feel much more solid, “not wifty like my mom.”

Kohut described the energy that motivated this part of the self as a “pull.” The pole of the parent imago is “pulled by ideals.” By merging with the calmness and competence of the selfobject (in this case, the therapist) those qualities can be established within the self. There can be anxiety in this pole also, and one form is the potential loss of self. This loss may happen if the merger with the idealized selfobject becomes total. Anxiety arises from trying to maintain the delicate balance between the good merger experiences that enhance the self because one feels protected and strengthened by the power and calm of another, and the problematic merger experiences that lead to loss of self cohesion because too much of the self has disappeared into the bigness and greatness of another. Probably everyone can think of a time when he or she needed to “sink into” the calm and strength of a parent, a spouse, a lover, a friend, or even a beloved TV program at the end of a hard day. Finding such a selfobject to merge with is a wonderful experience that can, however, become frightening if the immersion in the other results in a loss of self so complete that disorientation or panic ensues. Jim, an athletic, middle-class, Black teenager who suffered from very low self-esteem, began to feel much better about himself once he started idealizing Michael Jordan’s skill and prowess. He discovered a sense of power and possibility and applied himself much more diligently to his studies and to training for the basketball team. However, he scared himself at times when he realized that there were moments when he was thinking about Jordan’s prowess so intensely that he “kind of lost it” and forgot who he himself was. He realized that he had to learn to balance seeing Jordan’s skills and fame as a source of strength while maintaining a realistic awareness of himself and without losing his own sense of identity. He also learned to value something very different—namely, the therapist’s calmness—and was able to take that into himself as well.

Aside from problems of merger, self psychologists see other risks inherent in idealization. If others are idealized too much, the self can be left devalued, feeling little, worthless, and ashamed. This is a new way of looking at the psychological perils of idealization. Drive theorists understood idealization primarily as a defense, as a way of denying hostile impulses against a loved one: “See, I don’t hate you. I think you’re great.” Ego psychologists understood that idealization could potentially interfere with the regulation of self-esteem. The object relations theorist Melanie Klein believed that overidealization could lead to unmanageable envy. Self psychologists also acknowledged the potential problems with idealization but chose to focus more attention on the contribution that healthy idealization can make to a person’s very sense of self. When there are sufficient selfobjects in a person’s life to idealize, the mature qualities of the pole of the idealized parent imago can develop. These are the abilities to delight in and grow from qualities in others and eventually to experience pleasure and pride in one’s own

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qualities, standards, and values. The qualities of the idealized selfobject are taken into the self as a result of successful merger experiences. Kohut called the selfobject transference that develops from the need to merge with an ideal object the idealizing transference. Chessick (1993) says of this transference, “The goal of the idealizing selfobject transference is to share, via a merger, in the power and omnipotence of the therapist” (p. 164). The need here, as illustrated in the cases of Annie and Jim, is for the patient to be able to grow strong and important and safe by virtue of a connection to a good, powerful, important therapist. But, as has been mentioned before, the helpful merger can be with almost anything in the personal surround—a neighborhood, a school, a synagogue, a superhero, a rap star, a spiritual leader, a teacher, a mentor, or a friend. The Pole of Twinship—the Need for a Similar Other The third pole, the pole of twinship, refers to the need to feel that there are others in the world who are similar to oneself. This mutual recognition, this finding of a sameness in a pal or a soul mate or a philosophy or a political movement, provides another kind of universal sustenance from selfobjects. The need for a twin is related to, but also subtly different from, the need for the grandiose self to be mirrored or the need of the pole of the idealized parent imago to have strong and wondrous selfobjects to take in. Kohut came to consider the selfobject needs of the twinship pole as vital as the need of the other two poles for developing a vigorous and cohesive self, and therefore he eventually designated it as a distinct pole in its own right. Peter, a thirty-five-year-old Irish-American man from a working-class background, was immensely moved, and formed an instant, powerful, and permanent bond with his therapist, when he asked her what her major had been in college and it turned out to be the same as his—French literature. His family and his peers had ridiculed him throughout his childhood about his love of words, of reading, and of learning foreign languages. He had been strongly advised against majoring in French, not only by his parents but also by his guidance counselor in high school who had called his interest “an esoteric, useless pursuit.” The fact that the therapist had also been a French major was seldom talked about in therapy. It just remained there as a precious and reassuring similarity and, by its power, enabled him to see how little his need to be understood had been met in the course of his growing up. Oddly enough, this same therapist had had an unusual number of patients over the years who turned out to have been French majors and to whom that bond had great meaning. Over time, Peter discovered in himself a strong desire to leave his work as a clerk in a bank and began happily teaching poetry in middle school.

Because Kohut developed his ideas about the importance of the twinship pole toward the end of his life, he never posited the energy that motivates that part of the self or the anxiety it experiences. We would say that the energy is born of the need not to feel different or isolated or weird, and that anxiety arises when there is no one “the same as me.” One young woman described suffering greatly from the fact that her two siblings were seriously developmentally challenged and required institutional care all their lives. She talked, with guilt, about the embarrassment she felt when she was out in public with them. She expressed how wonderful she would feel in the hospital where she is a physician if just one of her siblings were a professional as well. Poignantly, she stated, “If only one of them could walk down the corridor beside me and be like me, I wouldn’t feel so different anymore. I wouldn’t feel so alone.” Her therapist expressed deep empathy for her longing for twinship and how that absence had made her feel desolate, and “less than.” Despite having peers in the same field, not being able to establish a feeling of twinship with her own siblings had made her feel so “different and strange” that

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she did not realize she could establish a sense of twinship with colleagues. When this was pointed out to her in a support group, she was able to mourn her lack of twinship opportunities within her immediate family and begin trying to find twinship selfobjects elsewhere.

Another example that many people can identify with is how welcome it is to encounter a fellow citizen when traveling abroad, especially for an extended period of time. A graduate student engaged in folklore fieldwork in Afghanistan described the pure joy he felt at meeting new American student after living many months in a small village. He laughed at the fact that the two would never have been friends back home in the United States because they disagreed wildly on many philosophical, cultural, and political issues. However, it was “worth its weight in gold” to be able to talk to someone who missed hot dogs, wondered what team had won the Super Bowl, and remembered spending Sunday mornings in pajamas reading the New York Times. Too much time spent without a feeling of twinship can make people feel like they are unraveling and losing touch with themselves. The mature qualities that develop when the selfobject needs of the twinship pole are met are security and a sense of belonging and legitimacy. These enhance the nuclear self and all its endeavors. Marco, a twenty-five-year-old Mexican-American man who worked as a janitor in a hospital, sought psychotherapy in a community clinic. He was assigned to a seventy-five-year-old Anglo upper-middle-class woman. If twinship turned out to be a selfobject need, would the therapist be able to help them to find it together? Would their seeming lack of shared backgrounds become a problem? At the beginning of therapy, Marco described a sense of hopelessness and despair and anxiety so severe that he was on leave from his job. He sometimes thought about suicide. To his great shame, he wept a lot in session. Using the power of empathy his therapist reassured him that, “those tears need to come and we will honor and understand them.” He was then able to recount the horrible experience of when, at age thirteen, he was taken to the local brothel so that his uncles could supervise his first time having sex with a woman and “becoming a man.” But instead of liking it, he started crying and was deeply humiliated when his uncles mocked him for his weakness. The trauma of that event remained with him, he said, and only began to diminish somewhat when he succeeded in becoming a full-fledged union member in the prestigious, university-based hospital in New York City where he worked. He described being accepted into the union community as the best thing in his life and one of the few things that “saved me a little bit,” and he always wore his union jacket, even when he wasn’t coming from work. Relying on the theory of self psychology, his therapist immediately (and happily) described the common human need for twinship and how belonging to the union gave him a clearer definition of himself. She noted that Marco’s fine intuition and wisdom had helped him to know that membership in the union had indeed saved him in an important way. Marco was thrilled to have his intuition mirrored—and he was fascinated by the concept of twinship as a developmental need. After that, he and his therapist often spoke with great joy and enthusiasm about psychodynamic concepts. There was their twinship! During those discussions, Marco would often say, “You see, I am not stupid,” and the therapist would reflect that not only was he not stupid but that he brought a special sensitivity, insight, and poetry to their conversations that was uniquely his. She shared how she was learning to understand certain aspects of psychodynamic theory better because of her conversations with him. His pride in his intelligence had been shattered during that first sexual experience when he felt dumb and inadequate. Now he would sometimes say in session, “How cool is it that we are like two peas in a pod!” Through transmuting internalization, he has now become confident in his intelligence and hopes to register for some college-level psychology classes, which he is able to do through his union. He would like to work in social services someday. His depression and anxiety have diminished dramatically without ever taking

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any medication. In one session recently he said to his therapist, “I  walked out of a dark cave shoulder-to-shoulder together with you and can now live in light and peace with myself.” The striking need for, and power of, twinship can be seen in phenomena such as the “Me Too” and “Black Lives Matter” movements. People who have been assaulted or abused derive enormous sustenance and strength from the simple fact of learning the stories of strangers who have had similar experiences. Many victims have found the courage to finally be seen and heard just because there are twin others “just like them” who have come forth. Yet it is important to remember that people may also be seeking twinship at “Make America Great Again” rallies or National Rifle Association meetings. This underscores peoples’ sometimes desperate need for similar others, especially in such painfully fragmented times, both in the United States and around the world.

The selfobject transference that develops from the needs of this pole is called the twinship or alter ego transference. If it is allowed to flourish, the client will feel a likeness, a sameness, with the therapist and therefore more known to herself and less alone. For the three parts of the self, self psychology does not postulate specific childhood developmental phases that are closely tied to certain months or years of life. However, Kohut did believe that there was a general sequence in development, with the needs of the grandiose self being predominant until around the age of four, and the need for ideal selfobjects to be at their most intense from four to six. He did not suggest an age-specific time for twinship needs, but they appear to be particularly strong in latency and adolescence. It is important to remember though that his main belief about selfobject needs from the three poles is that they continue to exist in some form, naturally and appropriately, throughout the entire life cycle. Here is an example of self psychological principles in action: In 2004 a Puerto Rican clinical social worker named Manuel began a post-master’s program in advanced clinical social work, stating that he had not found the psychodynamic theories particularly compelling or useful the first time round but would like to give them another try. He had found the four psychologies to be “good for privileged, upper-middle-class, white people” but not very relevant to anyone else. He worked in an agency in El Barrio, a neighborhood in New York City, and part of his job was to run a clubhouse-style afternoon program that included counseling for young teenage boys in the hope of providing them an alternative to joining the gangs that were prevalent in the neighborhood at the time. During the course of his advanced studies, Manuel fell in love with self psychology. Because of this he designed a program for thirteen- and fourteen-year-old boys based specifically on interventions that would address the three selfobject needs described by Kohut. With empathic attunement, he purposely mirrored a boy named Tomas by saying to him, “You are so funny. You always make us laugh and brighten our day.” And to Luis: “You are so good with your hands—you can fix anything. You should think of becoming a mechanical engineer someday.” And to Carlito: “You are smart and tough and a very good negotiator—what do you want to do with those qualities?” (Carlito later ran for class president when he was a junior in high school and won.) Manuel consciously offered himself as a figure to idealize, telling the boys stories of the challenges he had overcome by getting a higher education through earned scholarships and various awards. He took the boys to the Museo del Barrio so that they could see the art installations of Latino and Latina sculptors and painters and historians. He gave them biographies of famous Puerto Ricans to read. He organized an outing to Yankee Stadium to see the much-beloved Yankees Jorge Posada and Bernie Williams play. Membership in the clubhouse took care of the twinship needs all by itself. The therapist vigorously pointed out their similarities and growing brotherhood as often as he could.

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In his individual sessions with the boys, Manuel concentrated on converting their immature, fragile, superficial narcissism (“I’m more important than you are because I  have Nike sneakers”)—whose function was to deny shame, low self-esteem, and vulnerability—into sound healthy narcissism, solid self-regard, and more mature self-observation based on pride in real qualities. Not every client was helped by this application of psychodynamic theory to practice, but many were, in ways large and small. One great moment of success occurred when some sixteenyear-olds tried to recruit Tomas into a gang that promised him pocket money and prestige in exchange for joining them in stealing cigarettes and food from the local bodega, bullying some rival gang members, and taunting the police. “You’ll be part of a special gang, kid,” they said—to which Tomas answered, “But I am part of a special gang.”

This story seems almost too good to be true. But it really did happen, thereby demonstrating how psychodynamic theories can be useful in a diverse variety of settings, modalities, and populations. This story did not have a happy ending. Because of the financial crisis of 2008, the private fundraising for Manuel’s agency declined considerably, and the clubhouse program was shut down. The kids were basically tossed back out on the street, where opportunities for enriching experiences for twinship were few and far between. Nevertheless, the boys tried to support each other and to remain friends over the years. Sixty percent of the attendees of that program made it to some form of college or tech school—a much higher percentage than the general population in that school district at that time. Transmuting Internalization What is the process by which a person takes in the qualities and functions of selfobjects that are necessary for the development of a healthy, cohesive, vibrant self? Kohut called it transmuting internalization, which is defined as “the process through which a function formerly performed by another (selfobject) is taken into the self through optimal mirroring, interaction, and frustration” (Elson 1986, p. 252). He meant internalization to be an active verb describing an actual creation of self. Mutation means an alteration: changing, becoming something new. As the self takes in the functions of selfobjects, these are gradually changed and made one’s own so that the healthy self is not a replica of selfobjects but a unique self in its own right. The word transmuting was chosen carefully by Kohut to try to capture the transformative nature of internalization. The meeting of selfobject needs does not simply fill a person with well-being, strength, and a sense of cohesion. Rather, the meeting of selfobject needs acts as a catalyst for development so that the qualities that are internalized become a genuine, integral part of the self that has taken them in, in specific, personal, and unique ways. Some critics of self psychology hear the theory as advocating that clinicians simply should “give” to patients to help them heal, but a careful reading of Kohut and his followers contradicts this view. Empathic attunement to needs is not meant merely to fill or soothe; it is meant to stimulate the needed energy for clients to work and grow in their own ways in order to actually create themselves. Transmuting internalization is an action and achieves fundamental results in the actual cohesion and substance of the self. In the view of self psychologists, it is a different and more powerful process than introjection, identification, or idealization. It is important to note that although Kohut often spoke about the desirability of optimal gratification for selfobject needs, he also often spoke of the need for—indeed, the inevitability of—optimal frustration. He understood full well that perfect empathic attunement is not possible in human relationships and believed that empathic failures were actually necessary

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to stimulate growth. When there is optimal frustration, the developing child is challenged to find strength and comfort within the self. Handling difficult moments well on one’s own can contribute to the experience of a vital, cohesive self. In the section of Childhood and Society on “Initiative versus Guilt,” Erikson (1950) tells the wonderful story of the day Freud was asked what he thought a normal person should be able to do well. “The questioner probably expected a complicated answer. But Freud simply said, ‘To love and to work.’  .  .  . Thus we may ponder but cannot improve on the professor’s formula.” To love and to work—surely one of the greatest answers of all time. But, Kohut did want to improve on “the professor’s formula.” What he wanted to add was that people needed to be able to love and, especially, to work creatively and with vitality and joy—whether laying a brick wall, making a meatloaf, driving a truck, or writing the great American novel. For Kohut, the ability to work creatively was the most important motivation in human nature and the hallmark of mental health. For that to take place people have to have taken in and made their own enough good, strengthening selfobject experiences. Thus, to follow up on some of the cases mentioned earlier in this chapter, Mary eventually grew to experience her skill in storytelling with delight, but with her own “take” on it. She was ultimately amused by different things than the therapist was, and became aware of her capacity for observation at different times and in her own unique way, which was always somewhat wry and subdued. Annie’s pain was never fully soothed by her merger with the intelligence and calm of her therapist, but she found hope in the fact that a better selfobject was available to her. Peter derived a sense of legitimacy and “sameness” that allowed him to explore the specifics of what he was really like as a person in his own right, with his own special love of language and literature. Marco found his twinship needs met through his union membership and his shared appreciation for theoretical discussions with his therapist. All of these transmuting internalizations seemed to potentiate self-knowledge, growth, and cohesion in the nuclear self, and, very importantly, a sense of joy. Kohut coined the term microinternalizations to capture the flavor of the myriad number of times the self needs to take in psychological nutriment from selfobjects. The empathetic attunement of (human) selfobjects, including the willingness to admit and repair empathic failures, is the necessary groundwork for transmuting internalizations to occur.

A SELF PSYCHOLOGICAL VIEW OF PSYCHOPATHOLOGY: DISORDERS OF THE SELF When it comes to psychological suffering and illness, Kohut and the self psychologists speak of “disorders of the self” and offer various ways of classifying these disorders. Underlying all the disorders is the belief that psychological illness occurs when the legitimate developmental needs of the three poles are not met with optimal empathy and optimal frustration. This puts self psychology squarely in the “deficit model” of psychopathology rather than the “conflict model.” In the conflict model, psychological problems and illnesses arise when internal impulses and desires clash with reality or with prohibitions and guilt. In the deficit model, human beings are viewed as much more vulnerable to hurt, neglect, and deprivation, injured by what they needed and did not get, rather than to being disturbed by tumultuous forces from the drives within. Self psychologists (Kohut & Wolf 1978) distinguish among primary and secondary disorders, a variety of typical self states, and a variety of character or personality types. Notwithstanding the fact that they are offering a system of classification, they take care to point out that these are merely outlines and that no individual can ever be completely categorized by any of these classifications.

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The primary disorders of the self include the familiar categories from the American Psychiatric Association’s DSM-5 (2013): the psychoses, borderline states, narcissistic behavior disorders, and narcissistic personality disorders. The self psychological view of the etiology of these disorders is that severe deficits occur in the cohesion of the self when the mirroring, idealizing, and twinship needs of the developing individual have not been met due to chronic deprivation or severe trauma. Biological and social causes are not ruled out and are seen as contributing to the fragmentation of the inner world deep and serious ways. Evaluating how the self psychological needs have been either met or not met may contribute to a richer assessment than solely relying on the DSM criteria, which do not posit etiology. More will be said about the self psychological view of these major diagnostic categories in the later chapters on psychopathology. The secondary disorders that Kohut and Wolf refer to are “reactions of a structurally undamaged self to the vicissitudes of life” (p. 414), or the transient depression, nervousness, elation, detachment, or drop in self-esteem that individuals feel due to the inevitable stresses in life. These are called secondary because they do not shake the core of the person’s sense of herself as an integrated, whole human being. The self states identified by Kohut and Wolf do not follow psychiatric diagnostic criteria or categories. Instead, they are descriptive categories of disorders of the self that are useful in clinical work, especially in enhancing empathy and identifying the unmet selfobject needs of the client. Self States Kohut described several self states: the understimulated self, the overstimulated self, the fragmented self, and the overburdened self. These categories are not absolute. They refer to ways of experiencing oneself in the world that have become pervasive and enduring. Particular deficits are thought to have a tendency to lead to particular disorders, but there is a great deal of fluidity among all the categories. The understimulated self describes those individuals who often feel empty, bored, listless, or apathetic. Their selfobjects have not been able to mirror and nourish their grandiosity sufficiently. They feel flat, robbed of their buoyancy, their sense of aliveness and richness. Mary, whose case was presented earlier in this chapter, is, in fact, a painter who struggles mightily to “find something inside to put on her canvas.” She came into treatment describing herself as “arid, barren, and gray.” She felt hopeless and inept about the prospect of ever finding selfobjects that would awaken her to life. The overstimulated self describes those who have suffered from the opposite problem— intense, excessive, inappropriate, or erratic mirroring. Intense but not consistent behavior on the part of selfobjects can leave the developing self feeling overwhelmed and too full of feeling. There is not space or peace enough for transmuting internalization to take place because the person is always being crowded with demands and stimulation from the outside. In this case the person often also feels robbed, but robbed of the sense that her own unique strength and vigor reside within herself and are her own. An overstimulated self can also develop as a result of idealized selfobjects being too powerful, vibrant, or famous. In such instances there is no ideal calmness to merge with, and learning self-soothing becomes a problem. Sometimes the result is a kind of flatness, an underachievement in the service of keeping the self-system regulated. Sometimes the result can be an oversensitivity and aversion to anything new or stimulating. Syrie, the white upper-class daughter of a well-known, highly grandiose musician, feels constantly “full of ideas and projects and worries and pain.” A performer in her own right, she can’t shake

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either the wildly erratic praise from, or the self-aggrandizing attitudes of, her father. She grew up in a household where the doors were always open and no one had any privacy. Her father seemed larger than life and “took up all the space in the family.” He was also wildly inappropriate, watching pornography with the children, totally unattuned to how much this confused and upset them. At other times neither parent seemed to notice that the children were there at all and left them alone, bored, and eventually listless for hours on end. Syrie is often so overstimulated that she jumps if the phone machine clicks in the office or a car horn sounds in the distance. She becomes flooded with ideas, plans, and ambitions, but these often quickly drain away, leaving her feeling small, empty, and worthless. A  beautiful, talented, highly educated woman, she constantly becomes overexcited but then underachieves, trying to seek invisibility and peace. She cannot connect to other musicians, partners, friends, or herself. In treatment she hopes to develop a clearer, more realistic, sense of her own talents and resources. She already feels helped by the notion that it is possible to distinguish between real qualities or achievements and grandiose fantasies and beliefs. She is comforted by the example of the therapist’s quiet, solid pride in her own achievements and would like to develop the ability to merge with the therapist’s joyful yet appropriate sense of self-esteem.

While in healthy self states there is a basic cohesion, the fragmented self has little sense of cohesion. Individuals with this disorder have not been related to as a whole by their self­ objects. They have received attention, but it has been erratic, inconsistent, and unpredictable. The caregivers are often worried and distractible themselves, their attention flitting from one thing to another. Vicki, the daughter of a very anxious mother, has trouble paying attention to one subject at a time in treatment. She will sometimes fly out of the office at the end of a session leaving the door to the building wide open. She experiences herself as a “bunch of pieces—like a puzzle thrown on the floor.” She remembers with pain that her parents and all her older siblings would always interject “odd things” into conversations. One of them would say, “Your sweater is the wrong color” or “Wasn’t the weather nice today” when she would be trying to tell them about her day in school or about a feeling she had. She understands that it is hard for her to experience herself as a unified whole when people were always behaving and paying attention in a random, scattered way as she was growing up.

The overburdened self, however, has felt too alone and unsupported. Perhaps a person’s problems or neediness were not accepted or even allowed. Perhaps her idealized selfobjects were not calm and reliable. Perhaps there were no twinship selfobjects who seemed to be going through similar difficulties. Whatever the case, the overburdened self feels he must “go it alone” in what is experienced as an unnerving, demanding, even hostile, world. Neediness is experienced with guilt rather than with compassion. Nancy, the white bisexual daughter of a rural, midwestern family, feels she has to be responsible for all the problems of her family. Her mother was overwhelmed by her job as an elementaryschool teacher and her father was never able to find a steady job due to his obsession with hoarding. “I have always had to take care of them—they still need me to be strong.” She is also hyperalert to “the pain and suffering in the universe” while very reluctant to reveal her own, believing that no one could possibly ever want to help her. Both her parents suffered from major depression throughout her life, and family interactions revolved around the parents’ neediness and despair. Through the use of his deep empathy for Nancy’s plight, the therapist was able to have long conversations with her about the difference between serving, sacrificing, and surrendering the self on the behalf of others. She came to understand her pattern of falling in love with either men or women who needed her to take care of them in major ways, all the time. Nancy was excited at the prospect of distinguishing among those ways of behaving and learned to freely choose serving, sometimes choose sacrificing, when she determined it was truly called for, but

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never to fall into a position in which only the other person’s needs mattered, even if she was tempted to.

Kohut and Wolf also identified several character types: mirror-hungry personalities, ideal-hungry personalities, alter-ego-hungry personalities, merger-hungry personalities, and contact-shunning personalities. This way of looking at various personality types is selfexplanatory and the very use of the word hungry captures the poignancy of what can occur when the needs of each pole of the individual are not met or are met inadequately or traumatically. The resultant yearning can shape personality and leave the person in a perpetual state of craving and/or fear.

SELF PSYCHOLOGY TODAY Kohut’s new and stimulating ideas about the importance of the development of the self revolutionized psychodynamic thinking and treatment for many clinicians. Peter Fonagy (2001) described this revolution succinctly when he wrote, “He broke the iron grip of ego psychology by forcing psychoanalysts to think in less mechanistic terms, in terms of selfhood rather than psychological function, in terms of selfobjects rather than drive gratification that the object fulfilled” (p. 108). This shift in focus gave rise to an invigorated interest in infant observation and research, as theoreticians sought to identify the building blocks of the self from the moment of birth. Daniel Stern (1985), for example, conducted extensive pioneering work in the field of infant research. Upon direct observation, he found that the human baby can indeed experience moments of intense connectedness and intense differentiation from birth on. When Winnicott said “there is no such thing as a baby,” meaning without a mother or other caretaker, he started theoreticians on a path of looking beyond the subjectivity of each human being toward the intersubjectivity of every encounter with another. This seems to contradict some of the object relations theorists’ beliefs about the neonatal, objectless autistic phase and the symbiotic period of complete merger with the mother or other primary caretakers. Stern observed the baby to be deeply connected to the mother but also “outward looking” from the beginning. Researchers such as Beebe and her colleagues (2010) and Stern (1985) studied videotapes of mothers and babies, moment to moment, to see how each regulated the other—in feelings and in reducing or increasing stimulation. What they noticed was the power and importance of the power of the human gaze, just the way Marina Abromovic´ did during her performance art piece “The Artist Is Present” at MoMA. Upon extremely close observation, even the neonate appears to be moved by, and responsive to, the gaze of the other. Essentially mothers and babies shape one other in their relationship, cue each other, and influence each other in ways not dissimilar to the therapeutic relationship. Empathic attunement is key. Mothers, like attuned therapists, need to be able to “match” (Beebe et al. 2008) the baby’s states, vocally cooing, rhythmically breathing, gazing at and gazing away. Facial expressions, vocalizing, silences, and speech sounds have been studied in minute detail. The capacity and structure of the infant’s mind develop in dialogue. Relating is a shared process and the capacity for empathic matching and attunement is essential for bonding. Mothers and infants organize and cocreate the mind together. Orange et al. (1997) suggest that the mind is always a shared mind and that clients learn new ways of relating through the mutual regulation that is central to communication in the therapeutic relationship. This empirical research validates what Kohut wrote about how attuned selfobjects create a child’s self-cohesion. But it also led certain theoreticians beyond

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it to the conclusion that there is actually no such thing as the separate, bounded, supraordinate self. There is only an intersubjective self. In 2019, Hagman, Paul, and Zimmermann published Intersubjective Self Psychology—A Primer, which delineates how self psychology has developed, for many theoreticians and clinicians, into a truly new theoretical school of intersubjectivity, which now has its own literature, training institutes, and methodologies. This path forward has resulted in questioning whether there is any such thing as the supraordinate, totally separate self and concluding that there is not. Stolorow and his colleagues argue that psychological phenomena in general cannot be understood apart from the intersubjective context by which they mean the psychological field that is generated by the intersection of the psychological world of another as well as the world at large. . . . In other words, a person’s self experience is at all times dependent on the specific intersubjective contexts in which it is sustained (or not). (Hagman et al. 2019, p. 7)

The concept of intrapsychic determinism, which Stolorow and Atwood called “the myth of the isolated mind” (Stolorow & Atwood 1992, p. 7), is rejected in favor of unremitting belief in intersubjective contextualism. In this view of the human experience, any kind of therapeutic encounter takes on quite a different meaning. Therapy, then, does not consist of one person helping another person to heal and grow but is rather a transformative experience for both of them. Intersubjectivity takes another step toward creating a true two-person psychology. Beatrice Beebe and Frank Lachmann (1994) have formulated their theories about the structuralization of the self. They have been profoundly influenced by the research that shows that what infants internalize are interactions. They have developed “three principles of salience” that describe how internalization, representation, and structuralization begin in infancy. They name these principles “ongoing regulations,” “disruption and repair of ongoing regulations,” and “heightened affective moments.” They believe that these experiences, both in childhood and in therapy, are the stimuli necessary for the development of psychic structure. In other words, ruptures are inevitable, but repair is what helps the self to grow. Although they began as self psychologists, Beebe and Lachmann have been joined by other theoreticians such as Robert Stolorow and George Atwood and have moved on to the study of intersubjectivity, which they describe as a “metatheory”—a metatheory because the idea that human beings always co-construct their relationships can be applied to any clinical theory or treatment model. As Lessem (2005) says, “It is not as much a theory as a sensibility” (p. 173). Orange et al. (1997), three of the major creators of this theory, describe it like this: “It is an attitude of continuing sensitivity to the inescapable interplay of observer and observed. It assumes that instead of entering and immersing ourselves in the experience of another (the position of self psychology), we join the other in the intersubjective space” (p. 9). It is based on the concept that we all live at every moment in an intersubjective field. In a moving lecture at the New School in 2009, Donna Orange talked about the clinical importance of comprehending rather than interpreting. She cautioned therapists not to work like detectives, trying to figure someone out, but to work, rather, as partners “being alongside” the client. How can we help a client adequately mourn the “ghostly state of trauma,” she asked, if we cannot “go all the way down” into their pain and know “that once tortured, always tortured”? The therapist must enter into the lived experience of the other and know that she too can be transformed by it. Many in the intersubjective self psychology world are currently broadening their interests by folding history, philosophy, and ethics into their work. They have a radical political

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perspective and are passionate about social justice. Orange, for instance, has written a book called Climate Crisis, Psychoanalysis and Radical Ethics (2016), and she lectures and writes frequently about other current moral and political issues. A fuller discussion of intersubjectivity can be found in chapter 7 on relational and intersubjective theories.

A CRITIQUE OF SELF PSYCHOLOGY IN ITS SOCIAL CONTEXT Like most other psychodynamic theories, self psychology does not pay enough attention to specific issues of race, class, culture, gender development, sexual orientation, or even biology. That having been said, it must be noted that self psychology has been well received by those with feminist, LGBTQ, and sociocultural concerns. One reason for this is that mental health is defined by the subjective experience of well-being, cohesion, and vigour within the individual self. In the self psychological model, for instance, heterosexuality is not held out to be any more healthy than homosexuality or being transgender. To be mirrored means to be seen as you actually are to yourself. Although the attainment of genitality and the capacity for unambivalent object love have been features of many, perhaps most, satisfying and significant lives, there are many other good lives, including some of the greatest and most fulfilling lives recorded in history that were not lived by individuals whose psychosexual organization was heterosexual-genital or whose major commitment was to unambivalent object love. (Kohut 1984, p. 7)

Self psychology lends itself well to the acceptance and celebration of diversity. The goal of sexual development is for everyone, every person, to become more fully and vibrantly who they believe and experience themselves to be at any given point in time. This is a construct that allows greater fluidity in this area than many of the other theories, which postulate much more fixed psychosexual stages and outcomes. For many feminists, self psychological theory is welcome because it broadens the parenting role to include fathers and all significant others. Kohut did not believe in the existence of a symbiotic phase between mother and infant and, unlike Winnicott, did not think mothers have to regress to form attachments with their babies. Thus, aspects of the mother–child bond become demystified, less sacred and magical, and more available to any person in the baby’s life with parenting skills. The oedipal drama is also reformulated in significant ways. It is seen more as an opportunity than as a period and is understood as a time that is not necessarily filled with desire, competition, acquiescence, loss, guilt, or fears of revenge. For the clinician, self psychology offers the possibility that the story can also be one of joyful self-discovery. Having good selfobjects of different genders to love, and to be loved by, and to identify with, is seen as offering wonderful opportunities rather than painful choices. The impact of sociocultural factors can also be easily folded into self psychological theory, which enables us to understand the suffering to the self that is caused by social ills and is congruent with the current interest in intersectionality. Groups that are oppressed can be understood as suffering from selfobject failures on the part of a dominant and discriminatory society. As this edition of this book was being written, there were helicopters roaring overhead and thousands of protesters chanting in the street after the murder of George Floyd at the hands of the Minneapolis police. The whole world was able to see the pain and the anguish of those who have internalized and thus been wounded by hundreds of years of enduring racism. People who are of color, poor, female, LGBTQ, transgender, or disabled— and members of other oppressed groups—often are not mirrored sufficiently for their

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distinct qualities and their talents, and they often lack good, strong, calm role models to idealize and merge with, as well as strengthening twinship experiences. Hence, society, when it is oppressive, can be seen as a selfobject that has tremendous power to destroy, often contributing to dysregulation and a lack of self cohesion. There are a growing number of opportunities for twinship experiences in grassroots organizations and support groups, but, for some young people, the only twinship opportunities offered may, tragically, be on the street in gangs. A thorough understanding of the selfobject needs of the tripartite self would be a sound beginning in the formulation of better mental health and social policies as well as better clinical skills. Some critiques of self psychology center precisely on the fact that the theory places such a high value on individual development. Although such a value fits snugly with certain aspects of current American culture, it is certainly not espoused by all cultures. There are many other constructs that place the good of the group or the community far above the good of the individual. In such cultures, the mirroring of individual qualities would be seen as far less important than teaching individuals what they have to develop or sacrifice in themselves to benefit the community. Another critique of self psychology focuses on its belief about the nature of the human condition, which it sees as basically tragic. There is great compassion in the theory for the vulnerability and neediness of the human infant, but for some this is too passive and empty a vision of what it means to be and to become a person. Self psychology does not seem comprehensive and complex enough to those clinicians who believe that there are innate negative and destructive forces within people that need to be acknowledged and worked with, and who still want to look at the important role that guilt plays in the range of experiences that need to be understood. While self psychology suggests that pathologies arise from deficits in the environment, it has been critiqued for neglecting the intrapsychic conflicts from innate forces within human beings. Thus, some clinicians believe that mirroring should include all individual characteristics of the person, not just the shiny, positive ones. Additionally, some clinicians feel that self psychology does little to address the pain of those struggling with more innate affective instability, rage, and darkness. Empathy does not always soothe the soul. Current postmodern clinicians who are interested in developing a vigorous two-person psychology, fully co-constructed by client and therapist, find self psychology to be too much of a one-person psychology. Although much of the work of a self psychologically informed treatment takes place in the narcissistic transferences, thereby paying a great deal of attention to the therapeutic relationship, critics of the theory find that there still exists too much of a distinction between the empathic, attuned, omniscient, giving therapist healing the injured, needy, passive, receptive client. Nevertheless, despite what some see as its flaws or shortcomings, self psychology has made an enormous contribution to psychodynamic theory. Even those who do not see it as a comprehensive theory often make use of its concepts in their clinical work and find themselves enriched in their capacity for attunement and empathy.

CONCLUSION AND REVIEW What, then, does self psychology contribute to our knowledge of human psychological development? Self psychology offers a particular view of human nature and therefore of development. It offers new beliefs about the structure of the self. It offers a way of conducting treatment based on empathic attunement to selfobject needs. Self psychology posits that the achievement of a cohesive, well-regulated, empathic, and vigorous self is the goal of all

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psychological development. The health and well-being of the self derives from empathic attunement on the part of selfobjects, as well as the working through of empathic failures. According to self psychologists, the self is tripartite, with each part of the self having specific selfobject needs. The grandiose part of the self needs mirroring. The idealized part of the self needs wonderful people and things with which to merge. The twinship part needs to experience others as similar in order to recognize oneself in another and to be comforted. Qualities and functions of selfobjects are taken in by the process of transmuting internalizations; these then help the self to grow strong and whole, enjoying a sense of genuineness, authenticity, and individuality. According to self psychology, empathic failures are also inevitable and can be important to psychological growth. In the absence of good selfobjects, or through excessive disappointments with them, we all experience difficulties with healthy self-regard, with ambitions, values, or goals. In the absence of mirroring selfobjects, there may be difficulty recognizing and valuing the self and valuing others. In the absence of a strong other with whom to merge, there may be a sense of frailness and emotional vulnerability. In the absence of twinship experiences, there can be difficulties in achieving a sense of connectedness. Self psychology provides us with a way to learn about how selfobjects were or were not available to perform self functions. It provides an important lens to help us understand empathy’s potential to promote emotional growth in the present. Self psychology offers a way of understanding not only what was missing but also what can be provided via new relationships to make healing and growth possible. In introducing the concept of transmuting internalization, self psychology offers a new idea of how powerful a therapeutic experience can be, in that it can actually help the client become more substantive and whole. It posits that rage and anger are more often the result of disappointment and hurt rather than coming from an innate drive. It is very much a theory of how the “outside” affects the “inside” and how the inside grows into selfhood. As with all of the psychodynamic theories, there are clinicians who rely primarily or solely on self psychology to inform their treatment. We prefer to think of self psychology as one more useful theory to help us to understand, and empathize with, the experiences and struggles of another. It is particularly useful for the many moments in therapy when clients come to us, not so much struggling with conflicts, or deficits in ego functions, or impaired self- and object-representations, but rather with unmet needs in mirroring, idealization, and twinship.

REFERENCES American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM-5]. Arlington, VA: American Psychiatric Association. Beebe, B., Jaffe, J., Markese, S., Buck, K., Chen, H., Cohen, P., Bahrick, L., Andrews, H., & Feldstein, S. (2010). The origins of 12-month attachment: A microanalysis of 4-month mother-infant interaction. Attachment & Human Development 12(1/2):3–141. Beebe, B., & Lachmann, F. (1994). Representation and internalization in infancy: Three principles of salience. Psychoanalytic Psychology 11:127–65. Beebe, B., Rustin, J., Sorter, D.,  & Knoblauch, S. (2008). An expanded view of intersubjectivity in infancy and its applications to psychoanalysis. Psychoanalytic Dialogues 13(6): 805–41. Blanck, G., & Blanck, R. (1979). Ego Psychology II: Psychoanalytic Developmental Psychology. New York: Columbia University Press. Bowles, D. (1983). The impact of ethnicity on African-American mothering during the separationindividuation phase of development. Doctoral Dissertations 1896–Febrauary 2014, 4126. https:// scholarworks.umass.edu/dissertations_1/4126.

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Chessick, R. (1993). A Dictionary for Psychotherapists. Northvale, NJ: Jason Aronson. Cocks, G. (1994). The Curve of Life: The Correspondence of Heinz Kohut, 1923–1981. Chicago, IL: Chicago University Press. Edmundson, M. (2001). I’m O.K., and then some. Review of C. B. Strozier, Heinz Kohut: The Making of a Psychoanalyst. New York Times, June 3. Elson, M. (1986). Self Psychology in Clinical Social Work. New York: Norton. Elson, M., ed. (1987). The Kohut Seminars: On Self Psychology and Psychotherapy with Adolescents and Young Adults. New York: Norton. Erikson, E. (1950). Childhood and Society. New York: Norton. Fonagy, P. (2001). Attachment Theory and Psychoanalysis. New York: Other Press. Freud, S. (1914). On narcissism: An introduction. Standard Edition 14:67–104. Hagman, G., Paul, H., & Zimmermann, P. (2019). Intersubjective Self Psychology: A Primer. New York: Routledge. Kohut, H. (1971). The Analysis of the Self. New York: International Universities Press. ———. (1977). Restoration of the Self. New York: International Universities Press. ———. (1978). The Search for the Self. New York: International Universities Press. ———. (1984). How Does Analysis Cure? Chicago, IL: University of Chicago Press. Kohut, H., & Wolf, E. (1978). The disorders of the self and their treatment: An outline. International Journal of Psycho-Analysis 59:413–25. Lasch, C. (1978). The Culture of Narcissism. New York: Norton. Lessem, P. (2005). Self Psychology: An Introduction. New York: Jason Aronson. Mitchell, S.,  & Black, M. (1995). Freud and Beyond: A  History of Modern Psychoanalytic Thought. New York: Basic Books. Modell, A. A. (1975). A narcissistic defense against affect and the illusion of self-sufficiency. International Journal of Psycho-Analysis 56:275–82. MoMALearning. (2010). Abramovic cited in “The Artist Is Present.” https://www.moma.org/learn/ moma_learning/marina-abramovic-marina-abramovic-the-artist-is-present-2010/. Orange, D. (2016). Climate Crisis, Psychoanalysis and Radical Ethics. New York: Routledge. Orange, D., Atwood, G., & Stolorow, R. (1997). Working Intersubjectively: Contextualism in Psychoanalytic Practice. Hillsdale, NJ: Analytic Press. Oxford University Press. (2019). Retrieved from Lexico.com, January 15, 2020. Pine, F. (1990). Drive, Ego, Object, and Self. New York: Basic Books. Preston, E. M. (1969). I Hate It When . . . New York: Viking. Slap, J., & Levine, F. (1978). On hybrid concepts in psychoanalysis. Psychoanalytic Quarterly 47:499–523. Stern, D. (1985). The Interpersonal World of the Infant. New York: Basic Books. Stolorow, R., & Atwood, G. (1992). Contexts of Being. Hillsdale, NJ: Analytic Press. Strozier, C. (2001). Heinz Kohut: The Making of a Psychoanalyst. New York: Farrar, Straus and Giroux. Webster’s Third New International Dictionary. (1963). Springfield, MA: G. & C. Merriam Company.

7 Relational and Intersubjective Theories Joan Berzoff

Many early theorists such as Sandor Ferenczi, Melanie Klein, Harry Stack Sullivan, and D. W. Winnicott advocated relational approaches in their work with clients in the earlier parts of the twentieth century. While we tend to think of relational theory as something “new” and therefore somehow better, it is useful to think about relational theories historically, so we can understand how they have evolved, how they have been revised, and the ways in which they contribute to clinical practice today. This chapter will begin by tracing the history of relational theories and practice. Then we will look at the evolution of thinking about countertransference. Next, we will consider the role of infant developmental research on relational theories and practice. After that, we will consider many of the concepts in relational theories: enactment, mutual influence, self-disclosure, the irreducible subjectivity of the therapist, the unthought known, power and asymmetry, rupture and repair, dissociation and trauma, spontaneity in the clinical encounter, and, finally, intersubjectivity as a developmental achievement. We will also consider intersubjectivity as an extension of relational theory and as an epistemological stance and critique from a postmodern perspective. Intersubjectivity questions binaries, essentialism, power relationships, the social contexts in which practice occurs, and the multiplicity of identities that clients and their therapists hold, and it emphasizes the intersectionality of race, class, gender, and sexualities in the therapeutic relationship.

WHAT ARE RELATIONAL THEORIES? Relational theories recognize the importance and value of understanding how two people and two psyches are always interacting with one another in any clinical situation. These are ideas about how clients and therapists mutually influence each other (Aron 1996; Mitchell 1993, 1997). They look not just at the client as the unit of study or change but also at how each member of the therapeutic dyad is always affecting the other. These are theories that hold that there is no fully analyzed, and therefore omniscient, therapist (Aron 1996; Wachtel 2008). These are theories based on ideas that transference and countertransference 152

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cannot be understood as separate but as always interactional and bidirectional. These are theories that look at how, in therapeutic relationships, relational enactments are always inevitable. These are theories that suggest that it is not just the client who recreates the past in the present; rather, it is the particular and unique dynamics of any therapist and client that get activated and enacted between them. Further, enactments may be psychological or they may be social, but they are always played out within the therapeutic relationship. Enactments are seen not only as ubiquitous and inevitable but also as the core of what needs to be understood between client and therapist. In relational theories, the therapist’s subjectivity is not something to be gotten rid of or analyzed away, as was true in early psychodynamic theorizing. Instead, the therapist’s subjectivity is data about what might be going on in the room and is always worthy of exploration. Relational theories also hold that there is more that is the same about client and therapist than is different. This is a shift away from seeing the client as the pathological one and the helper as the healthy, healed one. Instead, both therapist and client are seen as trying to make sense of things as best they can; both are committed to understanding what is happening between them interpersonally, as both are attuned to the unconscious ways that they may be communicating with each other. From a relational perspective, then, the therapist is not a blank screen upon whom the client projects, displaces, and acts out contents of her separate mind. Instead, the therapist has her own mind and these two minds are always interacting with each other in unique ways. While once neutrality—being a blank screen and offering one’s self up as a clean container for projections, displacements, and distortions—was seen as the gold standard of orthodox classical psychoanalytic theory, now the therapeutic work involves attending to two people’s distortions, projections and displacements, feelings, and even moments of dissociation. Where once classical theory overly attended to analyzing the contents of the client’s mind, much more attention is paid to the mind of the therapist in interaction with the client. Where the therapist’s mind was once seen as empty, now the therapist’s associations, musings, and reveries are often seen as a part of the clinical conversation.

RELATIONAL THEORY AND THE HISTORY OF PSYCHOANALYSIS Ferenczi (1909, 1988; see also Aron 1992) was one of the first early psychoanalysts to understand just how important mutuality was to any therapeutic encounter. Writing in the 1910s, 1920s, and 1930s, he was particularly interested in how the client and the therapist were always caring for one another, mutually participating in the interactions between them, unconsciously trying to cure and heal each other, and always failing each other empathically. Rather than look only at the patient, Ferenczi (1909, 1988) was interested in exploring both the client’s and the therapist’s wishes to cure and their failures to do so. In fact, Ferenczi saw pure objectivity on the therapist’s part as a way of distancing from the client, including from the client’s traumatic experiences. Instead, he was interested in how traumatic experiences played out relationally between therapist and client and how the therapist needed to feel in her bones what the client was conveying unconsciously. In Ferenczi’s view, the client and therapist had to live through, together, the client’s experiences of trauma in order to face them with honesty and authenticity. Melanie Klein (1952/1975), as we learned in chapter 5, was also very interested in how a child’s projections and distortions of the mother shaped a child’s internal world as well as the child’s interpersonal world. Klein talked about the power of projective identification as a way to think about how a child can induce in another (first the mother, then others) what

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the child feels but cannot say. Similarly, the therapist may feel the client’s love, hate, deadness, or disturbance through projective identifications. Projective identifications are relational communications because they are unconscious, but they also shape the interaction between practitioner and client. Very often, the practitioner may unconsciously find herself holding, feeling, and having to bear her clients’ disavowed thoughts and feelings. Often the therapist will, if she does not understand what is happening, react or act out based on what she is experiencing but cannot name. Thus, in relational work, the therapist needs to be open to feeling and naming in herself, and then in the relationship, what the client may not have the words to say. Clients and therapists can then begin to create shared meanings based on their feeling states so that disavowed feelings and thoughts can be made examinable, be understood, and be metabolized by the client. This requires of the therapist a high level of self-awareness and self-knowledge. Sullivan (1953), whose work became the foundation for the interpersonal school of psychoanalysis, introduced the interpersonal mode and contributed a great deal to the foundation for relational theories as we think about them today. He saw the process of therapy as a form of participant observation. The therapist, as a real person, has to be fully and thoroughly engaged in what he called a detailed inquiry with the client. He advocated, especially in work with clients who suffered from psychosis, that the therapist always inquire about what was going on between the two of them. In other words, the therapist was always a participant in the client’s inner and interpersonal world in ways that needed to be understood by both parties (Mitchell 1997). Mitchell has further (1993) written, “In this vision, the basic unit of study is not the individual as a separate entity whose desires clash with an external reality, but an interactional field within which the individual arises and struggles to make contact and to articulate himself.  .  .  . The person is comprehensible only within this tapestry of relationships” (p.  3). Wachtel (2008) has further elaborated that the relational/interpersonal field does not cancel out the idea of an internal life or of an individual mind, but it enriches it by looking at the interaction between the client’s mind (the drives, defenses, and structures of the mind) and the therapist’s mind. Sullivan, however, did not receive from the relational school the recognition that he deserved, despite his appreciation for the importance of mutuality, spontaneity, and authenticity. As Melanie Klein was an early relational theorist, so, too, was D. W. Winnicott (1969, 1994), who gave voice to the hatred that clients may feel and often induce in those who work with them. Mothers, he thought, sometimes hate their babies, and babies can withstand their mother’s hate when it can be acknowledged and balanced with love. Winnicott gave us permission, as clinicians, to sometimes hate our clients too and to interrogate our countertransference, not as something to be rid of, but as a part of an interactional communication in a relationship. In light of Winnicott’s comment about there being no such thing as just a baby but a mother and child as a nursing pair, one might say that from a therapeutic perspective, too, there is no such thing as a therapist or a client—only a therapeutic dyad. Again, as is true in mothering or fathering, both parties in a clinical pair are shaped by one another. In relational practice, then, countertransference is necessary, valuable, and very important to the clinical relationship.

COUNTERTRANSFERENCE Since the 1980s, there has been ever greater attention to countertransference and transference dynamics. Countertransference refers to the therapist’s thoughts, feelings, fantasies, and unconscious reactions to a client; transference refers to the client’s thoughts, feelings,

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fantasies, and unconscious reactions to the therapist. Joyce McDougall (1986) saw countertransference as essential to understand because often our clients cannot speak directly of trauma or of very painful feelings, other than by the therapist being open to experiencing them. This means that the therapist not only has to be vulnerable and open but also has to be willing to be baffled, discouraged, and to “not know” what’s going on much of the time. In addition, just as young children cannot symbolize their experiences in language, the therapist has to be prepared to try to help to put into language what the client cannot. Hence when the therapist feels boredom, irritation, or anger, these may be communications from the client that need to be reflected upon in the relationship and selectively given voice to. They may be feelings from within the therapist as well—the chord within the therapist that responds to the invitation to experience what the client is feeling. Ultimately this enables the client to make these feelings thinkable and to formulate them as her own. Rather than seeing countertransference, then, as simply existing in the therapist’s mind exclusively, countertransference has come to be seen as a dialectic between the clinician’s subjectivity and client’s subjectivity. Ogden (1994) moved us to think about how the therapist’s responses in the clinical setting are never fully removed from the client’s, or from their interactions. Therapist and client, then, ideally create what he has called the analytic third, or what others have called a third space, which is neither the client’s mind in isolation nor the therapist’s mind in isolation, but a space that they cocreate and can reflect upon together. Rather than the therapist serving as a clean container for the patient’s split-off feelings or unwanted and painful self-states, the therapist and client are forever creating something new between them that they can examine, shape, and change. Aron (1992) writes, Transference always needs to be viewed as a joint creation between therapist and patient.  .  .  . Transference and countertransference interdigitate and just as it is inconceivable to analyze transference without reference to countertransference so too is it impossible to analyze the analyst’s countertransference without reference to the patient’s contributions. Transference and countertransference mutually constitute one another and can be studied only interdependently. . . . Transference and countertransference constitute a dialectic and always need to be analyzed with reference to each other. (pp. 186–87)

From a relational perspective, then, clients and therapists mutually influence each other. Clients may be encouraged to explore their fantasies about the therapist’s subjective reactions to the work as an important source of information on the therapeutic process (Aron 1996; Berzoff & Mattei 1999). For example, Dr. Campbell is a forty-nine-year-old Black PhD male scientist born in Jamaica. Slavery was violent in Jamaica, marked by beatings and whippings. My client was raised in a brutalizing country, in crushing poverty, sharing a room with his single mother and many cousins while he slept on the floor. His mother was fifteen when he was born. His father has never been a part of his life. His mother, who was uneducated and unemployed, beat him regularly and burned him with cigarettes. The scars are evident on his arms, his hands, and his face. He has described his hunger, poverty, and helplessness as a child. Those feelings have accompanied him throughout his life as they did then. As a child, there was no legal or familial protection from child abuse, hunger, or racism. As an adult, the only safety and security he could find was to withdraw into books and music. He is an intellectual, a distinguished-looking, and very elegant cisgender man with a wonderful sense of humor despite his suffering. When Dr. Campbell was twelve, his grandmother removed him from his mother’s home, and he was cared for by her along with many other cousins with whom he shared bedding on the floor. There he felt loved, though his physical hunger persisted. At seventeen, he

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moved to Miami, where he lived on couches while attending night school and then graduate school, ultimately earning a PhD. Dr. Campbell struggled mightily against racism, first in his employment and then at school. He made a significant suicide attempt while in college and was hospitalized for a year in a state hospital where he was misdiagnosed with psychosis. No doubt he suffered from depression and PTSD. He later married a light-skinned Nigerian woman from a highly religious Pentecostal family, unconsciously hoping to gain acceptance into her family. They had three children, but his wife was physically violent toward him, as his mother had been, and she ultimately divorced him. Parental alienation soon followed, and he rarely saw his three daughters as they grew up, a nine-hour drive from where he lived. After the divorce, he was shunned by his ex-wife’s extended family as well. Dr. Campbell, however, had a great gift in attracting mentors, not unlike his grandmother, many of whom took him in and made him a part of their families. This gift persists to this day. Dr. Campbell has wept openly and frequently when speaking about his suffering. A part of that suffering he ascribes to the repeated racism he experienced at work and in his family, based on his dark skin color. He has described roommates and classmates using the N word, refusing to share a bathroom with him, or insisting that he smelled. He has described workmates, when he was a janitor trying to pay for schooling, making fun of him for reading. In later sessions, he described being left out of scientific meetings or derided for not being scholarly enough. There is an enduring helplessness and defeat to his accounts of colleagues, or bosses, his first and second wives, failing and denigrating him. I feel the helplessness, the trauma, through the lens of my own trauma and grief. In his scientific teaching and research, Dr. Campbell has isolated himself from colleagues. He has experienced ruptures with both his friends of color and his white colleagues. At home, he reads excessively, losing himself in piles of classics, while his second wife, from whom he estranged, watches television on the floor above. He describes feeling worthless and alone. With me, he has often been inconsolable given the deprivation and emotional poverty with which he lived. I often feel utterly desolate sitting with him. He has imagined, each time the phone rings in my office, that it is one of my sons. He has told me how much he envies that they called me every day and that they had a Jewish mother (a fantasy, of course, since I  am lucky to hear from them once a week or even every other week!). He envies what he perceives as my easy life, and White privilege, and I cringe, wanting to tell him it was otherwise. Given the immensity of his unalleviated and unbounded suffering, it feels like no wonder that his partner needs to go to another floor. I, too, often wish that I could go somewhere else. Like him, however, I have no other room to go to. We swim in a sea of suffering together. Recently, however, much less depressed than he was four years ago when we began working together, Dr. Campbell proudly told me that he had begun to write his memoir, a compelling examination of his racial and psychological struggles that is self-reflective and notes many of his own strengths. The book begins when he arrives in Miami. It tells not only of his grief and suicidality but also of his resilience. It chronicles the invisible barriers to his finding a place to live, finding a way to pay for his education with no financial help from family. It talks about his resistance to taking anti-psychotic medication in the inpatient unit for his depression, knowing that doing so would leave him weakened and unable to think. In all of these things, I begin to feel hope in his resistance. Most recently, he has asked me to read a book, just as I am leaving for vacation. It is a Holocaust book, and frankly I have sworn off them because they are so sad. When I return from my trip, however, he wants to tell me what he wanted me to know: that the protagonists survived; they survived. I begin to feel in my bones that so will he and so will we.

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ENACTMENTS, MUTUALITY, SELF-DISCLOSURE, AND THE THIRD SPACE One of the most valuable relational concepts has to do with enactments: the ubiquitous and inevitable ways in which clients’ and therapists’ psychological and social minds collide and may be played out anew in the therapeutic setting. Often these take place around gender, or around race, sexuality, or class. Often they contain within them power dynamics (although intersubjectivity addresses these in much more nuanced ways that we will attend to later in the chapter). The following is another example of an enactment from the author’s own practice: Janie is a forty-year-old white middle-class mother who feels burdened, depressed, and alone in taking care of her two young sons at home. She would like to work again as a social worker, but she feels her children need her, and so she has made an active choice to be with them at home. Her own mother was always very busy and unavailable during her childhood and she felt quite neglected, unwanted, and unseen. Therefore, she wants her children to experience something different. She comes to therapy to try to understand and change how depleted she feels. With some guilt, she talks about how much she would just like to leave her children alone in the house and go to the gym or out with friends. She describes how conflicted she always feels, how her husband tells her how lucky she is in not having to work, and how angry she feels with him and with her family and children for not recognizing her and understanding her dilemma. I am a working mother and so I feel her conflicts deeply. I too often feel tired and angry and I too often worry about the choices that I have made and how they will affect my own children. I resonate with her depletion and her ambivalence about her choices. Soon after she leaves our session, she is back. The battery in her car has died. She left the car door open during our session; it is the coldest month of the year and she needs to call AAA. She can see that I have my coat on and am ready to go out. I have a lunch date with a friend that I have looked forward to for weeks. She offers to go wait in her car, but without heat, she will freeze. I am going to be, at best, very late or, more likely, have to cancel something I really want to do. I invite her in and give her a phone and a cup of tea. But I am not sure of what to do. I am in a bind. Do I now pursue my own desires and leave her, as she has said she would like to do with her own family and as her mother did to her? Do I stay and feel burdened by her dependency, as she does with her children? I make my decision, cancel my lunch date, and feel sad and angry as I awkwardly wait in the other room for assistance to come. The next week, I forget all about our next session and Janie leaves a note on the door when I am not there. When I call to apologize and set up a new time, she tells me she understands. She really is just such a burden; she can imagine how angry I must have been. In reality, I had felt her to be a burden the week before and I am all too aware of it. I suggest she come in and that we talk about last week and what is going on between us. When she comes in, I talk about the dilemma I felt of whether to go or stay. I do not say that I too am a mother who is ambivalent about working or not working, or that I too feel depressed, depleted, and cranky. Together we begin to look at what is being enacted between us: issues of dependency, our own wishes to be separate and pursue our own desires, having to take care of others, how angry this can make us feel, and the ways we unconsciously act out. In this there are elements of her past, my past, our present. It feels like the therapy has really begun to take off because we have created something that is not all her, not all me, but worthy of our full attention and understanding.

In the classical view, Janie would have been seen as enacting core issues in the transference: she was being unconsciously dependent in leaving her car door open and asking me to care for her. In a classically orthodox view, I  might have seen my countertransference annoyance of having to put my plans on hold as a problem of mine to analyze and get rid of in order to work with her. In the classically orthodox analytic view, Janie might have been seen as acting out, and my countertransference would have also been

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acting out—something I needed to analyze and rid myself of because it was now clearly getting in the way. In this view (Renik 1993, 1995), I  should maintain my neutrality and objectivity in order to understand the “truth” about her situation. According to the most orthodox of analytic theories (none of which this book has never endorsed!), I would have been a blank screen onto which Janie would be seen as projecting her longings and conflicts. If I were objective, and if her mind were separate, we could examine its parts and its workings. Further, I might have responded when her battery ran down with “I wonder why you left your car door open?”—looking to analyze her behavior as resistance and/or acting out, which would have made me the final arbiter and interpreter of her truth. In a relational view, my annoyance was a part of something that was being enacted that we both felt and needed to examine. Further, from a more relational perspective, she was unwittingly inviting me to participate with her in her conflicts over separateness, desire and dependency, and recognition. In a more relational vein, my job was to make us both more conscious of what we had cocreated between us. Further, in a more relational schema, we were both involved in something neither one of us fully understood or had worked out. Our work was to come to some meaning together and over time. In a more relational mode, I was a participant in her conflict and I needed to share my feelings and my dilemma about wanting my freedom, but needing to stay. Since this was the crux of her depression, we created a third space, neither only her nor only I, where we could collaboratively work together. This meant that first I  had to feel what I  felt (resentful, put out, conflicted about her intrusion into my life, and ashamed about “forgetting” her the next week as her mother often forgot her). She had to feel what she felt (dependent, abandoned, ashamed, hurt, and annoyed). We had to then think together about what we had created: a crisis of individual desire; guilt, longing, and hurt. She was not a passive aggressive client who left her car door open. We were two mothers—two women, with different kinds of issues, dilemmas, and choices in solving them—who were nonetheless mutually influencing one another. We both had to experience the conflict of desire and dependency in order to talk about it with authenticity. And while we, the authors, are not advocating enactments, they will inevitably occur with our clients, and we need to be open to exploring them. Additionally, from a more relational perspective, my gender, sexual orientation, place in the social structure, and role as mother further contributed to what was created between us. We both felt some gender oppression and a lack of recognition of our desires, and this gave me further insight into her suffering. Had she been a man, someone much older, or transgender, perhaps the relational dynamics would have played out differently, but they would have likely played out nonetheless. This is to say that enactments will inevitably occur; they are social and psychological, and they are never exactly the same between two therapist/ client dyads because relational theory and practice is always based on who the client is and who the therapist is, including their unique social and cultural subjectivities. Understanding enactments can lead to helping our clients and ourselves out of what otherwise feels like being stuck in an impasse. Let us take another example: I have been supervising Maria, a twenty-nine-year-old Italian American social worker, out of a graduate counseling program, for two and a half years. She is thinking of leaving the profession. She came to see me after working with a forty-year-old Black client, Kyla, who had been homeless and was finally living in a stable housing project. She had seen Kyla, a single mother, weekly over two years in the context of her daughter Alicia’s school problems, which included ADHD and not getting along with teachers or peers.

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Six months before, Maria and Kyla began to talk about Alicia’s dad wanting to have a greater role in his six-year-old daughter’s life. Maria was a little skeptical because he had not shown any previous interest in his daughter since her birth, but Kyla was hopeful that maybe the father of her child would become more involved, and so she sent her daughter for the weekend with her father. It was the last time Kyla saw her daughter alive. Alicia’s father brutally beat her with a baseball bat and was now in prison. Maria came to see me because she both wanted to, and did not want to, terminate the case and because she was thinking about leaving the profession. She had a six-year-old boy herself and she could not bear her sadness and her guilt over the death of Alicia, nor could she bear her feelings of vulnerability as a mother. Further, Kyla had broken two appointments, although, before having done so, she had sent both Maria and her supervisor a phone number where she could be reached. Maria, however, had not called her back. In fact, in the six months since the death of Alicia, neither clinician nor client, when they had been meeting, had talked about their trauma and grief with each another. Maria was having recurrent nightmares and undue anxiety about her own child’s safety. Furthermore, Maria’s clinic supervisor was strongly encouraging Maria to drop Kyla from her caseload because she had missed more than two sessions and because she saw Maria as burning out and wanted to take care of her and keep her in the clinic.

As I heard this horrific story of trauma, I found my throat constricting, my heart hurting, and my stomach churning. I could only imagine what Maria was feeling, and it was hardly bearable to think about what Kyla was feeling. When I could get past my own sadness and horror, I began to wonder what was going on between Maria, Kyla, Maria’s supervisor, and me. I wondered if we were all getting caught up in a trauma reenactment in which Maria was feeling like a perpetrator who wanted to drop the case, Kyla was likely feeling like a victim who was being abandoned, the supervisor was feeling like a rescuer who needed to take care of the social worker, and I was feeling like a helpless bystander. We were all implicated in these relational dynamics that had to do with trauma and dissociation and we were all experiencing different roles and self-states that needed to be explored and ultimately integrated in the work between Maria and Kyla. Bromberg (1998) speaks of trauma and dissociation in relational practice as the therapist having to hold dissociated and disparate parts of the client’s trauma until it can be integrated. Basham and Miehls (2004) discuss how relational trauma is always unconsciously enacted in the therapeutic situation such that therapist and client hold and play out parts of the trauma scenario (victim, victimizer, bystander) until the trauma can be metabolized. These roles are not static but oscillate between participants. Maria ultimately was able to go back to Kyla and discuss the many split-off parts that she was feeling. They then began to talk about Kyla’s loss and trauma, as she, Maria, was experiencing them. It was only then that the two could begin talking about the grief, sadness, guilt, hurt, anger, and anxiety that both were feeling with curiosity and empathy. Only when Maria could acknowledge to Kyla how much her own fear and agony had come to feel like Maria’s could they move past the impasse and begin to grieve together. What have we said so far? We have said there are inevitable transference and countertransference dynamics that occur in therapeutic relationships. These are neither pathological nor to be understood as just coming from the client or from the therapist but inevitably emerge in interaction in clinical relationships. These are co-constructed, and so we need to examine our feelings, the client’s feelings, our conflicts, the client’s conflicts, our desires, the client’s desires in an analytic third space—a playground that is neither just us nor just the client—to examine mutual experience in a new way. This third space is neither just about the client nor just about the therapist, but it is a place to understand what is going on between them that reflects the original trauma, conflict, or dilemma. Jessica Benjamin (2007) writes about the “moral third” and here she is describing how vital it is that the clinician hold the third space, a place she identifies as the space to hold meaning, in which the client and clinician

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create an understanding of what is going on between them. This is the function that Dr. Campbell’s memoir served: a third space between us.

SELF-DISCLOSURE Many clinicians erroneously think that relational theory espouses the disclosure of the therapists’ feelings, desires, needs, or reactions in the clinical encounter. Relational theorists such as Aron (1991, 1992, 1996) have eloquently noted that self-disclosure is an inevitability, as clients perceive and intuit information that is not explicitly expressed. However, relational theorists should not self-disclose for the sake of being “transparent.” The challenge is to be open to hearing and learning from what our clients perceive and to consider when conscious self-disclosures may be in the service of the clinical work. Sometimes we self-disclose; often we do not. Not every client wants to know what we are thinking or feeling. Many clients fear too much intimacy, and our disclosures can be scary and intrusive. Many clients want us to be separate and maintain our distance. Sometimes our self-disclosure may be a self-indulgence in which we are gratifying our own needs but which has nothing to do with what the client needs. Sometimes self-disclosure is used as a way of discharging feelings we cannot bear. But sometimes, as was the case for Maria, disclosing what the therapist felt then enabled a dialogue to finally begin and an impasse to be surmounted. Maria and Kyla, when the space could be opened, both shared their horror, sadness, and guilt. This helped them both to begin to bear some of the trauma and loss without having to turn away from each other. It is important to note that Kyla was not the least bit surprised that Maria felt guilty, overwhelmingly sad, and traumatized. She knew this about Maria without Maria having to tell her. That is, she recognized her therapist’s subjectivity as most of our clients do. Hoffman (1998) refers to this as the irreducibility of the therapist’s subjectivity. Our clients usually note what is in our offices, what we wear, what we laugh at, what we don’t. They know our quirks and eccentricities. We always bring our reactions to the work and our clients know them anyway. Our character traits, our styles, our own histories, our multiple identities (culture, race, class, gender, sexual identities) comprise our subjectivities, and often our clients know a great deal about us without our having to consciously reveal who we are. Subjectivity, then, is about one’s sense of self and all that comprises it, and it cannot be hidden. Let me give another example: I am referred a forty-six-year-old white cisgender male engineer whom I will call Lincoln. He has found out that his partner is having an affair and he alludes to being suicidal. I cannot get him to tell me how suicidal he is or get him to talk about a specific plan, but I find myself feeling very scared that he will kill himself and so I find reasons to refer him to a community mental health center. Yet he calls and comes to see me again and says, “I am back, just like a bad penny. I want to work with you and obviously I freaked you out.” I acknowledge the truth of this, and this is a self-disclosure, but it is about his very accurate observations of my experience of him and of my subjectivity. That he has read my anxiety and fear leads to an authentic conversation in which I can acknowledge how I felt. We can then inquire into whether we can build a trusting alliance together in which he will tell me the depth of what he feels and whether I can check out my own feelings with him. Hence, I acknowledge the truth of what he perceived about me and the anxiety that comes with sitting with someone who has not yet decided to live or die. In some ways I am self-disclosing; in other ways I am acknowledging what he already knows about me. I am also musing aloud about what is going on between us, and about making manifest what Christopher Bollas calls the “unthought known.”

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Bollas (1987) and others (Aron 1996; Ehrenberg 1995; Mitchell 1993, 1997) talk about relational theory as a way to formulate or muse with the client about what previously could not be formulated or known. By acknowledging my anxiety and making it into something “thinkable,” we begin to authentically engage together around it. Had I not disclosed my own anxiety, which he already had read correctly, it was unlikely that anything real could begin to unfold between us. As was true in the work with Dr. Campbell, Janie, Kyla, and Lincoln, then, the therapist is never simply neutral or objective. The therapist comes with her own feelings, conflicts, desires, and anxieties. The therapist arrives with a complex social history (gender, race, sexual orientation, class, religion, age, ability, privilege or lack of it, and culture) and these are always interacting with her client’s social history in ways that mutually influence one another. All of these feelings, conflicts, histories, desires, and social identities constitute intersubjectivity. In these four cases, self-disclosure helped to get beyond past impasses. But self-disclosure is not always useful, and many beginning clinicians may be disappointed to learn that sometimes self-disclosure is even harmful. In a previous paper, we (Berzoff & Mattei 1999) described: Daniel, a white working-class third-year social work student, who tended to be very passionate, to form intense relationships, and to be overly directive. His client, Debra, an Afro-Caribbean mother of four, had been very depressed because of her inability to leave an abusive relationship with an alcoholic man. She was both emotionally and financially dependent on her husband who also bore great resemblance to her father. She had nowhere to go if she tried to leave, and her children were totally dependent on her. But when Daniel heard from the client about a violent incident between her husband and herself, he said, “You better get out of there! You have to leave now! Just go! I know from my own experience that staying would be destructive for you and for your children.” He let her know that hearing about the violence and abuse was intense and painful for him and that it made him urgent and angry on her behalf. Daniel was a white male from a family in which violence routinely took place. But his mother was able to ultimately leave her abusive relationship because she was helped financially and had social supports that Daniel’s client does not. Daniel’s mother also had a different level of object relating, where she was less emotionally dependent on others. She had a different past history where she had not endured the same levels of abuse and trauma, and she had different set of defenses and greater self-esteem. Daniel thought that his self-disclosure was an important opening in the work with Debra. But his supervisor was less sanguine and asked whether Daniel had thought about whether Debra already felt ashamed about what the four children living at home had been exposed to. She asked whether Daniel had assessed the client’s object relations, trauma history, defenses, and developmental level. She wondered whether Daniel had thought about the power differential in the room, what it meant for Debra to be told to just leave by a white man, and whether this might be experienced oppressively. Daniel defended his disclosure as relational and intersubjective, but his client did not return.

Actively choosing to self-disclose, as I did with Janie or as Maria did with Kyla, can free up the work, illuminate what is going on, and lead to greater understanding of self and other. But undisciplined self-disclosure can be intrusive, ignore power dynamics, or blur boundaries between client and therapist. In the same vein, not every enactment can be examined by every client, and so one has to always be thinking about how a client might experience too much emotional information from a therapist.

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REVERIES, MUSINGS, AND ASSOCIATIONS Another relational concept has to do with the therapist’s reveries and associations (Ogden 1997). Often the therapist may have an “aha” moment and want to make an interpretation about the “truth” of a patient’s behavior or distortion or misperception. However, it is not the interpretation that is curative in relational practice but the sharing with the client the process by which the therapist came to the interpretation. In this view, the therapist’s associations, feelings, and ways of thinking about the client and her problem are what help the client become a participant in, and interpreter of, the therapist’s experiences ­(Bollas 1987; Hoffman 1983). Letting the client in on the therapist’s musings may help the client become more understandable to herself. Again, it is not the therapist’s interpretation, per se, that is so valuable to a client but the sharing of associations, thoughts, and reveries with the client that may help the client become knowable to herself. This requires a certain degree of spontaneity, playfulness, and dialogue about the therapist’s own mind. The therapist’s mind becomes open to the client’s scrutiny and to contradiction, paradox, and surprise. Swartz (2007), writing about being a South African therapist working with Black African clients, also raises the issue of power in the therapeutic relationship, questioning who has the power to name what is going on and the ways in which naming can also be oppressive.

VOICES FROM INFANT DEVELOPMENT Relational theories and practice have also been deeply influenced by research on infant-caregiver dyads. Beebe et al. (Beebe 2000; Beebe et al. 2008), Tronick (2001), and Stern (1983) have shown through extensive and intensive videotaping of infant-caregiver interactions that there is no such thing as an isolated mind. From birth onward, relational communications take place at a very fast pace between a child and her mother. Not only does the mother impact the baby, but the baby also impacts the mother. Both engage in a relational dance in which each regulates the others emotions in verbal and nonverbal ways. The mind, in this view, is not singular, but shared, so that two minds make up the early relational world of the child. This requires a parent’s playfulness, spontaneity, and holding. Mothers cue their babies; their babies respond. Mothers gaze toward their babies and away based on cues from the baby’s needs for connection or moments of solitude. Mothers breathe rhythmically to their babies’ breathing and babies relax in their mothers’ arms and match their mothers’ breathing (Beebe et  al. 2008). Communication, then, is not unidirectional but bidirectional in that both infant and caregiver are always engaging in interactive forms of mutual ­regulation. In other words, it is not only the mother (read therapist) who helps regulates the baby’s feelings but also the baby (read client) whose subjectivity always influences the therapist. This reminds us that there are never two isolated minds in clinical work, but that there is always an intersubjective field in which the therapist impacts the client, and the client impacts the therapist. Breathing, gaze, even touch, are mutual forms of communication and lead to the intersubjectivity between client and clinician.

ASYMMETRY AND POWER Relational theorists, then, over the century and much more actively over the past three decades, have paid great attention to enactments, self-disclosure, mutual influence, the

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unthought known, the analytic third, and the subjectivity of the therapist, and to spontaneity and authenticity as necessary parts of the therapeutic relationship. And yet relational theorists also acknowledge that the therapeutic relationship, like the parent–child relationship, is always asymmetrical. Clients come to us because we have some knowledge and skills that may help them with their suffering, and so by the nature of the fact that there is something our clients seek from us, there are always power dynamics in the room. Usually, clients have to pay for services and this too makes the relationship not equal. Clients always have less power than their therapists by nature of the institutions in which they are seen and the policies that govern their being seen or even mandate that they be seen. And while power and privilege are uncomfortable, especially to beginning clinicians, they are also a part of the relational matrix and need to be understood and sometimes made transparent.

INTERSUBJECTIVITY: FROM RELATIONAL PRACTICE TO THE POSTMODERN FRONTIER Relational theories and practice reached their ascendancy in a much larger zeitgeist of postmodernism. From the late 1980s to the present, many fields such as feminism, critical race theory, structural theory, philosophy, literary criticism, linguistics, sociology, science, political theory, and anthropology, to name a few, all began to question whether there is anything essential and true about that can be known about a text, a scientific problem, or a person. In this way, postmodernism has critiqued the positivism and objectivity of many disciplines and has taken an epistemological stance that truth is never absolute, observable, and knowable. Furthermore, postmodernists have suggested that the knower can never be separate from the known—that is to say, that the subjectivity of the researcher always affects what we can know about the subject. Postmodernism in the psychodynamic domain has called into question rationality, power, authority, and continuity (Aron 1996; Hoffman 1996) so that even a construct like identity, once seen as fixed, continuous, and coherent, has come to be deconstructed as fluid, multiple, discontinuous. Self, identity, and the other are created out of language (McLaughlin 1981, 1996), out of power relations, and within systems of meaning (see chapter 10 on gender). While modernists once spoke of the self as separate, individual, and bounded, postmodern theorists have critiqued a unitary self as based in Western cultural, gendered, and power arrangements (Benjamin 1995; Cooper 2010; Hoffman 1998; Mitchell 1997). Postmodernists, in fact, celebrate the discontinuities of human experience and the ways we are comprised of multiple selves that are sometimes harmonious and often are not. Postmodernists have also critiqued every theory for how it reflects the values of particular times and places in history. Every theory, then, is seen as a grand narrative (Lyotard 1994) and every theory is questioned for how it may have been used to colonize and maintain political and social power over others. Postmodern theorists, such as critical race theorists, also try to elicit the native voices of their clients, because grand narratives tend to exclude them. Postmodernists, then, always critique theories that privilege some and exclude others. In the psychological domain, for example, feminists have pointed out that women’s voices were ignored, devalued, or treated as defective. Gays, lesbians, and transgender individuals, and many ethnic and cultural groups, have made the same claim: that they have been invisible in grand psychoanalytic narratives such as the oedipal complex. Many who have not fit into the dominant discourse have found themselves as “othered,” marginalized, or simply invisible.

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Foucault also speaks to how psychological theories are always discourses of power (Chambon 1999). Theories define bodies of knowledge that contain the values and worldviews of the dominant culture. As such, they are often used for disciplinary practices and as forms of social control. We see this, for example, in clinics where clients are routinely disempowered on the basis of race and class. For example, a 2009 New York Times article cited the dramatic overuse of medications with children who are Black and living in poverty in New York. These young children are overly diagnosed with bipolar disorders and are then given medications exclusively. Their white counterparts, with the same behaviors, are far less likely to receive the same diagnosis and are routinely referred for psychotherapy (Wilson 2009). Diagnoses and treatment, then, enact oppressive and disciplinary practices that are shaped by discourses of economics and power. From postmodernism we also learn that blackness, whiteness, class, sexual orientation, and ability are not categories unto themselves but power arrangements, maintained within cultural and political domains of dominance and subordination. A postmodern perspective calls for the therapist to be cognizant of her own standpoint and of who is relegated to the margins in work with any client or client system. While relational theories were initially more interested in the dynamics in the room, in the interpersonal domain, in self-disclosure, enactments, and creating a third space, they were less interested in interrogating the complexity of subjectivity: power, privilege, and multiple identities that client and clinician bring to the encounter. Intersubjectivity attends to those dynamics. Jessica Benjamin (1988, 1995, 2004), a feminist psychoanalyst, for example, shows how a mother is not simply an object upon whom a child’s needs are enacted but also a subject with her own needs and desires. She sees recognition of the other’s subjectivity as a developmental achievement. In the same vein, therapists bring their own subjectivities, including power relationships, place in the social structure, desires embedded in the psyche, and social world, to the client. Intersubjective theorists attend not only to psychological subjectivities interacting with each other but also to how gender, race, culture, age, and class always oscillate in relationships between therapist and client. As clinicians, we need to be thinking about the ways our multiple subjectivities interact with our clients’ in the contexts of power and powerlessness. This is a more postmodern conception of self and other and of the clinical situation. For example, Annie, a white, Anglo-Saxon, upper-middle-class student, was working with a client who was homeless and being seen five times a week for chemotherapy in a breast cancer center. Her client, Joanne, a Black woman in her thirties, had been in sixteen foster homes growing up before moving to the streets. As an infant she had been left in a single-room occupancy hotel with her mother who had died from a drug overdose. Joanne was, by nature and history, prickly, urgent, and needy in her foster homes, where her physical and emotional needs were rarely met. After being sexually abused in her last foster home, she moved to the streets. Now she was very sick, probably dying, and she had begun panhandling the staff for money. Her social worker was offended by this behavior and called security to escort Joanne out of the hospital and back onto the streets. This was an intersubjective enactment. As Joanne had always been experienced as too demanding, too inconsolable, and too urgent in relationship to her caregivers, this was being reenacted in the regressive setting of a medical center. But race, class, illness, and trauma were also parts of the intersubjective dynamic, in that Annie unconsciously behaved toward Joanne in disciplinary ways. Rather than being able to understand how the breast cancer center was providing Joanne a holding environment that was meeting Joanne’s physical, spiritual, and emotional needs, and how Joanne might have felt justified in asking for more, Annie felt betrayed, taken advantage of, and therefore unable to see the panhandling as a natural extension of Joanne’s longings for comfort and care. Further, Annie found it particularly hard to empathize with Joanne’s neediness

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When Joanne began panhandling, Annie’s countertransference response was disciplinary, not clinical. Unconsciously she was a participant in reenacting Joanne’s trauma scenario of loss and abandonment as it played out in the contexts of class and race.

Indeed, Dalal (2002) reminds us that working with prejudice, culture, and class is always intersubjective work. Intersubjectivity reminds us that if enactments are always both psychological and social, discipline can easily leak into our work with clients unless we remain profoundly aware of the dynamics of privilege and power. Let me offer another example: Alexandra, another social work student, was white and in her fifties. She came from a middleclass background, although her parents had struggled mightily to put her through school. Now she was working with an African American mother, Christina, who lived in poverty and whose oldest child was in residential treatment. Christina was depressed and essentially unable to parent her other three children. Further, Christina described her institutionalized son as a “bad seed,” which greatly upset Alexandra. As Christina recounted her history of violence, abuse, betrayal, and abandonment, it was clear that she thought that she too was a bad seed. But Alexandra felt angry with this mother who could not empathize with her child and could not take responsibility for her other children, and she found herself musing on what a bad mother her client was. She reported that she even found herself thinking about her client, who was ill with sickle-cell anemia and bleeding ulcers, as a “welfare queen” taking advantage of the system. She was horrified by her own racist musings when she spoke them aloud but then was able to begin to look at some of the sources for her racist thoughts and feelings. How, she wondered, had her feelings of helplessness and anger over the way Christina saw her children led to the denigration of her client along racial lines? Had she been angry because her own unconscious privilege had enabled her to surmount social circumstances similar to her client’s? She was painfully aware in that encounter she had come to take a stance in which she too began to see her client as a “bad seed.”

Intersubjective theorists exhort us to examine our subjectivities not only as intrapsychic and interpersonal phenomena but also as embodying interlocking social relationships around privilege, power, race, class and the other signifiers that comprise our complex selves.

HOLDING WHAT IT IS TO BE HUMAN WHILE NOT THROWING THE BABY OUT WITH THE BATHWATER We think that relational and intersubjective theories capture some of the complexities of what it is to be human. They exhort us to tolerate the uncertainty, ambiguity, and paradox that are inevitable in working with others whose humanity is also deeply complex. But often beginning students see clinical theory and practice as either/or. That is, we sometimes hear our students saying, “That is a one-person psychology and I don’t want to learn it!” or “I only work in a two-person psychology model!” This dichotomizing overly simplifies all of clinical work. In fact, all relational practitioners have been trained traditionally. They should be knowledgeable about drives, defenses, and structures of the mind, about object relations, and self-psychology, attachment, neurobiology, and trauma. They should be able to assess a person’s strengths, developmental levels, trauma, and defenses, and their social, cultural, and internal worlds. Relational theories then highlight the context of the therapeutic encounter as the stage wherein these play out. We think that to work as two minds, one needs a sense of one mind first. Often the beginner who starts by learning relational theory may feel free, for example, to share any spontaneous thoughts, feelings, and reactions with her clients. Ehrenberg (1992) writes, “The issue is not simply one of

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being ‘authentic.’ There are ways of being authentic that can burden our patients unnecessarily and we can derail, rather than advance the process” (p. 84). Thus, we think there is a danger to undisciplined spontaneity, to disclosing without a great deal of thought and restraint, and to making transparent power relationships under any and every circumstance. Often our clients want and need us to have knowledge or power, for cultural reasons and/or for psychological reasons. Often our clients need us to listen and not to associate with our own reveries and musings. Often our clients need distance from our minds for reasons having to do with the dangers of too much closeness or fears of losing their own minds. Without learning to practice with some restraint, without learning first to listen, without learning first to start where a client is, there is the danger of excessive selfdisclosure, or of relativism, a kind of “anything goes,” or of seeing the client and therapist as equals when in fact—in the context of the therapeutic relationship—they are not.

CONCLUSION Many clinicians will say, then, that they are “two-person” therapists, not “one-person” therapists, but we think that these kinds of statements create a binary that denies the foundation upon which psychodynamic practice was built, which is based in relationships. As we have said throughout this book, we want clinicians to be full of knowledge and empty at the same time, to hold a great deal of knowledge, and to be able to be open. We want therapists to be aware of their power and privilege and to be able to deconstruct how power and authority play out in the work that we do. We want our students to understand the complexity of the mind and to see how two minds are always interacting with and shaping one another, whether in early development or in the clinical situation. We want clinicians to pay attention to the ways in which relationships construct new realities and to be able to think about how mutual influence, if understood, can create new spaces for reflection and change. Relational and intersubjective theories give voice to our stance of holding paradox and ambiguity and to not knowing. However, we agree with Cooper (2010) that the risk of intersubjective work can be the valorization, by those who deem themselves relational, of their own subjectivities, to the exclusion of a focus on the patient’s subjective experience. As always, our challenge as clinicians is to make our work, both/and, and not either/or.

REFERENCES Aron, L. (1991). The patient’s experience of the analyst’s subjectivity. Psychoanalytic Dialogues 1:29–51. ———. (1992). From Ferenczi to Searles and contemporary relational approaches: Commentary on Mark Blechner’s “Working in the countertransference.” Psychoanalytic Dialogues 2(2):181–90. ———. (1996). A Meeting of the Minds: Mutuality in Psychoanalysis. Hillsdale, NJ: Analytic Press. Basham, K., & Miehls, D. (2004). Transforming the Legacy: Couple Therapy with Survivors of Sexual Abuse. New York: Columbia University Press. Beebe, B. (2000). Co-constructing mother-infant distress: The microsynchrony of maternal impingement and infant avoidance in the face-to-face encounter. Psychoanalytic Inquiry 20:421–40. Beebe, B., Rustin, J., Sorter, D.,  & Knoublauch, S. (2008). An expanded view of intersubjectivity in infancy and its application to psychoanalysis. Psychoanalytic Dialogue 13(6):805–41. Benjamin, J. (1988). The Bonds of Love: Psychoanalysis, Feminism and the Problem of Domination. New York: Pantheon. ———. (1995). Like Subjects, Love Objects. New Haven, CT: Yale University Press. ———. (2004). Beyond doer and done to: An intersubjective view of thirdness. Psychoanalytic Quarterly 73:5–46.

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———. (2007). Intersubjectivity, thirdness and mutual recognition. Talk at the Institute for Contemporary Psychoanalysis, Los Angeles, CA. http://icpla.edu/wp-content/uploads/2013/03/ Benjamin-J.-2007-ICP-Presentation-Thirdness-present-send.pdf. Berzoff, J., & Mattei, L. (1999). Teaching intersubjectivity: Paradox or possibility. Smith Studies in Social Work 69(2):373–87. Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. New York: Columbia University Press. Bromberg, P. (1998). Standing in the Spaces: Essays on Clinical Process, Trauma and Dissociation. Hillsdale, NJ: Analytic Press. Chambon, A. (1999). Reading Foucault for Social Work. New York: Columbia University Press. Cooper, S. H. (2010). A Disturbance in the Field: Essays in Transference-Countertransference Engagement. New York: Routledge Press. Dalal, F. (2002). Race, Colour and the Process of Racialization: New Perspectives from Group Analysis, Psychoanalysis and Sociology. Hove, UK: Brunner Routledge. Ehrenberg, D. (1992). The Intimate Edge: Extending the Reach of Psychoanalytic Inquiry. New York: Norton. ———. (1995). Self-disclosure: Therapeutic tool or indulgence? Contemporary Psychoanalysis 31:213–28. Ferenczi, S. (1909). Introjection and transference. In Contributions to Psychoanalysis, pp. 35–93. New York: Basic Books. ———. (1988). The Clinical Diaries of Sandor Ferenczi, ed. and trans. J. Dupont. Cambridge, MA: Harvard University Press. Hoffman, I. (1983). The patient as interpreter of the analyst’s experience. Contemporary Psychoanalysis 19:389–422. ———. (1996). The intimate and ironic authority of the psychoanalyst’s presence. Psychoanalytic Quarterly 65:102–36. ———. (1998). Ritual and Spontaneity in Psychoanalysis: A Dialectical-Constructivist View. Hillsdale, NJ: Analytic Press. Klein, M. (1952/1975). The origins of transference. In Envy and Gratitude and Other Works. London: Hogarth Press. Lyotard, J.-F. (1994). Lesson on the Analytic of the Sublime, trans. Elizabeth Rottenberg. Palo Alto, CA: Stanford University Press. McDougall, J. (1986). Theaters of the Mind: Illusion and Truth on the Psychoanalytic Stage. New York: Free Association Press. McLaughlin, J. (1981). Transference, psychic reality, and countertransference. Psychoanalytic Quarterly 50:639–64. ———. (1996). Power, authority and influence in the analytic dyad. Psychoanalytic Quarterly 65(3):201–33. Mitchell, S. A. (1993). Hope and Dread in Psychoanalysis. New York: Basic Books. ———. (1997). Influence and Autonomy in Psychoanalysis. Hillsdale, NJ: Analytic Press. Ogden, T. (1994). The analytic third: Working with intersubjective clinical facts. International Journal of Psychoanalysis 75:3–20. ———. (1997). Reverie and metaphor. International Journal of Psychoanalysis 78:719–32. Renik, O. (1993). Analytic interaction: Conceptualizing technique in light of the analyst’s irreducible subjectivity. Psychoanalytic Quarterly 62:553–71. ———. (1995). The ideal of the anonymous analyst and the problem of self-disclosure. Psychoanalytic Quarterly 64:466–95. Swartz, S. (2007). The Power to name: South African intersubjective psychoanalytic and psychotherapy and the negotiation of racialized histories. European Psychoanalytic Psychotherapy  & Counselling 9(2):177–90. Stern, D. (1983). Unformulated experience. Contemporary Psychoanalysis 19:71–99. Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. New York: Norton. Tronick, E. (2001). Emotional connections and dyadic consciousness in infant mother and patient therapist interactions. Psychoanalytic Dialogues 11:187–94.

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Wachtel, P. (2008). Relational Theory and the Practice of Psychotherapy. New York: Guilford Press. Wilson, D. (2009, December 11). Poor children likelier to get antipsychotics. New York Times. http:// www.nytimes.com/2009/12/12/health/12medicaid.html?_r=0. Winnicott, D. W. (1969). The use of an object and relating through identifications. In Playing and Reality. New York: Basic Books. ———. (1994). Hate in the countertransference. Journal of Psychotherapy Practice and Research 3:348–56.

8 Attachment Theory Cynthia J. Shilkret and Robert Shilkret

Unlike many of the chapters in this volume, which deal with theories that were formulated for psychotherapy practice, attachment theory began as, and still is, primarily a theory of development, perhaps the most widely studied and influential developmental theory of the second half of the twentieth century. Attachment theory is considered a psychodynamic theory because it relies critically on a concept of an unconscious (the idea of “internal working models,” to be discussed below) and because it assumes the primary importance of early experience in influencing the development of interpersonal behavior. Recently, it has been very influential in several aspects of clinical work, including the role of trauma in the development of psychopathology; the importance of affect regulation and dysregulation in both early and later experience; the importance of the origins and development of mentalization; and understanding the process of psychotherapy, including the effect of attachment on the relationship between therapist and client. Aspects of attachment theory that have clinical relevance for such issues and current debates will be emphasized in this chapter. The theory sometimes seems difficult to teach to clinicians because it was not developed primarily as a theory of psychopathology or of clinical intervention. However, it is relevant to many other theories, including object relations, self-psychology, control-mastery, and trauma theory. We will emphasize the clinical importance of the theory in this chapter, while reviewing the basic propositions and findings of the theory and those implications currently supported by research evidence. Attachment theory has also become more relevant today because it is evidence based and research supported, and therefore holds an important place in clinical practice in both publicly and privately funded agencies.

BACKGROUND AND HISTORY OF ATTACHMENT THEORY Attachment theory began in the middle of the twentieth century with the work of John Bowlby (1907–1990), a British psychoanalyst, whose approach was further developed by Mary Ainsworth (1913–1999), an American psychologist who worked in collaboration 169

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with Bowlby. After graduating from Cambridge University in 1928, Bowlby volunteered at a school for maladjusted children. This experience, as well as his questions about the cool, distant parenting he had experienced himself—common in his culture and upperclass socioeconomic group—convinced him of the importance of children’s early parenting experiences in their subsequent development, and it set his professional course. He became a child psychiatrist and also received psychoanalytic training at the British Psychoanalytic Institute. There he was supervised by, among others, Melanie Klein, who emphasized the role of fantasy rather than reality in children’s difficulties. Bowlby seriously questioned Klein’s lack of concern for the child’s real world. In one case (Bretherton 1992), Bowlby recalled that Klein forbade him to talk with the mother of a three-year-old child he had in treatment. Bowlby, concerned about Klein’s emphasis on a child’s fantasy world to the exclusion of the importance of the child’s real world, argued and demonstrated with clinical case material that disturbed young children can be helped by working with their parents. While today this seems self-evident, ideas about the importance of the child’s real experiences and the critical importance of their parents’ interactions with them were scandalous in the British psychoanalytic community of the 1940s. The fact that they are so taken for granted today is largely a testament to the influence of Bowlby’s and Ainsworth’s work. In his early work, Bowlby drew on evolutionary theory and work with animals as well as on psychoanalytic ideas. He noted, for example, the important work of ethologists such as Konrad Lorenz, who had studied the “imprinting” in newly hatched ducklings and goslings. Shortly after hatching, baby ducklings follow their mothers. Lorenz had shown that this very early behavior was a response to the particular speed (relatively slow) that the mother walked, rather than to her shape, her odor, or other characteristics. The picture of Lorenz walking slowly around his laboratory followed by a line of ducklings, who had been removed from their mother immediately after hatching and had imprinted on Lorenz instead, made him famous. Bowlby proposed that all complex organisms, including humans, have an attachment system, one that is highly adaptive in that it keeps the young in close proximity to a critical older animal to whom they seek to return at times of danger. But Bowlby’s own work was not with animals; it was with much more complex human children. He wrote “Forty-Four Juvenile Thieves,” in which he documented the affectionless character and antisocial behavior of a group of children at his clinic, which he related to earlier maternal deprivation and separation (Bowlby 1944). World War II interrupted his career as a child psychiatrist. During the war, he was assigned to a research group studying officer selection criteria, and it was there that he learned research procedures. Incidentally, the British Secret Service, long before attachment theory was developed, knew about at least one result of impaired attachments, those formed by children raised in institutions (the orphanages of that time period, which cared adequately for the child’s biological but not social needs). When the Secret Service needed to find men who could work behind enemy lines and engage in very violent behaviors, including cold-blooded murders, they looked for soldiers who had been raised in orphanages. These men were known to have few feelings for others and to have little guilt or concern about the tasks they would be commanded to do. Later, Bowlby and his colleagues would demonstrate the deleterious effects of orphanages, in that most of them met the social needs of children quite minimally, if at all, and this work would be highly influential in the decline of the orphanage as a social institution, in favor of foster care in which children could have closer parenting relationships. Bowlby joined the Tavistock Clinic, an early psychoanalytically oriented London center, after World War II and continued his work with maladjusted children and with teenagers and their families. In one of the most fortuitous partnerships in all of developmental and clinical psychology, Mary Salter Ainsworth was in London in 1950 and looking for a job,

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having completed her PhD at the University of Toronto using Blatz’s “security theory,” which emphasized the importance of early dependence on parents. Bowlby had advertised in the London newspapers for a research assistant, and Ainsworth (having followed her new husband to London) answered the ad. Ainsworth became the research partner Bowlby needed. Following her husband again, Ainsworth, now in collaboration with Bowlby, found herself in Uganda, in East Africa, in the early 1950s. There she engaged in a major cross-cultural research project that would become the first true attachment research. She studied twentysix families with nursing infants by conducting long home visits (with an interpreter) every two weeks for nine months. When this work was eventually published (Ainsworth 1967), it outlined the sequence of behaviors characterizing the development of attachment to a primary caregiver. Some of these infant–mother relationships were better than others. Security of the infants’ attachment was correlated with mothers’ sensitivity (i.e., the mothers’ degree of attunement to the infants’ needs and their appropriate responses to those expressed needs). Less sensitive mothers (e.g., those who responded slowly or in ways that were not comforting) had insecure babies. To this day, attachment theorists do not speak in terms of “strength” of attachments; rather, attachments are described in terms of their quality: secure or insecure. The insecure attachment styles would soon be conceptualized as several subtypes. The function of attachment around the first birthday, particularly a secure attachment, seemed to give the infant a “secure base,” from which she could move away from the mother and explore the environment. Back in London, Bowlby’s work continued with a talented group of colleagues. Particularly noteworthy was the work of James and Joyce Robertson, who studied the effects of mother–child separation. They addressed, for example, the question of what happens when a separation occurs after a secure attachment has formed. They studied maternal separations prompted by the hospitalization of a mother for the birth of a second child. Earlier work had shown the deleterious effects of long hospitalizations on children themselves. For example, René Spitz had published controversial work on depression in hospitalized children in the mid-1950s. The Robertsons extended this theme with graphic films of how infants cope or fail to cope when separated from mothers in infancy and early childhood. They argued, actually against Bowlby, that another sensitive adult could largely compensate for the negative effects of early mother–infant separation. They demonstrated this by taking infants into their own home for the nine- or ten-day hospitalizations that were then routine for a mother’s childbirth. The famous film John: Nine Days in a Residential Nursery was part of this project. John’s family rejected the Robertsons’ offer to have John stay with them but allowed them to study John in the small orphanage in which they placed him, following their own pediatrician’s advice. John graphically illustrated the sequence of protest/despair/ detachment that Bowlby had outlined earlier as the consequences of loss of the caregiver. The deterioration of this securely attached, nondeprived seventeen-month-old was now not simply the word trauma on the printed page in a research or clinical report. The visible trauma of John’s separation with no single stable figure to take his mother’s place still upsets those who see it: John’s protest in banging his cup and refusing to eat; his dismay when his father leaves; his increasingly disorganized behaviors with other children; his futile attempt to cuddle into the lap of a nurse; and finally, his weak cries of despair at his failure to find a stable substitute mother figure all attest to the disintegration that can ensue when there is no primary caretaker available to a child. This dramatic illustration of the effects of the trauma of early separation on attachment became influential in shortening hospital stays for young children, and in allowing frequent parental visits, and in having a parent stay with a child in the hospital.

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After leaving Uganda in 1955, Mary Ainsworth settled in Baltimore. While based at Johns Hopkins University (eventually she would move to the University of Virginia, where she completed her career), she conducted a second large-scale longitudinal (i.e., the same participants observed over time) attachment study. The Baltimore Project, like the Uganda work, involved twenty-six families, who were this time recruited prenatally (Ainsworth et al. 1978). She and a team of research colleagues conducted eighteen four-hour home visits during the infants’ first year, recording many aspects of mother–infant interaction for subsequent analysis. Thus, the original attachment research involved detailed, home-based observations of mother–infant behavior during the first year, one group from Uganda, another from the United States. The two studies together were of enormous value: They introduced several new ideas and methodologies, and together, the studies were cross-cultural. The basic attachment findings were that attachment, now defined as “proximity-seeking” by the infant toward the mother or other primary caregiver, develops rapidly, across cultures, from six to twelve months after birth. It is preceded by differential behaviors toward the primary caregiver (e.g., smiling and vocalizing more toward the mother than toward others). By the children’s first birthday, attachment could be demonstrated; furthermore, all infants were shown to develop some kind of attachment to a caregiver, even those with rejecting or neglectful caregivers. Other investigators soon showed that attachments could form toward fathers, even when mothers were the primary caregivers, if the father had had an important role in the infant’s early experience. A  small number of such attachments could form by the first year, but one secure one would be sufficient for optimal development. Later work showed that adoptive parents could produce securely attached infants if their caregiving were sufficiently attuned to the infant’s changing needs. This basic work on the development of attachment in the latter part of a baby’s first year has been replicated in many different populations and cultures. Attachment, secure or insecure, to one or a small number of caregivers seems to be universal, while cultural differences are present in the forms of insecurity related to cultural differences in child-rearing (to be discussed later). Today, many psychodynamic clinical theorists relate their work to some of these basic findings. For example, the ability of the parent to mentalize (to imagine what the infant’s experience might be like) is thought to relate to the parent’s sensitivity to the infant’s needs (Fonagy et al. 2002). A bit later in development, the child’s own ability to empathize in early childhood is related to the caregivers’ ability to mentalize about the infant/child. This idea is related to the understanding from an intersubjective perspective of the importance of parental empathic attunement in the development of the infant’s self. The capacity to mentalize also helps in bringing about desired consequences with a parent and in managing affect, beautifully illustrated in the work of Daniel Stern (1985). From yet another theoretical point of view, that of control-mastery theory (see chapter  4), the first attachments to caregivers are seen as critical, constituting a set of expectations as to how fundamental needs will be satisfied (or not), and as the potential earliest origins of what will come to be pathogenic beliefs later in development (Shilkret & Silberschatz 2005). Attachments: Secure and Insecure During the Baltimore study, Mary Ainsworth and her team, almost as an afterthought, wanted a quick way to confirm in the laboratory the quality of the mother–infant interactions they were observing in the homes. They designed a half-hour procedure, the “Strange Situation,” which confirmed what they found in their home observations and which became one of the most widely used procedures in developmental research. In the Strange Situation procedure, mother (this term will be used to refer to the primary caregiver) and infant

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come to a comfortably furnished room with several toys scattered about. They are joined by a friendly female. The novel room, toys, and new person are “strange” to the year-old infant, and the experience typically is mildly anxiety arousing for such a young child. The mother then leaves the stranger and infant alone for a few minutes, and then returns for a while. There are a few more departures and returns, each for a few minutes. It is all observed. A securely attached infant at this age typically becomes upset, often crying when the mother leaves. However, one of the most important things Mary Ainsworth taught us was that, even more important than the infant’s reaction to mother’s leaving is, how the infant responds to the mother’s return. A secure attachment is marked by the upset infant’s welcome of the mother’s return and his use of the mother to calm down and to begin to explore the novel environment at her encouragement. Thus, it is a developmental milestone at this age for the infant to be upset by the mother’s leaving in a strange environment. This would not happen at home, where the environment is familiar and the caregiver’s comings and goings are routine. But the quality of the overall interaction is quite similar between home and laboratory. Furthermore, an older child, even a two-year-old, would not respond like this; an older securely attached child would not be as bothered by the mother’s brief absence. Thus, the Strange Situation procedure is appropriate only for infants from twelve to eighteen months. In Ainsworth’s families, replicated in many subsequent samples and in different cultures, about two-thirds of the infants were securely attached and one-third insecurely attached. Security of attachment at one year means the infant/toddler can use the mother as a secure base from which to move away and explore and as a haven of safety when distressed. The basic distinction (secure/insecure) across the lifespan has been one of the most robust developmental variables ever; thousands of studies have shown it to be related to everything from behavior in the preschool and beyond (secure toddlers/children do better socially and cognitively than insecure ones) to institutionalized children in Bulgaria. For example, impoverished mothers in Bulgaria are likely to institutionalize their children rather than choose some less disruptive form of childcare if they are insecure in their adult attachment style. It is likely that mothers who institutionalize their children, compared with other impoverished mothers who use day care, are less empathic with their infants’ needs. Furthermore, those with insecure attachments are more likely to contribute to intergenerational attachment problems in their children (Markova et al. 2008). Insecure Attachment Styles Of the one-third insecure attachments, Ainsworth differentiated two types. Avoidant infants often did not protest their mother’s leaving, and they typically did not respond to her immediately upon her return. At an earlier time, some critics of attachment theory thought these infants were prematurely independent, rather than insecure. But avoidantly attached infants typically had later difficulties in preschool, often acting out against peers. Further physiological studies demonstrated that avoidant infants in the Strange Situation had biological markers of anxiety when their mothers left, higher even than the overtly upset secure infants. This form of insecure attachment derives from caregiving that is not responsive to (at an extreme, rejecting or punishing) the infant’s dependency needs. Mothers of avoidantly attached infants are not necessarily neglectful; indeed, they might be quite responsive to their infant’s independence bids. But, even so, an important need of the infant is not being met, and by twelve months infants of such caregivers have developed a way of keeping their anxiety well under control. Ainsworth’s second type of insecurity, ambivalent infants (also called resistant) also were typically quite upset when their mothers left and seemed to welcome their return, but then

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did not calm down readily, and they often resisted their mother’s attempts to calm them. For ambivalent infants, clinginess alternated with anger. Ambivalent/resistant one-year-olds have typically had inconsistent (at an extreme, chaotic) caregiving. Again, these caregivers might not be frankly neglectful, but their responses to the infant’s needs are usually not timely or effective in reducing the infant’s particular need of the moment. By a year, such infants have learned that such a parent responds more consistently (or at least eventually) to overt and persistent expressions of needs. Thus, by one year we see a crying, clingy baby. Of these two types of insecurity in infancy, avoidant versus ambivalent/resistant, avoidance is more frequent than ambivalence in American samples, an asymmetry that is different in other cultures (to be discussed later). And the distinctly different psycho-physiological profiles of these two fundamentally different types of insecurity have been demonstrated (Roisman 2007). Bowlby and Ainsworth did not think that the differences in attachment styles observed for life’s first relationships were simply a catalogue of interesting and important behavioral differences in infancy. They proposed that the earliest attachment styles (and an infant can form a small number of attachments, as noted earlier) become the basis of internal working models (IWMs) of attachment, which are internal templates, or schemas, of interactions, defining the expectations of infant and young child for what close relationships are like. In later childhood, adolescence, and adulthood, these IWMs, significant parts of which function unconsciously, determine interpersonal expectations and behavior, especially with important people in one’s life—one’s friends, lovers, children, teachers, bosses, therapists. For example, Haydon et al. (2012) demonstrated that early attachment quality is among the best predictors of the quality of adolescent romantic relationships; she also showed how earlier attachment quality can be subsequently modified (to the good or ill), but not erased, by later secure versus insecure relationships. Returning to our historical narrative, Mary Main, a student of Mary Ainsworth, extended the idea of the IWM through adult life. She developed the Adult Attachment Interview (AAI) for assessment of attachment styles in adolescence and adulthood, corresponding to the Strange Situation for assessment of attachment in infancy. The AAI is a clinically sensitive, semi-structured interview, in which the investigator inquires about important attachment figures in the person’s past and present, instances of separation and loss, and how earlier attachments influenced later development. How the person talks about her attachments is much more important in the assessment than the “facts” of the history and current relationships. For example, even if someone had a significant trauma history, if the person can describe it coherently, with moderate affect (rather than overwhelmingly or in a highly distancing style) and with a degree of self-reflection, that usually indicates a secure (rather than some form of insecure) current IWM of attachment. Understanding the basis of the AAI, even if one is not formally trained in its use (although training is required for its use in research), is extremely useful today for any therapist listening to clients’ discussions of their past and current interpersonal difficulties and for understanding the attachment issues being brought into the therapy relationship itself. From her AAI, the detailed assessment of one’s “state of mind” regarding attachment issues, Main identified adult attachment styles corresponding to Ainsworth’s original categories of infant attachment. Secure adults are clear, consistent, and relatively succinct in their descriptions of their histories of close relationships; they modulate affect well and are not defensive or overwhelmed when they are angry. Again, this is not to say that secure attachment cannot be preceded historically by considerable trauma, but a secure resolution involves the ability to discuss such trauma relatively calmly with some desire and attempt to understand it.

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In contrast, dismissing adults (corresponding to Ainsworth’s avoidant infant attachments) remember little about early attachments, minimize their importance, often are superficial and contradictory within the interview, and may idealize their parents. For example: Ed, a working-class Greek American in his late twenties, entered therapy because his wife had had an affair. He wanted to decide whether or not to end the marriage. In therapy he focused on her behavior as he struggled to make a decision. The therapist’s attempts to connect this decision to other psychologically relevant material were politely ignored. He denied that his numerous dreams had any meaning and he also denied that his family history was relevant even though he mentioned that his father had had numerous affairs, which were both allowed and not allowed in his Greek community. When he did discuss his early life, he usually emphasized how independent he was as a child. He presented memories in an upbeat way no matter what the content. For example, he reported approvingly that his mother was a no-nonsense, “get on with business” type of person. He remembered one time when he was about seven years old. He came home from school upset because the teacher had criticized him. He was looking for comfort by following his mother around as she cleaned the house. She finally got annoyed and said, “Just get over it and stop following me.”

Ed’s memory of this interaction with his mother suggests that he developed an avoidant attachment style as an infant to enhance his attachment to a mother who had little tolerance for displays of neediness. As an adult in therapy he enacted his dismissing style with the therapist, minimizing the affective impact of her comments. Knowing Ed’s attachment style helped the therapist to understand that he was not uninterested in the therapy; rather, he was attached to her in the way that had worked best with his mother earlier. The therapist had to tolerate Ed’s minimization of their relationship as he slowly increased his ability to tolerate feelings of dependence. The dismissing form of insecurity is distinguished from preoccupied adults (an adult version of Ainsworth’s ambivalent infants), who dwell on early childhood conflicts without resolving them; they are often angry about and preoccupied with earlier and/or current attachment figures. Anna, the forty-year-old daughter of Italian immigrants, began therapy by presenting herself as desperate for the therapist’s help. Her husband was threatening to leave her because he could no longer tolerate her treatment of him. Sometimes she would go out with her friends after work without even calling him, while at other times she would get very upset if he did not want to stay at home with her. In therapy she found it difficult to discuss anything other than the way everyone mistreated her. The therapy was marked by frequent demands that she needed immediate answers to her problems, but she was rarely satisfied with any suggestions that the therapist made. Anna described a volatile and chaotic family life. When not focused on her own problems, her mother was usually overly involved and controlling. Her parents fought constantly and sometimes violently, and this was frightening for the children. When the parents were fighting, her mother typically ignored Anna’s increasing upset until Anna began to sob hysterically. Her mother would then try to calm her, but by that point Anna felt quite out of control and was hard to soothe.

Anna’s early experience of inconsistent mothering resulted in the development of a preoccupied attachment style as an adult (and, the therapist surmised, an earlier ambivalent/ resistant style as an infant and child). The therapist of an adult client often cannot know the client’s earlier attachment style. But this is less important than the client’s current style. As a young child Anna probably could not be sure that her mother would be consistently available and so she had to intensify her upset to be sure she truly had her mother’s attention. As an adult in therapy she enacted her preoccupied attachment style to be sure of holding her therapist’s attention. The therapist often felt barraged and burdened by Anna’s demands.

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Understanding Anna’s preoccupied attachment style helped the therapist to empathize with Anna and to recognize that she did not believe that the therapist would remain a consistent attachment figure unless she exaggerated her suffering. That understanding helped the therapist to worry less about Anna’s demands. Mary Main also reanalyzed Ainsworth’s Baltimore results and articulated a fourth infant category, called disorganized (sometimes called unresolved) attachment, for the small percentage of those who were unclassifiable in Ainsworth’s original system. These infants showed the absence of a consistent strategy in the Strange Situation in trying to deal with anxiety about separations. Only about 5 percent of the sample was so classified, but these were infants who were quite worrisome. Sometimes, obviously upset, they would approach their mothers but freeze midway toward them, appearing frightened. At other times, they might demonstrate equally puzzling behavior, such as moving in a very slow manner, as if underwater. Because these infants and young children behaved in these unusual ways only under stress, they were given a secondary classification (e.g., disorganized/avoidant) to describe their attachment behaviors more fully. This type of insecure attachment is the consequence primarily of fear in infancy and early childhood, fear of the parent (at the extreme, of abuse or severe neglect), or fear by the parent of unrealistic dangers or even of caregiving itself (Cassidy & Mohr 2001; Lyons-Ruth & Jacobvitz 2008). Main also found a similarly small group of unresolved/disorganized adults from her AAI assessments. In the context of an interview that might also be characterized as generally conforming to one of the other styles, such adults showed episodes of manifest disorganization in their discussion of early trauma or a recent upset. Grace, a middle-class, white administrative assistant, came to therapy because she was very depressed about her inability to develop a stable relationship with a partner. She was able to discuss her family history in a general way. However, when asked for details about specific family interactions, she often became vague and confusing and was frequently unable to remember events even if they had happened the previous week. Sometimes, as she tried to recall events, she felt increasingly frightened in the session and she did not know why. She often appeared to fall asleep in the sessions. Occasionally she reported strange bodily sensations during a session, such as the feeling that her body was changing size and floating away. After a very long period of not being able to remember many details of her early life, Grace began to recall that her mother had been seriously depressed for much of her childhood. Her mother left Grace in the care of the maid, and on the maid’s day off her mother did not seem to know what to do with her. If Grace got upset or had a tantrum, her mother stood by helplessly and did nothing. Grace remembered long periods of being alone.

Grace’s difficulties in forming stable relationships and her extreme fearfulness in therapy suggested an early history of inadequate attachment figures and possibly traumatic experiences. Her mother had been unavailable due to her severe depression, and the maid, although attentive to her physical needs, was not an adequate substitute. Because she had not been able to develop a consistent attachment style, relationships were frightening and mystifying. As Grace alternated between different affect states, her therapist often felt confused and very worried, unsure of what would be most helpful for her. Understanding Grace’s disorganized attachment history enabled her therapist to master her own uncertainties and to stay calm in the sessions; her consistency countered Grace’s experiences with her frighteningly unavailable mother. Attachment over Time What about Ed’s, Anna’s, and Grace’s developmental continuities? What is the correspondence more generally between the earliest attachments and subsequent adult attachment?

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There are now several large-scale longitudinal samples (see Grossman et al. 2005), and the concordance, or degree of correspondence between infant attachment and attachment later in life, is in the 70–80 percent range, which is quite impressive. This is understood in terms of continuity of care; the parent who is attuned (or misattuned) to the infant is likely to be similarly attuned (or not) to the older child and adolescent. Studies of the 20–30 percent lack of correspondence of attachment style over development have shown that insecure attachments might be improved (and the move from earlier insecurity to later security is called earned security) by (1) an advantageous change in parenting (e.g., divorce in a highconflict family; marriage of a beleaguered single parent to a caring new partner); (2) introduction of a helpful other, such as a concerned family member, teacher, or clergy person; and (3) psychotherapy. Likewise, the converse change (secure to insecure) can occur by trauma (e.g., the Robertsons’ John) or other deleterious changes in parenting or traumatic events. But the majority of cases demonstrate attachment continuity across the life span. Continuity is also influenced by the peers and adults that a child or adult encounters. Particular behavior toward others evokes responses that often recapitulate earlier attachment patterns. For example, children’s relationships with child care workers and later with teachers may be consistent with their earlier relationships with parents. But later attachments to particular people may also be different from the quality (secure versus insecure) of earlier attachments (Haydon et al. 2012). Another kind of developmental continuity is the intergenerational transmission of attachment patterns from parents to children and beyond. Mary Main’s original AAI study of adult attachment was done with first-time mothers. Their infants were assessed independently by the Strange Situation, and the degree of correspondence between mothers’ and infants’ attachment styles was high. Several other studies have confirmed this intergenerational correspondence (in the 70–80 percent range), even when mother’s attachment status is assessed prenatally. While the AAI is considered the gold standard of adult attachment status, there are now several self-report measures (i.e., questionnaires) of adult attachment used in research that do not require the time or special training that the AAI does and also take far less time to administer and score (see Crowell et al. 2016 for a review of those measures). Most of these measures, and indeed the attachment styles described above, can be understood in terms of two independent dimensions (Slade 2016). One is the distinction between the avoidant/ dismissing style and the ambivalent (resistant)/preoccupied style. This dimension is quite similar to one that many clinicians use, the one distinguishing, for example, obsessive versus hysterical defenses. A second dimension is that regarding the degree of organization of experience, from organized to disorganized. As Slade (2016) has argued, many clinicians who use attachment theory fail to understand this fundamental distinction. The avoidant/ dismissing and ambivalent/preoccupied styles are both organized ones, although perhaps less organized and certainly less effective than the secure style. Thus, one can think of three “levels” in terms of this system: the secure style; the original two organized but insecure styles (avoidant/dismissing and ambivalent/preoccupied); and, finally, the disorganized/ unresolved style. Attachment researchers are loath to regard the second level of insecurity, especially in infancy, as a “diagnosis” in itself. Rather, insecurity is seen as an exquisite adaptation to a particular history of parenting experiences, and it is formed by the end of the first year. Avoidant infants typically have primary caregivers who have a great deal of difficulty with dependency themselves, due to their own attachment histories. These parents do not like “lap babies”; they discourage, or even punish, crying and other expressions of dependence. By one year, their infants have developed a striking capacity to inhibit their expression of distress.

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Yet why should avoidance be considered an attachment at all? Recall Ainsworth’s original definition of attachment in terms of proximity-seeking in infancy. The avoidant adaptation keeps a parent who does not like dependency as close as possible. As noted earlier, these are not necessarily neglectful parents; they are often quite responsive to independence bids by the child. For example, Ed’s mother (discussed previously) was an adequate mother in many ways. She cared about her children and proudly recounted their successes. However, she was consistently disapproving of “weak” emotions such as sadness, neediness, or dependency. In contrast with the avoidant infant, the ambivalent infant typically has a parent who is generally inconsistent in her/his responses, and sometimes chaotic. But this parent is more consistent in response to overtly expressed dependency needs (e.g., crying), although the intervention might be ineffective in calming the infant due to a lack of attunement. This infant’s ambivalence in the Strange Situation directly follows from this history. The ambivalent infant may cry bitterly but is unsure that she can be comforted by the parent’s ministrations. She appears to want comfort but may arch away when her parent attempts to calm her. For example, Anna, the preoccupied client discussed earlier, reported that her mother was not always neglectful but was caught up in her own dramas with Anna’s father. She did respond to Anna’s crying, but by the time she did, both mother and daughter were so tense and upset that Anna did not feel soothed.

TRAUMA AND ATTACHMENT Insecure attachments are not necessarily related to trauma. Both dismissing and preoccupied attachment styles are adaptations that enhance attachment to the parent’s attachment style. Another reason why early insecure attachment is not seen as a diagnosis (but may be regarded as a risk factor) is that so much can change with a young infant over time. We know now the kinds of things likely to reduce insecurity and, it is assumed, later difficulties. Disorganized attachment, by contrast, is regarded as a matter of serious concern (similar to a diagnosis) in itself, because it is so clearly maladaptive. A great deal of theoretical speculation and research in the past decade has involved understanding trauma experiences from an attachment point of view and most of it has centered on the disorganized attachment classification. Recall that a good part of Bowlby’s original work involved the effects of the trauma of separation and loss of the mother on the infant/child’s development. But even when the trauma has not been as severe as a sudden or profound loss, specific caregiving behaviors that are traumatic have been a focus of attachment attention. The general transmission model is that the parent’s internal working models drive her/his caregiving behaviors and these behaviors affect the internal working models of the infant/child, which, in turn, are reflected in overt behavior. Disruptions in effective parental communication (e.g., mocking or teasing the infant, silent interaction, nonresponse to clear infant cues, unusual changes in pitch/intonation) can lead to the infant’s “fright without solution” and eventually disorganized infant attachment (Lyons-Ruth & Jacobvitz 2008). Research by Beebe and her collaborators (Beebe et al. 2012) have examined the interactions between four-monthold infants and their mothers. The mothers of infants who were later categorized as disorganized demonstrated a particular pattern of responding to infant distress with behaviors that denied the infant’s distress, such as smiling. Thus, one can speculate that as early as four months of age, the infant is dealing with “fright without solution” since the infant cannot rely on the mother to deal with the infant’s distress. And, as expected, frank abuse is also fear-producing and has been associated with disorganized attachment that continues into adulthood (Stovall-McClough & Dozier 2016).

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As noted earlier, studies have shown that disorganized attachment styles often develop under two surprisingly different circumstances: (1) when there is serious abuse or neglect; or (2) when a parent appears to be afraid of the child or of imagined environmental dangers and conveys this fear and sense of danger in her caregiving (see Cassidy & Mohr 2001). Melanie, a middle-class African American woman, had been sexually abused as a child. In adulthood she struggled to cope with numerous fears and phobias, occasionally severe enough to require hospitalization. She was a devoted mother who did not want to subject her children to her fears. When she became fearful, Melanie would often lock herself in her bedroom until her panic subsided. She believed this would protect her children from being contaminated by her fears. However, from her children’s perspective Melanie seemed to be afraid of being with them and they became extremely upset by her withdrawal.

Similarly, Grace (the client with the disorganized attachment style, discussed previously) was not abused or physically neglected. However, her mother’s inability to respond to Grace, as a result of her own severe depression, conveyed to Grace that her mother was afraid of being attached to her. That left Grace unable to find a safe attachment style to connect with her mother, and it left her fearful of attachments in general. Attachment Theory and Neurobiology In addition to the effects of mother–infant interactions on the child’s behavior, some researchers have been exploring the possible effects of those interactions on the neurobiology of the infant. Allan Schore (e.g., Schore & Schore 2008) has synthesized a great deal of research on early brain development and functioning. He believes that these attachmentrelated interactions shape the early organization of the brain—in particular, the right brain hemisphere with its extensive connections to the limbic system, both of which are important in processing emotions. While worthy of further study, the implications for adult functioning are speculative at this point and may, in fact, overemphasize the left brain–right brain distinction. There are no longitudinal studies of brain functioning and attachment. The exclusive emphasis on early right brain development overlooks the plasticity of the child’s developing brain, which continues at least until puberty (Davidson et al. 2000), as well as the extensive connections between the left and right hemispheres via the corpus callosum. The complexity of the brain’s functioning in emotionally charged relationships can be illustrated in a study by Lenzi et al. (2009), who measured brain activation (using an fMRI) in mothers while they looked at pictures of the faces of infants representing four affective states (joyful, distressed, ambiguous, and neutral). When looking at the infants expressing joy, mothers showed primarily right hemisphere activation. But “observing ambiguous expressions greatly activates areas in the left hemisphere, which is involved in higher cognitive and motor control” (p. 1131). It would seem that Schore’s speculations about nearly exclusive right hemisphere attachment correlates are premature and overly simplistic, and the exclusivity of the separate hemispheres can no longer be defended, given the work of Fonagy and so many other brain researchers since this was first written in 1996. Both hemispheres function continuously across development, with the left hemisphere highly involved when attempting to understand affect-laden expressions. (See Wachtel 2014 for additional discussion of this topic.) Coan (2016) has pointed out that while there have been many neurobiological studies of attachment in nonhuman animals, there have been many fewer studies of human infants. Modern imaging techniques, such as fMRIs and PET scans, may be useful in furthering research in this area but at this point “they are rarely capable of identifying causal brain-behavior relationships” (p. 244). In fact, Coan suggests that the whole brain might

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be considered an attachment system since so many different parts are involved in aspects of attachment. (See Coan 2016 for a detailed exploration of the neuroscience of attachment.) No doubt future research will differentiate further dominance characteristics of complex attachment-related behaviors and how these change over development. But how this relates to differential attachment patterns, much less to therapeutic issues, is unknown at this point. Also, while the brain-behavior connection is interesting, it is not crucial for good clinical work with clients. However, students do need a rudimentary understanding of neurobiology. Most schools of counseling, social work, and psychology teach some neurobiology, and it is helpful for understanding both attachment and trauma. Understanding the behavioral manifestations of the different attachment styles will encourage the client and therapist to feel comfortable with respect to attachment in the therapeutic relationship and should be sufficient for therapeutic progress. Attachment Theory and Temperament One early criticism of attachment theory (before the infant adaptations to differential parenting experiences were fully articulated) was that attachment was a developmental consequence of biological differences at birth (called temperament). Several kinds of evidence have addressed this alternative hypothesis. For one thing, a child often has different attachments, even secure ones along with insecure ones, to different adults depending on differences between multiple caregivers. Most parenting couples may be similar in their parenting styles, but a significant minority are not, and it is from those that we know about this kind of complexity. These different attachments suggest that attachment is not determined by temperament and that parenting can override differences in temperament. A strikingly convincing study addressed this issue in favor of the attachment ­explanation— that is, in terms of experiences after birth rather than inborn temperament. Dymphna van den Boom (1994) performed a critical experiment with 100 “difficult” infants—that is, infants who cry easily and are difficult to calm. (This was a heroic study in that it took her several hundred infant assessments to find this sample.) These were the very infants that the temperament hypothesis would expect to develop insecure attachments at one year and beyond. Half the infant–mother pairs (the control group) were left alone, with infant Strange Situation assessments done at one year. The other half of infant–mother pairs received three interventions by van den Boom herself after the sixth month, during which she helped mothers respond more effectively to their difficult infants. The choice to begin intervening midway through the first year was deliberate. It is around then that infant social behaviors begin to get organized as a discriminating response system to one or a small number of caregivers. Further, after six months with a difficult infant, the mothers were quite eager to receive help! The interventions consisted of clinically sensitive, nonjudgmental, problemsolving sessions with each mother–infant pair. In the control group (no intervention), about two-thirds of the infants were insecure at one year. Note that if you stopped here, you might be tempted to conclude that the temperament hypothesis was valid. In everyday life, difficult infants do often end up insecurely attached but, as it turns out, not primarily because of their temperament. In the intervention group, fully two-thirds were secure, not insecure, at one year, a percentage no different from the population of infants at large. Thus, van den Boom demonstrated how to prevent what would likely have been many insecure attachments. The study has obvious implications for very early intervention policies as well as for the theoretical controversy it largely laid to rest.

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Attachment and Psychopathology Some findings show specific psychopathological outcomes related to specific kinds of attachment styles among adolescents and adults. Borderline disorders have been related to disorganized attachment (Cassidy  & Mohr 2001; see DeKlyen  & Greenberg 2016; and Stovall-McClough  & Dozier 2016 for general summaries of this issue). For example, in a small group of hospitalized adolescents, Rosenstein and Horowitz (1996) found that those with dismissing attachments were more likely to have conduct or substance abuse disorders, narcissistic disorders, or antisocial disorders, while those with preoccupied attachments were more likely to have affective disorders and obsessive-compulsive characteristics. This makes sense, in that dismissing attachment involves externalizing one’s difficulties, whereas preoccupied attachment is characterized by a great deal of manifest anxiety and conflict. Virtually all of these hospitalized adolescents were insecurely attached, as were their mothers. But the relation between insecure attachment and diagnosis is far from one-to-one. There are many other insecurely attached adults who exhibit no consistent symptoms. Attachment and Gender It may be surprising to some that in the many hundreds of studies of infant attachment there have been very few sex differences found. Boys and girls seem to develop insecure attachments at about the same rate (about one-third are insecure of one type or another at one year). Infants seem to develop their types of insecurities independent of their gender— that is, in American samples, there are often more avoidant insecure infants than ambivalent insecure infants, but this seems to be true for both boys and girls. This is understandable when one considers that the needs of the young infant are the same for both sexes—that is, all infants need a “good enough caregiver” for optimal development (and for secure attachment). It is more surprising, perhaps, that there are still few reports of gender differences in attachments of young children, older children, adolescents, and adults. The avoidant (dismissing) attachment might be expected to occur more among males and the ambivalent (preoccupied) attachment more among females. Perhaps the failure to find robust, well-replicated findings regarding gender differences in attachment speaks more to our stereotypes about gender than about real differences. There are a few reported gender differences in children, but these are subtle. For example, Turner (1991) found no differences between secure fouryear-old boys and girls, but insecure attachment had different behavioral correlates for girls versus boys (e.g., insecure girls were more dependent; insecure boys showed off and boasted more). But even here, there were few gender differences in attachment styles themselves. The clinician, therefore, should be equally attuned to the possibility of any kind of attachment style in male and female clients. Attachment and Considerations of Race, Class, and Culture Attachment is a major influence on a child’s development. However, children grow up embedded in a larger community and are influenced by aspects of these larger communities. These other factors must also be considered alongside those of attachment style. Irene, a middle-class African American woman entered therapy wanting help with her preoccupation over an upcoming medical procedure. She denied that she was anxious about the procedure; she just wanted some advice about planning for her recovery. Her minimization of her worry,

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and her minimization of problems in general, suggested that her attachment style was dismissing. She decided to continue in therapy after the procedure was successful, although she was not sure why. What then emerged was that she was very concerned about her elderly mother who was showing increasing signs of dementia. Irene had cared for her at home but it was becoming very difficult since her mother had begun to wander the streets while Irene was at work. Irene was single and needed to work to support herself. She had one brother but he was of minimal help. He felt that caring for their mother was “women’s work” and that it was Irene’s responsibility to do so. Irene also believed that it was her responsibility and that “Black people don’t put their parents in nursing homes.” She thought briefly of quitting her job to stay with her mother. But she loved her job and, in the absence of a supportive partner or supportive relatives, it provided her major source of self-esteem. Over time, as the therapist remained sensitive to her dilemma, Irene was able to acknowledge the difficulty of her situation. She did a great deal of research, considering several assisted living facilities, and finally settled on one facility that had a number of residents of color so that her mother would feel comfortable. Once her mother was settled in the facility Irene abruptly ended her therapy even though she had begun talking about problems in her latest intimate relationship.

In this example, one can see the intersection of attachment style, race, culture, and gender norms. Irene felt very guilty about her wish to move her mother into an assisted living facility, since it went against her beliefs as a Black woman as to how she was supposed to behave. But her dismissing attachment style made it very difficult for her to acknowledge any uncomfortable feelings. (As the therapist learned during the therapy, Irene’s mother was very critical of “weak” feelings. She conveyed to Irene and her brother that life was hard and you just had to get on with it and not complain.) Given her dismissing style, Irene did not respond to any interventions that suggested she might feel guilty or anxious. She was not able to examine her feelings about the therapist or consider any feelings the therapist might have about her. The therapist also considered that, in addition to her attachment style, Irene’s minimization of her feelings might reflect understandable caution about discussing racial issues with a white therapist. However, Irene insisted that she had no concerns that she was discussing with a white therapist how a Black woman should behave. The therapist remained respectful of Irene’s viewpoint, which allowed Irene to control if and when racial issues would be discussed. The therapist’s consistently noncritical attitude allowed Irene to make this extremely painful decision. But she was not willing to go further in the therapy, and it ended at that point. Are attachment styles universal? Do the same kinds of attachment styles and distributions of attachment styles arise in cultures with different kinds of child-rearing and differing expectations and values for children? Might what is considered insecure in Western culture be considered secure in some other? As usual with this kind of question, it is far easier to speculate about or imagine cultural differences than to demonstrate them. There have been a moderate number of attachment investigations in other cultures, and generalizations are difficult. Still, in many different cultures, the basic finding of about two-thirds of secure attachments in infancy and beyond has held. Mothers from cultures with different values, when asked which of the three types of infant they would prefer (Ainsworth’s original secure, avoidant, and ambivalent), typically choose the “secure” description. However, close examination of the responses of these mothers by researchers who are familiar with the culture being studied can highlight subtle differences. For example, Harwood et al. (1995) compared working-class and middle-class Anglo mothers and Puerto Rican mothers and found that all four groups of mothers preferred the description of the securely attached child, but for different reasons. The Anglo mothers felt that the descriptions demonstrated a good balance between autonomy and relatedness, while the Puerto Rican mothers felt that they demonstrated a good balance between respect for and positive engagement with elders.

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Nonetheless, there have been intriguing findings regarding more subtle differences in types of insecurity in different cultures. Consider the avoidant/ambivalent distinction as a continuum. Many Western cultures value independence (avoidance) more than dependence (ambivalence); many other cultures have the opposite value. For example, in Western cultures that value independence and autonomy, it is not surprising that we find more avoidance than ambivalence among insecure attachments. In northern Germany, independence is valued even more than in American culture, and there seem to be even more avoidant attachments there (Grossman et al. 1985). The Israeli kibbutz, in contrast, values interdependence, especially among the peer group, over independence and autonomy. The attachments of kibbutz-raised infants and children have typically found few, if any, avoidant attachments; nearly all the insecurity seems to be of the ambivalent type (e.g., Sagi et al. 1994). And it has been found that the peer group itself can serve as an object of attachment in the kibbutz (Weiss & Shilkret 2010). Another culture that values interdependence more than Western culture is the traditional Japanese one. In childrearing, great value is placed on the mother’s anticipation of the infant’s needs and early response. When insecurity occurs, it is much more likely to be of the fussy, irritable sort characteristic of the ambivalent infant than the aloof avoidant one. Whether this supports attachment theory or questions it is currently a matter of healthy debate (Rothbaum et al. 2000, 2001). Attachment theorists tend to emphasize the universals of development; their critics emphasize cultural specificity. The fact is that there are still comparatively few large-scale attachment studies of a wide range of cultures, and this is still a “growing point” of attachment research. For the clinician, it is useful to know about differences in child-rearing and different values that parents have for their children. What an adolescent might consider parental intrusiveness in a Eurocentric society might well be considered appropriate concern in some other part of the world as well as in some cultures in the United States.

IMPLICATIONS FOR PRACTICE Although attachment theory is not in itself a theory of psychotherapy, as we have noted, it has several important implications for therapeutic practice. An understanding of the principles of the AAI (e.g., degree of coherence in the narrative; level and control of affect) sensitizes clinicians to listen in a particular way to the descriptions clients give of their early attachments and current close relationships (see Main 1995 for a full description of the AAI and Hesse 2016 for a summary of it and research using it). There is a similarity between the role of the parent of an infant/young child and the role of the therapist in that the therapist is trying to create a secure base from which the client can explore her difficulties (Bowlby 1988). The transference that forms in the client–therapist relationship increases the likelihood that the client will recreate with the therapist the type of attachment that she formed with her caregiver. According to Dozier, the therapist’s task is more difficult than the parent’s, however, in that the parent does not usually have to be concerned with modifying past caregiving and attachment difficulties or failures (Dozier & Tyrrell 1998). It is useful to see clients in terms of their particular attachment styles in the therapeutic relationship. Clients with dismissing attachments minimize the importance of close relationships and see little relevance in discussing early history. In therapy, they may minimize the importance of the therapy itself and denigrate the therapist’s comments. The therapist dealing with such a client may feel unimportant, even impotent. There is a temptation to allow premature termination; indeed, short-term therapy may be all that is possible for some of these clients. In contrast, clients with preoccupied attachments may become preoccupied with the therapy, brooding over the meaning of the therapist’s comments, vacillating

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between being overly needy and angrily defiant. Frequent countertransference reactions include the therapist’s experiencing worry and frustration. (See Shilkret 2005 for a full discussion of transference and countertransference reactions characteristic of different attachment organizations, with several clinical examples.) While clinicians have increasingly discussed the transference and countertransference aspects of attachment style, formal research originally focused on the impact on therapy of the client’s attachment style. For example, Hardy et  al. (1999) determined that therapists tended to make more cognitive interventions to dismissing clients and more affective interventions to preoccupied clients. However, some studies have now looked at the impact of the therapist’s own attachment style on the therapeutic process. Dozier and her colleagues have studied the impact of case managers’ attachment on the process and outcome of their work with clients with serious psychiatric disorders. While most of the case managers were rated “secure,” they found that case managers rated “more secure” tended to reflect on and respond to their clients underlying needs more than case managers who were less secure (Dozier et al.1994). Tyrell et  al. (1999) also found that insecure clients tended to show more improvement when they were paired with a case manager whose style contrasted with their own. These results can fit into an understandable clinical framework. In order to build a therapeutic alliance, it is probably helpful to use language that does not make the client excessively anxious. So a dismissing client may be more willing to accept an intervention that is framed in cognitive language (with the emphasis on thoughts rather than feelings) since feelings had to be defended against because her caregiver would not respond to them. However, if the role of the therapist is to help the client disconfirm the client’s usual expectations and defensive strategies so that he or she is able to change, then not matching the client’s attachment style should further the therapeutic work. In fact, therapist flexibility plays an important role when considering the effects of attachment. There is research evidence both that securely attached clinicians demonstrate flexibility in their clinical work (Slade 2016) and that experienced clinicians are flexible in their interventions, matching the client’s attachment style at the beginning of therapy and then challenging it as the therapy progresses (Daly & Mallinckrodt 2009). Again, attachment theory is a theory of development, not a theory of therapy. Therefore, it does not suggest specific therapeutic interventions or a specific theory of therapeutic change. As Slade has stated, “Attachment informs rather than defines intervention and clinical thinking” (2016, p. 761). For some clients, attachment issues may be the focus of therapy, while for others they may be a more minor part of treatment. As such, attachment theory is compatible with several current psychodynamic theories (e.g., control-mastery theory, object relations, relational theory), and many treatment models have incorporated attachment concepts into therapeutic work with children (see Berlin et al. 2016) and with adults (see Obegi & Berant 2009). For this reason, no specific clinical interventions were given with the examples of Ed, Anna, or Grace. What is important is to keep the client’s attachment style in mind when interacting with the client so that the client can tolerate the interventions. For example, Ed, with his dismissing style, could not tolerate any interventions that suggested he might have dependency needs. Therefore, particularly early in the therapy, the therapist made very few such comments. It might seem to an outside observer that the therapist was colluding in Ed’s denial. But eventually Ed developed the capacity to tolerate some acknowledgment of his own needs without fearing criticism (in the transference) from the therapist. From this perspective, there is no single “right” intervention. Any psychodynamic theory that includes the importance of early parent-child experiences in development can incorporate an attachment perspective.

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However, one therapeutic approach originated in the attachment theory research on the AAI, and that is mentalization-based therapy developed by Peter Fonagy and his collaborators (e.g., Allen  & Fonagy 2006; Allen et  al. 2008; Bateman  & Fonagy 2004). They define mentalizing as “attending to mental states in oneself and others” (Allen et al. 2008, p. 1). This ability develops naturally in secure relationships. But in relationships characterized by an insecure attachment, the caregiver’s inability to mentalize the child’s experience interferes with the child’s development of that capacity. Mentalization-based therapy works to help clients improve their ability to see another’s point of view. Therapeutic interventions focus on helping clients understand their own mind and, through the therapeutic relationship, understand the minds of others. This approach was first used in the treatment of those with borderline personality disorder and other severe pathologies (such as dissociative disorders) thought to be caused by attachment-related trauma but is now being used more widely (Allen et al. 2008; Slade 2016). The hope is that the increased ability to mentalize will help clients improve their ability to contain and regulate affects dysregulated by the original trauma. As its use has expanded, mentalization-based therapy is seen not as a unique therapy but as a type of intervention that is compatible with many psychodynamic and cognitive therapies, including self psychology (Allen et  al. 2008). However, recently Fonagy has expressed some doubts that mentalization alone is sufficient for therapeutic improvement. Looking at both clinical and research evidence, he noted that an improved capacity to mentalize did not necessarily correlate with improved social-emotional functioning (Fonagy et al. 2019).

CONCLUSION In concluding, it is useful to recall where we have come in the past 100  years. Sigmund Freud, in his earliest psychoanalytic writings over a century ago, assumed the importance of early experience for personality development, both adaptive and maladaptive. But Freud did not observe young children systematically, and his speculations about them remained unpersuasive to many. It is an extraordinary irony that John Bowlby, reacting against his psychoanalytic training, began the program of work that by the end of the century had moved the idea of the importance of early parenting experience out of the realm of speculation onto the firm ground of demonstrated fact, thereby confirming one of Freud’s earliest assumptions. Attachment theory has particular relevance both to those whose attachments have been problematic and to those who work with them.

REFERENCES Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant Care and the Growth of Love. Baltimore, MD: Johns Hopkins University Press. Ainsworth, M. D. S., Blehar, M.C., Waters, E., & Wall, S. N. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum. Allen, J. G.,  & Fonagy, P., eds. (2006). Handbook of Mentalization-Based Treatment. Chichester, UK: Wiley. Allen, J. G., Fonagy, P.,  & Bateman, A. W. (2008). Mentalizing in Clinical Practice. Washington, DC: American Psychiatric Publishing. Bateman, A., & Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford: Oxford University Press.

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Beebe, B., Lachmann, F. M., Markese, S., Buck, K. A., Bahrick, L. E., Chen, H., Cohen, P., Andrews, H., Feldstein, S., & Jaffe, J. (2012). On the origins of disorganized attachment and internal working models: Paper II. An empirical microanalysis of 4-month mother-infant interaction. Psychoanalytic Dialogues 22:352–74. Berlin, L. J., Zeanah, C. H., & Lieberman, A. F. (2016). Prevention and intervention programs to support early attachment security: A move to the level of the community. In Handbook of Attachment: Theory, Research, and Clinical Applications, 3rd edition, eds. J. Cassidy and P. R. Shaver, pp. 739–58. New York: Guilford. Bowlby, J. (1944). Forty-four juvenile thieves: Their character and home-life. International Journal of Psycho-analysis 25:107–28. ———. (1988). A Secure Base. New York: Basic Books. Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology 28:759–75. Cassidy, J., & Mohr, J. J. (2001). Unsolvable fear, trauma, and psychopathology: Theory, research, and clinical considerations related to disorganized attachments across the life span. Clinical Psychology: Science and Practice 8:275–98. Coan, J. A. (2016). Toward a neuroscience of attachment. In Handbook of Attachment, 3rd edition, eds. J. Cassidy and P. R. Shaver, pp. 242–69. New York: Guilford Press. Crowell, J. A., Fraley, R. C., & Roisman, G. I. (2016). Measurement of individual differences in adult attachment. In Handbook of Attachment: Theory, Research, and Clinical Applications, 3rd edition, eds. J. Cassidy and P. R. Shaver, pp. 598–635. New York: Guilford. Daly, K. D., & Mallinckrodt, B. (2009). Experienced therapists’ approach to psychotherapy for adults with attachment avoidance or attachment anxiety. Journal of Counseling Psychology 56:549–63. Davidson, R., Jackson, D., & Kalin, N. (2000). Emotion, plasticity, context, and regulation: Perspectives from affective neuroscience. Psychological Bulletin 126:890–909. DeKlyen, M., & Greenberg, M. T. (2016). Attachment and psychopathology in childhood. In Handbook of Attachment: Theory, Research, and Clinical Applications, 3rd edition, eds. J. Cassidy and P. R. Shaver, pp. 639–66. New York: Guilford. Dozier, M., Cue, K. L., & Barnett, L. (1994). Clinicians as caregivers: Role of attachment organization in treatment. Journal of Consulting and Clinical Psychology 62:793–800. Dozier, M.,  & Tyrrell, C. (1998). The role of attachment in therapeutic relationships. In Attachment Theory and Close Relationships, eds. J. A. Simpson and W. S. Roles, pp. 221–48. New York: Guilford. Fonagy, P., Allison, E., & Campbell, C. (2019). Commentary on “ ‘Trust comes from a sense of feeling one’s self understood by another mind’: An interview with Peter Fonagy.” Psychoanalytic Psychology 36:228. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press. Grossmann, K., Grossmann, K. E., Spangler, G., Suess, G,. & Unzner, L (1985). Maternal sensitivity and newborns’ orientation responses as related to quality of attachment in northern Germany. Monographs of the Society for Research in Child Development 50(1–2):233–56. Grossman, K. E., Grossman, K.,  & Waters, E., eds. (2005). Attachment from Infancy to Adulthood: The Major Longitudinal Studies. New York: Guilford. Harwood, R. L., Miller, J. G., & Irizarry, N. L. (1995). Culture and attachment: Perceptions of the child in context. New York: Guilford Press. Hardy, G. E., Aldridge, J., Davidson, C., Rowe, C., Reilly, S., & Shapiro, D. A. (1999). Therapist responsiveness to client attachment styles and issues observed in client-identified significant events in psychodynamic-interpersonal psychotherapy. Psychotherapy Research 9:36–53. Haydon, K. C., Collins, W. A., Salvatore, J. E., Simpson, J. A., & Roisman, G. I. (2012). Shared and distinctive origins and correlates of adult attachment representations: The developmental organization of romantic functioning. Child Development 83(5):1689–702. Hesse, E. (2016). The Adult Attachment Interview: Protocol, method of analysis, and empirical studies: 1985–2015. In Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd edition, eds. J. Cassidy and P. R. Shaver, pp. 553–97. New York: Guilford. Lenzi, D., Trentini, C., Pantano, P., Macaluso, E., Iacobani, M., Lenzi, G. L., & Ammaniti, M. (2009). Neural basis of maternal communication and emotional expression processing during infant preverbal stage. Cerebral Cortex 19:1124–33.

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Lyons-Ruth, K., & Jacobvitz, D. (2008). Attachment disorganization: Genetic factors, parenting contexts, and developmental transformation from infancy to adulthood. In Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd edition, eds. J. Cassidy and P. R. Shaver, pp. 667–97. New York: Guilford. Main, M. (1995). Discourse, prediction, and recent studies in attachment: Implications for psychoanalysis. In Research in Psychoanalysis: Process, Development, Outcome, eds. T. Shapiro and R. N. Emde, pp. 209–44. Madison, CT: International Universities Press. Markova, G., Shilkret, R., & Djalev, L. (2008). Parents’ attachment styles, mental representations, and institutionalization of children in Bulgaria. Infant Mental Health Journal 29:555–69. Obegi, J. H., & Berant, E., eds. (2009). Attachment Theory and Research in Clinical Work with Adults. New York: Guilford. Roisman, G. I. (2007). The psychophysiology of adult attachment relationships: Autonomic reactivity in marital and premarital interactions. Developmental Psychology 43:39–53. Rosenstein, D. S., & Horowitz, H. A. (1996). Adolescent attachment and psychopathology. Journal of Consulting and Clinical Psychology 64:244–53. Rothbaum, F., Weisz, J., Pott, M., Miyake, K., & Morelli, G. (2000). Attachment and culture: Security in the United States and Japan. American Psychologist 55(10):1093–104. ———(2001). Comments and a rejoinder. American Psychologist 56:821–29. Sagi, A., Donnell, F., van IJzendoorn, M. H., Mayseless, O., & Aviezer, O. (1994). Sleeping out of home in a kibbutz communal arrangement: It makes a difference for infant-mother attachment. Child Development 65:992–1004. Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal 36:9–20. Shilkret, C. J. (2005). Some clinical applications of attachment theory in adult psychotherapy. Clinical Social Work Journal 33:55–68. Shilkret, R.,  & Silberschatz, S. (2005). The developmental basis of control-mastery theory. In Transformative Relationships: The Control-Mastery Theory of Psychotherapy, ed. G. Silberschatz, pp. 171–87. New York: Routledge. Slade, A. (2016). Attachment and adult psychotherapy: Theory, research and practice. In Handbook of Attachment: Theory, Research, and Clinical Applications, 3rd edition, eds. J. Cassidy and P. R. Shaver, pp. 759–79. New York: Guilford. Stern, D. N. (1985). The Interpersonal World of the Infant. New York: Basic Books. Stovall-McClough, K., & Dozier, M. (2016). Attachment states of mind and psychopathology in adulthood. In Handbook of Attachment: Theory, Research, and Clinical Applications, 3rd edition, eds. J. Cassidy and P. R. Shaver, pp. 715–38. New York: Guilford. Turner, P. T. (1991). Relations between attachment, gender, and behavior with peers in preschool. Child Development 62:1475–88. Tyrell, C. L., Dozier, M., Teague, G. B.,  & Fallot, R. D. (1999). Effective treatment relationships for persons with serious psychiatric disorders: The importance of attachment states of mind. Journal of Consulting and Clinical Psychology 67(5):725–33. van den Boom, D. (1994). The influence of temperament and mothering on attachment and exploration: An experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Child Development 65:1457–77. Wachtel, P. L. (2014). When the context is in the room: Extending the relational paradigm. Psychoanalytic Dialogues 24:419–26. Weiss, Y.,  & Shilkret, R. (2010). The importance of the peer group in the Israeli kibbutz for adult attachment style. Smith College Studies in Social Work 80:2–19.

SUGGESTION FOR FURTHER READING The fullest treatment of attachment research, including relations to psychopathology and other clinical issues, is: Cassidy, J., & Shaver, P. R., eds. (2016). Handbook of Attachment: Theory, Research, and Clinical Applications, 3rd edition. New York: Guilford.

9 Neurobiology, Attachment, and Trauma Janet Shapiro

INTRODUCTION The intersection of research on attachment and trauma reflects a growing understanding of how, for the human infant, disruption in primary attachment relationships may constitute a form of toxic stress that, if left unmediated, poses significant risks to both the short- and the longer-term development of the child. As described in earlier chapters, attachment is a key organizational construct in models of risk and resiliency for the developing child. The enduring impact of attachment quality is seen in studies that demonstrate how, even in the face of adversity, access to warm, consistent, and empathically attuned care provides a social buffer from adverse experiences (Shonkoff  & Phillips 2000). The developing child’s relational experience, embedded within their unique familial and cultural contexts, is central to their well-being. Research on the social buffering effects of secure attachment also demonstrates that it is the quality of caregiving, more so than the structure of the family context, that is key to the child’s adaptive capacity over time (Keller 2018). As social workers, we see the capacity of children to develop unique relationships with multiple caregivers including parents, grandparents, and extended caregiving networks including family and community connections. More recent studies on the neural correlates of attachment demonstrate how a secure attachment relationship also confers neuroprotective benefits to the developing child, supporting brain development even in the context of stress and adversity (Cozzolino 2014; Gunnar 2003; Gunner et  al. 2006). Conversely, significant disruptions in attachment, or lack of access to meaningful attachment relationships, can be so disorganizing to a child’s developmental trajectory that these disruptions are themselves understood as traumatic stressors that can, if unmediated, compromise early brain development in ways that heighten the child’s vulnerability to future stressors (National Scientific Council on the Developing Child 2014). As an organizational construct in human development, attachment is being studied anew in light of research on early brain development and, in particular, research in the 188

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interdisciplinary field of affective neuroscience. This chapter explores the intersection of attachment, trauma, and the developing stress response system, and how these areas of research intersect in the study of affective neuroscience and the implications of this understanding for the well-being of children in the context of their families. The Centrality of Attachment as an Organizational Construct in Human Development For both psychosocial and neurodevelopmental outcomes, the development of an organized attachment to primary caregivers is a key developmental task in infancy and early childhood. As discussed in earlier chapters of this book, Bowlby’s work (1969a, 1969b, 1969c) demonstrated the evolutionary importance of primary attachments in supporting both security/safety and the developing infant’s capacity for exploration and mastery. While patterns of attachment vary and include “secure,” “insecure/avoidant,” and “insecure/ resistant,” each of these patterns is organized, though they are associated with differential developmental outcomes (Ainsworth  & Wittig, 1969; Sroufe 2000). Children who have lacked access to consistent care, as in the case of neglect; children who have experienced abuse and other frightening caregiver behaviors; and children who have had inconsistent access to attachment figures are at risk for the development of “disorganized attachments” (Solomon  & George 1999). Research has shown that “disorganized attachment” patterns are associated with the most precarious developmental outcomes, including higher rates of externalizing behavior (Solomon & George 1999). For the developing child, disorganized caregiving can constitute a “toxic stress” and thus, over time, may negatively impact the child’s developing stress response system as well (Dozier & Fisher 2014). Many groups of parents and children with whom social workers come into contact may be at risk for dysregulation and disruption in the parent–child relationship. These disrupted attachment processes may, in turn, result in impairment in the developing child’s capacity for affect- and self-regulation (Shapiro & Applegate 2018; Siegel, 2012; Stern, 1985). When a “good enough” caregiving environment does not exist, and the developing child lacks the scaffolded support for the regulation of affective experience, the child’s experience of stress is not modulated and she may develop maladaptive coping responses for managing intolerable levels of anxiety, fear, or other negative affective states. Selma Fraiberg, a pioneer in the field of infant mental health, described these coping behaviors as “infant defenses” such as gaze aversion, aggression against the self, extreme separation anxiety, and withdrawal to the self (Fraiberg 1980). It is important that caregivers be supported to recognize these behaviors as the infant’s coping strategies and not as a reflection of their need/lack of need for ongoing supportive and attuned care. It would not be uncommon, for example, for a withdrawn child to be described by child care provide as “doing well” or “being good” and “not needing anything” when in fact research has demonstrated that even a quiet, withdrawn child may have high levels of stress hormones as measured by salivary cortisol (Dozier et al. 2011). This idea that a child’s behavior may not match their stress psychophysiology is a key finding in the field of affective neuroscience and stress studies. The Co-construction of Brain Development and the Centrality of Attachment Relationships: Key Concepts A key finding from the study of brain development is that the architecture and organization of the human brain is incomplete at birth. In addition to access to adequate nutrition, freedom from abuse and neglect, and protection from environmental toxins, the quality

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of relational care, associated with variability in patterns of attachment, plays a key role in how the brain develops and organizes itself in early life. In this way, brain development is “experience-dependent” as it is particularly sensitive to environmental influences in infancy and early childhood. For this reason, this developmental phase is described as a “sensitive period” with regard to the development of the brain and central nervous system. The neural networks built during sensitive periods provide a foundation so that while the brain is still open to change later in development, it may require more significant efforts to change once the sensitive period has passed (National Scientific Council on the Developing Child, 2010). Thus, the earliest weeks and months of life are central both to the formation of attachment bonds and to the “foundations of brain architecture,” each being established through a “series of dynamic interactions in which environmental conditions and personal experiences have a significant impact on how genetic predispositions are expressed” (National Scientific Council on the Developing Child 2014, p.  1). The same early relational experiences that determine quality of attachment also shape neurobiological development. The neuroplasticity of brain development, or its openness to environmental inputs, is a double-edged sword that provides both opportunities and challenges for practitioners working with vulnerable children and families. For children who have access to “good enough” care, a wide range of parenting styles and early experience can support normative brain development. In these “good enough” relational contexts, attuned and contingently responsive care is a positive environmental influence on the developing brain. In situations of abuse and neglect, however, the developing child lacks the social buffer needed to support optimal neurodevelopment, especially with regard to the neurobiological substrates of emotional experience and the development of the stress response system (Shonkoff et al. 2012). Recently, researchers have discovered how environmental factors can influence whether particular genes are “turned on or turned off,” leading to variation in the expression of genetic potential in brain organization and function, and in other spheres of development as well. These changes are considered to be epigenetic in that the changes are not alterations of the genome, or genetic code, but instead reflect how environmental/experiential factors can activate or repress gene expression. From a social work perspective, the study of epigenetics centers our attention on key psychosocial indicators such as attachment quality and on mechanisms via which extended activation of the stress response system may link to a range of health outcomes. From an epigenetic perspective, “good enough” attachment to caregivers provides a social buffer against negative health outcomes by effectively modulating the stress response system, and we can understand chronic activation of the stress response system as resulting in stress “getting under the skin” by impacting whether particular genes are activated (McKewen 2008). Attachment and Affective Neuroscience: The Intersection of “Nature” and “Nurture” in Developing a Robust Capacity to Respond to Stress Affective neuroscience is a multidisciplinary field of study focused on the neurobiological substrate of those aspects of brain development associated with the experiencer and modulation of affective states. Many aspects of affective neuroscience align with research on attachment. In particular, affective neuroscience and the study of attachment intersect with regard to our understanding of the relational context in which the neurobiological substrate of the stress response system develops. Studies in affective neuroscience have begun to delineate how the same early relational experiences that lead to the emergence of attachment patterns become encoded in neural circuitry and carried forward as represented by the construct of the “internal working model” (Newman, Sivaratnam, & Komiti 2015; Shapiro & Applegate

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2018). In addition, research in affective neuroscience is focused on the neuroendocrine changes associated with experiences of stress and adversity and, relatedly, on the role of attachment figures as social buffers able to mediate the impact of stress on the developing child’s neuroendocrine systems (Cicchetti  & Rogosch 2012). Within the study of attachment, caregiving behavior has been construed as a “hidden regulator” of the child’s developing neuroendocrine system (Hofer 1995). Specifically, studies have shown that when the infant is stressed that the presence or touch of the caregiver has an influence on both growth and stress hormones, exemplifying how the social buffer of attachment confers neuroprotective benefits on the developing child. Each of these areas of research is supported by the emergence of new and noninvasive techniques that allow for both neuroimaging and the assessment of other key biomarkers such as salivary cortisol (Dozier & Fisher 2014). One of the most robust aspects of research in affective neuroscience is the research that demonstrates the impact of the social environment, including attachment experiences, on brain development in early life. Much of this research shows that infants who have access to stable, consistent care that is infused with an empathically attuned understanding of the child, and who live in an environment free of abuse and neglect and with access to adequate basic resources, are more likely to develop secure attachment relationships. These relationships, in turn, confer a neuroprotective benefit on the developing child. For human infants, the period of dependency on adult caregivers is long—with infants and young children depending on the adult caregivers to provide a developmental scaffold that supports the child’s own emerging capacities in areas such as the experience and modulation of affect. “Securely attached” infants and children may still experience developmental adversity and stress, but through the scaffold provided by adult caregivers, their stress response systems are protected from unmediated experiences of negative affect and anxiety. As pointed out by Bruce Perry, the child’s developing stress response system is shaped by the relational surround. “Serve and return” interactions with caregivers, in which the child’s signals are perceived and adult efforts are made to empathically respond, result in a neurobiologically mediated stress response system that “turns on” when needed and is able to “turn off” as soothing occurs. In their article on the “Neuroscience of Infant Mental Health Development,” Sampaio and Lifter (2014) describe the “neural correlates” of the developing attachment relationship. Researchers focused on the neurobiological correlates of attachment have focused their explorations on a range of applied clinical areas of work including: (1) the connection between early relational experience and the neurobiological substrate of the capacity for self- and affect- regulation, (2) understanding caregiver behavior as a coregulator of the developing infant’s experience and a key determinant of postnatal brain development, (3) the impact of contextual sources of stress and support on the developing caregiver–child attachment relationships, and (4) the ways in which the early relational experiences that shape attachment patterns of attachment (e.g., secure versus insecure versus disorganized) simultaneously shape key neurobiological substrates of emotional well-being, such as the stress response system (Schore & Schore 2010). Over time and within the caregiving context, the developing child’s own maturational processes combine with support from the caregiver(s) to develop a functioning stress response system. As with most aspects of neurodevelopment, the stress response system is shaped by a complex interplay of genetic, psychophysiological, and environmental factors. A functional stress response system is central to each person’s ability to mediate states of psychophysiological arousal, ranging from immediate needs such as sleep/wake cycles to longer-term challenges such as navigating significant losses or other adverse life events.

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When the developing child is exposed to toxic stressors and adversity, and lacks access to contingently responsive care, the stress response system may become chronically activated in a way that is associated with alterations in neurodevelopment and risks for other negative developmental outcomes. The stress response system is neurologically mediated along two pathways, the sympathetic adrenal medullary (SAM) system and the hypothalamicpituitary-adrenal (HPA) axis. Each is briefly described below. The HPA axis involves components of the autonomic nervous system and the endocrine system. The autonomic nervous system is central to the familiar “fight or flight” responses and also regulates key functions such as hormonal balance, body temperature, and dilation and constriction of blood vessels. The endocrine system is involved in both short-term and long-term stress responses and is mediated by hormones that are central to many physiological functions. Specific hormones that are secreted by the endocrine system include epinephrine, norepinephrine, and glucocorticoids. The pathway for this release begins in the hypothalamus where hormones such as corticotropin-releasing hormone and vasopressin are secreted into the bloodstream via the paraventricular nucleus. Secretion of these hormones elicits the secretion of adrenocorticotropic hormone from the adrenal cortex, which, in turn, leads the adrenal gland to secrete glucocorticoids, such as cortisol. Cortisol, broadly recognized as a “stress hormone,” is essential to our regulatory functioning in everyday life, playing a key role in the sleep-wake cycle, patterns of hunger and satiation, maintenance of blood pressure, information processing, and memory. Because cortisol can be measured not only through the blood but also through a saliva swab, it is a relatively simple biomarker of the stress response system that can be measured in both clinical and normative groups. The SAM system is comprised of two parts of the autonomic nervous system—the parasympathetic nervous system and the sympathetic nervous system. The sympathetic nervous system underlies what we may recognize as the “fight or flight” reaction to stress. When we perceive a stress, the sympathetic nervous system activates with a resulting cascade of hormonal changes. The adrenal gland releases catecholamines including adrenalin and noradrenaline and we may observe a range of effects that we may recognize as stress responses. These may include increased respiration and heart rate and dilation of pupils. When the sympathetic nervous system, or the “go” part of the autonomic nervous system, is activated, the parasympathetic nervous system works as a counterbalance. The parasympathetic nervous system works to decrease the level of psychophysiological arousal as evidenced, for example, by a decrease in heart rate and respiration. As an example of the SAM system at work within the context of an attachment relationship, picture an infant crying in frustration. At first, the infant may be crying, legs may be flailing, and her face may be turning bright red. However, if an attuned adult caregiver is available, the adult may pick up the infant and begin to rock the infant in a way that provides vestibular stimulation, which will, in turn, support the baby’s developing parasympathetic nervous system and help the baby to soothe in a way that results in regaining a state of homeostatic balance. If, however, an attuned caregiver is not available, the infant may not be able to engage her parasympathetic nervous system with the result perhaps being exhaustion and even a withdrawal to sleep. Why is it important for social work practitioners to understand the stress response system? A well-functioning stress response system is not only one that “turns on” when needed to mobilize energy to confront a challenge or threat but also one that “turns off” when the threat has passed. Research on trauma and toxic stress has shown that when the developing stress response system is chronically activated, the ability of the system to “turn off” or return to baseline when a threat has passed becomes impaired—resetting the stress thermostat to “on” almost regardless of the real-time presence of threats/challenges. In addition, chronic

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activation of the stress response system can damage process of brain development, organization, and function. For example, reduced volume of the hippocampus can occur if chronic increases in glucocorticoid levels result in overpruning of neurons in the hippocampus. The hippocampus is central to the capacity for explicit memory and thus central to the ability to form a narrative of one’s own experience and/or to retrieve explicit positive memories that could be called upon to help self-soothe in times of stress (Gunnar & Quevedo 2007). Reduced volume in the orbitofrontal cortex may be associated with deficits in the capacity for emotion- and self-regulation. Children who have experienced abuse and neglect have been observed to have atypical patterns of salivary and blood cortisol, a primary “stress hormone,” which is thought to be related to impairments in the immune system and sleepwake cycles—factors that are in turn associated with multiple indices of psychosocial and physical well-being (Bruce et al. 2009). Adverse Childhood Experiences (ACEs): Vulnerable Dyads, the Stress Response System and Needs for Supportive Intervention For infants and young children, lack of access to the empathically attuned and contingently responsive care associated with secure attachments can constitute a traumatic stress, especially in environments that contain other contextual sources of stress, such as housing insecurity, food insecurity, and community violence. And yet a key developmental task in childhood and adolescence is to learn age-appropriate ways of coping with stressors, particularly those associated with developmental growth. Initially, the developing infant is reliant on the scaffolding of adult caregiving and support to manage stress, including the regulation of psychophysiological states of arousal such as hunger/satiation, the regulation of temperature, and the sleep/wake cycle. Over time, in the context of supportive care, the developing child becomes more able to self-regulate and to modulate states of affective arousal. When such care is absent, inconsistent, or harsh, impairment to the child’s developing stress response system may occur and the child is left more vulnerable to future experiences of stress, even those associated with developmentally normative experiences and transitions. In their working paper, “Excessive stress disrupts the architecture of the developing brain,” researchers describe a typology of stress that helps practitioners to differentiate between stressors that may be manageable within the context of supportive caregiving and those that are severe enough to pose psychosocial and neurodevelopmental risks to the developing child. These distinctions are important to practitioners because not all stressors are “traumatic.” Indeed, some types of stress may be important to growth and mastery. For all types of stress, the availability of support, especially the relational support of a trusted caregiver, and the effectiveness of this support in coregulating the child’s stress response system are key factors in determining whether particular stressors are associated with risk to the child’s emerging stress response system and key aspects of neurodevelopment. “Positive stress” may be understood as those stressors that are developmentally normative and typically can be successfully managed within the context of “good enough” caregiving support. An example would be the infant taking her first steps—an important developmental achievement often managed well in the context of caregiver support. The child may stumble or fall but can also recover with the scaffold provided by caregivers. “Tolerable stress” refers to those experiences that are significant enough to strongly activate the developing stress response system, but that, with the help of caregivers, may be managed in such a way as to lower the volume on the stress response and help the child return to baseline from a psychophysiological perspective. These stressors can include experiences such as chronic illness, loss, and separation so long as caregiving is available to provide a social buffer that

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confers neuroprotective benefits to the child via exerting a regulatory effect on the stress response system. For example, a child who experiences chronic illness in childhood can be supported, through interaction with adult caregivers, to name and manage the stressors associated with ongoing medical intervention. For the young child, experiences of illness are often paired with medical assessment and intervention that can be intrusive and frightening. A strong attachment relationship can provide some social buffer by providing a scaffold for the child’s experience, infused with the caregiver’s capacity to modulate the experience by supporting the child’s capacity to understand what is happening, to offer opportunities for control and predictability when possible, and to support child’s capacity to regulate affect in ways that protect the developing stress response system. “Toxic stressors” are closest to what we might term “traumatic stress” or “trauma.” These are stressors that result in frequent or chronic activation of the body’s stress response systems. In addition, stressors can become “toxic” when the stress response system stays activated and the child lacks access to the types of supportive care needed to manage the stressful experience or when the child’s caregivers are themselves the cause of the traumatic stress, as in the case of abuse and neglect. Researchers have shown that during the early years, which comprise a sensitive period for brain development, children are particularly vulnerable to the developmental impact of toxic stress (National Scientific Council on the Developing Child 2014). In addition, unmediated exposure to traumatic stress can over time reset the central nervous system response to stress, including regions in the brain, in such a way that even more minimal exposures to stress may activate a strong stress response. It is this “wear and tear” on the stress response system that is thought to represent an increased “allostatic load” (McKewen 2008) that, in turn, may be associated with poor psychosocial, neurodevelopmental, and health outcomes over time. As social workers we know that many factors, across ecosystemic levels, may impact caregiver–child interaction in both acute and chronic ways. Research in neuroscience provides a new lens for understanding the mechanisms by which common challenges, such as untreated parental mental health challenges, financial insecurity, or community violence, can impact child development in many ways including impacting the quality of caregiver– child interaction and attachment formation. As practitioners who work with young children and their families, social workers realize that many families experience adversity and toxic levels of stress. These stressors can be parental factors (e.g., untreated parental mental health, substance use), community-level factors (e.g., community violence, stressors associated with financial insecurity), or policy-level factors (e.g., mass incarceration, the separation of children from their parents at U.S. border). These types of stressors can become “toxic” to the developmental well-being of children, particularly when they are associated with disruption in the child’s access to attuned and empathically responsive care. The ACE studies (Felitti 2009; Felitti et al. 2009) have transformed the way we think about the impact of early adversity and toxic stress. The original ACE studies represented a collaboration between the Centers for Disease Control and researchers from the Kaiser Permanente health system. These early studies asked adults to fill out a ten-item questionnaire in which they endorsed which of ten adverse events they had experienced in childhood. Adverse events included parental substance abuse, untreated parental mental illness, intimate partner violence in the home, having an incarcerated parent, psychological, physical and/or sexual abuse, and emotional and physical neglect. The central finding of the original ACE studies was that the higher an individual’s ACE score, the more likely he/she was to experience social and emotional challenges and negative health outcomes as an adult, even when researchers controlled for key demographic variables in data analyses (Dube et  al. 2003). Epidemiological in nature, the early ACE studies demonstrated the impact of psychosocial

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experiences associated with toxic stress on physical well-being including higher rates of morbidity and mortality in adulthood. More recent studies have also begun to contextualize the original ACEs, expanding the definition of ACEs to include community-level factors such as poverty, community instability and violence, lack of economic opportunity, housing insecurity and poor housing quality, and experiences of discrimination and marginalization. These factors are also known to be associated with parental stress, parenting behavior, and attachment patterns. While the original ACE studies were retrospective in nature, they were robust enough to demonstrate that higher levels of adversity in early childhood may precipitate neurodevelopmental changes that are, in turn, associated with increased health risk behavior, poor educational outcomes, deficits in social functioning, and, ultimately, poor health outcomes. Within the context of this large body of work, neuroscience researchers are exploring the processes by which early adversity and exposure to toxic stress impacts developmental well-being as well as how secure attachment relationships provide key neuroprotective benefits even within the context of other adversity and stress. For social work practitioners, the ACE studies point to the importance of primary prevention and protecting the developing child from exposure to toxic stress. In addition, secondary prevention efforts designed to mediate the impact of toxic stress and adversity must include programs designed to support parental well-being as caregivers are, in turn, a key social buffer for children exposed to adversity and stress. Last, children who lack access to consistent and responsive care are understood to face unique risks, as they may both be exposed to higher levels of adversity and lack access to the neuroprotective benefits of attuned care. Individual and community-level interventions can mediate the impact of adverse experiences on child development over time. For example, in the ACE studies, parental incarceration is identified as a significant adversity in childhood. Data on the impact of parental incarceration on children show that children with incarcerated parents are more likely to experience secondary adversities as well including family disruption, entry into the child welfare system, and acute traumatic experiences that may include being present at the moment of a parent’s initial arrest. Based on our understanding of the primacy of attachment bonds to the developing child, new efforts are emerging to support continuity in the parent–child attachment relationship even when the parent is incarcerated (Murphy  & Cooper 2015). These programs include components designed to encourage more parent-child visitation and communication and more support of incarcerated parents’ sense of agency with regard to their parenting role. Studies of these programs demonstrate that even within the context of the adversities associated with parental incarceration, that child developmental outcomes can be promoted and protected, in part, by supporting the child’s attachment relationships. In addition, studies on parental incarceration demonstrate the importance of extended family and community resources. Supporting the developmental well-being and resilience of children with incarcerated parents also requires community resources that assure the presence of supportive care to children who may be separated from their parents due to parental incarceration. This includes supports for extended kinship networks that may be social buffers to the developing child and community resources for parents reentering the community following experiences of incarceration (Annie E. Casey Foundation 2016). As described earlier, patterns of caregiving associated with the emergence of secure attachments promote optimal brain development and, specifically, a strong neural scaffold underlying the capacity for affect- and self-regulation. Neurologically healthy infants are primed for interaction through their multisensory capacities such as the ability to recognize human speech, a preference for facial characteristics, and the capacity to recognize familiar stimuli. When empathically attuned caregiving does not exist, or is inconsistent, suboptimal patterns

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of attachment quality may result and so may negative impacts on developing brain architecture, organization, and function (Maheu et al. 2010). Many social workers collaborate with parents and children in situations characterized by high levels of parental and situational stressors. Over time, attachment research has described parental stress as a determinant of parenting behavior, which, in combination with other factors, impacts the quality of attachment between caregiver and child and key child outcomes. When a parent is overwhelmed by stressors in the environmental surround, their own capacity for affect regulation may be strained and relatedly, the capacity to effectively coregulate the developing child’s psychophysiological states may be negatively impacted. In addition, current exposure to traumatic stressors may combine with parental histories of trauma exposure to affect key tasks of parenting. Parents with trauma histories may face challenges because if they have not received supportive interventions, they may struggle with difficulties in key areas associated with parenting competence such as executive functioning, decision making, affect regulation, delay of gratification, and frustration tolerance. In these circumstances, caregivers may lack the ability to modulate affect and may be more likely to rely on survival coping strategies that may include behaviors such as avoidance and substance use, which, in turn, may compromise their emotional availability. Similarly, caregivers with trauma histories may have a lower sense of parental agency or efficacy, feeling somewhat helpless in the face of the demands of caregiving, and may have less ability to realistically assess safety and danger on behalf of themselves or their children. Psychosocial research on attachment has shown that caregivers’ internal representations of their own early attachment experiences (e.g., internal working models) are associated with the quality of attachment bonds formed between them and their own children. For example, parents who themselves have secure models of attachment are more likely to have children who develop secure internal working models of attachment relationships. From a psychosocial perspective, researchers have explored how characteristics associated with secure attachment in the caregiver, such as the capacity for reflective function and mentalization, are also associated with parenting behavior that in turn is associated with the development of secure attachment in the developing child. Reflective function and mentalization refer to the caregiver’s ability to recognize and understand the internal experience of the child—thinking about the child’s needs from the perspective of the child. Parents who have a “good enough” capacity for mentalization are able to attune to the internal world and emotional state of the infant and, therefore, are more able to contingently respond to the infant’s experience. Parents who are able to attune to the emotional state of the infant are more able to help the infant modulate affective states in ways they support the infant’s emerging capacity for affect regulation. When infants lack access to care that is attuned and “good enough” (Winnicott 1965), the child may develop patterns of behavior that serve to guard against the dysregulation of interactions that are either understimulating, as in neglect, or fear inducing and intrusive. Research in affective neuroscience adds a neurobiological frame for understanding how the internal experience of the parent is transmitted to the developing brain and nervous system of the child. The neurobiological link between parent and child has been described as an interconnection of two nervous systems in that the ways in which the caregiver regulates their own states of affective arousal are transmitted to the developing child via patterns of dyadic interaction. In the vignette below, we are introduced to Veronica and Layla, a vulnerable mother–child dyad, in which both mother and child have experienced disrupted early attachment processes and neglect. We have the opportunity to see how this type of traumatic stress, in the context of current and past attachments, impacts the developmental well-being of the child

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and, in particular, her ability to make use of adult supports in navigating both normative experience and heightened levels of stress. Veronica and Layla Veronica is a 22-year-old, cisgender, Latinx, single mother of two children. She is in recovery from an opioid addiction that began in her late teens. As a child, Veronica spent several years in foster care after her father died and WHILE her mother was incarcerated. Even before these losses and separations, Veronica experienced many attachment disruptions as BOTH OF her parents were active substance users and her home environment also included violence between her parents which, at times, became directed toward Veronica as well. While Veronica liked school, she moved schools frequently and had difficult peer relationships, frequently getting into arguments and, according to her teachers, “over reacting.” Her teachers often commented that “While Veronica is very bright, she is often unable to focus and when she is in distress, no one can help her.” As a teenager, Veronica began to experiment with drugs. She reports that her drug use was the “best way she knew” to “handle her life.” She was able to curtail her drug use during her pregnancies, but as the mother of two young children, stresses began to mount. When she was 20, Veronica began to use more heavily and her children were placed in foster care. Veronica’s youngest child, only 8 months old, was placed in a kinship placement, where she currently remains and by all accounts is doing well. Veronica’s 18-month-old daughter is in non-kinship foster care. Both children were placed because of Veronica’s inability to provide for their needs, or to provide consistent or attuned care. During the assessment, Veronica commented that the baby “doesn’t seem to need much” and Layla, the 18-month-old, seems “just as happy to be left alone.” She further commented that when she would walk into the room, that Layla “wouldn’t even turn around.” At the time of placement, Layla and her younger sister were found alone in their apartment. They were unsupervised and in separate cribs. The social work assessment revealed that they had been left alone, unsupervised, for more than a day. Neighbors had reported hearing constant crying and ultimately called 911 out of concern for the children. When emergency services arrived, the children were found in their cribs, awake but unresponsive to outreach. After being transported to the hospital, the children were found to be dehydrated and in soiled clothes, but without other signs of physical harm. The younger infant was placed almost immediately in a kinship placement that was unable to also provide care for Layla. When Layla was released from the hospital she was placed in foster care. The foster parents reported that when Layla came to them, she would wander off without regard to whether the foster parents were with her or not, never looking back to receive any verbal or non-verbal signal from her foster parents. She remained very quiet, even though relatives reported that Layla was generally verbal. When the foster parents would try to engage in play with toys, Layla would sometimes take a toy, but would then “turn her back” and express no wish for connection. The foster mother noted that Layla was “not upset but not happy either.” Her vocabulary was very limited and the foster parents reported that they often felt that she was “alone” even when they were together. Layla was in foster care for just under a year. During that time, her foster parents received key support from their social worker who helped them to understand Layla’s apparent “indifference” to them not as a personal rejection, but as an effect of her experiences of neglect and, in particular, a learned behavior that could be understood as Layla’s efforts to cope with her past experiences of neglect. This understanding helped Layla’s foster parents to continue their efforts to engage Layla and to “follow her lead” with regard to how much interaction she could manage at any given time. Over time, Layla began to reach out more to her foster parents, accepting affection and, ultimately, engaging in “social referencing” towards them. Specifically, she would look back for them before leaving a room and get key information from them about whether what she was doing was safe or not. During play, Layla began to show her toys to her foster parents and was able to accept comfort from them that was effective in soothing her during

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Janet Shapiro times of distress. For example, she asked to be held by her foster mother while receiving a vaccine at the pediatrician’s office. During the time that Layla was in foster care, Veronica worked hard to address her addiction in the hopes of being reunited with her daughters. Veronica was able to understand how her addiction emerged. Through work with a social worker, she was able to reflect on her own feelings about having lived in foster care as a young child while her mother was incarcerated. She reports how much she loved to hold Layla when she was born, but that as Layla became mobile and more active, that she felt more and more unsure of herself as a mother. Without access to support for herself, she felt isolated and remembers feeling strongly that her daughter “didn’t care enough” about her and that nothing she did was “ever enough to satisfy Layla,” who was becoming more vocal and expressive at that time. When Layla would cry or become fussy, Veronica found it very difficult to soothe her and found herself becoming frustrated and angry. Often she would leave Layla in her crib as a way to “get away” and to “make sure nothing worse” would happen. Veronica remembers the day she left her daughters alone and, looking back, says that she had left to find drugs because otherwise she knew she would “lose it.” She reports that she expected to come back soon but that she had “lost track of time.” As she reflects back on it, her memories seem disconnected from any affective experience of the events, or any insight into the impact of her actions on her children. Over time and through work with her own therapist, Veronica began to gain more insight into her own feelings and behavior and supervised visits with her daughters were arranged. At first, Layla showed little reaction to her mother, leading Veronica to assume that her daughter “doesn’t remember her” and “doesn’t even like her,” often noting that Layla seemed more interested in her foster mother. Seeing Layla with her new toys and clothes, and also in a growing attachment relationship with her foster parents, would sometimes lead Veronica to refer to her as “spoiled” and “having more than I ever did.” Veronica remembers her own experiences in foster care and remarks that Layla is “lucky” compared to her and doesn’t understand why others are making “such a big deal” out of the situation. Observing her during play, Veronica stated “look, she’s fine, just like I told you.” Veronica shows little awareness of the traumatic separation she experienced from her own mother while her mother was incarcerated or how this separation may have affected her as a child and, ultimately, when she became a mother as well. As the social worker continued to work with Veronica, she sometimes found herself frustrated with Veronica’s lack of insight into Layla’s internal world. It required ongoing work with her own supervisor to be able to hold in mind that before Veronica would be able to empathically attune to Layla’s sense of loss and uncertainty, she might need time to mourn the losses of her own childhood and build new strategies for coping with affective dysregulation and distress.

Discussion of Veronica and Layla As social workers, we often work with children who, like Layla, have attachment histories characterized by experiences of loss, disruption, and exposure to the toxic stress of child abuse and/or neglect. For children like Layla, a type of “double jeopardy” may exist, in which children not experience neglect, but within the context of their primary caregiving relationships and so, they lack access to the adult support needed to modulate or cope with the traumatic experience. As in the case of Veronica, parents and caregivers may also have their own trauma histories and may also be experiencing multiple sources of stress, both personal and contextual, in the present. As we can see in this vignette, there are times when parental experiences of stress in the present and/or unresolved trauma from the past may be carried forward via their impact on current parent–child relational quality. In this instance, Veronica appears to not have processed or integrated the impact of her own childhood trauma and this, in turn, blocked her capacity to empathically attune to the impact of Veronica’s addiction and related absence, both physical and psychological, on Layla. In

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response, we see that Layla showed no expectation that her adult caregiver would be available to her and, in many ways, showed an “infant defense” of withdrawing to herself— avoiding neglectful interaction that was painful in its lack of attunement. At the same time, Layla showed plasticity in her attachment organization as she slowly became able to trust her foster parents’ interest in her and capacity to support her through episodes of affective dysregulation. Note that as Layla withdrew from the expectation of attunement, she shared neither positive nor negative affective states with her mother and, at first, shared neither of these with her foster parents. It would have been understandable for her foster parents to interpret Layla’s behavior as indifference, if not outright rejection (as Layla’s mother was interpreting the behavior). Attuned intervention and psychoeducation were critical in helping the foster parents to understand and reframe Layla’s behavior in light of her past attachment experience. This enabled the foster parents to “stick with it,” as opposed to disrupting the placement, and gave Layla the opportunity to learn a new set of relational expectations and responses.

CONCLUSION The case vignette presented in this chapter exemplifies core principles of infant mental health that have been reaffirmed by emerging affective neuroscience research: (1) infants are born with capacities that prime them for responsiveness to social interaction; (2) the environmental context, including parental and community factors, impact the developing child both directly and indirectly and often through their impact on parenting behavior and emotional availability; (3) variations in patterns of attachment are associated with differences in developmental outcomes and disorganized patterns of attachment are associated with the most precarious outcomes; (4) interventions designed to support the well-being of children must also attend to the internal experience of parents/caregivers, particularly when parents/ caregivers have experienced traumatic loss and grief; and (5) because working with children who have experienced attachment disruption can evoke painful affect in practitioners, the subjective reactions of practitioners to caregiver/child dyads are important. As social workers, we often work with children whose attachment histories include multiple experiences of loss, disruption, and exposure to many other sources of toxic stress and trauma such as child abuse and neglect. For many of these children, a type of “double ­jeopardy” may exist in which they experience trauma within their family context and then also experience disruption in their primary attachment relationships. Parents and caregivers may also have their own trauma histories and be experiencing multiple sources of stress, both personal and contextual, in the present. In such situations, parental experiences of stress in the present and/or trauma in the past may be carried forward via their impact on current parent–child relational quality—affecting the quality of attachment that develops and, relatedly, many developmental outcomes associated with attachment quality including the developing child’s capacity to tolerate and modulate states of affective arousal.

REFERENCES Ainsworth, M., & Wittig, B. A. (1969). Patterns of Attachment: A Psychological Study of the Strange Situation for Neglect: Results of a Randomized Clinical Trial. Hillsdale, NJ: Lawrence Erlbaum Associates. Annie E. Casey Foundation. (2016). A Shared Sentence: The devastating toll of parental incarceration on kids, families and communities. Accessed at http://www.aecf.org/m/resourcedoc/aecf-asharedsentence-2016.pdf.

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Bernard,  K.,  Dozier,  M.,  Bick,  J.,  & Gordon,  M. (2015). Intervening to enhance cortisol regulation among children at risk. Development and Psychopathology 27:829–41. Bowlby, J. (1969a). Attachment and loss: Attachment. New York: Basic Books. ———. (1969b). Attachment and loss: Loss, sadness and depression. New York: Basic Books. ———. (1969c). Attachment and loss: Separation. New York: Basic Books. Cicchetti, D., & Rogosch, F. (2012). Gene by environment interaction and resilience: Effects of child maltreatment and serotonin, corticotropin releasing hormone, dopamine, and oxytocin genes. Development and Psychopathology 24:411–27. Cozzolino, L. (2014). The neuroscience of human relationships. New York: W.W. Norton. Dozier, M.,  & Fisher, P. (2014). Neuroscience enhanced childhood maltreatment interventions to improve outcomes. Social Policy Report 28(1):22–24. Dube, S., Felitti, V., Dong, M., Giles, W., & Anda, R. (2003). The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Preventive Medicine 37(3):268–77. Felitti, V. (2009). Adverse childhood experiences and adult health. Academic Pediatrics 9:131–32. Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M.,  & Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine 14:245–58. Fraiberg, S. (1980). Clinical Studies in Infant Mental Health: The First Year of Life. New York: Basic Books. Gunnar, M. (2003). Integrating neuroscience and psychosocial approaches to the study of early experiences. In Roots of Mental Illness in Children, eds. J. King, C. Ferris, and I. Lederhendler. New York: New York Academy of Sciences. Gunnar, M., Fisher, P.,  & Early Experience, Stress and Prevention Network. (2006). Bringing basic research on early experience and stress neurobiology to bear on prevention interventions for neglected and maltreated children. Development and Psychopathology 18:651–77. Gunnar, M.,  & Quevedo, K. (2007). The neurobiology of stress and development. Annual Review of Psychology 58:145–73. Hofer, M. (1995). Hidden regulators in attachment, separation, and loss. Monographs of the Society for Research in Child Development 59:192–207. Keller, H. (2018). Universality claim of attachment theory: Children’s socioemotional development across cultures. Proceedings of the National Academies of Sciences. Accessed at https://www.pnas. org/content/115/45/11414. Maheu, F., Dozier, M., Guyer, A., Mandell, D., Peloso, E., Poeth, K., Jennes, J., Lau, J., Ackerman, J., Pine, D., & Ernst, M. (2010). A preliminary study of medial temporal lobe function in youths with a history of caregiver deprivation and emotional neglect. Cognitive, Affective, & Behavioral Neuroscience 10(1):34–49. doi:10.3758/CABN.10.1.34. McKewen, B. (2008). Central effects of stress hormones in health and disease: Understanding the protective and damaging effects of stress and stress mediators. European Journal of Pharmacology 583 (2–3):174–85. Murphy, D., & Cooper, P. M. (2015). Parents behind bars: What happens to their children? Washington, DC: Child Trends. Retrieved from www.childtrends.org/wp-content/uploads/2015/10/201542ParentsBehindBars.pdf. And, Child Trends’ analysis of the 2011–12 National Survey of Children’s Health for the Annie E. Casey Foundation. National Scientific Council on the Developing Child. (2010). Early experiences can alter gene expression and affect long-term development. Working Paper No.10. Retrieved from http://www. developingchild.harvard.edu. National Scientific Council on the Developing Child. (2014). Excessive stress disrupts the architecture of the developing brain. Working Paper No. 3 (updated ed.). Retrieved from http://www.developingchild.harvard.edu/resources/wp3/. Newman, L, Sivaratnam, C., & Komiti, A. (2015). Attachment and early brain development-neuroprotective interventions in infant-caregiver therapy. Translational Developmental Psychiatry. Accessed at https://www.tandfonline.com/doi/full/10.3402/tdp.v3.28647.

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Sampaio, A., & Lifter, K. (2014). Neuroscience of infant mental health development: Recent findings and implications for counseling psychology. Journal of Counseling Psychology 61(4):513–20. Schore, A. (1996). The experience-dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology 8:59–87. Schore,  A. (2000). Attachment and the regulation of the right brain. Attachment  & Human Development 2:23–47. Schore, A., & Schore, J. (2010). Clinical social work and regulation theory: Implications of neurobiological models of attachment. In Adult Attachment within Clinical Social Work Practice, ed. S. Bennett and J. Nelson, pp. 57–75. New York: Springer. Shapiro, J., & Applegate, J. (2018). Neurobiology for Clinical Social Work: Theory and Practice, 2nd edition. New York: W.W. Norton. Shonkoff, J., Garner, A., & the Committee on Psychosocial Aspects of Child and Family Health, Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics 129(1):e232–e246. Shonkoff, J.,  & Phillips, D., eds. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development. Committee on integrating the science of early childhood development, National Research Council and Institute of Medicine. Washington, DC: National Academy Press. Siegel, D. (2012). Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind. New York: Norton. Solomon, J., & George, C. (1999). Attachment Disorganization. New York: Guilford. Sroufe, L. A. (2000). Early relationships and the development of children. Infant Mental Health Journal 21(1–2):67–74. Stern,  D. (1985). The Interpersonal World of the Infant: A  view from Psychoanalysis and Developmental Psychology. New York: Basic Books. Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment. Madison, CT: International Universities Press.

10 Psychodynamic Theories and Gender Joan Berzoff

As we begin this chapter, we need to ask what we even mean by gender. While sex was traditionally referred to as being male or female based on the “objective” facts of a person’s genitalia, gender has always had more to do with the meaning ascribed to those differences. One can be very “masculine” and have female genitals; one can be very “feminine” and have male genitals. One can have ambiguous sexual organs, or one’s gender may be ambiguous and genitals not. In all times, gender reflects a series of expected roles and behaviors that are always socially and historically constructed. More recently, these expected behaviors have been challenged and that which has been unexpected, even celebrated. Gender is always situated in contexts of historical time, social class, ethnicity, race, culture, power, politics, physiology, and psychology. In 1903, Freud asked, “What does a woman want?” (Jones 1955, p. 421). It has taken over a century and a half just to begin to understand that the question itself is unanswerable. But the discourse on psychoanalysis and gender has produced a body of knowledge greater than Freud could have ever imagined and from so many domains: cultural studies, legal studies, philosophy, sociology, and psychology! Over the past hundred years, Freud has been both assailed and assimilated by feminists for his theories about women. He has been called misogynist and phallocentric for capturing the gender stereotypes of his Victorian times and labeling them as normative. He has been attacked for the heteronormativity of his times in ascribing sex role identifications during the oedipal period (Butler 1990). He has been seen as homophobic and heterosexist. However, many of his ideas have been used by feminists and even queer theorists who have critiqued, revised, and improved upon his formulations and who have articulated multiple pathways for understanding women’s development (Benjamin 1988, 1995; Butler 1990; Chodorow 1992, 1996; Harris 2011; Salomon & Corbett 2011). This chapter will look at the three waves in psychodynamic theorizing about gender, particularly about women. The first wave arose as a critique of Freud in the 1920s and 1930s in reaction to Freud’s views of women as masochistic, narcissistic, and less morally developed. The second wave came between the 1960s and late 1980s, when white middle-class 202

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feminism was at its height and when women’s differences (their moral development, their relationships, and their empathy) were being idealized as feminine strengths. During this second wave, and within the “difference” discourse, social structural theorists, particularly Marxist theorists, analyzed the relationship between women’s psychological differences and their place in the family and social structure. The third wave, from the 1990s to the present, has been dominated by postmodernists and poststructuralists who assert that gender can never be understood outside of power relationships, that gender is always a socially constructed category, and that gender ambiguity, fluidity, and paradox are to be appreciated, even celebrated. Now gender is no longer viewed as a singular category or as one of two binary categories, but rather as something that is multiple, ever-changing, multicultural, complex, performative, and entirely dependent upon context.

THE FIRST WAVE: EARLY CRITIQUES OF FREUD Let us begin, then, with Freud. As we said in chapter 2, Freud made some rather stunning statements about how psychosexual development occurs differently for little girls than for little boys at the oedipal stage of development. Freud began with the premise that little girls are really little men. He postulated that in early childhood, girls are unaware of their own vaginas and actually see their clitorises as small penises. When they discover the anatomical differences between themselves and boys, they feel envy. Girls become heterosexual, he postulated, almost by default. In trying to explain why girls break their preoedipal ties to their mothers and turn to men, Freud theorized that girls turn away from their original love objects, their mothers, when they discover that men have penises and that neither they nor their mothers do. Disappointed in their mothers for not having provided them a penis, girls then turn toward their fathers in the hopes of restitution and with the fantasy that their fathers will provide them with a baby. Heterosexuality, in Freud’s view, is a girl’s consolation for not having a penis. In other words, a girl’s sexuality is a compromise formation (Chodorow 1992). Unlike boys, who renounce their oedipal desires for their mothers because of fears of being castrated by their rivals (their fathers), girls do not ever fear castration because, in Freud’s view, they are already castrated. Here we are left with a view of women, not as different but as deficient. According to Freud, girls can never fully resolve their oedipal issues and, therefore, they develop weaker superegos than do boys. When girls do turn back to their mothers to identify with them, they identify with that which Freud thought was the essence of femininity: passivity, masochism, and narcissism. These features, he suggested, were hallmarks of female identity. Yet today we recognize that these traits were actually the hallmarks of powerlessness and the lack of female agency and autonomy in late Victorian Vienna. To be fair, Freud was vexed by the issue of sexuality and gender throughout his career, and he contradicted himself frequently. He argued that homosexuality was not deviant (1951); yet, at other times, he demeaned homosexuality (1905a). He acknowledged not having a sufficient theory to account for heterosexuality in women given that the one he came up with was based in women’s envy of men. It is interesting to note that while many of Freud’s theories about women reflected the patriarchal culture in which he was embedded, he was also surrounded by women whom he trained and encouraged, including his own daughter, Anna. Many of these women went on to challenge his ideas about female development, particularly penis envy, and the development of female identification as weaker and lesser than men’s (Martha Hadley, personal communication, 2005).

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Karen Horney (1924, 1926, 1967), for example, was among the first of Freud’s female contemporaries to challenge his phallocentrism and to say that penis envy was not an intrapsychic event, but rather a social one. When a girl becomes aware of her anatomical difference, Horney theorized, it is not the lack of a penis that makes her feel inferior. Instead, it is the symbolic meaning of her difference from boys that makes her experience herself as inferior. In fact, Horney maintained that it is not the male anatomical apparatus that women want, but rather it is the access to what men have: power, opportunity, and resources. The idea that women’s psychological development is inextricably linked to their unequal place in the social structure has dominated almost all subsequent thinking about the psychology of gender. Horney’s critique was the first of many to argue that there is no such thing as a woman “born.” Instead, a woman is “made.” She is psychologically constructed by the society in which she develops (Rich 1976), as is her “inferiority.” Further, Horney challenged Freud’s view of penis envy altogether. In fact, she thought that boys envied girls, and later women, for their capacities to bear children, and she referred to this as “womb envy.” She thought that this envy that men had for women’s reproductive abilities was one factor contributing to the domination of women by men. No one likes to feel envy; one way to deal with it is to devalue the person or the gender that one envies. In Freud’s case of Little Hans (see chapter 16), we see Freud’s blindness to womb envy. This little five-year-old little boy became phobic of horses and clung tenaciously to his mother after his new sibling was born. His father took him to see Freud. In the clinical data, Hans insisted that he could have a baby. Although his father and Freud tried to dissuade him, Hans persisted in the belief that he, like his mother, could give birth. Many, if not most, boys actually think that they can have babies, just as girls think they may yet get a penis. But in the case of Little Hans, Freud entirely ignored Hans’s womb envy. Perhaps his blindness to this important part of the case history reflected his own defensive position. Perhaps by denying his own envy of women, Freud accorded the penis a more central place in all of psychological development than it deserved. Yet envy is something to listen for in the clinical setting, be it envy of the penis or of the womb because all of us are likely to envy that which we do not possess. That is simply a part of the human condition. Bertha, a white, middle-class, three-year-old girl, was described by her parents who came for counseling. The parents were two social workers who worked diligently to establish gender equality in the family. Her father shared half of the parenting responsibilities, and anatomical differences in the family were discussed and celebrated. That mommy had a vagina and daddy had a penis were taught to Bertha in the context of both sexual organs being beautiful and powerful. In fact, Bertha was very identified with the power and glory of her mother, who was now pregnant with her baby brother. However, one day while her mother was changing her newborn brother, Bertha burst into tears, saying, “I want one, too! Why didn’t you give me one?” pointing to his penis. She was held and comforted and reminded of all that her parents had explained. When her parents, out of sheer curiosity, asked her what had upset her so much, she answered, “It just looks like more!”

The first wave of psychoanalytic theorizing about women, then, was often marked by essentialism, and by the not so subtle devaluation of women, gays, and lesbians. In this view, biology was destiny and women’s destinies often reflected their lack of power in the larger social world.

THE SECOND WAVE: WOMEN AS DIFFERENT BUT NOT DEFICIENT From the 1960s to the 1980s, much of the writing about the psychology of women was from a “difference” perspective, establishing women’s development as separate from men.

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At that time, a different and more contemporary critique of penis envy came out of cognitive developmental psychology, and although it was not a psychodynamic theory, per se, it was a way to try to understand gender identity. Irene Fast (1984) noted that “difference” dominated most of the discourse on women. She suggested that, cognitively, envy is ubiquitous to both boys and girls. Each gender wants what it cannot have, and envy is a cognitive achievement. But recognizing difference also means coming to terms with limits. When children must cognitively confront the limits of their own anatomy, they envy what they do not have. This view of envy as a cognitive developmental achievement de-pathologizes the concept of penis or womb envy. During the 1960s to the 1980s, other ideas emerged that de-pathologized women’s differences. These voices came from psychoanalytic and Marxist analyses of women’s places in the social structure. Many began to ask why women were so devalued by men and made to seem so powerless? Recall that in chapter  3, we discussed Melanie Klein (Grosskurth 1986), who saw women as always being the first love object of boys and girls. Kleinian theory therefore underscored women’s tremendous power over their children: the power to provide or withhold love. The mother, according to Klein, is the source of all of the infant’s experiences of being worthy or unworthy. She can also be the source of the child’s hatred, which may be experienced as an attack from without or within. For little boys and little girls, their utter dependence on a mother, a woman, also might make her dangerous. Could it be that women’s domestic power led to their denigration and then to acting out the denigration through the abuse of women? Dorothy Dinnerstein (1976) turned her attention to thinking about how women, who were experienced as ­all-powerful, could readily become recipients of gender oppression. Dinnerstein contended that the rigid sex roles and sex role ideologies that are so prevalent in Western culture stem from primitive fears about the power of women. Because neither boys nor girls develop a realistic sense of their own mothers as independent or autonomous agents, their fantasies about the power of their mothers become, paradoxically, greater. Because boys need their mothers and are entirely dependent on them, they also come to wish to control them so that the most pathological aspects of our current culture—violence against women, and humiliation of women, rape, pornography—have their roots in earliest child-rearing arrangements. Hence, in the 1970s and 1980s, patriarchal societies were seen as creating and maintaining rigid gender roles as a societal defense against the power of women. Mothers were viewed as the source of human creation and blamed as the source of all human malaise (Dinnerstein 1976). As long as gender roles were perpetuated through childcare arrangements in which only mothers cared for children, women would continue to be feared, and men and women would be robbed of their fullest opportunities for human development (Chodorow 1974; Dinnerstein 1976). Nancy Chodorow (1974), a Marxist sociologist who later became a psychoanalyst, was interested in the gender inequities in American society. Rather than outright reject psychoanalytic theories, she appropriated the theories to explain social inequality. She argued that in a society in which only women take care of children, boys and girls are socialized to develop rigid gendered senses of self in the context of an unequal nuclear family. Boys develop their gender identities by first separating and individuating from their primary love objects, their mothers. To develop his sense of self, a boy must develop strong ego boundaries between himself and his mother. Thus, a boy develops a self that is more boundaried, more differentiated, and more autonomous than that of a girl. In the process of his identity development, a boy learns to repress or deny the “feminine” parts of himself that were forged in close contact with his mother.

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However, in the process of developing a female sense of self, a girl never breaks her preoedipal ties to her mother. Her female sense of self develops in the context of a continuous relationship with her mother. As a result of this continuity, girls develop different kinds of relational skills than do boys. Girls develop more permeable ego boundaries with greater capacities for empathy than boys. The beginning of the theory that girls are more relational, and boys more autonomous and independent, then, was argued in the context of an analysis of the social structure of mothering and of the heterosexual nuclear family. While there is something binary and essentializing about this argument in our current discourse, it was nonetheless a way of trying to make sense of how gender differences emerged in the family using both sociological and psychoanalytic lenses. Chodorow (1974) also asserted that in a society in which women are predominantly mothers, girls and boys are socialized very differently, and their gender roles are then reproduced as asymmetrical. Boys, because they must separate and individuate from their mothers, reproduce a socialization process that fosters male autonomy, separateness, and individuation, while girls reproduce a social structure in which they maintain a relational orientation and a more fluid sense of self. In a society that values autonomy over connectedness, this gender asymmetry has not served women well. In the nuclear, heterosexual family especially, gender asymmetry perpetuates unequal gender roles. Only a revolution in parenting, then, could solve gender inequities. In later theorizing, Chodorow (1992;1996) began to wonder why nuclear families ever produce heterosexual girls, given that girls never break their preoedipal ties to their mothers. Instead, she began to wonder why all girls, and later women, are not lesbians. Jessica Benjamin (1988) also began as a Marxist sociologist and later became a psychoanalyst. She, too, wanted to understand how gender inequities in the social structure led to differences in gendered identities. She suggested that, for little boys, the father, at that time, represented the pure and idealized love that comes with independence and freedom. When their fathers left the family for work each day, boys recognized the freedom that their fathers had, and they identified with their freedom and separateness. For girls, the task of separation was far more difficult because in Western cultures, fathers represented separation and freedom to girls as well. But where boys identified with their fathers, girls had to come to terms with being different from their fathers. What does a girl do with her own desire for freedom and separateness? Benjamin asserts that girls defensively begin to idealize men and to subjugate their own desires for agency and separateness to the desires of men. Rather than experience themselves as subjects in their own right, girls are socialized to become objects of men’s desire. We can see the evolution of subjugation and loss of agency in the following example: Gina, a twenty-one-year-old cisgendered heterosexual, working-class, white college student, described her mother as “bland, ugly, fat, and frumpy.” Her father (who, it turns out, was all of these things) she described as “cool, brilliant, inventive, and creative.” She came to therapy because she felt so bad about herself in relationships with men. As her therapy progressed, it became clear that Gina’s mother was the more attuned and caring parent, whereas her father was quite self-involved and remote. Yet Gina found herself in sexual relationships in which she wanted to be cool, brilliant, inventive and creative, all of which she ascribed to her father, but she felt bland and frumpy. She became silent with boys because she felt unworthy, and she stated that boys would and should control the relationship. She tried to dress seductively for men, but she had no idea what style of dress she liked. She expended much energy becoming an object of men’s desires, but she had little sense of who she was or what she wanted.

In this second wave of feminism, then, women began to be seen as oppressed by having to become objects of men’s desire, and having difficulty being subjects of their own desire.

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A child who has some sense of socially sanctioned value will be less likely to be controlled by others. But girls, whose gender is devalued, learn to subsume their own desires. Perhaps this is why Margaret Mahler (1980) described how little girls in the rapprochement subphase lose some of their enthusiasm and become more depressed than little boys. Like Chodorow, Dinnerstein, and others writing in this vein, Benjamin argued that if female self and object representations are ever to become more robust and alive for girls and women, there would need to be changes in both the family structure and the social structure. Jessica Benjamin (1995) also used Lacan to identify how psychoanalytic language further exacerbates the problem. For example, when people are described as objects (as in object relations theories), they are rarely, if ever, seen as subjects in their own right. The language of object relations theory often implies that a woman (read mother) is someone who is submissive, accommodating, and a passive object who exists to meet the needs of others, but not a person who is recognized as having her own subjectivity, agency, and desire. In fact, Benjamin claims that the recognition of a mother’s subjectivity is a critical developmental step for boys and girls, and that without such recognition women continue to be treated as objects, not subjects, by men. Linda B is a white, 50-year-old, married lesbian, middle-class, Catholic social worker married with two children in pre-school. Her mother recently died of breast cancer and for Linda, losing her mother was excruciating because she felt she had already lost her so many times, years before. She had always longed for closeness with a mother whom she felt was temperamentally and intellectually like her. Linda knew that prior to marriage, her mother had been a bright, lively public relations executive with a strong group of women friends. After she married, she stayed home with three children and was clearly very depressed, neither engaging with friends nor with the world outside the home. From Linda’s perspective, her mother seemed subjugated to her abusive husband, who repeatedly physically abused Linda’s sister and sexually abused Linda’s brother. Throughout Linda’s childhood, her mother seemed lost and absented herself in crossword puzzles or books. Linda imagined, as her mother was dying, that they might establish the relationship she had yearned for all of her life. She finally had the courage to ask her mother why she had stayed in an abusive relationship when it did so much damage to her children, but Linda’s mother could only respond with impotent tears. She could not formulate why she had stayed. In therapy, Linda began to see her mother as a subject and surmised that her mother’s self-esteem had initially come from being married, even at the expense of her children. Linda had come to therapy to work on her own intimate partnership, and her fears about closeness. She was resistant to yielding in any way to her partner, and this led to conflict in the relationship. As she explored her identification with her mother, Linda came to like, and even embrace, her own feistiness in relationship to her partner while she mourned her mother’s subjugation.

In summary, this second wave of psychodynamic, feminist theorizing highlighted several critiques of earlier theories of female development. Feminist psychoanalytic theorists suggested that in nuclear family structures in which only one gender does the parenting, women may be feared. In a society that fears women, it is likely that they will be subjugated. In nuclear families, gender differences may become codified as gender roles and become reproduced as social inequities. In family structures in which men represent freedom and separation, women will come to subjugate their own desires. In nuclear family arrangements, women are made powerfully responsible for the care of others but are also subordinated and experience powerlessness in the larger social world. As long as mothers remain primary caretakers, these theorists wrote, they become the target of fear and loathing. Without the recognition of women as subjects, not only as objects, they remain invisible as agents of their own desires.

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SELF-IN-RELATION THEORIES: MORE FROM THE SECOND WAVE At the same time that women’s gendered senses of self were being understood as occurring within the social structural milieu, self-in-relation theorists (Gilligan 1982; Jordan et  al. 1983; Miller 1976) began to claim women’s relational capacities as strengths and as forms of survival. In this view, pejorative concepts such as female “dependency” were turned inside out and were celebrated as the strengths of cooperation and creativity. From this self in relation perspective (Jordan et al. 1983; Jordan & Surrey 1986; Surrey & Kaplan 1990), the female infant was understood as never fully separating from her mother, but as always developing a self in relation to others. Rather than pathologizing women’s dependency in relationships from birth on, these theorists suggested that girls develop greater empathy and attunement to others by virtue of their continuous relationships with their mothers. A girl’s sameness with her mother fosters her ability to see herself in her mother; her likeness catalyzes rather than impedes her development. In this analysis, there are echoes of self-psychology—the belief that maternal empathy fosters psychological development. Thus, during the same period of psychological theorizing in which Chodorow, ­Benjamin, and Dinnerstein were viewing women’s differences as based in inequality in parenting and societal arrangements, other theorists from the Stone Center at Wellesley College (Jordan et al. 1983; Jordan & Surrey 1986; Miller 1976, 1990; Surrey & Kaplan 1990) were explaining that within a Western society, where women have had to be subordinate to men, women found ways to act and react from their devalued positions. Like any subjugated group, women tended to form intense affiliations and relationships with other women in the workplace, the community, and the family. These kinds of relational bonds strengthen their identities and led to stronger senses of self. Yet while women have been socialized to make and sustain relationships, their development was still occurring in a society that values productivity over relationships (Berzoff 1989; Miller 1976). As self-in-relation theorists tried to correct the devaluation of women, however, they also tended to idealize women’s relational skills. Stone Center theorists, for example, tended to valorize women as affiliative, nurturant, and maternal, so much so that by the 1990s, many feminists began to wonder if these “differences” theories were not “essentialist,” meaning that they exaggerated the essences of maleness and femaleness in overly prescribed, stereotypic, and traditional ways. Women, in this view, were relegated to a separate sphere of maternal empathy and connectedness. How oppressive might this be for women who see themselves as dominant, agentic, or individuated? In fact, many of the critics of self-in-relation theories also began to ask: Which women are we talking about? Were these descriptions of women as nurturant, relational, and empathic true for working-class women, from all social classes? Were they true for African American and Latina women, or for lesbian women? Were these essentialist qualities, in fact, not yet another form of gender conformity that did not allow for views of men and women as more complex and variegated? Were such views of men and women overly dichotomizing, and thus actually constructing and maintaining women’s and men’s fixed and prescribed roles in society? These tensions can be seen in the treatment of Emily, a cisgender Latina woman who was a twenty-four-year-old graduate of a women’s college. She had come to college after very difficult immigration experiences during which she and her family climbed through barbed wire to New Mexico from Mexico. Without economic resources and with little social support in school, she spent four years in college with a self-in-relation therapist. When she talked of being Latina and having grown up in a very poor family, she felt understood. But she also described how very deficient she was made to feel in therapy because much of her nature and her personality strengths

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had to do with independence, assertiveness, critical thinking, control, and power. She felt that in her earlier therapy she had to hide her true self and her aspirations—to go into business, to be a “son of a bitch,” to become a CEO—because those qualities were reviled as “male” in her therapy, and therefore as less good. By nature, she was an active and agentic person who did not like sharing and processing her feelings. Only in the second therapy could she begin to articulate how hemmed in she felt by the essentializing nature of feminism at that time.

Just as Freud had been critiqued for devaluing women’s essential natures, the feminists of the 1960s and 1970s may have been guilty of overzealously glorifying women’s essential natures, in response to the strong currents of early feminism.

POSTMODERN FEMINIST CRITIQUES: THE THIRD WAVE Much of the third wave of psychoanalytic theorizing about gender, then, began as a critique of the second wave, noting that “differences” theorists were too often blind to social class, race, ethnicity, age, and sexual orientations—including transgender identities. Postmodern theorists began to ask whether there was anything essential about being a woman (Abel 1990; Butler 1990; Dimen & Goldner 2005; Flax 1990; Greene 2000; Pérez Foster et al.1996; Spelman 1988; Unger 1979). Do “female” qualities of nurturance and relationship apply to all women? In fact, the question emerged again whether there should even be a category such as “woman” at all? Peggy McIntosh (1988) pointed out that “white privilege” encouraged white feminist scholars to assume that their own middle-class experiences were universal, normative, and representative. In that way, white, heterosexual feminists assumed that all women were like them. As long as it was assumed that all women are empathic, or flexible, or affiliative, theorists lost sight of the ways that race, class, age, health, sexual orientation, and ethnicity mediate the many meanings of being female. For example, many middle-class women with children at this time wanted to work outside of the home and saw their work as fulfilling and gratifying while their white working-class counterparts, who had always had to work outside the home in sometimes unfulfilling jobs, did not share in many of those gratifications. As long as ways of being are dichotomized only as female or male, middle class or working class, we privilege some sexual arrangements—namely, middle-class ­heterosexuality—and marginalize others. As long as the only configuration that is discussed is that of the nuclear and heterosexual family, many women’s experiences of different sexual arrangements are marginalized. Many postmodern theorists, then, began to call instead for “psychologies” of women, which are pluralistic, multicultural, contextual, and egalitarian. Black feminists such as Collins and Bilge (2016) exhorted us to look at social context, complexity, social justice, and social inequality whenever we considered gender. Since the early 1990s, then, and from the postmodern frontier, has come the critique that the so-called “essential” attributes of women (and of men) need to be challenged. Do all women (mothers) produce boys who are separate and autonomous? Are all girls relational? Is all of society reducible to the nuclear family? Are there not boys and men who are more relational and girls and women who are less socially constrained by gender norms? Is gender a stable construct across social classes, ethnicities, races, and sexual orientations? By essentializing women as nurturant, could this even be a political means of maintaining the status quo? Have “difference” perspectives, in fact, inferiorized women as “other”? Hence, the very concept of gender has come into question as reifying and supporting the nuclear and heterosexual family. As long as psychological theories prescribe

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fixed gender categories that are dualistic and binary (i.e., males representing one set of behaviors, abilities, values, and capacities, and women another), realities become structured accordingly. This then unwittingly perpetuates gender stereotypes and norms (Abel 1990; Butler 1990; Dimen 2003; Dimen & Goldner 2002; Hare-Mustin & Marecek 1990; Spelman 1988). For example: Patricia is an African American bisexual thirty-five-year-old non-practicing Protestant woman, currently in a relationship with a woman. She is also in relationship with a man. A  graduate of an all-women’s college, she has been steeped in gender theory and thinks a great deal about gendered behaviors. She comes from a family in which her mother worked as a maid throughout Patricia’s childhood after fleeing her abusive husband in the middle of the night, with Patricia and her sister in tow. The family lived in poverty for all of Patricia’s 18 years at home. Located in a fire zone, the family’s home burned down twice. Patricia’s mother also contracted lung cancer when Patricia was in her early twenties and died without proper medical or psychosocial care. Patricia’s grandfather had also sexually abused her sister and likely her. For Patricia, bending the gender roles by having bisexual partners affords her the freedom and flexibility that had never been available in her family. Her male partner was very caring and nurturant; her female partner, the “go getter.” Non-binary gender configurations appear to have freed her from the constraints of a childhood where she felt her mother been “stamped down and stamped out” by her abusive relationships with men.

Current postmodern psychoanalytic theorists encourage deconstructing the concept of gender and analyzing it through the lens of power. As long as gender is conceptualized only as binary, gender conformity becomes the goal. When gender is dichotomized, there is a tendency toward relational “splitting” (Goldner 1991). In the course of any individual’s development, parts of the self are encouraged for one gender, while other parts of the self are prohibited. But this kind of gender splitting is regressive, prohibitive, and ultimately limits human possibility and human potential (Goldner 1991). Muriel Dimen (2003) has claimed that gender differences are the very paradox of selfhood. She has tried to capture gender complexity this way: Autonomy and dependence, activity and passivity, heterosexuality and homosexuality, body and mind, selfness and otherness, subjectivity and objectification, body superiority and inferiority, want and need, and I could go on: these apparent polarities are but diverse moments of the self, the passage between which might be regarded as pleasurable, even though when we leave the preferred polarity—when, for example, we transit from want to need—we are, as things now stand, extraordinarily uncomfortable. (pp. 197–98)

Other postmodern theorists (Foucault 1980, 1990) also note that words create worlds; language constructs reality. Lacan (1953) draws our attention to how language creates gender. Gender is not a given, but a series of cultural constructions created through language. Binary categories of maleness/femaleness tend to encode these categories with social expectations of what women (and men) should be. We cannot know the “meaning” or “truth” of anyone’s gender based on biology or development alone (Butler 1990), because cultures, environments, races, and relational contexts either encourage expressions of gender or constrict them. The same argument, by the way, has been made about sexual orientation. Just as psychoanalytic theories initially posited a theory of causality for why women were narcissistic and masochistic, so, too, did those same psychological theories posit causality for homosexuality, finding gays and lesbians or transgender people to be immature, deviant, and perverse. But, like gender, sexual orientation is not deviant, fixed, or immutable; instead, it changes

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over time within different kinds of relational contexts. Take, for example, Nina, who did not want to be constrained or limited by binary gender categories. Nina, middle class, of Iranian descent and from an immigrant family, came to therapy to deal with the loss of her mother from cancer. She was in her mid-twenties and thought that many of her problems with asserting her authority at work stemmed from difficulties she had asserting her autonomy at home at a time when her mother was weakened and wasting away. While struggles with her female boss had brought her into treatment, there was one area of her life that was playful and pleasurable. Nina described, with some delight, dating both men and women. She liked this part of herself that could be spontaneous, less prescribed, and more flexible. In contrast to seeing herself “stuck” at work, especially in relation to any authority figures, her sexual life felt like the one area of freedom, experimentation, and choice that she wished existed in other realms of her life.

Most gay men and women, those who are asexual, and many trans individuals maintain that sexual orientation is not a choice and that expressions of sexuality are fluid and change over time. When straight relationships were structured according to gender roles, many lesbian women tended toward also being “butch” or “femme.” That began to change (as it has in straight relationships) when the kinds of roles that men and women can play became more fluid. There was a time when being bisexual was rejected by the gay community, and the community itself pressured people to commit themselves to being gay only. Currently, there is a range of sexualities including being lesbian, bisexual, gay, straight, asexual, and transgender. Gender pronouns that “fix” a rigid gender role have been swapped for gender categories that can be chosen by each individual, who may choose a nongender pronoun (Zee, Zem, They, Them) or a cisgender pronoun. Sexualities are also now celebrated for being more experimental, and being based in strengths, not deficits. Transgender identities are also seen as emerging from having and expressing gender identities different from the one a person is born with. Corbett (2008) harkens back to ­Winnicott when he suggests that being transgender can now be seen as a “potential space” where paradox, playfulness, and ambiguity can be encouraged. Many academics (Butler 1990; Dimen & Goldner 2005) speak to the liberating discourses of gender “multiplicities” that push us to think about gender as possibility, rather than as difference. Other postmodern theorists (Comas-Diaz & Greene 1994; Dimen & Goldner 2002; Harris 1995a, 1995b; Layton 2002) focus on gender as discontinuous. In fact, the very categories of masculinity and femininity, or being straight or gay, have been constructed in relation to each other (Layton 2002). Postmodern perspectives on gender and sexuality tend toward becoming liberating discourses so that sexualities are not constrained by dualities or limited by binary categories. Categories such as trans identities have also come to be seen not as an end point but as a process of becoming (Goldner 2011). For gay, lesbian, bisexual, and transgender men and women, as for their straight counterparts, sexuality in the postmodern age is about breaking free of controlling social norms and about questioning the disciplinary power of fixed gender roles (Werner-Larsen, 2014). Thinking about gender requires thinking intersectionally. Gender is shaped by overlapping oppressions: heterosexism, homophobia, ableism, ageism, racism and other forms of oppression that shape what gender is “supposed to be.” The body is also regulated in terms of who defines it. What is acceptable or not, what is beautiful or not, is mediated by culture, race, and class (Salomon & Corbett 2014). Weight and size, for example, are defined as normative by those who have power. Hence, when we talk about gender and the body, we need to be thinking about who is defining what is normal, or beautiful, who is at the margins, and who is at the center of any definition (Forsell 2017).

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Gender theorists, then, extol the creativity of new forms of gendered expression. Yet beyond academic gender theorizing, there are many urban and rural populations of gay, lesbian, bisexual, and transgender youth who are routinely victims of verbal and physical assaults because of gender nonconformity. In fact, homophobic and transgender violence and discrimination are epidemic. For example, a gay, thirty-year-old man in New York City, was lured to a “party,” brutally beaten, burned, slashed, tortured, and sodomized by nine gang members for simply being gay, as were his brother and two younger lovers (Wilson & Baker 2010). That same week, a young and promising college freshman committed suicide in New Jersey when his roommates streamed his sexual activity with a young man across the campus via the Internet. Further, in the same week, the Republican candidate running for governor of New York made publicly homophobic remarks denouncing gay people as deviant and perverted. In New York City, two men were accused of beating and robbing a man in the Stonewall Inn, a landmark bar, while shouting homophobic slurs. Hate crimes are on the rise as well (Hate crime statistics, 2010). According to the Human Rights Council, “In 2017, there were 1617 hate crime offenses. Fifty eight percent were against male homosexuals; 25  percent were against female homosexuals; 20  percent were against women; and 2 percent were against heterosexuals.” According to the FBI, in 2016, LGBT people were more likely to be targeted for hate crimes than any other minority group (Dashow, 2018). In 2017, there was an even greater rise in violence against gay/lesbian and transgender people such that hate crimes doubled again (Astor 2017). In 2018, the National Coalition of Anti Violence Polices reported fifty-two violent homicides against LBGQT people, yet another 86 percent increase in the number of hate crimes against victims who were people of color, predominately African American and Latino. Furthermore, hate crimes against LBGTQ populations are both underrepresented and under-prosecuted (Keith & Galiano 2018). How does this affect the mental health of the victims? In 2015, of transgender men and women from fifty states, 39  percent experienced psychological distress as opposed to the general population where 5  percent experienced distress. For those transgender people, 54  percent experienced verbal assaults while 24  percent experienced physical assaults (Cor & Chan 2018). In another study of 106 transgender youth, there was a two- to threefold increase in depression, anxiety, suicide attempts, and self-harm. Furthermore, when ­Bostwick et al. (2014) looked at the mental health outcomes for transgender youth of color, they found that while Asian and Black youth are less at risk for mental health problems, Native American, Latino, and multicultural populations are at greatest risk. Further compounding the problem is that hate crimes against the LBGQT populations are underreported and often not prosecuted (https://www.public integrity.org/2018). Perhaps most troubling for transsexuals is the statistic that 53 percent have made suicide attempts (Massachusetts Governor’s Commission on Gay and Lesbian Youth 1993). And according to the New York Times, in 2018 we are on track for the deadliest year yet for hate crimes against LBGTQ people, which continues to make some gender expressions dangerous and even deadly. In the current political zeitgeist, then, many parts of the country and many political groups do not value or even tolerate gender nonconformity. Many gay, lesbian, and transgender people suffer greatly from homophobia and from racism that is enacted in violent ways. Hate crimes have risen steadily every year and the consequences to the victims are very serious. Additionally, while much has been written in the academic world about the need to deconstruct gender and sexuality and to be open to gendered possibilities, there is still work that needs to be done on how this actually occurs in the clinical situation, especially with clients who may already suffer with fluid identities. While a postmodern perspective—positing

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identities as always shifting based on culture, gender, race, religion, ethnicity, class, and power—is very valuable to the practitioner, there are still issues that postmodernists do not address, especially for those clients whose experiences of multiple shifting self-states contribute to their experiences of unbearable fragmentation. Multiplicity can be playful, creative, and enlivening, but for those whose senses of self are not coherent, multiplicity may also cause suffering. There is then a tension for the practitioner between fostering the paradox, playfulness, and ambiguity of gender identities, while also appreciating that, for some, discontinuities of self may be challenging. Under the best of circumstances, living with a multiplicity of gendered possibilities may be freeing for both women and men in achieving their full relational potentials, but there will also always be those who come to us for help because such discontinuities are overwhelming and fragmenting, or because they are the victims of a society that will not tolerate or celebrate their discontinuities. Let us return now to Patricia, who had evaded the “trap” of binary relationships, which she felt had contributed so negatively to her mother’s sense of self. While she was content and satisfied to be in two relationships, one with a man, the other with a woman, her female partner apparently felt differently and began a relationship with another woman. Ultimately, those two women became exclusive and Patricia’s female partner broke off her twelve-year committed relationship to her. Her partner sold their joint property and left the state with her girlfriend. Patricia was devastated by what she experienced as a total betrayal and became profoundly depressed. She felt fragmented, and overwhelmed, not unlike the state her mother had found herself in after leaving an abusive relationship. It took many years to begin to come back to herself given how traumatized and dissociative she was, and she could barely work or engage with friends and family. And so, we return to the question of what women want, to which we add, what do men and women who are gay, lesbian, transgender, racially diverse, old, young, able, or disabled also want? Some people want to stay at home with their children; some want to be the president of the United States. Some see themselves as affiliative; others see themselves as instrumental; many see themselves as both. Some men and women desire a man; some women and men desire a woman; many women and men desire both men and women. Some men and women are asexual and desire neither men nor women. Gender has been referred to as soft assembly (Dimen 2011; Salomon & Corbett 2011), and we like that term, asserting that women and men move in and out of gendered categories and through different performative roles, and these are always determined by historical time and social conditions. If the capacity to tolerate ambiguity, not knowing, fluidity, playfulness, fuzziness, soft assembly, and experimentation are, in fact, hallmarks of mental health, then we, as practitioners, need to be open to continually exploring the paradoxes that will always surround the gender(s) and sexualities of our clients. Yet it is important, too, that we recognize that while creativity and experimentation may be a part of gender representation, we also work with those for whom too much ambiguity may be difficult, dangerous, or both. In addition, we must be vigilant about the ways in which racism, classism, and homophobia interact with sexual orientations, with pernicious consequences for mental health. In this chapter, we have reviewed over 150  years of gender theorizing. Each wave of gender theorizing has been influenced by the values of its historical time and place. Each gender theory has reflected the political place of men and women, gays and lesbians in the society at that time. Whether it was the first wave of feminism that challenged Freud’s view that biology was destiny and that women were lesser or it was theories that suggested that what women wanted was power not a penis, whether it was theories that showed how the asymmetrical structures of power families were reproduced into rigid gender roles, whether it was idealizing women’s strengths of nurturance and affiliation or the current zeitgeist of

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deconstructing gender, our theories of gender always occur in unique social, cultural, and political contexts. As practitioners, we need to remain open to the many meanings and values of gender and sexual orientation expressions, privileging none and ignoring none while remaining open to paradox and possibility.

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———. (1990). The History of Sexuality, Vol. 1, trans. R. Hurley. New York: Vintage [English ­translation copyright 1978 by Random House, Inc.]. Freud, S. (1905a). Three essays on sexuality. In Standard Edition: The Complete Works of Sigmund Freud, ed. J. Strachey, pp. 134–243. London: Hogarth Press. ———. (1951). A letter to an American mother. International Journal of Psychoanalysis 32:331. Goldner, V. (1991). Toward a critical relational theory of gender. Psychoanalytic Dialogues 1(3):249–72. ———. (2011). Trans: Gender in free fall. Psychoanalytic Dialogues 21(2):159–71. Greene, B. (2000). African American lesbians and bisexual women in feminist-psychodynamic psychotherapies: Surviving and thriving between a rock and a hard place. In Psychotherapy with African American Women: Innovations in Psycho- dynamic Perspectives and Practice, eds. L. C. Jackson and B. Greene. New York: Guilford Press. Grosskurth, P. (1986). Melanie Klein: Her World and Her Work. New York: Knopf. Hare-Mustin, R., & Marecek, J. (1990). On Making a Difference: Psychology and the Construction of Gender. New Haven, CT: Yale University Press. Harris, A. (1995a). Gender as contradiction. Psychoanalytic Dialogues 1:23–24. ———. (1995b). Foreword. In Disorienting Sexuality: Psychoanalytic Reappraisals of Sexual Identities, eds. T. Dominici and R. C. Lesser. New York: Routledge Press. ———. (2011). Gender as strange attractor: Discussion of the transgender symposium. Psychoanalytic Dialogues 2(21):230–38. Hate crime statistics. (2010). http://gaylife.about.com/od/hatecrimes/hate_crimes htm. Retrieved November 10, 2011. Horney, K. (1924). On the genesis of the castration complex in women. International Journal of Psychoanalysis 5:50–65. ———. (1926). The flight from womanhood: The masculinity complex in women as viewed by men and women. In Woman and Analysis: Dialogues on Psychoanalytic Views of Femininity, ed. J. Strouse. New York: Grossman, 1974. ———. (1967). Feminine Psychology. New York: Norton. Jones, E. (1955). The Life and Work of Sigmund Freud, Vol. 3. New York: Basic Books. Jordan, J.,  & Surrey, J. (1986). The self-in-relation: Empathy and the mother-daughter relationship. In The Psychology of Today’s Woman: New Psychoanalytic Visions, eds. T. Bernay and D. W. Cantor. Hillsdale, NJ: Analytic Press. Jordan, J., Surrey, J., & Kaplan, A. (1983). Women and Empathy: Implications for Psychological Development and Empathy. Wellesley, MA: Wellesley College, Stone Center for Developmental Services. Keith, E., & Galiano, R. (2018). Hate crimes against LBGTQ organizations are underrepresented and underreported. https//www.public integrity org/2018. Lacan, J. (1953). Some reflections on the ego. International Journal of Psychoanalysis 34:242–55. Layton, L. (2002). Gendered subjects, gendered agents: Toward an integration of postmodern theory and relational analytic practice. In Gender in Psychoanalytic Space, eds. M. Dimen and V. Goldner. New York: Other Press. Mahler, M. (1980). The Psychological Birth of the Human Infant. New York: Basic Books. Massachusetts Governor’s Commission on Gay and Lesbian Youth. (1993). Making Schools Safe for Gay and Lesbian Youth. Malden: Commonwealth of Massachusetts, Department of Education. McIntosh, P. (1988). White privilege and mate privilege: A  personal account of coming to see correspondences through work in women’s studies. Wellesley College Center for Research on Women, Working Paper 189:1–19. Miller, J. B. (1976). Toward a New Psychology of Women. Boston, MA: Beacon. ———. (1990). The development of women’s sense of self. In Essential Papers on the Psychology of Women, ed. C. Zanardi. New York: New York University Press. Pérez Foster, R. M., Moskowitz, M., & Javier, R. A., eds. (1996). Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy. Northvale, NJ: Aronson. Rich, A. (1976). Of Woman Born: Motherhood as Experience and Institution. New York: Norton. Salomon, G.,  & Corbett, K. (2011). Speaking the body/mind juncture: An interview with Gayle ­Salomon: Assuming a body: Transgender rhetorics and materiality, New York: Columbia University Press. Psychoanalytic Dialogues 21:221–29.

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11 Psychodynamic Contributions to Understanding Racism: Implications for Clinical Practice Brian Rasmussen and Ann Marie Garran

INTRODUCTION We are living in disturbing and disillusioning times. As Dyson (2017) writes, “America is in trouble, and a lot of that trouble—perhaps most of it—has to do with race” (p. 3). Fantasies that eight years with President Barack Obama in power would usher in a post-racial era in the United States have been proven to be just that—fantasies (Zevnik 2017). It would seem that those wishes have now been replaced by fears that race relations in the United States are progressively eroding. Accordingly, racism has become a dominant issue in political and media discourse, and indeed in the everyday lives of racialized people. Of course, racism has been with us for a long time, indeed since the origins of the country. It is manifested in a myriad of ways, for instance as anti-immigrant policies, housing and employment discrimination, inequities in education, and unjust death row convictions. In concert with the rise of white supremacy movements, racism is further manifested with police killings of innocent Black and brown people and an uptick in violence toward Chinese Americans in response to COVID-19. Consequently, we need to make sense of racism, to understand its depth, complexity, and irrational insistence. We appreciate there are many theoretical approaches for analyzing racism, of which psychoanalytic theories are but one line of thinking. Because racism is embedded in all aspects of society, including economic, political, ideological, cultural, and social realms, multiple theoretical perspectives are required. But our approach here is not to review the full range of the ways that racism can be understood and enacted but rather to be curious about how psychodynamic theories contribute to our understanding of the dynamics of racism. Given racism’s vexing nature, its conscious and unconscious roots, and the depth of its hold on all of us in everyday life, psychodynamic theory is uniquely positioned to offer ways of comprehending its unconscious grip (Hart 2019). And while we will examine the problem of racism psychodynamically, we encourage readers to continue to explore the structural, social, economic, and political intersections of racism historically and in everyday life (Miller & Garran 2017). 217

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In this chapter, we will consider racism from drive, ego, object relations, self psychological, and relational perspectives and apply this understanding to the therapeutic situation in ways that can assist clinical practitioners in considering the racialized dynamics unfolding in the therapeutic relationship. But before we explore psychodynamic perspectives on racism, we first want to clarify some language used throughout this chapter. To begin, we concur with many scholars that “race” is a social construction, with no ontological basis (see Bonilla-Silva 2014; Kendi 2017; Miller & Garran 2017). That means that there are no objective categories based on skin color; rather, “race” was created by an intentional need to grow a particular economic order, which was and continues to be maintained by social forces. Therefore, we will use the term racism throughout, and put quotations around the word race. Thomas King, writing from an Indigenous perspective, observed, “The need for race precedes race” (2012, p. 19). Likewise, Ta-Nehisi Coates writes, “[R]ace is the child of racism, not the father” (2015, p. 7). In essence, we understand these authors to say that the creation of the “denigrated other” based on the construction of race meets political, social, economic, and personal needs, and establishes a privileged social order, benefiting some while harming others. Consequently, “race” as a construct becomes a valuable tool for advancing these agendas. Coates makes his case even more forcefully when he writes: Americans have sought to erase the crime of racism, which is active, with the concept of race, which is not. When we say “race” as opposed to “racism,” we reify the idea that race is somehow a feature of the natural world and racism the predictable result of it. Despite the body of scholarship that has accumulated to show this formulation is backwards, that racism precedes race, Americans still haven’t quite gotten the point. And so we find ourselves speaking of “racial segregation,” the “racial chasm,” “racial diversity”—as though each of these ideas is grounded in something beyond our own making. (2017, p. xi)

As we proceed in this chapter, then, let us be mindful in holding central the active nature of racism, in our search to understand its dynamic core.

PSYCHOANALYTIC PERSPECTIVES One way to think of psychoanalysis is to consider it as the study of the irrational (Clarke 2003). As such, one might be inclined to assume that racism would have been a prime target of analysis over the last century. Yet until recently psychoanalysis was largely silent on this topic, and on that account, its disregard of racism can itself be considered racist. As Melanie Suchet (2004) laments, “The history of psychoanalysis and race is intriguing, mostly by its absence. Given that psychoanalysis is a theory steeped in the construction of subjectivity, the lack of a serious analysis of race is notable” (p. 423). Finally, over the past two decades, we have witnessed a greater interest in the problem of racism from a psychoanalytic perspective. Below, we highlight some of these contributions emerging within various schools of thought, at times blending and incorporating competing paradigms. We will begin historically, looking at Freud and his followers.

FREUD Freud apparently never used the term racism (Clarke 2003). Nonetheless, as noted earlier in this text, he was no stranger to persecution and anti-Semitism. Forced by the growing threat

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of Nazism to flee his homeland, Freud was keenly aware of the need to understand this particular form of aggression and discrimination. In the subsequent decades, and borrowing on Freud’s own speculations about human nature, members of the Frankfurt School, in particular, Herbert Marcuse, Theodor Adorno, and Eric Fromm, sought to understand the irrational destructiveness of fascism and Nazism (Elliott 2004). Much of their effort focused on integrating Freudian theory with a Marxist analysis to offer a rich psychosocial perspective. Analyzing racial conflict, Freud turned his thinking to dynamics occurring at the group level. Here, his earlier theorizing about narcissism was particularly helpful. Individuals were thought to uphold a sense of their ideal self by maintaining an identification with a larger, idealized group; however, those outside the group are denigrated. This process appears very similar to the dynamics at an individual level whereby the person elevates her own self-esteem by denigrating another. Freud’s analysis put this theorizing in drive psychological terms, incorporating projection as the main defense. Projection rids a person of feeling powerless and bad by putting that unwanted feeling onto the reviled other, or group of others, diminishing the painful experience. Freud expressed his thinking about this process in Civilization and Its Discontents: One should not belittle the advantage that is enjoyed by a fairly small cultural circle, which is that it allows the aggressive drive an outlet in the form of hostility to outsiders. It is always possible to bind together a considerable number of people in love, so long as there are other people left over to receive the manifestations of their aggressiveness. (1930, p. 64)

Freud understood that people form a bond by harnessing their aggression toward those outside of the dominant group. To maintain an elevated position, they marginalize and reject those who are perceived to be different. Freud was observing something exceptionally valuable: the irrational fear of racialized others. Benefits accrue to the more powerful/dominant group by projecting unwanted aspects of themselves onto the other, and then scapegoating the other(s). Essentially, this is one way of creating the “other.” What gets projected may include aggression, sexualized desires, greed, powerlessness, or any other disowned psychological states. The dominant group, in this case those considered “white,” preserves their stability and cohesiveness at the expense of people who are different, and therefore viewed as deficient (see Fredrickson 2002 for a history of racism and the construction of whiteness). Projecting aggression outward and directing it at a specific group maintains the internal cohesion of the group that is enacting the projective process, as is often the case when countries prepare for war. Consider also that what is often projected onto racialized groups are impulses and desires found unacceptable to societal standards of the day by the dominant white group. Applying Freud’s ideas, we can also see that Indigenous people in North America have been subjected to white colonizers’ projections of their sexual and aggressive drives since the time of first contact. For instance, when Thomas King examined the history of Indigenous people portrayed in movies, he observed that they were “made for film,” as “Indians were exotic and erotic  .  .  . all sweaty and lathered up, before we rode off to fight the cavalry” (2012, p.  34). These overly sexualized and aggressive portrayals did not accurately reflect Indigenous people, but more likely revealed the split off and repressed inner worlds of the white settlers. Another contemporary example is Donald Trump referring to Mexicans as “rapists and murderers” during the 2016 presidential campaign when speaking to largely white audiences. In so doing, Trump projected sexual and aggressive drives onto groups with less power, stoking fears and division while reifying white supremacy.

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FANON Franz Fanon (1952) offered a piercing analysis of racist dynamics. In Black Skin, White Masks, Fanon explored the racist effects of colonization on Black identities. His essential argument was that Black people are forced to adapt to the white dominant world by learning how to “perform” whiteness, first through adopting the language of the colonizer. Fanon writes, “All colonized people—in other words, people for whom an inferiority complex has taken root, whose local cultural originality has been committed to the grave—position themselves in relation to the civilizing language” (1952, p. 2). For Fanon, such adaptation comes at great cost. He argued, “A normal black child, having grown up with a normal family, will become abnormal at the slightest contact with the white world” (p. 122). Clearly, Fanon moved beyond drive theory by articulating the external impact of racist environment on the psyches of Black people. It was important for Fanon to describe the lived experience of Black people and the effects of their subjugation to white dominance. The Black body, imbued with negative meaning, ensured that people of color were forever branded as bad and inferior. How the Black person resists, adapts to, or compromises the self in relation to this oppression is a dynamic that many theorists later explored. More recently, Sharmila Sen’s (2018) memoir Not Quite Not White: Losing and Finding Race in America provides an excellent contemporary example of Fanon’s thinking. Having immigrated from India at age twelve, Sen found herself preoccupied with blending in with American whiteness. Upon reaching university, Sen observed herself and other recent immigrants smiling excessively. She was curious as to why. Were they really all so happy, she wondered? A friend of hers, also an immigrant of color, suggested to her that an inauthentic self is the only face acceptable to show. This idea made sense to Sen, who reflected, “I know that if I stop grinning, I will frighten people with my anger” (p. x). Like Fanon, Sen was keenly aware of the costs of repressing her anger in order to adapt to white culture.

KOVEL Kovel (1970) wrote White Racism, at a time when ego psychology was at its height. He was clearly aware of its theoretical limits by the time of its second edition fourteen years later; however, Kovel wrote in defense of his earlier thinking that we need something like a drive, or an instinct theory, in order to really describe the “true madness and unfathomable range and hatred embedded in racism” (p. xl). Later, Kovel (1984) was more inclined to substitute the word violence for aggression in order to connote a particular kind of social relationship, rather than an instinctual target. Using the word violence evoked a more “experience near” descriptive term to capture the harm that white people do to people of color. To be precise, Kovel came to see racism as an act with purpose and intent, rather than simply as a discharge of instinctual aggression. It seems to us that the shift in thinking here was toward a more relational frame of reference, paving the way for a broader social analysis of racism. Extending Freud’s thinking, Kovel wrote that the white self is created through the denigration of Black people. To that end, Kovel said, the dominative racist is irrationally and profoundly dependent upon the object of his prejudice. He cannot leave him alone. Hate implies a kind of love or at least an inability to rid the mind of obsessions with the hated other. And these obsessions are invariably tinged with sexuality. . . [and with] the sexual excesses of the hated group, etched in the imagination by the acid of the hated group. (1984, pp. 56–57)

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We wonder what psychological benefit comes from the need to devalue and marginalize the other. For example, we have observed the ways that white supremacists are consumed with demeaning the “reviled other,” be they undocumented workers, Muslims, Jews, African Americans, Mexicans, or the disabled. Kovel also invites us to consider the role of power and how the structures of capitalism and imperialism maintain the paradigms of dominance and subordination. Kovel demonstrates how power is created and maintained by the dominant group to advance its own ends. An example of this kind of abuse of power can be found in the criminalization of Black and brown people along with the dramatic rise of the prison industrial complex (see Stevenson 2015).

KLEIN Television viewers watching a group of white men, holding tiki torches and shouting, “Jews will not replace us” in Charlottesville, Virginia, in 2018, may have wondered where all of this madness comes from. What irrational fears and forces cause the white men in Charlottesville, or in any American city, to harbor such hatred and express their derision so blatantly? Or, consider the example of landlords who steadfastly refuse to rent their apartments to Black people. What states of mind are necessary to hold these convictions? How does this behavior make the racist feel? How do beliefs that devalue marginalized groups bind dominant groups together? With these questions in mind, Melanie Klein helps us understand the intrapsychic and interpersonal dynamics of racism. We agree with Clarke (2003), who argued that Klein’s theory “provides a powerful basis for our understanding of the ubiquitous and visceral elements of racial hatred and discrimination” (p. 123). Klein’s Positions A central idea for Klein is that the mind holds two “positions.” In the earliest periods of development, which she calls the paranoid-schizoid position, people psychologically separate good and bad images of others and themselves. In the early stages of life, it is too scary to think that the person(s) we desperately need could be “bad.” To preserve the image of the good parent, the baby may unconsciously expel the “bad” into others or the external world (Clarke 2003). Thus, the good and bad images of people we need are kept separate by means of the defense called “splitting.” Developmentally a child moves next into the so-called “depressive position,” when they are able to see their parents and themselves as a mixture of both good and bad. This developmental achievement, however, comes with some sadness and loss because the child can no longer have the comfort that comes with idealization or the clarity that comes from splitting love and hate. (See chapter  5 for further review of Klein’s theory.) For our analysis, it is important to understand that throughout our lifespan we can move back and forth between these positions, with negative consequences for how we view others if we continue to operate from a paranoid position. Klein believed that the paranoid-schizoid and depressive positions continue to organize our psychic world in adult life, and we may shift back and forth between them under certain circumstances. When we speculate about the state of mind that generates racist thinking (which can occur in the mind of any white person), we suggest that the individual is operating from the paranoid-schizoid position. When racism occurs, the world is often viewed in black-and-white terms. The person who is hating believes themselves to be good and righteous, while simultaneously imaging others as bad and threatening. When white people

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feel persecuted, they hold a perceived fear of losing their power and privilege and of being deprived of other benefits that come with whiteness. For example, fears of being “overrun” by an “invasion” or “infestation” of undocumented people, Muslims, immigrants, or people of color are plainly paranoid. When disadvantaged groups press for equality, dominant groups feel further threatened and worry about losing something of value. The fears may include losing their way of life, their culture, their religious freedom, their right to bear arms, in essence, the fear of losing their identity.

Projective Identification Klein’s concept of projective identification is also very useful to understanding racism. The idea is complex and includes both ordinary communicative aspects and pathological paranoid states. Ogden (1982, 1990) helps us to understand projective identification by breaking down the process. To begin, the individual who is projecting needs to rid the self of unwanted parts and does so by putting them in another. Next, pressure is asserted to coerce the recipient to behave according to the projection. Finally, the recipient of the projection begins to experience themself in ways that are consistent with the projective fantasy. Kita (2019) does an excellent job of showing how projective identification on a social level helps us to comprehend the problem of mass incarceration. Her work helps us make sense of how and why the prison system is filled with people of color, many poor. Despite the system’s historic failures, indeed because it fails, it continues to serve a psychic function for white dominant culture to project, coerce, and control targeted populations. Recipients of these projections are made to feel devalued, to feel less than, and are forever banished to the margins of society. Projective identification operates unconsciously in many different forms, from ordinary communication to pathological machinations. But when we are examining racism, the role of projective identification is deeply problematic in that it alters our perception of and influences the subjectivity for the target. The following is an example taken from Rasmussen and Salhani (2010) highlighting projective identification in an educational context: A white university professor, self-conscious about her intelligence (but loath and unwilling to admit that to anyone, let alone herself), is asked to teach a course outside her expertise. During one class, the professor struggles to explain a difficult concept, one that she barely grasps. Most students in the class are confused; however, the instructor singles out two Asian international students seated at the front of the class because of the puzzled looks on their faces. While never acknowledging her own confusion, the instructor spends a good deal of time helping these students understand the concept. She has only limited success. As white students file out of the classroom, one can be overheard muttering to a fellow student that the international students are slowing the class down. In this example, the instructor projects her confusion onto the international students (vulnerable recipients of this disowned state) and then seeks to work out her own muddled thinking in them. The use of projective identification as an unconscious defense allows the instructor to maintain her self-esteem. However, there is a substantial cost to others. It is the international students, not the instructor, who leave the class wondering if they belong there. (pp. 497–98)

Clarke (2003) extends our understanding further by suggesting that “projective identification involves a deep split, a ridding of unpalatable parts of the self into rather than onto, someone else” (p. 147, italics in original). This view suggests that projective identification could potentially be a far more damaging process than projection itself, as the recipient is made to feel a certain way that conforms to the projector’s psychological needs. In similar

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ways, Fanon (1952), years ago, described the impact of colonization on the colonized. So, too, did Toni Morrison (2017) in The Origin of Others, in which she shows how whiteness exerts an impact on Black people. She wrote, “But for humans as an advanced species, our tendency to separate and judge those not in our clan as the enemy, as the vulnerable and the deficient needing control, has a long history” (p. 3). To project into another, alter the subjectivity of that person, and then attempt to control that person or group are central dynamics in the colonization of various peoples. Let’s return to the concept of positions and the shift that occurs with the depressive position so that we can consider the role of reparations. Most notably, when a small child begins to see the caregiver as a whole person—both good and bad—rather than a part object, the child experiences guilt and anxiety. To deal with these feelings, the child engages in acts of reparation to restore this important relationship and demonstrate love and gratitude for the caregiver. But Alford (1989) makes an important point with respect to reparative urges: things get in the way, in particular, envy. Holding an important place in Klein’s thinking, envy is a destructive emotion that we experience when we can’t have something we want. But if we can’t have what we wish for, we can destroy the object of our desire, thereby eliminating this unpleasant feeling. One student, upon hearing Klein’s theory of envy, told the story of how, when she was six years old, her twin sister received a doll as a birthday gift (one that they both longed for). When her sister wasn’t looking, she ripped the head of the doll off and threw it behind the couch. Forced by her parents to apologize, she could only insincerely mouth the words. Here we can see that envy interfered with any genuine desire for reparation. Suggesting that the racist envies the target that he or she devalues is not intuitive, but there are many reasons why whites envy people of color. For instance, Black and Latino athletes dominate some major professional sports, especially football, baseball, and basketball. The music industry is likewise disproportionately represented by Black artists, particularly in jazz, hip-hop, and rap. But such feelings are not limited to envy of fame and fortune. In everyday life, there are other reasons to envy people of color. Envy can be expressed toward close family ties, caring communities, and rich cultural heritage and rituals. We can wonder: What happens to all of this envy and how does it get expressed? Rasmussen (2013) provided an example of the manifestations of envy through analyzing the protagonist, Walt, in the movie Gran Torino: Walt is openly and crudely racist toward his Hmong neighbors. He is also envious of their closeness, care and concern for one another, and the spirit of their traditions. But, [h]is envy seeks to destroy in others what he can’t have for himself; his racism is the tool of that destruction. And if he succeeds in destroying it in others then he lessens the possibility of experiencing it within. However, the more he connects with his neighbors, the more time he spends with them, the more he relishes in their differences and experiences similarities, the less envy he feels—and the less destructive is his racism. (p. 57)

In a similar fashion, Rasmussen and Garran (2019) argued that a prime motivator for white people in the movie Get Out (Peele 2017) was envy. The film’s protagonist, Chris, is the African American boyfriend of a white woman; they travel to her home one weekend to introduce him to her family. Over the course of the film, we learn about her family’s deepseated, violent racism, whereby they seek to overpower and literally inhabit black bodies. Both her white family and their predominantly white friends openly envy Chris’s good looks, creative talents, black body, perceived sexual prowess, and athletic abilities. The envy in the white characters leads to them to desire the good parts for themselves. These wishedfor characteristics cannot be attained from Chris without destroying his essence.

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While individuals have the capacity for reparation and the ability to overcome envy, large groups appear rarely to develop a reparative culture (Alford 1989). For example, while many assert the imperative for reparations from slavery, the injustice is still unresolved 400 years after the first African slaves were forcibly transported to the colonies (see Coates 2018). What gets in the way? Perhaps those who resist offering reparations do so out of the fear of having to give up something. Also, to really provide reparations, there is the need for those who hold power to authentically and fully identify and empathize with the other. Alford (1989) points us in a hopeful direction. He suggests, “What is necessary is the development of cultural values (meanings) that encourage the transformation of reparative impulses into constructive reparative activities. What is needed is a group culture that supports the acting out of reparative phantasies and channels this acting out toward those genuinely in need of reparation” (p. 49). However, we are not holding our breath.

WACHTEL Wachtel (2014) is a relational theorist who approaches the dynamic interaction between the inner and outer worlds from what he terms “cyclical psychodynamics.” Wachtel sees a continuous interaction—a mutual back and forth—between people and those they encounter. This idea suggests an analysis of racist actions that is more complicated than limiting motivation to a person’s previous internalizations. Turning his attention to forms of oppression, Wachtel theorizes “vicious circles of racism.” The following provides a recent example of cyclical psychodynamics as captured on a cell phone video: An older white college professor requested that a Black male student move seats from the back of the class to the front. The Black student saw no apparent and reasonable need for this request and refused to move. The white professor then called the police. When the police arrived, a further confrontation and standoff ensued. Eventually, the Black student decided he had had enough and left the classroom. Likely not lost on the Black student is the lengthy history of white people with power using police to control Black bodies. That history goes back to slavery. Wachtel considers racial divisions a product of many factors—that is, more than one’s state of mind. In essence, he is urging us to take a more complex account of these internal and external variables, including historical residues of racism as mediated by current psychological forces. When we view discrimination through this lens, current forms and acts of racism cannot be dislodged from the past, as for example, the genocide of Indigenous people. Wachtel argues that the tendency for white people is either to ignore the injustices or to absorb self-blame and guilt, neither of which are likely to result in action. But whether white people ignore injustices, express guilt or shame, shed crocodile tears, or become zealous allies (or indeed be genuinely helpful), these behaviors are all part of cyclical psychodynamics. People of color are bound to react one way or another to each stance. One cannot not react. The oppressed person’s action or inaction will be bound up with a reciprocal action from the oppressor, as highlighted in the above example with the student and professor. And while some might argue that how we punctuate such interaction is arbitrary, we can never minimize the importance of power and privilege in our analysis, for to exclude power from our understanding serves only to perpetuate the cycle of racial oppression, replicating historical patterns.

SELF PSYCHOLOGY Miliora (2000), a self psychologist, contributes to our understanding of the effects of racism with an emphasis on the need for others to mirror us, reflecting back who we are. We need

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others who are like us and make us feel a part of humanity. Normatively, we need others whom we can idealize, helping us to stay strong and whole. In this light, Miliora shows how racism can lead to narcissistic trauma. She writes, “Cultural racism assaults persons in ways that are utterly opposite to the effects of mirroring” (p. 43). Here are some recent examples: Latinx people are often punished at work for speaking Spanish in the workplace break room. African American students are frequently suspended for their hairstyles or even have their dreadlocks cut off without their permission. Indigenous people are often prohibited from holding cultural ceremonies, for instance, smudging. In each case, living in a racist world generates cumulative effects that over time constitute narcissistic trauma, invalidating one’s sense of self. Failure to demonstrate empathy or to acknowledge expressed vulnerabilities interferes with twinship self object functions as well (Lee 2013). Burdened by constantly having to imagine (or know) how one is being perceived by others, and worrying (or knowing) that the perceptions are devaluing, can lead to a “disenfranchisement of grandiosity.” In ordinary terms, it is hard to feel good about yourself when the very essence of your identity is constantly undermined. In some respects, we think the idea of failures in mirroring is similar to the concept of double consciousness, first introduced by Du Bois in 1903 and described here by Walls (2006): Double consciousness refers to the mental strategy of viewing oneself through the eyes of one’s oppressor. This is one of the psychological effects of a dominant ideology on the people it oppresses: it is dangerous not to internalize the dominant ideologies’ definition of who you are, because those in power will feel threatened if you present yourself in any other way; for example, as equal. But to maintain a sense of sanity and self-respect, one also must maintain a separate non-racialized definition of who one is, and this constitutes an effortful and dysphoric (conflictual) double consciousness, one not shared by people assigned to the dominant groups. (p. 131)

From the perspective of self psychology, the burden of double consciousness can be viewed as interfering with healthy narcissistic development. For a racialized child, this process may become all the more complicated growing up in a world that devalues the very people that one needs to idealize. For example, in a social work class on oppression, students were asked to reflect on a personal situation where they experienced or witnessed an oppressive event. A few students of color painfully recalled specific incidences where they witnessed a parent being subjected to racist attacks. In recounting the events, it was clear that as children viewing their own parents devalued in this way interfered with healthy idealization and identification processes. One student recalled that, as a small child, she lost respect for her father who, she thought at the time, did not “stand up for himself.” Of course, at a young age she could not have appreciated the risks her father would have been taking if he had acted more assertively in self-defense. As an adult, she more fully understands her father’s acquiescence and experiences guilt for her reaction at the time, but also sadness and anger. As a child, racism interfered with her need to idealize, admire, and see her father as strong. Summary Let us then summarize some of the key psychodynamic ideas presented so far. Drive theorists point to the need to create and maintain group identity by devaluing the outsider or other group. Aggression and sexuality are also projected onto the “other,” who is seen as needing to be controlled. Central to many schools of thought is the concept of projection: ridding oneself of unwanted feelings or thoughts and putting them on others. We showed how projective identification takes it further when the racist attempts to control the other as a consequence of those projections. Splitting and devaluation serve to reduce anxiety in

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the racist, who often unconsciously envies people of color. These forces function to not only alter the subjectivities of the target group but also impact white subjectivities. Once racist actions are set in play, reciprocal psychodynamics account for the conscious and unconscious interactions by all participants. The idea of reparation, highlighted by Klein’s theory, has important implications for responding to the tangible impacts of racial injustice. Next we offer a case study to apply the theoretical concepts we have discussed and to explore the clinical implications that arise from it.

CASE STUDY OF DAN Dan is a twenty-seven-year-old, heterosexual, cisgender male, middle-class, U.S.-born American citizen. His parents immigrated from Pakistan in their early twenties and quickly established a successful travel agency business in a midsize city in the Northeastern United States. Throughout his youth, Dan was often the only child of South Asian descent in his classrooms. He described being taunted and bullied on several occasions. Dan recalled his peers making fun of his clothes and the lunches his mother prepared. His parents were frequently subjected to racial insults that made no sense to Dan. He felt isolated, depressed, and unsure where to turn, as his teachers seemed to ignore the abuse. Dan’s parents were supportive, but nonetheless he felt uneasy about discussing these personal attacks, predicting they would invariably advise him to “just turn the other cheek.” Dan presented for therapy following a recent traumatic incident at work. As a new graduate of a paramedic program, Dan was faced with a critically ill white woman who had collapsed on the sidewalk of the main street. Several white onlookers watched as Dan struggled to revive the patient. While Dan’s actions were appropriate to the situation, his initial hesitation suggested a lack of confidence and uncertainty. One white onlooker, who had tried unsuccessfully to revive the patient prior to Dan’s arrival, said, “You obviously have no clue what you are doing; why don’t you just go back to where you came from?” The racial attacks intensified as Dan provided mouth-to-mouth resuscitation to the woman. With the arrival of another first responder, the patient was transferred to the local hospital. In the days following this incident, Dan was full of self-recrimination, continuing to replay the scene in his mind. He was having trouble sleeping. Most disturbingly, he couldn’t get the voice of the onlooker out of his head. Compounding Dan’s suffering were the memories of earlier racial injuries resurfacing in his mind. Imagery related to his middle school lunchroom intrusively forced its way into consciousness. This experience was disturbing to Dan as he felt that he had moved on from those days. Dan spoke of feeling self-doubt, anger, shame, and futility. At other times, he stared out the therapist’s window, lost for words. Dan’s white clinician, Lily, found herself flooded with feelings and questions. She wondered: How was Dan coping with this racial attack? How did the earlier racial traumas interact with the recent assault? How did Dan feel about seeing a white practitioner? What did Dan need from her? Lily became anxious and guilty, with images of her overtly racist grandfather intruding into her mind.

APPLICATION OF THEORY In the case study of Dan, we can see that the white bystander’s earlier actions were unsuccessful in reviving the woman. Unconsciously, the onlooker projects onto Dan his disowned ineptitude. (We imagine that later, as this person recounts the story to friends, he leaves out

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his failed attempt to be helpful.) Further, expressing a well-worn racial insult, he tells Dan to go back where he came from—reinforcing a basic structure of white supremacy. It was not the first time that Dan had heard this form of racial insult. Indeed, repeated experiences of outright hostility and more subtle microaggressions were commonplace in Dan’s early years. This contributed toward his self-recrimination for not reacting more effectively at the outset. The racist comments of the white onlooker also contributed to the solidarity of the other white witnesses who could participate in the splitting process—that is, seeing themselves as good and belonging, and Dan (and those like him) as bad and unwelcome. Accordingly, we might speculate that the white attacker and white witnesses unconsciously experienced envy that Dan had “taken” this job from a “deserving” white person. The impact of this racial assault on Dan was traumatic, emotionally destabilizing, and invalidating (Comas-Diaz  & Hall 2019). This subjective experience is consistent with self psychology’s emphasis on mirroring and self-object needs. The effects of this kind of “discriminatory gesture,” in Hart’s (2019) words, mean “the humanity of the target of racism is symbolically negated. The discriminatory gesture invariably contains the implicit, if not explicit message that the target is not fully human, and that the target’s life is expendable” (p. 16). The racial taunt “go back where you came from” reinforces this underlying message explicitly. At the outset of treatment, Dan was hesitant to see a white clinician, worried that she would neither validate his experiences of racism nor fully appreciate its impact. Dan’s fears were not unfounded, as Mazzula and Nadal (2015) report that many white clinicians are hesitant to engage in therapeutic conversations involving racism. Dan was relieved to find that his clinician was, fortunately, willing to speak about the effects of racism and able to address, in a nondefensive manner, the racial differences between them. Accordingly, she wondered out loud what it was like for Dan to be working with a white clinician. Dan acknowledged that he was anxious at first but then relieved to find that the clinician was open and interested in exploring his experiences with racism. Together, they began a therapeutic process that was empathic and curious about the psychological effects of the racism Dan experienced.

IMPLICATIONS FOR CLINICAL PRACTICE We want next to briefly discuss the implications for clinical practice and to emphasize some ways in which racism is manifested in our work. This includes face-to-face clinical practice, in addition to the broader agency, organizational, and institutional contexts. Consequently, we need to be aware of the ways that racism impacts our practice and the people we serve. Some of the issues that we will touch on here include transference and countertransference, racial enactments, therapeutic alliance, the need for clinical supervision, and the mindfulness necessary to intervene at the institutional level. As Altman (2010) argues, “Unconscious racism is to be expected in our clinical work at this point in history and . . . truly reparative efforts depend on an acknowledgment of racism in the transference-countertransference matrix” (p. 137). What is important to know is that people of color, and African Americans in particular, use mental health services at substantially lower rates than white people (Jones et al. 2007; Ward et al. 2013). There are key reasons for this finding. All treatment places the client in a vulnerable position that necessitates trust, while the clinician retains considerable power (Ridley 2005). Given the historical and contemporary context of Black lives, it is understandable that a Black person would hesitate to trust a white stranger with intimate details

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of their life. What faith can a Black client have that a white clinician will be curious about, or fully appreciate, the historical-social-cultural differences between them? Will the chosen treatment respect these differences and be culturally appropriate and empirically valid for them? Failure to appreciate these important differences has been shown to account for poor levels of therapeutic engagement and poor mental health treatment outcomes (Mazzula & Nadal 2015). Research confirms that white clinicians are hesitant to engage in racial dialogue with clients of color (Chang & Berk 2009; Chang & Yoon 2011; Lee & Horvath 2013). Unfortunately, an avoidance of important racial conversations can only lead to a superficial level of clinical practice, obviously to the detriment of the client. Consequently, it is very important that clinicians be competent and willing to initiate, where appropriate, therapeutic conversations that include racism. The clinician needs not only to be skilled enough to have the conversations but also to be mindful to incorporate an understanding of the impact of their racial differences. This may be as simple as asking the client of color what it is like to have a white clinician. Clinicians of color working with white clients might encourage conversations about the clients’ feelings concerning having a person of color as their therapist. At a deeper level, clinicians must examine the racial dynamics of the therapeutic relationship, while actively reflecting on the ways in which their power and privilege is omnipresent, relative to each situation. In essence, this means focusing on the ways in which the clinician’s own racial identity influences the clinical work and the unique features of each therapeutic encounter. Given the above, it is not surprising that clinicians may find themselves entangled in racial miscommunications and missteps, despite their good intentions (see Garran 2013; Leary 2000; Suchet 2004). Accordingly, it is important to explore these issues with a clinical supervisor. Because discussions of racism evoke such strong emotions (e.g., shame, guilt, anger), powerful defenses keep such affect at bay. When we unpack the complexities of these racial dynamics in the transference-countertransference matrix, it lessens the tendency to distance ourselves from the discomfort, allowing the clinician to be more connected to important clinical material and, indeed, to the client. Because these encounters have unconscious elements, a clinical supervisor can provide an additional reflective lens on such situations (Sarnat 2015). For further exploration of discussions of racial dynamics in supervision, see Schen and Greenlee (2018); Hall and Spencer (2017); Hall (2018); Pendry (2012); and Lee and Kealy (2018).

IMPLICATIONS FOR INSTITUTIONAL CHANGE Before we conclude this chapter, we want to say a few words about institutional change, knowing that racism lives and breathes in the places we work. Our understanding of the psychodynamics of racism can help us understand how it is produced, sustained, and reproduced. It also helps us understand the ways in which racism can be ignored. For instance, in hospital settings it is an “open secret” that patients often refuse service from a physician of color (Garran & Rasmussen 2016). The idea of an open secret suggests that there is an implicit prohibition about talking directly about racism in this professional domain. If professionals can’t hold conversations about racism, no progress can be made (McGibbon & Etowa 2009). We recognize that there have been efforts to work on this issue directly; however, when pointed intervention is focused on white racism, some problematic dynamics occur. Di Angelo (2017), a leading anti-racism trainer, has employed the term white fragility to capture the dynamics of what happens when white people are challenged to consider the

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ways in which they contribute to and uphold structures of racism. Descriptively, these defensive behaviors include argumentation, avoidance, disavowal, denial, emotional diversion, fear, and guilt. The following examples are from our own experience: A white student in a clinical class made a thoughtless statement about people of color in her neighborhood. She was immediately challenged by a Latinx student to consider how her comments might impact others in the room. The white student burst into tears and promptly ran out of the classroom. Another white student, worried about her classmate, followed in order to check on her. As often occurs, the focus shifted to the distressed white student, leaving the impact of her insensitive comments unresolved. Later, the instructor reflected on his failure to effectively process the events in a timely manner. In another example, a student intern at a medical facility witnessed a racist request from a white patient, who insisted that he not be transported to the X-ray department by a Black porter. The intern, aware of the impact on the porter, was nonetheless recruited to transport the patient instead. Upon her return, the intern told her supervisor that she was very uncomfortable with the entire situation. Much to the intern’s dismay, her supervisor became annoyed and said, “Listen, these things happen all the time and you don’t want to get caught up in it—no one has time for that.” In the end, the needs of the person of color, in this case the porter, went unrecognized and unattended.

In the first instance, we see the student’s white fragility when challenged, accompanied by the collusion of fellow white students. In the second example, we observe the racist actions dismissed as not central to the operational demands of the medical organization. In both cases, whether through emotional distraction or blatant disregard, racism is perpetuated and the power structures are upheld. Making sense of the challenges to anti-racist actions not only requires a dynamic understanding of defenses, mentioned earlier in the chapter, but also necessitates analyzing and understanding the forces of power, privilege, and social structures that sustain racism. However, even well-educated and well-intentioned people who see themselves as advocates can manifest aversive racism. This form of racism is subtle but insidious, serving primarily to sustain the self-regard of the helpers themselves. For instance, we’ve observed white clinicians claim, “I was raised in a very liberal family and we were taught that everyone is worthy” or “I played on sports teams where there were a lot of Black players” as a way to create distance from their own unconscious internal biases. It is uncomfortable to acknowledge the benefits accrued from having power and privilege. Being confronted about one’s racism invariably evokes shame and guilt, two emotions that are difficult for us to admit or discuss. Another form of aversive racism is the overzealous advocate who will often resort to calling others out and bringing unnecessary attention to their missteps. This destructive and alienating behavior serves a defensive function for the advocate who may be avoiding their own unexamined and unconscious racism. Consider the example of a white person who “takes up all the space in a room,” speaking on behalf of the people of color who are present. They may aggressively pounce on any linguistic missteps by other white people, effectively shaming them into silence. Such actions tend to elevate the self-esteem of the zealous advocate but do little to change other white people or effectively support people of color.

CONCLUSION In this chapter, we have introduced a range of psychodynamic theoretical ideas that help us understand the unconscious psychic and interpersonal dynamics of racism. We have introduced ideas from drive theory about how unconscious aggression and sexuality are

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often projected onto people of color. We have shown how group dynamics work to support scapegoating, othering, and the devaluation of what may be feared within the self. From a Kleinian perspective, we examined the need to rid ourselves of unwanted feelings by using projective identification, unconsciously attributing what is bad in ourselves to others and then trying to control those projections in them. All of these mechanisms of defense are central to understanding racist interactions. Klein also offers the hope that in the depressive position, there may be true expressions of reparation. According to Alford (1989), however, reparation is less likely to occur as a consequence of group dynamics. Clarke (2003), Alford (1989), and Kovel (1984) drew our attention to the ways in which racist actions arise from a fear of others who are different and need to be controlled. Because the anxieties are projected onto the other, the person who is different is now viewed as hostile, aggressive, sexual, and threatening. Furthermore, while these processes help to manage the anxieties of white people, they negatively alter the subjectivities of their target victims. These dehumanizing behaviors may be internalized by the intended target, leading to cyclical dynamics of racism as shown by Wachtel (2014). We have also learned about the effects of racism on healthy narcissism and self-esteem through the lens of self psychology. We believe that applying psychodynamic theories to racism is more than an intellectual exercise. It has far-reaching applications for the clinical work we do. The traumatic effects of racism require clinicians to adeptly hold conversations about racism in the therapeutic dyad. But research demonstrates that many clinicians, particularly white practitioners, are uneasy discussing racism with clients. For some white practitioners, barriers to holding conversations about racism include unexamined countertransference, unacknowledged power and privilege, fear, shame, guilt, or white fragility. The failure to overcome these barriers results in a great injustice to people of color. Unquestionably, the problem of racism needs multiple points of intervention, directed at various levels, incorporating diverse theoretical understandings. Psychoanalytic theory is indispensable in making a contribution in this regard, dynamically linking the internal and external worlds. But theory is no substitution for action. The troubling times we mentioned at the outset of the chapter signal that things may get worse before they get better—if indeed they do. Even at the time of this writing, the COVID-19 pandemic reminds us of the dramatic health disparities in the rates of infection, access to testing and care, and morbidity for communities of color. These are disparities that have entangled roots in racism. Combatting racism requires the capacity to hold painful states of mind. It also compels us to hold difficult conversations in practice and in our personal lives. We need eternal vigilance and a sustained commitment to combating the destructive effects of racism. White people must own their projections, acknowledge how they benefit from racism, and accept that violence against people of color upholds white supremacy if there is to be any hope for reparations. Postscript As we finish this chapter, protests are raging in every state across the country following the murder of George Floyd, an African American man, by a white police officer. The civil unrest was ignited by Mr. Floyd’s tragic death. However, the protesters seeking justice are responding to a long, continuous history of violence against and murder of African Americans. The rise of white supremacy, the absence of justice, and a lack of accountability have fueled the current demands for change. We do not know how this outcry for equality and justice, and for an end to racism, will ultimately unfold. But, while acknowledging the despair, we cling to the hope that sustained collective engagement will prevail.

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REFERENCES Alford, F. (1989). Melanie Klein and Critical Social Theory. New Haven, CT: Yale University Press. Altman, N. (2010). The Analyst in the Inner City: Race, Class, and Culture through a Psychoanalytic Lens. New York: Taylor & Francis. Bonilla-Silva, E. (2014). Racism without Racists: Color-Blind Racism and the Persistence of Racial Inequality in America. New York: Rowman & Littlefield. Chang, D. F., & Berk, A. B. (2009). Making cross-racial therapy work: A phenomenological study of clients’ experiences of cross-racial therapy. Journal of Counseling Psychology 56(4):521–36. Chang, D. F.,  & Yoon, P. (2011). Ethnic minority clients’ perceptions of the significance of race in cross-racial therapy relationships. Psychotherapy Research 21(5):567–82. Clarke, S. (2003). Social Theory, Psychoanalysis, and Racism. New York: Palgrave Macmillan. Coates, T. (2015). Between the World and Me. New York: Spiegel & Grau. ———. (2017). [Foreword]. In T. Morrison, The Origins of Others, pp. viii–xvii. Cambridge, MA: ­Harvard University Press. ———. (2018). We Were Eight Years in Power: An American Tragedy. New York, NY: One World Publishing. Comas-Diaz, L., & Hall, G. (2019). Racial trauma: Theory, research and healing: Introduction to the special issue. American Psychologist 74(1):1–5. DiAngelo, R. (2017). White Fragility. Boston, MA: Beacon Press. Du Bois, W. E. B. (1903). The Souls of Black Folk. Chicago, IL: AC McClurg. Dyson, M. (2017). Tears We Cannot Stop: A Sermon to White America. New York: St. Martin’s Press. Elliott, A. (2004). Social Theory since Freud: Traversing Social Imaginaries. New York: Routledge. Fanon, F. (1952). Black Skin, White Masks. New York: Grove Press. Fredrickson, G. (2002). Racism: A Short History. Princeton, NJ: Princeton University Press. Freud, S. (1930). Civilization and Its Discontents. Oxford, England: Hogarth. Garran, A. M. (2013). Lessons learned: Racial enactments in the treatment process. Journal of Social Work Practice 27(3):305–17. Garran, A. M.,  & Rasmussen, B. M. (2016). In the line of duty: Racism in health care. Social Work 61(2):175–77. Hall, J. C. (2018). Black women talk about stereotypical transference enactments in cross-cultural supervision. Journal of Human Behavior in the Social Environment 28(8):1019–32. Hall, J. C.,  & Spencer, R. E. (2017). Illuminating the phenomenological challenges of cross-cultural supervision. Smith College Studies in Social Work 87(2–3):238–53. Hart, A. (2019). The discriminatory gesture: A psychoanalytic consideration of posttraumatic reactions to incidents of racial discrimination. Psychoanalytic Social Work, 1–20. Jones, L. V., Hardiman, E. R.,  & Carpenter, J. (2007). Mental health recovery: A  strengths-based approach to culturally relevant services for African Americans. Journal of Human Behavior in the Social Environment 15(2–3):251–69. Kendi, I. X. (2017). Stamped from the Beginning: The Definitive History of Racist Ideas in America. New York: Random House. King, T. (2012). The Inconvenient Indian: A Curious Account of Native People in North America. Toronto: Doubleday. Kita, E. (2019). “They hate me now but where was everyone when I needed them?” Mass incarceration, projective identification, and social work praxis. Psychoanalytic Social Work 26(1):25–49 Kovel, J. (1970). White Racism: A Psychohistory. New York: Pantheon Books. Kovel, J. (1984). White Racism: A Psychohistory. New York: Columbia University Press. Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic Dialogues 10(4):639–53. Lee, E. (2013). Understanding anxiety and facilitating twinship self object functions among social workers: Psychodynamic contributions to multicultural education. Journal of Social Work Practice 27(1):63–78. Lee, E., & Horvath, A. O. (2013). Early cultural dialogues in cross-cultural clinical practice. Smith College Studies in Social Work 83(2–3):185–212.

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Lee, E., & Kealy, D. (2018). Developing a working model of cross-cultural supervision: A competence and alliance-based framework. Clinical Social Work Journal 46(4):310–20. Mazzula, S. L.,  & Nadal, K. L. (2015). Racial microaggressions, whiteness, and feminist therapy. Women & Therapy 38(3–4):308–26. McGibbon, E., & Etowa, J. (2009). Anti-Racist Health Care Practice. Toronto: Canadian Scholars’ Press. Miliora, M. T. (2000). Beyond empathic failures: Cultural racism as narcissistic trauma and disenfranchisement of grandiosity. Clinical Social Work Journal 28(1):43–54. Miller, J., & Garran, A. M. (2017). Racism in the United States: Implications for the Helping Professions, 2nd edition. New York: Springer. Morrison, T. (2017). The Origin of Others. Cambridge, MA: Harvard University Press. Ogden, T. (1990). The Matrix of the Mind: Object Relations and the Psychoanalytic Dialogue. Northvale, NJ: Jason Aronson. Peele, J. (Producer and Director). (2017). Get Out [Motion Picture]. Universal Pictures Home Entertainment. Pendry, N. (2012). Race, racism and systemic supervision. Journal of Family Therapy 34:403–18. Rasmussen, B. (2013). Making sense of Walt: A psychoanalytic understanding of racism. Psychoanalytic Social Work 20(1):50–61. Rasmussen, B., & Garran, A. M. (2019). Psychodynamic analysis of racialized interactions: The Get Out case study. Smith College Studies in Social Work 89(2):179–96. Rasmussen, B., & Salhani, D. (2010). A contemporary Kleinian contribution to understanding racism. Social Service Review 84(3):491–513. Ridley, C. (2005). Overcoming Unintentional Racism in Counseling and Therapy. London: Sage. Sarnat, J. (2015). Supervision Essentials for Psychodynamic Psychotherapies. Washington, DC: American Psychological Association. Schen, C.,  & Greenlee, A. (2018). Race in supervision: Let’s talk about it. Psychodynamic Psychiatry 46(1):1–21. Sen, S. (2018). Not Quite Not White: Losing and Finding Race in America. New York: Penguin Books. Stevenson, B. A. (2015). Just Mercy: A Story of Justice and Redemption. New York: Random House. Suchet, M. (2004). A relational encounter with race. Psychoanalytic Dialogues 14(4):423–38. Wachtel, P. L. (2014). Cyclical Psychodynamics and the Contextual Self: The Inner World, the Intimate World, and the World of Culture and Society. New York: Taylor and Francis. Walls, G. (2006). Racism, classism, psychosis and self-image in the analysis of a woman. In Psychoanalysis, Class and Politics, eds. L. Layton, N. Caro Hollander, and S. Gutwill. New York: Routledge. Ward, E. C., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women’s attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing Research 62(3):185–94. Zevnik, A. (2017). Post-racial society as a social fantasy: Black communities trapped between racism and a struggle for political recognition. Political Psychology 34(4):621–35.

12 The Bridge: From Theory to Practice Patricia Hertz, Laura Melano Flanagan, David S. Byers, and Joan Berzoff

The preceding chapters explored the contributions offered by a range of psychodynamic theories and offered an integration of biological and sociocultural perspectives with these theories. We looked at how forces from the “inside” and “outside” combine to influence development and shape the lives of individuals. The content of these chapters can be studied on their own, as these theories are often taught in separate courses on developmental, social, or neurobiological theory in programs of social work, counseling, nursing, and psychology. However, in our experience as teachers and practitioners, this content is too readily divorced from the practice in which people then engage. Students learn about psychodynamic, relational, trauma, and attachment theories during one semester, for example, and then move on to a course in clinical practice or psychopathology but not how to apply the theories they just studied apply. The theory thus becomes a body of knowledge to learn or to memorize, but not to integrate and use in the room with clients. In this chapter, we hope to introduce how and why theories matter in practice, beginning with the initial and ongoing work of clinical assessment. At their best, the theories in the first half of this book provide us with hypotheses— socially constructed conceptualizations that help us begin to make meaning of the turmoil and resilience in the lives of our patients and ourselves. They are metaphors that organize our clients’ information and enable us to decipher some of the patterns in our patients’ experiences that strengthen, enhance, and hinder growth. Theories give us hope that we can offer an idea, a perspective, that can engage the curiosity of those with whom we work and help improve their lives. As Pine (1998) notes, our theories are our tools, imperfect though they may be. As we hold these theories loosely in our minds, however, how do we allow them to inform our practice in meaningful and possibly transformative ways? How do we hold in our minds a multiplicity of theoretical models without letting them clutter our thoughts or our hearts, or without creating an agenda that may be irrelevant to the person with whom we are sitting? How do we organize what we hear into meanings that do not foreclose other possibilities and other interpretations? 233

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To address these questions, we must first acknowledge the paradox inherent in this process. We must “know” and “not know” simultaneously; we must strive to be “full” of knowledge and theory while being “empty” enough to be surprised, to learn, and to appreciate the uniqueness of every person with whom we work. In this era of managed cost and care, we are forced to know too soon—to offer diagnoses and treatment plans, medications and discharge plans with too little information and far too much certainty. Many educators tell their students to “keep it simple.” We do the opposite. If we could impress a single axiom upon every intern and staff member, we would ask them to keep their work complicated. We would encourage them to believe that the capacity to tolerate uncertainty is a prerequisite for our profession, as is the capacity to welcome mystery and surprise in our work. As Freud struggled with the paradox of how to achieve being full and empty at the same time, he developed the concept of “evenly suspended attention”—the foundation upon which all the other clinical techniques (interpretation, confrontation, clarification, examination of the transference) rest. Freud (1958) described this complex internal state in the following way: It consists simply in not directing one’s notice to anything in particular and in maintaining the same “evenly suspended attention” (as I have called it) in the face of all that one hears . . . Or, to put it purely in terms of technique: “He should simply listen, and not bother about whether he is keeping anything in mind.” (p. 111)

Freud says this is simple, but it is not at all easy to achieve in clinical work and needs to be practiced over a lifetime. Ralph Greenson (1967) believed that evenly suspended attention (sometimes called “evenly hovering attention”) is a necessary component in the development of empathy. Alfred Bion (1970) took the concept even further, stating that somehow the clinician needs to be “unstained by any element of memory or desire”—a mysterious, hauntingly evocative phrase (p. 32). For how can a clinician really be without understanding, memory, or desire? Are we not supposed to remember our patient’s history and diagnosis as well as all the theories we have studied so that we can choose the best possible interventions? Are we not supposed to desire to help our clients heal old wounds and develop new strengths? Are we not supposed to understand our clients’ life experiences, joys, and pain? The answer of course is yes, but also no, because often the best, most meaningful clinical work is done when the therapist is in the emptiest, most receptive, most impressionable state. Nina Coltart (1986), a member of the British Independent Tradition of object relations, was interested in the same phenomenon and taught that the clinician must always find a balance between reliance on theory and “a willingness to be continually open to the emergence of the unexpected.” She wrote: It is of the essence of our impossible profession that in a very singular way we do not know what we are doing. Do not be distracted by random associations to this idea. I am not undermining our deep, exacting training; nor discounting the ways in which—unlike many people who master a subject and then just do it, or teach it—we have to keep at ourselves, our literature and our clinical crosstalk with colleagues. All these daily operations are the efficient, skillful, and thinkable tools with which we constantly approach the heart of our work, which is a mystery. (p. 186)

Mystery: This takes us back to the Mary Gordon passage we quoted in the first chapter about the importance of never knowing for sure how a particular experience will affect a person’s development. It has been amusing and sometimes touching to notice over the years that students often first hear the phrase “evenly suspended attention” as “eagerly suspended

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attention.” This may not quite be what Freud and Bion had in mind, but it does add a nice note of enthusiasm to the process! The theories that we have presented in the first half of this book, then, should ideally remain available and accessible in our minds in order to teach us why a person may come to us with certain struggles and strengths at a given time and in a particular fashion. They can then help deepen our understanding of our clients’ emotional turmoil and help create options for growth. They can offer us empathic windows through which we can see our clients’ pain and strengths. They must not, however, become prescriptions for how the work should proceed. If we know too much too soon, we stop listening to the unique essence of our clients’ lives; then we run the risk of deciding where the therapeutic journey will take us, rather than having it evolve out of the interactions unfolding in the process. Another crucial way that psychodynamic theories inform assessment and practice is that they disrupt common or safe distinctions between so-called health and illness. In the first half of the book, we noted that only by appreciating external and internal dynamics can we more fully understand the pain with which many of our clients present—the concept of “psychopathology” itself. Psychopathology generally refers to “disease” and creates a division between those who are allegedly “well” and those who are “sick.” This ignores, however, that definitions of mental health and illness are largely social constructions. A fundamental insight of psychodynamic theories is that psychopathology is an everyday phenomenon. We all fall along a continuum of mental health and illness, and our place on that continuum is never static. If we can move to an understanding of pathology that is more closely linked to its Greek origin, with pathos meaning suffering, we can then use the term psychopathology to connote not just disease but also the suffering of the mind or soul, a dis-ease. We all have experienced suffering and disharmonies, with which we are able to cope with varying degrees of success at different points in our lives. Biological, psychological, and social forces combine to determine where we fall in a given moment along the many possible continuums from mental illness to mental health. As Harry Stack Sullivan (1940) noted, “In most general terms, we are all much more simply human than otherwise; be we happy and successful, contented and detached, miserable and mentally disordered or whatever” (p. 39). How difficult it is actually to live and practice by this seemingly obvious reminder of our common humanity was illustrated quite vividly once when a case was being presented to a group of social work students. The class had already met for several weeks and had heard all the cautions about pathologizing and the tendency of clinicians to distance themselves from patients by seeing them as “different” or “sick.” The topic was personality disorders; the case was of a woman presenting many features of what diagnostically would be called “low-level borderline” organization. She relied on severe splitting and projective identification as major defenses, and experienced episodes of disorganizing rage and self-destructive behavior. Then a student asked what the patient did for work. When the answer was “she’s a social worker,” the class gasped in shock and disbelief. Many students asked agitatedly, “How can a social worker have borderline personality disorder?” or “How can someone with a borderline organization be a social worker?” At first, the teacher was very disappointed. Had the lectures failed so thoroughly that no one understood the principles and values that she had been stressing? As the class talked further about their reaction, however, many students began to understand more deeply than ever before how ingrained the desire is to distance ourselves from illness and psychic distress. It became clear that “we are all much more simply human than otherwise” is not such an easy tenet to fully espouse and practice by. In many courses on psychopathology, students feel in themselves every illness and syndrome that is being discussed. This is how it should be. Students should barely be able to leave

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the room after the lecture on depression, whereas they should fidget and worry all through the description of anxiety disorders, and even experience a loss of contact with shared reality in the classes on schizophrenia. The old saw about psychopathology courses is that you get everything you learn about. This is what we want. In fact, if the students do not feel in themselves some of what is being described, then they are keeping themselves too distant, too separate, too apart from the material, needing to hold on to the illusion that pathology is something outside of, and different from, themselves.

ASSESSMENT: THE PROCESS AND ART OF ENGAGEMENT An empathic and client-centered approach is vital to the ongoing and collaborative work of biopsychosocial assessment. Beginning clinicians often approach assessment with both excitement and trepidation. Assessments involve identifying as well as describing the client’s presenting problems, symptoms, and strengths, and exploring their potential causal and contextual origins: biological, social, and psychological. Many of us were trained to do assessments by filling out a long intake form and arriving at a diagnosis that rarely captured the complexity of people’s subjective experience of their distress. Today, we still see students and professionals collect data, diligently fill out forms after one session, and yet never refer to that information again. Their assessments become a collection of information archived in a clinic’s or hospital’s medical records. Assessments are not understood to be a process over time from which meaningful formulations are derived and perpetually evolving, which guide both understanding and intervention, let alone an invitation to begin a dialogue with a client about the many forces—both internal and external—which shape their current challenges. An assessment, then, at its best, can be a profound intervention. It is the many moments of meeting with our clients that provide the framework for how we engage in a collaborative process to help make sense and meaning of another’s distress, identify sources of joy and strength, and help promote change in their lives. By the time individuals are sitting across from us, whether it be in an office, a hospital, a prison, or a treatment program, they are often saturated with a sense of failure or hopelessness. The first assessment meeting can provide hope to clients that the future might offer something different from the present, and that they will not have to face the challenges of “getting there” alone. There is a “we,” an “us,” committed to facing life’s challenges together. As a client said after her first session, the most helpful word uttered by her social worker in the meeting was “together”—that is, “we will make sense of your pain together, and together find ways to the other side.” Clients rarely present their stories in the organized, sequential, or detailed manner that we need for our record keeping. The seemingly simple question “What brings you here today?” can be responded to with a flood of tears, with few words, with “the court mandated me to be here and I have nothing to say,” or with a delusional comment such as “Prince Harry requested my presence.” The art of the assessment process is in how we meet clients where they are and how we and they begin to hear and then process their stories. We are always widening the lens to try to understand how developmental history, strengths and vulnerabilities, social and cultural forces, and biological factors come together to explain why someone is struggling in particular ways at a particular time. During the initial assessment process, beginning clinicians often feel pressure to offer quick fixes to their clients’ problems in order to be helpful. They may offer a technique before understanding the conditions that gave rise to the need for that technique (­McWilliams 2011). If the problem had been that simple to “fix,” the client would have done it already! What can be forgotten in the desire to be helpful is the importance of clients

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first feeling authentically heard with an appreciation for the complexities—neurobiological, psychological, social—that inform the presenting issues. It is not enough for the clinician to grasp the patient’s suffering and strengths; that understanding must be communicated back to the patient for a therapeutic alliance and engagement to begin. The client needs to feel heard and seen, to know how the clinician will engage authentically in the therapeutic journey that lies ahead. Throughout this book, we invite the reader to keep the work complicated, to avoid the simplification of the suffering at hand—something that is particularly essential during the assessment process. Even just the task of describing in detail a client’s problems, symptoms, and strengths is never truly objective. What we notice and ask more about always reflects our own values, our histories, our politics, our training, and the theories that guide our work whether or not we realize it. As Stephen Mitchell (2009) put it, “No matter how much we try to listen to the patient’s experiences from within the context of his or her own phenomenology, no matter how scrupulous we are to not superimpose our own theoretical presuppositions on clinical data, to listen is to arrange” (p. 90). At the same time, when describing clinical phenomena, clinicians do need to strain for some objectivity, even as they embrace and use their own subjectivities. Each of the psychodynamic theories and social theories discussed earlier in the book elicits an understanding of the historical and current forces that both hinder growth and promote resilience. Which theories clinicians use in an assessment will depend on which ones “speak” more to the client’s struggles and which ones are “pulled forth” by the stories that a particular client offers. We must not be wedded to only one model of theory or practice. We need instead to use a biopsychosocial perspective that holds in mind multiple theoretical frameworks. Consider how essential this perspective is in assessing the following case. One of the authors was asked to interview a patient and his family at a teaching conference on an inpatient psychiatric unit. The son in the family, a twenty-four-year-old Muslim cisgender male born in the United States to an Iraqi father and Lebanese mother, had been hospitalized after making a suicide attempt in the midst of a psychotic break. The parents had reluctantly settled in the United States after the murder of family members in their worn-torn countries. In the meeting, the social worker spoke of the challenges that the family faced as Muslim immigrants in this country, of the hopes they had placed on their son to create a new legacy for their traumatized family, of the transmission of generational traumas, and of ways to begin to understand the tortured thoughts and mood swings of their beloved son. After the family left, the students in the conference grappled with how to hold the many factors that accounted for this family’s suffering, including the racism the family had encountered, the complicated psychological and family dynamics that had contributed to the young man’s despair, and the biological underpinnings of his psychotic break. Some wanted to focus exclusively on how discrimination shaped the patient’s experience, others on the patient’s diagnosis. The challenge, of course, was in how to invite the students to integrate an understanding of the “inside” and “outside” factors in their assessment, to look at the interconnected nature of these factors, and to address their own role in providing compassionate and effective care. A biopsychosocial assessment, then, entails interviewing clients about their presenting problems, symptoms, and strengths across biological, psychological, and/or social domains. Biopsychosocial assessments cannot simply consist of listing and categorizing symptoms as if they are static and isolated. They should include etiological considerations—the possible causes and contexts of problems—with an understanding of the interrelatedness of these considerations in the development of symptoms.

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Take, for another example, a client who begins an initial session describing acute social anxiety that keeps him from attending classes at his high school. The clinician might begin by thinking about the client’s symptoms of social anxiety (sweating, feeling nauseous, heart racing, stomach aches) in psychological terms. However, symptoms of social anxiety also involve neurobiological processes when the sympathetic nervous system is activated. Anxiety symptoms can also be epigenetically transferred down through biological lines, for example in the case of racialized trauma impacting generations of families. We can see that problems, symptoms, and strengths do not tend to stay neatly categorized. They are mutually reinforced by each other, as seen in the themes and patterns that often weave through clients’ lives. The question of how to do a full biopsychosocial assessment is beyond the scope of this book, but readers can choose from many excellent sources on this topic, for example, ­Gabbard (2014) and Shea (2017). Our goal is rather to emphasize the role of conscientious and critical assessment work in bridging theory and practice. Nancy McWilliams (2011) makes a strong case for starting therapy with a structured assessment interview. While many clinicians take a more organic approach to assessment work, believing that the most relevant information will emerge if the clinician simply listens to and follows the client, McWilliams points out that clients may be more likely to share the concerns that they are ashamed about if they are asked directly and early on. For example, a client might not mention substance use, the verbal or physical violence faced at home, eating concerns, or gender identity questions unless the clinician asks as a matter of routine. Structured interview questions—if asked with care and interest, rather than bureaucratic indifference—can invite the client to share more. At the same time, assessment work does not stop at the end of a structured interview. It is an essential part of the collaborative process at all stages of therapy.

ASSESSMENT: USING THE LENS OF PSYCHODYNAMIC THEORIES We have talked from the beginning of this book of the necessity of holding a biopsychosocial perspective. Beginning clinicians always ask at the beginning of their field placements, “But what are we supposed to actually do with all these psychodynamic theories we have just learned?” Needless to say, the clinician cannot hold all of these theories in mind during an initial assessment and there will be ample time to ponder them throughout the course of treatment. But in that state of “evenly suspended attention,” we offer some of the theoretical questions and concepts to hold in mind (and heart) in order to explore the person’s internal world, while remembering that the biological and social aspects of the client’s life are equally important. As we list these questions that we hope can hover in the clinician’s mind, they sound essentialist and either/or. We intend the opposite, however. We hope that they can float in our hearts and minds, not as answerable questions, but as musings. Drive Theory • What symptoms does the client present with? To what degree might they symbolize underlying unconscious conflicts? • How might early conflicts around sexuality and aggression have shaped ongoing development? • What fixations might the client experience? What regressions? • To what degree might sexual and aggressive drives be repressed? • What might the interplay be between the id, the ego, and the superego?

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• To what degree might the client feel driven by impulses that she does not understand? • How might current symptoms and behaviors represent repetitions of past unresolved unconscious conflicts? Ego Psychology • How do the client’s memory and perception function? • How intact are the client’s capacities for reality testing, judgment, regulation of affect, self-esteem regulation, and the capacity to postpone gratification? • What might we say about defenses: are they helping or hurting the client to live with and adapt to life’s challenges? • Are defenses such as denial, repression, displacement, sublimation, projection, and projective identification employed flexibly or rigidly? To what degree do defenses help to manage overwhelming anxiety? • What is the predominate level of anxiety: annihilation, loss of the other, loss of love of the other? • What are the client’s ego strengths? How have they helped the client negotiate the demands of the external world? What enduring strengths have emerged at each stage of psychosocial development? • Was the environment average and acceptable? • What Eriksonian stages has the person negotiated? Object Relations • To what extent is the client able to engage in mutually satisfying relationships with others? • How have internalized self and object representations with the client’s caregivers been generalized to others? • Have past relationships prepared the client for experiences of trust and comfort with others? • Because of relational and societal experiences, does the client experience annihilation anxiety, separation anxiety, fears of abandonment, or fragmentation of self? • Can the client experience herself as an authentic or true self or does she depend on a false self? • How well might the client have negotiated separation-individuation and rapprochement, and has she achieved object constancy, noting that separation and individuation are culture bound? Self Psychology • Does the client appear to have a sense of distinct identity that remains consistent across a variety of situations and relationships? Has it been possible for healthy narcissism to develop? • What degree of self-cohesion might the client experience? Does she appear fragmented? • Does the client seem to be a distinct, self-regulating person during intimate interactions with others or might her sense of self become blurred or lost during those times? • How does she use herself as a resource, as in self-soothing, or must she turn to external sources such as other people, objects, or mind-altering substances to sustain self-esteem and self-cohesion?

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• How has she used self-object experiences to thrive? Has there been sufficient mirroring? Have there been others to idealize? Has the client had twinship experiences and with whom? Attachment Theory • What is the characteristic attachment style of the client (i.e., secure; insecure—avoidant, ambivalent; disorganized—chaotic, dismissive, fearful)? How might it have developed, keeping in mind both intrapsychic and social/environmental factors? • How might life experiences have contributed to either problems or strengths with attachment? Have there been attachment traumas and losses? To what degree did the person experience neglect and abuse and how has that affected attachment? • To what degree can the patient mentalize—perceive and interpret another person’s mental states? Relational Theory and Intersubjectivity • How might the client experience the relationship with the therapist and how might the therapist experience the relationship with the client? • How can the therapist actively use the “space between” the therapist and client to deepen the clinical work and promote further growth? How do the therapist’s and client’s subjectivities influence one another? • How can the client’s and clinician’s experiences of transference/countertransference help to explain the client’s interpersonal experiences historically and her current presenting concerns? • How might the client and clinician regulate and co-regulate each other’s affect and sympathetic and parasympathetic nervous systems? • How might enactments of past pain, trauma, and other interpersonal ruptures be experienced and worked through in the present?

ASSESSMENT: AN ANTI-OPPRESSIVE FRAMEWORK In every clinical assessment, consideration must also be given to the historical and ongoing social and cultural forces influencing a case, with a particular focus on the interplay of intersectional oppressions. Psychodynamic assessments have been used in oppressive, biased ways throughout their history. Clinicians must therefore try to hold awareness of the harm done by pathologizing and stigmatizing difference from biopsychosocial norms of whiteness, ableism, heteronormativity, and cisgender male identity and of what Byers, Thigpen, and Wolfson (2020) have referred to as the “clinical aggression” that many people have faced, and continue to face, when seeking care. Rather than simply trying to guard against oppressive thinking in clinical assessment, clinicians must hold an assertively anti-oppressive orientation (Martinez & Fleck-Henderson 2014; Miller  & Garran 2017; Quiros  & Berger 2015) to inform their assessment and conceptualization work with every client. Indeed, clinical social workers and other community mental health clinicians have often taken the lead in integrating theories of social oppression centrally within clinical conceptualizations. An important early example of clinical activism toward anti-oppressive reconceptualization comes from the work of the Lafargue Clinic, one of the earliest mental health clinics

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focusing on psychotherapy for African American clients, which operated in Harlem from 1946 to 1958. As chronicled by Gabriel Mendes (2014), clinicians at Lafargue were guided not only by psychodynamic theories but also, importantly, by understanding racial and economic injustice. Many of the problems that clients faced, they contended, were rooted in social oppression. Their focus on oppression always informed how they assessed and conceptualized a client’s struggles using psychodynamic theory. For example, drawing on archival records from the clinic, Mendes (2014) describes a case of a six-year-old African American boy who was brought by his parents for treatment with symptoms of asthma, acting defiantly at home toward his parents and sister, and misbehaving in school. The parents also noted that the child had a preference for friends with light skin, although his parents had darker skin. In their assessment work, the clinicians at Lafargue identified that his development of asthma and behavioral concerns were rooted in internalized racism. The symptoms were greatly exacerbated by the family’s recent move from Harlem to a largely white neighborhood in Queens and by his experiences of racist bullying. Building on their conceptualization of causes and contexts for his concerns, the clinicians referred him to a playgroup to provide “a space for interaction with an interracial group of children that countered the experience of displacement and alienation in his new, whiter environment” (Mendes 2014, p. 17). It is not hard to imagine this child and family receiving very different treatment in another clinic that failed to address issues of power and oppression in its clinical assessment and conceptualization. Centering an anti-oppressive framework fundamentally changes the clinician’s work in assessment and conceptualization (Byers et  al. 2019). For example, the Eromin Center in Philadelphia was one of the earliest LGBT affirmative counseling services in the United States, in operation from 1973 to 1984. Even before removal of homosexuality as a diagnostic label from DSM-II (1968), Eromin and other clinics like it innovated new affirmative understandings of sexual and gender variance, applying concepts from psychodynamic, humanistic, behavioral, gestalt, feminist, anticolonial, and anti-oppressive theories. In one case documented in the clinic archives, a white woman questioning her sexual orientation described seeking treatment at a different community mental health clinic before starting at Eromin. She explained that the therapist had asked repeatedly about her past relationships with male partners and would not discuss her interest in relationships with women. As those clinicians well understood, a pathologizing and oppressive conceptualization created a feedback loop of stigmatizing assessment work. It is impossible to see or help a client on her own terms without tools for understanding her experiences with empathy and respect. In addition to rejecting pathologizing and stigmatizing formulations, taking an antioppressive stance means carefully assessing for social considerations. Here are just a few questions that clinicians need to ponder: Social Considerations • To what degree was the client “held” (seen, cared about, valued, and attended to) within their schools, doctors’ offices, social service agencies, and other social institutions? • Did they experience housing scarcity? Food scarcity? • Has the client been exposed to environmental assaults (i.e., lead poisoning, environmental toxins)? • What forms of education were available and were they adequate? • What forms of discrimination has the client experienced based on race, class, gender, and sexual orientation? What forms of housing, educational, or employment discrimination has the client faced?

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• Has the client been discriminated against on the basis of disability, mental health status, gender non-conformity, immigrant status, culture, or religion? • Do the client’s symptoms or struggles represent cultural issues (such as ataque de nervios, or psychosomatic equivalents)? • Has the client experienced physical, emotional, or sexual abuse, violence, or neglect? • What religion(s), community and culture(s) does the client identify with and what strengths does she derive from them? Biological Considerations As with the psychological and social parts of the equation, a clinician must always be thinking biologically. Some questions to hold in mind include: • What medical problems has the client experienced? • What is the client’s history with drugs and alcohol? • Is there a family or genetic history of mental illness: schizophrenia, bipolar disorders, anxiety, trauma, or depression? • What medications is the client taking and for what? • What is the history of disease in the family? • What is the history of accidents, deaths, and suicide? As you can see from this extensive, yet still incomplete, list of biopsychosocial variables, there is a tremendous amount of knowledge to keep in mind while doing a biopsychosocial assessment. The good news is that this cannot and should not be done all at once. Whatever is learned at the beginning will be enhanced and deepened in the course of the therapeutic relationship. And if the work goes well, assessment can, will, and should change, both because the therapist understands the patient better and because the patient develops psychological strengths and self-awareness that lead to healing and growth. A person whose life was made difficult by excessive splitting might not need such an early defense anymore and may therefore be able to have less chaotic relationships. Someone with very insecure attachment might grow to feel much more secure because of learning to trust her clinician. A person whose self-esteem has been diminished by racism or transphobia may reclaim a healthier sense of self once structural inequities are addressed within the treatment relationship and in other meaningful relationships in the client’s life. One of the main points of doing this beginning and ongoing a biopsychosocial assessment is to set goals to help clients heal and grow and to have richer lives. In the first half of the book, we noted that only by appreciating external and internal dynamics can we more fully understand the pain with which many of our clients present. Recall the two clients we described in chapter 1—Martin and Michael. Both had been seen by clinicians in an advanced post-master’s program who had effectively intervened on their behalf in the external environment, but who were bewildered by what their clients experienced internally. Michael was a Latino man, raised in a chaotic, physically abusive environment in which conflicting messages abounded. Michael described himself as three Michaels—a good Michael, a bad Michael, and a middle Michael—and his therapist was mystified by the meaning of this statement. His history revealed severe and persistent physical abuse at the hands of his stepfather and an early abandonment by his mother, who had been abused by the same man. The therapist who worked with Michael began by helping him adjust to life outside the hospital, focusing on how discrimination, poverty, and the stigma of mental illness affected

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his ability to function. Indeed, any clinician who does a psychological assessment knows that social and biological factors are always a part of the equation. With the theories we have studied in this book, we can augment the therapist’s understanding of Michael’s suffering. From object relations, for example, we learned that people are not born with integrated senses of themselves and that psychological integration develops over time; babies and young children often feel that they have good parts and bad parts, but with time and care children can realize that they are a complex combination of both good and bad. We learned that there can be profound effects on a child’s sense of self and ability to trust when the child has been neglected, abandoned, or abused. Using this theoretical knowledge, we can start to make sense of the way Michael “carried” his suffering. Michael came to understand that his symptoms reflected the ways he had tried to manage external and internal struggles and found “solutions” to them. We can begin to develop hypotheses about how splitting the “good” and “bad” parts of himself helped him cope with the abuse and neglect from his environment and with his internal rage and disappointment. We can see how this experience of himself left him fragmented in the face of oppressive and destructive forces from within and from without. In the second part of this book, we will show how the theoretical constructs that have been described thus far can be used in the discussion of psychopathology that is to follow. In addition to object relations, self-psychology would suggest that Michael did not have enough good mirroring from selfobjects to help him know himself as cohesive self. Very importantly, trauma theory combined with ego psychology would suggest that the chaos and abuse occurring in both Michael’s home and his underserved neighborhood did not give him much of a chance of developing solid, organized ego functions and defenses. The story of Martin affords us a similar opportunity. Recall that Martin, a twenty-eightyear-old Black Haitian man, came to treatment worried about what terrible thing would befall him next. He had become so preoccupied that he was unable to function in school, work, or his marriage. Martin had grown up in a Catholic Caribbean culture, raised by a father who was a policeman and who set extremely high standards for himself and his son. Prior to contacting the clinic, Martin had been capriciously arrested by white officers and had been the victim of racial assaults by fellow prisoners who had poured buckets of urine on him throughout his night in jail. Upon his release, he could not stop berating himself or feeling that he deserved to be punished. Each theory we studied can illuminate some aspects of Martin’s symptoms and his internal struggle. A drive theorist might focus on Martin’s own aggressive impulses and wonder how they were discharged or checked both during and after his arrest: Had the anger he felt toward the white officers and prisoners been turned against himself? Or were Martin’s feelings of unworthiness related to his sense that he had failed his church’s and father’s high expectations of him and were therefore a result of too rigid a superego? An ego psychologist might focus on Martin’s overwhelming annihilation anxiety and on the failure of his defenses to ward this off. An object relations therapist might attend to Martin’s self and object representations, which under the strain of trauma led him to experience himself as worthless and others as dangerous. An attachment theorist might assess Martin’s early attachment style, trying to understand how the racial assaults were experienced in light of it. A self-psychologist might focus on how this frightening experience caused a tremendous injury to Martin’s sense of self. How might his previous trust in his own emotional strength or his belief in the wisdom of police officers like his father been shattered by this racist assault? How might this have affected his goals and ambitions? A relational theorist might wonder with Martin how he was experiencing working with her. Each theory advances a set of hypotheses about what may have led to the symptoms with which Martin presents. All

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of them would consider the strong possibility that Martin suffered some form of trauma. In the second part of this book, we will offer ways to understand both Michael’s and Martin’s emotional struggles by focusing on several psychopathological syndromes. Additionally, a therapist assessing Michael and Martin would consider their religions, their social experiences (poverty, trauma, abuse,) their access to education, discriminatory experiences in housing or employment, their history of racism, their cultures, and the spiritual strengths they derived from them their communities. Their biological predispositions to mental illness, along with their physical health, medications, and substance use, would be a part of the biopsychosocial equation.

ASSESSMENT AND THE DIAGNOSTIC AND STATISTICAL MANUAL Once the initial assessment is complete, the clinician is often asked to classify the identified symptoms using a descriptive diagnostic system, such as the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5). A  diagnosis is frequently required for administrative purposes for insurance companies to fund the treatment. The language of “diagnosis” in this context is misleading, however. In fact, a DSM-5 diagnosis should more aptly be called a “label.” It may sometimes be useful for pragmatic shorthand in communication between clinicians and for organizing simple description of presenting problems and symptoms but should not be confused with the more holistic and individualized work of a biopsychosocial assessment. To arrive at the DSM-5 label, clinicians must carefully identify with the clients each of their symptoms, how long they have lasted, and how much they are interfering with their goals in life. Symptoms are clustered based on how they commonly co-occur, rather than on any underlying causes. Therefore, when a clinician provides a label of “Generalized Anxiety Disorder,” for example, she is simply referring to the presence and absence of symptoms over a specified period of time, rather than any causes or treatments. The APA’s diagnostic system was not always only descriptive. Prior to the publication of DSM-III (1980), the system was based on psychoanalytic understandings. The first and second editions provided general synopses of disorders rather than operationalized criteria, because the diagnoses were thought to be distinguishable by their root causes. Often the causal theory was evident from the name given to the diagnosis, for example, “Psychoneurotic Depressive Reaction” in DSM-I (1952). Although the current model of descriptive labelling has many limitations, most would agree that the use of operationalized diagnostic criteria improves transparency and represents an advance for the rights of people receiving treatment. Prior to the third edition, clients who disagreed with a diagnosis had little recourse. They could not easily argue with interpretations of dynamics that were supposed to be unconscious. Today clients can agree or disagree with the descriptive diagnosis based on outwardly observable criteria. Still, many clinicians and researchers continue to challenge the value of the DSM and point out, for example, that the labels—divorced from etiological considerations—have little to no role in guiding the treatment approach. Indeed, if the goal is just to provide a description, it would be clearer to simply list each client’s symptoms, the history and interactions of the symptoms, and the severity and impact on the client and the people around them. The act of labeling in practice can limit a deeper and broader understanding of any psychological condition. At the same time, in the current context, when clinicians can remember these limitations, the process of coming up with a DSM diagnosis can help by encouraging them to pay careful

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attention to presenting symptoms that they might otherwise overlook. Describing problems, symptoms, and strengths with accuracy, detail, and without judgment—considering the client’s perceptions of them as well as the clinician’s—can help them both to feel less daunted by the problems. A focus on very clear description can help a client and therapist to find multiple perspectives, to begin to shift the situation, and to contemplate opening up spaces to inquire about what is outside and inside of another human being that affects their development and functioning.

BRIDGE TO PSYCHOPATHOLOGICAL SYNDROMES Our goal in the following chapters is to introduce the reader to several psychopathological syndromes from a biopsychosocial perspective. We hope to illustrate how an application of the theories we have studied in the first half of this book deepens our understanding of the complexities of people’s emotional distress and mental illness. From a psychodynamic perspective, we will look at how different theories help explain the etiology and course of people’s inner turmoil and outward dysfunction. From a social perspective, we will look at the impact of race, gender, sexuality, culture, and class on diagnosis, and how the forces of oppression can create the context for—and fuel the development of—emotional difficulties under oppressive and pathological social conditions. From a biological perspective, we will explore how genetic, hormonal, biochemical, and neurobiological factors can predispose and/or lead to the development of particular disorders. The mental disorders we have chosen to describe do not cover the full range of psychopathological syndromes that affect people’s lives. They represent an arbitrary and perhaps idiosyncratic selection of several major diagnostic categories, including psychoses (with a special emphasis on schizophrenia), personality disorders, mood disorders, anxiety disorders, and trauma. We chose to explore these five broad categories because they reflect a range of emotional problems with which many people struggle, and because they illustrate how a biopsychosocial lens can help us fully assess people in the context of their inner and outer worlds. They also lend themselves to exploration from a psychodynamic perspective. In the following chapters, then, we will study psychopathologies from the inside out and the outside in. In each diagnostic category, we will look at how what originates from the outside is experienced internally and how what is experienced intrapsychically influences a person’s perception of, and experiences with, the external world. Only then can we begin to appreciate the multiple levels of meaning in our work with our clients.

REFERENCES American Psychiatric Association. (1952). Diagnostic and Statistical Manual of Mental Disorders [DSM-I]. Washington, DC: American Psychiatric Association. ———. (1968). Diagnostic and Statistical Manual of Mental Disorders [DSM-II]. Washington, DC: American Psychiatric Association. ———. (1980). Diagnostic and Statistical Manual of Mental Disorders [DSM-III]. Washington, DC: American Psychiatric Association. ———. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM-5]. Arlington, VA: American Psychiatric Association. Bion, A. (1970). Attention and Interpretation. Northvale, NJ: Jason Aronson.

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Byers, D. S., Thigpen, K. Z., & Wolfson, S. (2020). Working with LGBTQIA+ clients in the context of trauma, with a focus on transgender experience. In Trauma: Contemporary Directions in Theory, Practice, and Research, eds. S. Ringel and J. Brandell, 2nd edition. New York: Columbia University Press. Byers, D. S., Vider, S.,  & Smith, A. (2019). Clinical activism in community-based practice: The case of LGBT affirmative care at the Eromin Center, Philadelphia, 1973–1984.  American Psychologist 74(8):868–81. http://dx.doi.org/10.1037/amp0000523. Coltart, N. E. (1986). Slouching towards Bethlehem . . . or thinking the unthinkable in psychoanalysis. In The British School of Psychoanalysis, ed. Kohon, pp. 185–99. New Haven, CT: Yale University Press. Freud, S. (1958). Recommendations to physicians practicing psycho-analysis. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, ed. J. Strache (Vol. 12, pp. 109–120). London: Hogarth Press. (Original work published 1912). Gabbard, G. O. (2014). Psychodynamic Psychiatry in Clinical Practice. Washington, DC: American Psychiatric Publications. Greenson, R. (1967). The Technique and Practice of Psychoanalysis. New York: International Universities Press. Martinez, D. B., & Fleck-Henderson, A., eds. (2014). Social Justice in Clinical Practice: A Liberation Health Framework for Social Work. New York: Routledge. McWilliams, N. (2020). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd edition). New York: Guilford Press. Mendes, G. (2014). An underground extension of democracy: The Lafargue Clinic and the promise of antiracist psychiatry. Transition 115:4–22. Miller, J., & Garran, A. M. (2017). Racism in the United States: Implications for the Helping Professions. New York: Springer. Mitchell, S. A. (2009). Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press. Pine, F. (1998). The four psychologies of psychoanalysis and their place in clinical work. Journal of the American Psychoanalytic Association 36:571–96. Quiros, L., & Berger, R. (2015). Responding to the sociopolitical complexity of trauma: An integration of theory and practice. Journal of Loss and Trauma 20(2):149–59. Shea, S. C. (2017). Psychiatric Interviewing: The Art of Understanding. Edinburgh, UK: Elsevier Health Sciences. Sullivan, H. S. (1940). Conceptions of modern psychiatry. Psychiatry 3:35–45.

13 The Psychoses, with a Special Emphasis on Schizophrenia Spectrum Disorders Patricia Hertz

A man in torn and dirty clothes walks in circles on a street corner, gesticulating in the air while shouting to others; no one else sees. A parent calls a crisis line, panicked about her twenty-one-year-old daughter who had called from college stating that her suite mates were poisoning her food, her professors were imposters trying to harm her, and she was going to be arrested for harboring state secrets. These are two of the many faces of major mental illness, in this case of people who were later diagnosed with schizophrenia. In spite of the advances made in the treatment of this disorder, the condition known as schizophrenia still triggers feelings of fear and despair in those afflicted, and in their loved ones. Schizophrenia, and the range of other psychotic disorders that affect millions around the world, remains etiologically perplexing and challenging to treat. They can create havoc in the lives of the patients whose minds have betrayed their owners’ trust, and in the lives of those who care for them. For beginning clinicians, who often use logic and linear assessment tools to understand their clients, working with psychotic patients can be especially overwhelming. Our hope is that with a greater understanding of the complexities of this condition, we can help clinicians develop greater compassion for, and connection to, those afflicted with schizophrenia, particularly in the face of the alienation that is an all-too-common by-product of this disease. In this chapter, we will examine the etiology and characteristics of schizophrenia, and the interface of environmental, psychological, and social factors in the cause and course of the illness. We will use a biopsychosocial perspective to help us understand the internal worlds of people with the disease, and offer thoughts on treatment issues. Before turning our attention to schizophrenia, however, let us first turn to the general concept of psychosis, which can emerge in disorders other than schizophrenia. In fact, it is essential that we not assume that the presence of psychotic symptoms means that an individual is suffering from schizophrenia given the many other disorders in which psychotic symptoms may emerge. The term psychosis refers to a mental disorder in which there is a partial or complete withdrawal from reality. Psychosis, or a “break” from reality, can assume many forms. The two most notable symptoms of a psychosis are (1) delusions, which are fixed, false ideas 247

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believed by the person that cannot be corrected by reason; and (2) hallucinations, which are sensory experiences leading a person to see, hear, feel, or smell things that cannot be established in reality. Even in the absence of delusions or hallucinations, the capacity of a person with psychosis to evaluate reality in a sustained fashion is impaired. A person with psychosis may be continually responding to voices in her head, for example, or may be lucid much of the time while living with an encapsulated delusion that impacts a small aspect of her functioning. In order to appreciate the range of psychiatric disorders in which psychotic features may be present, let us consider several examples of people who present with psychotic symptoms. Each of the case vignettes below illustrates a person who is experiencing a psychotic episode; yet each is suffering from a different mental illness. In his first meeting with his therapist, Sam, a twenty-seven year old white cisgender male, presented as a well-related, casually attired, and articulate young man. He discussed problems he was having in his relationship with his girlfriend in a thoughtful, logical manner. However, when he returned for a second appointment, he entered the room with a bloody and swollen face, stating that he had been in a fight with the devil the previous evening. The devil, he said, had taken Sam’s head in his hands, yelled at him, and repeatedly banged his face against the bedroom floor. When questioned about the events preceding this episode, Sam reported that he had shot a quarter gram of cocaine shortly before the fight.

Sam experienced both auditory and visual hallucinations precipitated by his use of cocaine. He suffered from a cocaine-induced psychotic disorder. Illegal drugs, as well as prescription medications, can precipitate psychotic episodes during which visual hallucinations frequently emerge as a prominent characteristic. Psychotic symptoms can also be present in a range of organic mental disorders, such as dementia, delirium, and substance-related disorders. When clients present with psychotic symptoms—especially for the first time—it is essential that they be assessed medically to determine if medication, a medical condition, or substance use may have triggered the psychotic episode. Had Sam arrived at a clinic for the first time without either reporting his substance history or receiving a medical workup, he could easily have been misdiagnosed and hence mistreated. Mental health professionals are often the first people who evaluate these clients, so it behooves us to complete a thorough assessment of biopsychosocial factors before determining a patient’s diagnosis. Our next illustration is of a thirty-three-year-old white cisgender married female who was hospitalized on an inpatient psychiatric unit due to psychotic symptoms: Carol brought her active, vibrant, and well-fed three-month-old daughter into the hospital office. She noted tearfully that her daughter was not moving, was starving herself, and was close to death. When the therapist commented on the medical reports documenting her daughter’s good health, Carol angrily replied that the medical staff were actors involved in a plot to torture patients and to kill their babies.

Carol was suffering from a postpartum psychosis, which is estimated to occur in one out of every one thousand women following the birth of a child. This type of psychosis, usually brief but invariably disturbing in nature, is triggered most frequently by physiological changes that occur after birth (hormonal, immunological, circadian), which can precipitate disease in genetically vulnerable women (Bergink et al. 2016). Postpartum psychosis is often characterized by either severe depression or mania and by delusions and hallucinations that usually center on the baby. Although a discussion of the complex combination of biological, psychological, and/or environmental factors that precipitate this condition is outside the scope of this chapter, we can all appreciate the ways in which a postpartum psychosis

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is terrifying to the parties involved in what they had hoped would be a joyful moment in a family’s life. For Carol, the delusions about her daughter and her medical providers robbed her of an opportunity to bond with her infant during the months following the baby’s birth. The last vignette we will consider illustrates a woman in the throes of a manic psychosis: Susan, a thirty-two-year-old cisgender Dominican mother of two, felt increasingly energized and high. Over the course of several weeks, she charged thousands of dollars to her credit card for what (under other circumstances) she would have considered extravagant purchases, slept only two to three hours a night, and had racing thoughts and pressured speech. After a few weeks, she began hearing voices that told her to take leadership of the treatment unit on which she worked as a psychiatric nurse.

Although Susan had no prior psychiatric history, she developed a bipolar mood disorder in her early thirties. Susan’s mental status was characterized by an elevated and expansive mood, flight of ideas, a distorted and grandiose self-perception, and, ultimately, hallucinations and delusions. Her psychosis emerged in a discrete episode and disappeared entirely when she began treatment with a mood stabilizer. The majority of people who have mood disorders do not become psychotic, and when psychotic symptoms do arise, they are usually congruent with the person’s mood state. Susan’s psychotic thoughts, for example, reflected grandiosity and omnipotence consistent with her mania. The conditions noted above by no means represent an exhaustive list of psychotic disorders or conditions in which psychotic symptoms may appear. They reflect, however, a sampling of the many ways that people’s minds can stray from reality and their lives become drastically disrupted from within. None of us is immune to these conditions, which present with varying degrees of severity and duration. Additionally, as we will discuss at greater length later in the chapter, what is deemed psychotic by mental health providers—and what is perceived as psychotic by patients and those around them—must be assessed within the cultural, social, and political context in which the diagnosis is made.

SCHIZOPHRENIA Myles was a 20-year-old man who was brought to the emergency room by the campus police of the college from which he had been suspended several months ago. A professor had called and reported that Myles had walked into his classroom, accused him of taking his tuition money and refused to leave. Although Myles had much academic success as a teenager, his behavior had become increasingly odd during the past year. He stopped seeing his friends and no longer seemed to care about his appearance or social pursuits. He began wearing the same clothes each day and seldom bathed. He lived with several family members but rarely spoke to any of them. When he did talk to them, he said he had found clues that his college was just a front for an organized crime operation. He had been suspended from college because of missing many classes. His sister said that she had often seen him mumbling quietly to himself and at times he seemed to be talking to people who were not there. He would emerge from his room and ask his family to be quiet even when they were not making any noise. Myles began talking about organized crime so often that his father and sister brought him to the Emergency Room. On exam there, Myles was found to be a poorly groomed young man who seemed inattentive and preoccupied. His family said that they had never known him to use drugs or alcohol, and his drug screening results were negative. He did not want to eat the meal offered by the hospital staff and voiced concern that they might be trying to hide drugs in his food.

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Patricia Hertz His father and sister told the staff that Myles’ great-grandmother had had a serious illness and had lived for 30 years in a state hospital, which they believed was a mental hospital. Myles’ mother left the family when Myles was very young. She has been out of touch with them, and they thought she might have been treated for mental health problems. (Excerpted from Understanding Mental Disorders: Your Guide to DSM-5 (2015))

Myles’s story is painfully familiar to those whose loved ones and/or clients are living with schizophrenia. Perhaps more than with any of the other disorders we will be studying, an overwhelming and unrelenting sense of loss invariably accompanies this illness. It is not just a loss of functioning in the present but also a loss of hopes and dreams nurtured in the past and envisioned for the future. Schizophrenia afflicts people from all walks of life and often has a chronic course. We are uncertain about its causes, unable to prevent it, and have limited success in treating it. Schizophrenia is a syndrome that can alter all aspects of a person’s life, creating deficits in cognitive, behavioral, affective, and social functioning. While individuals can live full, rich lives with this disorder (Saks 2007), for many of those afflicted, it can be experienced as a painful internal struggle for emotional well-being.

GENERAL DESCRIPTION A staggering number of people in the United States have been diagnosed with schizophrenia. According to the National Institute for Mental Health, approximately 29 million people suffer worldwide from this disorder, with up to 2.6 million of them living in the United States (NIMH 2010). Although studies suggest that schizophrenia occurs in all populations with similar prevalence rates, ranging from 0.87 percent to 1.4 percent (Barbato 1998; Jablensky 2000; Kulhara and Chakrabarti 2001; Perälä et al. 2007), questions have been raised about the accuracy of these numbers. In a recent article, for example, Torrey and ­Sinclair (2018) note that in 2017 the NIMH said there were approximately 2.8 million people in the United States with schizophrenia; however, that number was, without explanation, changed to approximately 750,000. According to Torrey, the more recent figure omitted people who were in hospitals, shelters, or jails, or living on the street—that is, a significant number of people with schizophrenia. Many of us have known people with schizophrenia even though we may have been unaware of the diagnosis. How often has someone been told of a relative who had a “nervous breakdown” and was sent “away,” or known of a high school senior who started acting strangely and never came back to complete the final semester at school? Euphemisms such as “nervous breakdown” have served to cloud our perceptions of this disorder and to prevent us from educating ourselves about it. The social stigma of this diagnosis often isolates those afflicted and further burdens their families. The onset of schizophrenia usually occurs in late adolescence or early adulthood. Approximately three-fourths of all people with schizophrenia are afflicted between the ages of seventeen and twenty-five (Torrey 2013). Often the onset is progressive, and the most striking symptoms are that a person gradually develops odd beliefs, affect, and mannerisms. At other times, however, the onset can be acute, as when a person suddenly becomes psychotic—has a “break”—with no prior indication of any psychological difficulties. It is important to note that in the physiologically vulnerable individual, schizophrenia can be triggered by a range of stressors, such as the loss of a loved one, being the victim of a crime, the negotiation of a new developmental task such as leaving for college, or interpersonal or societally induced trauma. These stressors may also be shaped by cultural norms or traditions, as, for example,

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when a young Indian woman in an arranged marriage is uprooted from her home and begins an entirely new life with strangers in a foreign land (Luhrmann & Marrow 2016). The complex interplay of genetic, neurobiological, and environmental factors, particularly in the changing adolescent brain, appears to set the “schizophrenic process” in motion. Just as the onset of schizophrenia can take different forms, the course of the disease can be quite variable. Although by definition all people with schizophrenia undergo an active psychotic phase at some point during the illness, some recover with little residual deficit, some restabilize at a lower level of functioning, and others remain chronically psychotic. Studies suggest the following possible course of the illness from time of onset through a tenyear period: 25 percent completely recover; 25 percent are much improved; 25 percent are improved but need extensive support; 15 percent are hospitalized, with no improvement; and 10 percent are dead, mostly from suicide (Torrey 2019). This last figure is important because suicidal ideation and suicide attempts are a common and often overlooked occurrence in schizophrenia. Clients sometimes attempt suicide when they feel flooded with thoughts they cannot control, or during periods of depression when they feel despondent over the discrepancy between their early achievements and their current level of functioning. This figure is also important because the public frequently misperceives people with schizophrenia as homicidal whereas they are far more often victims of crime perpetrated by others, or, as tragically, at their own hands. Most researchers agree that several factors predict a more favorable course of the illness, including a sudden onset; a predominance of positive symptoms (delusions, hallucinations, disordered thinking) rather than negative symptoms (apathy, loss of interest, emotional withdrawal); perceptual changes that are experienced subjectively by the individual as strange; having no relatives with the disease; and last, the clear presence of a precipitating event. Women with schizophrenia also have more favorable outcomes than men, who are afflicted with the illness far more frequently than women (Torrey 2019). Supportive networks, comprised of family members, friends, and mental health professionals, can also be important elements in influencing the course of the disease. Some findings suggest that the thirty-year course of the illness is more favorable for most patients than the ten-year course, which contradicts the long-standing belief that most people become sicker as they age. Rather, current studies show patients having fewer “positive” symptoms as they age, although “negative” symptoms may “flatten” the person until they seem a shell of their former self (Torrey 2019). The most common course consists of a series of acute phases with increasing personality deterioration between episodes. For example, a sixty-year-old man with schizophrenia may have had frequent psychotic episodes in his twenties and thirties, very few in his forties and fifties, and none at sixty but by then appear to be a diminished version of himself. His personality, not just his thoughts or affects, may be altered over time. Of note, both the understanding of the disease and its outcome are context-specific and differ across cultures, as will be discussed in further depth later in this chapter.

CLINICAL PICTURE Max is a thirty-seven-year-old articulate man who is paranoid and delusional. Christina is a twenty-seven-year-old woman whose speech is frequently incoherent and whose affect is incongruent with her mood and the content of her thoughts. Bob is a forty-five-year-old man who postures in a rigid, catatonic fashion. How can we understand how all of these patients, each with a somewhat different set of manifest symptoms, can be diagnosed with schizophrenia? Indeed, this wide range of symptoms has fueled the debate over whether

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schizophrenia is a single disease, one (like tuberculosis, for example) that manifests in different ways but has a single cause, or a collection of illnesses, a syndrome that has genetically distinct origins, each with its own set of symptoms. In either case, schizophrenia can be understood as a “disease of the brain that is expressed clinically as a disease of the mind” (Andreasen 1999, p. 646). In the DSM-5 (2013) classification system, the diagnosis of schizophrenia requires the presence of at least two symptoms listed under “Criteria A”: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms (American Psychiatric Association 2013, p. 99). At least one of the symptoms required for the diagnosis must be the presence of delusions, hallucinations, or disorganized speech. Additionally, in order for a person to be diagnosed with schizophrenia, continuous signs and symptoms of the illness must persist for at least six months, including one month of “active phase” or “Criteria A” symptoms. Significant impairments in a person’s level of functioning must also be noted in areas such as work, school, interpersonal relations, or self-care. If symptoms persist between one and six months, the diagnosis of schizophreniform disorder is made, whereas the diagnosis of brief psychotic disorder is given when the episode of disturbance lasts for at least one day but less than one month. Of note, previous editions of the DSM had differentiated among subtypes of the disorder (paranoid, disorganized, catatonic, undifferentiated, and residual), with each subtype reflecting the predominant symptom picture at the time of evaluation. These subtypes were eliminated in the DSM-5, as it was determined that there was little reliability or clinical utility in their application given how frequently people’s symptoms shift over the course of the illness. For example, an individual might have an acute episode of psychosis with paranoid delusions, only to subsequently fall into a state of catatonia. The DSM, as we have discussed in a previous chapter, gives us a brief snapshot of the symptom picture—from the “outside in”—of schizophrenia. Let us now examine the clinical picture of this illness in greater depth and explore the ways in which it presents most characteristically in people’s lives. Disturbance in Thought and Cognition One of schizophrenia’s most striking symptoms is the disturbance in the afflicted person’s cognitive functioning, from the most basic sensory processes to more abstract thinking and complex problem solving. Schizophrenia is often characterized by the slower processing of, and response to, stimuli, difficulty sorting out information and excluding nonessential data, and impairments in attention, memory, and all the executive functions. These have been identified in part as the result of “neurological sensory gating deficits,” a decrease in the brain’s normal ability to inhibit its response to unimportant stimuli. At the same time, the brain’s ability to initiate, choose, and actualize important information is significantly compromised. From a clinical standpoint, the disturbances in thought can be manifested in the content and form of people’s thoughts, as well as in their perceptions. People’s thoughts may be characterized by concrete thinking, as evidenced in the inability to move from the literal or concrete to the abstract. Their thinking may also be permeated by delusions, fixed false beliefs that cannot be validated in reality. Of utmost importance, before ascertaining that seemingly bizarre beliefs are indeed delusional, it is critical to assess them in their sociocultural and political contexts. A  Haitian man who complains that a curse was put on him through voodoo, or a U.S. political activist who states that the FBI is wiretapping her phone, must be heard in the context of the norms and realities in which they live. Even

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Woody Guthrie, the famous singer songwriter, was incorrectly diagnosed with schizophrenia when his murmurings about being famous were thought to be delusions when in fact he was suffering from what was later determined to be a degenerative nerve disorder. Herein lies the need for caution: what sounds delusional may be so only to the ears of the uninformed listener. Delusions vary enormously in content, and they take shape in the context of a person’s sociocultural norms. Delusions of a religious nature, for example, have been reported to be common in Europe, but rarely in Asia. In industrialized Western countries, delusions involving witchcraft and magic seem to have been replaced by those involving wiretapping, electronics, TV, and radio. What this demonstrates is that, although the brain may be processing information incorrectly, it is not processing it in a vacuum; the content of the delusions evolves within an individual’s culture and belief system. Delusions may be people’s attempts, in part, to make meaning of the strange and inexplicable experiences brought on by their illnesses. If you are hearing intrusive, frightening voices that no one else can hear, how might you make sense of their source? The answer to that may be different depending on whether you believe in communications from the gods or believe in an intrusive and malevolent government. They can also be understood as expressions of deep-seated wishes or fears, and can lead to self-destructive behaviors. For example, a person may be afraid that his thoughts are being broadcast to the world by an electronic device that was secretly planted in his ear. Would it be any wonder, then, if he attempted to gouge out part of his ear to remove it? A fairly common manifestation of delusional thinking in individuals with schizophrenia is the presence of ideas of reference—that is, believing (with no basis in fact) that things are related to, or refer to, them. They may “find” messages on billboards or in a news anchor’s report on television, which they believe are secret communications directed exclusively at them. As one woman with schizophrenia described, “In psychosis, nothing is what it seems . . . An advertising banner revealed a secret message only I could read. The layout of a store display conveyed a clue. A leaf fell and its falling spoke” (Weiner 2003, p. 877). The forms delusions assume can also be quite varied. They can be persecutory (“The CIA is spying on me”), grandiose (“The peace postcard I mailed to you brought about a cease-fire in Nicaragua and again in the war of Iraq and Iran”), somatic (“There is a knife growing in my stomach and it causes me pain”), and/or religious (“I am Christ”). Whatever the content of the delusion, primary process thinking, in which thoughts are not governed by logic and reality, but rather by unconscious material, usually prevails. The following comments of a thirty-four-year-old woman with schizophrenia illustrate some of the many disturbances in thought content: I heard my name on the radio. They said the Christ child had been born. I am God, but would never admit it. I’d rather be a pathological liar . . . I saw myself in a Michael Jackson cartoon. I saw my picture in the subways. How did they get it? I thought I looked good. It was scary. I sang and they applauded. I turned on the radio again and they offered me a Motown contract. They must have heard my voice in the underground.

The following letter, written by a man with schizophrenia to his therapist, offers us another illustration. Note his grandiose delusions and how these delusions provide an explanation for the painful loneliness in his life. I am in true birth the living God child and son, kidnapped from Berlin, Germany, of Adolf and Eva Hitler. Yes, dear, Eva Braun Hitler and Adolf physically are my true Ma and Pa. Because I had been trying to save the American flag from being taken down since June  1959 daily at work,

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I have not been able to get a date with a girl. I am at war—Honest and True . . . Please mail a copy of this letter dearest to a man I am very proud of, President Richard Milhous Nixon.

In addition to the presence of delusions in thought content, perceptual difficulties abound in the thought processes of people with schizophrenia. These often take the form of hallucinations—that is, sensory perceptions that cannot be validated in reality. Auditory hallucinations are the most common type experienced by individuals with schizophrenia, and can assume a range of forms: a repetitive sound (“I keep hearing a clicking noise”), a familiar voice (“My [dead] mother tells me to sleep”), or multiple voices of unknown origin (“I hear children’s voices outside my window at night”). Hallucinations can be visual, olfactory, or tactile as well. They are often unpleasant and, dynamically, may reflect intense anxieties and unresolved, conflictual thoughts. A  client with schizophrenia, for example, struggled with enormous ambivalence about conceiving a child and worried that she would be a “bad mother.” Although these are somewhat common concerns among prospective parents, these anxieties triggered in her psychotic-level fears. She began hearing a clamping sound arising from her stomach, and voices that kept yelling at her that she was going to be arrested for treason. Perceptual difficulties can assume forms other than hallucinations. There can be an increased acuity of perceptions, a flooding of the senses with stimuli. Noises may appear louder, colors may look brighter, and odors may be more pronounced. This intensification of perceptual sensitivity can be distracting. An adolescent client, for example, was unable to concentrate on his thoughts in the office because of how loud the ticking of the clock sounded to him. At the other end of the spectrum, there can be a dulling or blunting of the senses so that a person appears oblivious to noises and activities in the environment. Although there are several possible causes for this “blunting” of affect, we can certainly imagine why someone unable to bear the flooding of the senses may “shut down” and withdraw from the external world. Cognitive impairments are also present in the form of a person’s thoughts, which is referred to as a thought disorder. A “loosening of associations,” in which unrelated ideas are strung together with no awareness of their lack of logic, continuity, and purpose, is a prominent characteristic of a thought disorder. Words are sometimes associated by their similar sound (these are referred to as clang associations) or can be made up (neologisms). In the following exchange between a man with schizophrenia and his therapist, note the gradual loosening of associations as the client began discussing his most recent psychiatric hospitalization. It is my opinion that these three men belong in a mental institution. In fact, I think all three of them act kind of funny and either belong in a jail or a mental institution. They constantly make fun of me and my good name. In fact, all of them do, and my name is McAuliffe, same as Dick McAuliffe, formerly of the Boston Red Sox, and also General McAuliffe, like General McArthur. McAuliffe, General McAuliffe that is, said nuts when told to surrender to the Japs or Germans, and is not nuts, and neither am I.

When listening to this client, the therapist initially assumed that he was describing his experience in the hospital. As is common with tangential thinking, however, this client’s associations became increasingly illogical and irrational, even as they remained loosely related to his initial point. Given the range of cognitive difficulties in the minds of people with schizophrenia, from the possible occurrence of delusions and hallucinations to the loosening of associations and tangential and concrete thinking, we can better understand why those afflicted with this disease frequently choose to spend time alone, keep lights and/or the TV on all night,

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or struggle to follow seemingly simple directions. The world may seem a frightening place when it is impossible to determine what are external rather than internal stimuli, to identify real versus imagined dangers, or to engage comfortably in sustained conversations with others. Disturbances in Affect and Behavior Whereas the cognitive disturbances described above are the symptoms most frequently associated with schizophrenia, affective and behavioral abnormalities are frequently the more noticeable symptoms of the illness, often alienating people around the afflicted individual. Someone with schizophrenia may assume inappropriate or bizarre postures, shout out impulsively, and show a reduction in spontaneous movements, pace, or rock back and forth. Although these behaviors are often attributed to antipsychotic medications, particularly the older antipsychotics, they can also occur in patients who have never taken medication. When they do occur as a result of the medication, it is important to carefully weigh the risks and benefits of continued drug therapy. Affective abnormalities may be manifested in negative facial expressions unrelated to the content of a person’s words, and in “inappropriate” emotional communications that are dys-synchronous with the reality of the moment. A  person may scowl when describing a pleasurable exchange, or laugh when discussing a tragic event, seemingly unaware of the discrepancy between the meaning of the words and the expressed emotion. Problems with the intensity and regulation of affect can also be seen in the person’s experience of rage. Rage, understood by some theorists (Bion 1965; Robbins 1993) to be at the core of the person with schizophrenia’s emotional life, can be expressed in the language of destruction, which is often seen in the content of hallucinations. Poorly organized and often nonspecific, this rage can fuel self-destructiveness and promote an “attack” on one’s own thoughts, feelings, and/or body. Over the course of the illness, particularly when a person has suffered multiple psychotic episodes, there may be a loss of a subtle gradation of affect. An individual’s emotions may become blunted (a severe reduction in the intensity of their affective expression) or flat (no signs of affective expression). The mother of a woman with schizophrenia, for example, brought her daughter’s therapist pictures of, and letters written by, her daughter before she became ill. The mother tearfully recounted how the expressionless woman that the therapist had come to know was once a passionate, intense girl whose laughter and tears flowed easily. The disease had robbed her vibrant daughter of her previously rich emotional life. This loss lies at the heart of the suffering for family and friends of the person with schizophrenia: the essence of the person they knew may be diminished, if not destroyed, by the progression of this disease.

ETIOLOGICAL CONSIDERATIONS As we look at the evolution of our understanding of schizophrenia, let us first state that this illness is understood to be caused by a combination of genetic, neurobiological, and environmental factors. Schizophrenia was first classified in the late nineteenth century by the neuropsychiatrist Kraepelin (1896/1919), who used the term dementia praecox to describe an illness that progressed toward a state of dementia and began in adolescence (hence praecox) as compared to old age. He defined it as a disease that never improves. In 1911, the Swiss psychiatrist Bleuler (1911/1950) renamed the syndrome schizophrenia, a term broadly

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meaning “splitting of the mind.” Although frequently and inaccurately confused with the concept of split or multiple personalities, this term referred to the splitting or fragmentation of various mental functions. Bleuler identified several traits common to patients with schizophrenia including disturbance of affect, loose associations of ideas/thoughts, and an autistic-like turning away from reality. It was Freud (1894) who first attempted to explain the psychodynamic etiology of this psychotic process. He initially explored how intolerable ideas, inadequately rejected by the ego, return in the form of hallucinatory wish fulfillments (Arieti 1974). Freud (1924b) later understood psychosis as developing from a conflict between the ego and the external world, leading to a total denial and reshaping of reality. He wrote: Both neurosis and psychosis are the expression of a rebellion on the part of the id against the external world, of its unwillingness—or if one prefers, its incapacity—to adapt itself to the exigencies of reality . . . [N]eurosis does not disavow reality, it only ignores it; psychosis disavows it and tries to replace it . . . Thus the psychosis is also faced with the task of procuring for itself perceptions of a kind which shall correspond to the new reality; and this is most radically effected by means of hallucination. (pp. 185–86)

Although we now know that Freud’s understanding of the causes of schizophrenia is inaccurate, he offered valuable insight into the psychological mechanisms operative in psychotic disorders. His description of the role of repression, projection, and symbolization remains helpful in exploring the primary process thinking so central to the person with schizophrenia’s cognitive processes. Contributions made by various theorists over the decades that followed Bleuler’s and Freud’s attempts to classify and decode schizophrenia—some of which emphasized the brain and others the environment—have been alternately refined, elaborated, or discarded. Critically, one explanation that dominated the understanding of schizophrenia for decades has been thoroughly rejected. This was Gregory Bateson’s argument that schizophrenia was caused by a “schizophrenogenic mother,” a mother who puts her child in a “double bind”: the child can neither please nor separate from the mother and constantly receives conflicting messages that negate one another and cannot be addressed. Current researchers point out that the stress and conflict in a family with a child who has schizophrenia may certainly create complicated and conflictual communications, but it is a pattern that can be observed in many families in which one member is seriously ill—that is, a consequence or result rather than a cause of the illness (Freedman 2010). It is difficult now to imagine that forty-five years ago, in a college Psychology 101 class, a professor still proffered the double bind theory even as he commented that there might be an inheritable component and that “something in the brain” might contribute to the illness given that there is a (roughly) 50 percent chance that if one identical twin has schizophrenia, the other one will too (personal communication). As seen in our discussions of psychodynamic theory and gender, “mother blaming” was both implicit and explicit in many of the mid-twentieth-century theories about schizophrenia, written primarily by male researchers and theorists. The reluctance to see a “brain” component to the disease can be better understood in the context of that era. During the 1970s, many people preferred to emphasize nurture over nature. The notion of inborn/genetic limitations was unwelcome. The “science” of eugenics had used genetics to argue for the inherently inferior character of large swaths of humanity— Jews, Gypsies, homosexuals, and others in Nazi Germany, African-Americans in the United States, and Eastern and Southern Europeans at the time of the 1924 National Origins Act. Anything that was considered genetic or inborn was essential and unchangeable, whereas anything that was a result of nurture and the environment—poverty, discrimination, family

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troubles—could be addressed by social change or aid to families. Additionally, it was simply difficult to determine much of what “the brain” was doing. DNA had not been described in detail until 1958, there was little brain imaging at that time, and the abnormalities found in the brains of dead people who had been diagnosed with schizophrenia could have been the cause of the disease, the result of the disease, or the result of a lifetime of psychotropic medications. Even now, with our considerable abilities to image the brain and to compare the genetics of people who share a diagnosis, neither the genetics nor the neurobiology of schizophrenia is clear. By the 1990s, with the advent of PET scans and MRIs, schizophrenia was understood to be a psychiatric illness caused by an individual’s genetic make-up and alterations in the brain, and requiring pharmacological treatments (Luhrmann & Marrow 2016). To the dismay of researchers, however, schizophrenia did not prove to be a “simple” genetic disease caused by mutations in a single gene (allele) or even in many genes. Instead, there are over 180 locations in the genome that put someone at risk for schizophrenia. Furthermore, these locations may be on the “noncoding” regions of DNA, now identified as epigenetic DNA, which contain (among other things) the instructions for the genes and the switches that turn genes on or off, and that affect their expression. This is relevant in part because research suggests that DNA causes genes to express themselves differently throughout the life cycle, shaped both by what is happening in the brain and by factors in the environment. In fact, it is this interplay between nature and nurture that contributes to the emergence of schizophrenia. Impactful environmental factors can be as wide ranging as the diet of the mother while pregnant (a baby conceived during a famine has a higher chance of having schizophrenia), the age of the father, brain insults such as head injuries, childhood poverty, adult experiences of immigration, trauma of all kinds, and the season in which a person is born (babies born in the late winter or early spring are statistically more likely to develop schizophrenia) (Javitt and Coyle 2004). Any discussion of the etiology of schizophrenia must take into consideration the interplay between nature and nurture, between genetics and the environment. Another factor that has been identified as relevant in the etiology of this disorder is heredity—that is, the generational transmission of the disease. The risk of developing schizophrenia is elevated in individuals who have a biological relative with the disorder. The closer the level of genetic relatedness, the greater the likelihood the relative will also suffer from schizophrenia. Stetka and Correll (2014) suggest that “offspring of one parent with schizophrenia have a 10 percent risk of developing the illness, whereas identical twins have approximately a 50 percent concordance rate.” Other twin studies have also shown a significantly higher concordance for schizophrenia among monozygotic (identical) twins than dizygotic (fraternal) twins, with estimates suggesting that identical twins have two to three times the rate of concordance for schizophrenia than their fraternal counterparts (­Gottesman 1991). However, there is no definitive linear causality that has been found along genetic lines. Ninety percent of people with schizophrenia do not have a schizophrenic parent, and 81  percent have neither a parent nor a sibling who suffers from schizophrenia (Robbins 1993). People who have inherited a predisposition for developing schizophrenia, therefore, may or may not actually develop the disease. Many other hypotheses have been advanced in an effort to identify the neurobiochemical factors in schizophrenia. Particular neurotransmitter systems (dopamine, serotonin, and glutamate) have been explored as central in the pathogenesis of the disorder. For many years, dopamine played the central role in theories about the biochemistry of schizophrenia. The early dopamine hypothesis speculated that an excessive level of the neurotransmitter dopamine causes schizophrenia (Creese et al. 1976). This hypothesis explains why the antipsychotic medications that block postsynaptic dopamine receptor sites in the brain have been

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somewhat effective in treating this disease. There has been a growing interest in the role of the neurotransmitter glutamate as researchers (Walker et al. 2004) have found evidence of diminished activity at the glutamate receptors among patients with this disorder. Additionally, with advances in neuroimaging, researchers have identified structural abnormalities in the brains of people with schizophrenia. Enlarged brain ventricles and reductions in the size of structures such as the thalamus and hippocampus have been found with the use of brain scans. New research is continually conducted on the possible causes of this perplexing illness. This includes but is not limited to research looking at the role of inflammatory processes in the etiology of the disease (Potvin et al. 2008); on the ways that each person’s microbiome (the flora of our intestinal tract) affect health; and at the possibility that there is an infectious basis for schizophrenia. In short, the research is wide ranging, ongoing, and ultimately inconclusive in pinpointing a definitive etiological framework for this disorder.

THE INTERFACE OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS Embracing the complex interplay of innate factors and environmental “insults” in our understanding of schizophrenia, Gilmore (2010) responded to the question of what causes this illness as follows: “The short answer may be ‘nothing’ or more precisely ‘no one thing.’ In most cases, schizophrenia is an end result of a complex interaction between thousands of genes and multiple environmental risk factors—none of which on their own causes schizophrenia” (p. 9). As we hold this integrative perspective, let us now turn our attention to particular environmental factors that can impact the evolution of schizophrenia. Race, Class, Gender, and Culture Just as personality is shaped and molded by culture, ethnicity, gender, and socioeconomic status, illness itself is given form and meaning by these variables. As we discussed earlier in the chapter, “risk factors” impact the way we develop at the cellular level. Social forces such as poverty, discrimination, and inequality can deplete emotional and psychic resources, creating undue stress on people who are already constitutionally vulnerable to schizophrenia. Conversely, favorable social environments may compensate for or mediate against these vulnerabilities. What are some of the risk factors that impact the evolution of this condition? Studies have repeatedly shown a higher incidence of schizophrenia in the lowest socioeconomic strata of urban communities (Barbato 1998; Eaton 1985; McGrath 2007; Torrey 2013). Menezes’s (2010) analysis found that “urbanicity was associated with about a twofold increase in the incidence of schizophrenia, as compared to less-urbanized or rural areas” (p. 12). Werner, Malaspina, and Rabinowitz (2007) determined that low individual and community socioeconomic status at the time of a child’s birth is associated with an increased risk of the individual’s developing the disease. It is estimated that 60  percent of people with schizophrenia live in poverty, one in twenty end up homeless, and fewer than one-third hold jobs. Different theories have been proposed to account for the relationship between social class and schizophrenia, including the migration of people with illness to cities where more services may be available, the disease itself causing a decline in people’s earning potential,

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poor maternal and obstetrical care in lower socioeconomic neighborhoods, and industrial urban centers providing less support and creating greater levels of stress than rural agricultural areas. Conversely, traditional cultures with strong family ties and a sense of collective responsibility for all members of the community may account for the more benign course of the illness in patients from these societies (Weisman 2005). Luhrmann and Marrow (2016) found a common factor among the severely mentally ill to be “social defeat.” This hopeless, “beat-up” state of mind is understandably not conducive to recovery from mental health disorders. A person’s “felt sense” of their place in the hierarchy, as embodied in part by social class and economic hardships “predict many health outcomes, including depression, sometimes even more powerfully than objective socio-economic status alone” (p. 19). In addition to poverty and discrimination contributing to psychological stress, they are significant variables in people’s ability to access the resources available for treating this disease. Options for treatment are far more limited for the uninsured than for those with insurance and/or other economic resources. Hospitalizations and follow-up care are frequently determined by financial resources. Ask any case manager making a discharge plan for a person leaving a psychiatric unit, and they will tell you that the hardest part of their job is finding appropriate care for their patients when they leave the unit. Although money provides no protection against developing schizophrenia, the lack of it creates great stress in people’s lives and limits treatment options. We must therefore consider how the course of the illness may be adversely impacted by social class and the uneven distribution of wealth and resources. The disproportionately higher rate of schizophrenia falls not only along economic and geographic lines but also along ethnic and racial ones, a finding that deserves examination. The incidence of schizophrenia reported among African Americans is higher than the rate of diagnosis for Whites (Strakowski et al. 1993; Torrey 2013). According to Trierweiler et al. (2000), clinicians attributed more negative symptoms of schizophrenia to African American patients than their non-African American counterparts, who were more frequently determined to suffer from mood-related problems. We must therefore remain vigilant about bias in diagnosis, as well as the effects of discrimination on vulnerable members of specific racial and ethnic groups, their experience of social defeat, and, as previously noted, their access to care. It is interesting to note that a variety of gender-related differences have been found in studies of schizophrenia (Angermeyer et al. 1990; DeLisi et al. 1989; McClashan & Bardenstein 1990; McGrath 2007; Piccinelli & Gomez Homen 1997). Schizophrenia is more prevalent among men than women, and the onset of the illness is later in women than in men. Other studies reviewing gender differences in schizophrenia found that women display more affective symptomatology, respond better to neuroleptic medications and treatment, experience a higher level of functioning both prior to the illness’ onset and upon recovery, and manifest different structural brain abnormalities than men (Canuso & Pandina 2007). These gender-related differences raise many questions. Has the diagnosis of schizophrenia been based primarily on studies of men? What might be learned from more closely examining the spike in schizophrenia among women during menopause? What protective role, if any, might hormones (particularly estrogen) play in determining the course of the disease? What effects might women’s greater affiliative behaviors and expression of emotion have on the diagnosis and course of the illness? And last, what differential interventions may be needed based on gender differences? There are clearly many questions in this realm still to be answered, leaving in their wake much uncertainty for patients with schizophrenia, their family members, and their providers.

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Some of the cross-cultural studies of schizophrenia can shed light on how cultural norms and resources—especially familial—impact the outcome of the illness. Cross-­ cultural research of schizophrenia (Hopper et al. 2007; Luhrmann & Marrow 2016) suggest that about 50 percent of people diagnosed with schizophrenia do better in developing countries than in the developed world. Luhrmann and Marrow (2016) note the ways that Indian culture, for example, may produce better outcomes for people with schizophrenia than in developed countries. Central to this phenomenon is the place of the family and the understanding of what makes a person “valid” rather than an “invalid” in the society. In India, only 20 percent of adults have jobs for which they receive money. A person can be a functioning and valued family member without going out to work each day because the capacity to cook, to take care of a house, to farm with family members, or to engage in piece work done at home are completely acceptable adult ways of being. Additionally, there is no assumption that adult children leave home to live on their own. Thus, two of the more stressful tasks of adult life are removed as burdens for someone living with schizophrenia. People with schizophrenia in India and in developing nations are also more likely to remain at home rather than being institutionalized. They are less likely to become homeless, and even homelessness does not carry the stigma that it does in the West. Additionally, families often do not know the diagnosis of their ill family member, unlike in Western cultures, and therefore may be spared the despair or hopelessness that goes along with this diagnosis—a diagnosis that can become an identity, a label of a “permanently defective self.” It is a state of affairs that Luhrmann and Marrow (and the researchers in the book they edited) are anxious not to romanticize; yet for some who continue to live with those with whom they are familiar, they may be afforded an opportunity to function to the best of their abilities.

MEDICATION AND SCHIZOPHRENIA Many medications have been developed over the years to treat schizophrenia, although none of them are cures. Conventional antipsychotic medications such as Haldol and ­Thorazine, otherwise known as “typical” or “first-generation” antipsychotics, were introduced in the 1950s and 1960s, replacing the heavy sedatives used earlier. For some people, they can be effective in reducing the “positive” symptoms of schizophrenia, such as delusions, hallucinations, over-acuteness of the senses, and the other debilitating characteristics of a thought disorder; yet they frequently produce a range of serious side effects. Known as extra­ pyramidal symptoms, these side effects include restlessness, pacing, muscle stiffness, tremors, and changes in breathing and heart rate. A condition called tardive dyskinesia, characterized by involuntary movements of the tongue and mouth, as well as jerky movements of arms, legs, and body, can also develop, and is estimated to be drug induced in approximately 10–20 percent of those treated with these drugs (Torrey 2013). The “atypical” or “second-generation” antipsychotics—“second generation” because they were developed later and because they use a slightly different mechanism to reduce symptoms—including Resperidal, Zyprexa, Seroquel, Abilify, Invega, and Latuda, were introduced in the 1990s, with the hope that they could alleviate both the positive and the negative symptoms of schizophrenia and produce fewer side effects. Clozaril (clozapine), another second-generation antipsychotic medication, is considered the most effective for the treatment of schizophrenia (Torrey 2019) but is used infrequently in the United

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States because one of its possible side effects, a decrease in white blood cells, can be fatal. Thus, it is used only when other drugs have failed and requires very close monitoring of the patient. A study by Lieberman et  al. (2005) and others since then have found that the atypical antipsychotics are no more effective in treating schizophrenia than the older, less expensive medications. They cause different side effects, including metabolic side effects such as weight gain and elevated blood cholesterol and triglycerides, that increase the risk for ischemic heart disease and diabetes (Tandon & Rankapalli 2010). Furthermore, almost three-quarters of the patients in the study stopped taking their prescribed medication before the end of the eighteen-month study because their symptoms did not improve and/or because of intolerable side effects. This rate of “noncompliance” is extremely high and, as we will discuss later in the chapter, has significant implications for clinicians and insurers who use these medications as the first and sometimes only treatment intervention for this population. In addition, when medications are dispensed in the context of very brief psychiatric visits, there is little time to explore side effects or to assess the fears, wishes, and concerns that clients understandably bring to the decision to embark upon a pharmacological course of action. It is axiomatic that medications are only a component of care; they are not a substitute for care. Ideally, they should be prescribed and received in the context of a relationship that allows for adequate dialogue and thoughtful attention. Learning which—if any—of the antipsychotics work for a patient and what side effects he or she will experience and tolerate can be assessed only over time. Can the psychiatrist, in the fifteen-minute time block usually allotted, truly help the patient sort out whether the improvements in her functioning are worth the possible significant weight gain, risk of diabetes, and/or fatigue? Recent advances in the development of antipsychotic medication have included longacting injections, which result in better compliance but also, unfortunately, may come with more Parkinsonian disease–like side effects. Clearly, the hope is that as we increase our knowledge of neurobiology, we may eventually develop drugs that do more than blunt the symptoms of schizophrenia. In spite of the current limitations of pharmacological interventions, the contributions made by medical research to our understanding of the cause and course of schizophrenia have been enormous. The neurobiological disease model of schizophrenia has helped, to some extent—but only to some extent—destigmatize the illness, and it has offered patients medications that relieve some of their symptoms. However, if medication is the only intervention, then psychological dilemmas are minimized, clients’ complex inner worlds are left unexplored, and the focus of care all too often turns to the management of behaviors and the treatment of symptoms rather than to the person with the symptoms. Robbins (1993) captures the isolation and loneliness that can be the by-products of this kind of care: A consequence of viewing the mental manifestations of schizophrenia as expressions of an organic disease entity separate from the personality of the sufferer, manifestations that are meaningless and incomprehensible even to the schizophrenic himself, is the direction of so-called treatment measures to expunge these with “tranquilizing” drugs and to persuade the patient to conceal his thinking, symptoms, and limitations from others and try to function as if he were normal. . . . But the preferred “treatment” of today mirrors and enhances the schizophrenic’s basic alienation from others, and, regardless of the impression conveyed by his compliance, lends reality and substance to whatever mistrustful paranoid beliefs he may have that the world is a dangerous place and that others are basically inimical to his well-being. (p. 187, italics added)

More than twenty-five years after Robbins wrote this, it sadly remains true.

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USING A PYSCHODYNAMIC LENS TO UNDERSTAND THE EXPERIENCE OF SCHIZOPHRENIA Notwithstanding our recognition of genetic, neurobiological, and environmental factors, we still invite readers to use psychodynamic theories to deepen their understanding of people with this illness. Regardless of causality, the person with schizophrenia lives with powerful affects, drives, relational longings, and thoughts that are deserving of comprehension, empathy, and compassion. The content of an individual’s psychotic processes may be internally logical, rational, and meaningful to that person. An individual may wear sunglasses all the time in order to block out the lasers he believes are blinding him, for example, or another may hold daily conversations with Queen Elizabeth in order to feel connected to a special, powerful individual. The time we take to understand these “narratives” in the face of a client’s internal disruptions and external pressures will enhance our capacity to work empathically with them. Psychosis leaves many people isolated yet yearning—in spite of their fears—to be heard. As noted by a woman with schizophrenia, “I wanted to learn to talk about my psychotic experiences, to communicate about them, and to learn to see their meaning. I  learned that this wish is not accepted as a legitimate need for care” (Boevink 2006, p. 18). Using the psychodynamic theories described in the first part of this book, let us now explore aspects of the internal world of people with schizophrenia so that we may be better able to hear what clients might be trying to communicate while helping them feel less alone. This approach allows us to focus on more than “symptom management”; it invites us into a relationship in which the patient is seen as a “whole” person, not the sum of her symptoms, and ideally helps diminish the experience of “social defeat” that can be so corrosive with this illness. Drive Theory Freud (1911, 1914) initially postulated that schizophrenia resulted from a regression in the face of intense frustration and conflict with others, a literal turning of the energy attached to others (and the representations of others) back onto the self. Although Freud’s theory does not explain the etiology and many manifestations of schizophrenia, the psychic energies—in the form of the aggressive and libidinal impulses—significantly impact the cognitive and affective states of people with schizophrenia. People with schizophrenia often make valiant attempts to avoid experiencing intolerable rage, anxieties, and other emotions, which are often expressed through bodily symptoms. Semrad (1960), a gifted and talented psychiatrist known for working with the most troubled of clients, would gain access to this hidden but important emotional landscape “held” by the body. He would do a “verbal tour” of the client’s body, asking him or her to locate the bodily organ in which he or she felt the pain, in order to bring it to consciousness. It is interesting to see this work as a precursor to some current mindfulness-based and somatic therapies. We must remember that because individuals with schizophrenia have difficulty sorting through and processing external stimuli, they are vulnerable to experiencing the world as a dangerous and frightening place. Statements such as “You better put me in restraints because I’m dangerous” or “I  am powerful enough to stop the war” reflect aggression in the face of helplessness or a perceived (internally or externally generated) threat. This aggression, frequently accompanied by intense anxiety, can be a regression to early stages of development, as expressed, for example, in themes of orality (“I swallowed his body when we met”). Sexual and aggressive urges are also often poorly controlled and regulated. As illustrated in

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the following letter, these impulses can become “fused,” as loving relationships can switch precipitously to hostile ones. This excerpt from a letter, written by a man hospitalized after becoming increasingly psychotic, was sent to his therapist whom he cared about deeply and to whom he had expressed loving feelings until his hospitalization: Listen i am getting strung out about the whole thing [his relationship to his therapist] you just want to fuck yourself to death, then when your through see if i’m any good—then i thought i remembered the stern looks and when i’d come in your face would be shiny like you had vaseline on it i use to hate that you use to look like you worked there i like it better when you just look like somebody’s wife but any way those things scared me I don’t want to die.

The pain at feeling abandoned and the rage at needing his therapist whom he perceived as discarding him for being “no good” are expressed in disorganized, disturbing, yet meaningful prose. The client projected both his loving and his aggressive impulses onto the therapist, whom he then perceived as dangerous and stern. Terror of his therapist’s and his own aggression, experienced at a psychotic level, threatened his very existence. Ego Functions Early writings on schizophrenia postulated that the ego of the person with schizophrenia was weak, and thus unable to withstand the dilemmas posed by reality (Freud 1924a). But what is meant by a “weak” ego? As with all the illnesses we will be studying, the degree of impairment of ego functions depends on the severity and the stage of the illness. Before looking at two functions of the ego in greater depth—the modulation of anxiety and the defenses—we can make the following general comments about the ego functions of many people with schizophrenia: First, perception, memory, and the range of autonomous functions of the ego suffer some degree of impairment. Second, judgment is frequently poor, as is reality testing. Third, thought processes are hindered by the intrusion of primary process material. Fourth, the synthetic-integrative functions of the ego, which help organize and integrate the disparate aspects of one’s personality into a coherent whole, are compromised. As described in the first part of this chapter, cognitive processes (another function of the ego) are greatly impacted by schizophrenia. In addition to the disturbances in thought content and thought process, the thinking of people with schizophrenia can be characterized by what Searles (1965) describes as the lack of differentiation between the concrete and the metaphorical. As such, idioms may be interpreted literally, and the richness of nuances and metaphor in language can be lost. Searles, who was renowned for his gift at engaging psychotic patients in meaningful and transformative dialogue, suggests that this concreteness of thought serves an important function: it helps maintain various anxiety-laden affects “under repression.” With great compassion, he helped patients understand their underlying anxiety and conflicts as he explored the layered experience of their emotions and thoughts. The Experience of Anxiety Depending on how it is managed, anxiety can be a source of motivation or a source of paralysis. In developmental terms, we have noted that anxiety can be experienced as “threatening” on different levels. People may fear losing another person’s love; they may fear being abandoned by others; or, on a more “primitive” level, they may fear losing themselves. For the person with schizophrenia, anxiety is usually experienced as the last: as a fear of annihilation. The intensity of annihilation anxiety can be so overwhelming that individuals may fear that they will cease to exist, or that their identities will be reduced to a part of a person rather

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than a whole. Themes of disintegration and engulfment often emerge in their language as a manifestation of this intolerable anxiety. Comments such as “Nuclear war is here and my being is exploding into pieces” and “I saw myself in the center of the earth eaten and swallowed up” reflect this annihilation anxiety. Annihilation anxiety can be precipitated by loss, by frightening interpersonal contacts, and by the experience of powerful affects. In the following example, note how Mark, a man with schizophrenia, expressed his anxiety in his first session with a new therapist. Mark, a 44-year-old white man with schizophrenia, noted that his father owned a deli. He handed the therapist a bag, saying he had brought her a corned beef sandwich. He then hesitated, appeared anxious, and said, “I thought I brought you a corned beef sandwich, but maybe it was a piece of my arm.” The therapist, using humor to handle her own anxiety, replied, “Hold the mustard.”

Imagine the level of panic that Mark experienced during this first encounter. Most, if not all, of us would approach a first session with a therapist with some trepidation and perhaps fear. For this psychotically vulnerable individual, however, meeting someone new provoked fears of disintegration, if not annihilation, of parts of himself. Establishing a safe relationship with his therapist, in which these feelings could be tolerated and understood, was a crucial part of the therapeutic work. A psychodynamic lens offers a bridge to understanding the experience of anxiety for the person with schizophrenia, and in the process helps foster empathy for those who are suffering. Pao (1977) used the term organism panic to describe this state of fear. He noted that “the predisposition to anxiety may become so enhanced that each time [the person with schizophrenia] should experience anxiety he experiences panic instead” (p.  394). Panic interferes with the development of healthy ego functions and relationships with others, leading a psychiatrically vulnerable person to use more primitive “tools” to manage his or her affect. Psychotic symptoms can be the end result when this individual is flooded with overwhelming panic. Using similarly evocative language, Semrad (1960) spoke of the “subjective holocaust” to capture the annihilating experience of anxiety and distress that people with this illness can experience.

The Defenses As we have noted, we all use a range of defenses to cope with the challenges of processing internal and external stimuli. It is the rigid and pervasive use of primitive defenses that most disrupts a person’s ability to function in the world. For people with schizophrenia, the heavy reliance on denial, projection, introjection, and externalization helps them manage chaotic and intrusive thoughts, and avoid the experience of unbearable loss and frightening contact with others. These defenses are attempts at a solution, and on some level “work”—but at an enormous price. Painful feelings and thoughts are disavowed but reality becomes distorted. We can see how this process unconsciously unfolded for Karl, a client whom we will discuss at greater length later in this chapter: Karl, a twenty-three-year-old white cisgender male, struggled with his sadness and rage as he was repeatedly shunned by his peers. In the face of his isolation, he “constructed” a reality in which he believed that three girls whom he barely knew were in love with him, and other boys were “after him” because of his popularity. His pain was transformed through denial and projection. His delusions reflected: (1) his avoidance of relationships, (2) his wish to feel valued and special, and (3) his attribution of his own aggressive fantasies to “the boys” rather than to himself.

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In another illustration, we can see how introjection served a function, albeit maladaptively, for another client. A forty-three-year-old cisgender Latina, angry and sad about the loss of a relationship that had ended ten years earlier, reported that she had swallowed her ex-boyfriend’s head. She heard his voice regularly, an occurrence that was alternately pleasurable and annoying. Over time in treatment, she recognized that this represented a symbolic taking in and retaining of the “lost object” as part of her internal psychological structure.

While the use of these defenses can take a heavy toll, they can also help people construct a world in which their external realities are more tolerable and their internal reality is easier to bear. Object Relations and the Sense of Self As implied in our clinical description of schizophrenia, many people with this illness have difficulty negotiating relationships with others. Their aversion to contact with others often reflects their difficulty maintaining self-object boundaries—differentiating themselves from others—due in part to the “gating” or filtering deficit discussed earlier. Their minds can become overwhelmed by confusing stimuli, and their relationships are often characterized by simultaneous longings for, and terror of, fusion. Attachments to others can be experienced as mergers, and separations can feel like death or disintegration of the self or the caregiver. The plea of an adult man with schizophrenia to his mother, who was leaving for a visit with her other son, captures this psychological dilemma: “You can’t go visit John. If you leave, I’ll die. But if you stay, your spirit will swallow me up.” People at all developmental levels experience feelings of loss or anxiety in the face of perceived abandonment. When experienced by a person vulnerable to psychosis, however, these feelings can create the unbearable paradox that both separation and intimacy may lead to destruction. It is not surprising that poor differentiation between self and other undermines the development of a clear self-image or identity as a whole intact being, separate from others and distinct from one’s surroundings. This confusion about identity is not an existential search to understand “Who am I?” but, on a more primitive level, how or do I even exist? From a self psychological perspective, it is a disintegration of the cohesive self, an absence of internal coherence in one’s identity. Goals and ambitions, self-esteem, and twinship needs must then be negotiated within the context of this fragmented self-experience and are inevitably compromised in the process.

CARING FOR THOSE WITH MENTAL ILLNESS Treatment Issues An attitudinal shift has occurred over the past several decades in how we think of treatment for schizophrenia. We have moved away from the belief in “magic bullets” and from the exclusive focus on decreasing symptoms as if they are separate from the people in whom they are embedded. Rather, we are embracing models of practice that help people make meaning of living with chronic mental illness, that support the creation of relationships that allow for grieving while building on strengths, and that add spiritual dimensions to the soul. Psychosocial rehabilitation models (Leclerc et al. 2000; Stromwall & Hurdle 2003) have grown in number and breadth, including services such as supervised shelters, training

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in social and occupational skills, groups to improve cognitive functioning and teach coping strategies, and case management services that honor people’s wishes to live within their communities. Hospitals have developed programs to help people following a “first break” with specialized evaluation, treatment, and education. The National Alliance for the Mentally Ill has programs that support the family, once seen as the cause of the problem, recognizing them as an essential resource that needs to be nourished in the face of the emotional and financial depletion that can occur when caring for an ill loved one. The Recovery Movement (Ahern & Fisher 2001; Anthony 1993), which has challenged us to focus less on the pathology of the person with schizophrenia and more on the potential for growth, has promoted the perspective that recovery does not mean cure but the development of new purpose as one grows beyond the “catastrophe of mental illness.” People in this movement note that recovery rates can be much greater when a person is supported in a rehabilitation model that emphasizes self-sufficiency, self-determination, and the potential for growth, as well as the presence of someone who believes in their recovery. This perspective can be problematic if it is understood to suggest that full recovery is possible for everyone or if it demands self-sufficiency and self-determination for someone whose goals, for example, are to prevent the government from sending secret messages to their TV, or if it contributes to a further sense of failure in someone who has already lost so much. Rather, its great value consists in recognizing the supports needed for someone to live to their fullest capacity, even though that may not be what it was before the diagnosis, and in challenging the exclusively pathologizing perspective used so often in assessing those with major mental illness. Psychoeducational approaches (Sundquist 1999) have been invaluable in helping clients and their families understand mental illness. They have also assisted families in identifying some of the triggers that contribute to clients’ relapsing and needing additional hospitalizations. A  more recent study (Kane et  al. 2016) demonstrated that treatment that included comprehensive care improved functional and clinical outcomes in first episodes of psychosis. This care encompassed medication management, family psychoeducation, individual therapy, employment, and education. The treatment of the “whole” person, and not the treatment of symptoms alone, enhanced the quality of people’s lives. As biological and social interventions take center stage in the treatment of schizophrenia, valuable though they are, there is less and less written about the psychological world of people living with this disorder. Psychotherapy is often overlooked as a treatment intervention, because it does not cure the illness (although medications do not either!). It does, however, offer a relationship in which a person’s daily struggle is recognized and shared (read Saks 2007 for a moving account of this struggle; Adler 1978), where tears are shed for the dreams not realized, and new hopes are constructed for the life yet to be led. In an article describing his own brother’s battle with mental illness, Neugeboren (2006) asks what had made the difference for the many patients he interviewed who had recovered after years of institutionalization. He answered: Some pointed to new medications, some to old; some said they had found God; some attributed their transformation to a particular program, but no matter what else they named, they all—every last one—said that a key element was a relationship with a human being. Most of the time, this human being was a professional—a social worker, a nurse, a doctor. Sometimes it was a clergyman or family member. In every instance, though, it was the presence in their lives of an individual who said, in effect, “I believe in your ability to recover, and I am going to stay with you until you do” that brought them back . . . [T]he more we emphasize medication as key to recovery, the more we overlook what is at least as important: people working with people, on a sustained long-term basis . . . Let’s find resources to give people afflicted with mental illness what

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all of us need: fellow human beings upon whom we depend to help us through our dark times and, once through, to emerge into gloriously imperfect lives. (p. 17)

Families It would be a mistake to talk about schizophrenia and the psychoses without reflecting a moment on the financial, emotional, and physical impact the disease has, not just on the individual but on the family members who attempt to take care of their loved one as well. Although some individuals with schizophrenia become estranged from their families, we are aware of the often painful journey that parents or caregivers may have to take as they try to help a family member regain health and a capacity to function independently. After years of witnessing her son’s psychotic episodes, hospitalizations, and court dates, a mother captured her fear about her son’s future well-being: [T]here was no certainty. So many of the safeguards now in place were temporary: the court order he’d agreed to that required he take his meds; the Worcester discharge plan, with its visiting nurses; and the probation Mike had been sentenced to for punching the security guard, which brought the threat of jail if he veered off track. Together, the measures had coaxed cooperation. But when one or all expired, what would happen then? (Russell 2014)

Parents of adult children with schizophrenia typically experience a range of emotions, including sadness, hopelessness, shame, and grief. After the frequent costly disruptions caused by psychotic episodes and visits with countless mental health providers, weary parents may feel anger, which can then elicit guilt: how can I be angry at someone who is so ill? Family members grapple with a complicated process of bereavement, one they often experience in isolation given the stigma associated with mental illness. As Jones (2004) poignantly describes in his qualitative study of families and mental illness, individuals with schizophrenia are alive and physically present, on one hand, but, on the other hand, they may be significantly “altered.” Families describe the experience of their child being alive yet often unrecognizable to them: the child who once existed is no longer there. A form of chronic, unresolved grief may ensue, without the societal supports typically afforded parents whose child had actually died. As one parent stated, “One thing is I can’t grieve properly . . . [I]f he had died you know what to do” (p. 966). As we consider the treatment of individuals with schizophrenia, we must always keep in mind the importance of providing emotional and psychoeducational support to their families and loved ones. Those who comprise the individual’s support systems need and deserve care themselves, including help from mental health providers, and friends and family in their communities. Availability of Resources No full understanding of the lives of people with schizophrenia can occur without an appreciation of the resources, or lack thereof, available to the chronically mentally ill. As we discuss resources, we must consider all of the supports needed. Access to housing, mental health and legal services, home visiting, hospital beds, and supportive networks are critical variables in determining the quality of life of people with schizophrenia. In the wake of deinstitutionalization, many seriously mentally ill clients were discharged into the community, where community-based services were supposed to provide alternatives to hospitalization. Housing, day treatment, and community mental health services were established in some communities to offer a comprehensive network for these clients. The

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positive outcomes of deinstitutionalization can be seen in the establishment of social clubs, transitional employment programs, and consumer groups such as the National Alliance for the Mentally Ill. However, despite the generous and compassionate vision behind deinstitutionalization in the 1970s, adequate funds were not made available to realize many of its original goals. The long-term results of this failure are apparent in all parts of society: our city streets and shelters are crowded with homeless, chronically mentally ill individuals; our jails and prisons are overflowing with people who are psychotic; our community mental health centers are inundated with more persistently mentally ill clients than their beleaguered staffs can handle; and the waiting lists for residential programs for the chronically mentally ill are months, if not years, long. In addition, funding for community mental health centers and state hospitals continues to dwindle at alarming rates to balance local budgets. While state hospitals close, private for-profit hospitals compete to serve this population in order to keep their beds full. The sickest people in our society “fall through the cracks” as they are discharged from institutions to poor and inadequate aftercare. What solutions are there to the lack of resources available to those with major mental illness in the United States? No simple answers exist. On one level, a commitment to the most vulnerable members of our society is needed to provide funding for inpatient, outpatient, and outreach community psychiatric services, and for housing alternatives. On another level, a shift in our priorities must occur so that we all see the care of society’s neediest as our joint responsibility. We also need to reconsider our expectations of “recovery” by providing more ways for people to succeed within the strengths and the limitations brought on by their psychiatric condition. Let us end this chapter by moving from theories about schizophrenia to the human costs of the disease. The story of the life and struggles of a young man with schizophrenia, quoted earlier in the chapter, follows. It is a somewhat typical story in that it chronicles the gradual deterioration of functioning that we see so often in people who are not among those fortunate enough to recover more fully from this illness. It is also a unique story, as is every person with schizophrenia, in that it reflects this particular man’s expression of the emotional turmoil in his life. Karl is a twenty-four-year-old white cisgender man who, as a high-school student, was referred to a community counseling center by a guidance counselor. At that time, school personnel had grown increasingly concerned about his declining grades and obsessive preoccupation with his love for a fourteen-year-old girl. Karl was found stalking this young girl, whom he barely knew, writing her long love letters, and buying her expensive gifts. When Karl was five months old, his father died of cancer. His mother, who remained depressed for many months, struggled to support herself and her son for several years. She remarried a couple of years later and bore three more children. Karl identified strongly with his biological father’s heritage, keeping his last name and maintaining ties to his father’s family. A cousin, aunt, and grandfather on this side of the family had all been diagnosed with schizophrenia. In latency, Karl began spending an increasing amount of time in his room playing with dolls, watching TV, and building houses with cards. The family began to hear Karl’s voice from behind the closed door, as he talked to himself about the plot of soap operas and the best strategies for winning college basketball games. By the beginning of his senior year in high school, this academically average student was failing all his courses and isolating himself from his peers. As the therapist became acquainted with Karl over the first few months of his psychotherapy, she was struck by his persistent inability to greet her, to make eye contact during the hour, or to display any affect regardless of the content of his speech. Showing little insight, he described the auditory hallucinations he had been having since his “rejection” by the fourteen-year-old “girl of his dreams.” The hallucinations were most frequently made up of voices of children at play, laughing with one another, and were usually most pronounced at night. Karl slept with the radio

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or television turned on all night to drown out these sounds. More significant than these hallucinations, perhaps, was Karl’s pervasive distortion of reality. He believed that he became Jason from the Friday the 13th movies, a teenager taunted and eventually drowned by his peers at a summer camp, who then returned from the dead to seek violent revenge on them. When angry or upset, Karl donned a goalie mask (as Jason had), grabbed an ax from a storage closet, and acted out his own violent homicidal fantasies in his room. On occasion, he walked the streets in costume, and approached passersby to ask them where he could buy a chain saw. Karl developed numerous delusions about random girls to whom he would become attached. If he briefly met a girl on a checkout line in a store, he would believe that she was madly in love with him. For months, he would think about sending her love notes, engagement rings, and money as his fantasy grew, although he would initiate no face-to-face contact. He furthermore believed that his “connections” to the FBI and Mafia would assist him in learning of, and doing away with, his potential rivals. During the many hours spent locked in his room, Karl created something he called “my world.” With dolls and cards, he spent his time reenacting scenes from soap operas and his fantasies, adding, changing, and deleting events as he pleased. He assumed a range of parts in each plot, which usually entailed a woman, her suitors, and a jilted lover.

Before we turn to Karl’s treatment, let us consider his emotional difficulties in the context of what we have studied in this chapter. Given the family history of schizophrenia, it appears that Karl was born with genetic and possibly constitutional/neurobiological risk factors for developing the illness. He suffered the significant loss of his father at an early age, and his mother was under great emotional and financial stress for many years. The onset of his difficulties was gradual, although the emergence of his most serious symptoms occurred following the rejection of his fantasized “girlfriend” in adolescence. Dynamically, both his aggressive and his libidinal drives were poorly differentiated, as his objects of love were quickly transformed into sources of rage. Given his sense of helplessness (in relation to his own mind and to the world), he was frequently flooded with murderous aggression directed alternately toward himself and others. During the first year of his treatment, he was chronically suicidal; he brought the therapist new wills that he had written (in a black-and-white composition notebook) on a biweekly basis, in which he delineated to whom his records, tapes, and TV should be left. He had homicidal fantasies toward his stepfather and toward boys perceived as rivals. Karl’s object relations were impoverished, as actual contact with others felt threatening and overwhelming. His delusions and “his world” served to defend Karl against the despair and loneliness he felt. People were experienced as extensions of himself, and not as complex, separate individuals. They were most safely present in his fantasy life, over which he had greater control. Karl relied on primitive defenses (denial, projection, splitting, and externalization), and interpreted events in his life in a concrete, distorted fashion. Working with Karl was a variously frightening, rewarding, boring, and interesting experience. He was given antipsychotic medication at the beginning of the treatment, which helped to diminish his auditory hallucinations. For the first several years of therapy, he and his therapist constantly assessed how much of a risk he was to himself and to others, and elicited his family’s help with this task. They were referred to a support group for families of clients with major mental illness. As Karl came in week after week with the same details of imagined and real injustices committed against him, he and his therapist began to explore the disappointments, losses, and limitations in his life. He required two brief hospitalizations, the first following a suicide attempt and the second when he became more psychotic (when he believed he was Jason of Friday the 13th) and planned to harm another person. As he gradually felt safer in the treatment relationship and more aware of his sadness, he

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stopped writing wills and threatening to hurt other people. He repeatedly shared the intricacies of his daily rituals, allowing the therapist to see the depth of his despair and loneliness. For the first several years in their work together, the therapist felt as if she were a nonentity, interchangeable with any individual and having no defining characteristics of her own in his eyes—an extension of his needs in the moment. When disruptions occurred in the treatment due to holidays and vacations, Karl responded with anger and confusion at being left alone in his “dangerous world,” and struggled with an upsurge in psychotic symptoms. Over the years, Karl began to use the therapist as an auxiliary ego, someone who could help him differentiate between fantasy and reality, between his feelings and his actions, and between the impulses arising within him from those expressed by others. He relied on the therapist to help him control his impulses, modulate and differentiate his affect, and at times simply explain confusing aspects of life. He and his therapist shared the pain of his losses and of the limitations brought on by his illness and the small joys and successes in his life. A student once asked the therapist if she thought therapy “cured” Karl. If we define “cure” as meaning that Karl no longer suffers from schizophrenia, the answer would have to be no. Karl continued to have delusions about various girls in his life, and to have limited social and vocational engagements. But, as we have noted, the concept of recovery needs to be defined more broadly than “cure.” We need to measure Karl’s gains in the context of his own life and his capabilities. We need to assess whether therapy assisted him in returning to his optimal level of functioning. In this framework, significant changes occurred in Karl’s treatment and life. When angered by a perceived rejection, he no longer became Jason, with hockey mask and ax; he stated instead, “I’m getting those Jason feelings,” and then discussed what he was feeling and assumed others were feeling about him. Although wedded to the rituals with his dolls and cards, he was able to be in the presence of others without behaving or talking in an obviously bizarre fashion. As he noted in one session, “I can keep my crazy stuff in my room and in this office, so not everyone has to know about my emotional problems.” This enabled him to periodically sustain part-time work and to attend social gatherings with his family. As he grew more accepting of himself, he was also able to experience the therapist as a separate person with her own personality traits. Karl greeted her and made eye contact when he entered her office, said “Bless you” when she sneezed, and even asked about her vacation following her absence. Will society (and insurance companies) deem the work Karl and this therapist completed significant enough to warrant the time and money devoted to his case? We do not know. We are certain, however, that medication alone would not have decreased his sense of alienation, or helped him grapple with the challenges in his life, or improved his sense of himself in the ways a consistent, caring treatment relationship did. Karl will have to carry the burden of his illness through the rest of his life. At least he was able to share the weight of that burden for a period of time in a relationship that could also bear his pain.

REFERENCES Adler, G. (1978). The psychotherapy of schizophrenia: Semrad’s contributions to current psychoanalytic concepts. Schizophrenia Bulletin 5(1):11–137. Ahern, L., & Fisher, D. (2001). Recovery at your own pace. Journal of Psychosocial Nursing and Mental Health Services 39(4):22–33.

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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition. https://doi.org/10.1176/appi.books.9780890425596. Andreasen, N. C. (1999). Understanding the causes of schizophrenia. New England Journal of Medicine 340:645–47. Angermeyer, M., Kuhn, L., & Goldstein, J. (1990). Gender and the course of schizophrenia: Differences in treatment outcomes. Schizophrenia Bulletin 16:293–307. Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal 16(4):11–23. Arieti, S. (1974). Interpretations of Schizophrenia, 2nd edition. New York: Basic Books. Barbato, A. (1998). Schizophrenia and Public Health. Geneva: World Health Organization, Division of Mental Health and Preventions of Substance Abuse. Bergink, V., Rasgon, N., & Wisner, K. (2016). Postpartum depression: Madness, mania, and melancholia in motherhood. American Journal of Psychiatry 173(12):1179–88. Bion, W. (1965). Transformations. New York: Basic Books. Bleuler, E. (1950). Dementia Praecox or the Group of Schizophrenias. New York: International Universities Press (originally published 1911). Boevink, W. (2006). From being a disorder to dealing with life: An experiential exploration of the association between trauma and psychosis. Schizophrenia Bulletin 32(1):17–19. Canuso, C. M., & Pandina, G. (2007). Gender and schizophrenia. Psychopharmacology Bulletin 40(4), 178–90. Creese, I., Burt, D.,  & Snyder, S. (1976). Dopamine receptors and average clinical doses. Science 194:545–46. DeLisi, L., Dauphinius, I., & Hauser, P. (1989). Gender differences in the brain: Are they relevant to the pathogenesis of schizophrenia? Comprehensive Psychiatry 30:197–208. Eaton, W. (1985). Epidemiology of schizophrenia. Epidemiologic Reviews 7:105–26. Freedman, R. (2010). The Madness within Us: Schizophrenia as a Neural Process. Oxford: Oxford University Press. Freud, S. (1894). The neuro-psychoses of defence. Standard Edition 3:45–61. ———. (1911). Psycho-analytic notes on a case of paranoia (dementia paranoides). Standard Edition 12:3–88. ———. (1914). On narcissism: An introduction. Standard Edition 14:67–102. ———. (1924a). Neurosis and psychosis. Standard Edition 19:149–53. ———. (1924b). The loss of reality in neurosis and psychosis. Standard Edition 19:181–87. Gilmore, J. H. (2010). Understanding what causes schizophrenia: A developmental perspective. American Journal of Psychiatry 167(1):8–10. Gottesman, I. I. (1991). Schizophrenia Genesis: The Origins of Madness. New York: W. H. Freeman. Hopper, K., Harrison, G., Janca, A., & Sartorius, N., eds. (2007). Recovery from Schizophrenia: An International Perspective. A Report from the WHO Collaborative Project. The International Study of Schizophrenia. Oxford: Oxford University Press. Jablensky, A. (2000). Epidemiology of schizophrenia: The global burden of disease and disability. European Archives of Psychiatry and Clinical Neuroscience 250:274–85. Javitt, D. C., & Coyle, J. T. (2004). Decoding schizophrenia. Scientific American 290(1):48–55. https:// doi.org/10.1038/scientificamerican0104-48. Jones, D. (2004). Families and serious mental illness: Working with loss and ambivalence. British Journal of Social Work 34(7):961–79. Kane, J. M., Robinson, D. G., Schooler, N. R., Mueser, K. T., Penn, D. L., Rosenheck, R. A., Addington, J., Brunette, M. F., Correll, C. U., Estoff, S. E., Marcy, P., Robinson, J., Meyer-Kalos P. S., Gottlieb, J. D., Glynn, S. M., Lynde, D. W., Pipes, R., Kurian, B. T., Miller, A. L., . . . Heinssen, R. K. (2016). Comprehensive versus usual community care for first-episode psychosis: Two-year outcomes from the NIMH RAISE Early Treatment Program. American Journal of Psychiatry 173(4):362–72. Kraepelin, E. (1919). Dementia Praecox and Paraphrenia, trans. R. M. Barclay. New York: R. E. Krieger (original work published 1896).

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Kulhara, P., & Chakrabarti, S. (2001). Culture and schizophrenia and other psychotic disorders. Psychiatric Clinics of North America 24(3):449–64. Leclerc, C., Lesage, A., Ricard, N.,  & Lecomte, T. (2000). Assessment of a new rehabilitative coping skills module for persons with schizophrenia. American Journal of Orthopsychiatry 70(3):380–88. Lieberman, J. A., Stroup, S., McEvoy, J. P., Swartz, M. S., Rosenheck, R. A., Perkins, D. O., Keefe, R. S., Davis, S. M., Davis, C. E., Lebowitz, B. D., Severe, J.,  & Hsiao, J. K. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine 353(12):1209–23. Luhrmann, T. M., & Marrow, J., eds. (2016). Our Most Troubling Madness: Case Studies in Schizophrenia across Cultures. Berkeley: University of California Press. McClashan T. H., & Bardenstein, K. (1990). Gender differences in affective, schizoaffective, and schizophrenic disorders. Schizophrenia Bulletin 16:319–30. McGrath, J. J. (2007). The surprisingly rich contours of schizophrenia epidemiology. Archives of General Psychiatry 64(1):14–16. Menezes, P. R. (2010). Incidence and outcome of schizophrenia across the globe. In Advances in Schizophrenia Research 2009, eds. W. F. Gattaz and G. Busatto. New York: Springer Science + Business Media. https://doi.org/10.1007/978-1-4419-0913-8_1. National Institute of Mental Health (NIMH). (2010). Mental illness. https://www.nimh.nih.gov/ health/statistics/mental-illness.shtml. Neugeboren, J. (2006, February 5). Meds alone couldn’t bring Robert back. Newsweek. Pao, P. (1977). On the formation of schizophrenic symptoms. International Journal of Psycho-Analysis 58:389–401. Perälä, J. A., Suvisaari, J., Saarni, S. I., Kuoppasalmi, K., Isometsä, E., Pirkola, S., Partonen, T., TuulioHenriksson, A., Hintikka, J., Kieseppä, T., Härkänen, T., Koskinen, S., & Lönnqvist, J. (2007). Lifetime prevalence of psychotic and bipolar I  disorders in a general population. Archives of General Psychiatry 64(1):19–28. Piccinelli, M., & Gomez Homen, F. (1997). Gender Differences in the Epidemiology of Affective Disorders and Schizophrenia. Geneva: World Health Organization, Division of Mental Health and Prevention of Substance Abuse. Potvin, S., Stip, E., Sepehry, A. A., Gendron, A., Bah, R., & Kouassi, E. (2008). Inflammatory cytokine alterations in schizophrenia: A systematic quantitative review. Biological Psychiatry 63(8):801–8. Robbins, M. (1993). Experiences of Schizophrenia: An Integration of the Personal, Scientific, and Therapeutic. New York: Guilford Press. Russell, J. (2014, August 26). The longest road. Boston Globe. Saks, E. R. (2007). The Center Cannot Hold: My Journey through Madness. New York: Hyperion. Searles, H. (1965). Collected Papers on Schizophrenia and Related Subjects. London: Hogarth. Semrad, E. V. (1960). Teaching Psychotherapy of Psychotic Patients. New York: Grune & Stratton. Stetka, B. S., & Correll, C. U. (2014, January 16). 7 Advances in schizophrenia. Medscape. http://www. medscape.com/viewarticle/819068. Strakowski, S. M., Shelton, R. C., & Kolbrener, M. L. (1993). The effects of race and comorbidity on clinical diagnosis in patients with psychosis. Journal of Clinical Psychiatry 54(3):96–102. Stromwall, L., & Hurdle, D. (2003). Psychiatric rehabilitation: An empowerment-based approach to mental health services. Health and Social Work 28(3):206–13. Sundquist, A. (1999). Family psychoeducation can change lives. Schizophrenia Bulletin 25(3):619–22. Tandon, R., & Rankapalli, B. (2010). Comparative efficacy and safety of first and second-generation antipsychotics in the treatment of schizophrenia: Facts and fiction. In Advances in Schizophrenia Research 2009, eds. W. F. Gattaz and G. Busatto, pp. 389–401. New York: Springer. Torrey, E.F. (1988). Surviving Schizophrenia: A Family Manual, revised edition. New York: Harper & Row. ———. (2013). Surviving Schizophrenia: A Family Manual, 6th edition. New York: HarperCollins. Torrey, E. F., & Sinclair, E. (2018). Hocus-pocus: How the NIMH made 2 million people with schizophrenia disappear. Psychiatric Times 35(3):1, 10. Trierweiler, S., Neighbors, H., Munday, C., Thompson, E., Binion, V., & Gomez, J. (2000). Clinician attributions associated with the diagnosis of schizophrenia in African American and non-African American patients. Journal of Consulting and Clinical Psychology 68(1):171–75.

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14 Personality Disorders, with a Special Emphasis on Borderline and Narcissistic Syndromes Patricia Hertz and Meg Hertz

Everyone has moments—even days—of being somewhat self-absorbed, overly dependent, slightly paranoid, completely withdrawn, full of obsessions, antisocial, or flooded with intense emotions. These experiences are simply part of the human condition. But there are those among us who struggle with those ways of being for most of each day, every day of their lives. Their day-to-day lives are impacted by these struggles, which can weigh heavily on their relationships as well as on their overall emotional well-being. These individuals may be living with a personality disorder. Just as we discussed that schizophrenia cannot be diagnosed from occasional psychotic episodes, so, too, a personality disorder is not a transient occurrence. In fact, it is the very pervasiveness of the dysfunction, both personally and professionally, that is a hallmark of these disorders and contributes to some of the hardships experienced by those afflicted, as well as by those closest to them. In the clinical setting, individuals with these disorders can be among the most challenging to work with and also the most rewarding to treat. The study of the personality disorders is rich and complicated, and full of controversies. Many of the diagnostic labels we use—narcissistic, borderline, antisocial—have become integrated into our popular culture and everyday language, whether we are referring to a character on television, a celebrity, or a politician. Yet what do these terms actually mean, and how can we define them in ways that ultimately promote our ability to understand and help our clients? In this chapter, we hope to address these questions and to bring a biopsychosocial perspective to our discussion of these conditions. As we examine the classification of these disorders, we will discuss the concept of “personality,” the epidemiology and characteristics of several of the disorders, and the value of a psychodynamic lens in understanding their development. We will also touch upon some of the controversies that have emerged in relation to the diagnosis and treatment of personality disorders. Before turning to these specifics, however, let us begin by considering a brief anecdote that illustrates some of the key elements of personality disorders. Catie, a cisgender 27-year white female, called the therapist for a first appointment upon getting her name from an acquaintance. With a sense of urgency in her voice, Catie told the therapist that she 274

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had fired all of her previous providers, that her friends always let her down, that she felt desperately alone in the world and was cutting her inner thighs so that she could feel something. Although the therapist was merely a name on a piece of paper she had received from a friend, Catie shared personal details about her life with an intimacy and insistence that evoked an uneasy feeling in the therapist. As the therapist came to learn more about Catie over time, a picture emerged of a talented woman who could be the “life of the party,” who had been highly sensitive to emotions her whole life, who had suffered a sexual assault at college, who felt chronically invalidated by selfabsorbed parents and who struggled with powerful emotions which flooded both her and her relationships with others. For Catie, childhood adversity, temperamental vulnerabilities, and trauma left her dysregulated emotionally and full of self-loathing. Her relationships had come to be equated with yearning, disappointment, and betrayal; alternating threads of enmeshment and abandonment were woven through her connections to others, leaving her with the conviction that she would always be left hurt and alone.

What might Catie’s story illustrate about personality styles and disorders? People are generally consistent in how they deal with the world and with other people, and in how they react to life’s stressors and demands. Behaviors, attitudes, interests, and aptitudes reflect particular styles and character traits, and form each individual’s unique personality. When these characteristic patterns are shaped by problematic constitutional, neurobiological, psychological, and/or social forces, they can become maladaptive and ultimately disruptive to a person’s overall level of functioning. The result can be the development of a personality disorder. In our study of personality disorders, we have chosen to focus on two of the syndromes delineated in the American Psychiatric Association’s DSM-5 (2013): borderline and narcissistic personality disorders. We have chosen these two for several reasons. Although there is overlap in the symptomatology of many of the personality disorders, understanding the etiology and development of these two disorders helps us appreciate key processes in all of the personality disorders. In addition to the diagnostic value in exploring these two syndromes, the treatment of people with these disorders is frequently the focus of theoretical and clinical attention due to both the challenges and the rewards in working with this population. Therapists can be drawn into reenactments of the central conflicts and struggles in the patients’ lives, surprised by the intensity of the feelings directed toward them as well as the feelings evoked in them. The therapeutic work can thus be taxing but hopeful, as new, more constructive relational experiences unfold within the treatment relationship.

DEFINING PERSONALITY AND PERSONALITY DISORDER: DSM CLASSIFICATION The concept of personality disorder originated in the psychoanalytic study of character, a term used in earlier writings and subsequently replaced by most authors with the word personality. Before focusing on the description of a disordered personality or character, let us first define what we mean by the word personality. The American Heritage Dictionary (2000) defines personality as “the combination of the characteristics or qualities that form an individual’s distinctive character.” Early psychoanalytic theorists captured the more dynamic aspects of character/personality formation in their definition of the term. Fenichel (1945) described character as “the habitual mode of bringing into harmony the tasks presented by internal demands and by the external world” (p. 467). Reich (1945) defined it as “an armoring of the ego” against the dangers of the outside world and repressed instinctual demands, and emphasized that it represents “the sum total of all that the ego shapes in the way of typical modes of reaction” (p. 171). Personality, then, reflects a pattern of adaptation, unique

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to each individual; once formed, it is relatively constant and enduring. Although controversy remains about what most shapes personality formation, we believe that constitutional and neurobiological factors, developmental and psychological processes, and environmental challenges and opportunities all contribute to personality formation—in both its normative and pathological forms. Infants are clearly not blank slates at birth; they have the seeds of a personality and temperament that blossom differentially based on the influences of the external environment (family, culture, economic opportunities, forces of oppression) as well as the organization of their internal worlds. The forces of nature and nurture shape development; when problems exist in either or both of these realms, personality structure will be affected. Our personalities are made up of numerous traits, some of which can be useful and adaptive in one context, but dysfunctional in another. Being obsessional, for example, may be an enormous help during tax season but a hindrance during a crisis that requires a spontaneous decision. At what point do traits become so problematic that a personality might be considered disordered? According to DSM-5, a personality disorder exists when personality traits are so inflexible and maladaptive that they cause either significant impairment in social or occupational functioning or significant subjective distress. We are not referring here to a sudden or temporary change in a person’s behavior but to features typical of a person’s long-term functioning in nearly all aspects of life. As noted in DSM-5 (2013): A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. (p. 645)

According to the criteria set forth in DSM-5, the abovementioned pattern must be manifested in two or more of the following areas: cognition, affectivity, interpersonal functioning, and impulse control. The distress or impairment can be experienced by individuals in social, occupational, or other important areas of functioning (p. 646). It is interesting to note that there were a number of changes, some proposed and some implemented, in the section on personality disorders in the DSM-5. In the DSM-IV-TR (2000), personality disorders were assigned their own axis (Axis II). DSM-5 eliminated the multi-axial system, and combined Axis 1–3 into a single axis that accounts for mental and other medical diagnoses. (As an aside, in practice, many clinicians continue to refer to “Axis 2” diagnoses when referring to personality disorders.) While the DSM-5 has maintained the ten personality disorders listed in the DSM-IV-TR (2000), they are now grouped into three “clusters” based on their similarities. The clusters are described in DSM as follows: Cluster A includes paranoid, schizoid, and schizotypal disorders, with the unifying trait being that individuals may appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic disorders, with the principal similarity being that these individuals often appear emotional, dramatic, or erratic. Last, Cluster C includes avoidant, dependent, and obsessive-compulsive disorders, with the unifying theme being that individuals feel anxious and fearful (p. 646). While these descriptions are reductionistic, the authors of DSM-5 attempted to create a broad organizational framework within which to classify similar personality styles and dysfunction.

BRINGING A PSYCHODYNAMIC LENS TO THE CLASSIFICATION OF PERSONALITY DISORDERS From a psychodynamic perspective, personality disorders are located along a continuum from higher to lower levels of functioning, “positioned” in between what are considered

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neurotic and psychotic conditions. Whereas people with neurotic disorders tend to recognize their own contributions to their difficulties and to be more fully individuated and boundaried, those with personality disorders tend to attribute causality of their problems to external forces, and to engage in dyadic relationships with weaker boundaries. Whereas people at the neurotic level of development may struggle with more internally driven conflicts and anxiety related to guilt, those with personality disorders more often struggle with conflicts between themselves and others and with anxiety related to abandonment. In the context of this continuum of functioning, people with psychotic disorders typically have areas of functioning that are more compromised than those with personality disorders. As we learned in our chapter on schizophrenia, people with psychoses have impaired reality testing as manifested in hallucinations, delusions, and an inability to distinguish what originates within and outside the self. Individuals with personality disorders, however, demonstrate more intact reality testing; if they do have psychotic episodes, they occur infrequently, are transient, and are generally ego-dystonic. People functioning at the psychotic level may experience anxiety as an annihilation of the self, whereas those with personality disorders have a greater degree of identity integration. Their personalities are relatively stable over time—even if their symptoms are not. This is, in fact, why the diagnosis of personality disorder is not generally made until late adolescence or early adulthood. Although traits may be evident in childhood, it is the relative stability of these traits over time that is one of the hallmarks of personality disorders. Whereas the DSM-5 provides a snapshot of various symptoms and behaviors, a psychodynamic perspective offers a developmental and descriptive understanding of personality disorders. This perspective allows for the exploration of a range of factors—including superego development, ego functions, quality of object relations, and defensive structure—that helps us determine how particular styles of being and relating are developed and maintained. The psychodynamic perspective invites us to understand how two distinct and interacting dimensions—the development of personality organization and a defensive style within that level— shape the ways we experience our inner and outer worlds (McWilliams 2011). It also helps us appreciate that common vulnerabilities, such as distorted perceptions of self and others and deficits in self-regulatory capacities, may underlie a range of different personality disorders. The actual symptoms of the particular disorders will vary, however, based on which of these vulnerabilities is more pervasive and which defenses are mobilized to manage them. Some individuals, for example, may cope with their sense of helplessness and fear of being alone by becoming excessively dependent on other people; others may cope by attaching to others with great and unrelenting intensity, including passion and rage. These individuals’ respective personality styles may hence look very different in spite of the similar core vulnerabilities with which they are grappling. Their psychological and constitutional makeup, along with social and environmental factors, will determine whether a personality disorder will actually develop and, if so, what form it might take. The challenge for us, as practitioners, is to “hold” all of these factors as we try to understand and ultimately help our clients navigate the challenges in their lives.

PERSONALITY DISORDERS AS A DIAGNOSTIC ENTITY: GENERALIZATIONS, CONTROVERSIES, AND LIMITATIONS What generalizations might we offer about the personality disorders as a diagnostic entity? Broadly speaking, the following characteristics are associated with these disorders: 1. Individuals usually feel that their problems lie not within themselves but in others or in the environment. They are often untroubled by their behavior and, in fact,

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can perceive themselves quite differently than others do. The manifestations of their difficulties, however, are often distressing to those in their environment. We say the problems of these individuals are ego syntonic, as they are “acceptable” to the self and do not create internal conflict within their psychological lives. 2. The ego functions (including reality testing, capacity to tolerate anxiety and delay frustration, judgment, and impulse control) of people with personality disorders are impaired to varying degrees. Responses to intense emotions and stress are often inflexible and maladaptive, and self-regulatory capacities are compromised. 3. Perceptions of the self, and the self-in-relation to others, may be distorted. As we will discuss further, the capacity to hold an integrated, differentiated, and boundaried sense of self is often compromised, as is the ability to shape and sustain personal goals. 4. The ability to maintain loving, consistent, and mutually satisfying relationships with others is impaired to varying degrees. Intimacy and empathy can be undermined by the lack of nuanced and integrated internal experiences of others. 5. Because these individuals’ issues are frequently enacted in the interpersonal realm, the countertransference reactions of the therapist in the treatment relationship are significant tools in diagnosing, assessing, and treating these clients. As we reflect on these broad generalizations about the personality disorders, let us remember that we all have some of the traits delineated in these diagnoses. It is the prominence, rigidity, and clustering of these traits that lead to the diagnosis of personality disorder. Regardless of the different perspectives used in the classification of personality disorders, many problems and much controversy surround the use of these diagnoses. Research suggests that personality disorders are not distinct entities or homogeneous conditions but are instead overlapping constellations of maladaptive traits that “shade” into one another (Widiger 2018). Furthermore, whereas personality disorders are conceptualized as lifetime diagnoses, some patients can slip below the threshold of required criteria in as little as six months to a year. What then becomes of this diagnostic classification? Can we acknowledge that a person’s personality may undergo significant changes as a function of treatment, circumstance, and/or aging that may make the diagnosis less valid? Perhaps what makes the classification of these disorders most troubling is that they are inevitably defined by prevailing social, cultural, and political norms in spite of being perceived as objective diagnostic entities. Views on what constitutes health and illness are rooted in implicit assumptions about “normal” roles for men and women, about “correct” displays of emotion, and about “reasonable” needs for dependency on others. Who defines these “objective” standards for “adaptive” levels of functioning? How is it fair to label behavior outside of its complex environmental and cultural context, or, for example, apart from responses to chronic oppression and abuse? Let us consider an illustration written almost forty years ago by Kaplan (1983) as she captured the gender bias codified in DSM-III in her critique of the criteria for “dependent personality disorder.” Kaplan created a fictitious personality disorder, “independent personality disorder,” to satirize DSM-III’s assumption that women’s dependency needs, and the way they express them, are unhealthy. Her “independent personality disorder” included criteria including: puts career above relationships with loved ones (e.g., travels a lot on business, works late at night); is reluctant to take into account the other’s needs when making decisions, especially concerning leisure time and work; passively allows others to assume responsibility for major areas of social life because of inability to express necessary emotion (e.g., lets spouse assume most childcare responsibilities) (p. 790).

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Sound familiar? In another culture and time, might these “normative” traits associated with “successful” men be labeled as disordered? Might aspects of dependency—a reliance on advice, reassurance, closeness—be associated with health? As exemplified in this satirical illustration, pathology is determined, in part, by the assumptions and biases of those who define it. The traits of the “independent personality disorder” reflect the way many men have been socialized to function in certain cultures and have been rewarded for so doing. The characteristics of white, heterosexual men, many have argued, have been used as the criteria in prior editions of the DSM to ascertain “healthy” psychological functioning. Other authors have challenged the diagnostic entity of personality disorders because the category does not adequately attend to the profound effects of trauma and oppression on psychological functioning. The social context—especially in regard to gender, race, class, sexual orientation, and immigration status—is often overlooked as people are frequently pathologized for their response to oppression (Shaw  & Proctor 2005). As Brown (1992) suggested many years ago, there is a wide range of behaviors that can result from being powerless, oppressed, and discriminated against in a repetitive, ongoing manner that do not reflect a disordered personality. They may be adaptive behaviors that have become entrenched over time due to, for example, repeated exposure to traumatic experiences. “Certain forms of behavior which in isolation may appear dysfunctional or pathological are actually appropriate and precise responses to other aspects of the interpersonal environment” (p. 217). Although there is currently a greater appreciation of the effects of post-traumatic stress disorder than when Brown shared this perspective, we still lack a comprehensive diagnostic framework that describes how repetitive victimization and/or exposure to sexism, racism, and poverty affect psychological functioning and our understanding of personality development. Another concern regarding the diagnosis of personality disorders is how stigmatizing its label continues to be. There is often an implicit judgment and warning associated with this diagnosis—that is, this client will be “trouble.” Clients’ complexities and strengths are disregarded and replaced instead with pejorative assumptions about their emotions and “problematic” styles of relating to others. In fact, they are often referred to as “being” a particular personality disorder, as in “she is a borderline,” not she is someone who has borderline personality disorder. When used as a way to understand, engage, and empathize with an individual’s struggles, this diagnosis can be enormously helpful. However, when used as it so often is in our field as a reductionistic and demeaning label, the effects of this diagnosis can be dehumanizing and distancing, creating barriers to both care and meaningful engagement with those who are suffering. One last cautionary note about cultural context: The DSM definition of personality disorders is based on Western models of an individualistic self and assumes the perspective of an individual within Western culture (Mulder 2018). Although the DSM specifically notes that a personality disorder diagnosis can be given only when behavior deviates markedly from the expectations of an individual’s culture, in practice this consideration is often overlooked. Given each culture’s unique norms in regard to socially acceptable expressions of conflict and pain, symptoms diagnosed out of context may erroneously appear to reflect a disordered personality. For example, Mendez-Villarrubia and LaBruzza (1994) note that women in some Hispanic cultures may develop episodes during which they shout, cry, tremble, lose consciousness, and become nervous and angry. These symptoms may reflect an ataque de nervios (“attack of nerves”), a culturally acceptable way to respond to stress. Through this culturally condoned expression of pain, people mobilize the support of the family and community, and are temporarily relieved of their social roles. Without an understanding of

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cultural norms, these same symptoms may result in an incorrect diagnosis of a personality disorder (such as histrionic disorder) and lead to inappropriate treatment interventions.

NEUROBIOLOGICAL AND GENETIC CONSIDERATIONS IN THE DEVELOPMENT OF PERSONALITY DISORDERS Although an estimated 15 percent of the general population has a personality disorder, there is little agreement about the causes of specific disorders (Bender 2004). Genetics, neurobiological factors, psychological mechanisms, and sociocultural processes have all been deemed relevant to our understanding of these disorders (Livesley  & Larstone 2018; Millon 2000; Thomsen et  al. 2018). Different types of childhood adversity (including poverty, familial conflict, physical and sexual abuse, bullying, and violence in schools) have been associated with specific personality disorders (Hengartner et al. 2013). Most of this chapter will explore how environmental and psychological forces shape the developmental processes from which problematic personality traits can emerge. First, however, we want to turn our attention to the research on the genetic and neurobiological systems associated with these disorders. Studies of genetic factors (Livesley et al. 1993, 2003) have shown a higher concordance for personality disorders among monozygotic (identical) twins than among dizygotic (fraternal) twins, suggesting that certain personality traits may be inheritable. Other studies (Widiger et al. 2009) have suggested that certain temperamental traits identified in children under three years of age may predict the development of a personality disorder later in life. Among the DSM-5 Cluster B disorders (antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder), it is generally understood that a combination of vulnerable genetics along with early environmental factors, in particular childhood trauma, are implicated in the development of particular character traits and behaviors. With the advancement of brain imaging techniques, a number of researchers (Boschert 2007; Cattane et al. 2017; Crowell et al. 2009; Soloff 2018) have demonstrated that there are biological systems involved in the development of borderline personality disorder. Cattane et al., for example, report that “neuroimaging studies in BPD patients have shown volume reductions in the hippocampus and amygdala, both brain regions mainly involved in stress responses, cognition, memory and emotional regulation” (p. 11). Other researchers have found changes in the limbic system (a set of structures in the brain that controls emotion, memories, and arousal) in people diagnosed with personality disorders. While exploring the etiology of antisocial personality disorder, for example, Blair et al. (2014) looked at the early development of certain psychopathic traits, such as deficiencies in empathy and decision-making, as well as a heightened sensitivity to threats. In one study, they examined MRI images of children to see if there were differences in the brain scans of “healthy” children as compared to children who had been diagnosed with conduct disorder with “callous-unemotional traits” (p.  4)—a precursor to antisocial personality disorder. They found that the scans of the children in the “conduct disorder group” consistently showed lower amygdala activation in response to fearful faces, a finding, like Cattane’s, that suggests noteworthy markers in the brains of individuals with personality disorders. Why, one may ask, is it important to have a working understanding of the neurobiology of personality disorders? In no way does this research diminish the centrality of the environment, in particular the role of trauma, neglect, abuse, and deprivation, in the development of particular character traits. Nevertheless, the appreciation of the role of neurobiology can help to minimize the stigma of the personality disorder diagnosis. This is captured quite

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sensitively in Barbara Hagerty’s article, “When Your Child Is a Psychopath,” in The Atlantic (2017). Hagerty describes both the journeys and the treatment of families in which a child, as young as three or four, exhibits psychopathic tendencies, including trying to kill siblings, harm animals, and plan the murder of family members and teachers. Hagerty speaks with researchers looking at “callous and unemotional traits” in youth, all of whom reference the latest work done in the area of brain development. Her point is that this research not only allows parents to avoid being “blamed” automatically for a child’s severely dysfunctional behavior but also, as importantly, has contributed to the development of treatment programs that approach these troubling behaviors in nonjudgmental, novel ways. As the etiological factors in the development of personality disorders continue to be explored, we encourage clinicians to sit with the complicated questions concerning etiology and allow for the rich interplay of nature and nurture in understanding psychopathological development. We invite the holding of multiple perspectives simultaneously as our field continues to grapple with how the interactions of neurobiological predispositions, ecological contexts, socioeconomic realities, and psychological influences lead to the development of personality disorders.

BORDERLINE PERSONALITY DISORDER Let us now bring our attention to one of the personality disorders, borderline personality disorder, with an anecdote that illustrates several of its characteristics. The therapist’s phone rang at 12:45 AM. Sandra, a thirty-two-year-old cisgender woman who had been in treatment for three months, was on the other end of the line. Through intermittent sobs, she told the therapist that a man to whom she was attracted had “ghosted” her at a concert earlier that evening and that she was sitting on the bathroom floor with a bottle of aspirin in her hands. “I can’t hold on to anything good anymore,” she said. “If I take all the aspirin, the pain will disappear real fast . . . When I get close to guys, they leave me. Then the little hurt sets off the big hurts, and I feel like total shit. Like what’s happening in me will destroy any relationship. When I look at myself, I see a crippled mess. Like I’m running a race with my feet tied. I don’t have normal hurts. I feel I have all the outside things. Inside I’m crummy.”

Sandra’s pain was overwhelmingly acute in the face of her disappointment. She felt abandoned and enraged, became enormously self-loathing, and impulsively grabbed a bottle of aspirin to stop the hurt. She also felt that she could not hold on to any positive sense of herself in the face of the rejection. On the other end of the phone line, the therapist experienced a range of feelings: helplessness, anxiety, concern, and annoyance at the intrusion. This “crisis,” in which both parties experienced their emotions with great intensity, is not atypical of the dance that unfolds in the treatment relationship between clients with borderline personality disorder and their therapists. Why has the concept of borderline received so much professional and popular scrutiny? The reasons for this attention are varied. Whether in psychotherapy offices, inpatient units, or medical practices, people with borderline personality disorder often absorb more time and energy, and create more angst in their providers, than the general population. Their tendencies to experience others as either “all good” or “all bad” can lead to splitting in their care teams; their often intense pleas/demands for help, yet rejection of what is offered may lead to anger, a sense of worthlessness, and depletion in those who care for them; and their often self-destructive actions can evoke feelings of anxiety and helplessness in their treaters. At the same time, the complex and intense relationships that develop in the therapy between these

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patients and their therapists are often rich, deeply moving, and ultimately transformative as the work unfolds in the moments, in the “space” shared by both parties. Although the prevalence of this disorder is estimated at between 1.6 and 6.0 percent of the general population (Crowell et al. 2009; Grant et al. 2008; Kulacaoglu & Kose 2018), individuals with borderline personality disorder constitute between 9.3 and 11  percent of psychiatric outpatients and 20  percent of inpatients (Kulacaoglu  & Kose 2018). Much discussion and supervision time is devoted to the work with these clients, who frequently need support from mental health systems to provide stabilization for their emotional dysregulation and self-destructive tendencies. Suicidal and self-injurious behaviors are particularly prevalent in this population, with the rate of suicide estimated between 8 percent and 12 percent (Kulacaoglu & Kose 2018) and the rate of self-injurious behavior estimated between 69 to 75 percent (Clarkin et al. 2001). Complicated and intense transference and countertransference reactions are engendered in the treatments of these clients; clinicians may be alternately idealized and then devalued, and seemingly secure attachments may be precipitously disrupted. The gains in treatment can be great, the risks challenging to bear, and the powerful and at times dissociated affects hard to hold, all of which help explain the time and attention devoted to the work with this patient population.

CLINICAL PICTURE Borderline symptomatology can manifest in dramatic and intense ways. Virtually all aspects of functioning can be impacted by this condition, including affective expression, cognitive processes, identity formation, and relationships with others. Linehan (1993), in fact, describes borderline functioning as a form of dysregulation in emotional, interpersonal, behavioral, and cognitive realms. In the following sections, we will explore the prominent features of this disorder within a psychodynamic paradigm. We will look at the traits of borderline personality disorder in the context of a person’s object relations, ego functions, and sense of self. Throughout this discussion, remember that the traits we identify as maladaptive are frequently attempts at a “solution” to overwhelming internal and external stressors. These traits live on—maladaptively, perhaps—as survival strategies so that fundamental needs can be met and wounds healed. Object Relations Individuals with borderline personality disorder usually have relationships characterized by instability and great intensity, as their need for attachment alternates with their need for distance. Fears of excessive dependency are counteracted with flights from involvement with others. People with this disorder search—at times desperately—for unconditional love and acceptance in relationships to fill the emptiness inside of them and to provide ongoing external support for their fluctuating and frequently poor self-esteem. Others in their lives can be idealized one moment then devalued the next, with no sense that the person they hate today is the person they loved yesterday. Relationships often end abruptly, while new attachments are made precipitously. In their hypervigilance, they may look for cues that reveal that the person they care about does not love them after all and is about to desert them. When their fears are confirmed, they may engage in destructive and/or self-destructive behaviors, engaging in self-mutilating acts, seeking revenge, and acting out sexually (Mason & Kreger 1998). This dynamic can be repeated countless times in their relationships, depleting those who care for them and deepening their own pain.

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The attachment theorists (chapter  8), who describe various attachment styles ranging from the secure to the insecure, might consider these relational patterns reflective of the insecure attachment style called ambivalent. Although patterns of attachment do not correlate directly with diagnostic categories, the ambivalent attachment style—described as inconsistent and preoccupied—is predominant among people with borderline personality disorder. Individuals with ambivalent attachments do not develop a consistent strategy for attachment, frequently as a result of inconsistent attunement and attachment patterns in early caregiver–child bonding. In more severe cases of borderline personality disorder, the attachment style may be characterized as disorganized, reflecting a more chaotic and unstable style of relating than the ambivalent one. How might the tenets of object relations theory help us understand the challenging relationships so typical in the lives of people with borderline personality disorder? First, although these individuals have a differentiated sense of self and other, the boundaries between the self and other are quite weak and permeable. Closeness can be experienced as merger—that is, the individual may long for an all-encompassing attachment. This experience of fusion is captured in the following comment a client made about her relationship with her partner “We’re so close I feel like we’re one person . . . Sometimes it feels so good—like we’re two parts of one whole.” With poor boundaries, an optimal distance is difficult to establish. Closeness may be stifling at times; yet separation may feel like an abandonment. In fact, as we will discuss shortly, the fear of abandonment shapes many interactions with others. This fear is greater than a passing moment of anxiety; it is a terror that can lead to frantic measures (e.g., hurting oneself to manage pain or to compel others to reengage). As Mason and Kreger (1998) note, this situation results in the central irony of borderline personality pathology: People who suffer from it desperately want closeness and intimacy, and yet the things they do to get it often drive people away from them (p. 30). How can we make sense of the abandonment fears so central to these problematic dynamics? Many people suffering from this disorder have not achieved object constancy—that is, the ability to internalize a whole object as an emotionally soothing inner presence that sustains them during the other’s absence. Without a solid capacity to evoke the memory of others in their absence, individuals cannot retrieve soothing, comforting images when alone. This leads to a feeling of terror at being alone, a characteristic that Adler and Buie (1979; Buie & Adler 1982) consider the central, organizing feature of this pathology. The terror is not simply a fear of being lonely; ordinarily, when people are lonely, they can picture or feel the presence of loved ones whom they are missing. When people with borderline personality disorder feel alone, they can experience a total void, an emptiness that renders the world a frightening place. This struggle is frequently manifested in therapy, as seen when the patient cannot hold on to the therapist during absences. Listen to the articulation of this struggle in the following example. Margie, a 34 year old white woman, was raised by two alcoholic parents who frequently left her and her siblings home alone while they went bar hopping at all hours of the night. During the first six months of treatment, Margie often called between sessions, stating, “I just need to hear your voice to make sure you’re still there.” Following the therapist’s vacation, she missed several appointments; when coaxed to come back into the office, she reported the following: “I was literally paralyzed when you were gone. I broke out in hives; I felt hollow inside. I couldn’t picture your face, hear your words to reassure me. You might as well have been dead. I thought maybe if I did something desperate you’d come back sooner; then I just decided to stay away from you so I wouldn’t have to worry about your leaving me again.”

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Margie could not evoke a comforting image of her therapist during the break in treatment. She responded to her ensuing despair and anger by alternately becoming self-destructive (e.g., she made superficial lacerations on her arm) and then by rejecting the therapist whom she yearned for yet feared losing. Although self-destructive behaviors are frequently characterized as “manipulative,” Margie’s actions can be understood as her attempt to engage her therapist the only way she knew how at that point in her life. As she became more able to hold on to the image of the therapist during ensuing breaks in the treatment, and as she developed greater trust that the therapist would indeed return as planned, these behaviors abated. Another reason for the relational difficulties of people with borderline personality disorder lies in their difficulty integrating both positive and negative self and object representations (Kernberg 1975). Simply stated, individuals with borderline personality disorder tend to experience themselves and/or others as “all good” or “all bad.” When needs are gratified, the other is experienced as all good; when needs are frustrated or disappointed, the other is experienced as all bad. This splitting of object representations can be seen in the following comments made by a client about her mother: “When I  hate my mother, I  just hate her. I can’t remember her ever being wonderful or nice. When she’s nice, I think she’s the best mom in the world, but I know I’ll hate her again and never want to see her.” Anticipating the therapist’s attempt to help her integrate these split representations, the client added, “And when I only feel hate for her, you’ll remind me that I once thought she was nice.” Note that this client has developed the capacity to recognize—on an intellectual level—the pattern of her splitting. Emotionally, she has not yet achieved the integration of positive and negative object representations. We can see her difficulty tolerating ambivalence in her feelings for others, with no shadings of gray in between these two affective states. How painful must it be for this client to be unable to sustain an inner experience of her mother as simultaneously wonderful and awful, loving and frustrating, gratifying and depriving—the complex realities of human relationships. The therapeutic relationship can provide fertile ground for the emergence of splitting and precipitous endings and reattachments, making the work feel a bit like a roller-coaster ride. While the therapist may be idealized at some point, it can be a “quick trip from the penthouse to the basement!” The next client gave her therapist just such a ride: Leah, a twenty-five-year-old biracial woman who ultimately completed a five-year therapy, “fired” her therapist eight times in the first two years of their work. During a stable period of the treatment, she told her therapist, “You gave me words for my thoughts and feelings. I felt mute before. You just seemed to know me and understand me.” Two weeks later, when she and her therapist disagreed about the meaning of the contents of a letter sent to the Welfare Department, Leah shouted over the phone, “I’m never coming back to see you. You don’t know a thing about me. You’re as incompetent as the rest of them. I can’t believe your college gave you a social work degree,” and then hung up.

For people in the helping professions, this type of “help rejecting” stance can be enormously frustrating and painful—as we noted, like a roller-coaster ride over which one has no control. It is important to understand, however, that these fluctuations are often an inevitable and critical part of the work; they are the clients’ attempts to navigate twin fears of abandonment and engulfment, as well as their overwhelming needs, hurts, and fears. The lack of integration of positive and negative representations occurs not only in relation to others but also, and just as powerfully, in relation to the self. People with borderline personality disorder tend to be easily flooded by shame and to experience themselves as all good or all bad, with few shadings of emotion in between. In one moment, they may

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be angrily self-righteous, believing that they are entitled to special treatment and that all of their problems result from their victimization in a cruel world. In the face of a failure or disappointment, however, they can lose all sense of self-worth, become enormously self-loathing, and invite punishment for their “badness.” Prior experiences of competence and adequacy disappear completely, as they perceive themselves as worthless, damaged human beings. One day, Carmen, a Latina cisgender female, described feeling that she was the most attractive, competent woman in her workplace. Following a rejection from her lover and a slight from a co-worker the following day, she said, “I looked in the mirror and all I saw was this disgusting face; it had bulging eyes and crooked teeth. That, I realized, was me. I wanted to tear me apart limb by limb.” Only one reality existed for Carmen then: the reality of that moment. Any experience of herself as an attractive, competent individual dissipated and could not be retrieved; it was replaced by her experience of herself as inherently defective.

Given the central role of impaired object relations in the pathology of individuals with borderline personality disorder, it may be helpful (and hopeful) to trace a client’s object relations through the evolution of a therapy. Cassie, a thirty-year-old cisgender woman who successfully completed a treatment of several years’ duration, described her relationships with others, particularly her mother, in notably different ways during successive stages of treatment. The development of her object relations shifted from merged self-object representations to a more differentiated sense of herself and others, as can be seen in the following vignettes. In the first year of her therapy, Cassie, a white bisexual female, reflected on her relationship with her mother as follows: “My mother is totally dependent on me. She copies my haircuts, takes my advice. I can’t get angry at her because she’d fall apart. I can’t leave my mother; could you leave a kid who’s trying to learn a new dance step while her shoe laces are tied together?” [Turning abruptly to the therapist, who had recently returned from a vacation] “I  couldn’t picture your face when you were away. It was like you no longer existed—you were so removed from my life.”

At this point in the treatment, Cassie’s object relations were characterized by poor boundaries between herself and others, and by her lack of object constancy. Two and a half years into the therapy, Cassie stated: “It used to be when my mother was upset, I’d spend all night with her. I’m first realizing what the word separation means. I don’t have to feel all of my mother’s feelings. I will always choose to give to my mother, but I can’t give her all of what she wants. It’s scary—this could be the end of my relationship with her—she could flip out. During her hospitalization, I felt like we were the kids in Sophie’s Choice, and I had to decide who’d live. If I separated, she would die. If I didn’t separate, I would die . . . I sometimes dream that one day I’ll wake up and my mother will be an adult.”

At this juncture, Cassie was struggling to develop a separate sense of self. Although she feared that separation would lead to dire consequences, she fought against her fears and depression to establish her own identity. During the last year of treatment, Cassie married, was promoted at work, and planned to move out of state. She reflected on her relationships as follows: “My mother taught me how to love as one [hands clasped] but not as myself. Now I love as much, but from one step back, you know? Like before it was like I looked at a painting and saw colors up close. I’d find a color I’d like, focus on it, and it was beautiful. But I couldn’t see the whole painting. If I’d move my face I’d maybe see one other color—like black. Yes, black—it was scary and awful. Now I can see the complex whole.”

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During her last year of treatment, Cassie had clearly moved toward integrating positive and negative images of herself and of others, and toward a fuller, nuanced affective life. In a letter she wrote to her therapist following her move, she described the pleasure she felt during a visit from a friend whom she had once threatened to “cut off” because the friend had not been good at keeping in touch with her in the past. Cassie tolerated the ambivalent feelings reflected in her love of this friend along with her disappointment, as poignantly described in her words below: I guess I’ve never given my friend the opportunity to show how loyal and loving she can be with me. I am so glad I took the time and went through the pain of adjusting my expectations of our relationship. With you [the therapist] standing by my side, I worked hard at and won a treasure I could never have imagined—a relationship that stayed.

Cassie had achieved object constancy and with it, a sense of hope and trust in how relationships could enrich her life. This outcome, by the way, is not uniquely tied to this form of treatment. Many authors discuss how situational change (i.e., gaining relief from severely stressful situations), psychosocial supports, and genuine acceptance and validations of the client’s experience from others can lead to dramatic improvement in the individual’s functioning (Gunderson 2008; Linehan 1993). In fact, Gunderson (2008) cites two longitudinal studies that suggest that with intervention and highly supportive new environments, “about 50% of BPD patients remit by two years and . . . once remitted, it is unusual for them to relapse” (p. 6). This is extremely hopeful data for all those struggling with this disorder, for their loved ones, and for those of us working with this population. Ego Functions Although there is a range of functioning along the borderline continuum, the ego functions of people with this disorder tend to be impaired to varying degrees. We have already taken an in-depth look at the nature of object relations in individuals with this disorder. Let us now look at a number of other ego functions that are impacted by this condition. Impulse Control and Judgment Individuals with borderline personality disorder are more vulnerable to acting in impulsive ways that often reflect a lack of consideration to the consequences of their actions. With little forethought, they may engage in self-destructive behaviors such as self-mutilation, sexual promiscuity, gambling, and substance abuse. Substance abuse, in fact, has a comorbidity with borderline personality disorder of more than 50  percent (Harned et  al. 2008; Stone 2000). These behaviors are usually ego-syntonic during the act, but ego-dystonic afterward. A client, who frequently engaged in sexually promiscuous behavior, captured this sequence in the following lament: “I was so mad that I said ‘fuck it’—I drank, picked up a guy at the bar, took him back to my place, and had sex. It was fun at the time—I needed it. Now I’m worried I have AIDS.” As described in earlier examples, impulsive behaviors often occur in response to the threat of abandonment. Suicidal and self-destructive gestures may erupt with little forethought, and with little consideration given to potential consequences. Suicidal acts lead to death in approximately 10  percent of patients with borderline personality disorder, with the majority of self-harm behaviors carrying a risk of low lethality (Kulacaoglu & Kose 2018). Self-mutilation is a common form of expression for impulsive behavior and carries different meanings that need to be assessed and understood on a case-by-case basis. At times, for

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example, individuals may cut themselves with the hope that they will die; at other moments, the act may be an attempt to engage others in their lives and compel them to take notice; at still other times, people may cut themselves to “feel,” to literally see that they are filled with warm blood and are alive—and to counteract the emptiness and deadness they feel inside. An example of this type of self-mutilation, along with features common to borderline pathology such as rage, self-loathing, and the use of projection, can be seen in the following illustration: Sonia entered her therapist’s office looking angry and sullen, and wearing a bandage on her arm where she had cut herself following the previous therapy session. She began the hour: “You made me feel like a fucking loser on Monday. I’m pissed. Don’t look at me like I have three heads. Turn away! You think I’m some kinda failure. Well fuck you too. I’m such a loser. I feel unsafe, but I won’t let you put me back in the hospital. [Looking at her arm] I didn’t even feel the pain. Like one minute I was unloading the dishwasher and the next there was blood trickling down my arm. It kinda made me feel like a person again.”

Sonia had been overwhelmed with feelings of self-loathing and rage. Cutting, she later explained, gave her a physical release for her emotional pain. Also, she added, if there was blood, she still existed. When people with borderline personality disorder engage in these kinds of gestures, they are frequently described as being “manipulative.” These acts can indeed be manipulative, but that characterization alone does little to help us understand what underlies the acts, and often leads to patients being judged, demeaned, and dismissed. We have to recognize that the suicidal and destructive behaviors labeled “manipulative” are often attempts to manage intolerable pain. They can be a form of communication, an attempt to let others “see” their distress, or to provoke a response of some kind from others. When the term “manipulative” is used pejoratively, it leads to the devaluing of the client and creates a distance between the therapist and client that may contribute to an escalation in the acting-out behavior. As therapists, we of course have a range of responses to this self-destructive behavior, including feelings of worry, anger, shame, helplessness, frustration, and compassion. Our job as clinicians is to learn to recognize and understand what is being evoked in us countertransferentially, and to use these feelings as tools in the treatment process. Cognitive Functioning Some studies have found deficits in discreet cognitive functions in people with borderline disorder, as demonstrated in poorer test scores for attention, cognitive flexibility, planning, and memory (Soloff 2018; Thomsen et al. 2018). Cognitive processes may be particularly impaired in the context of negative emotional stimuli, leading at times to distortions in how information is processed. When overwhelmed with intensely negative emotions, for example, people may misperceive what is being said, and become intensely reactive and unable to use logic or reasoning to accurately assess the situation at hand. Defenses Although everyone uses a range of defenses to manage anxieties and powerful affects, individuals with borderline personality disorder tend to rely more consistently on the more primitive defenses of splitting, projection, projective identification, denial, primitive idealization, and devaluation (see chapter 5 for definitions). Several theoreticians, in fact, consider borderline personality disorder a condition centered around splitting—as both a

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defense and a fixation at an earlier level of development. In addition to splitting, the defenses of projection and projective identification are central to borderline pathology. In an attempt to “rid” themselves of toxic feelings, of an internal sense of their own “badness,” individuals may project their negative thoughts and feelings. Others may then be vilified as the self is “rid” of the negative, critical thoughts and feelings that are intolerable to hold. In the moment, the projections may “work.” They feel entitled to their righteously held perspectives, while the other is held responsible for all that is bad or wrong. The victory is short-lived, however, as relationships can be harmed and the negative feelings about the self ultimately return. Furthermore, as these projections continue in relationships, another complicated defensive dynamic emerges—that of projective identification (see chapter  5 for a fuller discussion). As the people onto whom these projections are targeted resonate unconsciously with what is being projected, they may act on the very things that were attributed to them but which they denied feeling. For example, a client Sam repeatedly accused his partner Jose of being on the verge of leaving their relationship. Jose had little desire to leave Sam, an assurance he offered frequently. Eventually, however, as the accusations continued, Jose himself began to feel the doubt about the relationship that had been projected onto him by Sam. Ultimately, feeling exhausted and defeated, he decided to leave the relationship. This dance of projective identification can sometimes evolve in the course of a treatment relationship as well. When, for example, a therapist is repeatedly accused of being incompetent and not caring, a chord within the therapist—who may struggle with questions about her own competence and adequacy—is struck. Worn down and disliking both herself and the patient, she may act out in ways that confirm the patient’s worst, yet predicted, fears. In the following statement, a therapist speaks candidly about the challenge to her own self-esteem when working with a chronically suicidal patient with borderline personality disorder: The patient made me feel that if I knew more, the treatment would be going better and she’d be saved. I’d started to think maybe she was right—I should switch her to another therapist, someone more experienced and wiser than me. I’d feel awful about myself, and then start to get mad at the patient for making me feel that way. Part of me wanted her to finally kill herself so I could get out of this treatment. I began hating her for making me feel this way, and of course hating myself for being such an uncaring, incompetent therapist.

The therapist struggled with these feelings, and then (with good supervision!) recognized that she needed to stop disavowing those feelings in herself, and to bring them into the room with the patient in order to demonstrate that the feelings are painful but bearable, and can be worked with rather than projected “out.” Affect Regulation Another impairment in ego functioning that has come to be seen as a hallmark of borderline personality disorder is the poor regulation of affect, also known as affective instability and emotional dysregulaton. Difficulties with affect regulation have led some researchers (Smith et al. 2004) to consider borderline personality disorder as part of a bipolar phenomenon due to the similarities in their presentations and etiological features, or as a disorder of the emotion regulation system (Linehan 1993). Although we all experience depression, anger, and dissatisfaction in our lives, the persistence, lability, and intensity of these affects is what differentiates the person with borderline personality disorder from those without the disorder. In studies described by Soloff (2018), individuals with borderline personality

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“revealed heightened affective instability compared to control subjects, manifested by more sudden, large decreases from positive to negative emotions, and frequent switches from anxiety to sadness and anger” (p. 274). Anger, in fact, is considered by many to be the dominant affect that individuals with borderline personality disorder experience. Two aspects of its manifestation are noteworthy. First, anger is often not modulated or experienced with any degree of gradation; a “little anger” suddenly becomes rage, or, as a client explained, “I go from number one on the anger scale to number one hundred in two seconds flat.” Second, the anger is often not differentiated from other affects. Situations that may engender hurt, sadness, or disappointment in many people are experienced solely as anger. A  range of patients, for example, were told that their therapist would be leaving the clinic. Most discussed feeling angry, scared, sad, and disappointed during the weeks leading to the termination. One woman with borderline pathology stated consistently, “I’m just pissed. What else is there to feel? It’s black or it’s white.” There was indeed no shading, “gray area,” or ambivalence in her feelings of anger, which were experienced with great intensity and at the exclusion of other feelings. Some authors have noted an interesting phenomenon in the area of affect regulation. They suggest that it is the way the individual responds to their affective state, not just the intense emotions themselves, that is central to understanding this disorder. As Sauer-Zavala and Barlow (2014) state, “These findings suggest that BPD and other emotional disorders symptoms are not simply a product of high levels of negative affect; instead, the combination of strong negative emotions and how one relates to them when they occur appears to be important for the development of these disorders” (p. 121). The authors go on to suggest that the coping strategies that individuals with borderline personality disorder tend to use in an attempt to manage the intensity and frequency of negative emotions paradoxically increase their presence (Sauer-Zavala & Barlow 2014). Strategies such as avoidance of negative emotions (i.e., through self-harm, addictive behaviors, eating disorders, sexual promiscuity) invariably lead to an intensification of the anxiety, anger, and depression. The following example illustrates how a client uses avoidance in relation to his feelings, which he cannot envision being modulated: Paul was discussing his rejection from a graduate program he had yearned to attend. When questioned about his feelings, Paul noted that he was not feeling at all disappointed. As his therapist explored his seeming reluctance to acknowledge even a little disappointment, Paul exclaimed in surprise: “You mean I can be feeling a little disappointed? Just a little? I don’t get it! That sounds like being a little pregnant to me. I’m either overwhelming disappointed, or not at all.” He then explained why he could not feel anything in response to the rejection. “If I feel disappointed, if I feel anything in fact, how will I know the feeling won’t engulf me, that I won’t enter a black hole of despair and anger? I can’t risk it . . . It’s like the Loch Ness monster—there’s always danger lurking in the waters.”

Because he could not differentiate or modulate his affect, Paul shut down emotionally. In place of a potentially rich tableau of human emotion, he struggled with a numbness and a pervasive deadness in his emotional life. How individuals respond to their affective state has significant implications for the treatment of this disorder. Helping our patients learn how to differentiate among various affects and how to modulate and integrate them is a critical part of the therapeutic work. Teaching skills to improve distress tolerance, like those taught in DBT (to be discussed more later in this chapter), help patients become less overwhelmed by their emotions and thereby engage in fewer destructive and impulsive behaviors.

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Reality Testing and Sense of Reality Although people with borderline personality disorder have an intact capacity for reality testing, they can be vulnerable to transient psychotic episodes, episodes of dissociation, and distortions of reality. In the following example, Cecilia, who suffered from no prior or subsequent episodes of psychosis, briefly lost touch with reality. Cecilia left for vacation with great fears about being on her own and tremendous guilt—reinforced by her parents—for leaving her children for several days. Despite being thirty-three years old, she packed an entire suitcase full of stuffed animals to “keep me company” and to help soothe her when alone. On the third day of her trip, she walked down the street and “saw” her parents at the corner. She ran over to these two strangers, calling them Mom and Dad. Over the next twenty-four hours, she had auditory hallucinations as her parents “continued to talk” to her, criticizing her for neglecting her children. Cecilia had never before been psychotic and recompensated fully upon her return home.

Brief and transient psychotic episodes such as Cecilia’s can emerge in people with borderline pathology, but unlike in psychotic disorders, the episodes are ego-dystonic. Except during psychotic regressions, individuals with borderline personality disorder retain the capacity for reality testing; they can distinguish between fantasy and reality, and between self and other. Their sense of reality can, however, become distorted. They may have experiences of depersonalization, dissociation, or derealization, related to traumatic experiences and/or overwhelming anxiety. They may also develop distorted views of themselves or misperceive others’ intentions as malevolent. When there is evidence of these kinds of distortions, it is particularly important to assess whether past trauma has led to a dissociative process. Level of Anxiety As noted throughout our discussion, individuals with borderline pathology often have difficulty modulating their emotions, particularly their anxiety, which can be experienced as chronic and/or episodically intense and overwhelming. Given their lack of object constancy, they can experience tremendous anxiety in response to real or perceived abandonment. Unlike people with neuroses, their principal anxiety is not the loss of love from the other or the loss of regard for the self. Rather, their anxiety emanates from the loss of the significant other, and the emptiness, rage, and aloneness it triggers. In treatment, disruptions such as when therapists leave for vacation or are ill can precipitate experiences of intense anxiety. Phone contact, appointment cards, or notes cocreated ahead of time can often decrease the anxiety that arises in the face of these challenging separations. The Experience of the “Self” Having explored the quality of object relations and several ego functions in people with borderline personality disorder, let us now examine the concept of the “self.” Central to borderline pathology is the lack of an integrated, cohesive identity and sense of self. Whether due to neurobiological and temperamental vulnerabilities, environmental deprivation and neglect, trauma, and/or the interplay of these forces, individuals with borderline personality often struggle with the development of healthy self-esteem, ambitions, and goals. They struggle with unstable “self-structures” and often lack the capacity for balanced self-reflection and appraisal. When early lives are shaped by neglect, abuse, and/or more generally invalidating environments, selfobject needs—for mirroring, idealization of others, and twinship—are not met (chapter  6). As noted by Linehan (1993), “Identity becomes defined in terms of

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each current moment and interaction experienced in isolation, and thus is variable and unpredictable rather than stable. In addition, there is no other moment in time to modulate the impact of the current moment. For a borderline patient, another person’s anger at her in a particular interaction is not buffered in time when this person is not angry at her. ‘You are angry at me’ becomes infinite reality. The part becomes the whole” (p. 36). What is the subjective experience of this lack of a cohesive sense of self? A client described this state as follows: “I  feel fragmented, like there are two parts of me that have nothing in common but that they’re a part of me .  .  . I  sometimes feel like a zillion tiny specks, surrounded by gelatin.” Although we all have different parts in our “selves” that emerge differentially depending on context, people with borderline personality disorder struggle with a greater sense of identity diffusion and a lack of continuity in their sense of self. This may lead them at times to seek external forces to define and validate them. Their identity disturbance may manifest in a variety of ways, including chronic confusion about goals and desires (beyond developmentally normative expectations), frequent geographical moves, and shifting, unconsolidated views of themselves and others. Without a coherent sense of self, they may not achieve their full potential despite their considerable talents, as we can see in the life of Gary, a forty-six-year-old bisexual cisgender white male. Gary, an extremely bright, engaging man, spoke of functioning well below his professional aspirations as he worked part-time for fifteen years as a home health aide, making ten dollars an hour. He spoke alternately of his wish to do more with his life and of his sense of entitlement about what the world owed him. He was involved in two consecutive long-term relationships, one with a man and one with a woman, which he said provided him with the security of not being alone—but no more. At age forty-one, he stated, “I don’t really know what or who I am. I don’t have a clue about my sexual preference—I’m scared of closeness with both men and women. I don’t even know what I want to be when I grow up, because I don’t have a clue as to who the ‘I’ in me is.”

ETIOLOGICAL CONSIDERATIONS: THE ROLE OF NEUROBIOLOGY AND TRAUMA The concept of borderline evolved in an effort to categorize a group of clients who seemed to exist “on the border” between neurosis and psychosis. Despite the general acceptance of the term borderline in current literature, theorists continue to debate the etiology of the disorder. As we discussed earlier in this chapter, it is critical to hold an explanatory framework that integrates genetic, neurobiological, constitutional, and environmental influences (in particular risk factors associated with adversity) in our understanding of this disorder. An integrative perspective is captured in the work of Graybar and Boutilier (2002), who propose a stress-diathesis model to underscore the multilayered, bidirectional interaction of hereditary and environment in the etiology of mental health disorders. As they state, “Extremely negative contributions from either end of the nature-nurture continuum have the potential to override or offset very good genes or very good parenting” (p. 154) and account for the varying degrees of severity of all psychological disorders. An area of innate vulnerability that is often overlooked yet recognized by many of us in clinical practice involves the constitutional and temperamental variables that play a role in the development of this disorder. Many of us have worked with families with multiple children, all raised in similar fashion, in which only one child grows up to be diagnosed with borderline personality disorder. How can we make sense of this? While there are many variables to consider, we have seen children who are born emotionally reactive and

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difficult-to-soothe develop attachments to caregivers that are sorely strained. Parents who would have little difficulty raising a temperamentally well-modulated infant may face major challenges raising a child prone to states of dysregulation. This can lead to additional strain on parent–child bonding as well as negatively impact the attunement that leads to a more secure sense of self. One possible outcome of this phenomenon is the emergence of problematic personality traits as these children become adults (Kernberg & Michels 2010). Although no one factor is causal in the development of borderline personality disorder, constitutional vulnerabilities within a nonsupportive environment appear to be the most significant factors in the development of this disorder (Kulacaoglu & Kose 2018). As noted by Linehan (1993), the impact of a “pervasively invalidating environment” contributes significantly to this syndrome. Linehan defines an invalidating environment as one in which the communication of private experiences is met not only with inappropriate or extreme responses but also with trivializing or punitive ones. In this environment, the child’s emotions are disregarded, her perceptions are dismissed, and the factors that may be causing distress are denied. Perhaps the most extreme example of an “invalidating environment” is evident in the role of trauma in the etiology of this condition. It is widely recognized, in both case studies and research, that a history of childhood trauma, including sexual and physical abuse, is a significant risk factor in the development of borderline personality disorder (Hengartner et  al. 2013; Paris 2018). The effects of trauma on some individuals may indeed create a character structure that becomes organized at the borderline level of functioning. Studies (Zanarini et al. 2003) have shown that people with borderline personality disorder report rates of abuse, including physical, sexual, and verbal abuse, as well as neglect as high as 60–80 percent. Let us be clear: this does not mean that individuals who have suffered traumatic experiences will necessarily develop borderline personality disorder; rather, a history of trauma may be one of many factors that leaves an individual more vulnerable to developing this disorder. Of note, clients (particularly women) are frequently misdiagnosed as having borderline personality disorder with little consideration given to the possibility that they are actually suffering from post-traumatic stress disorder. Some of the symptoms that many of these women manifest, such as hypervigilance and affective lability, are often adaptive responses to traumatic events in their interpersonal world. When their trauma histories are recognized and addressed, many of their “borderline” symptoms abate. Molly Layton (1995) invites us to consider symptoms in the context of trauma rather than through what may be an erroneous labeling of character pathology. What is added to our treatment of so-called borderline functioning when we locate its roots in a history of trauma? It is a profound shift in focus from character to context, like uneasily observing a person on the crowded street who seems to be gesturing and talking to himself, and then, thankfully, spotting the person across the street with whom he is in conversation. Viewing borderline traits as the fallout of real suffering ineluctably shifts therapy from a mission impossible to a mutually constructed more empathically demanding task of naming and sizing the effects of trauma. (p. 39, italics added)

Layton is eloquent in the naming of the suffering caused by trauma, and the plea to consider its effects even as we recognize the borderline traits in our clients. She advocates for something that we ask our readers to do throughout this book, and in each day we sit with our clients: honor the complexity of forces as we assess and treat those who entrust us with their greatest vulnerabilities.

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ETIOLOGICAL CONSIDERATIONS: CONTRIBUTION OF PSYCHODYNAMIC THEORISTS Psychodynamic theorists have offered a rich tableau of writings to help us understand the etiology of borderline personality disorder. Their work explores how poorly negotiated tasks from early developmental stages create a foundation from which problematic patterns may develop. It captures the profound impact of childhood adversity on psychological functioning. The theorists discussed below wrote in another era, one in which larger contextual and neurobiological factors were unfortunately not integrated into their understanding of pathology. Nonetheless, these early conceptual frameworks remain valuable as we explore the dynamic issues that contribute to the evolution of borderline personality disorder. Kernberg researched and wrote extensively about borderline pathology (1967, 1970, 1975) from a drive-defense model that traced the fundamental pathology in this disorder to problems in early object relations. He believed some children cannot integrate positive and negative self and object representations due to a constitutionally based predisposition toward aggression as well as anger from traumatic, abusive early relationships. The child’s good, loving images of self and other are protected from their excessive aggression through the development of a primitive defensive structure. The defenses of splitting, denial, devaluation, projection, and projective identification are used to keep the positive images of self and/or other from being destroyed by rage or “badness.” These defenses also serve to ward off the anxiety that would otherwise result from their contradictory experiences of themselves and others. Interestingly, some of Kernberg’s work on pathological internalized object relations, as well as his description of their defensive structure, actually foreshadow the many current theories that work with people’s “parts” (i.e., Internal Family Systems). As Kernberg stated in his interview with Lata McGinn in 1998: When, as children, we relate to important people in our lives, we internalize the memory of intense emotional states we experience during our interactions with them, and these intense emotional states get organized in two parallel series of loving and hateful emotions. These emotions are embedded in the relationship between representations of the self and representations of significant others. . . . [A] prototype of . . . a pathological internalization is what happens as a consequence of severe aggressive trauma or sexual trauma, physical abuse or sexual abuse, extreme long-term physical or sexual abuse. What we find in these cases is that, say in the case of physical abuse, individuals unconsciously identify themselves both as victim, i.e., internalize the self that has been attacked, and as abuser, i.e., internalize the memory of the abusing figure. Internalizing both these memories as a dyadic self representation—object representation unit brings about the unconscious temptations to reenact these roles again and again as if the only relationships that count in the world are those between the abuser and the victim. (p. 192)

Another influential early theorist, Masterson (1976, 1981), focused on abandonment depression and the defenses against it as central to borderline pathology. Recall in our discussion of object relations theory (chapter 5) the developmental struggle called ambitendency: the tendency to swing between two intense wishes (the wish to be close and the wish to be separate) and two enduring, intense fears (the fear of engulfment and the fear of abandonment). Masterson hypothesized that the lives of people with borderline personality disorder are organized around these twin wishes and fears. He suggested that as children their attempts to separate and individuate are met with emotional withdrawal by the caregiver; if

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the children remain dependent and clinging, they are rewarded. Whether they cling or not, the children pay an enormous psychological price. Those who move toward autonomy are faced with abandonment and depression; those who remain dependent and regressed never develop a separate, boundaried sense of self. In adult relationships, these individuals subsequently seek intimate ties with nurturing substitutes. When those relationships are established, however, the unresolved issues pertaining to autonomy and individuation reemerge. A pattern of unstable relationships then develops, in which intense unions are followed by precipitous ruptures. Unlike Kernberg and Masterson, Buie and Adler (1982; Adler & Buie 1979) focused on deficits, not conflicts, as central to borderline pathology. They integrated Piaget’s (1954) theory of cognitive development, Mahler’s (1975) theory of separation-individuation, and Winnicott’s (1965) concept of the holding environment to develop their theory about this disorder. They hypothesized that due to a lack of “good enough” mothering during the separation-individuation phase of development, a core deficit results—an impaired capacity for solid evocative memory. Without the capacity to evoke the positive mental representation of a soothing, holding caregiver, a profound sense of aloneness and emptiness prevails. In times of stress—often precipitated by abandonment—panic and then rage emerge because individuals cannot evoke a positive representation of another, nor rely on their own impoverished resources to soothe themselves. They also state that aggression is not primary in the development of borderline pathology; it is secondary to the despair and panic that result from the lack of nurturing, soothing introjects. With an impoverished inner world, relationships are alternately experienced as life sustaining or nonexistent. Buie, in more recent years, describes this impoverishment in terms of self-maintenance deficits; emotional equilibrium, he notes, is built on the capacity to feel held and soothed, to experience self-worth and self-love, and to experience oneself as having a core (Buie 2013). From this vantage point, we can see how people with borderline personality disorder may live with a painful dearth of essential self-maintenance and self-regulatory tools. These theories are embedded in a narrow cultural context; they do not address how issues of race, culture, class, and gender create the context in which development unfolds. They do, however, provide a historical and foundational perspective to our understanding of borderline personality disorder, and offer valuable insights into the “internal” world of people with this disorder.

TREATMENT APPROACHES, WITH AN EMPHASIS ON DIALECTICAL BEHAVIORAL THERAPY There are many approaches currently being used in the treatment of people with borderline personality disorder, which we can broadly classify as: (1) supportive psychotherapy, (2) psychodynamically and relationally oriented psychotherapy, (3) cognitive-behavioral therapy, and (4) dialectical behavior therapy. Although discussions of treatment approaches are generally outside the scope of this book, we want to highlight the contributions made by the introduction of dialectical behavior therapy (DBT) to the field. Linehan (1993) devised DBT to help patients who engage in parasuicidal (deliberately self-injurious, with or without the intent to die) and self-mutilative behaviors learn how to relinquish these destructive tendencies in favor of more adaptive ways of interacting with others.

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Linehan introduced the concept of dialectics—“the reconciliation of opposites in a continual process of synthesis” (p.  19)—to capture the seemingly competing and contradictory tasks to be addressed by the person with borderline personality disorder. As noted by Robins and Chapman (2004), the most fundamental dialectic to be explored is that of acceptance (without judgment) and change. In the treatment relationship, this dialectic is “held” by the therapist who models acceptance of patients as they are while supporting their efforts to change. Skills are actively taught in DBT to address some of the following goals: increase behavioral control over severely self-destructive behaviors; identify, regulate, and feel emotion without it becoming overwhelming or triggering impulsive behaviors; achieve interpersonal effectiveness and improved self-esteem; tolerate distress; and increase a sense of joy and connectedness. These goals are accomplished through a structured program of sequential modules and includes group skills training, individual psychotherapy, telephone consultation between sessions, and consultation with the therapist as needed (Robins  & Chapman 2004). Linehan and her colleagues draw on cognitive-behavioral techniques along with mindfulness practices and psychodynamic psychotherapy to attend to the needs of this population. DBT has proven to be very effective for many patients with borderline personality disorder, but studies have also shown the efficacy of other psychotherapeutic approaches. Clarkin et  al. (2007) compared three psychotherapeutic approaches—DBT, transference-focused psychotherapy, and dynamic supportive therapy—and found that all three were beneficial, with the transference-focused psychotherapy providing change in more domains than the other two approaches. Psychotherapy can be very effective, as it helps patients organize and make sense of their internal chaos (Gabbard & Horowitz 2009) and live with a more integrated, harmonious sense of self and of others. It is not our goal in this chapter to debate the effectiveness of different treatment models; instead, we want to invite clinicians to hold multiple treatment approaches in mind as they consider the particular needs of their patients, their own theoretical orientation and comfort with particular models of practice, and of course the “fit” between the two. The lives of many patients with borderline personality disorder do indeed improve with intervention. The research regarding prognosis is hopeful for those who receive adequate treatment along with psychosocial supports. As noted by Stone (2010) as he summarized a ten-year prospective study of patients at McLean Hospital: For symptom remission, the results of the McLean study are most encouraging: nearly seven of every eight borderline patients achieved symptom remission lasting at least 4 years. Half the patients achieved a more total recovery, no longer meeting diagnostic criteria for borderline personality disorder as well as achieving good social and occupational functioning. (p. 618)

This is extremely hopeful data for all those struggling with this disorder, for their loved ones and for those of us working with this population. This hope is reflected in the life of Cassie, the young woman we discussed earlier in the chapter who moved away from home and established a full, balanced life separate from her family. In a note mailed to her therapist, she reflected on the past turmoil and distress she experienced in her life and the sense of peace she found as a result of treatment: “I now know what it must feel like to be more ‘normal’: to have hurts that don’t destroy me or the people I care about, to see that I don’t have to sacrifice myself to my parents, to get to know myself and find I can love and be loved over time. . . . So, how’d we do it???? I guess that’s been our work in the therapy!”

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BORDERLINE PERSONALITY DISORDER AND RACE: LIMITATIONS AND AREAS FOR FUTURE STUDY As we write this latest edition of Inside Out and Outside In, we are only too aware that our country is in the midst of a cultural and systemic revolution. Brought about in part by the confluence of a global pandemic (which highlighted the long-standing inequities in access to health care and economic opportunity for people of color), the strength of the Black Lives Matter movement, and the availability of in-the-moment viewing of police brutality, we are finally reckoning with how people of color are underrepresented in the design of our social, economic, and healthcare policies. This underrepresentation extends to research in the mental health field, as studies of symptomatology and treatment modalities have most often been based on a population of white individuals. We therefore would like to end our discussion of borderline personality disorder by referencing work that explores some of the differences in the presentation of borderline personality disorder in African Americans and White Americans. Newhill, Eack, and Connor (2009) conducted one of the first studies comparing the differences in affective and behavioral presentation of borderline personality disorder in African American and White American individuals. As they note, BPD had primarily been considered a “white, female disorder,” and subsequent understanding of the condition and treatments were based on this specific population. Although their study was small, the authors found a number of very significant differences in the symptom presentation of these two groups: African Americans tended to experience greater affective intensity and emotional dysregulation, more thoughts of interpersonal violence, and generally greater positive affects than white Americans; at the same time, they were significantly less likely to engage in self-harming and suicidal behaviors, which were found to be much more prevalent in the group of white Americans (p. 92). For our discussion, what is of utmost importance is that the authors tried to understand their findings by focusing on the societal, cultural, and religious factors at play. For example, the role of religion (specifically the belief that suicide is unacceptable), as well as strong family support in the community, were seen as protective factors against self-harming behaviors so often seen among white Americans diagnosed with borderline personality disorder. At the same time, the role of stress among African Americans, in the form of racial discrimination, oppression, and economic inequities, was found to be central to the behavioral manifestations of the disorder in this group. As Newhill et al. explain, the stress and stigma of having a personality disorder and being a member of a racially oppressed group seem to contribute to vulnerabilities in the areas of affect regulation and anger often seen in individuals with borderline personality disorder. Therefore, is it possible that some African Americans with BPD, a group that experiences the double stigma of being a racial minority as well as having a highly stigmatized psychiatric diagnosis may exhibit righteous anger? Righteous anger is, in fact, a coping mechanism protecting individuals from the detrimental impact of stigma. These individuals may be protecting their own self-esteem by turning their anger outward, instead of turning it inward. (p. 93)

Fortunately, more attention is being paid to understanding the role of race and socioeconomic status in both the symptom presentation and the treatment of borderline personality disorder among people of color (De Genna & Feske 2013; Gaztambide 2018; Walsh et al. 2013). Throughout this book, we have advocated understanding our clients by using a biospsychosocial lens, and appreciating the varied and complex factors that impact their worlds and their experiences of themselves. The treatment of those with borderline personality disorder demands that we be humble and open to recognizing what we know and what we don’t know, especially as we accompany individuals of diverse races, ethnicities, gender identities, and cultures in the therapeutic process.

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NARCISSISTIC PERSONALITY DISORDER Over the last several decades, authors from Lasch (1979) to Twenge and Campbell (2009) have described the emergence of a “culture of narcissism” characterized by self-absorption, arrogance, and entitlement. They chronicle people’s devotion to the perfecting of the self, striving for perfection and success at any cost. In the United States, this has taken on different forms depending on the prevailing social and cultural norms. For some, this devotion to the self may emerge in an obsession to amass personal wealth and power, to undergo repetitive cosmetic surgeries, to be consumed by the latest diet and exercise regimens in order to defy the aging process, and/or to ensure that children are afforded the “best” opportunities in all aspects of their lives. (Consider the college admissions scandal, in which wealthy parents paid for their children’s college applications to be falsified, so they would gain admission to their school of choice.) The media reinforces this narcissistic preoccupation with perfection through countless reality shows such as The Kardashians, The Bachelor, and Survivor, which glorify the ethos of greed, of beauty as defined by the prevailing social norms, and of winning at all costs, often at the expense of others. Tweets from our president exalting himself (“My IQ is one of the highest—and you all know it! Please don’t feel so stupid or insecure; it’s not your fault”) (Trump 2013) splash across screens every night. Social media promotes the sharing of images and stories through selfies, Snapchat, TikTok, Instagram, and Facebook posts that tend to project lives of happiness and fulfillment that may bear little resemblance to reality. Some of this preoccupation with self-improvement and self-promotion may be beneficial. When it becomes central to our culture, however, self-obsession can replace collective responsibility, and empathy for those who are different or less fortunate can diminish, if not disappear. In this section, we will explore the concept of narcissism as it manifests in psychological development, focusing on the characteristics of narcissistic personality disorder. Before we study its pathological manifestations, however, we must appreciate how narcissism encompasses normative and healthy characteristics as well as pathological ones. All levels of psychological development include aspects of narcissism. Healthy narcissism, an ability to love oneself and/or to regard oneself positively, is critical in the development of self-esteem. In his book Rethinking Narcissism (2015), Malkin promotes this view by challenging the prevailing notion of narcissism as primarily pathological. He defines narcissism as a way to feel special, as a “habit” that “is vital for us to lead happy, fulfilled and productive lives. Feeling special . . . can make us better lovers and partners, courageous leaders, and intrepid explorers” (VII–VIII). He refers to numerous studies that “have found that people who see themselves as better than average are happier, more sociable, and often more physically healthy than their humbler peers . . . Their rosy self image imbues them with confidence and helps them endure hardship, even after devastating failure or horrific loss” (p. 9). Think for a moment of the iconic words from the song “I Feel Pretty” from Westside Story and how it captures the joy of feeling so very special: “I feel pretty, oh so pretty, I feel pretty and witty and bright! And I pity any girl who isn’t me tonight!” Malkin notes that narcissism exists on a spectrum: too much, as we will discuss, is destructive and can shatter relationships, and too little can leave people without a voice, diminished in their sense of worth. Narcissistic issues are displayed in varied ways across the life cycle and across cultures, and should be evaluated in context before being deemed pathological. Imagine, for example, the behavior of a two-and-a-half-year-old girl who spontaneously stands before a crowd of people and begins to sing, dance, and clap her hands in glee. Many of us might smile at this exhibitionistic display and delight in this girl’s pleasure with her own accomplishments; however, we would likely have a very different reaction if this same behavior was exhibited by a fifty-year-old woman! As we have discussed throughout this book, culture is also critical to consider in terms of the context in which behaviors and traits are evaluated. What is deemed normative regarding an individual’s bold displays of wealth

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and power in the United States, for example, might be met with disapproval in many Asian nations which prize collectivism and self-effacement in social engagements. Expressions of narcissism, then, assume markedly different meanings depending on when they occur in the life cycle, and in which cultural context they are embedded.

CLINICAL PICTURE OF NARCISSISTIC PERSONALITY DISORDER The term narcissism was drawn from the Greek myth of Narcissus, summarized by Cooper (1986) as follows: Narcissus was a physically perfect young man, the object of desire among the nymphs, for whom he showed no interest. One nymph, Echo, loved him deeply and one day approached him and was rudely rejected. In her shame and grief, she perished, fading away, leaving behind only her responsive voice. The gods, in deciding to grant the nymphs’ wish for revenge, contrived that Narcissus would also experience the feelings of an unreciprocated love. One day, looking into a clear mountain pool, Narcissus spied his own image and immediately fell in love, thinking that he was looking at a beautiful water spirit. Unable to tear himself away from this mirror image, and unable to evoke a response from the reflection, which disappeared every time he attempted to embrace it, he gradually pined away and died. (p. 112)

Which features present in this myth do we currently associate with the concept of narcissistic personality disorder? Cooper (1986) delineates some of the traits evidenced by ­Narcissus: arrogance, self-centeredness, grandiosity, lack of sympathy or empathy for others, poorly differentiated self and object boundaries, and lack of enduring object ties. Let us hold this evocative myth in mind as we now turn our attention to the clinical picture of the narcissistic personality disorder. Toward the beginning of the movie Sunset Boulevard, William Holden comments to Gloria Swanson, the aged, well-past-her-prime, silent-screen actress, that she was once famous. Denying the reality of her fall from stardom and masking the humiliation she feels about her current life circumstances, Swanson responds with indignation, “I am big. It is the pictures that have become small.” Her desperate attempt to remain special and unique, her unrealistic self-concept, and her devaluation of all that has occurred in the film industry following her departure are captured in this poignant and painful moment on screen. Swanson’s character embodies many of the characteristics that DSM-5 (2013) identifies for the diagnosis of narcissistic personality disorder. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) has a grandiose sense of self-importance; (2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love; (3) believes that he or she is “special” and unique; (4) requires excessive admiration; (5) has a sense of entitlement; (6) is interpersonally exploitative; (7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others; (8) is often envious of others or believes that others are envious of him or her; (9) shows arrogant, haughty behaviors and attitudes. (pp. 669–70)

The traits listed in the DSM focus on the disorder’s grandiose features, and not on the manifestations of the vulnerability that is evident in many individuals with narcissistic personality disorder. In fact, it is now generally accepted that there are at least two phenotypic presentations of pathological narcissism: grandiose or overt narcissism and vulnerable/ introverted or covert narcissism (Cain et  al. 2008; Yakeley 2018). In both presentations,

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people’s subjective experience of their narcissistic traits may differ markedly from their outward behaviors. People with grandiose features may feel worthless and inadequate at core, whereas vulnerable or covert narcissists may present as timid and self-effacing but have an underlying belief that they are superior to others (Malkin 2015). These traits give us a snapshot—from the “outside in”—of the characteristics of a person with narcissistic personality disorder. Let us now explore this disorder using several psychodynamic concepts so that we can understand the experience of narcissistic personality disorder from the “inside out.” In this spirit, we will look at disturbances in the sense of self, in object relations, and in ego functions of individuals with this disorder. Keep in mind that, as with all the psychopathological syndromes we have studied thus far, it is the pervasiveness and inflexibility of the characteristics we will describe that lead to psychological dysfunction. Self-Concept As displayed in Gloria Swanson’s character mentioned above, people with narcissistic personality disorder have difficulty maintaining a realistic concept of their own self-worth. On the one hand, they have an inflated and grandiose sense of self-importance. A desire for, or fantasies of, magnificent achievements that lead to fame and fortune may preoccupy them. Self-righteousness, contempt for others, and a belief in their superiority are central to their self-concept. For example, Geraldine, a white college professor, repeatedly spoke about her colleagues at the university where she taught in the following terms: “I can’t stand their stupidity, their constant drivel. I won’t waste my time in their committee meetings or at their social gatherings when I have more important things to do. Don’t they know how fortunate they are to have me in their department?” On the other hand, the self-concept of people with narcissistic personality disorder often includes a deeply embedded sense of worthlessness and a propensity toward profound shame. Feelings of inadequacy and self-loathing often coexist with—and underlie—arrogance and self-importance. In fact, grandiosity can often serve as a compensatory counterpart to a sense of worthlessness, and may mask a core experience of vulnerability. Perry and Presniak (2013) capture this polarity in their observations about defenses often used by individuals diagnosed with narcissistic personality disorder: Individuals with NPD have split off their negative self-images from those that are positive, allowing the grandiose self-image into awareness. Although the defense splitting may not be evident until a narcissistic injury occurs, they tend to idealize those that they envy (those that are rich and powerful) and devalue all others. However, when presented with severe failure they may also devalue themselves. (pp. 157–58)

Listen to how Geraldine, the college professor who generally conveyed a belief in her superiority over her colleagues, grappled in a moment of unusual self-reflection with her “secret” sense of worthlessness: “I  have wildly inflated my accomplishments so as not to feel like a fraud. I have secretly resented my colleagues for being better than me. I have pretended to be the most competent, because there’s nothing worse than being reminded of one’s worthlessness.” With her contempt for others unmasked, Geraldine’s vulnerability emerged, and we can hear the pain, envy, and shame that clearly underlie her grandiose stance in the world. In the following illustration, we see how these themes may emerge in the course of a therapy. Miguel, a Latino cisgender gay male, frequently entered his therapist’s office with a demeaning comment about someone in his life, or with a question to the therapist about whether she had

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read a certain article or novel. The therapist often felt stupid in his presence, wondering if Miguel would not be better served by a more intelligent, better-read clinician. On this particular day, Miguel began his session in silence, more aloof and distant than usual. After a period of time, he asked in a demanding tone, “Who was that professional-looking man you smiled at when he left your office?” The therapist momentarily felt guilty—as if she had done something wrong—then recognized that much of her self-doubt in her work with Miguel was evoked through projective identification. She felt as incompetent and inadequate with him as he felt perpetually in the world. After some exploration of his thoughts, he stated, “I  assumed that I  was your favorite client—in fact, in my head I pictured myself as your only client.” He became devaluing momentarily, defending against his hurt, and said, “My last therapist would never have smiled at another client leaving her office.” He then added with a sense of sadness and resignation, “If I’m not your special client, I feel like a nobody.”

Although Miguel usually presented as arrogantly self-assured, he had a fragile sense of self, a self that deflated—like a balloon full of air that is pricked—in the face of a perceived slight, hurt, or disappointment. He usually concealed his vulnerability with a condescending, critical attitude toward others. Morrison (1986) described this seeming paradox as follows: This need for absolute uniqueness, to be the sole object of importance to someone else, symbolizes the essence of narcissistic yearning . . . What are the affective implications of this yearning for uniqueness? We have noted that it may lead to an outpouring of untamed aggression, or of reactive rage against the offending object. Internally, however, I suggest that such an experience leads to a sense of utter despair, profound depression, and reflects the paradoxical extremes of grandiose entitlement, on the one hand, and vulnerability to mortification, on the other. (p. 4)

Those struggling with narcissistic issues have a disproportionate need to attain gratification as well as support for their self-esteem from others. This preoccupation promotes a self-centeredness that obscures a subjective experience of emptiness and shame. It should be noted that the experience of shame is quite different from that of guilt, which reflects the belief that one has committed a wrongdoing. Shame, by contrast, is the experience of being exposed as not good enough, as weak or worthless or “small.” It is understood to be the central affect of narcissistic pathologies (Lecours et al. 2013). With shame, a person may feel that he or she is losing the competition and everyone can see it. With guilt, the critical voice is within the self (super-ego); with shame, the audience is outside of the self (McWilliams 2011), ready at any moment to expose and humiliate the individual. As McWilliams notes: In every vain and grandiose narcissist hides a self-conscious, shame-faced child, and in every depressed and self-critical narcissistic lurks a grandiose vision of what the person should or could be (Meissner, 1979; Miller, 1975; Morrison, 1983) . . . What narcissistic people of all appearances have in common is an inner sense of, and/or terror of, insufficiency, shame, weakness, and inferiority. Their compensatory behaviors might diverge greatly yet still reveal similar preoccupations. (pp. 178–79)

Implied in the traits we have thus far reviewed is the tendency of people with narcissistic personality disorder to be self-centered and self-referential. As noted above, in spite of the seemingly arrogant pride in their many talents, they can feel like a fraud at core. Profound self-doubts and self-reproaches may lurk beneath the bravado. Jake, a twenty-seven-year-old, cisgender white man, struggled with many of these character traits in his life and relationships with others. The youngest of four children, he had been raised by a distant, cold father and a critical, depressed mother. Jake felt ignored by his parents, who he remembers attended his siblings’ performances and school functions, but never his own.

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“I could’ve jumped on the table and they wouldn’t have noticed . . . I wanted my mother to love me, to stop saying I was an ‘accident’ and to say instead I was her miracle child . . . I preferred being hit by her with a paddle [which she did routinely] than ignored.” Jake sought therapy because of feelings of emptiness and depression, and a pervasive dissatisfaction with his life. He had begun a career as a stand-up comic, and alternated between thinking he was truly the next Jerry Seinfeld or Chris Rock and believing he had absolutely no talent. Jake was obsessed with what others thought of him, and married an attractive woman with whom he had little connection because “she was beautiful, self-assured—and I thought she’d make me more comfortable with myself.” Performing before crowds was the only way Jake could defend against the dreaded sense of inadequacy and worthlessness he feared in his life. Jake noted that he needed the audience to feel alive and, describing his anticipation of a performance, likened himself to “a tiger standing tall before the crowds at a circus.” When the audience departed, he would inevitably “crash,” feeling empty and deflated.

Despite the confident swagger he exhibited onstage, Jake had the fragile sense of self so typical of people suffering from narcissistic personality disorder. Although intensely ambitious, he felt chronically bored, ashamed, and unable to channel his intellectual abilities and talents into any ongoing sustainable vocational, academic, or personal pursuits. Object Relations People with narcissistic personality disorder have relationships with others that are frequently superficial, shallow, and lacking in emotional depth. Showing little capacity for empathy, they can be insensitive to others’ needs and exploitative in their behavior towards others. Remorse, which may to them reflect a “defect,” is rarely shown, and gratitude, which may reflect a need, is rarely displayed (McWilliams 2011). Although their psychological boundaries are less permeable than people with borderline personality disorder, they tend to take advantage of others, whom they also may envy. With an underlying sense of themselves as powerless and unimportant, they can be intensely rejecting of people as a way to avoid feeling their own sense of worthlessness (Perry & Presniak 2013). At times, individuals with narcissistic personality disorder may seek out associations with others whom they perceive as perfect, basking in the glory of their intelligence, success, or fame. At other times, they search for admirers who can gratify their need for affirmation and idealization. These tendencies breed a superficiality and lack of mutuality in their relationships. In addition, individuals with narcissistic personality disorder often have a sense of entitlement, believing that the mundane details of life—such as attending mandatory team meetings—should be the purview of others rather than of themselves. A colorful illustration of this can be seen in the film The Devil Wears Prada (2006) in which Miranda, the character played by Meryl Streep, disdainfully tells her assistant Andy, “Please bore someone else with your questions,” as Andy seeks her input regarding details of an upcoming fashion show. Miranda is a demanding, entitled, condescending boss who treats her staff as extensions of herself, seeing them only in terms of how they can gratify her needs. Statements such as “Oh, don’t be ridiculous, Andrea . . . Everybody wants to be us” and “Truth is, there’s no one who can do what I do” are clearly “made-for-Hollywood” lines reflecting the grandiosity of the leading character. They do, however, reflect aspects of individuals with narcissistic personality disorder: an inflated belief that they are always right; an inability to tolerate imperfections in themselves and others; and last, a tendency to engage in relationships in which others are seen only as need gratifiers or narcissistic extensions of themselves. In the film, Andy was only valued by Miranda when she became totally

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devoted to her boss, mimicking her style and some of her behaviors, and when she began to relinquish her own separate life (including giving up her friends and family) in order to remain the loyal and admiring subject. While the discussion above is referencing a film, it is important to note that we see similar interpersonal dynamics in families in which a parent has narcissistic tendencies. Specifically, such caregivers convey a powerful message to their child—you are highly valued, but only for the role that you play (McWilliams 1994). The child learns to engage in behaviors that feed the narcissistic needs of the parent, while simultaneously learning to suppress feelings and behaviors deemed undesirable by the caretaker. This “molding” to the needs of the other in this way can contribute to the development of a “false self” (Winnicott 1960). As we consider the quality of people’s relationships with others, it is easy to see how intimate bonds are deeply affected by excessive narcissism. People with narcissistic personality disorder may fall in love easily but superficially, and frequently come to devalue what they receive from their partners. As McWilliams (1994) notes, “Their need for others is deep, but their love for them is shallow” (p. 183). Relationships become organized around the person’s need for attention, with little acknowledgment that their loved ones may have needs and interests markedly different from their own. Tom, a cisgender white man involved with his partner for fifteen years, wryly commented on the success of his relationship as follows: “The relationship works because Bobby knows that everything has to be about me. I’m incredibly selfish; I just take, and Bobby waits on me. But it’s okay, most of the time. Bobby is a passive guy anyway.” When asked about his desire to explore this issue in treatment, Tom replied: “The truth is, I don’t really want to change anything, change who I am.”

Despite their seeming imperviousness to others’ opinions of them, people with narcissistic personality disorder can be extremely sensitive to perceived slights. An unempathic statement, a felt criticism, or an unmet need can trigger a narcissistic injury—that is, the experience of feeling deeply wounded, humiliated, and hurt. When “injured” in this fashion, people with this disorder may respond with intense rage. Following a session in which a therapist made what was experienced as an unempathic comment, for example, a client said angrily, “I was furious at you after last week. I’m not the least bit interested in what you think of me. I have my own agenda here, an important one that has nothing to do with yours. I know far more than what you learn in your psychiatry and social work texts about what human nature is about.” The client felt exposed and misunderstood by her therapist; she subsequently became enraged and then assumed a grandiose stance while devaluing her therapist. As we will see in the next section, this posture characterizes the defensive style of the narcissistically disordered individual. Ego Functions In contrast to people with borderline personality disorder, those with narcissistic personality disorder have egos that are relatively intact. Their judgment, reality testing, and cognitive processes are sometimes distorted by emotional issues, but they are more likely to function with greater consistency and proficiency than individuals with borderline pathology. They may be articulate and opinionated, traits that may boost their self-esteem while masking what is, sometimes, a superficial knowledge base. This accounts in part for the large number of narcissistic people in positions of power: their sense of certainty (i.e., they are “right”), self-confidence, desire to assume control, and pleasure in giving orders to others frequently result in promotions to powerful roles. Anxiety is generally masked lest it

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expose a weakness or vulnerability in their character; nonetheless, anxiety is central to their psychological make-up, and can emerge in their terror of losing approval, acceptance, and adoration/love from others. Unlike people with borderline personality disorder who live with abandonment anxiety (“I’m worried you will leave me once we get close”), those with narcissistic personality disorder live with the anxiety that they will lose the admiration of others (“You have to show me your loyalty so I know I am the most popular and special person on this team”). Who among us does not grapple with some of these fears, these pangs of anxiety rooted in self-doubt? Yet for those with narcissistic personality disorder, this type of anxiety is central to their experience of themselves and others, and to the compensatory strategies they use to manage it. As we will learn in chapter  16, anxiety is managed through the mobilization of our unconscious defenses. The defenses of people with narcissistic personality disorder serve to protect their fragile self-esteem. Grandiosity and arrogance, rather than simply being unpleasant character traits, are actually central coping strategies that enable the narcissist to avoid experiencing intolerable helplessness and shame (Lecours et al. 2013). A defense such as idealization helps create “perfect” others with whom they can merge; devaluation and projection help rid them of their own imperfections, which they then “see” in others to whom they can feel superior; denial and rationalization help them avoid their own weaknesses and vulnerabilities. The use of some of these defenses, and the function they serve, can be seen in the following case: Anna, a twenty-seven-year-old affluent white, cisgender woman, talked frequently about her looks in her therapy sessions and acknowledged that she was obsessed with her appearance. She applied facial cream eight times a day, was drawn to mirrors on all surfaces, and sought constantly to be sexier or more glamorous than other women so she would be noticed by others. At the beginning of each visit to her therapist’s office, she would find something to criticize about what she saw: “The picture on the wall is crooked.” “The tag on the rug is showing.” “Your skirt doesn’t match your top.” When a therapeutic alliance had been established in the work, Anna and the therapist explored why she made so many devaluing comments. After months of looking at this pattern with little effect, Anna gradually started to show some self-awareness and said: “I do say something critical every time I come in here. Maybe I’m trying to make this—and you—imperfect because I feel so insecure. If I saw you as okay, or even perfect, I’d have to deal with how shitty I really feel about myself.” Anna was ultimately able to understand how her preoccupation with her appearance reflected her attempt to “fix” a deep-rooted sense of inadequacy. As she developed a more cohesive sense of self and greater self-compassion, she became more comfortable with the reality of her physique and more tolerant of imperfections in others. She no longer projected her worst fears about herself onto others, became more comfortable in her own skin, and slowly demeaned others less often as she valued herself more.

THE ETIOLOGY AND TREATMENT OF NARCISSISTIC PERSONALITY DISORDER Much of our understanding of the causes of narcissistic personality disorder is rooted in the work of psychodynamically and psychoanalytically oriented theorists. Very few studies have explored the genetic basis for this disorder, and there are few studies that measure the prevalence of narcissistic personality disorder in the general population. One large study in the United States (Hasin  & Grant 2015) showed an overall prevalence rate of narcissistic personality disorder of 6.2 percent, with rates higher for men (7.7 percent) than for women (4.8 percent).

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In recent decades, contributions to our understanding of narcissistic personality disorder have been made through research done in the areas of neurobiology, attachment theory, and temperament. We all know children who, from an early age, are viewed as “overly sensitive” or “thin skinned.” They may be constitutionally more sensitive than others to people’s emotional cues, and exquisitely attuned to slights, criticisms, and expectations held by others. Researchers such as Daniel Stern (1985) have demonstrated that these children bring this vulnerability to their interactions with caregivers, who face a more challenging task parenting in supportive, nonshaming ways. Avoidant/dismissive styles of attachment (see chapter  8) may then result from the problematic fit between these children and their caregivers. Traits we associate with narcissistic personality disorder—including minimizing the value of connections with others, disliking dependence because it exposes vulnerability, and superiority and aloofness—may arise from these early attachment issues, rooted in the styles of caregivers and/or the temperamental vulnerabilities of children. Additionally, research in attachment styles has shown an association between dismissing and anxious/preoccupied attachment styles and the grandiosity and vulnerability found in people with narcissistic personality disorder (Meyers & Pilkonis 2011). Individuals with narcissistic personality disorder do not generally report childhood histories of physical or sexual abuse. However, there is often a pattern between the caretaker and child of “frequent, even daily, experiences of feeling overvalued, undervalued, or devalued” (Stern 1985, p. 153). These alternately gratifying and depriving early experiences can lead to distorted perceptions of oneself and of others (Perry & Presniak 2013), accounting in part for the alternately inflated and critical views of self and others. Psychodynamically oriented theorists have offered varied accounts of the etiology of the narcissistic personality disorder. In his essay “On Narcissism: An Introduction,” Freud (1914) attributed narcissistic problems to a withdrawal of libido from the outer world into the ego—that is, a retreat from attachments to others to a state of self-absorption. He noted that this regressive retreat could be caused by stresses secondary to trauma, disease, the onset of old age, and/or by frustrations in relationships with others. He believed that an infant optimally evolves from a normative stage of autoeroticism or self-love to a love for others. If, however, there is an obstacle to the fulfillment of the love for and from others, narcissistic disturbances arise. Britton (2004) described this development as follows: “Those unfortunate enough to find love unrequited are thus deprived of self-esteem as well as the other’s love, thus suffering pain and loss of self-regard” (p. 480). Although recognizing that all people have residual aspects of narcissism, Freud believed that the amounts of libido directed toward the self accounted for differences in people’s capacities for loving others. Individuals, then, who lavished excessive attention and love on themselves would suffer from the greatest disturbances in narcissism. Over time, the discourse about the etiology of narcissistic personality disorder was largely shaped by the competing theoretical understandings proposed by Heinz Kohut (1977a, 1977b; Kohut & Wolf 1978) and Otto Kernberg (1974, 1975, 1995). It has been suggested that these theorists developed their models based on two very different client populations, with Kohut’s theory evolving from work with a healthier and higher-functioning population than Kernberg’s. We believe, nonetheless, that each of their models offer an instructive accounting of the many possible causes and manifestations of narcissistic personality disorder along with helpful treatment considerations. Kohut (as noted in chapter 6) understood pathology in terms of deficits in what he refers to as “self structure.” He attributed narcissistic pathology to the failure of the environment to provide age-appropriate empathic and attuned responses to the child’s needs. Without

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relationships in which children are adequately mirrored by the caregiver, and in which they have someone to idealize/emulate and feel “similar” to (twinship), they may lack the validation, admiration, and modeling necessary for the development of a healthy self-esteem. A three-year-old child who sings “Happy Birthday” off-key with incorrect words needs to see the gleam in his caregiver’s eyes to support his healthy exhibitionistic display and positive self-regard. Consistent critical or neglectful responses to displays of this kind can contribute to the development of the fragile self that is so central in the development of a narcissistic personality disorder. Kohut (1977a) also noted that the environment must provide children with an “optimal level of frustration” so that they can learn to cope with disappointments, anger, and frustration. After all, the three-year-old child who sings off-key will have to recognize, when older, that he may not be the next Pavarotti! He needs to experience a balance of praise and constructive feedback to develop a healthy self-esteem. If children chronically experience too much frustration and disregard for their age-appropriate selfobject needs, they may struggle with internalizing selfobject functions—the ability to love themselves, to develop healthy goals and ambitions, to feel like others in the world. They may become hungry for love and affirmation, and prone to idealizations of others to replenish their depleted selves. Conversely, if they chronically experience too little frustration, they may become entrenched in states of grandiose omnipotence, self-absorption, and primitive entitlement; they may come to expect that what they think and need will automatically be affirmed and gratified. Either state can lead to the development of the traits associated with narcissistic personality disorder. Kohut’s views on treatment derived directly from his understanding of the etiology of narcissistic disorders. He believed that narcissistic issues would emerge in the transference over the course of a therapeutic treatment, reactivating the client’s needs for mirroring, idealization, and twinship. Other authors (Brodie & Gravitz 1995; Schore 1994) have also looked at this phenomenon, as well as the ways that therapists working with the transference can address the client’s wishes for affirmation, connection to idealized others, and twinship. Brodie and Gravitz (1995) note: Three distinct components of the narcissistic transference promote completion of the self’s arrested development. The initial mirror transference provides continuous empathic mirroring of the grandiose self, followed by the idealizing transference in which the therapist assumes the role of the omnipotent, soothing selfobject. Ultimately, through the twinship transference, the patient is able to relate to the therapist as a separate human presence. (p. 60)

In addition, according to Schore (1994), this kind of empathic attunement helps the brain regulate feelings of rage or worthlessness. It is interesting to note that in Kohut’s model, rage and entitlement on the part of the client are not interpreted exclusively as shortcomings of the client, but rather as reactions to the empathic failures of the therapist. Ultimately, Kohut believes that when these empathic failures are acknowledged, the deficits leading to narcissistic vulnerabilities can be addressed and repaired, a hopeful outcome of treatment. Kernberg (1974, 1975, 1995) offers a strikingly different view of the etiology of narcissistic disorders. Unlike Kohut, who sees narcissistic disorders as reflective of arrested development of the self, Kernberg describes the self in the narcissistic personality as a “grandiose pathological self,” formed from the fusion of the real self, the ideal self (comprised of fantasies of one’s own special power, beauty, wealth), and the ideal object (comprised of fantasies of the ever loving, giving, perfect other). What is bad or weak in this grandiose self is projected onto others, who are then devalued and dismissed. What is left is grandiosity that defends against worthlessness, and an internal world devoid of representations of significant others

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who support self-esteem. Rather than feel the pain of their sense of worthlessness and of their unmet need for support and love, individuals with narcissistic personality disorder valiantly protect themselves from experiencing their neediness. They become self-centered, shallow, and aggressive, seeking excessive admiration from others, whom they also envy. Although Kernberg believes narcissistic individuals function at a higher level than those with borderline personality disorder, he sees narcissistic personality as a subtype of borderline personality organization. To what does Kernberg attribute this disturbance? He notes that “the most important cause is the chronic frustration of the need to be loved and a consequent, inordinate development of rage. That rage takes the form of envy—namely, envy of the person who is needed, who has what the patient needs but will not give him—love” (1995, p.  11). ­Kernberg’s “­narcissists” are thus full of aggression, which may be constitutionally and/or environmentally induced. Neglected and enraged, they interact arrogantly and aggressively toward others. They unconsciously protect their fragile sense of self by devaluing others and depending on no one—a defense against the reality of their impoverished relational lives. Kernberg’s treatment interventions evolve from his theory about the development of this disorder. He suggests that people with narcissistic personality disorder must renounce their yearning for perfection and accept the terror inherent in true intimacy. Unlike Kohut, who allows the transference to unfold so that the therapist is ultimately internalized as an idealized selfobject, Kernberg challenges this idealizing transference. He interprets clients’ idealization of the therapist as a defense, so they will acknowledge their envy, rage, and, ultimately, their dependency needs. He advocates a tactful but insistent confrontation of people’s grandiosity so that clients will ultimately be able to love and be gratified based on a realistic appraisal of their behavior. In practice, most clinicians draw from techniques offered by a range of theorists as they grapple with treating clients with narcissistic disorders. Regardless of one’s theoretical orientation, however, the treatment of these clients can be enormously challenging. The therapist may alternately be devalued or idealized, or feel as though she doesn’t exist as a separate individual. During some periods in the therapy, she may experience herself as the very best clinician to treat a given client, buoyed by the idealization in play; at a moment’s notice, however, perhaps following an unknowingly unempathic comment, she may come to feel as if she is a fraud—the most incompetent, worthless clinician in the whole clinic. Her perceived value depends in part on how exquisitely attuned she is to her client’s emotional needs in the moment and how well she serves as narcissistic extensions of those needs. During the treatment of those with narcissistic disorders, therapists may also feel as if they do not exist in the room, their presence merely “tolerated.” If they offer an observation that is different from the client’s, the ensuing rupture in the alliance may trigger feelings of shame or annoyance in the client, or possibly an outburst of rage. For clinicians working with this population, the lack of curiosity and interest in the therapists’ separate views can contribute to a range of countertransference reactions, including boredom, self-doubt, irritability, and a fear that the treatment is not progressing. Ultimately, patience is needed in the ongoing work as well as faith that the relationship itself will be curative as narcissistic wounds are healed and the hope for being loved in an authentic relationship is realized.

CONCLUSION Individuals with personality disorders tend to consume more time, attention, and worry among mental health providers than those from almost any other diagnostic category. They

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can leave us questioning our basic level of competence, engaging in debates with colleagues about treatment approaches, and feeling alternately frustrated and gratified to be part of a life-altering therapeutic journey. They carry the complexity of the human condition in all its manifestations. We want to leave you with the story of Diana, a client of one of our colleagues, whose life captures some of this complexity. Diana grappled with debilitating traits of several of the personality disorders. Often erratic, volatile, and needy, her skin bruised from self-mutilation, she fit the criteria for borderline personality disorder. At times she was so schizoid that she locked herself in her apartment away from everyone, not able to dress or bathe or sleep, unable to go out for days. At other times, she briefly “crossed over the border” into paranoid psychosis, hearing the voices of her dead parents or believing that devils were coming to kill her. She alternatingly presented as feeling arrogantly superior to others or full of deep self-loathing. Periods of being able to work and pay the rent were followed by periods of homelessness. This was the “illness” part of Diana—the part that would lead to a diagnosis of personality disorder. But that illness both coexisted with and was embedded in other parts of her. Diana had a dazzling intelligence, a wicked sense of humor, a keen interest in journalism, politics, and popular culture, and—when she was well and not enraged—a very kind and loving heart. During the period when she was able to work in international advertising, she was a star in her field. One of her proudest moments was arranging a tea with the Queen Mother for her agency! Our colleague worked with Diana pro bono for over twenty-six years and was always able to find a clinic that would provide her with much-needed medication. Never once in all that time did Diana have to be hospitalized for her severe problems. The work proved to be a roller-coaster ride of challenges, frustration, small triumphs, and many disappointments, but Diana never ceased to be an engaging, interesting, and gratifying person to work with. This past October Diana was found lying dead on a street in Brooklyn. She had suffered a massive heart attack. The following letter to her therapist was found in her pocket, unmailed: Dear Marie, I was blindly, irrationally upset when I walked in today, and then there you were, smiling a welcome for me. I suddenly believed in miracles of sunshine again. Indeed, I had just been given one. I think I don’t know how to declare an end to pain, and this perhaps is the next step forward— to be able to accept the fact that even with so many things still wrong, I have been able to put a little bit of terra firma under me and I can live my life from a position of strength. God know there’s a lot to be afraid of, but I can’t be that terrified if I let it sink into my bones and my soul that with people like you on my side, it has to be a more beautiful world than I thought. Much much love, Diana

Until the last day of her life, Diana never stopped trying to get better. People with personality disorders often have that kind of energy and perseverance. They can wear you down. They can lift you up. And they remind you of the possibility that transformative change can occur within the context of a caring, empathic, and attuned therapeutic relationship.

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15 Mood Disorders, with a Special Emphasis on Depression and Bipolar Disorders Joan Berzoff, Teresa Méndez, and Daniel Buccino

INTRODUCTION Mood disorders are the first diagnostic category we have addressed with which virtually every one of us is familiar. Who hasn’t felt sad, empty, bereft, unworthy, utterly alone in the world? Who hasn’t felt a lack of motivation, a sense of dullness, a loss of meaning? Who hasn’t felt, at some time, that life is not worth living or that the world would be better off without us? Andrew Solomon (2001) says that the opposite of depression is not happiness. It is vitality. And who has not felt gray, dulled, enervated? When we speak of moods, we are speaking of a range of everyday feelings, from sadness to joy, despair to elation, anger to acceptance. Moods refer to the prolonged emotions that color our psychic lives. Affects, however, refer to feeling tones or emotional states at a given moment, and to their outward manifestations. A  person’s mood may be sad while her affect is blunted. We may fail an examination and experience a mood of utter hopelessness, but we may show no affect, or we may get an A on the paper and experience ourselves as exceptional, brilliant, wildly promising, and our affect may be manic. As with several of the other disorders we have studied, mood, or affective, disorders are complicated precisely because they derive from an interaction among psychological, social, and biological sources. Journalist Daphne Merkin (2009) captured this complexity when she wrote of her own depression, “The precipitating factors included everything and nothing, as is just about always the case—some combination of vulnerable genetics and several less-than-optimal pieces of fate.” Depression is a common and troublesome affect. Mania, though perhaps less universal, can be equally troubling. Much of this chapter will focus on these two affects as they manifest in depressive and bipolar disorders. One way to conceptualize a mood disturbance is by considering what has been referred to as the manic-depressive spectrum. Imagine a continuum running from “unipolar depression,” where an elevated mood is never present, to full-blown mania, which poet Robert Lowell described as like striking a match that “brought my blood to a boil” (Parini 2006, p. 828), and usually results in hospitalization or 312

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incarceration. Between these two states lie people with bipolar disorders, marked by swings through deep depression and feverish mania; along with milder and less clearly delineated mood states known as “soft” bipolar disorders with subtler gradations of hypomania, more tempered and less reckless than true mania, and depression; and “mixed” mood states, where both depressed mood and agitation, a sort of dark energy, may be present simultaneously. All of us live between these two poles: sometimes we feel down, experiencing hopelessness, loneliness, and despair; sometimes we are up and full of ourselves, irritable, agitated, and even jumping out of our skins. Depression refers not just to a syndrome, with all of its technical definitions, but also to feelings, or affective states, that are part of being human: states of sadness, deflation, emptiness, hollowness, worthlessness, hopelessness, and boredom. Depression feels like flatness, an absence of color. It is, as one client recently described, like a hole in the heart. And yet, because we often begin from the position that everyone knows what depression is, we can too easily minimize its potentially debilitating impact and its complexity. True depression differs from ordinary unhappiness in its severity and in its disproportionality. Depression is the most widespread emotional disorder and the leading cause of disability in the world, afflicting 2–3 percent of the world’s population, or over 264 million people (World Health Organization 2020). Of American adolescents and adults, 10–15  percent (20  million) are estimated to have had at least one major depressive episode (SAMHSA 2017). As many as 60 percent of the reported 47,000 people a year who commit suicide have had a mood disorder (Health and Human Services 2014; Heron 2019). Complicating this picture, influential researchers and clinicians have argued that many people diagnosed with depression may actually suffer from a bipolar illness. They estimate that 40–60 percent of people with a diagnosis of major depressive disorder may also have experienced a hypomanic episode and fall somewhere along the bipolar spectrum (Angst 2006; Angst et al. 2010). Diagnosed bipolar disorders are believed to affect approximately 3 percent of adults (5.7 million) (Harvard Medical School 2007); yet there is speculation that the number could be 5–7  percent (Glick 2004). Bipolar disorders occur in men and women equally, with a median age at onset in the early twenties (Goodwin & Jamison 2007, National Institute of Mental Health 2008). Some affective disorders are exogenous and reactive in origin, meaning they are precipitated by a significant event such as the loss of a person, of work, or of ideals. Less obviously, an individual may react to a typically positive event—a graduation, childbirth, a promotion, moving to a new city—with depression, because any of these joyous occasions might also present a new type of loss or revive past losses. Loss, however, is not the precipitating factor in all cases of depression. Affective disorders may also be endogenous—that is, internal. There may be no obvious external event precipitating the shift in mood. There are many biological causes for these disorders that are not fully understood but may be genetic, hormonal, or biochemical in origin. Intrapsychic factors and life-cycle issues also play a role in affective disorders. For instance, one life-cycle development that can precipitate depression for some women is having two or more young children below the age of six at home (Brown 1991; Brown et al. 1987). Another life-cycle predictor is found in older, single, widowed men, living alone with a physical illness. These men are at high risk for depression and for suicide (NIMH 2010). It is clear that mood disorders occur in people of all ages and genders, and from all social classes. No one is immune. Yet some racial and ethnic groups have higher incidences of mood disorders. Adolescent depression is currently highest among those who identify as mixed race (Federal Interagency Forum on Child and Family Statistics 2016). Whether this

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is due to a growing number of people who now identify as multiracial or because multiracial individuals must navigate a complex and poorly understood set of identities and identifications is unclear (Jamali  & Méndez 2019). American Indian and Latinx teens experience the next highest rates of depression (Federal Interagency Forum on Child and Family Statistics 2016), with suicide highest in Latinx adolescents (Centers for Disease Control and Prevention 2015). Among teenage girls, Latinx show one of the highest rates of depression (Zayas & Pilat 2008) with 18 percent of Latinax girls attempting suicide (Heron 2019). This might reflect the strains they face through acculturation, or the pressures from peers or teachers who exhort them to be autonomous, putting them in conflict with families who may value greater interdependence. And what impact does anti-immigrant sentiment and racism have on increased depression? We know that gender also plays a significant role in affective disorders. Women are two to three times more likely to be diagnosed with depression than men, which raises questions about why women suffer more from depressed moods. At least some of this difference is likely attributable to a greater number of women seeking treatment and thus receiving a depression diagnosis. Women suffering from bipolar disorders have also been shown to be more likely than men to experience rapid cycling or shifts between depressed and manic episodes (Mondimore 2006). Sexual and gender identity, especially for teenagers, are other factors in depression and in high rates of suicide (Bostwick et al. 2010). Suicide rates are higher among gay, lesbian, bisexual, and transgender youth than in the general population (Bagley & Tremblay 2000; The Trevor Project 2019). This is connected to extremely high instances of discrimination, stigma, and bullying (Nordgren et  al. 2011; Russell  & Joyner 2001). It also reflects the impact of rejection by families during adolescence (Boylan 2015; Ryan et al. 2010). In fact, gay and lesbian adolescents who have experienced rejection by their families of origin are eight times more likely to attempt suicide than their heterosexual peers (Ryan et al. 2010). (See chapter 10.) Social class also has a significant impact on affective disorders. Poor and working-class women are at greater risk for depression. People in the lowest socioeconomic classes have two times the risk of being diagnosed with major depression than those in the middle- and upper-middle classes. The risks for depression among the poor may be even greater than reported, since poor and working-class people are often overly diagnosed with schizophrenia without adequate clinical justification. As a result, they may be underdiagnosed with depression and other mood disorders (Weissman & Klerman 1977; West et al. 2006). Finally, age is implicated in depression. It is difficult to face one’s bodily limitations and to be stripped of some the privileges of adulthood—whether through the loss of work, the capacity to drive, or the loss of one’s home. It is difficult to lose memory and to lose the people who remember one’s life. Many people move into old age, lose partners, and experience the loneliness of living alone without supportive networks. Bereaved, elderly people struggle further with existential issues around death and dying (Berzoff & Silverman 2004). Chronic pain and physical illnesses also contribute to depression in older adults. Depression often goes undiagnosed in older people, but its effects can be lethal. It doubles a person’s risk of cardiac arrest (Singh & Misra 2009). Suicide among the elderly is twice that of the general population (Alexopoulos 2005). In this chapter, then, we first describe the experience of depression. Next, we draw on psychodynamic theories to help us understand some of the internal psychological dynamics of these disorders from the vantage of each of the four psychologies. We consider depression at different developmental levels. From there we review our understanding of people who suffer with bipolar affective disorders. This is followed by a look at the experience,

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symptomatology, diagnosis, and treatment of those with bipolar illnesses. From a biological perspective, we consider the influence of genetics, neuroanatomy, and endocrine factors on mood disorders. Social factors contributing to depression and bipolar disorder are then explored. Next we consider suicide: its risk factors and its demographics. Finally, we describe the ways in which mood disorders affect not only the client but also the clinician.

THE EXPERIENCE OF DEPRESSION How do we draw the line between ordinary human suffering, with all its attendant sadness, ennui, and pessimism, and clinical depression? The term “depression” is used in many ways. In its wider usage, it often refers to a “lowering,” for example, of an economy or of barometric pressure. In a person, it often refers to lowered self-esteem and decreased functioning across a variety of domains. To help us understand the symptoms of depression, it may be instructive to turn to people who have themselves been clinically depressed. In their own voices, they provide access to what are perhaps some universal experiences of depression. William Styron (1992), a novelist, found himself at a loss for words to describe his own severe depression at age sixty. In his autobiography Darkness Visible, he writes with such power that: Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self . . . as to verge close to being beyond description. (p. 7) For myself, the pain is most closely connected to drowning or suffocation—but even these images are off the mark. (p. 17) My brain ha[s] begun to endure its familiar siege: panic and dislocation, and a sense that my thought processes [are] being engulfed by a toxic and un-nameable tide that obliterate[s] any enjoyable response to the living world. Instead of pleasure [it is] a sensation close to, but indescribably different from, actual pain. (p. 16) The pain of severe depression is quite unimaginable to those who have not suffered it and it kills in many instances because its anguish can no longer be borne. (p. 33)

In this passage, and throughout his memoir, Styron describes many depressive symptoms. He turns inward, feeling flat and monochromatic. He is panicked and anguished and suffers from a sleep disorder that slows him down and leaves him fatigued. He feels helpless, pained, inarticulate, suffocated, and lacking any capacity for pleasure. Styron contemplates suicide, aware that not only his emotions but also his thinking are disordered by his mood. His despair envelops his world in what he later describes as a visible darkness. Author and journalist Elizabeth Wurtzel, once called a cross between Sylvia Plath and Madonna, wrote in her confessional memoir Prozac Nation (1994): In my case . . . I was certain, quite certain, that I was already dead. The actual dying part, the withering away of my physical body, was a mere formality. My spirit, my emotional being, whatever you want to call all that inner turmoil that has nothing to do with physical existence, were long gone, dead and gone, and only a mass of the most fucking god-awful excruciating pain, like a pair of boiling hot tongs clamped tight around my spine and pressing on all my nerves, was left in its wake. That’s the thing I want to make clear about depression: It’s got nothing at all to do with life. In the course of life, there is sadness and pain and sorrow, all of which, in their right time and season, are normal—unpleasant, but normal. Depression is in an altogether different zone because it involves a complete absence: absence of affect, absence of feeling, absence of response, absence of interest. The pain you feel in the course of a major clinical depression is an attempt on nature’s part (nature, after all, abhors a vacuum) to fill up the empty space. But for all intents and purposes, the deeply depressed are just the walking, waking dead. (p. 24)

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Like Styron, Wurtzel feels flattened, dulled, emptied, all but dead. As with many depressed people, Wurtzel is irritable and angry at feeling so robbed of her feelings, her vitality, and her experience. Like Styron, she is enveloped by a deadened darkness, tormented by an absence of affect. Shakespeare’s Hamlet also experiences the losses of pleasure and meaning that characterize depression. Hamlet cries out: I have of late . . . lost all my mirth, forgone all custom of exercises, and indeed it goes so heavily with my disposition that this goodly frame, the earth, seems to me a sterile promontory. This most excellent canopy, the air, look you, this brave overhanging firmament . . . why, it appears no other thing to me than a foul and pestilent congregation of vapors. . . . Man delights not me—no, nor woman neither. (Shakespeare 1917, p. 50)

In Shakespeare’s Hamlet, we once again encounter the futility, pessimism, and loss of humor that are signs of a depressed mood. Hamlet is angry—both at himself and at his world, which now seem “foul and pestilent.” His external world seems depopulated and sterile. People are not only absent but no longer experienced as valuable. Indeed, what is interesting here is that not only are events and people outside of Hamlet devalued, but Hamlet includes himself among those most derided. It is not surprising when he says to Polonius, “You cannot, sir, take from me anything that I will more willingly part withal— except my life, except my life” (p. 47). Hamlet experiences his life as a burden to be willingly surrendered. What all three writers have described, in different voices, to varying degrees, and at different ages, are the very markers of depression. Each reader, no doubt, has felt these feelings at some time or other, and struggled to override them and regain some zest for life.

SYMPTOMS OF DEPRESSION What, then, are the symptoms of depression? Each author notes what we refer to as “vegetative symptoms”: changes in sleep, appetite, weight, interest in love, and/or interest in the world. Each has vividly described fatigue or physical pain. Styron experiences a slowing down, or what we call “psychomotor retardation.” Often in mania, we see the opposite: a state of speeding up or of agitation. Hamlet speaks of a poverty of ideas accompanied by his lowered sense of worth. Each author describes a prolonged sad mood. Each had difficulty with concentration and indecision. At different moments, two of the authors consider suicide because their numbness, pain, darkness, and withdrawal were so unbearable. In fact, there can be so many symptoms and combinations of symptoms associated with depression that they become bewildering to the clinician, threatening to make the concept too inclusive. To help achieve some useful clarity about depression, we usually focus on three of the altered mood states described by the aforementioned authors. In Styron, we find a loss of interest (“apathy”); in Wurtzel, a loss of energy (“asthenia”); in Shakespeare’s Hamlet, a loss of pleasure (“anhedonia”). None of these states alone, however, constitutes clinical depression. To make the diagnosis of depression, at least two of these states must be present (Kaplan & Sadock 1985). What is happening psychologically when people experience such symptoms? Our knowledge of drive, ego, object relations, and self psychological theories may help us understand the internal worlds of those who are depressed.

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Freud’s Ideas about Depression Let us begin with Freud, who provided a framework for conceptualizing the dynamics of depression in his very important paper, “Mourning and Melancholia” (1917). Freud proposed that we understand depression by first looking at grief. He described grief as a normal reaction to the loss of a loved one. When someone we love dies, we feel sad, empty, bereft. We turn away from the world to do the work of mourning, and every culture has customs to honor the process and make the reality of death or loss official. In mourning, we remember the person who has died, retaining their images and memories (as we described in chapter 5). When a relationship with a loved person is disrupted forever, memories of that person are “cathected” or held on to, as if the memories were the person himself or herself. Freud wrote that we “hypercathect,” or intensely clasp, our memories: we remember a favorite song, how that person laughed, the way it felt to be with him or her, places that were shared, and we hold on to those memories tenaciously. Ira Gershwin wrote a song with his brother who was dying of a brain tumor that beautifully describes hypercathecting his memories. “They Can’t Take That Away From Me” took on special meaning after his brother died prematurely. The song talks about remembering the way his loved one wore his hat, the way he drank tea. In remembering each aspect of the beloved, the tie grows stronger. Here the Gershwin brothers were describing not only how, with loss, we are filled with the memories of the person whom we have lost but also how we hold on to those memories as a way of keeping that person alive in us. However, with the passage of time, Freud believed, the energies bound up in thoughts and memories of the lost person become freed up to help us form new attachments. But Freud noted that no one abandons a libidinal position willingly, even when a substitute beckons. That is why we do not fall in love immediately after a significant loss. Yet with the passage of time and the acceptance of reality (whatever that may be), and through the process of bringing old memories to consciousness and experiencing anew the pain of the loss, we gradually begin to reinvest in the world. We are now, to quote Loewald (1980), “sadder and wiser” and, with that, more open to new relationships. Freud, however, also suggested that we never fully give up the person we have lost—that instead, we hold on to the lost person by identifying with aspects of him or her and unconsciously taking in features of that person as parts of ourselves (Freud 1923). An attitude, behavior, or characteristics of that person (or that we experienced in our relationship with the person) may become part of us. In this way, we are actually transformed by our losses. Mourning changes who we are. A  mother who loses her daughter, a writer, to cancer, becomes a writer herself. A senator’s wife, who loses her husband in a plane crash, runs for the senate. A  social worker who loses her sister writes a book and runs a program about death and dying. All these are ways of holding on to the lost object through identifying with him or her. “Melancholia” (Freud’s term), or complicated grief, shares many of the same characteristics as mourning. One feels dejection, loss of interest, and inhibition of activity, as well as something else: a disturbance in self-regard. Often this feeling is expressed in angry, reproachful, self-blaming, even self-hating statements. Melancholia, which begins as feelings of loss, soon moves toward feeling worthless and self-critical. How does that happen? Why does the person who is melancholic become self-loathing? Freud thought that the clinically depressed person’s self-reproaches almost always turn out to “fit someone else . . . the patient loves” and has lost. He hypothesized that the person’s self-criticisms are actually “complaints” about the object, but this dissatisfaction is unacceptable to the conscious self.

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Melancholia frequently derives from a conflicted and ambivalent relationship with a lost object. When anger at the person one has lost cannot be acknowledged consciously, it is often turned against the self. Freud suggests two things: (1) that the depressed person is unaware of the more negative or hateful feelings toward the lost object; and (2) that the lost object is too essential to the maintenance of the self to be given up through grieving. In depression, the ambivalently held relationship with the deceased leads the griever to experience self depletion and self-hatred. Whereas in mourning, it is the external world that has become impoverished and empty; in depression, it is the internal world that becomes poor and barren. Freud (1917) wrote quite beautifully that in melancholia, as well as in grief, “the shadow of the object [falls] upon the ego” (p. 249), suggesting that the quality of the relationship (positive and negative) to the loved one (or object) affects the outcome of grief. Freud wrote: One feels justified in maintaining the belief that a loss has occurred, but one cannot see clearly what it is that has been lost. The patient cannot consciously perceive what he has lost either even if the patient is aware of the loss which has given rise to his melancholia, but only in the sense that he knows whom he has lost but not what he has lost in him. (1917, p. 245)

Take, for example, Jane: Jane, a seventy-five-year-old cisgender Italian Catholic woman, began treatment because she was profoundly depressed, having lost her husband of forty years, eight years earlier. She talked with him daily, said prayers with him morning and night, and visited his grave twice a day. This, in itself, would not be pathological, except for the way in which she described her apartment as a “tomb.” She could not sleep, shop for herself, make any decisions, pay her bills, or take care of herself or her cat. She lost twenty pounds and had driven her children away with a litany of complaints about them and about herself. Jane married at twenty-seven, after taking care of her aging parents and her six siblings’ children. She had forgone college to do so, and yet denied that she ever felt any anger about sacrificing herself to her siblings and her emotionally abusive parents. In fact, through clenched teeth, she let it be known that she was never angry. Jane saw herself as something of a saint and viewed her husband as nothing less than the same. Jane’s husband had been a childhood friend, and she had, on some level, always known that he was gay. After conceiving two children with Jane, he moved into another room in the house, and took a lover at work. Jane felt that her children blamed her for the couple’s disaffection, and although she could not remember, her children described her murderous rages where she would hit them with brushes and shoes. What made her grief even more unbearable was that on his deathbed, her husband told her that he had never loved her and wished that it were she who was dying, not he.

Why had Jane become so depressed and even suicidal? Freud might surmise that Jane was unaware of her unconscious anger toward her husband (or parents and siblings) and that the anger she was now recognizing toward him threatened her ability to hold on to his memory. Her ambivalent feelings about him, especially her anger and hurt, had now been set up inside herself, directed against herself. The other more difficult problem for Jane was that she needed to maintain in fantasy what was never true in reality. For Jane, and for so many others, it can be simply debilitating to internalize an unresolved and highly conflictual relationship. Melancholia can be difficult to treat because the person who experiences it is so invested in denying ambivalence, and that denial threatens to obliterate any memories at all, which further impoverishes the person’s inner world. Freud’s concept of complicated grief has also been used to understand other forms of loss, grief, alienation, and depression, including those resulting from racism. David Eng, an

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English professor, and Shinhee Han, a psychotherapist (2000, 2018), use melancholia as a framework through which to consider the immigrant’s experience of assimilation and exclusion. In their paper on Racial Melancholia, Eng and Han argued that something is felt to be lost in the process of assimilation, but exactly what is lost can be hard to identify. In order to succeed in a white world, Asian American immigrants often aspire to the norms and ideals of whiteness and may experience depression in never being able to attain these phantom ideals, in always being designated as “other, and as non- white.” Just as the melancholic finds himself in mourning without end, Eng and Han raise the question about whether Asian American immigrants and people of color find themselves in ongoing states of suspended assimilation (p. 671), expected by the dominant culture to blend in but excluded from true membership, while also melancholically holding onto their own cultural authenticity in protest. Suspended assimilation takes a toll. To succeed at the stereotype of the “model minority,” the authors suggest, Asian Americans must split off a part of themselves, giving up a fuller, active subjectivity, and sacrifice their clear cultural voices rooted in their ancestral past, along with the chance to upend stereotypes. Assimilation, the authors explain, must be perpetually negotiated as the Asian American immigrant moves back and forth between mourning and melancholia. Thus, both mourning and melancholia come to be implicated in the immigration experience. Navigating two cultures simultaneously requires considerable strength. Ego Psychology Ego psychology offers a different but complementary theory for understanding depression. We learned in chapter 3 how anxiety may serve as a signal to take action to protect oneself from danger. So, too, can depression serve as a signal—to do the work of mourning that we have seen is a necessary part of growth. In this sense, depression is not necessarily pathological. This is why psychodynamic theorists so staunchly resist the idea that all depressive affects—sadness, bereftness, helplessness—are useless afflictions to be removed or avoided in whatever way possible. In fact, the capacity to bear depression—to live with grief, sadness, and hurt—is one of the greatest and most useful ego strengths (Zetzel 1970) and a hallmark of mental health. Interestingly, it is when we cannot bear depression that we often become clinically depressed. Edward Bibring (1968), an ego psychologist, proposed an alternative explanation for depression that extended and modified Freud’s original views. He noticed that in everyday life, the death or loss of a loved object, country, or ideal is not the most frequent trigger for depression. Rather, depression is more often precipitated by a state of felt helplessness brought on by not living up to one’s own ego ideals. This state results from “a tension within the ego” between the universal aspirations to be worthy, loved, and strong, and the ego’s experience (judgment) that it cannot achieve those aspirations. Bibring, then, reconceptualized depression as a state deriving not from aggressive drives originally directed toward a lost object and now misdirected against the self but rather as a conflict between one’s ideals and one’s perceived inability to achieve them. The loss of self-esteem central to depression is not only the consequence of depression but, in fact, often the cause. Daniel is a fifty-four-year-old cisgender African American realtor, who often experiences a substantially diminished sense of self-esteem. Despite many attempts to invite colleagues out, he finds himself isolated in his office. When decisions are made, he is left out of the loop. Early in his career, he called out his colleagues on their discriminatory practices of redlining, where African Americans are directed to failing neighborhoods and given exploitatively high loans. Ever since,

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he has noticed that there are different rules for his behavior in the group. He is not to get mad, for example. Nor is he to speak up. He feels ignored, disenfranchised, and discriminated against. Now, in his work with black clients, he finds himself at a loss for words; he berates himself for how powerless he feels. He wonders whether he actually knows anything anymore. He reports feeling low, depleted, lacking energy. He finds himself eating too much and sleeping too little. Daniel is disappointed that he is not living up to his own expectations, imagining reproaches from family and friends as he harangues himself for his perceived inadequacy.

Daniel suffers from low self-esteem whose origin is based in racism and discrimination. Although his depressive symptoms are mild and transient, and relatively proportional to the discrimination he faces at work, a sense of helplessness, self-doubt, and self-recrimination are central to his depressive experience. Yet whereas Daniel feels he is not living up to his own expectations, it is actually the business for which he works that is not living up to his. An ego psychologist would formulate Daniel’s experience as helplessness that involves some negative judgment or negative assessment of his ability to effect needed change. With helplessness also comes self-reproach and the expectation of similar reproaches from others. One can easily see how these elements trigger a repetitive, self-reinforcing downward spiral of “felt helplessness,” inaction, self-reproach, and loss of self-esteem. If the ego cannot reestablish a reasonable sense of self-esteem, experiences of unhappiness and self-reproach increase and lead to a greater sense of helplessness. How do we escape such spirals in everyday life? Daniel reports that factors such as the pressure of deadlines (external interpersonal connections), the memory of his past competencies, and the use of some energy from self-reproach to “get angry” and “cut the task down to size,” thus rebutting internal criticism, help him mobilize and get on with his work. An interesting footnote provided by Saari (1989, personal communication) highlights how Bibring used himself as a core example of his theory. Bibring developed his theory of depression when faced with his own helplessness over a diagnosis of terminal cancer. He was able to make his (presumably painful) experience the subject of observation, thereby gaining mastery over his depression by contributing intellectually to the field. Bibring wrote that depression, in the form of lowered self-esteem, is relieved by anything that reverses the condition of helplessness. In this way, we can see from Daniel and from Bibring the strength that can come from depression. As Ernest Hemingway (1929/2014) wrote in A Farewell to Arms, “The world breaks everyone and afterward many are strong at the broken places” (p. 216). We have just presented two complementary theories of depression. From Freud, we suggested that depression results from unconscious anger directed at the lost object, which in turn is directed against the self—or, in the case of racial melancholia, from the impossibility of suspended assimilation. This depletes and impoverishes a person’s self, leading to a depressed state. From ego psychology comes the idea that depression involves a discrepancy between one’s ideals and aspirations and one’s perception of one’s capabilities and worthiness. The result is helplessness and self-reproach. Here, the problem is of regulating selfesteem. This theory also explains how depression can result from expectations to conform to the norms of dominant culture despite constant microaggressions experienced within it. While the first theory of depression suggests that one identifies with the hated object and that hatred is directed toward the self, the second implies a different kind of problem—having to do with not living up to one’s own or the dominant society’s expectations or ideals or having to adapt to that which is unbearable, such as racism and discrimination. Object Relations Theory An object relations view of depression had already been anticipated by Freud’s emphasis on the centrality of object loss to depression. In object relations terms, often a melancholic

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person cannot mourn successfully because, in the absence of a lost other, she is unable to sustain an emotionally useful, enduring object representation. Perhaps the key contribution of object relations theory is its elaboration of the development of internal object representations and the relationship of that development to depression. Object relations theorists address two important aspects of this relationship: the developmental level of representations at the time that loss occurs and the effect of loss at different stages of development. Recall that object relations theorists depict relationships with others as existing from the very first moments of life and as organizing internal experience. Relationships form the structure of psychic functioning. We have seen how central to many object relations theories is the idea that representations of others (literally, the mental representation of the absent person) undergo a developmental progression from the infant’s fleeting, poorly differentiated (between self and other) images to the adult’s enduring, well-differentiated, multifaceted representations (Jacobson 1964; Kernberg 1966; Klein 1940; Mahler  & McDevitt 1980). Obviously, the actual loss of a needed loved one, whether to death, physical absence, abuse, or emotional unavailability, can produce very different depressive reactions. These may depend on the developmental stage of the representation of the loved one in the person experiencing the loss, as well as compensatory factors such as other forms of emotional support, strengths in the community, strong faith, and family cohesion. Early attachment theorists, such as Spitz and Wolf (1946) and Bowlby (1958), studied the reactions of infants and toddlers to prolonged separations from the mothers to whom they had been attached (see Shilkret and Shilkret and Shapiro in chapters 8 and 9). They noted that in the absence of another dependable caregiver, these infants became distressed, disorganized, profoundly sad, and, finally, detached and apathetic—almost a prototype of the symptoms we have seen in depressed adults. Some infants even died. Spitz and Wolf called such depression “anaclitic.” An anaclitic depression occurs at the stage when the representations of the lost loved object can only be sustained by the almost constant visual and physical presence of that person. Loss of the actual person at this stage of object representational functioning produces intense feelings of emptiness, aloneness, helplessness, and powerful feelings of love and cravings for immediate contact with the lost person. Spitz and Wolf and later theorists (Blatt 1974) note that such depressive experiences are not unique to infants but are seen in persons of any age whose internal world of object representations has not gained a measure of object constancy. Such depression will be marked by the same intense feelings of helplessness, abandonment, and emptiness, but with less guilt and lowered selfesteem than in other forms of depression. Indeed, it often seems to the person suffering depression at this level that there is no “self” without the lost other. Marc was a twenty-eight-year-old cisgender married man of Polish-American descent with a history of substance misuse (alcohol and marijuana) and of psychiatric hospitalization for “nervous breakdowns,” during which he experienced himself as unable to function at all. He referred himself for individual therapy, despite a stated “hate for all shrinks.” About eleven months after his father’s death, Marc began having symptoms, including sudden uncontrollable weeping (“for no reason, I just feel so empty and alone”), and an intense fear of going to work by himself. Marc reported that if his wife or mother accompanied him to his place of business, “I can work just fine.” Marc had been in business with his father, who he described as “the most unhappy, bitter, critical guy anyone who met him ever knew—not just me.” He described working with his father as “me doing all the work while my father stood around criticizing me.” Marc was mystified that now, so many months after his father’s death, he could not do the work he had always done, “unless someone is there so I  know it’s all right.” When he was alone, Marc felt “like I  forget everything, I don’t know anything—I’m not sure I can even remember my name.”

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An object relations approach to Marc’s depression would focus on his difficulty maintaining an object representation of his father that could sustain him in his father’s absence. He cannot feel even the presence of the angry, critical father he has known; instead, he feels no presence at all. He is empty, depleted of all energy and content, as though (in his words) “I don’t really exist.” Marc is experiencing depression with clear anaclitic features. An object relations theorist might note that he seeks relief from this depression by trying to establish a new relationship with another “hated” person, the therapist. It is as though Marc is trying to reconstitute the same kind of relationship he had with his father, without which he feels he cannot survive. As a child develops beyond infancy, his or her object representations become more enduring and better differentiated from representations of the self. We have seen how object relations theorists picture these newly independent and more stable object representations as first being organized (or “split”) along the emotional lines of how the person feels toward the object. Thus, representations associated with pleasurable interactions with the object (“good object” representations) may be kept separate from representations of frustrating interactions (“bad object” representations). Later, under good enough circumstances, the child is able to integrate these representations into a more realistic image of the object in which the same person both pleases and frustrates. This consolidation, as we have seen, is called “object constancy” by object relations theorists, or referred to as achievement of the “depressive position” by Klein (1940) (see chapter  5). Object relations theorists consider this a major developmental advance in that it involves some depression, as Klein’s term suggests. Forever after this developmental step, the individual lives in a more complicated, sadder-but-wiser representational world in which the object, and also the self, can be experienced as all good and all bad, all loving and all hating, all pleasurable and all painful. The capacity to bear this developmental step has impact on the individual’s lifetime “capacity to bear depression” (Zetzel 1970) and makes possible the uncomplicated but painful mourning that Freud described as normal. Object relations theorists suggest that when a person who has suffered an object loss lacks sufficient integration of good and bad self and object representations, he or she may feel depletion, object hunger, guilt, self-reproach, and lowered self-esteem (Blatt 1974; Jacobson 1964). Jacobson (1964) noted that when children experience a lack of parental understanding and empathy, it diminishes a child’s self-esteem. This then leads to angry feelings toward the parent(s), accompanied by guilt, which further lowers self-esteem. In order to protect the parent, whom the child needs, the child may turn his anger toward himself. Disappointment and fury at the person who was emotionally depriving are then experienced as disappointment and fury at the self. Pedro, a cisgender Mexican male who had immigrated from Mexico City when he was two, was thirty-four years old when he came to therapy depressed about his lack of professional success (he was working as a low-level computer salesman) and his inability to make a commitment to his fiancée, with whom he lived, or show affection to her two children, who he planned to adopt. He had recently lost his father and was confused by his lack of feelings, his depressed mood, and his anger at himself. Pedro’s father, despite language obstacles, the loss of his own family of origin, and early financial struggles, had become a successful computer technician. Pedro had two brothers, who were both married, professionally successful college graduates. Pedro had dropped out of community college after his first year, because, he said, he partied too much. He returned home to live with his parents, which produced much interpersonal conflict as he felt himself the object of his parents’ disappointment.

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Growing up, Pedro felt that his parents preferred and rewarded his brothers. Each was very capable in school and had many friends, while Pedro’s only notable success was soccer. Pedro felt his parents saw his brothers as embodying the American Dream, while he was living an American stereotype they disapproved of: a college dropout who only excelled at sports, living with a woman who was not yet his wife. He appeared to have been neglected by his parents. He had had significant learning issues that went undiagnosed and were never addressed. He also could not recall either of his parents ever attending his soccer games; even when he made it into the semifinals, neither parent was willing to go to practices or competitions. Nor did his parents show interest in his friends. Pedro was very guilty about feeling angry at his parents, who had sacrificed so much as immigrants to give him a decent life. Now that his father had died, he felt especially guilty and incompetent. He would say repeatedly in therapy, “I wish I had done more; I wish I had done more for him.” On one level, it appeared he was lamenting not having been able to do more for his dying father; on another level, he was saying that he wished his father had done more for him. After his father’s death, Pedro needed to hold on to an idealized view of his father as a highly skilled and competent man, while seeing himself as without skill or value.

Object relations theorists have concerned themselves not only with a developmental understanding of depression at the time it becomes a problem but also with the study of how losses affect representational development. They note that the kinds of losses that occur—when they occur, and how often they occur—play crucial roles in development. Infant and child studies have documented specific relationships between object experiences, later representational development, and depressive symptoms. Bowlby (1958, 1961, 1963) was among the first to suggest that different kinds of losses predispose people to different kinds of depression. He noted that when faced with prolonged separation, children go through three phases: protest, despair, and detachment. His studies of children separated from their mothers revealed that when a caregiver is emotionally or physically absent for significant periods of time, a child will first try to bring back the lost object. If unable to mobilize the caregiver’s attention or bring her back, the child may become more disorganized. The child will protest, and ultimately despair. Finally, if over time the child is unable to reengage the caregiver or a substitute, she may detach entirely, leading to a kind of hopelessness and turning away from the object world. Attachment theorists point out how early relationships with others that are insecure or unstable can lead to the development of internal working models of the self as unlovable and unworthy, and the experience of others as attacking or rejecting. Such individuals tend to be vulnerable to depression and experience everyday disappointments as evidence of a lack of self-worth or of a lack of care and support from others (for further elaboration, see chapter 8 on attachment theory). Gianino and Tronick (1988) have captured this phenomenon in detail on videotape with healthy mothers and their children under experimental conditions. Well-functioning mother–infant dyads were filmed in the process of mutually cueing one another. In one scene, a mother expressively engages her infant through smiling and laughing. In the next scene, her face becomes blank. In response, the child first tries to reengage the mother and reinitiate the “dialogue.” The mother’s face remains blank. As these efforts fail, the infant cries and fusses. When there is still no response from the mother, the child’s protest becomes louder and her behavior becomes more disorganized. Finally, we see the infant look away, no longer interested in attempting to bring her mother back. For children with severely depressed mothers, or children who have suffered profound early losses, the experience of withdrawal is not simply an isolated event. When this pattern

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recurs again and again, depression emerges in reaction to the accretion of millions of these tiny events. For children separated from their mothers for prolonged periods, or children who have chronically unresponsive or abusive caregivers, a depressive hopelessness and disengagement is frequently the outcome. Studies of abused toddlers and preschoolers reveal that extremes of maltreatment interfere with the development of a representational internal world, which can affect states of self and other, pleasurable interactions between self and others, and a stable, positive sense of the other both in person and in absence (Cicchetti 1989). Follow-up studies suggest, as object relations theory would predict, that such children are at a heightened risk for depressive symptoms by adolescence (Cicchetti 1989). Such extreme cases provide powerful evidence of the object relations view that later self-esteem is constructed in the crucible of early relational experiences that offer what Winnicott might have referred to as a “good enough” holding environment.

Self Psychology Self psychologists conceptualize affective disorders as emerging from a pattern of empathic failures by significant caregivers. Recall that every individual needs to be admired by an attuned and admired other with whom the person can merge for the achievement of vigor, grandiosity, and healthy self-esteem. Parents, teachers, coaches, neighbors, extended kin, and siblings in a child’s world can provide these selfobject functions. They affirm the child and respond to the child’s needs with empathy, acceptance, and admiration. When this occurs, the child has the building blocks for mature self-esteem and the pursuit of realistic ambitions and goals. But when mirroring fails, the child may treat herself poorly, establishing unrealistic ideals, behaving recklessly, attending to neither danger nor limits, unable to mobilize self-care. Liza, the oldest of six children in a white working-class family that was emotionally impoverished and financially drained, described herself as always exhausted as a child and underachieving in school. She grew up in a family in which she felt that there was “no one home.” She felt neither noticed, nor special, nor talented in any way. Liza spent much of her childhood on the couch, simply too tired to move. It seemed to her that no one noticed her existence nor had any sense of who she was. As a consequence, neither did she. Now, as a forty-year-old adult, she lies on the couch much of every day watching TV, unable to mobilize, waiting for her husband to come home to make her dinner. She describes feeling like an irritable baby who simply cannot soothe herself. Nothing seems to engage her interest; she looks around her house and is overwhelmed by all the half-finished projects. She lacks the sense that she can accomplish anything. At one point in therapy, Liza brought in baby pictures and noticed for the first time that all of the pictures were of her in a crib, lying on her back. She first wondered what kind of baby she must have been for no one to want to pick her up. Later, she wondered what kind of family she must have had to let her lie so much alone.

A self psychologist might posit that Liza grew up lacking sufficient selfobjects to mirror her and help her develop healthy goals and ambitions. This lack of mirroring and affirmation from others, and the absence of available adults with whom to merge, contributed to a sense of herself as a depleted, empty big baby. While she was aware that she had had some achievements in school (baton twirling, cheerleading, and academics), none of these were mirrored back to her by a family that was impoverished—financially and emotionally.

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Unlike drive theorists, ego psychologists, or object relations theorists, who might see Liza’s depression as a result of anger now turned against herself, or of not living up to her ideals, or as a failure to integrate self and object representations, or as a function of neglect, a self-psychologist would understand her depression as an appropriate by-product of unmet selfobject needs. Liza’s inability to soothe or develop a coherent sense of self might stem from a developmental failure to attain the capacity for activity, given the lack of transmuting internalizations of available, empathic selfobjects who could mirror her or let her merge with them. The differences in the four theoretical perspectives are not simply academic. They lead to different kinds of clinical interventions and choices. A drive theorist, for example, might help a depressed client become conscious of her unconscious anger and of the ways in which that anger is turned inward in the form of self-hate or self-harm. An ego psychologist might attend to the client’s superego ideals and to the client’s sense of worthlessness, which results from excessive or unrealistic expectations. An object relations theorist might attend to early abandonment and loss, the lack of a nurturing holding environment, the inability to integrate good and bad self and object representations, or the effects of abuse in which a person idealizes the abusive or neglecting parent while blaming the self. A self psychologist might serve as a new selfobject to the client, offering strength, affirmation, mirroring, and appreciation for the client’s needs. There is no one psychodynamic formulation for depression, nor is there one treatment. Instead, there are multiple dynamics and multiple approaches for treating depression from a dynamic perspective. As with all disorders, choices are made based upon the uniqueness of each individual client, the genetic history of that client, and the particular ways in which depression manifests itself. All choices should be informed by the client’s strengths.

DEPRESSION AT DIFFERENT DEVELOPMENTAL LEVELS Depression and bipolar disorder are the first diagnostic categories we have considered that are defined in terms of an affect or mood, rather than functioning. So far in this book we have studied three different developmental levels: psychotic, borderline, and neurotic. Depression can be experienced at any of these developmental levels. As clinicians, a developmental approach offers a way to understand how depression is experienced and how the internal world of a client is constructed. Only by entering into that world can we join with our client empathically and introduce some different and, one hopes, helpful experiences that will be tolerable to the client. Below, we consider three prototypic cases of depression at the psychotic, borderline, and neurotic levels of functioning. Depression at a Psychotic Level of Functioning Recall that psychosis is characterized by a loss of reality testing and the concomitant loss of a sense of self and object relationships. These characteristics are also seen in psychotic depression, in which the depressive affects and symptoms we have been studying reach psychotic proportions. It is important to mention here that biological and psychosocial vulnerabilities predispose a person to psychotic depression (Heslin et al. 2016). Indeed, psychotic symptoms are evidence of very severe illness and can be seen in both unipolar and bipolar mood disorders.

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Prior to the onset of her psychotic depression, Susan, a thirty-four-year-old, white, cisgender, middle-class, Catholic woman of Irish descent, was considered a cheerful, outgoing, “perfect” wife, mother, and part-time dental hygienist who was active in her church. Gradually, she became increasingly somber at work. At home, she spent more and more time alone in her room. She became extremely apologetic about minor paperwork errors, worrying aloud that she would be fired by her boss (whom she knew to be benevolent). She was obsessed with the fear that through lack of proper hygiene or a neglectful procedure she would hurt her patients. She began to accuse herself, muttering that she should be fired. Susan’s retreats to her room were accompanied by her berating herself for failing “to feel better.” Eventually, she could “no longer go through the motions.” Life became meaningless. She did not leave her room and barely spoke—and then only in a raspy, low voice. Her husband brought her to the hospital because he was afraid that feeling she had “nothing to live for” might indicate she was suicidal. In the hospital, Susan heard a mocking voice telling her that she was not real and that she should “die” for an “affair” that she had six months earlier with a fellow church member— though the affair was never sexually consummated and there had been little actual time spent with this person. In one early session, Susan confused her therapist (a male) with her mother, who commanded her to “Go to your room until you get yourself under control” (a clue to her early object experience). Another time, she thought her therapist was her priest.

At the psychotic level of functioning, a person’s greatest fear is that death or annihilation of the self has occurred. Susan felt, at a level of stark terror and disorganization, as if she were already dead or disintegrated. Nothing made sense to her—she no longer made sense to herself. With a collapse of self-object differentiation, Susan was no longer able to tell whether the mocking, reproachful voice she heard came from inside (from memories or internal dialogue) or outside herself. At such an early level of ego functioning, her reality testing was compromised. Thinking was organized along the lines of primary processes; primitive feelings rather than logic or empirical fact predominated. Thus, Susan experienced a psychotic transference to her therapist of her very rigid priest, without being able to test the reality of who was actually in the room with her. Other aspects of Susan’s experience were also typical of a psychotic depression. There were early hints that some of her self-reproaches about being “not real” or being psychically dead were actually criticisms of an emotionally dead parent (or one experienced that way), who was being treated as part of Susan’s (criticized) self. Indeed, Susan had experienced both parents as extremely reserved and disapproving of any emotional display, happy or sad, on her part. At times (not necessarily accompanied by other overt psychotic functioning), she would experience her dead mother as inside or a part of her body. Such experience reflected her fantasized “eating” or incorporation of the loved (and hated) other, a primitive operation that is sometimes the best the ego can do to retain a needed object relationship. Also typical of a psychotic level of depression was her grossly distorted superego. Susan believed herself to be dangerous to others—accusing herself of killing her mother or hurting her family or her patients—and sentenced herself to a kind of living “death,” a nonexistence in which she felt she could do no more harm. Her harsh superego injunctions were at the psychotic level. How was understanding Susan in developmental terms useful for the clinician? First, it helped the therapist tolerate Susan’s overwhelming feelings of panic, emptiness, and rage, and made these feelings understandable in terms of her internal world. That, in turn, allowed Susan to sense dimly that “someone was with me who seemed to know where we were, but was not afraid.” Later, as Susan’s ego functioning improved, she still suffered intense depressive affects but was able to use her therapist’s recognition of her experiences to differentiate herself from her feelings. In her words, “Now I feel there is an I, who ‘had’

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those experiences” (Hayes 1996, personal communication). By disconfirming Susan’s beliefs about her badness and proving not to be like her rigid priest or angry parents, Susan’s therapist helped her internalize new kinds of object representations. Depression at a Borderline Level of Functioning We previously characterized borderline-level functioning as resulting from a difficulty in integrating a sense of self and others so that these images are “split” into all good or all bad representations. People who function at this level also tend to experience aggression as un-neutralized and coming from the outside rather than inside. Depression at this level of functioning does not reach the psychotic state of Susan’s but still has an “all or nothing” totalistic quality to it. Louisa, a twenty-three-year-old, cisgender Puerto Rican mother of a six-year-old son, Raphael, was admitted to the hospital in a diabetic coma because of failure to comply with her medical regimen. As she recovered, she complained of many specific physical pains and symptoms, centered in her abdomen, chest, and head, whose location shifted so frequently that she could not be successfully diagnosed. Louisa gradually became friendly with a nurse who was alarmed by what she heard in their conversations and asked for psychotherapeutic services. Louisa told her therapist that she and Raphael had moved to the mainland from rural Puerto Rico a year before for “no special reason.” Louisa held a clerical job, but was socially isolated except for Raphael, who had become “very hostile” over the past year. He had, in fact, been dismissed from several daycare centers for violent behavior. Louisa was living in a housing project. Neither a member of a church nor part of a cohesive community, she experienced significant isolation. Without family she felt particularly alone. Louisa clearly described a cycle at home in which she experienced Raphael’s abundant (but perhaps normal) curiosity and activity as maliciously aimed at “getting on my nerves,” and she retaliated by getting very angry and then raging at him. She would then become frightened of her wish to hurt him physically and would angrily withdraw all contact, sometimes for hours. It was during these times that she would withhold medication from herself and eat dangerous foods. Death, she thought, was the only escape. She had in fact “taken pills” on several occasions before her son’s birth in attempts to die. Initially, Louisa described a “happy childhood.” Only after some months of outpatient work did she “remember” her father’s desertion of the family when she was seven (remember that her son was six), and her mother’s alcoholism and physical abuse of her. She had, in fact, left her hometown at age twenty-two to follow an unfaithful lover with whom she reunited for a time. Her hospitalization was immediately preceded by news that this man had left her for another woman who had just moved to their city. That woman turned out to be her father’s stepdaughter, for whom “he left me when I was seven!”

Louisa, while never manifesting overt loss of reality testing, experienced her depressed moods as timeless and cut off from any hope of improvement. Memories of feeling better held little meaning when she was depressed. The sadness, helplessness, and badness would seem to exist forever in an eternal “now.” Louisa’s anxiety fluctuated between terror of merger and terror of abandonment. She experienced unbearable aloneness when left by her lover or cut off from her son. Yet she felt invaded when she thought her son was abusing her and when she abused him. She regarded her son (and her therapist) as “all good” or “all bad,” and viewed herself in this “split” fashion. She was prone to savage attacks on herself, including physical pounding and even suicide attempts, as primitive superego retribution for her badness. By punching herself, Louisa could both punish the (poorly differentiated) abusing mother with whom she was identifying and reexperience herself as the abused child.

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Work with Louisa was aided by a developmental approach to her depression. Her white, female therapist was able to empathize accurately with her utter hopelessness and the extreme urgency of her need for relief when she and everything around her felt “bad” and lonely. Only after they had together experienced several cycles of good and bad times would her therapist begin to bridge these states, which Louisa experienced as timeless and “forever” when she was in them, reminding her that they had “been here before” and she had survived. Such bridge building with a reliably available, nurturing therapist helped Louisa’s begin to build object constancy. Louisa was encouraged to join a church and become engaged in her son’s school, both of which she was able to do. Depression at a Neurotic Level of Functioning We now consider a developmental approach to understanding depression in people whose depression is at the neurotic level (as we will discuss more fully in the next chapter). A person who has achieved more integrated self and object representations, and whose ego functions are more intact, may experience depression as a result of conflicts at the superego level of development. Feelings of low self-esteem, of not living up to one’s ego ideal, and of disappointment in the difference between one’s aspirations and one’s reality are usually experienced at the neurotic level. Al, a gay male school principal and father of two, came to treatment for depression. He had grown up in an Evangelical Texan family with high expectations for its four children and corporal punishment if those expectations were not met. He described a cold and exacting father who was unsupportive of his sexual orientation and who, at times, could be highly critical. Al was an excellent student who did well in many spheres of his life (including sports and after-school activities) but suffered bullying at home that undermined his self-esteem.

Al is an example of someone whose depression is primarily at the neurotic level of functioning. Experienced at the superego level, his reality testing, judgment, and sense of self and others were intact. But there were times when he felt unable to live up to his own ideals and did not know why. Al’s low self-esteem and chronic mild hopelessness may have stemmed from having always been “in the wrong” with his parents, which further contributed to his current feelings in the workplace and in his family.

BIPOLAR DISORDER Now let us turn our attention to bipolar disorders, another class of mood disorder that can occur in people at all levels of functioning. Like depression, and the other psychopathologies delineated in this book, bipolar disorders do not distinguish between men and women, among wealthy or poor, or by race or ethnicity. In fact, one of the leading authorities on bipolar disorder, Kay Jamison, is a clinical psychologist and successful scholar and writer (1993, 1996) who herself suffers from the illness. Bipolar disorders are often conceptualized as biological in origin, and there is indeed a strong genetic component. About 50 percent of those who suffer with bipolar illness have a family member with the same diagnosis. Identical twins often have the same disorder, even when raised in wholly different families. However, despite tremendous gains in molecular genetics, the search for risk genes for mood disorders continues to be elusive (Flint  & Kendler 2014). Even the incredible ability to sequence individuals’ genomes has had little impact on this particular quest (Mondimore 2019, personal communication). Rather than

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searching for the genetic underpinnings of specific, but heterogeneous diseases, like bipolar disorder, researchers are beginning to search for genes for certain symptoms (like apathy, rumination, agitation, etc.) that cut across multiple syndromes, from depression to schizophrenia to bipolar disorder and some personality disorders (NIMH 2020). For millennia, physicians and scientists have postulated that melancholia (meaning black bile in ancient Greek) and mania (from the Greek word for madness) were related—as different sides of the same coin, like the Janus mask’s sorrowful and smiling visages. In the second century AD, the Greek physician Aretaeus of Cappadocia wrote, “I think that melancholia is the beginning and a part of mania. . . . The development of a mania is really a worsening of the disease (melancholia) rather than a change into another disease” (Angst & Marneros 2001, p. 6). This ancient formulation underscores the interplay between depressive and manic presentations. Some contemporary psychodynamic theorists have suggested that individuals with borderline and narcissistic character organizations may be especially susceptible to mood fluctuations between despair and elation. In psychodynamic terms, we might think of mania as a defense to ward off depression and avoid intolerable feelings of sorrow, loss, or loneliness. Indeed, Freud suggested that mania was a way to escape depression, while Klein (1940) characterized omnipotence, denial, and idealization as the central features of what she termed the “manic defense” against the pain and discomfort of dependency. The Experience of Bipolar Disorder Earlier we described the stultifying, smothering, emptying experience of depression. While depression is also present in bipolar illness, what makes it a distinct disease are the periods of elevated mood, which can manifest as pressured speech, heightened activity, periods of sleeplessness, jumpiness, irritability, or racing thoughts. Once more, let us turn to the voices of those who have lived with this mood disturbance to hear the unique experience of mania in their own words. In her memoir, An Unquiet Mind, Kay Jamison (1996) records with beauty and poignancy a life marked by manic-depressive illness. Initially, Jamison experienced her mania as pleasurable: “My manias, at least in their early and mild forms, were absolutely intoxicating states that gave rise to great personal pleasure, an incomparable flow of thoughts, and a ceaseless energy that allowed the translation of new ideas into papers and projects” (pp. 5–6). She describes the tantalizing twinkle of hypomania as a “light, lovely tincture of true mania” (p. 37). Here, Jamison elucidates what may be most confusing for the beginning clinician. If elevated moods are pleasurable, euphoric, and conducive to professional success, what is so troublesome? Why is mania considered such a maddening affect? In part, the answer lies in the aftermath of a manic episode, the pieces left for the sufferer and family to gather up: extravagant bills, ruptured relationships, lost jobs. Mood disorders have a tremendous impact on family, friends, and social networks. By the time clients with mood disorders arrive in the clinic, they may have long burned through their remaining outside supports. Perhaps understandably, many people are resistant to embracing treatment while in the grip of a pleasurable hypomania or mania. But mania also has a much darker side, marked by agitation, aggression, psychosis, suffering, even suicide. Symptoms of Mania When a person is manic, everything is heightened and sped up: mood, speech, thought, physical and mental activity. The diagnostic criteria (American Psychiatric Association 2013)

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for mania includes abnormally and persistently elevated, expansive, or irritable mood with increased energy or activity. There can be inflated self-esteem or grandiosity, where one may, for example, believe himself to be Jesus (Akiskal & Pinto 1999). There can be “flight of ideas,” experienced as racing thoughts that appear as pressured, rapid, disorganized speech. Occasionally, this leads to “hypergraphia,” where a compulsion to write can result in copious journal entries or voluminous letters. The manic person may be intensely distractible, as each new idea or project, irrelevant details included, momentarily grips the attention. A loss of inhibitions and an increase in pleasure-seeking activities, with potentially problematic consequences, can also be present. This might manifest as “hypersexuality” with heightened libido leading to numerous sex partners, exhibitionism, or excessive spending, gambling, speeding, or substance misuse. Some of this symptom picture is captured by National Public Radio correspondent Jacki Lyden (1998), who arrived at her mother’s home in the wake of one of her mother’s manic spells: The Christmas tree had been spray-painted gold and stuck in a bucket of plaster of paris.  .  .  . The crackling, shrunken branches of the tree were festooned with dog biscuits and expensive, lacy bras, and a baby bracelet that I recognized as belonging to one of my sisters. A pair of gold panties dangled from one branch.  .  .  . This was my mother’s Christmas tree, a gold shrunken skeleton, wearing panties. On the walls, my mother had stuck large drawings, diminishing the living room. There were giant praying hands and an Infant of Prague, the Catholic icon of childlike confidence. . . . The smell like a rotting catch of mackerel came from the dining room. My mother had laid on an elaborate and careful party, betraying days of manic effort: radishes carved with tiny faces and spelling out the word “love” on a silver tray, steak tartare decorated with whipped cream and tiny plastic ballerinas on swizzle sticks, dancing merrily; oysters on platters with paper feet cut from magazines; and clams wearing pink feather fluffs. I checked the Christmas place cards, little angels bearing names. Lord Jesus the Christ, of course, was at the head of the table, and there was Mary Baker Eddy, the Christian Scientist founder who was always a portent of my mother’s insanity. Harvey the Six-Foot Pooka had a place of honor (“You can’t see him,” it said on his card, “but he’s here! Shake Paws with Harvey!”). (pp. 15–16)

The tableau that Lyden’s mother composed was chaotic, frenetic, distracted—the work of a mad hatter zipping from one off-kilter decorating project to the next. One can imagine the effort, energy, devotion, and forgone sleep that went into carving those tiny faces into radishes, appending individual oysters with paper feet, and festooning clams in pink feathers. There are hints of hypersexuality and a loosening of inhibitions in the bras and panties that adorned the Christmas tree. Lyden’s mother’s increasingly tenuous grip on reality was apparent in her grandiose expectation that both Jesus and an invisible, imaginary film-star rabbit would be joining the family for dinner. The Diagnostics of Bipolar Disorder Perhaps more than any other mental illness, the medicalization of people with bipolar disorders has marched steadily forward since the 1970s. One explanation is that the bipolar illnesses respond quickly to medications, among them the mood stabilizer lithium, anticonvulsants, and atypical antipsychotics. From a biopsychosocial perspective, we might say that in the case of bipolar illness, the biological has come to overshadow the psychological and virtually obscure the social. Among the many challenges in assessing people with bipolar disorders is the fact that, as clinicians, we are most likely to see bipolar clients when they are depressed. Rare is the individual who shows up in an outpatient clinic complaining of psychiatric difficulties while

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suffused with the warm glow of hypomania. When floridly manic, a client may not feel ill or may be too deep in denial to seek help, which, sadly, often results in hospitalization or incarceration. It is easy, then, to see how the incidence of bipolar disorders may be markedly higher than previously believed. This was poignantly brought home in the treatment of Sadie, a twenty-five -year old c social worker at the start of her career, who came to see one of the authors complaining of depression. Sadie had recently graduated from college and was living in the same town as her overbearing and critical mother, who found her to be “too fat, too much, and too unmarriable.” Sadie spent her first months in treatment complaining about her mother and her mother’s effects on her self-esteem. At some point, when Sadie was feeling particularly self-defeating, self-denigrating, and low, her therapist suggested trying an antidepressant. Sadie’s psychiatrist began sertraline (Zoloft), and much to her horror and that of her therapist, she began acting in uncharacteristic ways. She demanded that her boss give her a raise; she took over in meetings with no regard for others; she began buying things she did not need; and she experienced racing thoughts and pressured speech. When she cut up her credit cards in a meeting, muttering to herself, she was asked to leave the clinic. Sadie went directly to an emergency room where she was admitted as an inpatient and diagnosed with bipolar disorder. Her therapist did not know there was a family history of bipolar disorder. Had Sadie’s therapist or psychiatrist known this information, Sadie would not have been started on an SSRI, which can trigger bipolar illness.

The onset of bipolar illness tends to be abrupt, emerging over a few days. Depressive events that are part of bipolar depression are generally thought to develop more quickly than with other types of depression. Prior to a full-blown manic episode, there may be what is known as a “hypomanic alert,” when a person experiences hypomanic symptoms for a few days or weeks, most commonly starting as sleep disturbance (Goodwin  & Jamison 2007). When depression and mania are simultaneously present, in so-called “mixed states,” the sufferer must contend with both the anguish of depression and the agitation of mania. Mixed states are characterized by insomnia, psychosis, and suicidal thinking: “My mind would race from subject to subject, but instead of being filled with the exuberant and cosmic thoughts . . . it would be drenched in awful sounds and images of decay and dying; dead bodies on the beach, charred remains of animals, toe-tagged corpses in morgues” (Jamison 1996, p. 45). The exact relationship between stressors, the environment, and genetics in precipitating bipolar events is unclear, but earlier episodes may be triggered by psychosocial stressors such as a loss of relationship or a major life transition, like graduating from college. Bipolar disorders have also been linked to traumatic life events and to overexposure to stressful situations (Aas et al. 2016). The course of bipolar illnesses are episodic. Later episodes can seem to come out of nowhere and may accelerate with age and over time in what is known as “kindling.” For this reason, attempting to prevent relapse is important. Once a bipolar event has occurred, there is a high likelihood of recurrence, with more than 90 percent of individuals who have had one manic episode going on to experience another (American Psychiatric Association 2013). The majority of people suffering from bipolar disorders experience near full recovery between episodes. Long-term outcome, however, remains difficult to gauge.

CASE EXAMPLE Now we turn once more to a case vignette, a snapshot of treatment with a woman experiencing symptoms of hypomania:

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Alicia, an attractive, freckled, cisgender twenty-nine-year-old white woman of Italian descent, arrived to a session about a month into therapy. She dropped into her chair and, without pause, launched breathlessly into a monologue: “I  really need to get a car. I  drove over here with my sister in my father’s Expedition or Explorer—whatever the big one is. He’s really her father, my stepfather, but I call him my father. I need to get a car but I need to deal with that license thing first. Me and Antony got in a fight about it. My grandparents used to do everything for me: my car was in their name and I just had a learner’s permit. But Antony won’t do that. There’s a station wagon I want, for the kids, and I told him to just buy it. But he said he won’t buy a car until I get my license. He bought me a car once, an Acura, but he wouldn’t register it in his name and since I didn’t have a license, he had to take it back. He put $5,000 down and then he had to get it back. He says he won’t do that again. And I know I need to get a licence but I just can’t make myself do it.” Alicia’s speech was pressured as her thoughts raced from the car she arrived in, to her relationship with her stepfather to her desire to drive herself and gain greater independence. This flight of ideas rested briefly on the grandparents who had raised her, before returning to her desire for a car and the conflict this wish had caused in her relationship. All the while, Alicia was restless and fidgety. Feeling overwhelmed by her outpouring, Alicia’s therapist, who had never before sat with someone experiencing hypomania, tried to slow her down: “Okay, so let’s talk about the license. Why do you think it’s so hard for you?” Looking bewildered, Alicia replied, “I really don’t know.” Alicia began psychotherapy at the urging of an addiction counselor in the program for addiction and pregnancy that she attended while pregnant with her infant son. She had a history of multiple psychiatric hospitalizations for detox from a variety of drugs. During one such hospitalization, years earlier, she was diagnosed with bipolar disorder. But this was the first time that Alicia had followed through on the recommendation for mental health services, explaining that since this was also the first time that she she was drug-free, she figured she “might as well go the full nine yards.” Alicia’s family history included overwhelming mental illness, suicide, and traumatic loss. Her mother was depressed and hung herself when Alicia was just twelve—shortly after, Alicia began using drugs. She was raised by her maternal grandparents, who doted on her and did “everything” for her. Growing up, Alicia had not been close to her father, who had a substance use disorder, but the two had grown closer during Alicia’s teenage years. When Alicia was 24, her father was diagnosed with terminal cancer. A  year later, as his health began to decline, he killed himself. Around the same time, Alicia’s elderly grandparents passed away. “I wonder,” asked Alicia’s therapist during their session, “if part of what makes going to the DMV to get a driver’s license so hard, is because it’s the kind of thing your grandparents would have helped you with. Maybe it feels like if you don’t do these things on your own, your grandparents might still help you?” For the first time since she had arrived, Alicia slowed down and looked at her therapist. “I never thought of that,” she said. “But maybe. I know it’s been a while, but sometimes I do feel like they’re still alive. I never thought they would die. Like when they called to tell me my grandfather was dead. I  thought they were joking. I  thought they would live forever.”

This anecdote captures some of the complexity of working with clients with bipolar illness. It took years before Alicia sought treatment, despite a clear genetic vulnerability for a mood disorder. She had self-medicated for years, her symptoms masked by drug use—not uncommon in people with a bipolar illness. At home, Alicia was experiencing sleep disturbance, staying up late cleaning. She said that she felt “hyper,” like her “head was going nuts—everything was going too fast.” Alicia was so distractible and scattered that she frequently misplaced appointment cards, rushing into the clinic on the wrong day. There were periods where she forgot or lost her medication, which meant titrating her medication to a therapeutic dose took months. Yet beneath her buzzing energy and constant motion was breathtaking trauma and loss.

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Initially, her therapist, new to clinical work, was overwhelmed, bewildered, and at times distracted by the whorl of words, energy, and activity seated across from her. There was little space for conversation, let alone understanding. But by remaining present and interested and holding on to her own equilibrium, she was able to help contain some of Alicia’s hypomanic energy. Over time and with the help of medication, Alicia’s sleep improved, her speech slowed, and she was more able to keep track of her thoughts, her prescriptions, and her appointments. Snippets like those involving her grandparents expanded into longer conversations. She and her therapist were then able to explore and make thinkable the profound loss and unresolved grief that drug use and a manic defense had distorted for so long. Treatment Issues In the treatment of individuals with bipolar disorder, there is an undeniable place for medication. Research has shown that left untreated, manic episodes can increase in length over time, with recovery becoming more difficult. Very often, relapse occurs as a person discontinues medication and drops out of treatment. Yet rather than being a case for medication management alone, this underscores a point that we have made throughout the book: Choosing whether to take medication can have meaning for a person, meaning that can and should be discussed and worked through in therapy. While medication may help reduce symptoms, therapy helps with overall relational functioning. Had Alicia not had a therapist who patiently reminded her of her appointment times when she arrived on the wrong day and problem-solved with her when she lost her refills, would she have grown to be as consistent with her medications and therapy as she did? In their work together, Alicia and her therapist discussed her relationship with her boyfriend and what it meant to mother their children, having lost her own mother at twelve. She was able to begin to create the stability and “harmonious” life that she so desired for herself and for her children. None of this would have been possible with medication alone, without the warm relationship that unfolded between Alicia and her therapist. Once again, Jamison (1996), the clinical psychologist who suffers from bipolar disorder, movingly articulates the relationship between psychotherapy and psychopharmacology: At this point in my existence, I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. But, ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality; they only bring one back headlong, careening, and faster than can be endured at times. Psychotherapy is a sanctuary; it is a battleground; it is a place I have been psychotic, neurotic, elated, confused, and despairing beyond belief. But, always, it is where I have believed—or have learned to believe—that I might someday be able to contend with all of this. (pp. 88–89)

BIOLOGICAL FACTORS There are many additional factors to be considered in the etiology and treatment of mood disorders, which we will touch upon now. Genetics, hormones, brain structures, and temperament may all play significant roles in a person’s predisposition to the triggering and prolonging of depressive and manic states. Let us consider each of these factors separately.

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Genetics Next to stressful life events, genetics is the second-largest risk factor predicting mood disorders. Bipolar illness has a clear genetic basis, clustering in families. Precisely how having a biological relative with bipolar disorder impacts risk varies by study. But by some estimates, the chance of children born to parents with bipolar disorder developing the illness is 1 in 10, while the chance that they will develop any type of mood disorder is 1 in 4 (Mondimore 2006). In one study, if one parent had a mood disorder, the lifetime risk to the offspring of having a mood disorder was found to be 27 percent. If two parents had mood disorders, the offspring faced a very significant risk (74 percent) of developing the disorder (Gershon et al. 1982). The mode of transmission of depression remains uncertain, but it does not appear to follow classic single-gene disease patterns. Several studies have cited similarities between blood types in families that manifest these disorders. Researchers are also seeking to isolate other genetically transmitted traits, such as light sensitivity, which may characterize families with mood disorders. It is important when taking a family history that we ask not only about the history of mood disorders but also about alcoholism and gambling in the family. These addictions often mask bipolar illness and may be genetically transmitted or cluster with depression. In fact, cooccurring substance misuse with bipolar I disorder is estimated to be 60 percent. Even as the search to isolate a gene predominately responsible for mood disorders has remained elusive, pharmacogenomics is bringing a modicum of personalized medicine to psychiatry and medication management. These genetic panels have been shown to help physicians determine which medications patients are more likely to respond to and can improve outcomes. As more phamacogenomic genes and alleles are identified, we can expect the usefulness and impact of this approach to continue to improve patient care (Mondimore 2019, personal communication). Hormonal Theories Hormonal theories also contribute to our understanding of mood disorders. Female hormones may play a role in the finding that depression is two to three times more likely to be diagnosed in women than in men. Hormonal changes may also affect the course of bipolar disorder in women. Menstrual cycles and menopause can have subclinical effects on women’s moods, and may result in irritability, sadness, or hopelessness. Likewise, postpartum depression (which often signals an underlying bipolar disorder) and ordinary postpartum blues appear to be related to hormonal changes. Miscarriage can also trigger depression. No single hormone, such as progesterone, has been identified as the causative agent for depression. Rather, it seems that multiple hormones may work in concert in predisposition to depression and cycling moods. It is also clear that we should not limit our thinking to sex hormones, as many of the hypothalamic and pituitary hormones can also affect emotions. Agents like prednisone and adrenocorticotropic hormone (ACTH), which are administered to treat cancer and inflammatory reactions, are commonly found to cause mood disturbances. The Brain There have been enormous changes in the treatment of all affective illnesses as a result of our use of medications that impact the brain. Early theories suggested that neurotransmitters

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and receptor sites were the basis for the effectiveness of pharmacological interventions. Antidepressant medications were believed to block the metabolism of the neurotransmitters, making them more available to the brain’s receptor sites. Mood disorder research has since shifted to a focus on the brain’s ability to respond and adapt to change, a phenomenon known as neuroplasticity. Medications that are effective in treating mood disorders are now believed to be beneficial in part due to their ability to enhance neuroplasticity. Though our understanding of the mechanisms has changed, some antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), are still considered a treatment of choice for many people. Slightly newer antidepressants such as the serotonin and norepinephrine reuptake inhibitors (SNRIs) work on multiple neurotransmitter pathways at the same time. And older tricyclic antidepressants are still prescribed regularly and can be very effective and economical medications. Often, prescribing evaluations include consideration of side effect profiles and whether patients may benefit more from slightly sedating or more activating medications. One exception is in the treatment of those with bipolar illness, where some antidepressant medications are thought to potentially precipitate underlying manic episodes and put a person at increased likelihood for developing bipolar disorder. This risk is believed to be lower with the antidepressant bupropion (Wellbutrin), a norepinephrine-dopamine reuptake inhibitor (NDRI). The gold standard for treatment of bipolar disorder continues to be the mood stabilizer lithium. A naturally occurring salt with antimanic, antidepressant, and anti-suicide properties, its healing powers were recognized as far back as the early nineteenth century. Additional medications for bipolar disorder include the anticonvulsants Depakote and Lamictal, which are also prescribed for epilepsy. A newer class of antipsychotics with fewer side effects are also frequently applied in the treatment of bipolar disorder. In the realm of neuroscience, the discovery of the importance of chemical pathways beyond those involving the neurotransmitters dopamine, serotonin, epinephrine, and norepinephrine, has led to new pharmacological approaches. Ketamine, an anesthetic, is one intriguing new option. Other clinical trials include older drugs, like the cough suppressant dextromethorphan, that are being repurposed and new classes of medications with novel mechanisms of action like neurosteroid drugs such as brexanolone. All these agents share the benefit of rapid-onset—something of a Holy Grail in mood disorders treatment. Indeed, ketamine shows promise as an acute anti-suicidal medication for potential administration in the emergency room (Mondimore 2019, personal communication). In addition to oral medications, for treatment-resistant mood disorders there is emerging interest in interventional psychiatry where infusions of rapid-acting medications like ketamine can be administered and monitored. Brain-stimulation treatments such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and transcranial direct current stimulation (tDCS) continue to evolve and can be expected to play a larger role in the treatment of mood disorders as more devices find their way to market and costs come down (Mondimore 2019, personal communication). Contemporary ECT is thought to be  considerably safer than  historical stereotypes suggest. And along with the other newer brain-stimulation treatments, ECT can be indicated for patients who have failed multiple medication trials or who require a more rapid onset of effects. Medication and other biological interventions can be life-saving, helping a person regain perspective, stability, and a psychological mindedness that helps enormously. Recalling Styron, Wurtzel, Hamlet, and Jamison: if darkness, hopelessness, cognitive deficits, and agitation can be lifted and balanced with medication, clients may begin to engage in the work of understanding the underlying causes of their mood disturbances.

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Temperament Yet another biological basis for affective disorders can be found in temperament (Kagan et al. 1988; Thomas et al. 1968). The “fit” between a child’s and parents’ temperaments may be one factor (Kaplan & Sadock 1985) in mood and other disorders of adult life. Children who are sensitive or shy may be more vulnerable to early loss and separation (Kramer 1993) and those who grow up timid and vulnerable to stress or change may be more predisposed to adult depression. From a young age, Jamison (1996), the clinical psychologist, explains that she was “frighteningly, although often wonderfully, beholden to moods.” She charts the way her early temperament grew into something more encompassing, as someone who was “Intensely emotional as a child, mercurial as a young girl, first severely depressed as an adolescent, and then unrelentingly caught up in the cycles of manic-depressive illness by the time I began my professional life” (pp. 4–5). All of these biological explanations offer a complex window onto some of the multiple causes of mood disorders. It is virtually impossible to consider biological factors, intrapsychic factors, or social factors as distinct or separate causes of affective disturbance. Perhaps more than any other illness, mood disorders require that we take a fully informed biopsychosocial view of psychopathology that includes age, gender, class, and race. However, with the increased emphasis on symptom reduction and on brief, intermittent managed care, there can be a pull to treat only the symptoms with medication or with cognitive behavioral treatment. We maintain that one needs to pay careful attention to the psychological roots of affective illnesses and the social conditions that perpetuate them. As even a founder of Johns Hopkins Hospital, Sir William Osler, once said, “It is more important to know what sort of patient has a disease than to know what kind of disease a patient has” (1892/2013).

SOCIAL FACTORS We have observed throughout this book that there are many privations and tragedies in the social world: unemployment; isolation; discrimination based on race, gender, age, sexual orientation, religion, and class; lack of access to housing, health care, and education; poverty; disability; and dislocation due to war, natural disasters, or homelessness—among others. All these factors may contribute to an individual’s feelings of helplessness, hopelessness, unworthiness, and lowered self-esteem. And while some people may be highly resilient, others are more predisposed to mood disorders in the face of loss and upheaval. As we noted at the beginning of this chapter, the lifetime risk of a major depressive episode is two to three times greater for women than for men, and also may manifest differently in women and men. For example, whereas women may internalize their emotional suffering, becoming overtly depressed, men may be more likely to deny, externalize, or extrude their feelings of depression (Real 1997). One explanation for gender difference is found in the complicated expectations of women in Western cultures. Women may be more stressed than men as they manage a variety of conflicting roles. Socialized to believe it is acceptable to express emotion, women are also more likely to present with sadness and tearfulness. Men, by contrast, often minimize their affective disorders, explaining them by the loss of something external, such as a job firing or a failure to be promoted. Men may present in the consulting room with irritability, anger, or neurovegetative symptoms, such as sleep difficulties. In a study of 400 women by Deborah Belle (1982), the presence of a confiding, intimate relationship with a partner or friend, even in the face of stressful conditions such as poverty,

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inadequate housing, young children in the home, and young children with illnesses, was the most important factor women identified in not becoming depressed. Blau (1973) found that among elderly women, having a confiding and intimate female friend was more predictive of women’s emotional health than any other factor. In a study of fifty midlife women, ­Shydlowski (1982) also found that, aside from good health, female friends were cited more often than husbands, work, or children as the resources that prevented depression. In another study of midlife women, Berzoff (1985) found that female friends were consistently cited as enhancing adult self-esteem. All these studies bear out the premise that in the presence of intimate and confiding relationships, women are less vulnerable to depression. But dependency on others, in a patriarchal culture that rewards separateness and autonomy, can lead to conflicting expectations: to be independent and autonomous, or to be intimate and dependent. Many women fear that if they are truly independent, they may lose their relationships. Furthermore, if we think that depression is anger turned against the self, what happens to women who are consistently socialized to internalize their anger? As discussed in chapter 10, we might suspect that this dynamic contributes to female depression. Patriarchal culture also takes its toll on men (Baker et al. 2014; Real 2017). Beginning in boyhood, men are socialized to separate from and deidentify with their mothers. They are raised to believe that they must embody a masculinity that is independent, stoic, strong, and competitive, at the expense of intimacy and a more relational orientation. The disconnection that results may leave men vulnerable to depression. Yet, rather than being turned inward, male depression may be extruded and expressed as emotional distance, workaholism, alcoholism, womanizing, or rageful outbursts, which may be more painfully apparent to and felt by the people they love than by the men themselves (Real 1997). This, of course, only exacerbates men’s feelings of disconnection and depression. When considering the epidemiology of depression in women, we must also be aware of the many other social factors (Hyde & Mezulis 2020) that promote dependency and helplessness. Women are physically vulnerable to violence, particularly domestic violence. Such vulnerability undermines self-esteem. In divorce, women who care for dependent children can become economically disadvantaged, often resulting in downward social mobility. Women’s worth in the workplace is materially devalued through a society that pays men more than women. As part of a culture in which the norm is that women work full-time and still maintain responsibility for the household, women often feel depleted and empty. Even in a social structural arrangement in which childcare is shared, a husband is often perceived as “helping out” his wife. Judy, who is white, Jewish and middle class, came to a women’s therapy group feeling depressed. She is a full-time professor currently writing two books, a mother, and a wife. Judy’s income is close to that of her spouse’s; however, in the group she complains that when her children are ill, it is assumed that she will cancel her work. She arranges the social life of the family, remembers and handles all medical appointments, attends parent-teacher conferences, is responsible for providing transportation to school and extracurricular events, and maintains responsibility for the household (shopping, cooking, and so on). She participates in all school and athletic events for her children. Yet her spouse and children tease her and deride her “easy” life. When Judy isn’t angry, she feels depressed.

For Judy, a group that helped her examine not only her own individual dynamics but also the social structural causes of her depression allowed her to make systemic changes in her family life that made her feel more effective. Gender, of course, is not the only risk factor in depression. As noted earlier, families in poverty and women in poverty are at serious risk for depression. Consider the effects on

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low-income people of early loss, exposure to pathogenic environments, inadequate financial resources, limited education, unemployment, sole responsibility for care of dependent children, and lack of access to safe and affordable housing. Psychosocial stressors are known to be implicated in the neurobiology of recurrent affective disorders (Post 1984). As Bibring (1968) noted, depression is likely to occur when there is a gap between aspirations and accomplishments. Consider, then, the experiences of low-income, marginalized, and oppressed people who must daily negotiate less-than-average “expectable” environments. In a 2015 research study with sixty-five Palestinian social work students living under Occupation (Kokaliari et al. 2016), the students identified depression as the leading mental health issue in Palestine. Contributing factors included helplessness due to the Occupation, the loss of freedom as a result of the Separation Wall, unexpected searches, lack of control over one’s time at checkpoints, the loss of income, and the loss of homes and schools destroyed in bombings and searches. It is important to remember that for many disadvantaged families, the anomie that underlies depression often goes undiagnosed and untreated. Yet another social factor in the epidemiology of mood disorders is the inherent bias in diagnosis. African Americans, you will remember, are diagnosed with schizophrenia at twice the rate of white Americans. This suggests that depression and other mood disorders in the African American community may go undiagnosed, misdiagnosed, and untreated. In addition, as with every diagnostic category we have studied, we need to consider the different cultural meanings of depression. Cultures have different attributions for depression. For example, clients from some Asian countries may complain of somatic equivalents of depression (e.g., constipation, insomnia, sexual dysfunction, weight loss, a wind in the heart, a pain in the belly). In countries with a strong Judeo-Christian perspective, guilt may be the predominant feature. In some Native American cultures, it is considered a mark of maturity, not of pathology, to feel profound grief over losses, sorrow for the pain of causing suffering to others, and sorrow for those less fortunate. In those cultures, depression is seen as a positive sign of interdependence, of connection to the community, and of moral virtue. We have looked at how psychological, biological, and sociocultural factors affect the diagnosis of mood disorders. Let us now consider suicide, one of the most devastating outcomes of severe affective disorders.

SUICIDE Suicide poses an enormous public health risk and is one of the most tragic effects of both depression and bipolar disorder. Suicide rates continue to rise. In 2017, suicide was the tenth leading cause of death in the United States (American Foundation for Suicide Prevention 2019). Suicide can occur when someone is psychotic or suffers a major loss, like losing a life partner or a job, during a separation or divorce, or in the midst of postpartum depression. Suicide may ensue when a person is misusing substances, when there has already been a suicide in the family, where there is a history of sexual or physical abuse or impulsivity, or when facing severe or terminal illness. As described earlier, suicide can be a tragic consequence for adolescents who are gay, lesbian, bisexual, or transgender given bullying and stigma and the isolation and rejection they may experience in their families or by society at large (Bostwick et al. 2010; Russell & Joyner 2001; Ryan et al. 2010). In fact, Boylan (2015) suggests that 40 percent of those who identify as transgender have attempted suicide. Some people with major depression are too depressed to kill themselves, and it is only when they begin to feel better that they have the energy to follow through. Others may express a wish to go to sleep and never wake up or have harm beyond their control befall

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them, a type of thinking called “passive death wish.” Suicide is almost always a response to unbearable anguish and almost always contains both a wish to die and a wish to be rescued, to make visible an unbearable intrapsychic pain. Over the past decade we have also seen a decrease in life expectancy in the United States due to the surge in so-called “deaths of despair,” particularly among middle-aged white males. The diseases of despair leading to these deaths include alcohol, prescription, and illegal drug overdose; alcoholic liver disease/cirrhosis of the liver; and suicide (Case & Deaton 2015, 2020), all mechanisms of self-destruction. For the clinician, a biopsychosocial suicide assessment is enormously important. One must look at risk factors and take into account whether the person has made a previous suicide attempt. DSM-5 now pays greater attention to suicide throughout the manual, including providing tools for assessing suicide risk (American Psychiatric Association 2013; see also the Columbia-Suicide Severity Rating Scale). We know those most at risk are people who believe their loved ones would be better off without them, those who have an actual plan and a means with which to follow through on that plan (pills, a firearm, rope), and those who have a day and time in mind. In people suffering from bipolar illness, a mixed state of depression and mania is the most dangerous time. Suicide can be understood, intrapsychically, in many ways. It may be a result of unbearable shame, guilt, dependency, hopelessness, and hostility. It may result from wanting to hurt or kill another. Maltsberger and Buie (1980) see suicide as a form of murder, but one that reflects a client’s disturbed inner world. We see this complex interplay illustrated in the case below: David was a fifty-year-old white psychiatric nurse. He had a family history of depression and a sister who had killed herself in her late twenties, after being asked to take a year off from law school because she was unable to complete her work due to depression. She hanged herself in her apartment, where their parents were likely to find her. David had two children, a wife, and a satisfying career. He was beloved in his community and known for his kindness in his work with children at risk. To his utter dismay, however, his wife left him for a woman, asking for a divorce. David became extremely depressed. Unable to function at work, he wept, railed, had difficulty sleeping and eating, isolated himself from his children and friends, and was eventually hospitalized for severe depression. After two weeks, and having started taking medication, David was discharged. He began drinking heavily. His friends and neighbors, extremely worried about him, kept an around-the-clock vigil to see that he did not harm himself. David’s mother came from another state to stay with him, but on the first night that she was there he hanged himself, leaving her to once again find the dead body of one of her children.

David had many risk factors for depression. He felt worthless without a partner who could mirror his value back to him. He had been quite dependent on his wife and was devastated by her rejection and wish for a divorce. His internal world lacked soothing introjects, and his hostility was so great that it overwhelmed his inner world. David’s suicide served multiple functions: it was a way to punish his wife for abandoning him and a way to destroy his rage, which could not be soothed. He was also strongly identified with his sister who had committed suicide, and he carried a genetic risk of suicide. His use of alcohol to deal with increasing despair was a further risk factor, especially as he was mixing substances with medication for his depression. Whereas he had initially been too despondent to harm himself, his antidepressants lifted his depression just enough that he could act on his self-hatred. Perhaps most tragically, he had been very conscious of the effects of his sister’s suicide on him and his parents and spoke often of wanting to make sure that his children never experienced the kind of pain that he had endured after his sister’s death.

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Now, let us finally turn to how a client’s experience of mood disturbances can affect the clinician.

WORKING WITH MOOD DISORDERED CLIENTS The Effects on Clinicians When faced with hopelessness, despair, or self-criticism in a client, it is not uncommon for the beginning clinician to feel hopeless or anxious too. Depressive affects often feel to the client like dead ends and dead weights. We, the clinicians, though presumably less depressed, may begin to wonder how to help a client move on from a seemingly interminably bleak state. Because depressive affects can seem to lead nowhere, it becomes difficult for the clinician to hold on to the conviction that, in the telling of a client’s story, there can, in fact, be relief. Initially, in sitting with depressed clients, clinicians often find that they are experienced as a kind of medicine. The client may begin to feel better. But gradually, the clinician seems to become less helpful, beginning to feel herself as lacking in a variety of ways. Finally, the clinician may experience herself as inadequate, heir to many of the same criticisms that were once directed by the client against herself. This can induce in the clinician the same feelings of unworthiness, ineffectiveness, hopelessness, and helplessness that the client feels. Some clients feel so hopeless that in sitting with them, we clinicians can feel paralyzed. A client’s mania may also induce in us similar feelings of doubt and uncertainty. The pressured speech of the person sitting across from us may fill and take over the room, leaving the clinician feeling absent, invisible, and helpless. What can we really offer? These are moments when it is helpful to recall Bion’s (1962) notion of the clinician as a “container”: to imagine ourselves holding for our clients the complexity and chaos of their affective experience, even when—especially when—they themselves cannot. Suicidal clients can lead us, as clinicians, to feel tormented. There may be times when, while sitting with suicidal clients, we begin to hate them or feel an aversion toward them and, even worse, find ourselves turning away (Buie & Maltsberger 1983). This aversion and withdrawal can be lethal to the client. Yet if we can acknowledge to ourselves and to our supervisors our hopelessness and helplessness, then we may not need to disavow these feelings. When we can be aware of our depression and our hate, we will not be unconsciously asking our clients to bear our aggression as well as their own. There are other pitfalls for beginning clinicians who work with depressed clients. One very common error is to try to “cheer up” or talk a depressed client out of being depressed. To do so may repeat other failures in empathy, sending the message that we cannot tolerate the overwhelming affect, and lead to the experience of a loss of self-cohesion for the client. In psychodynamically oriented work, we need to empathize with a person’s depression, while enlisting her help to find its causes in both internal and external realities. Sometimes, a client’s depression may make us want to mobilize to action. We want to give advice or do something that will relieve the suffering. This, too, can lead away from what the client needs—someone who can tolerate painful affects, which up until now may have seemed unbearable. If, as we have said, one of the greatest ego strengths is the capacity to bear depression, then we must be able to do this ourselves if we want to help our clients do the same. Likewise, we must always be able to elicit as strengths sources of humor or joy, wherever they exist.

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CONCLUSION Beginning clinicians need to hold a biopsychosocial lens when working with people in the throes of any mood disorder, whether depression, mania, or a mood state in between. As therapists, we do not treat depression or mania, but rather the person in her environment who is experiencing a mood disorder. The goal should be to alleviate symptoms and restore, or create the capacity to do the constructive rebuilding work that allows for a more creative, vital, and flexible use of the self. Cognitive behavioral therapies that cut the problem down to size, reduce negative cognitions, and externalize the problem can be helpful to depressed clients, just as medication can be critically important in treating mood disorders. However, in our current climate of managed care, the danger is that we have moved toward a model of simply medicating mood disorders or helping our clients reframe their cognitions, without attending to their complex psychosocial causes. In fact, in the worst kinds of managed care, organized only around diminishing symptoms, the pressure to contain costs by limiting care may unintentionally join with the therapist’s unexamined countertransference motives to avoid mood disordered clients altogether. Eighty percent of people with affective disorders improve with the combination of medication and talking therapies. In the march toward time-limited therapies, we must continue to recognize the value of an enduring treatment relationship in understanding the client’s inner world and restoring functions that may have become disturbed. In the Chinese language, the word crisis is designated with two characters that signify both danger and an inflection point or opportunity. Affective disorders pose enormous dangers, not least of which is the risk of suicide. Yet these disorders can also open a moment for change: to restore lost functions, to heal internal wounds, to gain sufficient mobilization to make social changes, to become able to bear previously unbearable affects, to return to or find community, and to be able to use a helping person to sort out the meaning of the crisis. The felt danger of a crisis is often the loss of meaning or of loved ones. The actual danger is that, without the crisis, we may never discover our own strengths.

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16 Anxiety and Its Manifestations Joan Berzoff and Susan Pasco

In the preceding chapter on affective disorders, we discussed the experience of depression and the biopsychosocial factors that contribute to it. This chapter describes the experience of anxiety and reviews psychological, sociocultural, and biological causes and treatments for anxiety disorders. Whereas depression is felt when loss, hurt, disappointment, and disillusionment have already occurred, anxiety is more often about what might happen. Anxiety is an anticipatory feeling, related to the future, not the past. It is about something dreadful that might occur outside the self, or something terrible that may emerge from inside of the self. Intrapsychic conflicts and early developmental issues may contribute to anxiety disorders. Social factors—oppression, trauma, discrimination, exposure to random violence, pandemics, neglect, or abuse—may increase a person’s experience of helplessness and vulnerability and result in the development of anxiety symptoms. Other psychological vulnerabilities, such as too much separation from others or unsupportive early relationships in which we feel trapped, frustrated, or resentful, also predispose us to anxiety disorders. Biological vulnerability, genetics, brain organization, chemical imbalances, drug and alcohol use, and physical illnesses also predispose individuals to anxiety. Additionally, understanding the cultural idioms for anxiety and its expressions is important, as anxiety is expressed differently in different cultures. Thus, there is always an interface between these biological, social, and psychological factors, which allows for the greatest appreciation of the complexity of these disorders. These days, psychodynamic theories and therapies are not always considered the first treatments of choice for anxiety. Cognitive-behavioral therapies of many forms—behavioral exposure therapies that desensitize patients such as prolonged exposure therapy, cognitivebehavioral interventions that help change distorted thinking (cognitive processing therapy), meditation, eye movement desensitization reprocessing (EMDR), sensory motor integration therapy, group treatment, and mindfulness—have come to be seen as treatments of choice for some who suffer with anxiety disorders (Ballenger & Tylee 2003; Stultz 2006). So, too, have medications such as SSRIs and benzodiazepines come to play a prominent role in treatment. Nonetheless, we think it is crucial, whether providing CBT, behavioral, and/or 346

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medication treatments, that we understand anxiety disorders as behaviors that are sometimes rooted in attachments, in early experiences, and/or in fears about not living up to expectations. Anxiety disorders may arise from real traumatic exposure to threats or danger and/or they may be biological in origin. But we think, that without question, these disorders affect body, mind, and spirit, and that they are mediated by an individual’s temperament and culture. Some people are simply predisposed to stress; others may be flooded by stress hormones which are endocrinological. Others may have a shy temperament or may be hardwired to be more reactive. As we have maintained throughout this book, people with psychological disorders are more than the sum of their symptoms so that understanding a person with an anxiety disorder requires more than treating a person’s symptoms alone. Psychodynamic theories and practice help us to understand them more deeply.

THE EXPERIENCE OF ANXIETY According to the NIMH, 19.1 percent of adults in the United States suffer from anxiety disorders (NIMH 2017). Worldwide estimates are that 264  million people are living with an anxiety disorder (WHO, 2017). The Department of Health and Human Services reports that it spends one-quarter of its mental health budget on anxiety disorders. In fact, in 2012, Americans filled fifty million prescriptions for Xanax (Strossel 2014)! Further, there is a 2:1 ratio of females to males who report anxiety symptoms (American Psychiatric Association 2013). In recent years we have seen a dramatic rise in anxiety disorders among youth in the United States. Approximately 31.9 percent of adolescents, age 13–18, are affected by anxiety disorders (NIMH 2017). In a 2018 national survey of college students by the American College Health Association, approximately 65 percent of the students reported feeling overwhelming anxiety in the past year and 24 percent reported having been diagnosed with an anxiety disorder (ACHA 2018). This rise in the incidence of anxiety in young people seems to correspond with a dramatic increase in the public’s awareness of, and preoccupation with, anxiety—evidenced by the plethora of articles and media focus on the issue (Rosen 2017). Since everyone experiences anxiety, which is different from having a formal anxiety disorder, we informally polled some of our colleagues to ask them to describe what they felt when anxious. This is what they said. One reported difficulty falling asleep and staying asleep as he contemplated a promotion at work. He would awaken with free-floating anxiety and a sense of impending doom. He began to dread being with his family or being at work. He was short-tempered, preoccupied, and generally restless. The physical illnesses of coworkers, family, and friends loomed larger than life. He could not put into perspective the newspaper articles he read documenting wars, ecological disasters, or medical illnesses and pandemics. He began to exercise excessively. His anxiety was not only about something potentially good (a promotion) but also about feeling he would not be able to live up to the expectations of a more challenging job. Another colleague remembered her terror at having accidentally been locked in a bathroom when she was five years old. As she tried to get out, her head began to pound, and her heart raced. She could not breathe and was left feeling helpless and alone. To this day, she avoids public bathrooms, because when she locks herself in, she feels like that little girl, anxious and afraid. Another recalled her annual terror of lecturing to a classroom of a hundred students. At each first class, she became nauseated, clammy, and dizzy, and her ears rang. Often, she experienced examination dreams in which she failed to bring her notes to class, was unprepared and undressed, and felt humiliated. Her anxiety was about whether her performance would be deemed good enough.

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What all of our colleagues describe is what every reader has also experienced. Anxiety is a universal affect. It can make our hearts beat faster, our tongues tingle, our palms sweat. Anxiety can make us ruminate or obsess. Anxiety can take the form of irrational fears of such things as flying in planes, driving over bridges, being locked in, or being too exposed in open spaces, or even in supermarkets. Following the national trauma of 9/11, many New Yorkers feared riding in the subway or working in a tall office building. Parents and students of all ages today fear that they might be the next victim in a school shooting. With the recent COVID-19 pandemic, we know that anxiety and fear of contagion is even more widespread. In fact, anxiety is probably the most common symptom with which clients present. Anxiety manifests itself in a variety of forms and in varying degrees of severity. At its most useful, it serves as a signal of danger and it motivates us to act: to prepare for our papers or to write our lectures, to meet deadlines, to socially distance and wear masks, and to attend to what was initially threatening. At its most disruptive, anxiety paralyzes us, preventing us from leaving home, from concentrating on work or family, from sleeping, from traveling, from enjoying pleasures, or from functioning at all. In fact, anxiety can feel like helplessness, hopelessness, and a lack of control over one’s mind and one’s body. However, at its best, anxiety can equip us to be active agents, creative thinkers, and even leaders.

ANXIETY AND CULTURE Before exploring the kinds of anxiety disorders described in the DSM-5, it is important to recognize how the expression of anxiety might be different according to the cultures in which it is experienced. Jewish, Hispanic, or Italian families, for example, may express their anxieties with high emotionality that may appear exaggerated to those of different backgrounds. Joshua, a white eight-year-old Jewish boy from a middle-class family, had been referred to his school psychologist for an evaluation because he repeatedly said, “Oh my God, I’m gonna kill myself!” whenever he missed the ball while playing kickball, or whenever he forgot his homework. While his predominately white Anglo-Saxon Protestant school thought a suicide evaluation might be in order, within his ethnic family norms, “killing oneself” was idiomatic for the expression of any anxiety or frustration and did not reflect any overt pathology.

In some Eastern cultures, such as India or Japan, anxiety may often be expressed physically. People from some Eastern cultures may experience anxiety when they feel shame or fear of losing face, and they may express their anxiety through blushing or somatic complaints, or with what, from a Western perspective, might look like obsessive-compulsive rituals. In Singapore, anxiety can take the form of a panic-like disorder called Koro, in which a person fears that his sexual organs will retract into the body, causing death. Other cultures also present with psychosomatic equivalents of anxiety. At the risk of overgeneralizing, people in many Middle Eastern cultures, for example, may express their anxiety as pains in the heart, as weak nerves, as shaking, or as body pain. In Latin America, anxiety is referred to as susto. It is often characterized by phobias, tachycardia, irritability, or insomnia (Ho 1987). In some Caribbean and Latin cultures, anxiety is often expressed as an ataque de nervios, in which a person may experience crying attacks and heat in the chest rising to the head, or find herself shouting uncontrollably, or even physically attacking others. In these cultures, stigma and shame are often associated with mental illness, so for many Latinx families using the term nervios is much more acceptable than discussing anxiety as a mental health concern (Varela et al. 2019). Anxiety also is impacted by

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gender. For example, in Latinx cultures, men, more than women, experience anxiety symptoms (Craske 1999). Anxiety may also emerge over different kinds of cultural prohibitions. For white AngloSaxon Protestants, whose culture may value independence and stoicism, anxiety may erupt when autonomy is threatened. By contrast, in collectivist cultures where interdependence is the norm, anxiety may arise when there has been some inability to rely on others or too much separateness from others. In Japan, there is a particular form of social phobia, Taijin Kyofusho, in which a person becomes anxious when he or she fears having offended others by exposing them to bodily functions that are viewed as socially inappropriate. Flatulence, giving off body odors, staring inappropriately, showing inappropriate facial expressions, or having a physical deformity are seen as potentially offending others. The results are often isolation from others, feelings of dread related to social activities, rapid heartbeat, and trembling. More common in men than women, the lifetime prevalence is estimated at 3–13 percent (Craske 1999). In Western cultures, however, anxiety may emerge when a person fears being ridiculed, shamed, or humiliated for those same behaviors (Craske 1999). In addition, as a result of differences in attributions for anxiety, many Native Americans, Latin Americans, native Alaskans, African Americans, or Asian Americans may not present to the mental health field with anxiety symptoms, nor will they seek medication or psychotherapy for symptom relief. Rather than view anxiety as a symptom, different cultural groups may understand anxiety as a spirit or ghost, for example, and seek cures through magic, shamans, monks, or herbs. Deeply religious Americans may seek spiritual cures, and use their clergy, not therapists, for help with their anxiety (Neal-Barnett  & Smith 1997). Thus, it is important to remember that cultures and religions express affects in culturally specific idioms, and that individuals will seek culturally prescribed treatments for their pain and discomfort. These cultural norms may also be reflected in the manifest behaviors of children who are struggling with anxiety disorders. Some cultures that emphasize a collectivist group orientation where self-control and emotional restraint are highly regarded may be more likely to socialize their children and youth to internalize their symptoms of anxiety. These may then manifest as behaviors such as shyness or fear (Varela  & Hensley-Maloney 2009). In comparison, in individualistic cultures (e.g., the United States or Western Europe) that value self-promotion and autonomy, we see more instances of anxiety in children and adolescents that result in disruptive acting out behaviors (Varela & Hensley-Maloney 2009). And beyond culture, we must also always keep in mind temperament. Some children are naturally shy or fearful; others are not.

ANXIETY AT DIFFERENT DEVELOPMENT LEVELS Just as in the previous chapter, where we discussed depression as experienced at different developmental levels, so, too, is anxiety experienced differently according to a person’s level of psychological development. Therefore, in assessing a client’s internal experience of anxiety, it is important to assess a client’s developmental level of anxiety. We described, in chapter 4, how anxiety can be experienced as what we might call neurotic anxiety (the fear of something bad happening to the body because of unacceptable wishes or desires), as separation anxiety (the fear of loss of love and loss of a needed person), and as annihilation anxiety (fears felt at the level of the destruction of the self). Each of these anxieties corresponds to a person’s psychological level of development: neurotic, preoedipal, or psychotic. Below, we discuss how anxiety may manifest at these different levels of psychological development.

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Whereas, in other chapters, we began first with the most troubled level of development, in this chapter we begin with the more functional level, because anxiety is so often experienced by those who are at the neurotic level.

Anxiety at the Neurotic Level Ginny, a thirty-year-old white single, upper middle class, heterosexual historian, complained of chronic headaches and anxiety, which were precipitated by her father’s recent suicidal ideation. The middle of three children, she came from a Jewish family that had initially viewed itself as “golden.” Her father was a successful and attractive businessman, and her mother worked for a music publishing house. Both parents presented an ideal and enviable life to the community. However, when Ginny was five, her seven-year-old brother became ill with meningitis. Ginny both loved him and felt him to be her rival. In fact, as an adult, she remembered a song she had made up and sung to her brother: “Die, die, my little darling pie.” When he left for the hospital, Ginny, suffering from a bad cold, kissed him good-bye. Overnight her brother developed pneumonia secondary to meningitis and died. Ginny remembers feeling vaguely as a child that she herself was the “kiss of death,” which made her feel anxious much of the time. Ginny remembers trying to comfort her mother and father, and recalls sitting on her father’s lap, reading with him and snuggling after her brother’s death. To Ginny’s delight, when she was six and a half, her mother announced another pregnancy. With her mother’s pregnancy, Ginny felt, in fantasy, that she had had something to do with this event. Ginny felt especially thrilled (and a little guilty) to be having a baby in the family, whom she thought of as hers and her father’s. When her new sister was born with Down syndrome, however, Ginny experienced her loving feelings toward her father as dangerous and destructive. Ginny unconsciously began to feel guilty about her oedipal wishes and her desires. At age thirteen, she wrote a birthday song for her sister. Her mother had the song published, and it was an overnight success. Ginny was coronated by her classmates for her new fame as a children’s songwriter. But she renounced the success, not seeing it as her own, and was uncomfortable with this achievement and with the public acclaim it brought her. Her academic successes at school were also experienced as anxiety provoking, and she sought invisibility. Though popular, successful, and intelligent, when angry or frustrated as a child she would literally hide in the back of her closet, so great was her anxiety. As an adult she experienced both generalized anxiety and headaches, often brought on by an event that disappointed or angered her. Her symptoms required that she retreat to a darkened room. These often came on after she was happy and excited, or furious or frustrated.

We would say that Ginny experienced anxiety at the neurotic level. What do we mean by neurotic? In drive theory terms, Ginny’s anxiety may have emerged from unconscious sexual and aggressive wishes (toward her father and her siblings) that occurred at the oedipal stage of development. Freud thought that sexual or aggressive memories, fantasies, and feelings were kept out of consciousness through the defense of repression. When Ginny’s aggressive or sexual impulses broke through (e.g., when the baby she had wished for with her father was born disabled or when she wrote a song for her brother wishing for his death, and he died), she became anxious about anything that made her feel too visible or successful. According to structural theory, Ginny’s unconscious aggressive feelings toward her brother had been realized by coincidental damage and death. As a result, she suffered neurotic guilt and anxiety over conflicts between her superego and her impulses. In addition, her father’s serious depression had heightened her sense that she was somehow responsible for her lost brother and her sister’s disability. In ego-psychological terms, Ginny suffered from neurotic anxiety (as distinguished from psychotic anxiety) because her reality testing remained intact. She knew she hadn’t really

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killed anyone. Furthermore, she used the high-level defenses of sublimation, intellectualization, and reaction formation to deal with her unacceptable wishes and urges. She adapted to her family’s losses by attempting to be good, quiet, and non-assertive, which became ways of relating that shaped her character. Some of her anxiety also derived from her critical superego, having identified with her parents’ high standards for both themselves and their surviving children. But she also had good judgment, humor, and an excellent capacity for insight, which were later invaluable in treatment. In object relations terms, Ginny’s anxiety was at the neurotic level because her early relationships had been secure, and she had internalized integrated and coherent representations of herself and others. She could engage in deep friendships in which affection and mutuality were genuine. She did not need to split her relationships into good or bad and she recognized that she, like most people, was flawed without resorting to seeing others as all good or all bad. She had some difficulties in close relationships with men, feeling that they (like she) could not live up to her expectations. But she viewed other people as being whole, and not part objects. Her attachments were secure. Her anxiety, at the neurotic level, was more about fear of loss of love of the object: that one or both parents would blame her for her aggressive fantasies and wishes and would withdraw their love then from her, than about disintegration or annihilation anxiety. In self psychological terms, Ginny’s anxiety was neurotic because she had a relatively cohesive sense of self. But because her narcissistically injured parents had needed her as a selfobject to compensate for their many real losses, their own depletion had left them unable to be fully empathic to her. As a result, she sometimes felt that her successes were narcissistic achievements for her parents and not for her. But she largely had healthy ambitions. She had close friends who served twinship needs. As she experienced herself to be understood in the course of treatment, and as she came to understand and forgive herself for her imagined crimes, she began to experience greater empathy for herself and for her parents’ losses. She could also acknowledge her family’s less than ideal lives. Also indicative of her neurotic-level anxiety was her strong observing ego that enabled her to develop a transference to her therapist and to examine it. Initially, she felt that she had to live up to her fantasies of her therapist’s expectations, as she had felt she had to live up to her parents’ expectations. Often the therapist felt “obligated” to live up to hers. Ginny would bring in volumes of nineteenth-century history and ask if the therapist had read them. She would discuss in great detail the latest avant-garde music, which the therapist had not heard. The therapist often, through projective identification, felt like a disappointment, not bright, witty, or urbane enough. This made the therapist anxious, paralleling Ginny’s anxiety. In the treatment, Ginny dared to become angry and disappointed with the therapist and later dared to make a career change that required considerable self-assertion and self-differentiation. She made a change in career, toward becoming a librarian, that was different from that of her therapist’s, her father’s, or her mother’s. She ultimately met a man who she felt was good enough for her. Over the course of treatment, her headaches remitted. If we look at Ginny’s anxiety from the perspective of attachment theory, we might surmise that her inability to self-soothe and seek support at times of distress represented an insecure attachment style. Her withdrawal from others in times of distress, hiding in the back of a closet as a child or retreating to a dark room as an adult, might have indicated an avoidant attachment style. In Bowlby’s construct of attachment theory, humans are born with an innate psychobiological system that motivates them to seek proximity and support from attachment figures such as parents or caregivers as a means for regulating distress (Mikulincer & Shaver 2015). In situations where a child’s attachment figures are not reliably available or supportive,

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“attachment insecurity” develops, which hinders not only emotion regulation but also the development of self-confidence and esteem. In Ginny’s case, she lost the support of a beloved older brother, and she also had two grieving and depressed parents who could not be emotionally available. Ginny’s lack of reliable attachment figures during such a painful childhood trauma helps us to understand why, even as an adult, she continued to react to stress by emotional distancing and why she struggled to see herself as loved and esteemed by others. Prior to DSM-IV, we would have understood Ginny to be neurotic. Whether looking at her anxiety from a drive, structural, ego, object relations, self-psychological, or attachment perspective, we would have pointed to her intact reality testing and her superego conflicts around her sexuality and aggression. We would have assessed the quality of her anxiety as oedipal anxiety. We would have identified her defenses as high level and would have seen her as relatively successful in work and love, noting her ability to form and maintain triadic relationships. Hence, we would have referred to her anxiety as “superego anxiety,” emerging at the time when a child has both a conscience and ego ideals The disappearance of neurosis as a diagnostic category in the current DSM (chapter 12) does not mean that the neurotic processes cease to exist. An understanding of neurotic anxiety, such as that experienced by Ginny, is still extremely relevant for the treatment of some anxiety disorders today. If Ginny had been psychotic, her anxiety would have looked very different. She might have been convinced that she had murdered her brother or had given birth to her father’s child. This would have produced anxiety so developmentally early that it would have been experienced as if her very self were dissolving under the weight of her sexual or aggressive impulses. Were she psychotic, she would have been unable to distinguish wish from deed, thought from action. Her thoughts would have been distorted by delusions that she was powerful enough to either wreak havoc upon her family or else save them from destruction. She might have had hallucinations that God or the devil had told her to kill family members. If she had been psychotic, her defenses would have distorted reality. She might have denied her sibling’s death, or projected her own badness onto the world outside, making it a dangerous place. Her relationships would have been at the level of selfobject merging with few, if any, boundaries between herself and others. Her capacity for enduring friendships, intimate relationships, or a therapeutic alliance might have been more tenuous. In short, because her anxiety was at the level of superego concerns, she did not experience annihilation anxiety, as do people who function on a psychotic level. Ginny also did not suffer from the kind of anxiety that we associate with people who have severe character pathology. She did not express profound separation anxiety—the terror of being alone or of feeling that she would be swallowed up or engulfed if separated from those she needed. She did not exclusively use defenses such as splitting, primitive idealization, or projective identification as ways of keeping contradictory feelings separate, which would have seriously distorted her perceptions of other people. Because she had not experienced severe neglect or trauma, she had been able to make secure enough attachments in friendships and later in love. As we noted earlier, she was the one who suffered; she did not cause suffering in those around her. Had Ginny been suffering from anxiety at the level of severe separation anxiety, she might also have had transient breaks with reality. She certainly would have presented with a more fragmented sense of self. Ginny had clear boundaries about where she began and where others ended. She was able to exercise strong judgment. She was able to function well at work and to use her strong intellect at work. She was able to regulate her emotions, except for feeling vaguely anxious much of the time.

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The hallmark of anxiety at the neurotic level, then, is that the anxiety does not impair reality. It functions to signal intrapsychic danger and to mobilize the defenses. The hallmark of anxiety at the character-disordered level is separation anxiety (fear of loss of the other), and its function is to try to restore psychic equilibrium by holding on to needed others. At the psychotic level, anxiety is experienced as annihilation anxiety, a fear of the loss of the self and the terror of disintegration. It also serves to convey feelings of total helplessness and disintegration to others.

ASSESSING SYMPTOMS AT DIFFERENT DEVELOPMENTAL LEVELS To understand and assess the source, the nature, and the developmental level of a person’s anxiety, it is necessary to go beyond the symptoms to the story. For example, obsessive-compulsive behaviors are often anxiety symptoms, signs that unmanageable anxiety is present. But obsessive-compulsive symptoms (excessive handwashing, checking, counting, obsessions, or rituals) do not reveal what the anxiety is about, nor at what developmental level it is experienced. This point was brought home very forcibly to one of the authors at a time when two of her patients were experiencing severe anxiety that manifested in a very similar manner. Both could be said to suffer from obsessive-compulsive disorders. Yet the cause, the story, of the anxiety could not have been more different. Both Darla and Patty described themselves as “neat freaks.” Everything in their apartments had to be clean and meticulously arranged. Darla, a young white cisgender female who worked in a factory, spoke of the sense of “relief and safety” that she felt when she would look in her closet at all her clothes “hanging in perfect order and symmetry.” Her shirts were all lined up in one section, pants in another, and so on; each hanger faced the same way. If anything was out of order, she became very anxious, experiencing a nameless dread. Patty, an African American cisgender businesswoman, spoke of very similar activities and feelings. Any kind of messiness made her very uncomfortable. She needed to feel that “everything was always under control,” that “nothing could go wild.” Darla could no longer go out to eat with friends, who might drop crumbs on the table, and Patty was starting to get frightened of driving. As each examined the sources of her fears, the following emerged: Darla grew up in a chaotic family on a farm in the Midwest United States. Her father was sadistic. In the nature/nurture paradigm, nurture was uneven at best, and Darla’s nature was very sensitive, finely tuned, and shy. At the beginning of treatment, she presented a line drawing of herself with the parts not connected at all, a kind of stick figure in pieces. The figure was a poignant manifestation of her internal disorganization, fragility, and vulnerability. As the therapist looked at it, she wondered if Darla’s love of, and need for, order arose out of her internal feeling of falling apart and going to pieces, of never feeling whole, solid, and connected. Darla wept in sessions as she talked about how desperately she needed her closet to look perfect to reassure her momentarily that maybe she could hold herself together a little longer. Developmentally, her level of anxiety had to do with the fear of total disintegration or annihilation. Relating to the consistent presence of the therapist and telling the myriad terrifying experiences of her abusive childhood on the farm enabled Darla to heal in such a way that, eventually, this primitive early anxiety did not recur with any great frequency. She became free to live a much more spontaneous, full, and joyful life. When Patty talked about her life, she described a very organized structured family that was quite close, loving, and strictly religious. Patty attended only Catholic schools and had been very influenced by the nuns and priests who taught her. By far the most traumatic event in her life occurred when she was the victim of a date rape at nineteen years of age. After a pleasant meal, the rapist invited her to his apartment, locked the door, and then, at knifepoint, forced her to submit to hours of sexual activity. When she tried to resist, he cut her on the throat and

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ejaculated for the third time as he licked her blood. Arrogantly, he released her, stating that no one would believe he would do such things and he would never be convicted. Patty did report the crime to the police, and after years of legal battles, the rapist was hospitalized in a psychiatric facility for six months. Patty, in the meantime, attended a rape victims’ group and worked through many of her reactions but felt that she nevertheless was growing more anxious and compulsive with the passage of time. She was beginning to have short periods of dissociation when she entered treatment. It took many months to get to the trauma because she had total amnesia about it, but what finally emerged was that Patty had, at one point, experienced an orgasm as she was being penetrated by her rapist at knifepoint. She had not been able to remember it because both her guilt and shame made having an orgasm under such circumstances unacceptable to her superego. Her anxiety was about having to face what she considered a terrible, sinful aspect of herself. Her symptoms of needing excessive orderliness and control were unconscious attempts at denying the possibility of being as out of control as she felt during her orgasm. Eventually, Patty made peace with the fact that her body had responded to unwanted sexual stimulation. Her great anxiety then diminished because she had faced what terrified her about herself. In Patty’s case, the danger (following the rape) did not come from hostile forces outside herself but from feared impulses within. Whereas Darla manifested annihilation anxiety, Patty experienced superego anxiety. The latter anxiety, like Ginny’s, was at the neurotic level.

Let us now consider the anxiety disorders (generalized anxiety, panic attacks, phobias, obsessive-compulsive disorders, posttraumatic stress) separately, recognizing again that often there are multiple causes of anxiety disorders, causes that are intrapsychic, biological, and social. As indicated earlier in this chapter, early trauma, intrapsychic conflicts, or deficits in personality structure in any one individual also may impact to what extent an anxiety disorder manifests for that individual. Additionally, it is wise to assess a client’s attachment style and to distinguish whether a client experiences secure or insecure attachment as this has bearing on how anxiety is experienced. Generalized Anxiety Disorders Imagine the anxiety you feel before taking an examination. You have difficulty sleeping the night before. You feel agitated, distracted; your heart begins to race faster and faster. Now imagine being in that state for days, for weeks, even for years. With generalized anxiety disorders (GAD), people are worried and fearful that something will happen to harm them or their loved ones and feel that all of the time. They may experience anxiety dreams and sleep disorders. Their form of anxiety is usually chronic, and they may see themselves as “high strung.” Because of how pervasive and diffuse generalized anxiety disorders are, and because of the intrapsychic conflicts that often underlie them, they are more responsive to psychodynamic treatment and the least responsive to behavioral interventions. They are very responsive to medication, especially SSRIs. More often, although by no means exclusively, generalized anxiety disorders are experienced by women. GAD involves free-floating anxiety, and most often occurs in conjunction with another psychiatric disorder. Annette, a fifty-year-old, cisgender Latina mother of two teenagers, worked as a telephone marketer, at home, because she felt too anxious to go out of the house or to work next to other people. She also came from a strict Catholic background where her sexuality was closely monitored by her very tight, extended family. She had come to be seen in a community mental health center, sent by her husband, because she could not stop worrying about what would become of her fifteen-year-old daughter, who, she had learned, had had sex for the first time. Annette found herself obsessing about her daughter, unable to sleep, unable to derive any comfort about her own parenting. Every time her children went out, she felt she would never see them again; she

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began to listen in on their phone calls and found ways to read their e-mails and follow their social media accounts. While she had always been “high strung,” now she could not get through the day without catastrophizing that her husband might have an accident at work, her daughter would become pregnant, or her son (who was an excellent student) might lose interest in school. It appeared that, as her children were becoming more independent, her anxiety was becoming intolerable. In a brief therapy of six sessions, Annette was able to explore many feelings about that which she could not control. Her own single mother had been paralyzed with polio during Annette’s whole childhood, which had been terrifying to her, and had also limited her freedom. Her mother had been especially strict with Annette regarding going out of the house. Annette had also come to believe that she could control whether her mother lived or died by staying close by her mother’s side. She did exactly what she was told to do, took care of her mother’s physical needs, and developed an early and enduring belief that the same kind of vigilance was required to keep her current family safe. In early adulthood, her first marriage was to a man who totally controlled her (in unconscious ways not so dissimilar to her mother). He would not let her leave the house without permission; he was physically abusive and so jealous of her friends that she stopped seeing them. Now, in her second marriage, her daughter had become sexual, reviving fears about her own life careening wildly out of control, which caused constant and chronic anxiety. With medication and six sessions of talking in a relationship that she deemed safe, Annette was able to understand some of the causes of her anxiety and to get symptom relief. Upon terminating, she gave her social worker a gift of relaxation soaps and candles, clearly something she wished had been given to her in the past.

People who suffer with generalized anxiety often seek out a medical practitioner because their symptoms—such as sweating, palpitations, shortness of breath, gastrointestinal symptoms—are physical. Often clients with this disorder are reluctant to take medication because they fear becoming dependent on medications or losing control by using them except when the medications are prescribed for the treatment of their physical symptoms. Panic Attacks A professor of African American studies, Steven, described his panic attacks this way: Scary. It feels like you’re not even here on earth. I  don’t feel human when I  get one of these attacks. My heart starts racing, my palms get sweaty, and all I want to do is run! When I experience a panic attack, I feel like I can’t breathe, my heart beats very fast, and then I feel like I’m going to die! Everything just gets very hazy, almost but not that. It’s like I’m dizzy and I’m going to faint!

People with panic attacks often feel that they are going crazy. They experience intense psychological symptoms: choking, hyperventilating, or heart palpitations so severe that they may fear they are dying. Often, clients with panic attacks do not recognize that their attacks have a psychological origin. When the medical findings (often cardiac in nature) are normal, they are often sent home with no treatment at all. Panic attacks can be devastating because they can so dramatically constrict life functioning. Mark, a white, cisgender, middle-class potter, spoke eloquently about how his panic attacks made his life a prison. Describing his first panic attack, he said: I was standing in front of my potter’s wheel, when a feeling of absolute terror overtook me. It felt like an explosion, like a reflex, almost like a sneeze. I had no idea what was happening or why. All I can recall is that I next found myself curled in a ball, on the floor, with my heart racing. Tears

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poured down my cheeks. I was perspiring, and I couldn’t breathe. In fact, my fingers had swollen; so had my eyes. My body had become numb. I felt completely out of control.

As Mark’s panic attacks worsened, his freedom decreased. Going to exhibits, out for dinner, or using public transportation became impossible. The boundaries of his world had become increasingly circumscribed. In trying to describe his feelings, he said: Some people compare panic to what you feel when you find yourself unprepared and have to go onstage; others say it’s like having to fight in a war. I think it’s more like this: Imagine that you are driving along peacefully when, suddenly, out of the blue, a car lurches at you. Try to imagine the terror, confusion, instantaneous racing of your heart, the split-second when the world is utterly out of your control. Remember the out-of-body experience, the way that your nerve endings are almost electrified, and then take that moment and expand it into hours, even days. That’s a small scintilla of what a panic attack feels like for me.

As we have said throughout this chapter, people with anxiety disorders such as Mark’s or Steven’s may be functioning at a neurotic, personality-disordered, or even psychotic level. While Mark’s and Steven’s levels of functioning were both at the neurotic level, some people with severe character pathology experience panic disorders as a result of anxiety about being separated from others. Panic disorders can often be linked to stressors that occur before their onset: a loss, a separation, a change in expectations from others, frightening experiences in childhood, or a chronic sense of being trapped or frustrated. Clients with poorly developed object constancy often experience severe panic attacks when they cannot evoke the image of a needed other. For example, Darla was able to ward off her panic attacks when she called her therapist’s answering machine and heard her therapist’s voice every night. Her temporary “connection” served as a transitional object that soothed her and diminished her anxiety symptoms. Mark said this about his recovery from his panic disorder: My recovery will continue slowly. I may have painful and discouraging setbacks. . . . I am not cured. I am still living with, and will for a long time, an illness I am learning to manage, the way diabetics learn to manage their diet and insulin. I have a long way to go, but I have come a long way. I have hope again. The more I speak of my panic attacks, the more I realize that I am not simply a potter with severe or debilitating anxiety. I am a father, a husband, an artist. . . . I am a person with a disorder, not the disorder itself. This is the important piece of the story.

While it is thought that vulnerability to panic disorders may lie in our biochemical and genetic makeups, these disorders may also develop when dynamic issues trigger their onset. Panic disorders often are rooted in childhood physical or sexual abuse, vicious cycles of parental neglect or rejection, and fears of losing ties to the parent altogether. Often people with panic disorders perceive their parents as overly controlling, frightening, critical, and demanding. Quite often they have difficulties in tolerating anger (Sadock & Sadock 2004). Phobias Phobias can be specific, or they can be general. They, too, are anxiety disorders. Like panic attacks, they do not have one simple cause or one simple treatment. There are biological, psychological, and social reasons for phobias, and there are different approaches to their treatment. In general, people who suffer from phobias feel dread, panic, or terror when faced with the situations that they fear or cannot control. Among some of the specific phobias

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may be the fear of enclosed spaces (claustrophobia), the fear of heights (acrophobia), or the fear being trapped far from home (agoraphobia). They may be about fearing germs (bacillophobia), or flying (aerophobia), or of vomiting (emetophobia) or losing bodily control. The anxiety is specific, anticipatory, and very intense. As a result, those with specific phobias go to great lengths, even if it interferes with daily functioning, to avoid what is feared. There have been interesting psychodynamic formulations of phobias. Freud formulated phobias as symptoms that are compromises. Like so many of the anxiety disorders, phobias partly disable the individual, but they also make anxiety more manageable. When we can see the danger as coming from without, rather than from within, we may avoid the situation onto which we have displaced our anxiety, solving one problem, but creating another. Phobias may disguise unacceptable instinctual wishes by displacing them onto something else that can be feared and then avoided (Gabbard 1990). One of Freud’s most classic cases (1907) was of a phobic four-and-a-half-year-old boy named Little Hans. This little boy developed terrible phobias of horses and open spaces. Like many boys his age, Hans both loved his father and feared him. Hans’s mother had recently given birth to his little sister, and Hans was jealous of her. Hans clung more than ever to his mother. Freud postulated that, being an oedipal child, Hans experienced conflicts over his love for his mother and his unconscious and competitive feelings toward his father. Hans also feared that his father would retaliate for his intense feelings for his mother. Since Hans wanted to be loved by both parents, Freud hypothesized that he “projected” his own aggression onto his father and then displaced the aggression onto horses. By developing a phobia about horses, and not his father, he could keep his father close. But a fear of horses also restricted his movement, as in Victorian Vienna horses were a common means of transportation. Hans’s phobia had a secondary gain as well; it kept him physically close to his mother and it kept him psychologically close to his father because he did not need to acknowledge his aggression. As long as his unconscious conflict around wanting his mother and fearing, but also wanting, his father’s love continued unresolved, he became more phobic, projecting and displacing his feelings about horses onto boxcars, railways, and open streets. Now his freedom was very restricted. It was not until some of his unconscious conflicts were interpreted and made conscious that Hans began to experience some symptom relief and could go out into the world without fear. A drive theorist conceptualizes phobias as representing unacceptable sexual or aggressive wishes or impulses that are defensively displaced onto something outside of the self. But the defense of displacement is not always adaptive because it circumscribes and ultimately limits a person’s functioning. Object relations theorists, however, formulate phobias differently. A phobia may encapsulate a wish for, or fear of, merging with significant others. People who are phobic may wish to move toward independence, as did Hans, but may fear losing others and thus need to stay close to them. From an object relations point of view, Hans’s phobia might have expressed an unconscious dilemma over separation, autonomy, and closeness. Whether from a drive theory or an object relations perspective, the person who has a phobia is truly restricted because the objects, locations, or situations that are feared must be actively avoided. Unlike in Little Hans’s day, however, medications and behavioral interventions, such as exposure desensitization treatments, now exist as effective interventions to treat the symptoms of phobias. Also, in Freud’s day, clinicians thought of all phobias as the same, while today we distinguish between two kinds of phobias: specific phobias and social phobias.

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Agoraphobia Ruth entered her sixth anxiety group session with much trepidation. Today she was scheduled to embark on her much feared “mission” with one of the group’s co-therapists. She was to drive her car across the bridge that connected her town to the clinic. Ruth sat in the driver’s seat, her therapist at her side, and took off toward the city. She chatted comfortably with her therapist for the first ten minutes of the trip until they were about a quarter of a mile from the bridge. Then, silence descended upon the car. Her therapist looked at Ruth and noted several things: Ruth’s chest was rising and descending rapidly as her breath became shorter and shorter. Her hands gripped the steering wheel so tightly that her knuckles turned white. Beads of perspiration appeared on her forehead. As they stopped at a traffic light, Ruth began to shake. She turned to the therapist and said, “We can’t drive over the bridge. We’re gonna die.”

People with agoraphobia may be afraid of standing in line; being on a bridge; traveling in a bus, train, or car; or being in open places, such as supermarkets, malls, shopping centers, and streets. All of these fears are of being in situations where escape is difficult or in which help might not be available. It is interesting to note that 75 percent of people with agoraphobia are married women. The onset of their phobias usually occurs between the ages of twenty and thirty. Agoraphobia may be more common in women because these symptoms express the stresses in marriage and child-rearing for women who either stay at home or try to combine work with parenting. We know that women who are at home full-time with small children under the age of five sometimes have limited social support and may feel especially vulnerable. Agoraphobic symptoms may exaggerate their experiences of powerlessness in the larger world, and, at the same time, keep women close to their homes, where they feel safest. Often people with agoraphobia suffer from severe separation anxiety and must be accompanied by a spouse, child, or other relative in order to be able to leave their homes. From an object relations perspective, then, agoraphobia may have the secondary gain of keeping others close and so the disorder provides a symptom and its solution. For example, a mother who developed agoraphobic symptoms after her children left home had them return daily to run the errands that she could no longer do. Her symptom represented her early need to be taken care of, which had been satisfied while she was taking care of her children. The symptom provided a solution to her need for others to remain with her. By becoming dependent, she kept them close. But her symptoms of agoraphobia also strain interpersonal relationships, so that it can be important to involve the couple or family in the treatment itself. Other Specific Phobias Specific phobias are persistent, excessive, and unreasonable fears that come from anticipating or experiencing the situations that are feared (e.g., flying, heights, animals, injections, the sight of blood, etc.). Usually, people with specific phobias recognize that their fears are unreasonable but knowing this does not keep them from anxiously anticipating or avoiding what they fear. People with specific phobias feel great distress, as their phobias interfere with social relationships, activities, and many other aspects of life functioning. Elena was a twenty-five-year-old Greek American cisgender secretary who was terrified about becoming trapped in an elevator. Unfortunately, she worked in a high-rise building on the thirtysecond floor. When she arrived at work each morning, she often thought she should try riding the elevator. But her ears began to ring; she became dizzy, she could not breathe, and, finally, she would take the stairs. By the time she reached her office, she was exhausted and out of breath.

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Each time she left the building she faced descending thirty-two flights, so she did not join colleagues for lunch. She had been passed up for promotions because she seemed disinclined “to go the extra mile” for her company: to attend meetings with her boss in other parts of the city, to travel when necessary, or even to attend parties and social functions for work.

For Elena, intrapsychic conflicts around achievement at work had been displaced onto elevators. She came from a patriarchal family in which she was encouraged not to leave home, except to marry, and felt that she could not “rise” in her work. Now her anxiety has been displaced onto the very conveyance that would carry her there. Social Phobias People with social phobias fear being humiliated or embarrassed by a social situation. They may feel dread or panic around being with others. Often they avoid social or performance situations, and when they cannot, experience great distress. Elizabeth a fifty-six-year-old white cisgender single woman raised in a poor Rust Belt city, lived alone and had not had a satisfying intimate relationship. She had also been passed over for jobs that require expressing herself. She experienced her lack of a promotion in her work as yet another proof of her inadequacy. Elizabeth came from a large and overburdened family where being heard and being noticed required acting out boldly and loudly. Two brothers were alcoholic—one was often arrested for petty theft—and her two sisters were able to get parental attention through a litany of physical complaints. Elizabeth’s response was to be very quiet and hope that she would be noticed for her more saintly qualities. However, rather than be noticed, she was largely ignored, and when her father left the family when she was thirteen, she withdrew even more. Throughout her adult life she experienced great discomfort speaking at meetings, and even more discomfort imagining discussing anything with her brothers and sisters, all of whom had families of their own. Now, she consistently avoids not only family members, but colleagues at work and the few men she has met from time to time. She is terribly anxious around other people, feeling that she has nothing to say and that being with others will reveal her inadequacy. She is acutely self-conscious and analyzes any interaction she has with others, even innocuous interactions with store clerks, wait, or service people She excuses herself from meetings at work and does not attend workshops with colleagues because again, it feels too painful to think of how everyone might view her.

Sometimes we do not see people with phobias in our clinical practices at all because they self-medicate, using antianxiety drugs such as Ativan or Xanax to deal with their fears. The appropriate medications, however, are antidepressants such as SSRIs rather than antianxiety agents. Antidepressants tend to motivate change, while the antianxiety agents have a depressant effect and may become addictive. For people with phobias, behavioral techniques are often seen as the treatment of choice. Clients who are exposed to that which they most fear, slowly and incrementally and in conjunction with relaxation techniques, often feel symptom relief. Behavior modification groups may help clients support one another, while teaching them techniques such as assertiveness, mindfulness, or systematic desensitization. In desensitization groups, people can learn to confront what they most fear in small doses. Groups, including chat rooms, also offer particular support because they provide places to share experiences, information, common symptoms, and methods that have worked. Despite the fact that phobias respond to behavioral, cognitive, behavioral, spiritual, and biological techniques, individual therapeutic relationships have value. A client who is phobic feels a great deal of shame. A therapeutic relationship allows the expression of the shame and the acknowledgment of the fears. It

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helps put words to the frightening and intolerable feelings and helps make meaning out of what feels incomprehensible to most people. It can act as a bridge in helping to make behavioral changes. A  therapeutic relationship can also help someone understand and resolve some of the psychological sources of their avoidance. Obsessive-Compulsive Disorders We mentioned earlier that both Darla and Patty suffered from obsessive-compulsive disorders. Like all of the anxiety disorders, obsessive-compulsive disorders occur at different developmental levels. Because of this they are sometimes confusing to clinicians. Sometimes they can look like depression or even schizophrenia. Obsessions are intrusive, recurrent, and persistent stereotypic thoughts, images, and ideas. They cause marked anxiety and distress. The thoughts can range from having to check the weather or baseball scores before one can sleep, to having to check the internet for everything ever written on each physical symptom one experiences, to having to weigh oneself three times a day lest one gain any weight. More serious and acute obsessions may include anxieties about having committed harmful acts, being contaminated, and harboring unacceptable thoughts or impulses toward others. Jenny, a single white bisexual graduate student, had struggled with obsessive and intrusive thoughts throughout her adolescent and college years. She presented for treatment when she began to have intrusive thoughts about wanting to strike out and hit strangers on the street. She had no history of homicidal thoughts or violent behavior. However, as she began to ruminate about these thoughts, she worried that she harbored violent tendencies. She was overwhelmed with feelings of guilt and fear that she was morally corrupt. In an attempt to avoid interactions with others, she isolated herself in her apartment and began missing classes and social events. She also began to abuse marijuana and alcohol as a means to selfmedicate and escape from her anxiety and fears. Jenny’s childhood and early life experiences provide a context for understanding how her obsessive thoughts might have developed. Jenny had grown up in a single-parent household with a depressed and alcoholic mother. Her mother was often unable to leave her bedroom due to periods of extreme intoxication, or simply being too depressed and fatigued to attend to household duties. Jenny and her younger sister were left to fend for themselves as young children, preparing their own meals, getting themselves to bed, or off to school in the mornings. During Jenny’s middle school and high school years, her mother grew extremely critical in her interactions with her daughters. Her mother’s hostility made it difficult for Jenny to be open not only about her sexual orientation but also about her academic aspirations. She feared being ridiculed by her mother and at times was overcome with feelings of self-doubt and shame. When Jenny began to spend more time with friends who identified as gay or queer, Jenny’s mother made it clear that she would not accept her daughter’s sexual orientation. Her mother routinely made homophobic comments and slurs in the presence of Jenny and her friends. These experiences made it difficult for Jenny to be comfortable exploring her own sexual orientation and engaging with campus activities involving the LGBTQ community during both her undergraduate and graduate years. She worried about how her faculty mentors and peers would view her if she were more open about her queer identity. More recent models for understanding obsessive-compulsive disorders have noted how dysfunctions of the attachment system can disrupt the process of coping with intrusive experiences as well as increase maladaptive or dysfunctional cognitions such as thinking “I’m a

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bad or evil person” (Doran et al. 2015). Attachment theory provides us then with another perspective for understanding Jenny’s obsessive thoughts. Insecure adult attachments can emerge from early developmental experiences, and an ambivalent attachment style may predispose one to obsessive-compulsive disorders (Seah et al. 2018). Jenny’s experience of having a primary caregiver who was emotionally and physically unavailable likely led to forming attachment insecurity and also impaired her ability to develop distress regulation strategies for managing unwanted intrusions related to her negative self-image or the activation of “feared self” cognitions (Doran et al. 2015). For most of us, experiences that challenge our self-constructs can be managed through regulatory processes. But in Jenny’s case, attachment insecurities prevented her from developing a positive internal working model of herself and others. This undermined her ability to self-regulate in times of distress or to restore her emotional equanimity (Doran et al. 2015) even when not threatened. Treatment for Jenny focused on using supportive psychotherapy to help her to gain insight about her cognitive distortions and irrational fears in order to view them as less threatening or benign. Cognitive interventions were used adjunctively with psychodynamic therapy as a means to teach her adaptive coping strategies such as thought stopping and mindfulness. These helped her manage the obsessive and intrusive thought patterns and to tolerate the activation of her “feared self.” Additionally, fluoxetine, an antidepressant, was prescribed to assist with decreasing the intensity of her symptoms, which allowed for her to more fully explore her emotions and the impact of her developmental history during the course of therapy. Clients like Jenny who have experienced childhood trauma can benefit from attachment-based therapies (Allen  & Fonagy 2015). In these therapies, expressing, experiencing, and understanding previously unbearable emotional states, and thereby rendering them “meaningful and bearable” (p. 166), is key. With time, and by using this combined approach treatment, Jenny became more accepting of herself and was also more open with others about expressing her thoughts, aspirations, and other aspects of her identity. Compulsions are repetitive ritualized behaviors that feel obligatory and that are an attempt to manage intolerable levels of anxiety. Compulsions include such acts as handwashing, counting, checking, touching, praying, or other acts that are ritualized. People with obsessions are often plagued with blasphemous thoughts or by murderous impulses. They may experience impulses to hurt another person (as described above in the case of Jenny) or to say something unacceptable. (For a further discussion of some of the intrapsychic factors in these disorders, see the case of Mr. Johannson in chapters 2 and 3.) Tanya suffered from an obsessive-compulsive disorder. As is common, her disorder had begun in adolescence. A nineteen-year-old, white, cisgender born-again Christian who attended a religious college, she came for treatment because she was washing her hands forty to fifty times a day. They were chapped, raw, and bleeding, but when she tried to stop, she would be flooded by intolerable levels of anxiety. She was terrified of germs and would tap three times on a surface to avoid them. She was isolated at college and was indeed shunned for her odd behaviors. Tanya was also disheveled and had difficulty making eye contact. At age two, she had suffered a blood disorder and had since worried excessively about her fragility and her mortality. When she began menstruating at thirteen, her obsessive-compulsive disorder flourished, and she began washing her hands. She often looked very disturbed, almost schizophrenic. Tanya was, in fact, quite functionally impaired. But her symptoms could be distinguished from schizophrenia in that people with schizophrenia often overvalue their thoughts and lack insight, and their symptoms are not alien to them. For Tanya, as for many people with obsessive-compulsive disorders, the symptoms were dystonic. She felt enormous shame and desperation over her obsessions and compulsions and wanted them to stop.

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Although Tanya’s disorder had intrapsychic causes, she needed to be medicated first with SSRIs to help her manage her anxiety. While psychotherapy was not of particular benefit in helping to extinguish her compulsive behaviors, it did provide a safe context in which to examine her isolation from others, her rigid use of her religion’s rituals to bind her anxiety, and her fears of being away from home, which had revived intense separation anxiety.

For many people with obsessive-compulsive disorders, it can be difficult to make a direct correlation between psychological events and biological responses. A drive theorist working with Tanya might have emphasized her difficulties with her own aggression and concerns about her sexuality as stemming from when she first became ill. From this perspective, Tanya’s compulsions began when she became sick at the anal stage of development. Now they might serve to control her sexual and aggressive impulses, which were revived in adolescence. Tanya’s harsh superego injunctions, now expressed as rigid rituals, might have had their roots in earlier unresolved preoedipal issues. An object relations theorist, however, might focus on Tanya’s attempts to gain control over her fears of separation. Perhaps having faced her own mortality so early and as a child and having been separated from primary caregivers when ill, she was left more vulnerable to severe separation anxiety. It is likely that her anxiety over medical procedures she could not understand, coupled with the anxieties of her parents, who thought she was going to die, predisposed her to severe anxiety. Perhaps her blood disease left her filled with self-representations full of dangerous, bad, and destructive forces. The obsessions and compulsions might be a solution and a compromise to help her stay clean, ordered, and checked, in order to manage her own internal world and make it less dangerous. Jenike’s (1990) work on obsessive-compulsive disorders indicates that, as with many of the anxiety disorders, there is also a strong biological component. Serotonergic antidepressants such as chlorimipramine, fluoxetine, and fluvoxamine have anti-obsessional effects. But as with patients with phobias, there is a high rate of noncompliance with drug prescriptions among patients who do not want to ingest substances because they fear that they may control them. Cognitive-behavioral and behavioral therapies are useful for people with obsessive ­compulsive disorders. Here, as with panic disorders and phobias, clients can be exposed to anxiety-provoking situations, and be behaviorally trained not to engage in typically compulsive responses, including hoarding. Mindfulness, meditation, and other forms of stress reduction are helpful. However, many people with obsessive-compulsive disorders may be resistant even to complying with behavioral or mindfulness injunctions because of their anxieties about being controlled. Most of us have at some time experienced a fleeting obsessive thought or compulsive act. Did we remember to lock the door or turn off the oven? Did we have to suppress an impulse to shout an obscenity at someone who made us angry? But people who chronically suffer from these disorders feel at the mercy of their impulses, which they cannot ignore or suppress.

Post-Traumatic Stress Disorder: The Role of Trauma in Anxiety Disorders Trauma and crises are also sources of profound anxiety. Clients who have been traumatized are usually the victims of overwhelming psychological, physical, sexual, or large-scale abuse. They may have suffered prolonged childhood abuse, been victims of relationship abuse, rape, or been witness to other forms of violence (kidnapping, hostage taking, attempted murder, torture, mass shooting, terrorism, genocide, internment, etc.). They may

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have experienced large-scale disasters/catastrophes or experienced trauma associated with military combat or war. Such experiences usually result in feelings of shock, helplessness, vulnerability, fear, or terror, which may later manifest as symptoms of an anxiety disorder. Post-traumatic stress disorder (PTSD) and acute stress disorder are diagnoses associated with trauma-related symptomology. In some cases, a trauma survivor may not have had direct physical injury but instead has witnessed death, serious injury, or a threat to the physical integrity of others. More recently, there has been growing awareness that the effects of experiencing repeated racist/ethnic discrimination result in trauma-related symptomology (Holmes et  al. 2016). Higher rates of diagnosed PTSD in racial and ethnic minorities indicate that culturally relevant factors such as intergenerational transmission of trauma and minority stress need to be considered when examining the effects of trauma (Carter et al. 2019; Coleman 2016). Cross-cultural studies of the effects of cumulative trauma posit that traumatization is “triggered by systemic social structural violence and interpersonal and intergroup macro and micro aggressions” (Kira et al. 2013). The violence of macroaggressions such as hate crimes, extreme poverty, slavery, and genocide (past, present, or historical) are significant threats to the welfare and safety of marginalized groups. Further, the microaggressions experienced by marginalized/oppressed populations are also daily reminders of danger and, coupled with macro aggressions, may trigger annihilation anxiety and re-traumatization (Kira et al. 2013). Many of our current clinical interventions used to treat anxiety disorders only address symptomology through a lens of single personal identity: trauma. However, we think that a cross cultural and racially informed approach is imperative for those clients who have experienced cumulative collective identity trauma or stressors (Kira 2010). Given the overwhelming anxiety that results from experiencing severe or cumulative trauma, it is understandable that trauma survivors resort to defense mechanisms such as depersonalization, derealization, and dissociation to manage the lingering effects of PTSD. This may result in almost phobic avoidance of any details associated with the trauma, but this can then interfere with the ability to process or integrate trauma-related memories. A person suffering from dissociation may also show a restricted range of affect such as numbing of emotions or feelings of detachment from others. The inability to integrate or process the traumatic event can undermine the person’s capacity to manage anxiety and deal effectively with the resulting feelings of helplessness, vulnerability, and terror related to the trauma. While defenses such as dissociation or depersonalization are expected immediately after a trauma, when they reach a level that causes clinically significant distress or impairment in the immediate days after the event, the survivor is considered to be experiencing an acute stress disorder. In cases where the trauma is not severe or the person has sufficient internal and external resources available to support processing the incident, the symptoms of acute stress usually dissipate within a few weeks or months. However, the diagnosis of PTSD is made when one or more of the following symptoms persevere: chronic anxiety, anger, irritability, insomnia, recurrent and intrusive memories or dreams of the traumatic event, exaggerated startle response, hypervigilance, and/or a sense of reliving the experience (flashbacks). PTSD occurs in us all, whether neurotic, characterologically challenged, or psychotic. However, it is important to note that the severity or chronicity of the trauma itself can erode aspects of personality development such as object relations, identity, defenses, and ego functioning. When trauma occurs repeatedly and early on in a child’s development, it effects self and identity, internalized self and object relations, and self-regulating functions (Mills 2008). Thus, the original trauma and the inability to cope with it can result in overwhelming anxieties. We can see this in the following example of Marge, who suffered persistent sexual abuse perpetrated by both her father and her brother.

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Marge was a twenty-one-year-old, white gay identified incest survivor for whom trauma had begun early on. At intake she presented with complaints of insomnia, hypervigilance, depression, self-injury, suicidal thoughts, and recurrent nightmares. She compulsively checked that the doors were locked, and the windows were covered. She reported feeling “spacey” much of the time. Marge began treatment by presenting her therapist with many years’ worth of her journals documenting her multiple traumas. She had been adopted at age three by the parents who raised her, having been in multiple foster homes prior to the adoption. Despite her adoptive family being upper middle class and displaying a patina of normal family life, her upbringing was marred by abuse. Her journal contained an early childhood memory of her father punishing her by taking her to the town landfill and leaving her there, ­saying, “This is where I found you, this is where I’m leaving you.” He did not return until early nightfall. In her journals, she documents how from age seven through adolescence she would awaken to finding her father’s penis in her mouth. She was beaten repeatedly by him and witnessed him shooting the family’s cat after it chewed on furniture. At age thirteen, she disclosed to the mother the father’s abuse, but this did not result in any change. Her mother bought her a motorcycle at that time and, although underage, Marge took it out and totaled it, ending up in a body cast with her father continuing to sexually abuse her. Marge described succeeding scholastically and athletically and earned a full scholarship to a local college at age seventeen and made plans to leave home. Her mother, a physician, kept a bottle of pills in an open cabinet, and Marge would often take them as well as sell them at her high school. As Marge made plans to separate, her mother “noticed” the missing pills, which the mother had replenished many times prior, but this time she accused Marge of being an addict and prevented her from leaving home for college. During the beginning of treatment, Marge was quite unable to talk about the traumas she survived despite her prodigious journals. She often arrived at sessions mute and many times would be unable to sit still and would pace, or else she would sit, but only on the floor. There were times when Marge’s therapist herself felt fragmented during the sessions under the weight of Marge’s disorganized ego states. Because Marge’s sense of self had been so damaged, the ego boundaries between herself and her therapist seemed weak. Often her therapist experienced Marge’s confusion, helplessness, and dissociated and depersonalized states as if they were her own. Marge’s trauma history had undermined many of her ego functions and her anxiety was at the level of separation anxiety and at times the level of annihilation anxiety. She needed a consistent presence in the therapy room that would not only bear witness to the abuse and its consequences but also work tirelessly to assist her with developing strategies for coping with the pain of her past abuse. Working with a client who has experienced abuse like this requires the therapist to carefully titrate the trauma with the client in order to arrive at some level of integration (Herman 1992). In working with a vulnerable client like Marge, it is also important for the therapist to guard against being vicariously traumatized by her client’s experiences and thus regularly monitor and process the therapist’s own reactions (Saakvitne 1995). Although Marge’s therapy did not commence until adulthood, early intervention with children and adolescents who have experienced early and severe trauma can help in mediating the deficits caused by attachment disorder and developmental trauma. Ameliorating the effects of the trauma is accomplished by teaching younger clients the skills in identifying, understanding, tolerating, and managing internal experience (Blaustein  & ­Kinneburgh 2019). In Marge’s case, a psychodynamic approach, which emphasized the lending of ego strengths by the therapist during her regressive episodes, coupled with techniques

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of cognitive reprocessing therapy that strengthened her adaptive coping, were helpful for improving ego functions of affect regulation and object relations. We have now discussed the anxiety disorders: generalized anxiety, panic attacks, phobias, and obsessive-compulsive disorders and trauma disorders. But all of the anxiety disorders have complex biological roots, and therefore biological treatments that must be understood as well. Biological Factors As will be shown in the chapter on trauma (chapter 17) and the chapter on attachment and trauma (chapter 8), brain development begins before birth, and continues sequentially. The development of the brain is shaped by social and psychological factors: constitution, good enough parenting, nutrition, safety, consistency. The brain is also shaped by the effects of trauma, neglect, war, severe deprivation, parental psychopathology, genetic and biological difficulties, and lack of nutrition and health care—all of which can have negative effects on brain development. The nature of the environment plays an essential role in shaping a child’s developing neural networks and affects memory, emotion, affect regulation, attachment, and a child’s sense of self (Schore & Schore 2014). Research that looks at the integration of neurobiology and attachment theory supports the role trauma may play in inhibiting or disrupting brain development. Bettman and Jasperson (2010), in a review of attachment research, recognize that in addition to shaping behavior, attachment serves in the process of brain development and organization. They propose that having the opportunity to successfully resolve experiences of fear or trauma in childhood appears essential for the development of brain structures that support organized responses to stressful situations. However, adverse childhood experiences, which result in insecure attachment, likely interfere with important brain functioning that supports adaptive responses to stress. The brain comprises the frontal cortex, the amygdala, and the hippocampus. These are made up of millions of neurons that form neural networks. These networks create patterns that help us to complete increasingly complex tasks, feel emotions, and relate to others. How any brain functions is a result of genetic makeup and of the individual in relationship to the environment. We know that stimulating environments, for example, can expand brain development so children may learn new things. Children who are under-stimulated, by contrast, may have greater problems with learning, mastery, and the regulation of emotions (Cozolino 2002). Stress is a major force in shifting the biochemistry of the brain. Extreme stress can inhibit learning and growth while moderate stress can stimulate the production of hormones. When there is overwhelming stress, such as in severe trauma or other adverse childhood events, the neural networks are disrupted, and neural integration does not occur. This affects learning, behavior, emotion, sensation, and cognition. Under extreme stress, the integration of information processing may shut down, as we see in the case of dissociation. The roles of therapy and medications, then, are to restore neural network integration and coordination, so that emotion, cognition, sensation, and learning can occur without being overwhelmed by stressors from within or outside of the self. In each of the anxiety disorders, biological factors are implicated in their etiologies and treatments. In the case of generalized anxiety disorders, heightened cortical activity accounts for intense arousal and hypervigilance (Hollander  & Simeon 2003). This then causes alterations in the amygdala, the part of the brain that controls emotions. There is also a genetic link and a higher frequency of people with generalized anxiety disorders among relatives with other anxiety disorders. However, the genetic links are modest (19–30  percent), suggesting that environmental

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factors play a larger role in the development of generalized anxiety disorders than do biological (Wilson et al. 1995). In the case of panic disorders, there are a number of biological explanations. Noradrenergic neurons may misfire into the hippocampus and amygdala, affecting the limbic system and cerebral cortex. These misfires interfere with normal fight-flight responses, which increase cortisol and serotonin. SSRIs and benzodiazepines are effective in lowering cortisol (Ballenger  & Tylee 2003) when treating panic disorders. There is also a genetic basis for panic disorders. About 50 percent of people with panic disorders have relatives with panic disorders (Wilson et al. 1995). Among the biological vulnerabilities for phobias are blunted growth hormones that lead to noradrenergic dysfunctions (Hollander & Simeon 2003). It is thought that phobias, like PTSD, may involve structural changes in the brain, which are initially environmentally induced, but may lead to changes in the limbic system that then permanently maintain an anxiety response. There are also strong genetic components. Furthermore, an inborn temperament such as shyness may also play a role in the development of some phobias (Wilson et al. 1995). In the case of PTSD, where abnormalities in the brain are presumed to be acquired as a consequence of the trauma, there is new interest in determining whether other pre-existing factors in the neurobiological systems may also contribute to a vulnerability for developing PTSD (Sherin & Nemeroff 2011). These might include factors such as genetic components, female gender, physical injury (traumatic brain injury), prior trauma, or developmental stage at the time of traumatic exposure (Lehrner, Pratchett, Yehuda 2016). Obsessive-compulsive disorders are linked to a number of biological causes: birth trauma, diabetes, dopamine dysregulation, even autoimmune diseases such as strep (Tyree 1999). There is a strong genetic component as well (Tsuang & Tohen 2002). People with obsessive compulsive disorders may also have other kinds of neurological disorders such as tics or even Tourette’s syndrome (Wilson et al. 1995). In addition, these disorders represent potential abnormalities of the serotonin system and the prefrontal cortex, which mediate circular and repetitive thoughts. Many other kinds of biological factors also precipitate anxiety symptoms. People who have hyperthyroidism, for example, may experience a racing heart and have startle responses, difficulty managing emotional feelings, insomnia, or increased anger. Their anxiety symptoms are caused by changes in their hormone levels. Someone with an adrenal tumor may present with a full-blown anxiety attack, often not distinguishable from a panic attack. Those anxiety symptoms are primarily caused by the tumor and are not a psychological reaction to the tumor. Clinicians who work with anxious clients always need to ask about the client’s medical conditions and medications and should always keep in mind that physical illnesses requiring medical treatment may produce anxiety symptoms. Otherwise, someone with Crohn’s disease or ulcerative colitis who fears not being near a bathroom may be treated for anxiety, rather than for the underlying bowel disease that causes the anxiety. Substance-induced anxiety disorders can also appear indistinguishable from other psychogenic anxiety disorders. When someone is intoxicated or in withdrawal from amphetamines, alcohol, caffeine, cocaine, hallucinogens, sedatives, marijuana, or inhalants, her symptoms of hyperventilation, fear, confusion, derealization, depersonalization, numbness, and/or dissociation may look like anxiety symptoms. It is important therefore to know whether the anxiety disorder has been induced by a substance or whether it preceded taking it. We cannot stress enough the importance of attending to organic factors, including substance abuse, illness, and medications, in understanding the sources of anxiety.

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CONCLUSION We have said in this chapter that under the best of circumstances, anxiety serves to warn us of danger and to help us to mobilize effective defenses. Under less optimal circumstances, anxiety can overwhelm us, or our egos, resulting in a variety of inhibiting symptoms. Anxiety disorders are always compromises: the best adaptation a person can manage in relation to what is experienced as a dangerous situation: internally or externally. Every anxiety is always experienced at different levels: neurotic anxiety, anxiety about the loss of love, separation anxiety, and annihilation anxiety. Sometimes anxiety is the result of instincts that break through. Sometimes anxiety may emerge as a function of superego conflicts. Some anxiety may be related to an unresolved developmental issue: for example, an obsessive-compulsive disorder may reflect a fixation at or regression to anal conflicts, in which we see heightened ambivalence, obsessional doubts, and defenses such as doing/undoing, intellectualization, and reaction formation (Salzman 1980). In phobias, there may be anxiety associated with disavowed sexual or aggressive urges that are displaced onto someone or something else, which can then be avoided (Gabbard 1990). In the case of some phobias such as agoraphobia, the level of anxiety may be related to early losses, neglect, or traumatic separations. A  phobia or panic attack may arise from an internal world filled with harsh and critical introjects that are then projected onto other persons or things. Or a phobia might be associated with a traumatic situation (a rape, a war trauma), memories of which must be avoided in the present. Every anxiety disorder, whether the root be superego anxiety, separation anxiety, annihilation anxiety, rejection, physical or sexual abuse, deprivation, or loss, affects the body. But the process of becoming conscious of the sources of the anxiety, of creating new narratives, and of developing the use of language (Busch & Sandberg 2014) to identify feelings and describe what has only been felt in the body, can be very helpful. Not only is it important to put into words what was felt as a physical symptom, but a therapeutic relationship can foster greater neural integration (Cozolino 2002; Schore & Schore 2014). Often feelings and bodily states have been dissociated. The work in practice is to bring soma and psyche together in a more integrated form. In most of the anxiety disorders, medication plays an important part in regulating heightened cortisol and serotonin responses, as does slowing down the mind, facilitated by mindfulness and by meditation, which can also help with integration. Studies have indicated that there are direct links between mindfulness-based interventions and changes in the neurological mechanisms involved with emotion regulation, which may affect and reduce mood- and anxiety-related symptoms (Shanok et al. 2019). Recent studies of the neurobiological impact of mindfulness have identified an association between increased activation of the prefrontal cortex in long-term meditators as well as increased thickening of cerebral areas related to attention. Increased regulation of the prefrontal cortex meditators is engaged in a more equilibrated mind–body interaction, which possibly facilitates reduced emotional reactivity to negative emotions or physical pain (Hatchard et  al. 2017). This is why yoga and mindfulness are increasingly being introduced into neighborhood schools where children are exposed to toxic levels of violence. While there is no question that some anxiety disorders have a biological basis, there has been a tendency in managed-care situations to treat anxiety disorders exclusively by medicating the patient. We think that not enough attention is being paid to the environmental stressors or psychological conflicts that may underlie the disorders. Perhaps our zealousness to see anxiety disorders as exclusively biological and/or behavioral is related to just how overwhelmed we, the clinicians, can feel in the face of many of the anxiety disorders. In

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treating clients with PTSD, for example, it is simply hard to bear the experiences of brutality or human cruelty that we hear about. Anxious people can be hard to sit with. People who see danger in situations we ourselves don’t find dangerous may make us feel impatient and eager to find a “quick fix” to their problems. These clients can evoke a range of negative and helpless feelings in us, the helpers. Anxiety disorders also confront us with our own confusion and our own sense of being overwhelmed. As we are now having to use evidence-based behavioral models to treat symptoms, and not people in sociocultural environments with symptoms, it may seem easier to just treat the biochemical conditions by giving medication than it is to pay attention to the social condition and/or the intrapsychic conflicts that may underlie the symptoms. As with each of the disorders we have addressed in this book, then, it is essential to pay attention to the ways in which social conditions such as community violence or racism shape brain functioning, and to how anxiety may look different at different developmental levels. Whatever the treatment—biological, cognitive-behavioral, or psychodynamic—we must appreciate the ways in which creating an attuned, accepting therapeutic relationship is essential for change. It is equally important to recognize that some environments are more toxic than others; that chronic unemployment, or violence, or racism, or lack of access to education or health care, predispose communities to higher levels of chronic anxiety. Social stressors such as terrorism, or pandemics, also contribute to increased social anxiety. Steve Strossel (2014), the editor of the Atlantic Monthly, wrote an essay on his vast array of anxiety disorders, which included social phobias, emetophobia, panic disorders, generalized anxiety disorder, and fears of public speaking, of flying, and of heights. While he described many treatments that had not worked for him, desensitization among them, he also focused on the strengths that his anxiety disorders have produced in him. He wrote this: Anxiety may be intolerable. But it is also, maybe, a gift or at least the other side of a coin I ought to think twice about before trading in. As often as anxiety has held me back—prevented me from traveling or from seizing opportunities or taking certain risks—it has also unquestionably spurred me forward. . . . I do know that some of the things for which I am most thankful—the opportunity to help lead a respected magazine; a place, however peripheral, in shaping public debate; a peripatetic and curious sensibility; and whatever quotients of emotional intelligence and good judgment I possess—not only coexist with my condition but are in some meaningful way the product of it. (p. 80)

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17 Trauma Theories and Disorders Kathryn Basham

INTRODUCTION Throughout history, traumatic events brought about by natural disasters and by interpersonal violence have plagued human beings. Relational violence between individuals and within families and communities persists, while unresolved political, economic, and religious conflicts fuel terrorism and warfare across the globe. Given global environmental shifts in the past few decades, a record number of devastating natural disasters have occurred. In fact, violent hurricanes, catastrophic earthquakes, flooding, and destructive tsunamis have wreaked havoc throughout the continents. Overall, the cost in human life and suffering has been massive. Although many individuals cope with these dire circumstances without suffering long-term negative effects, others respond with a range of mental and physical health concerns. Denial of both the enormity and the reality of traumatic events further distorts our understanding of trauma. Often, survivors of mass genocide describe their recollections as unbearable as memories often disappear from conscious awareness (Courtois  & Ford 2009). In fact, we frequently hear explanations and rationalizations about traumatic events that minimize or negate the reality of relational violence. Often victims are blamed for their own victimization. A form of cultural denial supported by racism and bigotry further contributes to our distancing from traumatic events. An example of this cultural denial of trauma occurred during the aftermath of Hurricane Katrina, which struck the Gulf Coast of the United States in September  2005. Immediately following the disaster, many individuals were stunned by the glacially slow pace of the government’s response to provide aid, primarily to economically challenged African American citizens and their families. As denial and inaction persisted, the issue of racism surfaced as a likely basis for the massive neglect of traumatized citizens, already marginalized in our society. Between 2018 and 2019, many asylum seekers heading to the Mexico/U.S. border met with dehumanizing treatment along with inhumane living conditions in detention camps that reflect culturally imposed trauma. 371

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More recently, in 2019, the world started to experience the early wave of a global pandemic featuring the COVID-19 virus that rapidly swept throughout the world population resulting in 1.9 million infected and 109,200 deaths in the United States, and 6.7 million confirmed cases with 381,000 deaths globally (CDC 2020). On a national scale, strict measures of “lockdown” and social distancing accompanied the stressors of a plummeting economy, massive loss of jobs and homes. The illness and death rates and reduced access to health care associated with the virus have been disproportionately associated with African American individuals. Concurrently, repeated violent events have occurred where Black men have been killed following detainment or arrest by a police officer, fomenting outrage at pervasive social injustices. Peaceful demonstrations have been interrupted by expressions of understandable anger and counterbalanced at times by undue police and military force. With continuous media coverage and immediate virtual access to activating traumatic events, individuals, families, and communities have been repetitively retraumatized. Many people are regularly drawn to watching, experiencing, and intensely reacting to these events. As we will learn in this chapter, a range of responses can emerge in reaction to these kinds of traumatic events, from numbness and detachment to activation and emotional dysregulation. And we must remember that the profound effects of these traumatic events will fall disproportionally on the shoulders of those burdened by poverty, ill health, and stigmatized social identities. This chapter will address the biopsychosocial-spiritual contexts for our understanding of trauma, the wide range of responses to traumatic events (including the effects upon partners and children), and the central role of resilience in aiding individuals as they cope with these events. We will explore some of the psychological challenges that arise as a result of traumatic experiences. We will examine the cultural relativity of diagnosis, the neurobiology of the “traumatic stress” response, and the connections with leading-edge research in infant development, attachment, and trauma. We will review how the psychodynamic theories we have studied help us understand trauma-related intrapersonal and interpersonal dynamics, both outside and within the treatment relationship. The effects of practice with traumatized individuals will also be discussed, including how the clinician may experience secondary trauma, vicarious traumatization, and transference/countertransference phenomena in the therapeutic work. Finally, implications for individual, couple, and group clinical social work practice will be addressed.

HISTORICAL CONTEXT Our understanding of trauma has changed dramatically over the years, often depending on the social forces that support or discourage an acknowledgment of the impact on individuals, families, and communities. Freud (1905b) grounded his theorizing, early on, in the strong belief that symptoms of hysteria were caused by internal intrapsychic conflicts between traumatic events that were out of consciousness and feelings that remained conscious, but that were not integrated with the trauma. In contrast, Breuer (1893), a contemporary of Freud, maintained that hysterics entered a “hybrid” state, experiencing two states of consciousness following a traumatic event (Breuer & Freud 1893). Breuer understood that his patients dissociated in response to trauma, while Freud thought that patients experienced intrapsychic conflict. An important shift in psychodynamic theory occurred when Freud (1905a) developed his theory of oedipal conflict and abandoned his earlier seduction theory of neurosis (see chapter 2). Freud asserted that the narratives heard from patients regarding sexual abuse were likely based on fantasy and wishes, rather than actual child maltreatment. As a result,

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the recognition of the pernicious effects of real childhood sexual abuse was then replaced with the notion that children “fantasize” experiences of sexual abuse. To this day, similar denial of childhood sexual abuse exists strongly embodied in part in the “false memory movement” that questioned the validity of many allegations of sexual abuse (Loftus 1993; Loftus et al. 1994). Societal responses have also been subdued, if not absent, in response to combat survivors. From as early as ancient times, accounts have revealed how war-related stress symptoms impair daily life. For example, descriptions of the physical and psychological plights of warriors are vividly depicted in Homer’s Iliad (Shay 1994). Historical medical literature clearly documents postcombat distress starting with the Civil War when soldiers described disrupted sleep, heart palpitations, and breathlessness, an enigmatic syndrome that was consequently called “irritable heart” (or the Da Costa syndrome). In the early 1920s, World War I  veterans suffered “shell shock” characterized by mutism, amnesia, and blindness. Originally thought to be caused by concussions inflicted by the force of deafening sounds from exploding shells, this syndrome was later associated with psychological origins. Following World War II, veterans reported reexperiencing their traumatic combat-related events through intense symptoms of hyperarousal, through an acute syndrome referred to as “battle fatigue,” or through “combat exhaustion.” A persistent and chronic form of battle fatigue was further documented long after World War II had ended (Friedman & Marsella 1996). However, interest in the biological underpinnings for traumatic stress seemed to wane during this postwar time period. After clinicians listened to the narratives of Holocaust survivors and then treated thousands of male and female veterans of the Vietnam War, the mental health community recognized the clear existence of post-traumatic stress disorder (PTSD) as a psychological syndrome. Finally, in 1980, the American Psychiatric Association officially included this disorder in the DSM-III (APA 1980). The public recognition of an actual trauma-related diagnosis helped many veterans to affirm the “realness” of their suffering following deployment. As trauma-related issues appeared in the family members and offspring of traumatized individuals, groundbreaking research explored the intergenerational transmission of legacies of trauma for survivors of the genocide of Native Americans, the Holocaust, and the Vietnam War (Bravehart, 1999a,b; 2007; Evans-Campbell 2009; Wischelt et al. 2019). Family members, exposed to the distress and unresolved grief experienced by their traumatized loved one, also became parts of the legacies of unresolved trauma that have been passed along from one generation to the next. This transmission process can be understood through the lens of trauma theory in which secondary trauma sets the stage for a “contagion” (Figley 1988, 1995) or a vicarious internalization of the worldviews and symptoms of a traumatized family member (Bride & Figley 2009). From a psychodynamic perspective, we can say that, in response to trauma, we often see projective identification processes where disowned and disavowed internal conflict and affect are projected into and enacted by those individuals who are relating directly with the traumatized family member (see chapter 11 for a further explanation). Affirmed by public acknowledgment of horrific events and research, we have been able to validate the daunting realities of the relational, environmental, combat, and historical trauma experienced by many. In summary, several sociopolitical forces led to critical shifts in heightening public awareness of trauma during the 1960s and early 1970s. In particular, the emergence of the “feminist revolution” in the United States ensured advocacy to work toward protection for survivors of domestic violence, rape, and childhood abuses. These influential events confirmed the harsh realities of wartime trauma and armed conflict, on both a national and an international scale, as well as within the internal domestic war zones of families and communities plagued by relational violence.

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DEFINING TRAUMA What do we mean by trauma? In everyday usage, the word trauma is often used incorrectly as a synonym for stress. Stress is typically triggered by a stressor that may range along a continuum of intensity from mild to moderate to severe (McEwen 1999; McEwen & Sapolsky 2006). Trauma refers to an event or an experience that involves the imposition of severe (or traumatic) stressors—exposure to actual or threatened death, serious injury, or sexual violation. DSM-5 (American Psychiatric Association 2013) addresses trauma and stressor-related disorders in a separate diagnostic category and no longer defines these conditions as anxiety disorders exclusively. Another major change between DSM-5 and DSM-IV-TR (American Psychiatric Association 2000) involves drawing a clearer line in defining a traumatic event. Trauma exposure must result from one or more of the following situations, where an individual: (1) directly experiences the traumatic event; (2) witnesses the traumatic event in person; (3) learns that the traumatic event occurred to a close family member or close friend (with the actual or threat of death violent or accidental); and (4) experiences firsthand repeated or extreme exposure to aversive details of traumatic events—not through television or movies (American Psychiatric Association 2013). In DSM-5, the emotional states of helplessness or intense fear have been deleted as a criterion for PTSD since research data have not supported that these emotional states predict the onset of PTSD. More attention is now paid as well to behavioral symptoms that accompany PTSD by proposing four distinct diagnostic clusters rather than three. They include: (1) reexperiencing—spontaneous memories of the traumatic event in recurrent dreams or flashbacks; (2) avoidance—steering away from emotional reminders of the events; (3) negative cognitions and mood—a distorted sense of blame of self or others, diminished interest in activities and difficulty recalling events associated with trauma; and (4) arousal including hypervigilance, aggression, self-destructive behavior, and insomnia. Figley (1988, 1995) offers a definition of trauma that is particularly useful to clinicians. He refers to trauma as an emotional state of discomfort and stress resulting from memories of an extraordinary, catastrophic experience that shatters the survivor’s sense of invulnerability to harm, rendering him acutely vulnerable to stressors. With a slightly different slant, Herman (1992) concludes that trauma overwhelms an ordinary system of care that gives people a sense of control, connection, and meaning in the world, while Allen (2001) addresses how traumatic events disrupt attachments between individuals and within families (see chapter 8). Clearly, we need to make a distinction between events that are traumatic (i.e., represent a threat to physical integrity) and the responses to trauma. A traumatic stress response involves a set of neurobiological reactions along with strong affective experiences (Cozolino 2010; McEwen 1999) that is described later in the chapter. Not all people react to a horrific event in the same way. Some respond to traumatic stressors with a temporary traumatic stress response. Others respond to traumatic stressors with long-term negative effects. For example, ten persons who live on the same block of a neighborhood subjected to the terror of a catastrophic earthquake will have ten different responses to this traumatic event. Types of Traumatic Events In order to understand the range of responses to trauma, Lenore Terr (1999) proposes a typology that explains the nature of certain traumatic events, including natural disasters along with man-made tragedies. She calls these type I and type II traumas. Type I trauma refers

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to a single discrete horrific event of catastrophic proportion. These events include: (1) natural disasters, such as hurricanes, earthquakes, flooding, and fires; (2) violent acts, including rape, assault, robbery, school shootings, suicide bombings, carjacking, and racialized police brutality; (3) witnessing injury or death, killing, handling body parts, and dangerous duties for police officers, firefighters, EMT’s, and military servicemembers; (4) accidents and diagnoses of life-threatening illnesses; and (5) losses of family, friends, property, community, cultural traditions, and/or primary language associated with asylum, refugee, or immigrant status. Although described as discrete, specific traumatic type 1 events, there are also relationship ruptures and betrayal trauma involved in many of these situations. Amira, for example, exhibited many psychological symptoms in the face of several Type I traumatic events: After fleeing a camp for displaced persons in Syria, Amira, age thirty-one, started to meet with a clinical social worker at a healthcare setting in an urban Northeastern American city. She complained of nightmares, acute anxiety, “shakiness,” hypervigilance, and bouts of weeping, countered by feelings of “deadness” and inertia. While escaping from her war-torn village, Amira and her sisters were raped and her father was brutally murdered. Following these horrors, a neighbor helped Amira to travel twenty miles by foot to reach her temporary refuge—the resettlement camp. Without an opportunity to actually grieve these many losses, Amira secured adequate food, shelter, medical care, and eventual passage to the United States. Upon arrival in the United States, her previously high-functioning (albeit detached and dissociated) stance was replaced by severe hyperarousal symptoms and an acute re-experiencing of her traumatic events. Even though she had experienced sound parenting during her early childhood that helped to have a solid psychic structure, the devastating traumatic events dismantled her internal structure and altered her sense of well-being. The traumatic rape and witnessing of the deaths of her father and neighbors were compounded by many devastating losses of her family, primary language, sense of home and community, and the integrity of physical/psychological self. Since sharing personal feelings with a stranger was an anathema in her family of origin, Amira took a long while to gradually describe her feelings. Although tentative, she gradually started to trust her therapist, who had the added advantage of speaking Amira’s native language. For Amira, as for traumatized clients in general, she needed to feel safe, to be stabilized, and to be able to care for herself first. A full range of supports was extended to Amira, including assistance with housing, health care, vocational counseling, language training, and mental health counseling. For relief from very intense trauma-related physical symptoms, Amira engaged in stress-reduction practices, cognitive-behavioral techniques, and Eye Movement Desensitization Reprocessing (EMDR). Slowly, she began to recover her sense of connection to herself and to others within the context of a nurturing, culturally responsive therapy. According to a Winnicottian object relations therapy perspective, Amira, needed a reparative “holding environment” that offered a sanctuary as she learned to reconnect with others and adapt as best as possible to her new life (Appelgate & Shapiro 2005; Winnicott 1958, 1965).

In contrast to the singularity of type I trauma, type II trauma refers to the chronic repetitive abuses experienced by children as they grow up. More specifically, children who have been repeatedly subjected to physical, emotional, and/or sexual abuse endure what is considered type II trauma. These traumatic experiences often lead to the developing of “complex traumatic stress disorder” (Courtois & Ford 2009). Similarly, adult victims of intimate partner violence suffer type II traumatic abuses. Thus, the persistence and chronicity of recurrent maltreatment differentiates type I  trauma from other types of traumatic events. A  clinical example illuminates type II traumatic experience. Jeannie, Caucasion, age forty-one, and cisgendered, originally reared in a poor, rural town, presented in therapy with fears of overdosing on barbiturates once again. Concerns with “constant edginess,” “despair,” “isolation,” frequent nightmares, and alienation from her two children

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plagued her continually. Although she had been hospitalized and stabilized, Jeannie worried about the constant verbal arguments that she experienced with her husband, Johnnie, an enlisted Army sergeant who was deployed twice to Afghanistan. As a child, severe physical abuse under the guise of corporal punishment was meted out by her parents to her and her five siblings. Between the ages of seven and twelve, she was sexually abused on a continuous basis by her stepfather. By the time she entered high school, Jeannie was ingesting opiates, barbiturates, and alcohol regularly; had cut her upper arms to “remind herself that she was real”; and had abandoned her self-care by binging and purging. And so, by the age of thirty-six, when she met Johnnie in the emergency room of a hospital, she had survived childhood physical and sexual abuses, rape by a stranger, and a gunshot wound to her head inflicted during a soured drug deal. Clearly, the cumulative effects of these Type II traumatic events devastated Jeannie’s sense of well-being as well as her functioning in the world.

Her partner, Johnnie, also suffered symptoms of post-traumatic stress (or injury) following his tours of duty and also experienced a contagion effect of absorbing and internalizing the trauma-related symptoms and moods of Jeannie. According to several traumatologists, secondary traumatic stress and secondary trauma involve the natural behavior and emotions resulting from knowing about the traumatic events experienced by another person (Basham 2008, 2013; Bride & Figley 2009; Stamm 1999; Tyson 2007). These responses may involve full-blown PTSD symptoms in the partner of an individual coping with “complex posttraumatic stress disorder.” That person may feel dysregulated moods, insomnia, flashbacks, irritability, nightmares, and the swinging pendulum of hyperarousal to numbness. Although affected by secondary trauma, a family member or helper does not always experience the complete dismantling of the inner world of a traumatized person. However, the neurobiological responses and symptoms are clearly apparent. As Jeannie and Johnnie interacted with alternating fighting and verbal abuse, their respective primary and secondary trauma-related symptoms fueled their trauma symptoms and augmented their peaks of escalating numbness. Hence, both Jeannie and Johnnie, while interacting with each other, experienced secondary traumatic stress that included nightmares, flashbacks, hyperarousal, and numbness. Theorists have also described type III trauma, related to the effects of violent torture. For example, hostages from wartime report how they survived continuous threats to their survival through a wide range of ways of coping (Kira 2002). Faced with continuous terrifying threats to his life, a POW who was imprisoned for three years in a cage by the Viet Cong described how he disciplined his mind through word puzzles and fantasy to endure the enormity of his situation. Such coping allowed him a semblance of agency and the experience of control over his mind, if not his body or life choices. In recent years, another form of traumatic experience has been proposed, which is described as cultural trauma or racial trauma. Allen (1998); de Gruy (2005); Green et  al. (1990); Holmes (2016); Pouissant  & Alexander (2000); and Tummala-Narra (2016a, b) assert that the day-to-day verbal and, at times, physical, racist assaults inflicted on people of color perpetuate the legacies of slavery and colonization. They strongly assert that such racist attacks, or “microaggressions,” should also qualify as chronic repetitive trauma in the same vein as Terr’s (1999) type II trauma. We can also think about the kind of cultural trauma that ensues in the face of daily aggressive verbal and physical assaults hurled against persons who are marginalized by their ethnicity, religion, sexual orientation, or disability. This form of cultural trauma can be understood through Pahir’s story: A twenty-four-year-old, partially blind, East Indian American graduate student, Pahir, described his early childhood years as dominated by continuous teasing and bullying by other children. He recalled an incident, at age seven, when his classmates taunted him at recess. While he was

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floundering to master baseball, several classmates screamed to him that a bee had landed on his head. They yelled: “Why can’t you see it? It will kill you! Aren’t there any bees where you came from? Why don’t you go back home where you belong?” Pahir was terrified and tried to brush off the invisible bee, while his classmates surrounded him, laughing uproariously. They reveled in his humiliation.

While Pahir lived through this one frightening and shaming incident without emotional scarring, similar situations were repeated continuously throughout grade school and high school as he navigated his way through hostile territory. Regular harassment about Pahir’s blindness, his East Indian ethnicity, Muslim religious beliefs, and dark brown skin color fueled ongoing racist and bigoted remarks from his fellow students. Such mean-spirited treatment functioned in the same coercive ways as type II cumulative trauma. “Impersonal” versus “Interpersonal” Trauma Another distinction drawn frequently is between impersonal trauma (i.e., natural disasters) and relational or interpersonal trauma (i.e., childhood abuses, domestic violence, criminal assaults, rape, sexual harassment, combat, and other forms of political violence). Some theorists suggest that relational trauma adds a different kind of devastation based in a violation inflicted by another person (Allen 2001). For example, a serious car crash may be devastating to those involved; yet an auto accident caused by a drunk driver adds an interpersonal component of intention that stirs feelings of betrayal. Similar experiences of distrust and betrayal are also central in the psychological lives of children who have been neglected and abused. We will look at the impact of this form of trauma when we explore the interpersonal consequences of early childhood trauma (Allen 2001; Schore 2003a, 2003b). Combat Trauma War involves a combination of combat trauma and deployment stressors that affect service members in distinct ways. Although many Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) troops that have been deployed to war zones experience a sense of mastery, patriotism, and excitement, others report the absence of any safe space “outside the wire” when they left camp or moved out on patrols. Similarly, life inside the base camp is often frightening and an unsafe space as well, especially with increasing threats of military sexual assault, primarily, but not exclusively, inflicted by men against women (IOM 2013, 2014; Suris & Lind 2008). Many servicemembers have experienced types I, II, and III traumas along with cultural and racial trauma. Unlike warfare during World War II and the Korean War, when periods of boredom were interrupted by violent intermittent episodes of combat on the front lines, the war zones in Iraq and Afghanistan involved continuous exposure to danger. Combat exposure is one of the most severe stressors that a person can experience in life. Servicemembers report continuous encounters with improvised explosive devices (IEDs), suicide bombers, sniper fire, and an indistinguishable insurgency. Similarly, veterans describe seeing exploding vehicles with body parts thrown about and soldiers blanketed in shrapnel as everyday events. Unrelenting continuous horrors of attacking or being attacked, killing and witnessing killing, or of mutilations change individuals. While one set of skills may have been learned that were enormously useful during deployment, they do not work well in day-to-day life back home. For example, service members learn to control fears and suppress emotion, cunningly devising ways to survive and parse information while restricting communication.

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Often, these new capacities, once they are home, alienate other people and interfere with reconnecting with a partner, friend, or children (Basham 2008, 2013, 2021; Castro, Kintzle & Hassan, 2015; Shay 1994). Hypervigilance needed to respond to dangerous situations during combat may frighten family members on the home front. Finally, some of the fixed rules of hierarchy that were broken in a danger zone need to be respected upon return to life back in the community. For example, while speeding was adaptive to flee from danger while in war, the same behavior at homes is dangerous and illegal. Lengthy separations and extended time apart from loved ones also weigh heavily on servicemembers, their partners, and children and affect reentry and reintegration back home. The burden of suffering major losses due to death often leads to plaguing survivor guilt or moral injury. For example, when faced with the death of a colleague or noncombatant, a soldier or marine might experience a deep sense of failure or abdicating responsibility to protect this individual, leading to moral injury. Grieving may often be thwarted. One OIF soldier who lost a revered unit leader repeated, “I should be the one who is dead,” over and over—totally convinced that he did not deserve to remain alive. Following a return from deployment, couples need to renegotiate parenting roles and decision-making responsibilities, and discuss and validate the accomplishments achieved by each partner during deployment. Research data suggest that children have the most difficulty dealing with the detachment and avoidance experienced by veteran parents who are struggling with post-traumatic stress (Basham 2013; Samper et  al. 2004). Unchecked, repeated cycles of rage eruptions and detachment by the veteran can adversely affect families. Although many of these troops and their families harness their collective resilience to navigate a smooth reunion, in other homecomings, a servicemember might respond to the smells, sounds, and visions of stimuli that are reminiscent of the original traumatic event, activating the traumatic stress response in unexpected ways. This often leads to a flashback as well as heightened fear and distancing within the family (to be discussed in greater length with the clinical vignette of the Arrozo family).

RESPONSES TO TRAUMATIC EVENTS Resilience So many kinds of traumatic events have disturbed and overwhelmed children, adolescents, and adults throughout the world. However, the ways that people respond to these events vary considerably depending upon other moderating factors, including resilience. Constitutional “hardiness,” sociocultural factors, family and community support, and preparation/education regarding trauma-related effects may all mediate the potentially negative effects of trauma (Bartone 1999; Southwick et al. 2015). The age when a traumatic event(s) occurs is important given the anticipated developmental challenges that the person is facing. For example, when four-year-old Arlene is showered alternately with random affection followed precipitously by a screaming harangue about her “stupidity,” she feels confused and overwhelmed by the harsh, contradictory messages. In fact, her mother’s unpredictable rages traumatize her. Arlene fears for her safety and sinks into an abyss of terror and insecurity. Given the absence of protection or other moderating protective factors, Arlene approaches new tasks with timidity. Rather than exuberantly taking initiative to meet new challenges, her enthusiasm and initiative have been squelched. Many individuals who have coped with traumatic events approach their lives with optimism, a sense of mastery and sound functioning, often demonstrating post-traumatic

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growth (Tedeschi & Calhoun 2004). However, other trauma survivors experience difficulties in developing attachments and managing work responsibilities, while still others develop full-blown neuropsychological symptoms and psychiatric disorders. We will first address the role of resilience in coping with adverse traumatic stressors, as well as explore the role of risk factors and the protective factors that guard against mental and physical health problems. We will then explore a range of responses to traumatic stressors including posttraumatic stress (PTS) or injury; post-traumatic stress disorder (PTSD); acute stress disorder (AST); complex post-traumatic stress disorder (C-PTSD); and other anxiety disorders and depression. We can learn a great deal about adaptation and survival from these resilient individuals. The question arises as to what are the protective factors that guard against developing psychopathology and support coping. Rutter (1993) talks about constitutional factors that predispose some persons toward resilience, including strong physical health, sound mental health, and innate intelligence. Let us recall Amira, the Syrian refugee introduced earlier, who demonstrated noteworthy resilience in response to the wartime conflict and rape and who possessed all of these attributes. Current research literature addressing combat stress focuses on hardiness, defined as a positive, optimistic outlook, a belief in the purposefulness of one’s actions, an esprit de corps, and a hopeful outlook toward the future (Bartone 1999). This worldview combined with a sound constitution may serve soldiers very well in combat. Other factors that aid active-duty soldiers include emotional support from family members and friends, a hospitable and respectful welcome from their communities of origin following a return from combat, and substantial education about trauma-related effects. Respectful and consistent leadership can provide salutary effects for soldiers in combat; without this clearheaded vision and adequate training, many soldiers experience enhanced vulnerability and powerlessness, dangerous ingredients for the development of PTSD. If we think that trauma shatters a sense of meaning, purpose, and security, then traumatic experiences will increase when wars are waged for ambiguous reasons. Not surprisingly, certain sociocultural factors can also serve as moderating or mediating factors in developing stress disorders. For example, class and race served as mediating factors that increased PTSD for Vietnam veterans (Kulka et al. 1990). During the war, many draftees of color were assigned the most horrific duties and subjected to discrimination from officers as well as from fellow soldiers (Green et al. 1990). Incidents of racism and classism added stress to these combat situations, often exacerbating and mediating the effects of combat trauma.

MENTAL HEALTH RESPONSES AND COOCCURRING CONDITIONS There are no universal ways that individuals respond to traumatic experiences. Many may demonstrate similar psychophysiological responses to traumatic events yet cope with the trauma without developing long-term mental health or physical health concerns. Others may experience PTS or injury, ASD, PTSD, C-PTSD, other anxiety disorders, and/or depression (Gradus 2017; IOM 2014; Yarvis et al. 2012). Post-Traumatic Stress Disorder PTSD is a syndrome frequently encountered in clinical settings. This psychiatric disorder may occur following life-threatening events such as natural disasters, serious accidents,

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violent assaults, abuse, terrorist attacks, and wartime combat. Although individuals with PTSD experience nightmares, flashbacks, sleep problems, agitation, detachment, and numbness, these symptoms are not uncommon during an early adjustment to a traumatic event. In general, seven major factors determine the likelihood that an individual will develop PTSD following relational traumatization. They are: (1) a higher degree and intensity of exposure to violence; (2) a higher degree of physical violation; (3) longer duration and greater frequency of abuse; (4) more heightened sense of unpredictability and uncontrollability; (5) a closer, familial relationship with the offender; (6) younger age; and (7) an unsupportive social environment that inflicts stigma, shame, and guilt (IOM 2014). Although the research literature points to the intensity of exposure as the most influential factor in mediating the emergence of PTSD, a wide range of risk and protective factors also influences how well an individual and family adapt to the traumatic event (Basham & Miehls 2004; IOM 2014; Kessler et al. 1999). When these symptoms occur for a short duration (up to one month), they are classified as an “acute stress disorder.” In contrast, PTSD can only be fully assessed as chronic after one month following the traumatic incident, although many individuals present with a delayed onset of symptoms as well. Although the PTSD diagnosis arose in response to the needs of war veterans, the syndrome occurs in a much broader population of traumatized men and women, children, and adolescents who have been reared in Western and non-Western cultures and diverse socioeconomic strata. We now understand that veterans often experience PTS following their deployments to a combat zone as a normal response to an abnormal situation while facing the extreme horrors of war (IOM 2008, 2010, 2013, 2014). While most who encounter war will experience traumatic stress, not everyone experiences full PTSD or depression. However, current research suggests that one in three post-9/11 service members is reporting symptoms of PTSD during post-deployment (Hoge et al. 2006; IOM 2013, 2014). Further research supports a strong link between PTSD and depression and substance abuse and addictions (Southwick et  al. 1994). Traumatized individuals may also develop other anxiety disorders, such as panic disorders, phobias, and generalized anxiety disorders. Given this complexity, we must be rigorous in our assessments of these disorders to ensure that a correct diagnosis is completed. Only then is it possible to craft a useful, multilayered treatment plan that addresses all issues involved. We cannot underscore sufficiently how important it is to explore the possibilities of these other cooccurring conditions, especially depression, substance abuse, traumatic brain injury, and intimate partner violence (see chapter 16 on anxiety disorders and chapter 15 on affective disorders). Clinical Vignette: Arrozo Family and Failed Treatment The following clinical vignette provides an example of how an Operation Iraqi Freedom (OIF) veteran and his wife struggled with the effects of PTSD, depression, moral injury, survivor guilt, secondary traumatic stress, and interpersonal conflicts within the family. This clinical vignette reveals strengths and obstacles to successful treatment and demonstrates how the multimodality practice model relies on a psychodynamic developmental scaffolding while including a full range of somatic, cognitive-behavioral, and family approaches. Sergeant Carlos Arrozo, a thirty-five-year-old Army reservist veteran of Puerto Rican descent, has been working for fifteen years as a technician while coparenting his three children, Antonio (age ten), Sara (age eight), and Ana (age two), with his wife, Maria (age thirty-one), an occupational therapist. During his first tour in Iraq, Sgt. Arrozo believed that the search for weapons of mass destruction and the overthrow of Saddam Hussein proved to be just and fair reasons for war. In the first month, he witnessed the killing of two of his “buddies” during a

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random explosive attack of an improvised explosive device (IED). He survived an eight-month tour of duty without suffering any physical or mental health injuries. One year later, when he was deployed once again to Iraq, he found himself working with a reconnaissance unit that was investigating homes to “ferret out” terrorist insurgents. One day, his unit mistakenly opened fire on a home occupied by four adult women and six children ranging in ages from about three months to ten years. Four of the children were killed during the raid, while the other children and women were wounded. Although his initial homecoming reunion brought great relief and pride to the family, within six weeks Sgt. Arrozo started to experience pervasive anxiety, poor concentration, headaches, insomnia, and nightmares. Flashbacks of horrific memories of violent actions were often triggered by smells of burning rubber, sights of men and women cloaked in heavily layered garments, sounds of cars backfiring, and visions of a vast expanse of sand blowing through vacant space. Such events stimulated an intense traumatic stress response that activated alternating hyperarousal followed by numbness and detachment, consistent with post-traumatic stress. Sgt. Arrozo’s moods were totally dysregulated. During these episodes, his wife and the children fled in terror from him, seeking safety in distant rooms throughout the house or garage. Fighting ensued between these marital partners with Sgt. Arrozo frequently yelling loudly at his children when they failed to follow his directive orders quickly enough. Although Sgt. Arrozo sought refuge with his buddies at a local bar several times per week, he did not view his consumption of eight beers per evening as a problem. The Arrozo home environment was characterized by fear, uncertainty, and detachment. Secondary trauma took hold when Maria herself started to complain of nightmares and depression. The eldest child, Antonio, started hitting other children at school; Sara complained of stomach aches and started to wet her bed at nighttime; while little Ana clung to her mother anxiously while bursting into tears when her father approached her. After receiving a medical discharge from the Army based on service-connected PTSD and physical injuries (i.e., second- and third-degree burns to his arms and a broken pelvis), Sgt. Arrozo expressed most distress about potentially losing his wife and children. He also worried deeply about finding a job to support his family. Obsessional thoughts of his “accidental killing” of a young child invaded his mind unrelentingly and plagued him with guilt, shame and moral default. According to Sgt. Arrozo, he felt “tense, distractible, agitated, useless, enraged, and numb.” These symptoms are not only compatible with post-traumatic stress and/or PTSD, but they also signal conditions of depression, substance abuse, and traumatic brain injury. In fact, this constellation of conditions represents the “signature injuries” of the conflicts in Iraq and Afghanistan, the longest wars in U.S. history. From that point onward, Sgt. Arrozo’s faith in the justness of the war was shattered and he experienced a strong antipathy toward Iraqis and any other individuals who he assumed had emigrated from the Middle East. During deployment, he experienced a strong esprit de corps within his unit, but an absence of protective support from his command. He received no mental health intervention during his active deployment. Eventually, his traumatic exposure to the killing and maiming of children and women dismantled his belief system. These multiple, corrosive stressors eroded Sgt. Arrozo’s resilience and led to the emergence of PTSD. When Sgt. Arrozo agreed to seek mental health intervention, his wife telephoned a mental health provider in the community. After a one-hour assessment with this nonmedical clinician, a preliminary diagnosis of PTSD and depression were established based on the client’s self-report and confirmation through the military record. In order to help Sgt. Arrozo find rapid relief from his combat-related psychological injuries, the clinician referred him to a colleague for prolonged exposure therapy and to a psychiatrist for medication management. Weekly psychotherapy sessions focused on the use of cognitive-behavioral techniques (CBT) skills to track his depressed mood through journaling. Sgt. Arrozo could not concentrate on these daily writing assignments and expressed deep shame with his incapacity to complete the task. After three weeks of this combined treatment plan, Sgt. Arrozo reported a flooding of emotions activated by the exposure therapy that overwhelmed him. He was consumed with suicidal thoughts, and terminated the therapies. His therapist felt that Sgt. Arrozo failed as a client due to alleged noncompliance. However, although well-intentioned, she did not see the unintended iatrogenic effects of her interventions, including the absence of a thorough biopsychosocial-spiritual assessment and poorly

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timed interventions that contributed to Sgt. Arrozo’s decompensation. The clinician also failed to attend to the totality of this soldier’s struggles as well as exploring areas of strength, for example, his faith-based community and cultural traditions. She might have focused on Sgt. Arrozo’s areas of competence, leadership skills, and resilience at work, at school, and in the military. Apparently his undiagnosed, mild, traumatic brain injury and substance abuse further interfered with his benefiting from a cognitive-behavioral method that requires reasonably sound cognitive functioning. Finally, the absence of attunement to the volatile relationship between the marital partners and between the parents and their children set the stage for increasing escalation of emotional abuse and destabilization. Because no risk assessment had been completed to determine the safety or lack of safety in this home, intimate partner violence went unrecognized. His children’s symptoms of secondary trauma, evidenced by their heightened insecurity, were also ignored.

This treatment plan for Sgt. Arrozo reveals the central importance of a complex theoretically grounded biopsychosocial-spiritual assessment that guides the crafting of an effective practice plan. The absence of collaboration with other providers (e.g., psychiatrist, school counselors, career counselors) and the lack of attunement to sociocultural influences, especially the supports from their extended family and faith-based community, undermined the work. Finally, the clinician ignored timing, reasonable pacing, and maintaining the locus of control with the client—all basic principles of trauma-informed treatment. Cultural Relativity of Diagnosis PTSD, as a diagnosis, has been critiqued for its relevance cross-culturally (Holmes, D. 2016; Tummala-Narra 2016a, b). Several researchers have concluded that the neurobiology of trauma-related responses in the body is universal. Following the impact of trauma, an individual often experiences increases in blood pressure, an increase in perspiration, and a racing heart, all the while alternately feeling numb or excited. Different cultures attach different meanings to both the traumatic events and their physical and psychological responses. In Western cultures, there is often a fight-flight response, while in some Latino families, a response to traumatic stress involves a “pause-collect” reaction. In the latter situation, an individual responds to the neurophysiological stress state by seeking out loved ones to protect, rather than fleeing or fighting. The experience of collecting oneself may relate to the numbing or stillness effect that looks like flight in another individual. The end goal here might be to care for and protect vulnerable children and elders, rather than switching into a “fight-flight” mode. In other words, behaviors and reactions associated with PTS are culturally determined (de Jong et al. 2005; Friedman & Marsella 1996; Tummala-Narra 2016a, b). For example, Yoki offers a glimpse into the cultural issues in trauma. Attention to spirituality provided important clues related to this client’s presenting concerns. Yoki, a twenty-eight-year-old Cambodian immigrant who suffered sexual and physical abuse from ages ten to thirteen, reported experiences of seeing ghosts, difficulty sleeping, and nightmares of being killed following her rape by a stranger. In therapy with a culturally responsive clinician, she was able to discuss her fears, yet felt comforted by the “ghosts of her ancestors,” who were protecting her. She also benefited from acupuncture to help her with her migraine headaches and generalized anxiety.

From a Western mental health perspective, we need to be careful to avoid pathologizing the nature of the ghosts, since they function as culturally adaptive supports rather than maladaptive hallucinations. In this situation, we observe some PTSD symptomatology along with the understanding that Yoki’s “ghosts” are culturally syntonic or, in other words,

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compatible with her views of spirituality. In general, we recommend that cultural world beliefs and views need to be considered in all assessments of the mental health and health responses to all forms of trauma in traumatized individuals, families, and communities. Complex Post-Traumatic Syndrome (C-PTSD) When an infant or young child is traumatized by neglect or abuse, she may develop problems with establishing basic trust, a cohesive identity, and a capacity for secure attachment. Since ordinary developmental tasks are often disrupted following a traumatic experience, clinicians must rigorously explore how these overwhelming events may have influenced various developmental achievements. Although an Eriksonian life-cycle model is limited by the linearity of the developmental progressions and the absence of an adequate sociocultural context, it can still be useful (Erikson 1980). There is wisdom in exploring the effects of an infant’s developing trust or mistrust when traumatized; the capacity of a toddler to assert confident autonomy, rather than experiencing self-hating shame; the ability of a young child to express curiosity and initiative, rather than suffer strong guilt based on perceived wrongdoings; or the capacity of a latency child to feel deep excitement related to mastery and industry, rather than retreat into a paralyzing withdrawal. Many resilient children manage to grow up mastering these various developmental challenges while also weathering significant traumatic events. However, many children are not as fortunate. Without sufficient relationships that repair the effects of trauma and/or treatment that intervenes, these children often grow up to develop complex trauma (Courtois 1999; ­Courtois & Ford 2009; Goodwin 1990; Herman 1992). This diagnosis tells the clinician that identity formation may be compromised and that dissociation will likely be used to cope. The symptom clusters associated with complex trauma (i.e., reexperiencing, numbness, and hyperarousal) combine with three other important factors. They include (1) a full range of somatic, psychological, and emotional symptoms; (2) reenacting of traumatic relationships in the present; and (3) distorting identity and diminished self-esteem. For example, Jeannie, who was introduced earlier, suffered migraines, irritable bowel syndrome, severe asthma, generalized anxiety, panic disorder, as well as self-harming and suicidal behavior. All of these conditions were trauma-related. Throughout her adult life, Jeannie also found herself in consecutive destructive relationships. After escaping from a physically abusive relationship with an addicted partner, she gravitated, only two years later, to an emotionally abusive relationship with Johnnie. Although adult trauma survivors often seek the familiar attention of the early victimizer in their adult relationships, they are often unaware that they are preserving some idealized version of the original offender by repeating the “victim-victimizer-bystander” trauma scenario (Basham 2008, 2013; Herman 1992; Staub 1989). We must be vigilant, however, to avoid blaming victims during these traumatic reenactments and must hold any emotionally or physically violent offender responsible for one’s actions. Although complex PTSD often interferes with all aspects of a person’s life, some treatment interventions have been helpful. They include (1) relationship-based psychodynamic individual therapy, (2) psychopharmacology with SSRI medication and other pharmacological innovations, (3) cognitive-behavioral therapy, (4) cognitive-processing therapy, (5) group therapy, (6) couple and family therapy, and (7) complementary and alternative medical approaches (e.g., EMDR, yoga, Reiki therapy). Traumatized individuals and communities that have been subjected to armed conflict, torture, and warfare in non-Western nations have often found healing approaches that draw upon indigenous storytelling, dance, spiritual rituals, and community building to alleviate trauma-related suffering (Corbin 2012; Tummala-Narra 2012,

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2016). Each of these modalities has been helpful, differentially, in remediating symptoms, strengthening connections, and enhancing overall work and social functioning.

IMPACT OF RELATIONAL TRAUMA AND PSYCHODYNAMIC THEORIES We have now seen how psychological and cognitive development may be undermined or derailed in response to traumatic events during childhood, adolescence, or adulthood. As each psychodynamic theory model focuses on different aspects of the legacies of trauma, each perspective must be synthesized with contemporary trauma theories to yield a more complex assessment and treatment plan. For example, drive theory addresses how trauma interferes with an adequate regulation of aggressive and sexual drives, or impulses, paying attention to failures of repression and unconscious conflicts in response to traumatic events. Ego psychology focuses on how effectively an individual copes and adapts to environmental and developmental challenges with subsequent emergence of a range of defenses in response to trauma-induced anxiety. Such defenses include denial, splitting, dissociation, and projective identification. From an object relations theoretical perspective, when a child has been abused, she faces a formidable dilemma. On the one hand, she may have to renounce her abusive parent in order to view herself as “good.” On the other hand, she might maintain her connection with her parent and yet view herself as deserving of the abuse (perpetuating the notion of the internalized “bad” object). Finally, from a self-psychological perspective, interpersonal trauma may rupture empathic attunement between a child and her most important idealizing and/or mirroring selfobjects, those who provide life-preserving caregiving functions. Traumatic events may cause fragmentation and disintegration anxiety while interfering with the emergence of a cohesive “I” or “we” self. Clearly, traumatic events that occur during the first four to five years of life may have enduring effects that undermine the development of a cohesive sense of self, object constancy, and mature range of defenses. When a young child has received “good enough” caregiving (in a Winnicottian object relations framework), she may then rely on these earlier developmental strengths and capacities to weather devastating events that occur in adolescence or adulthood. We want to trust our caregivers but their acts may cause distrust and a sense of having been betrayed. Subsequently, in adulthood, people who have been traumatized engage in power and control conflicts, while frequently remaining attached to their victimizers. They may use distance and dissociate interpersonally. They may have problems with boundaries and have trouble communicating. For clinicians, this work may also be traumatizing. Often we see the clinician experience a rupture of boundaries, difficulties healing, and dissociation and distancing as ways of coping with traumatic narratives. We will describe the aftereffects of relational trauma through the theoretical lenses of ego psychology, object relations, and relational theories as well as self psychology. Ego Psychology The focus of ego psychology rests on the ways that individuals cope and adapt throughout the life cycle with continuous dynamic interactions for a person in the environment ­(Hartmann 1964; Schamess 2016). Ego psychologists captured an interest in moving beyond a biologically driven instinctual emphasis to include the role of sociocultural influences in a post-World War II intellectual climate. Individuals are biopsychosocial beings shaped by complex experiences during past and present experiences. Achieving conflict-free zones of functioning occurs as various ego functions mature and develop. Difficulties and conflicts

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often emerge when traumatic events and stress interfere with this maturational process, leading to ego deficits, maladaptive defenses, and maladaptive patterns of relating. Although a full range of ego functions must be explored, affect regulation, mastery-competence, selfesteem, object relations, and defenses proceed to the foreground. Specific defenses that are regularly associated with the effects of trauma include denial, withdrawal, projection, projective identification, splitting, withdrawal, and dissociation. Denial When the ego is overwhelmed by a traumatic experience, the emotions associated with the painful event may be ignored or disavowed in an effort to protect the vulnerable ego. For example, individuals and families who are coping with fatal illnesses may employ adaptive denial at times to strengthen hope and a will to live. Along similar lines, military servicemembers rely upon denial to reduce fears and anxieties in dangerous situations while also bolstering their abilities to keep fighting. Withdrawal When a child has been mistreated, she may retreat from the person and situation, setting the stage for a pattern of withdrawal or distancing, as an adaptive defense. After the child grows up, she may well experience persistent distrust and heightened wariness toward other people. Withdrawal from a threatening person serves to protect a traumatized child, adolescent, or adult from further hurtful interactions. For example, Jane, a second-generation Norwegian American who survived childhood sexual abuse, immersed herself in homebuilding, finding very little time for conversation with her lesbian partner, Maria. As a survivor of childhood sexual abuse, Maria, who was reared in ­Argentina, maintained distance by providing overly zealous caretaking for relatives and friends, taking her away from home and her partner. Although both partners complained bitterly about their withdrawal from the other, they explained this dynamic as a “basic culture clash.” Although their different ethnic backgrounds shaped their respective world views, culture alone did not explain the trauma-related detachment.

Projection/Projective Identification An ego overwhelmed by traumatic events often deals with intolerable anxieties and impulses by attributing them to a person or people in the external world who are then blamed for victimizing and hurting the traumatized person. While struggling with intermittent slippage into psychotic states, a seventeen-year-old white and queer-identified client, Alex, yelled at me, “You are a mean, stupid, control freak therapist,” following a comment made to empathize with his fears and self-doubts about his own competence. Suddenly, I became the enemy who was perceived as “embodying” meanness, inadequacy, and domination. Projective identification as a defense will be discussed in the section focused on an object relations theoretical perspective on the aftereffects of relational trauma. Splitting When a child is subjected to sexual, physical, and/or emotional trauma and abuse, integrating the good and bad parts of the parent leads to internal splitting between the good and bad parts of the self. When development moves forward without traumatic intrusions,

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the good and bad parts of the “other” are internalized and integrated in a more coherent whole with a textured view of self and the other. Alex, the seventeen-year-old, white and queer adolescent client presented earlier, suffered sexual abuse from a coach in elementary school from ages six to nine, internalizing good and bad experiences from this beloved (“allgood’) and hated (“all-bad”) parental figure. As a result, he internalized a self-image that was fragmented into an “all-bad” devalued, impotent Alex as well as an “all-good” engaging and smart Alex. He also projected this internalized relational template onto the outside world and viewed certain peers and his therapist as alternately either brilliant and accomplished or stupid and weak. Dissociation Dissociation, as an adaptive defense mechanism, has been observed frequently in clients who have suffered traumatic experiences either in childhood or during their adult years. In the field of traumatology, considerable attention has been paid to understanding the function of dissociation as well as the most helpful clinical interventions that minimize reliance on this adaptation (Briere 1996; Briere & Scott, 2006; Cohen et al. 1995; Courtois 1999; Kluft 1995). Dissociation involves the key features of detachment and compartmentalization, operating on a continuum from mild to severe processes. Clients who have suffered especially brutal childhood abuses often demonstrate the most extreme dissociative responses, resulting in dissociative identity disorders (DIDs). Evidence of dissociation is often apparent in memory lapses and an experience of internal fragmentation. For example, gaps in memory may last for several seconds to several hours. Providing an example of a common occurrence of dissociation helps people understand the process of dissociation. Most people can identify with a situation that has been terrifying, like a car accident, where a victim automatically detaches her emotion from the event. Most of us have had a moment of terror when we are unaware of our feelings, have felt numbness, and have forgotten the details of the event. Our memory lapses related to dissociation are not deficiencies, but adaptive coping. When dissociation occurs regularly, however, aspects (or parts) of one’s self-structure may be undermined. As a result, the client may experience tremendous internal chaos or mental clutter when memory and feelings are split off. Object Relations Theories The focus of object relations theories is on the internalization of interpersonal relationships as they form an internal scaffolding or psychic structure for a relational template that shapes a view of both oneself and the other (object). Based on the premise that an individual is “object seeking” from birth, a baby requires a nurturing environment to adequately develop in cognitive, affective, and social realms. When parental aggression or deprivation occur, a child takes in many bad self and object representations in addition to some good self and object representation. Such “good” and “bad” self and object representations are often split off and projected into all interpersonal relationship with object replication. This process leads to repetitive self-defeating behavior with alternating idealization and devaluation of oneself and the other. Mental health problems and symptoms may also emerge that are associated with emotional suffering and distress. The processes of projective identification will be illustrated through the depiction of the “victim-victimizer-bystander” trauma scenario and boundary challenges in day-to-day life and in treatment. In addition, “the attachment to the abuser” will be addressed with attention paid to the effects of trauma on communication and sexual intimacy.

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Projective Identification and Victim-Victimizer-Bystander Trauma Scenario Trauma survivors have typically experienced victimization at the hands of someone who has hurt them. Usually a bystander has been present who has either failed to help or remained detached or uninvolved. Occasionally, someone has intervened to rescue the victim and/or interrupt the abuse. These ways of relating predispose a trauma survivor to relate to other people within this trauma scenario. Not only does this pattern appear in day-to-day life in interactions with other people, but trauma survivors internalize this victim-victimizerbystander relationship template, which guides their vision and way of relating to the world (Herman 1992; Staub 1989). From an object relations perspective, our traumatized clients often experience internal conflict surrounding this relationship template. Through projective identification (see chapter 6), others are enlisted to act like a victimizer, a bystander, or a victim. Other people at times are experienced as victimizers (even when there is no apparent objective reality), and in response to a hurtful remark, a trauma survivor may experience augmented anger and victimization. In a relationship, each person may shift back and forth with alternating oneup or one-down power positions. Polarizations in affect, thought, and behavior emerge as they argue about who is right or wrong, or good or bad. A clinical example of this victim-victimizer-bystander paradigm occurred early on in couple therapy with Rod and Yolanda, a dual-trauma African American couple. They engaged in bitter, destructive verbal battles characterized by alternating roles as the victim, victimizer, and bystander. They disrespected and mistreated each other in destructive ways, yet denied the damaging effects of their victimizing behaviors. Each of them could readily express their feelings of victimization, while neither partner experienced anyone in their lives as an especially helpful bystander. During the course of their couple therapy, both partners moved toward addressing multiple oppressions related to their childhood abuses and racialized maltreatment. Reared in the Deep South, Rod lived with four brothers and one sister with his parents in an economically impoverished neighborhood. As a dark-skinned child, he was teased and humiliated by his brothers and children at school, who alternately degraded him with verbal assaults and taunted him with remarks that he is “special and privileged” since he was the only child in his family to be bussed to a neighboring school that primarily enrolled white students. While frequent racialized remarks burdened Rod most days, he internalized a sense of shame and diminished self-worth. Carrying the corrosive internalized effects of these racial and cultural traumatic encounters, Rod mobilized to head north to New York City to attend community college. Early on, Rod met and was enchanted by Yolanda—the woman he would marry the next year. In contrast to Rod’s childhood experiences, Yolanda carried the legacies of pride in her cultural heritage from Dominica, valuing higher education and leadership roles for women in the community. Yet, after arriving at age nineteen with her family in New York, she did not fit into her multicultural neighborhood populated by immigrant families from many different countries. She was teased in school because of her accented English and her “differentness.” When Yolanda fought back verbally and challenged the bullies at school, her fighting stance reinforced a sense of mastery. Yet other students proceeded to situate her as a racialized and sexualized target—a new, brown-skinned, young, feisty, female immigrant in the community who “needed to be taught her place.” Years later, in couple therapy, Rod and Yolanda enacted their earlier dynamics through projective identification. Rod accused Yolanda of acting superior and contemptuous while disavowing his confidence and assertiveness. Yolanda accused Rod of passivity and

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“weakness” rather than addressing her own disavowed feelings of fear and vulnerability as a target in her community. As Rod and Yolanda gradually recognized the compounding effects of abuses of power within their intimate relationship, they also understood how societal bigotries and abusive treatment in their families and school affected them deeply. The commonalities and differences in their experiences related to race, ethnicity, gender, language, class, and country of origin not only shaped their interactions with each other but also led to internalized, devalued self-states that undermined a sense of well-being. Once they understood the forces of projection and the counterbalancing strength of their shared resilience, Rod and Yolanda were each able to reown the disavowed projections and restore a sense of personal integrity and harmony in their marriage. Boundary Ruptures Boundary ruptures are common among trauma survivors. A traumatized individual may intrude upon the privacy of another person or may experience another person as intrusive or violating. She may also express the other extreme in attempting to maintain clear and flexible boundaries by disengaging. An example of a boundary rupture involved Rhonda, a white, cisgender female probation officer who had survived beatings and sexual abuse during her childhood. Recently, she described her road rage. After a car had driven too close to her, Rhonda had chased down the car while screaming loudly and clenching her fists wildly before careening to an abrupt halt. Having experienced the car’s intrusion as a retraumatizing boundary violation, she reacted with rage, terrifying her husband, who sat by speechlessly as an unsuspecting passenger. Trauma survivors often engage in battles for power and control in relationships. Once again the alternating victim-victimizer-bystander pattern sets the stage for such struggles. Attempts to dominate or subjugate the will of the other person characterize unrelenting conflicts about who will gain power in any number of arenas. For example, at the height of the intense fighting between Rod and Yolanda, they battled regularly about who was the better caregiver, parent, or financial manager. Attachment to the Victimizer One question baffles many of us: Why do so many trauma survivors maintain an attachment with their abusers? When a child has been actively hurt and mistreated by a parent, she frequently sustains a strong attachment to the abusive parent (see chapter 5). Especially in the case of chronic repetitive (type II) abuses, traumatized children or adults often assume responsibility for the abuse and blame themselves. In order to hold on to a positive internalized image (or in object relations terms, an introject) of the offending caretaker, they often blame and hate themselves for the abuse so that they can maintain an idealized tie to their offender. British object relations theorist Ronald Fairbairn (1952a, 1952b) refers to this internalized object as the “internal saboteur” that undermines healthy growth. In addition to the ambivalent tie that many trauma survivors maintain with their offenders, they may reenact the trauma scenario by gravitating to an intimate adult partner who is abusive. In speaking about reenactments, we must be very cautious in recognizing this pattern of “traumatic bonding,” yet clearly hold an offender exclusively responsible for any violent or abusive behavior. Although a continuing attachment to the victimizer perniciously motivates many destructive reenactments, we must also vigilantly avoid blaming the victim. Ellen, a twenty-eight-year-old healthcare professional, gravitated to a sixty-five-year-old male partner, Ed, who provided for her financial and emotional security. However, after

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three years of marriage, Ellen felt tyrannized and entrapped when Ed questioned all of her outside friendships, preferring to be the sole focus of her existence. She found herself distancing from all social contacts, feeling despondent, and fantasizing about escape. In therapy, she was shocked to recognize that she had metaphorically married her very fragile mother, who had battled both a major mental illness and a life-threatening cancer during her lifetime. Ellen had nursed her mother until her death several years before, ignoring the abusive physical outbursts leveled by her mother during her unmedicated manic states. Ellen sought the security of a familiar, albeit possessive and tyrannizing attachment, which also provided some sustaining nurturance. Rather than blame the man she was with, she blamed herself. Dearth of Rituals Finally, a paucity of rituals surfaces as another important relational pattern. When children are abused physically, sexually, or emotionally, they live amid violence, disorganization, and shattered relationship with others and self. A  very strong correlation between substance abuse and addictions with childhood trauma sets the stage for incendiary toxic family environments where celebratory or healing rituals are virtually destroyed or absent. Needless to say, when holidays arrive, family chaos often interferes with any ritual that might help a family celebrate meaningful connections with each other. For example: Elana, a middle-aged Polish Catholic trauma survivor, recalls that most Thanksgiving dinners were punctuated by some terrifying eruption of rage. In particular, she recalled that her abusive, alcoholic father threw the festive turkey across the dining room on more than one occasion. Only after recounting these terrifying memories of family gatherings could Elana’s husband recognize why she rejected any formal celebrating of the holidays and religious traditions.

Self Psychology The self object milieu plays a central role in self psychology as the environment needed during early childhood to ensure adequate psychological provisions of idealizing, mirroring and twinship selfobject experiences that help develop sound self-esteem and healthy narcissism. Empathically attuned attention from parents is essential for the emergence of a cohesive self. In contrast, parental empathic failures often lead a child to feel depleted and invalidated. With reference again to Elana, the Polish American adult client previously introduced, we recognize the shattering of idealizing selfobject experiences through the destruction of the beloved family rituals. The passing down and celebrating of important religious, ethical, and family traditions were destroyed as well, reflecting similar earlier experiences during childhood. Mirroring selfobject experiences were absent or distorted as well since Elana’s pride and joy related to the holiday were destroyed. Now that we have demonstrated how psychological and cognitive development may be either supported or undermined through traumatic events, we will turn to a discussion of the neurobiology of trauma to explore a different theoretical lens.

NEUROBIOLOGY OF TRAUMA Groundbreaking developments in the field of neurobiology, neuropsychology, and traumatology have challenged the mental health community to expand our knowledge base.

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Relying on positron emission topography (PET) and magnetic resonance imaging (MRI) data, direct associations have been established between relational and nonrelational trauma and effects on the human brain and body (Cozolino 2010; Siegel 1999, 2010; van der Kolk et al. 2005). Since the aftereffects of trauma clearly influence an individual’s neurobiological and neuropsychological status, I will draw attention briefly to the impact of trauma on an infant’s developing physical and mental health. Affect Regulation, Trauma, and Infant Development For infants, relational stressors are far more “detrimental” to child development than are nonrelational assaults, such as an accidental fall (Schore 2000). The neurophysiological status of an infant is based on a combination of factors, including genetic, constitutional, environmental, and psychosocial supports and stressors. Many studies have demonstrated the link between dysfunctional maternal behavior and fetal development, suggesting that mothers who abuse alcohol, tobacco, and other drugs during their pregnancies may interfere with their infant’s cognitive and physical development (Espy et  al. 1999; Fergusson et al. 1998; Streissguth et al. 1994). Ironically, when mothers behave in this way, their activities are not generally considered traumatogenic, even though they may cause long-term damage to their babies. Abuse and neglect from an early caregiver, however, do qualify as relational forms of trauma. Schore (2000), a prolific infant researcher, believes that caregiver-induced trauma basically contributes to more frequent and more intense psychopathology in children. In his groundbreaking research, Perry (1997) reported two separate psychobiological responses to trauma experienced by an abused infant. When a child is threatened, she experiences an alarm or startle reaction resulting in increased heart rate, blood pressure, respiration, and muscle tone. Hypervigilance emerges, followed by crying, and ultimately screaming. Beebe (2000) vividly describes how this overarousal escalates when there is a lack of empathic attunement from the caregiver, whether this is the parent or any designated primary caregiver. In her videotape, after the infant expresses extreme distress, including averting her head totally, arching away, and screaming, the mother continues, unrelentingly, to react with a poorly attuned response. She ultimately fails to soothe the infant. This lays down a way of relating where the infant withdraws into her internal world and dissociates. A state of numbness, withdrawal, compliance, and restricted affect occur. This parallels the familiar traumatic stress response, which vacillates between hyperarousal and numbness. We can see how early trauma alters the development of the right brain of the infant, the hemisphere that is responsible for processing social and emotional information, bodily states, and attachment (Schore 2001). The right hemisphere, more so than the left, is involved with the limbic system and the sympathetic and parasympathetic components of the autonomic nervous system. Therefore, it plays a central role in emotional processing on cognitive as well as physiological levels. In addition, the right hemisphere secretes stress hormones and activates vital functions that support survival. Executive control functions are regulated in this area as well. Since the right prefrontal cortex of the brain is critical in processing emotions, any intense and unregulated stress usually induces heightened negative feelings, chaotic biochemical reactions, and a developmentally immature defective right brain. Needless to say, these are serious long-term effects that bear scrutiny (Schore 2001, 2003a, b). When a person lacks efficient right brain functioning, she inevitably experiences problems with self-soothing during times of stress. Often, heightened aggression is associated with these decreased right-brain functions as well as the development of a disorganized/

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disoriented (“Type D”) attachment style (Lyons-Ruth et al. 1991, 1993). As children protect themselves from the ravages of cumulative relational trauma, they then retreat both psychologically (through dissociation) and neurobiologically (by overly restricting their yearnings for attachment). Social interactions are then replaced with withdrawal and dissociation as predominant defenses. Without any intervening reparative caregiving, these stress-induced responses start to organize the neural system, resulting in enduring aftereffects. As a result, permanent shifts in the affective centers of the limbic system may result, which ultimately influence affect regulation and the attachment pattern for the child, adolescent, and the adult trauma survivor. The infant PTS reactions of hyperarousal and dissociation may well set the template for symptomatology in later life, including adult PTSD or C-PTSD. When infants express stress responses to threatening stimuli, their immature brain processes resemble appropriate “flight-flight” responses (Nijenhuis et al. 1998). However, adults who were traumatized as children retain these immature responses to stress. As a result, when confronted with severe stress in adult life or triggered by an event reminiscent of the earlier traumatic experience, the adult brain will then regress to an infantile state. Because of the consequent alterations in brain neurophysiology related to childhood trauma, these adults experience a state of retraumatization. A clinical example illuminates this process: Patricia, a thirty-seven-year-old white-identified queer social worker, recalls an incident during the past week when she returned home from work to find her partner, Alice, toiling away cleaning the house. Although Patricia felt initially appreciative of her partner’s efforts, she suddenly felt overwhelmed by nausea, terror, and agitation. She smelled a strong solution of Clorox, which was being used as a cleaning agent. In therapy, what emerged was Patricia’s connection of these olfactory sensations to a triggering of traumatic memories stored in her body. Her right-brain activity was subdued at the time, while her stress response activated automatically in reaction to the olfactory stimuli of the bleach smell. Ultimately, she wove a narrative of physical abuse during infancy where her day-care provider hit and scratched her frequently. She often tended to the wounds by first applying a strong antiseptic solution. As a result, Patricia’s body “remembered” the physical injury through the associated channel of smelling the cleaning agent. Within seconds, her early traumatic body memory was triggered with the associated traumatic stress response.

Somatic Responses to Traumatic Stress Researchers have demonstrated the ways in which overwhelming traumatic experiences are stored in somatic memory and expressed with significant changes in the body (Curry 2016; Ogden et al. 2006; Siegel 2010; van der Kolk 2003; van der Kolk et al. 2005). Porges (2011) has elaborated on the role that heart rate and respiration have in relation to affecting social behavior. As the creator of polyvagal theory, he shares interesting data to support how our autonomic nervous system mediates trust, connectedness, and social engagement. There are complex neurobiological processes involved in the response to traumatic stress as compared with ordinary life stressors. Further, a traumatic stress response in reaction to a traumatic event influences the encoding of body memories. Typically, a person in an ordinary low-stress situation registers information through various visual, auditory, olfactory, or tactile senses. This information is then passed on to the neocortex, or the “thinking brain.” Information is typically organized and assigned appropriate meaning after being ferried to the limbic system, which attaches emotion that is congruent to the situation. Then this information is stored in the hippocampus, the brain’s filing cabinet, in logical, declarative memory. In this low-stress scenario, emotions

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accommodate and facilitate the orderly functioning of laying down logical memories in the hippocampus. For example: A forty-five-year-old Cambodian refugee, Phum Sreng, who fled the Pol Pot regime as a young adolescent, moved with her family, initially to Thailand, and then later, when she was thirty, to the United States. Soon after arriving in the Pacific Northwest, Phum Sreng attended ESL (English as a Second Language) classes. Phum reported learning new words, grammar, and sentence structure fairly rapidly in spite of apprehension about her accent. Since she did not worry a lot, Phum was able to hear and see new English words, integrating the content quite rapidly as her new language was being stored in a structured, logical manner in the hippocampus. This contrasted with her almost complete paralysis when she first entered school in Thailand. At that time, she recalls her total incapacity to take in new learning. Flashbacks of her earlier traumatic experiences of witnessing multiple executions of trusted relatives interfered with any deliberate purposeful processing of new information. During that time, she experienced regular nightmares, mood changes, intense fears, and physical symptoms of headaches, stomach upset, and hyperventilation. With this full-blown PTSD symptomatology, she was unable to take in new information until her acute distress eased.

We know that adults respond to auditory, tactile, and olfactory stimuli. When the thalamus (a section of the brain) registers these messages as dangerous, the person responds with a fight-flight-freeze reaction. First, the sympathetic regulatory system, anthropomorphized as “the agitator,” excites the amygdala, the brain’s alarm system, which mobilizes to defend and protect the person from harm. When the amygdala hijacks the ordinary process of information processing, it broadcasts distress and disaster, thus triggering a cascade of physiological responses. Instead of laying down a logical, clearly defined memory of an event, the hippocampus is flooded with intense emotionally laden stimuli that are then laid down as body memories. They are also referred to as iconic or symbolic memories. Concurrently, the parasympathetic regulatory system (or the “paralyzer”) activates as well. When this system is aroused, opiates are released in the brain, contributing to a state of numbness. Other physiological changes include an increase in cortisol levels along with a decrease in blood pressure. In this state, a person may experience restricted affect, withdrawal, and “freezing,” or emotional paralysis. For example, many survivors of wartime combat describe a calm state of detachment devoid of feeling when they are actively involved in a violent exchange. During these times of extreme stress, both the “agitator” (the sympathetic system) and the “paralyzer” (the parasympathetic system) are activated simultaneously, creating a chaotic toxic neurochemistry. Therefore, when a person’s cardiac system is stimulated and inhibited at the same time, the body freezes. Metaphorically, this is like riding the gas and applying the brakes of a car at the same time. This familiar state translates into the blank, dazed look of a traumatized child or the frozen watchfulness of a traumatized adult. When an individual repeats this draining stress response over and over, all systems become challenged and compromised, ultimately leading to ill health.

CLINICIAN RESPONSES TO WORKING WITH TRAUMATIZED INDIVIDUALS Vicarious Traumatization and Secondary Trauma Clinical practice with trauma survivors evokes strong feelings and alterations in our own belief systems (Chu 1998; Figley 1995; Pearlman & Saakvitne 1995). Pearlman and Saakvitne

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(1995) state that, especially in work with survivors of sexual abuse, we, as clinicians, are vulnerable to vicarious traumatization. This process is defined as “the transformation in the inner experience of the therapist that comes about as a result of empathic engagement with the clients’ trauma material” (p. 3). Trauma shatters assumptions not only in the client but also in the worldview of the clinician. This is an insidious process, which starts off at an unconscious level but gradually erodes a sense of hopefulness, coherence of self, and meaning. Unlike countertransference, which is understood as specific to the therapist-client dyad and omnipresent in all therapies, vicarious traumatization exists in a more generalized way in response to intensive continuous therapeutic work with trauma survivors. Many who work with traumatized individuals, couples, or families—or with communities in disaster work—experience compassion fatigue (Figley 1995), or what is also referred to as secondary traumatic stress (Bride & Figley 2009; Catherall 1995; Stamm 1999). These responses may involve full-blown PTSD symptomatology, including the hyperarousalnumbness pendulum, affect dysregulation, startle reactions, and reexperiencing including flashbacks and nightmares. Yet these helpers do not always experience the complete transformation or dismantling of the clinician’s inner world that occurs when someone is traumatized. There are numerous approaches that can assist a clinician in dealing with vicarious traumatization. First, it is important to understand that the experience is normative and expected in practice with trauma survivors. Second, clinical supervision and supportive clinical teams provide clinicians with an opportunity to connect with each other and talk about their experiences. Not only does this help to counteract a sense of despair or powerlessness, but the actual talking helps to change neocortical brain activity. For these interventions to be successful, institutions and organizations need to support their viability (Catherall 1995). Furthermore, one might take care of oneself through (1) sustaining self-care practices, including exercise, nutrition, and stress-relieving practices; (2) developing of a sense of spirituality that counteracts a loss of hope; and (3) ongoing self-awareness (Pearlman & Saakvitne 1995; Yassen 1995). Transference/Countertransference Phenomena with Trauma Survivors In most therapeutic relationships with trauma survivors, there are a number of predictable countertransference traps based to a large extent on the victim-victimizer-bystander relationship template. These countertransference traps may occur through the processes of projective identification. For example, the clinician might slip into a passive and indifferent bystander stance that mirrors the client’s numbness and detachment. Another trap leads to helpless victimization, or not knowing how to proceed. When a clinician finds herself extending the boundaries of sessions, losing clarity around professional role and financial compensation, or shifting into an overly zealous omnipotent helper, she may be succumbing to a rescuer enactment. An eroticized countertransference trap is very common as well, where a clinician may experience a range of sexual feelings activated within the therapeutic relationship, especially in practice with survivors of childhood sexual abuse. Understandably, caution is urged to avoid eroticized reenactments that recapitulate the earlier childhood trauma. Behaving aggressively toward a client may be another form of countertransference enactment while identifying with a victimizer role. And finally, reaction formation represents a trap where the clinician, while disavowing anger, may act in a false and overly solicitous manner. For example, a clinician may avoid dealing with conflict or negative transference responses by steering away from the conflict while behaving in a vaguely supportive, jocular manner.

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In summary, enactments on the part of the clinician are inevitable. However, it is very important to understand the nature of the countertransference enactments to strengthen the empathic connection with our clients, to repair therapeutic ruptures when enactments occur, and to minimize the occurrence of enactments, as best as possible.

IMPLICATIONS FOR CLINICAL PRACTICE Although this chapter has focused primarily on the basic constructs of psychodynamic and trauma theories, we will briefly address some relevant implications for clinical practice. Since many trauma survivors have been mistreated physically and/or psychologically, they often neglect their physical and mental health. Living with post-traumatic symptomatology undermines the ease with which traumatized individuals navigate their lives. As a result, many contemporary trauma therapy practice models for individuals and couples are phaseoriented and synthesize knowledge about the neurobiology of trauma along with psychodynamic constructs within social context (Allen 2001; Basham 2016; Chu 1998; Courtois 1999; Davies & Frawley 1994). Biopsychosocial-Spiritual/Structural Assessment: Outline Grounded in Trauma Theories Having reached the end of this book, we harken back to the first chapter, which started with the questions “Why psychodynamic theories?” “Why a biopsychosocial-spiritual/­ structural context?” In that chapter, we described our deep commitment to intersectionality and the central importance of a thorough and complex assessment shaped by the biological, psychological, social, spiritual, and structural factors affecting the lives of our clients. We now offer an assessment outline that serves as an exemplar to support a treatment plan and includes various questions that directly focus on the influences of trauma in the lives of our clients. Specific questions are posed that are grounded in trauma theories. Not all questions can be answered quickly, and some will never be answered. Yet responses to the following questions provide a scaffolding and guide to develop a flexible treatment plan while remaining open and curious about the unexpected, mysterious, and profound experiences shared by our clients. Here are some possible questions that aim to explore the nature and effects of a range of traumatic events that have influenced the lives of clients, including individuals and families. General 1. What traumatic events has the client experienced? Are they single event or chronic traumatic experiences? On a continuum of stress from mild to moderate to severe to traumatic, what is the level of severity expressed (McEwen, 2004)? 2. How does the client cope with the traumatic events and what are the aftereffects, if any? 3. What are the important factors that promote and sustain resilience in the face of traumas (e.g., social supports, flexibility, efficacy, and mastery)? Biological 4. Following the traumatic event (s), has the client revealed neurobiologically based symptoms of PTS, PTSD, or C-PTSD?

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  5. Do you note affect dysregulation in terms of a shifting pendulum of hyperarousal and hypoarousal?   6. Are there indicators of a “fight-flight-freeze” response or a “pause-collect” trauma response?   7. Does the client express concerns with nightmares, flashbacks, intrusive thoughts, hypervigilance, startle responses, and bodily complaints?   8. What is the client’s relationship with drugs—both prescribed medications or selfmedication with recreational and/or controlled substances?   9. Are compulsive/addictive behaviors and suicidal ideation/behavior presented as issues related to the cooccurring conditions of addiction and depression? 10. Are there other cooccurring physical conditions that are stress-related? Psychological 11. Is there evidence of dissociation, ego fragmentation, and identity distortion? 12. Do you see the “victim-victimizer-bystander” trauma triangle revealed in relationships where traumatic reenactments recur? 13. Do you see evidence of splitting? Part object relations? Merged object relations? 14. Are there power and control struggles apparent in relationships? 15. Are distancing and distrust pronounced? 16. Does boundary-setting in relationships fluctuate between rigid and overly merged boundaries? 17. Have communication and problem-solving capacities devolved in relationships within couples and families? Social 18. Has the client experienced cultural and/or racial trauma that relate to intersecting social identities? 19. Are trauma-related projection and projective identification processes evident in families, workplace, and communities? Spiritual 20. Has a spiritual or religious commitment been affected by traumatic events? 21. Has “moral injury” emerged as a pressing internal dilemma? Structural 22. In what ways do socioeconomic status (SES) and financial resources affect access and engagement with health, mental health, and psychosocial services? 23. In what ways do social policies and institutional racism affect the creation and delivery of a range of services that are attuned to social justice and equity? Individual Treatment Approaches In working with an individual trauma survivor, the first phase of therapy involves helping the client to attend to her physical and mental health by establishing safety and strengthening self-care. Symptom relief and affect regulation are central themes during this early phase (Rosner et al. 2019; Schiavone et al. 2018).

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Now that we know the inextricable connections between the mind and body, various somatic treatment approaches have been utilized effectively to help clients regulate their affect. For example, sensorimotor therapy (Ogden et al. 2006), somatic experiencing (Levine 2005), eye movement desensitization reprocessing (EMDR) (Shapiro 2018), and mindfulness-based stress reduction (MBSR) (Kabat-Zin 2005) utilize interventions that address affect regulation, symptom and stress reduction, as well as mindful attunement, with different emphases stressed by each model. An innovative adaptation of the MBSR model has been developed by Kelly (2014) in her dissertation research. She introduced a trauma-informed group intervention with women who had suffered intimate partner violence, yielding significant findings that support the efficacy of this model in reducing symptoms of PTSD and depression and increasing capacities for attachment. In addition to helping traumatized individual clients to develop skills for stress reduction and affect regulation, they may often need assistance in building social supports through friends and family. Most trauma-informed therapy models stress the value of community in facilitating healing and recovery (Basham 2013, 2019; Courtois & Ford 2009; Herman 1992; Tummala-Narra 2016). When the client is relatively stabilized in these phase I goals, she may start to talk about the effects of her traumatic experiences on her current day-to-day life. This phase II trauma work focuses on narrating the trauma while reflecting on the meaning of the legacies of trauma and facilitating unresolved grieving. After gaining some perspective on ways that the traumatic experiences have affected a person’s psychological, social identity, and relational development, the client and clinician then move along to address phase III psychotherapy tasks. In fact, many clients who strengthen their self-care capacities ultimately transform their identities from a position of ‘victim,’ defining themselves almost exclusively through the traumatic experiences, to a “survivor” of tragic, traumatizing events. Here, clients move from a state of powerlessness and hopelessness to positive agency and ultimately toward heightened creativity and assertiveness—or post-traumatic growth (Tedeschi  & Calhoun 2004). Intersecting social identities including race, ethnicity, gender, and sexual identities cohere as well during this transformative process. As clients move beyond therapy and a self-definition that relates to their legacies of trauma, they often begin to view themselves as “thrivers” who are living their lives with vitality and purpose. Couple Therapy Approaches Couple therapy with survivors of childhood and/or combat trauma focuses on the relational themes evident for the couple related to conflicts around power and control, emotional and sexual intimacy, and the repetitive pattern of the victim-victimizer-bystander scenario, while also attending to the individual and intrapsychic issues for each individual in the couple (Basham 2008, 2016). With single trauma couples, where one partner has insufficiently resolved trauma-related issues, the other partner is often subject to the intense effects of secondary trauma, leading to a similar set of PTS responses. Dual trauma couples, where each partner has survived the impact of debilitating traumatizing events, are often drawn to each other through traumatic bonding (Basham & Miehls 2004). On the one hand, they sense a commonality based on similar life experiences; on the other, they often form styles of relating through the victim-victimizer-bystander scenario. In general, couple therapy relies on a phase-oriented trauma therapy approach that focuses on the needs of the couple as the client, as well as the individual biopsychosocial needs of each partner. The three phases of treatment are similar to the phase-oriented individual therapy models with several exceptions. They include the following: Phase I  tasks include learning to communicate more

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effectively with each other, developing coparenting skills while also strengthening self-care and stress reduction skills. Phase II tasks involve the development of empathy and mentalization for each partner as they share their respective reflections regarding their traumatic experiences, their attachment injuries, and feelings of betrayal (see chapter 8). Finally, phase III adds the dimension of further enhancement of the interpersonal relationship in addition to intrapsychic movement for each partner along with movement toward social vindication (Basham & Miehls 2004). Vignette of Couple Therapy with the Arrozos As we return to the case of Sgt. Arrozo, his wife Ms. Arrozo, and their children, we interrupted the story at the point where Sgt. Arrozo experienced failure in treatment that had been poorly attuned to his and his family’s needs. Burdened by shame and disillusionment, Sgt. Arrozo refused to pursue any additional psychotherapy. However, six months later, the principal of his older children’s elementary school called to express deep concern about Antonio’s bullying behavior and Sara’s many absences from school. Worry and deep devotion to the children inspired both Sgt. Arrozo and his wife to subsequently meet with a new clinical social worker to initially discuss ways to help the children. From this point onward, the couple and their clinical social worker engaged in an ongoing interactive biopsychosocial-spiritual assessment that explored their strengths and sources of resilience. As this clinician harnessed the resilience and collective family resources, she also collaborated with a full range of professionals (including the school social worker and the family’s primary care physician and pediatrician). Sgt. Arrozo accepted a referral to meet with a psychiatrist and neuropsychologist to assess for possible traumatic brain injury and substance abuse along with his existing issues related to PTS and depression. Since group therapy is considered one of the “best practices” for combat veterans, Sgt. Arrozo entered both a mutual support group facilitated by veterans and an open-ended psychotherapy group that addressed issues of readjustment back home (Kingsley 2007). This complex multimodal approach to working with the Arrozo couple addressed the full range of their biopsychosocial-spiritual strengths and vulnerabilities. Only when this couple had established a scaffolding of safety, sound self-care, and mobilization of their family and friendship supports, could they move on to talk about their respective trauma narratives. When Sgt. Arrozo shared his despair that his toddler daughter, Ana, regularly ran from him in terror, he started to talk about a devastating sense of guilt and “moral default” after witnessing the killing of an innocent four-year-old girl. As he expressed his deep sense of sadness and remorse to his wife, she was better able to understand his combat-related psychological injuries and deepened her empathy for him. He continued to share his feelings of shame and profound grief in losing his “warrior” identity in the military, as a result of his involuntary medical separation from service. In turn, Ms. Arrozo tentatively spoke about her fears of losing her husband, both worrying about his physical safety during deployment and concern about his harming himself now that he has returned home. His detachment felt hurtful and rejecting to her. As each partner developed greater understanding for the other’s psychological and moral injuries and unresolved grief, they were able to talk about next steps and ways to enrich their emotional and sexual relationship. Couple therapy at this phase II focused on enhancing communication related to sharing their psychological injuries, strengthening their coparenting roles, dismantling the victim-victimizer-bystander dynamic, and helping them to find alternative ways to address conflicts. As they regained a sense of mastery in their capacity to regulate intense feelings and communicate more

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effectively, they were able to talk about their lapsed faith fueled by feelings of betrayal by their “God” who had failed to protect them from destructive traumatic events. Sgt. Arrozo was also able to recognize and unpack the layers of hateful projections that had been employed in displacing his feelings of powerlessness and rage onto all individuals who appeared to have been reared in the Middle East. As he discussed his complete helplessness to rescue his buddies and innocent children from the carnage of war, he recognized how his racialized hatred defended him against his feelings of powerlessness. With an awareness of how his “victimizing” stance mirrored the intense racialized bigotry hurled against him and his family, he assumed responsibility for his judgmental aggression. In turn, Ms. Arrozo expressed her gratitude in witnessing the reemergence of her husband’s integrity, a quality that she had always admired. As the Arrozo couple continued to directly address conflictual issues, they recaptured trust in one another and a renewed, albeit tentative, commitment to their shared religious faith. Only after the difficult work of building their internal and external scaffolding as marital partners and coparents, could they weather the painful sharing of their respective hurts, fears, and profound losses. Ultimately, the children resolved their anxieties related to secondary trauma, while Sgt. Arrozo and Ms. Arrozo renewed their loving connection toward each other. Although each family member had changed inalterably during deployment, everyone was successfully able to navigate the changes to craft new, yet different, ways of relating with each other. In summary, this clinical vignette, once again, demonstrates the central importance of a complex biopsychosocial-spiritual assessment that shapes the development of a relationship-based, culturally responsive, racial justice grounded, theoretically supported, and research-informed clinical social work practice approach.

CONCLUSIONS It is important to remember that many trauma survivors have prevailed in coping with traumatic events without developing subsequent psychopathology. They continue to lead healthy and zestful lives. However, other trauma survivors struggle with the legacies of childhood trauma, war, or natural disasters that undermine their capacities for growth in their relationships and life dreams. Trauma can disable a person and lead to shattered assumptions and shattered lives. Yet traumatic experiences can also be addressed in ways that lead to renewed strength, convictions, and hopefulness in the face of adversity. Most compelling are the tales of individuals who have overcome tremendous adversity and emerge from their journeys all the stronger. Toward the end of her psychotherapy, Claire, a thirty-six-year-old woman who had suffered severe physical abuse during early childhood years, brought me a large, variegated conch shell that she had discovered along a rugged Jamaican beach. To her surprise, it was intact. On most beach walks, Claire carefully selected multicolored and geometrically shaped stones, pebbles, and shells along with twisted driftwood that had been buffeted and dispersed by cross currents. “I am designing a colorful mosaic with this debris from the sea as a continuous steady reminder of ways in which you and I have helped to re-collect ‘the fragments of my mind.’ ” Claire spoke metaphorically about the healing forces of the ocean that washed away her terrors and self-hatred. “But I want this weathered conch shell to be a continual reminder of our powerful connection,” she said. “Like the predictable flow of the tides, I am better prepared to accept the tumultuous waves of my strong feelings—and am grateful to be able to live with myself and also feel more connected to the world.” In

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parting, Claire hoped that whenever I picked up this shell and placed it to my ear, I, too, would be “grounded by the soothing sounds of the sea.” To this day, I look with deepening respect at this weathered artifact, settled into my bookshelf as a continuous reminder of our transformative work together.

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Cohen, L. M., Berzoff, J. N., & Elin, M. R. (1995). Dissociative Identify Disorder: Theoretical and Treatment Controversies. Northvale, NJ: Jason Aronson. Corbin, J., ed. (2012). Children and Families Affected by Armed Conflict in Africa: Implications and Strategies for Helping Professionals in the United States. Washington, DC: NASW Press. Courtois, C. (1999). Recollections of Sexual Abuse: Treatment Principles and Guidelines. New York: Norton. Courtois, C., & Ford, J. D. (2009). Treating Complex Traumatic Stress Disorders: Scientific Foundations and Therapeutic Models. New York: Guilford Press. Cozolino, L. (2010). The Neuroscience of Psychotherapy: Healing the Social Brain. New York: Norton. Curry, M. (2016). Decision-Making Process: A Mixed-Methods Study of Somatic Awareness Use by Clinicians in the Treatment of Trauma-Related Disorders. Unpublished doctoral dissertation, SCSSW, Northampton, MA. Davies, J. M., & Frawley, M. G. (1994). Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books. De Gruy, J. (2005). Post-Traumatic Slavery Syndrome: American Legacy of Ending Injury and Healing. Milawulie, OR: Uptone Press. de Jong, J. T. V. M, Komproe, I. H., Spinazzola, J., van der Kolk, B. A., & Van Ommeren, M. H. (2005). DESNOS in three post-conflict settings: Assessing cross-cultural construct equivalence. Journal of Traumatic Stress 18(1):13–21. Erikson, E. (1980). Elements of a psychoanalytic theory of psychosocial development. In The Course of Life: Psychoanalytic Contributions toward Understanding Personality Development, Vol. 1, Infancy and Early Childhood, eds. S. I. Greenspan and G. H. Pollack. Washington, DC: National Institute of Mental Health. Espy, K. A., Kaufman, P. M., & Glisky, M. L. (1999). Neuropsychological function in toddlers exposed to cocaine in utero: A preliminary study. Developmental Neuropsychology 15:447–60. Evans-Campbell, T. A. (2009). Social work practice with Native Americans. In Social Work Desk Reference, eds. A. Roberts, pp. 949–54. New York: Oxford University Press. Fairbairn, W. R. D. (1952a). An Objects Relations View of the Personality. New York: Basic Books. ———. (1952b). Psychoanalytic Studies of the Personality. London: Routledge and Kegan Paul. Fergusson, D. M., Woodward, L., & Horwood, L. J. (1998). Maternal smoking during pregnancy and psychiatric adjustment in late adolescence. Archives of General Psychiatry 55:721–27. Figley, C. (1988). A five-phase treatment of PTSD in families. Journal of Traumatic Stress 1(1):127–41. ———. (1995). Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatized. New York: Brunner/Mazel. Freud, S. (1905a). Three essays in sexuality. Standard Edition 7:135–243. ———. (1905b). The aetiology of hysteria. Standard Edition 3:191–225. Friedman, M.,  & Marsella, A. (1996). Post-traumatic stress disorder: An overview of the concept. In Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications, eds. A. J. Marsella, M. J. Friedman, E. T. Gerrity, and R. M. Scurfield. Washington, DC: American Psychological Association. Goodwin, J. (1990). Applying to adult incest survivors what we have learned from victimized children. In Incest-Related Syndromes of Adult Psychopathology, ed. R. Kluft, pp. 55–74. Washington, DC: American Psychological Association. Gradus, J. (2017). PTSD and death from suicide. PTSD Quarterly 28(4):1–8. Green, B. L., Grace, M. C., Lindy, J. D., & Leonard, A. C. (1990). Race differences in response to combat stress. Journal of Traumatic Stress 3(3):379–93. Hartmann, H. (1964). Essays on ego psychology: Selected problems in psychology theory. New York: International Universities Press. Herman, J. (1992). Trauma and Recovery. New York: Basic Books. Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295:1023–32. Holmes, D. (2016). Culturally-imposed trauma: The sleeping dog has awakened? Will psychoanalysis take heed? Psychoanalytic Dialogues 26(6):641–54.

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Institute of Medicine (IOM). (2008). Gulf War and Health: Physiologic, Psychologic and Psychosocial Effects of Deployment-Related Stress. Washington, DC: National Academies Press. ———. (2010). Preliminary Assessment of Readjustment Needs of Veterans, Service Members and Their Families. Washington, DC: National Academies Press. ———. (2013). Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members and Their Families. Washington, DC: National Academies Press. ———. (2014). Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: National Academies Press. Kabat-Zinn, J. (2005). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Bantam. Kelly, A. (2014). Trauma-Informed Mindfulness Stress Reduction: Development of a Model and an Application with a Sample of Women Who Have Survived Interpersonal Trauma. PhD dissertation, Smith College School for Social Work, Northampton, MA. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B., & Breslau, N. (1999). Epidemiological risk factors and treatment of PTSD. In Risk Factors for Posttraumatic Stress Disorder, ed. R. Yehuda, pp. 23–59. Washington, DC: American Psychiatric Press. Kingsley, G. (2007). Contemporary group treatment of combat-related PTSD. Journal of American Academy of Psychoanalytic and Dynamic Psychiatry 35(1):51–69. Kira, I. A. (2002). Torture assessment and treatment: The wraparound approach. Traumatology 8(1):23–51. Kluft, R. P. (1995). The confirmation and disconfirmation of memories of abuse in DID patients: A naturalistic clinical study. Dissociation 8(4):253–58. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. Levine, P. (2005). Healing Trauma: A Pioneering Program for Recognizing the Wisdom of Your Body. Boulder, CO: Sounds True. Loftus, E. F. (1993). The reality of repressed memories. American Psychologist 48(5):518–37. Loftus, E. F., Polonsky, S., & Fullilove, M. T. (1994). Memories of childhood sexual abuse: Remembering and repressing. Psychology of Women Quarterly 18:67–84. Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool classroom. Child Development 64:572–85. Lyons-Ruth, K., Repacholi, B., McLeod, S.,  & Silva, E. (1991). Disorganized attachment behavior in infancy: Short-term stability, maternal and infant correlates, and risk-related subtypes. Development and Psychopathology 3:377–96. McEwen, B. S. (1999). Allostasis and allostatic load: Implications for neuropsychopharmacology. Neuropsychopharmacology 22(2):10–124. ———. (2004). Protection and damage from acute and chronic stress: Allostasis and allostatic overload and relationship to the pathophysiology of psychiatric disorders. Annals of the New York Academy of Science. https://doi.org/10.119/annals.1314.001. McEwen, B. S., & Sapolsky, R. (2006). Stress and your health. The Journal of Endrocrinology and Metabolism 91(2):E2. https://d.org/10.1210jcem.91.2.9994. Nijenhuis, E. R. S., Vanderlinden, J., & Spinhoven, P. (1998). Animal defensive reactions as a model for trauma-induced dissociative reactions. Journal of Traumatic Stress 11(2):234–60. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: Norton. Pearlman, L., & Saakvitne, K. (1995). Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors. New York: Norton. Perry, P. B. (1997). Incubated in terror: Neurodevelopmental factors in the “cycle of violence.” In Children, Youth and Violence: The Search for Solutions, ed. J. Osofsky. New York: Guilford Press. Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York: Norton.

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18 Some Final Thoughts Joan Berzoff, Laura Melano Flanagan, and Patricia Hertz

What, then, have we learned in this book? We began our journey with Freud, the “father of psychoanalysis,” whose explorations into the unconscious life of individuals helped us enter into an uncharted, inchoate underworld of internal forces that govern psychic life. We learned about how passions, when unknown, may lead to human suffering, while we studied the absolute value of self-knowledge for effecting psychological change. We came to see how important the therapeutic relationship can be to both therapist and client, and we examined the symbolic and real aspects of that relationship to the people within it. We came to appreciate the complex ways in which drives shape child development, resulting in lifelong symptoms, character structure, and strengths. We learned how Freud and his contemporaries conceptualized most of mental life as a battleground in which unconscious conflicts between the drives, the self, and society were played out within and between the structures of the mind. We came to see how intrapsychic conflicts result in compromises, called symptoms, and how our understanding of unconscious conflicts can set us free. We studied the increasingly central role of the ego in mediating between the drives and society and its important functions in providing an individual, coherence and equilibrium. We studied the ego’s capacities and strengths in adapting to and mastering the environment and overwhelming trauma and anxiety and we learned about the kinds of defenses that the ego employs to ward off danger. We learned about the ego’s other autonomous functions: thinking, feeling, and motility. In addition, we saw how the ego seeks coherence and continuity over the entire life cycle, as each individual negotiates psychological and social tasks at every stage of life-cycle development. We learned that ego development is mediated by psychological and social forces (race, class, gender, culture, age, ability) so that the individual always interacts within the sociocultural context in which she develops. We studied some of the many ways in which an individual develops an internal sense of self, occurring first through earliest relationships with others. We examined the central place of early maternal relationships on a child’s sense of self as conceptualized by object relations theorists and began to see how external relationships come to be uniquely metabolized as internal representations of the self and of others. We looked at the tragic 404

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consequences that can accrue when the external world cannot provide the necessary nurturance for achieving internal psychological wholeness. From self psychology, we came to see how a person’s self-esteem and self-cohesion are based on the attunement and empathy provided by others in the environment, as we continued to move away from models that located psychological problems as deriving only from problems in the earliest years of life. Self psychology offered a more hopeful view of the curative power of ongoing relationships (including the therapeutic relationship) for promoting healthy self-esteem. From a relational perspective, the therapeutic inquiry began to shift its emphasis from the individual to the ways in which the relationship between the therapist and client became the unit of study and of change. Here we looked at the intersubjective field between client and therapist, the ways in which each of their subjectivities influences the other, and how selfdisclosure and therapeutic authority are reconceptualized. We considered the influence of postmodernism on the therapeutic relationship, with its emphasis on the influence of race, class, gender, and sexual orientation as inevitably interwoven into the dialogue. We also considered how relational theories decenter therapeutic authority and emphasize mutuality. Attachment theory taught us that the powerful and complex ways that we connect to others are laid down from birth and can influence all later relationships for good or for ill. Attachment styles are formed by both nature and nurture and have a narrative of their own. They reveal themselves in the therapeutic relationship where they can be experienced, examined, and modified, often helping the client to lead a fuller and more satisfying life. Think of what it might mean to a person if a frightening, insecure attachment style could be transformed into a more secure one. We also learned about the important effects on the brain when there has been attachment trauma and loss. We also studied the consequences of racism on the individual and the particular contributions offered from drive theory, ego psychology, object relations, self psychology, and intersubjectivity in understanding the dynamics of racism and its pernicious effects on the individual. We again gained another way of conceptualizing how what is external and outside of the individual comes to be experienced internally. We learned the ways in which individuals develop their ethnic and racial identities and the value of this knowledge for any cross-racial therapeutic encounters. As we looked at the relationship between gender and psychodynamic theories, we again encountered the ways in which psychodynamic theories have both oppressed and liberated our understanding of female development and sexualities. We came to see the complex relationship between women’s internal lives and their places in the social structures in which they live. We saw how a cross-fertilization of social and psychological theories helps us more fully understand intrapsychic and social oppression directed at gay, lesbian, bisexual and trans people. In the second half of this book, we learned about the biopsychosocial aspects of psychosis, borderline and narcissistic conditions, affective disorders, anxiety, and trauma. We studied how each diagnosis is rooted in its social times and expresses particular dilemmas of the culture and the society. We learned the ways in which people with these disorders are more than their symptoms, and we stressed, throughout, our own conviction about the power and value of a therapeutic relationship to effect meaningful change. In each of the diagnostic categories, we exhorted the reader to attend to neurobiology, genetic endowments, biochemistry, hormones, internal psychological processes, and social oppressions. Throughout this book, we have held to a stance that “we are all much more simply human than otherwise” (Sullivan 1940, p. 39), expressing our conviction that every fear, symptom,

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sense of unreality, passion, urgency, longing, need, defense, and desire that our clients express may be similarly experienced by us, the clinicians. Therefore, as we have attended to the internal experiences of the clients we serve, we have encouraged the reader to also pay attention to the experiences of the helpers, ourselves, who work with people in psychological pain. We have held that we are not different, not other, and that in many ways, if we do not suffer our own moments of psychosis, or borderline and narcissistic longings, depression, anxiety, and early trauma, then we are keeping ourselves too separate from the people with whom we work. What do we hope that you, the reader, have taken away from this book? Some awe for the complexity of psychological life and some appreciation for the unique ways every individual has of mediating between psychological, cultural, gendered, racial, and biological variables within and outside of the self. We hope that you will be able to enter into and understand the inner worlds of the clients with whom you work, approaching each person with a sense of wonder with which all human phenomena must be clinically approached. We hope that our readers will keep alive their own sense of “not knowing,” continually learning anew from each individual client with whom they work. We hope to convey that with every client with whom we work, we are always changed in the process. George Bernard Shaw said, “For every complex problem there is a simple solution—and it is wrong!” As we move toward very brief, often cognitive or biological mental health managed-care models that tend to treat the symptoms but not the person in the environment with the symptoms, we hope that each reader will grapple with the complexities of a biopsychosocial perspective, rejecting simplistic solutions that attempt to reduce people to their manifest problems. In short, it is our hope that, the practitioners/readers/clinicians will, whenever possible, continue to keep the work as complicated as you can!

REFERENCE Sullivan, H. S. (1940). Conceptions of modern psychiatry. Psychiatry 3:35–45.

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Index

abandonment anxiety, 56, 303 Abramovic, Marina, 135, 146 abusive relationship, 161, 207, 210, 213, 383 Adler, G., 283, 294 adolescence, 33, 71, 72, 76 – 78, 83, 84, 86, 88, 89, 174, 361, 362, 384 adult caregivers, 37, 191, 194, 199 adverse childhood experiences (ACEs), 193 – 97, 365 adversity, 188, 191, 192, 195, 291, 398 affective disorders, 11, 134, 181, 313, 314, 324, 336, 341, 346, 380, 405 affective neuroscience, 189 – 93, 196 agoraphobia, 357, 358, 367 Ainsworth, Mary, 169 – 71, 172 – 74, 176, 178 Akhtar, Salman, 24 Alexander, A., 376 Alford, F., 223, 224, 230 Allen, I. A., 376 Allen, J. G., 374 alloplastic behavior, 66 Altman, N., 227 ambitendency, 119 ambivalent infants, 173 American Heritage Dictionary, 275 American school of object relations, 116 – 20 annihilation anxiety, 56, 243, 263, 264, 349, 351 – 53, 363, 364, 367 anxiety, 346 – 68; agoraphobia, 358; assessing symptoms, 353 – 66; biological factors,

365 – 66; and culture, 348 – 49; at different development levels, 349 – 53; experience of, 263 – 64, 346 – 48; generalized anxiety disorders, 354 – 55; at neurotic level, 350 – 53; obsessive-compulsive disorders, 360 – 62; panic attacks, 355 – 56; phobias, 356 – 57; post-traumatic stress disorder, 362 – 65; social phobias, 359 – 60; specific phobias, 358 – 59; symptoms, 238, 346, 347, 349, 353, 356, 366 anxiety disorders, 346 – 49, 354, 356, 357, 365 – 68, 379, 380; role of trauma in, 362 – 65 Applegate, Jeffrey, 100 Aron, L., 155, 160 assessment: anti-oppressive framework, 240 – 44; and DSM, 244 – 45; process and art of engagement, 236 – 38; using lens of psychodynamic theories, 238 – 40 The Atlantic, 281 attachment patterns, 177, 189, 190, 195, 199, 283, 391 attachment styles, 174, 175, 177, 180 – 82, 184, 283, 304, 391, 405 attachment theory, 7, 97, 169 – 85, 188 – 99, 351, 405; affective neuroscience and, 190 – 93; attachment over time, 176 – 78; background and history, 169 – 78; co-construction of brain development, 189 – 90; gender and, 181; implications for practice, 183 – 85; insecure attachment styles, 173 – 76; neurobiology and, 179 – 80; organizational construct, human

435

436 development, 189; psychopathology and, 181; secure and insecure, 172 – 73; temperament and, 180; trauma and, 178 – 85 avoidant infants, 173 babies, 2, 9, 26, 61, 79, 92, 97, 99, 103, 116, 117, 121, 146, 154, 162, 192, 204, 248, 257, 324. See also infants Barlow, D., 289 Basham, K., 159 Beebe, Beatrice, 147, 390 Belle, Deborah, 336 Benjamin, Jessica, 8, 159, 164, 206, 207 Berzoff, J., 337 Bettelheim, Bruno, 15, 31, 38 Bettman, J. E., 365 Bibring, Edward, 319, 320, 338 Bion, Alfred, 234, 340 biopsychosocial approach, 1 biopsychosocial context, 1 – 12 bipolar disorders, 328 – 33; case example, 331 – 33; diagnostics of, 330 – 31; experience of, 329; symptoms of mania, 329 – 30 Black, M., 106, 136 Black people, 102, 122, 182, 220, 221, 223 Black Skin, White Masks, 220 Blair, R., 280 Blau, Z. S., 337 Bleuler, E., 255 Bollas, C., 161 borderline personality disorder, 279, 280, 281 – 96 Bostwick, M. B., 212 Boutilier, L. R., 291 Bowlby, John, 97, 169 – 71, 174, 178, 185, 189, 323 Bowles, Dorcas, 137 Boylan, J. F., 338 brain development, 188 – 91, 193, 194, 281, 365 Brenner, C., 30 Breuer, J., 21, 372 British school of object relations, 98 – 109; Fairbairn, 105 – 7; Guntrip, 108 – 9; Klein, 102 – 5; Winnicott, 98 – 102 Britton, R., 304 Brodie, P., 305 Bromberg, P., 159 Brown, G. W., 279 Buie, D. H., 283, 294, 339 Byers, D. S., 240 Campbell, W. K., 297 caregivers, 28, 54, 55, 65, 78, 79, 117, 118, 172, 191, 193, 196, 223, 304, 323

Index castration anxiety, 30, 57, 58 Chapman, A. L., 295 Chessick, Richard, 3, 133, 139 child development, 25, 26, 79, 90, 195, 390 Childhood and Society, 143 childhood trauma, 198, 292, 391, 398 child maltreatment, 372 children, 12, 30, 64, 65, 81, 87, 121, 122, 157, 170, 189, 195 – 98, 293 – 94, 318, 323, 339, 381 Chodorow, Nancy, 205, 206 Clarke, S., 221, 222, 230 Clarkin, J. F., 295 client experience, 39, 238 – 40, 354 Climate Crisis, Psychoanalysis and Radical Ethics, 148 Coan, J. A., 179 – 80 Coates, Ta-Nehisi, 218 cocaine-induced psychotic disorder, 248 cohesive self, 115, 125, 128, 133, 134, 136, 139, 143, 243, 265, 389 Coltart, Nina, 234 Comprehensive Dictionary of Psychoanalysis, 24 conflict theory, 21 – 22 Conner, K. O., 296 conscious mind, 23, 24, 31, 35, 39, 58, 61 control-mastery theory, 67 – 70, 73, 172, 184 Cooper, A. M., 298 Cooper, S. H., 166 Corbett, K., 211 Correll, C. U., 257 couple therapy, 387 – 88, 396 – 98 Crenshaw, Kimberlé, 94 cultural trauma, 376 The Culture of Narcissism, 128 Dalal, F., 165 Darkness Visible, 315 defense mechanisms, 37, 42, 54 – 56, 58, 59, 70, 230, 264 – 65, 363 defenses, hierarchy, 58 – 64; developmentally early/psychotic, 59 – 60; immature, 60 – 61; mature, 63 – 64; neurotic, 61 – 63 De Gruy, J., 376 depersonalization, 290, 363, 366 depressed clients, 325, 340, 341 depression, 315 – 28; at borderline level of functioning, 327 – 28; ego psychology, 319 – 20; experience of, 315 – 16; Freud’s ideas on, 317 – 19; at neurotic level of functioning, 328; object relations theory, 320 – 24; at psychotic level of functioning, 325 – 27; self psychology, 324 – 25; symptoms of, 316 – 25

Index depressive position, 5, 103 – 5, 108, 221, 223, 230, 322 developing stress response system, 189, 191 – 92, 193 – 94 developmental arrest, 10, 101, 110 The Devil Wears Prada, 301 – 2 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), 8, 144, 244, 252, 275, 276, 298, 374 dialectical behavior therapy (DBT), 294 – 95 Di Angelo, R., 228 A Dictionary for Psychotherapists, 3, 133 Dimen, Muriel, 210 Dinnerstein, Dorothy, 205 dreams, analysis, 23 – 24 drive theory, 262 – 63 DSM-I, 244 DSM-II, 241 DSM-III, 244 DSM-IV-TR, 276, 374 DSM-5. See Diagnostic and Statistical Manual of Mental Disorders, fifth edition Du Bois, W. E. B., 225 Dyson, M., 217 Eack, S. M., 296 economic theory, 34 – 35 Edmundson, Mark, 127 ego, concept of, 41 – 42 “The Ego and the Id,” 36, 38 ego functions, 49 – 54, 263; judgment, 50 – 51; mastery, 53 – 54; modulating and controlling impulses, 51 – 52; modulation of affect, 52 – 53; object relations, 53; reality testing, 50; self-esteem regulation, 53 ego psychology, 47 – 73; anxiety and defense mechanisms, 56 – 58; autonomous ego functions, 64 – 66; conceptualizations, 48 – 49; control-mastery theory, 67 – 70; defense mechanisms, 54 – 55; ego functions, 49 – 54; hierarchy of defenses, 58 – 64; mastery reconceptualized, 66 – 67 Ehrenberg, D., 165 – 66 eight ages of man, 77 – 88; adolescence, identity vs. role confusion, 83 – 85; adulthood, generativity vs. stagnation, 85 – 86; early childhood, autonomy vs. shame and doubt, 79 – 80; infancy, trust vs. mistrust, 78 – 79; old age, integrity vs. despair, 86 – 88; play stage, initiative vs. guilt, 81; school age, industry vs. inferiority, 81 – 82 Eliot, T. S., 86 emotional dysregulaton, 288

437 emotional states, 36, 196, 312, 374 Eng, David, 318 – 19 Erikson, Erik, 82, 85, 89, 143; critiques of, 88 – 90; ego psychologist, 75 – 77; eight ages of man, 77 – 88; theory of, 75 – 91 Fairbairn, Ronald, 105 – 7, 113, 388 False Self, 101 – 2, 239, 302 Fanon, Franz, 220, 223 A Farewell to Arms, 320 Fast, Irene, 205 Fenichel, O., 275 Ferenczi, S., 153 Figley, C., 374 Fonagy, Peter, 146 fragmented self, 145 Fraiberg, Selma, 30 Franz, C. E., 89 Freud, Anna, 58, 76, 126 Freud, Sigmund, 1, 48, 56, 96, 103, 219, 234, 256, 262, 304, 318, 357, 372; analysis of dreams, 23 – 24; common misinterpretations, 42 – 45; conflict theory, beginnings, 21 – 22; early critiques of, 203 – 4; on early experience, 185; economic theory, 34 – 35; ego, concept of, 41 – 42; evaluation, 45 – 46; evolution of a theory, 17 – 21; hysteria and trauma, understanding, 17 – 21; id, concept of, 39 – 40; intellectual traditions, 16 – 17; psychoanalytic concepts, 14 – 46; psychopathology and, 22 – 23; psychosexual development, genetic theory, 25 – 34; repetition compulsion, 24 – 25; self-knowledge, role of, 25; sociocultural influences, 17; structural theory, 36 – 38; superego, concept of, 40 – 41; topographic theory, 35 Gabbard, G. O., 238 Garran, A. M., 223 gender: postmodern feminist critiques, 209 – 14; psychodynamic theories and, 202 – 14; self-inrelation theories, 208 – 9; women, psychology of, 204 – 7 generalized anxiety disorders, 117, 244, 354, 365, 366, 368, 380 Gershwin, Ira, 317 Gianino, A., 323 Gilligan, C., 89 Gilmore, J. H., 258 Gomez, Lavinia, 106, 122 Gordon, Mary, 11 grandiose self, 133 – 37, 139, 141, 305 Gravitz, M. A., 305

438 Graybar, S. R., 291 Green, B. L., 376 Greenson, Ralph, 63, 234 Gunderson, J., 286 Guntrip, Harry, 108, 109 Hagerty, Barbara, 281 Hagman, G., 147 Han, Shinhee, 319 Hardy, G. E., 184 Hart, A., 227 Hartmann, H., 64 Harwood, R. L., 182 Haydon, K. C., 174 healthy self-esteem, 290, 305, 324, 405 Hemingway, Ernest, 320 Herman, J., 374 Hoffman, I., 160 Holmes, D., 376 Horney, Karen, 204 Horowitz, H. A., 181 humor, 64 id, concept of, 39 – 40 idealized parent imago, 133, 134, 137 – 39 I Hate It When . . ., 131 – 32 Indigenous people, 219, 224, 225 individual self, 7, 127, 148 infantile sexuality, 25 infants, 54, 65, 78, 97, 99, 111, 171 – 74, 176 – 80, 191, 192, 196, 321, 390 “Inhibitions, Symptoms and Anxiety,” 38, 56 “Initiative versus Guilt,” 143 insecure attachments, 176 – 78, 180, 181, 183, 185, 242, 354, 365; styles, 171, 173, 283, 351, 405 intellectual traditions, 16 – 17 interpersonal relationships, 27, 55, 93, 386, 397 intersectionality, 94 Intersubjective Self Psychology—A Primer, 147 intersubjective theories, 152 – 66; human, complexities, 165 – 66; relational practice to postmodern frontier, 163 – 65 intrapsychic determinism, 147 Jacobson, E., 322 James, P. D., 112 – 13 Jamison, Kay, 328, 329, 333, 336 Jasperson, R. A., 365 Jenike, M., 362 Jones, D., 267 Kaplan, Louise J., 99 Kaplan, M., 278

Index Kelly, A., 396 Kernberg, Otto, 116, 293, 304, 305 – 6 King, Thomas, 218, 219 Kita, E., 222 Klein, Melanie, 5, 92, 102 – 5, 129, 153, 154, 221 – 24, 322, 329; positions, 221 – 22; projective identification, 222 – 24 Kohut, Heinz, 125 – 27, 129 – 30, 132 – 33, 146, 148, 304 – 5; empathy, 131; self states, 144; transmuting internalization, 142 – 43; twinship pole, 139, 141 Kovel, J., 220 – 21, 230 Kraepelin, E., 255 Kreger, R., 283 LaBruzza, A., 279 Lacan, J., 210 Lachmann, Frank, 147 Lafargue Clinic, 240 – 41 Lasch, Christopher, 128, 297 Layton, L., 8 Layton, Molly, 292 Lenzi, D., 179 Lessem, P., 147 Levine, F., 126 Lieberman, J. A., 261 life experiences, 12, 125, 234, 240, 396 Lifter, K., 191 Linehan, M. M., 282, 290 – 91, 292, 294 – 95 Loewald, H. W., 317 “The Love Song of J. Alfred Prufrock,” 86 Luhrmann, T. M., 259, 260 Lyden, Jacki, 330 Mahler, Margaret, 116 – 20, 207, 294; autistic phase, 117; separation-individuation proper, 118 – 20; symbiotic phase, 117 – 18 Main, Mary, 174, 176, 177 Malaspina, D., 258 Malkin, C., 297 Maltsberger, J. T., 339 manic-depressive illness, 329, 336 Marrow, J., 259, 260 Mason, P. T., 283 Masterson, J. F., 293 – 94 Mazzula, S. L., 227 McDougall, Joyce, 155 McIntosh, Peggy, 209 McWilliams, Nancy, 238, 302 Men and Angels, 11 Mendes, Gabriel, 241 Mendez-Villarrubia, J. M., 279 Menezes, P. R., 258 mental illness, caring: families, 267; resources

439

Index availability, 267 – 70; treatment issues, 265 – 67 Merkin, Daphne, 312 Miehls, D., 159 Miliora, M. T., 224 – 25 Miller, Jean Baker, 89 Milne, A. A., 29 Mitchell, S., 106, 136, 154, 237 Modell, A. A., 128 mood disorders, 312 – 41; biological factors, 333 – 36; brain, 334 – 35; depression and, 315 – 25; effects on clinicians, 340; genetics, 334; hormonal theories, 334; social factors, 336 – 38; suicide, 338 – 40; temperament, 336 Morrison, A. P., 300 Morrison, Toni, 223 “Mothers: Tired of Taking the Rap,” 122 “Mourning and Melancholia,” 38, 317 Museum of Modern Art (MoMA), 135, 146 myth of Narcissus, 34, 298 Nadal, K. L., 227 narcissistic personality disorder, 275, 276, 280, 297 – 306; ego functions, 302 – 3; etiology and treatment, 303 – 6; object relations, 301 – 2; self-concept, 299 – 301 Neugeboren, J., 266 – 67 neurobiology, 188 – 99 neuroplasticity, 335 neuroprotective benefits, 188 neurotic defenses, 61 – 63; displacement, 62 – 63; reaction formation, 62; repression, 61 – 62; undoing, 63 Newhill, C. E., 296 Not Quite Not White: Losing and Finding Race in America, 220 object, 94 object relations, 265 object relations defenses, 109 – 16; devaluation, 115 – 16; idealization, 115; incorporation, introjection, and identification, 112 – 13; projection, 113; projective identification, 114 – 15; splitting, 111 object relations theory, 92 – 123, 207, 321, 386; American school, 116 – 20; beginnings, 95 – 96; British school, 98 – 109; critique, social context, 121 – 22; object relations defenses, 109 – 16; primary, basic attachment, 97 – 98 obsessive-compulsive disorders, 276, 353, 354, 360 – 62, 365 – 67 oedipal child, 29 – 32, 357 Ogden, T. H., 114, 155, 222 Oneness and Separateness, 99

“On Narcissism,” 130, 304 Orange, D., 146, 147 organism panic, 264 The Origin of Others, 223 Osler, Sir William, 336 overburdened self, 128, 144 – 45 overstimulated self, 144 panic disorders, 356, 362, 366, 368, 380, 383 Pao, P., 264 parental incarceration, 195 Paul, H., 147 Pearlman, L., 392 – 93 people of color, 102, 212, 220, 222, 224, 227, 229, 230, 296, 319, 376 Perry, J., 299 Perry, P. B., 390 personality, defining, 275 – 76 personality development, 11, 76, 185, 279, 363 personality disorders, 274 – 307; affect regulation, 288 – 89; borderline personality disorder, 281 – 82; borderline personality disorder and race, 296; clinical picture, 282 – 91; cognitive functioning, 287; defenses, 287 – 88; defining, 275 – 76; diagnostic entity, 277 – 80; ego functions, 286 – 90; etiological considerations, 291 – 94; experience of “self,” 290 – 91; generalizations, controversies, and limitations, 277 – 80; impulse control and judgment, 286 – 87; level of anxiety, 290; narcissistic personality disorder, 297 – 306; neurobiological and genetic considerations, 280 – 81; neurobiology and trauma, 291 – 92; object relations, 282 – 86; psychodynamic lens to classification, 276 – 77; psychodynamic theorists’ contribution, 293 – 94; reality testing and sense of reality, 290; treatment approaches, dialectical behavioral therapy, 294 – 95 personality traits, 1, 270, 276, 280, 292 phobias, 39, 348, 354, 356 – 59, 362, 365 – 67 Piaget, J., 120, 294 Pine, Fred, 26, 103, 117, 233 Playing and Reality, 108 Porges, S. W., 391 postmodern feminist critiques, 209 – 14 post-traumatic stress disorder (PTSD), 279, 292, 362, 363, 373, 379 – 84; clinical vignette, 380 – 82; complex post-traumatic syndrome (C-PTSD), 383 – 84; cultural relativity of diagnosis, 382 – 83 Pouissant, A., 376 preoccupied attachment style, 175, 176, 178 Presniak, M., 299

440 projective identifications, 114, 115, 153 – 54, 222, 225, 287, 288, 351, 352, 384 – 87 Prozac Nation, 315 psychoanalysis, 3, 15, 18, 20, 21, 24, 31, 36, 126, 153, 154, 218 psychoanalytic concepts, 14 – 46 psychodynamic psychotherapy, 4, 5, 295 psychodynamic theory, 2 – 7 psychological development, 75, 77, 92, 94, 96, 123, 126, 128, 131, 133, 204, 297, 349 psychopathological syndromes, 245 psychopathology, 22 – 23 psychoses, 247 – 70; clinical picture, 251 – 55; constitutional and environmental factors, 258 – 60; etiological considerations, 255 – 58 psychosexual development, 25, 26, 35, 42, 45, 54, 56 – 58, 64, 65, 77 psychosexual development, genetic theory, 25 – 34; anal stage, 27 – 28; genital stage (adolescence), 33 – 34; latency, 32 – 33; oral stage, 26 – 27; phallic phase, 28 – 32 psychosocial ego development, 75 – 91 psychotherapy practice, 169 psychotic symptoms, 247 – 49, 264, 270, 325 quality of attachment, 101, 117, 188, 190, 196, 199 Rabinowitz, J., 258 racism, 217 – 30; application of theory, 226 – 27; case study, 226 – 27; clinical practice, implications, 227 – 28; Fanon and, 220; Freud and, 218 – 19; institutional change, implications, 228 – 29; Klein and, 221 – 24; Kovel and, 220 – 21; psychoanalytic perspectives, 218; self psychology, 224 – 26; Wachtel and, 224 Rasmussen, B., 222, 223 Reich, W., 275 relational theories, 152 – 66; asymmetry and power, 162 – 63; countertransference, 154 – 56; enactments, mutuality, self-disclosure, and third space, 157 – 60; history of psychoanalysis and, 153 – 54; infant development, voices, 162; reveries, musings, and associations, 162; self-disclosure, 160 – 61 relational trauma: attachment to victimizer, 388 – 89; boundary ruptures, 388; dearth of rituals, 389; denial, 385; dissociation, 386; ego psychology, 384 – 85; object relations theories, 386 – 88; projection/projective identification, 385; self psychology, 389; splitting, 385 – 86; withdrawal, 385 repetition compulsion, 24 – 25

Index Rethinking Narcissism, 297 Robbins, M., 261 Robins, C. J., 295 Rosenstein, D. S., 181 Rutter, M., 379 Saakvitne, K., 392 – 93 Saari, 320 Salhani, D., 222 Sampaio, A., 191 Samuels, A., 8 Sauer-Zavala, S., 289 schizophrenia spectrum disorders, 247 – 70; medications, 260 – 61; using pyschodynamic lens, 262 – 65 Schore, A. N., 305, 390 “the science of the self,” 130 Searles, H., 263 seasonal affective disorder, 134 self, defined, 125 self-absorption, 85, 86, 297, 304, 305 self-cohesion, 130, 239, 340, 405 self-disclosure, 152, 157, 160 – 62, 164, 405 self-esteem, 40, 42, 44, 53, 71, 73, 80, 144, 145, 229, 230, 296, 297, 319, 320 self-in-relation theories, 208 – 9 self-knowledge, 25, 404 self-loathing, 112, 275, 281, 285, 287, 299, 317 self-love, 129, 294, 304 self-mutilation, 60, 286, 287, 307 selfobject functions, 133, 137, 142, 305, 324 selfobjects, 131, 132 – 34, 135, 137 – 44, 149, 150 self psychologists, 127, 132, 138, 142, 143, 147, 150, 224, 324, 325 self psychology theory, 125 – 50, 389, 405; critique, social context, 148 – 49; disorders of self, 143 – 46; empathy, role of, 131 – 32; intellectual and cultural contexts, 127 – 29; narcissism, theories, 129 – 30; psychopathology, 143 – 46; selfobjects, 132 – 34; self states, 144 – 46; transmuting internalization, 142 – 43; tripolar self, 132 – 42 self-representations, 93, 102, 129, 362 self-reproach, 7, 23, 96, 300, 320, 322, 326 Semrad, E. V., 262, 264 Sen, Sharmila, 220 separation anxiety, 54, 239, 349, 352, 353, 364, 367 separation-individuation proper, 118 – 20; differentiation, 118; practicing, 118; rapprochement, 118 – 19; on the way to object constancy, 120 Shaw, George Bernard, 406 Shea, S. C., 238

441

Index Shedler, J., 4 Shydlowski, B., 337 Sinclair, E., 250 Slade, A., 177, 184 Slap, J., 126 Soloff, P. H., 288 – 89 Solomon, Andrew, 312 Spitz, R., 97, 321 Stern, D., 97, 146, 162, 172 Stetka, B. S., 257 Stone, M. H., 295 stress response system, 190 – 97 Strossel, Steve, 368 Strozier, C., 127 structural theory, 36 – 38 Studies in Hysteria, 22 Styron, William, 315, 316 sublimation, 63 – 64 Suchet, Melanie, 218 suicide, 338 – 40 Sullivan, Harry Stack, 154, 235 superego, concept of, 40 – 41 supportive intervention, 193 – 97 “Surviving Hating and Being Hated: Some Personal Thoughts about Racism from a Psychoanalytic Perspective,” 95 Swartz, S., 162 A Taste for Death, 112 – 13 Terr, Lenore, 374, 376 therapeutic relationship, 404 Thigpen, K. Z., 240 topographic theory, 35 Torrey, E. F., 250 transference, 139 transference-focused psychotherapy, 295 transitional objects, 100, 101, 120, 356 traumatic events/experiences, 21, 363, 371, 372, 374 – 76, 378 – 79, 382, 383, 384, 385, 391, 394, 395, 396 – 398 traumatic stress/stressors, 188, 193, 194, 196, 373, 374, 379, 382, 391 traumatized individuals, 56, 372, 373, 380, 383, 392, 393 traumatology, 386, 389 trauma/trauma theories, 188 – 99, 371 – 99; affect regulation and infant development, 390 – 91; biopsychosocial-spiritual/structural assessment, 394 – 95; combat, 377 – 78; couple therapy approaches, 396 – 98; defining, 374 – 78; historical context, 372 – 73; histories,

161, 196, 198, 199, 292; “impersonal” versus “interpersonal,” 377; individual treatment approaches, 395 – 96; neurobiology of, 389 – 92; somatic responses to traumatic stress, 391 – 92; survivors, 363, 387, 388, 392 – 94, 398; transference/countertransference phenomena with survivors, 393 – 94; traumatic events types, 374 – 77; vicarious traumatization and secondary trauma, 392 – 93 Trierweiler, S., 259 tripolar self, 131 – 42; pole of grandiose self, 134 – 36; pole of idealized parent imago, 137 – 39; pole of twinship, 139 – 42 Tronick, E. Z., 162, 323 true self, 101, 102, 134, 209, 239 Tummala-Narra, P., 376 Turner, P. T., 181 Twenge, J. M., 297 twinship experiences, 149, 150, 240 Tyrell, C. L., 184 U.S. Census Bureau, 121 understimulated self, 144 An Unquiet Mind, 329 Vaillant, George, 58 van den Boom, Dymphna, 180 vicarious traumatization, 372, 393 vulnerable dyads, 193 – 97 Wachtel, P. L., 154, 224, 230 Walls, G., 225 Webster’s Third New International Dictionary, 2, 110, 125, 131 Werner, S., 258 “When Your Child Is a Psychopath,” 281 White, D., 89 White, Kathleen Pogue, 95, 102 White, R. W., 66 – 67 white people, 141, 220, 221, 223, 224, 227 – 30 White Racism, 220 Winnicott, Donald, 94, 98 – 102, 154, 294 Wolf, E., 144, 146 Wolf, K. M., 321 Wolfson, S., 240 women, 52, 88, 102, 202 – 11, 213, 259, 314, 336, 337, 358, 381; psychology of, 204 – 7 Wurtzel, Elizabeth, 315 – 16 Zimmermann, P., 147

About the Contributors

Kathryn Basham, PhD, L.I.C.S.W., professor, chair of clinical social work practice, has engaged in previous roles at the SCSSW as the codirector of the PhD program, chair of the Human Behavior in the Social Work Environment sequence, and editor of Smith College Studies in Social Work. Dr. Basham earned her MSW degree at the University of California at Berkeley and her PhD at the Smith College School for Social Work. She has been appointed to three congressionally mandated committees with the Institute of Medicine at the National Academies of Science, charged to evaluate approaches that enhance the mental health of servicemembers, veterans, and military families. With these task groups, she coauthored four books focused on the physical and mental health concerns facing Gulf War veterans, military families, post-9–11 veterans struggling with PTSD, and barriers related to accessing mental health care. She has also authored numerous peer reviewed articles, chapters, and a coauthored text titled Transforming the Legacy: Couple Therapy with Survivors of Childhood Trauma. Presentations have been offered, both nationally and internationally, that have focused on a range of issue including trauma and trauma-related conditions/disorders; combat trauma; woman in the military; intercultural practice; ethics and moral injury; couple therapy with trauma survivors; pedagogy and diversity; and professional development in clinical social work. Dr. Basham has received the honor as a distinguished clinical practitioner with the National Academies of Science and the Greatest Contribution to Social Education Award from NASW. She maintains a private practice in clinical social work practice, supervision, and consultation in Northampton, Massachusetts. Joan Berzoff received her BS from Washington University in St. Louis, Missouri, her master’s from the Smith College School for Social Work, and her EdD from Boston University. She is professor emerita at the Smith College School for Social Work, where she codirected the doctoral program, directed the End of Life Certificate Program, and chaired the Human Behavior in the Social Environment sequence. She is the author or coauthor of four books: Inside Out and Outside In, editions 1–5; Falling through the Cracks: Psychodynamic Practice with Vulnerable and At-Risk Clients; Living with Dying: A  Handbook for End of Life Care; 443

444

About the Contributors

Practitioners and Dissociative Identity Disorders: Controversies in Diagnosis and Treatment, over fifty articles, and has given over 150 presentations related to such issues as death, dying, bereavement, trauma, psychodynamic practice, race, suffering, women’s issues, renal palliative care, demagoguery, and compassion fatigue both nationally and internationally in such countries as Israel, Canada, Italy, Bulgaria, and Sweden. She has been a coprincipal investigator for a PCORI grant on advance directives for renal patients and families. Dr. Berzoff was awarded the Outstanding Scholar Award from the National Academies of Practice, the Outstanding Teacher of the Year Award from NASW, the Professional Clinical Writing Award from the American Association of Psychoanalytic Clinical Social Work, a Social Work Leadership Award from the Soros Foundations’ Project on Death in America, a Bogliasco Fellowship in Bogliasco, Italy, the Outstanding Teacher Scholar Award from Boston University, and received a runner-up award from the Goethe Institute. She currently works as a faculty at the Institute for Clinical Social Work, serves as a consultant to the Sue Fairbanks Academy for Psychoanalytic Social Work in Austin, Texas, and is in private practice in Northampton, Massachusetts. Daniel Buccino, MA, MSW, is the clinical manager of the Johns Hopkins Hospital Broadway Center for Addiction and was the founding clinical director of the Johns Hopkins Bayview Medical Center Mood Disorders Clinic. Mr. Buccino is an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and Director of the Johns Hopkins Civility Initiative. He has published and presented widely on topics such as mood and substance use disorders, psychoanalysis and consumer culture, and civility and health care. David S. Byers, MSW, LICSW, PhD, is assistant professor at Bryn Mawr College Graduate School of Social Work and Social Research and postdoctoral associate at the Bronfenbrenner Center for Translational Research at Cornell University. His research and other writing on community ethics, clinical practice, and teaching have appeared in journals including Social Work, American Psychologist, and Journal of Diversity in Higher Education. In 2020, Dr. Byers was awarded the Rosabeth Moss Kanter Change Master Research Fund Award at Bryn Mawr College. Dr. Byers completed his BA at Sarah Lawrence College, his MSW at New York University, and his PhD at Smith College School for Social Work. Laura Melano Flanagan, LCSW, graduated from Manhattanville College with a degree in French literature and received her MSW in casework from the Hunter College School of Social Work. She also earned a certificate from the Advanced Institute for Analytic Psychotherapy in New York City. Her past experience includes working at the Jewish Child Care Association’s Pleasantville Cottage School, the New York Community Service Society, and Downstate Hospital. She has taught as an adjunct instructor at the Hunter College and New York University Schools of Social Work in their Postmaster’s Certificate programs. She has been on the faculty of the Smith College School for Social Work since 1985, first as an adjunct professor and currently as a field faculty advisor. She maintains a private practice of psychotherapy and supervision in Manhattan and Brooklyn working with a variety of clients on a sliding scale. For over a decade now, she has been the psychological consultant to several programs for young opera singers, providing both psychological interpretation of roles and personal counseling. Ann Marie Garran is associate professor at the University of Connecticut School of Social Work, Hartford Campus. She worked as a clinician in New York City for more than twenty

About the Contributors

445

years in school-based settings, outpatient adolescent mental health, and employee assistance programs. She earned her BS from Georgetown University, her MSW from Hunter College School of Social Work, and her PhD from Smith College School for Social Work. She teaches courses on integration of clinical practice and theory, and on racism in the United States, particularly in social work education and practice. Her research focuses on racism, microaggressions, psychological safety in the classroom, and challenges teaching anti-oppression content for BIPOC instructors. She has published and presented on racism in social work education, microaggressions, and clinical practice, and is coauthor of Racism in the United States: Implications for the Helping Professions (2017). Meg Hertz, LCSW, graduated with a dual degree in psychology and sociology from ­Wesleyan University and received her MSW from the Smith College School for Social Work. She worked as a staff member and supervisor at numerous agencies in New York City, including the Jewish Board of Family and Children’s Services. Meg has been an adjunct associate professor at the New York University School of Social Work for over thirty years, where she teaches courses in the practice sequence and serves as a faculty advisor. Meg has a private practice in Manhattan and White Plains, where she works with individuals and couples and runs supervision groups; she also serves as a volunteer clinical consultant for the mental health and substance use teams at GMHC. Patricia Hertz, LICSW, graduated from Cornell University and received her MSW from Smith College School for Social Work. She worked in community mental health for many years before becoming the director of training in the social work department at Beth Israel Deaconess Medical Center. She was an adjunct professor at Smith College School for Social Work and Simmons College School of Social Work and taught courses in psychodynamic theory, psychopathology, and advanced clinical practice. She has provided clinical consultation and supervision to mental health agencies and college counseling centers, and is currently a clinical consultant in the Social Work department at Beth Israel Deaconess Medical Center, the Psychosocial Oncology Service at Dana Farber Cancer Institute, and for the Laughter League clowns at Children’s Hospital. Pat maintains a private practice in Brookline and Cambridge, in which she works with adolescents, adults, couples, and families. Teresa Méndez, MSW, graduated from Princeton University with a degree in cultural anthropology and received her MSW from the Smith College School for Social Work. She has published and presented on the intersection of race, ethnicity, culture, and identity. A candidate at the Washington Baltimore Center for Psychoanalysis, she maintains a private practice in Baltimore. Susan Pasco, PhD, LCSW-R, received her BA from the University of Chicago, her MSW from New York University, and her PhD from Smith College School for Social Work. She retired in 2020 from her position as associate director of the Syracuse University Counseling Services and coordinator of their Integrated Eating Disorder Treatment Team after spending thirty years in college mental health. In addition to her work as a practitioner and supervisor, she has conducted research on suicide intervention and prevention with college students as a coprincipal investigator on a Garett Lee Smith Campus Suicide Prevention Grant. She also served as a national trainer for both the Suicide Prevention Resource Center’s Assessing and Managing Suicide Risk Training and Syracuse University’s Campus Connect Suicide Prevention Gatekeeper Program. Currently, she maintains a psychotherapy private practice in Syracuse, New York.

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About the Contributors

Brian Rasmussen, PhD, RSW, received his MSW from Wilfrid Laurier University in Waterloo, Ontario, and his PhD from Smith College School for Social Work. He is an associate professor in the School of Social Work at the University of British Columbia, Okanagan Campus. He is on the editorial boards of the Journal of Social Work Practice, Psychoanalytic Social Work, and Smith College Studies in Social Work. He publishes in the area of clinical social work practice with a particular interest in applying psychodynamic theories to personal and social problems. Brian maintains a practice of clinical consultation and supervision. Gerald Schamess, MSS, died in 2019. He was a beloved teacher and supervisor. He had been a professor emeritus at the Smith College School for Social Work, where he served as chair of the Practice sequence, chair of Human Behavior in the Social Environment sequence, director of the Clinical sequence in the PhD program, and editor of the Smith College Studies in Social Work. He had published extensively on transference and countertransference, therapeutic process, clinical supervision, group therapy with children and adolescents, school-based clinical practice, and managed mental health care. He also maintained a private practice in Northampton, Massachusetts. Janet Shapiro, MA, MSW, PhD., Dr. Shapiro is dean and professor of the Bryn Mawr College Graduate School of Social Work and Social Research and codirector of the Center for Child and Family Wellbeing at Bryn Mawr. Her research, teaching, and practice focus on child and adolescent mental health, with a specific emphasis on the impact of traumatic stress on child and adolescent development. Her work examines risk and protective factors among children exposed to early adversity and trauma. Dr. Shapiro has worked in multiple community contexts including child welfare, infant and early childhood mental health, and school-based programs for adolescent mothers and their children. Her most recent publications include the second edition of a book titled Neurobiology for Clinical Social Work: Theory and Practice. Dr. Shapiro has been a social work educator for twenty-five years and has provided national leadership to the profession in supporting the training of social work students in traumainformed approaches to social work practice with children and their families. Cynthia J. Shilkret, PhD, received her BA from Barnard College and her PhD in clinical psychology from the State University of New York at Buffalo. She was an intern and also a postdoctoral fellow at Mount Zion Hospital and Medical Center (now the University of California Medical Center) in San Francisco, where her postdoctoral fellowship was in the area of psychotherapy research. She is a founding member of the San Francisco Psychotherapy Research Group. She has been an adjunct member of the faculty of the Smith College School for Social Work teaching courses in the MSW, PhD, and Continuing Education programs. She is in private practice in South Hadley, Massachusetts, specializing in individual psychotherapy and case consultation. She has lectured in the United States and Europe and has written on a variety of clinical topics. Robert Shilkret, PhD, received his BA from the Johns Hopkins University and his PhD in clinical psychology from Clark University. He interned at Judge Baker Child Guidance Center in Boston and was a postdoctoral fellow in clinical psychology and psychotherapy research at Mount Zion Hospital and Medical Center (now the University of California Medical Center) in San Francisco. He retired in 2014 after forty-two years at Mount Holyoke College as the Norma Cutts DaFoe Professor of Psychology Emeritus. There he served as department chair, dean of studies, and acting dean of faculty three times. His research was in children’s communication competence; college students’ development and relations

About the Contributors

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with their parents; and the influence of attachment and guilt on adjustment during the college years. He was an adjunct faculty member of the Smith College School for Social Work for approximately thirty years, where he taught classes in the MSW, PhD, and continuing education programs and supervised MSW theses and PhD dissertations. He also had a parttime practice of adult psychotherapy for some thirty years.