Rather, both are different aspects of a single complex phenomenon. Thus, when Freud speaks of "splitting of the ego" in fetishism versus id-ego conflict in neurosis what Kohut refers to as "structural conflict" between intact structures , he is not contrasting a structural defect with a dynamic conflict. For, in this view the "splitting of the ego" in fetishism is as dynamically determined as the id-ego conflict in neurosis. And for Freud, neurosis is not simply a dynamic conflict between fully intact structures so that one could, practically speaking, ignore structural considerations but is, from one vantage point, also a developmental failure.
The presence of a neurosis bespeaks, among other things, some inherited, constitutional component an earlier unresolved infantile neurosis, the persistence of infantile wishes, the presence of psychosexual fixations, and a failure of the ego to resolve conflict more adaptively. While some people may be more disturbed than others and may show a greater degree and wider range of developmental failures, it does not follow that issues of intrapsychic conflict are irrelevant to them. For those with so-called self defects and developmental arrests, there are also conflictual wishes and aims defensively dissociated from the rest of the personality because of the anxiety they would entail.
The wishes and aims may center on fantasies and themes of merging, engulfing, and being engulfed, symbiotic union versus separation, etc. The general point is that developmental failures and structural defects have dynamic aspects. Indeed, to say that someone is developmentally impaired or has an ego or self-defect means, in part, that certain characteristic wishes e. Clinically, one frequently observes that it is precisely the person deprived of love and empathy who is most conflict-ridden in regard to being loved. For example, very deprived children who are finally indulged e.
In one case with which I am familiar the mother forbade the trips to a restaurant with the child worker because she had to face the inevitably destructive behavior afterward. It is not uncommon to see children with a history of deprivation react with depression, tears, and rage following indulgence. One can also observe in adult patients who have had a battered and deprived childhood the strong tendency to re-institute conditions of misery and failure after a helpful and empathic relationship has been established, either in or out of therapy.
In a recent paper, Bowlby describes a patient who did not seem to be content until her needling succeeded in making him irritable. This urge to needle became stronger after Bowlby had done something that she felt was kind.
Her explanation for her behavior was that "I can't take kindness. Bowlby goes on to say:. Once I had become irritable any warm feelings that she might have felt in response to my kindness were snuffed out. Then she felt safe again, though of course terribly isolated" Bowlby, , p. The point I am making by all these examples is, to repeat what I have said above, that early traumas, early developmental impairments, and early structural defects are always accompanied by intense and conflict-laden wishes and feelings. The fact is that we have intense reactions e.
As I stated above, it is precisely the person deprived of love who is most conflicted about giving and receiving love. It is as if one of the costs and consequences of trauma is to develop an "allergy" to the very "substance" one needs and of which one has been deprived. Continuing the analogy, such an allergic reaction means that the therapeutic task will be far more complex than compensating for an earlier deficiency.
A subsidiary assumption that is part and parcel of the developmental defect-intrapsychic conflict dichotomy is that the former group of people pursue primarily self-cohesiveness, while the latter is concerned mainly with drive gratification and the conflicts in which they are implicated.
I suggest instead that Gedo , and G. Klein are correct in their proposal that the integrity and continuity of self-organization is a superordinate aim for all people, quite independent of diagnostic category. For more disturbed people, who are prone to what Kohut calls "disintegration anxiety," this aim is often pursued at the level of sheer intactness of self. For others, the pursuit of this superordinate aim mainly takes the form of striving to resolve and integrate the incompatibilities and conflicts among various subordinate aims G.
While satisfaction of basic drives and needs which are not limited to sex and aggression generally tends to be self-enhancing and deprivation tends to be self-diminishing, their psychological meaning and consequence cannot be divorced from superordinate issues of self-organization. However, the frustration of a specific wish or need in a context of non-conflict will have different psychological consequences.
Many people can endure serious frustration of certain basic needs without marked psychological consequences if the frustration is experienced in a context compatible with "self-values. Klein notes, issues of sensual craving, gratification, and deprivation are intimately bound up with "self-values. There is no logical or clinical incongruence between the structural point of view of which notions of developmental arrest and self-defects are examples and the dynamic. The integration of the two points of view is made possible with the recognition that whatever one's developmental level and structural limitations, the resolution of incompatibilities is a universal task and the failure to resolve incompatibilities or their attempted resolution through dissociative means weakens the integrity of the personality.
Another way to make the same basic point is to say that a self psychology and a dynamic conflict psychology are congruent insofar as degree of self-integrity is intimately linked to the resolution and integration of incompatible aims and motives. What follows is that while the content and nature of conflicts may vary, resolution of conflict will be likely to be therapeutic for all levels of pathology which is not to say that other factors, such as identification with the therapist, will not also be therapeutic or that other factors will not be especially relevant for certain classes of pathology.
Since the pre-psychoanalytic writings of Janet and Charcot, it has been recognized that both severe incompatibilities and the resort to dissociation as the solution to such incompatibilities weakens the personality. This basic point is echoed in current discussion of the use of "splitting" in borderline conditions. Kernberg , who has written most extensively in this area, makes the explicit point that the use of splitting tends to erode ego strength. I have noted above that according to most current writers, the essential factor in the etiology of developmental defects and arrests is early trauma of some kind.
Thus, we have already noted that according to Kohut, early lack of empathic mirroring and opportunities for idealization are the primary etiological factors in accounting for lack of self-cohesiveness. I have already noted and will discuss again later in the chapter that there is little or no evidence for these etiological claims. I want to highlight here the degree to which the emphasis on trauma and ensuing defect represent a return to the relatively static and exclusive structural emphasis of pre-psychoanalytic continental psychiatry and a giving up of the insights provided by the psychoanalytic emphasis on intrapsychic conflict.
One will recall that the pre-psychoanalytic emphasis was on constitutional factors in accounting both for extent of the incompatibilities and the inability to resolve them in non-pathological ways. It was Freud's contribution and, in a sense, the beginning of psychoanalysis that he essentially reversed the causal sequence. That is, it was not that constitutional weakness and relative incapacity for integration produced conflict and dissociation and thereby, further weakened the personality - though Freud did allow some weight for such assumptions , but that incompatibilities and the use of repression in order to resolve them weakened the personality and left one prey to symptoms.
By contrast, the current emphasis on developmental arrests and self-defects, in a somewhat different language, shares the same explanatory form as the pre-psychoanalytic concepts of Charcot and Janet. Thus, Kernberg, for example, wonders whether those characterized by borderline personality organization are handicapped by a constitutionally given, overly intense aggressive drive. And when constitutional factors are not invoked, one need merely substitute for constitutional weakness and hypnoid states the newer factors of arrests and defects which are held to be brought about by early trauma.
This kind of etiological explanation is similar in form to early Freud's seduction theory and to pre-psychoanalytic accounts. It is a straightforward A causes B account, much as one would say that lack of vitamin D A causes rickets B. In short, whether the result of heredity or early trauma, what is proposed in much current literature as the core explanation of serious pathology is that one is dealing with a deficient and defective organism. I have referred elsewhere Eagle, to the tendency of some current psychoanalytic writers to depict their patients as so infantile and so defective that one wonders how they can function at all.
The example I used was Giovacchini's description of a patient in the following terms: Both visual and auditory modalities were fixated at early post-symbiotic levels and did not undergo confluence as occurs during the course of psychic development and integration" Giovacchini, , p. How is it possible for someone incapable of synthesizing visual and auditory modalities to do all these things?
As Levine points out, conceptualizations in terms of developmental arrests and self-defects tend to confirm the patients' fantasies that he or she is, in fact, detective. I would add that these sorts of formulations also serve to preclude the analytic examination of these fantasies, including their defensive function and their enmeshment in conflict. This is a particularly important point to make insofar as so-called defects and arrests are not necessarily transparent but rather involve the theoretical interpretation and judgment that certain behaviors are expressions, often indirect and subtle ones, of underlying developmental defects and arrests.
What follows is that if one's theoretical predilections are in a particular direction, one can view a particular set of behaviors as indications of self-defects and developmental arrests, while someone with a different theoretical inclination will give a different diagnostic meaning to these behaviors. I remind the reader of Gedo's observation, noted earlier, that the Goldberg case book is replete with instances of self-defects and hardly mentions Oedipal conflicts, while the Firestein case book dealing with seemingly similar phenomena bas not a word about self-defects, but much about Oedipal issues.
And, as Rangell has noted, the kinds of patients described as narcissistic personality disorders and as suffering from self-defects by Kohut and his followers have long been observed by many analysts who viewed them as neurotic rather than as warranting a distinct diagnostic category.
Accompanying the developmental defect-intrapsychic conflict dichotomy are corresponding differential emphases in therapy. If one conceptualizes pathology in terms of unconscious intrapsychic conflict, anxiety, and defense, then therapy consists in helping the patient better deal with conflict through increased awareness and insight and through increasing the ego's province and control. One's aim is to examine infantile wishes and the conflicts, anxieties, and defenses that surround them in the light of current reality so that one can consciously select such options as renunciation or gratification.
If, however, one conceptualizes pathology in terms of developmental defects, then the therapeutic aim is some sort of repair of this defect - usually via the therapeutic relationship. One sees this latter conception of psychoanalytic therapy with increasing frequency in discussion of work with more disturbed patients.
In this latter conception, one can no longer say that the basic aim of psychoanalysis is either to make the unconscious conscious or to enlarge the scope of the ego "where id was, there shall ego be". One is not as likely to think of therapy as a process in which one gradually owns the wishes that one has disowned, in which one comes to claim as part of oneself "ego-alien" desires and aims that one has disclaimed Schafer, Instead the patient-therapist relationship itself - whether described as a "holding environment" or as permitting mirroring and idealizing transferences - in some fashion helps repair the defect, facilitates the building of new structures and the resumption of developmental growth which was interrupted by early trauma.
As Stolorow and Lachmann put it,. As to the specific means through which the latter is to be accomplished, to the extent that this issue is addressed, the authors refer to the therapists' empathic understanding and "empathic clarifications" of the patient's need to maintain his or her archaic state, including the use of the therapist as a self object, for the purpose of maintaining self-cohesiveness and stability. According to the authors, "the analyst's empathic clarification of the patient's specific need for archaic self objects promotes differentiation and structuralization" p.
In general, the authors contrast intrapsychic conflict in which early experiences that are defended against are analyzed in the transference with developmental arrest in which the experiences the patient needed but lacked are understood. Finally, in Fairbairn's conception, therapy helps the patient dissolve the cathexis of the bad object through the good object relation represented by the therapeutic relationship.
Whether or not therapy leads to all these desirable outcomes, the point is that this conception involves a basic alteration of the psychoanalytic theory of therapy.
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Furthermore, this alteration is based on the mistaken notion that in developmental arrests and structural defects assuming that these are identifiable phenomena intrapsychic conflict is not a primary issue. Many recent conceptualizations of therapy suggest that treatment compensates for early traumas and the deficiencies they bring about. I have referred to this elsewhere as a "deficiency-compensation" model of therapy. However, it is likely that the salutary effects of therapy have mainly to do, not with eliminating developmental failures and structural defects, but with ameliorating the effects of the unrealistic anxieties and unresolved conflicts typically accompanying whatever failures and defects are one's lot.
Furthermore - and this seems to me a critical point - whatever the level of one's constitutional or historically endowed degree of ego strength or self-cohesiveness, unresolved conflict and accompanying anxiety weaken the personality, and the resolution of conflict and decreases in anxiety strengthen the personality.
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I share Gedo's skepticism toward talk about resumption of developmental growth and the claim that psychotherapy somehow directly repairs developmental impairments and structural defects - whether through "transmuting internalizations" or any other hypothetical process. Rather, as Gedo points out, the effects of such impairments and defects are more likely to be ameliorated through "new functions learned in the context of a satisfying and age-appropriate human relationship" Gedo, , p.
For some patients the new learning consists in such things as more efficient tension regulation, the prudent avoidance of understimulation or disruptive over-excitement, and raising unrecognized biologically based needs e. For many patients, as noted earlier, the experience of the therapist as a supportive symbiotic partner sufficiently reduces anxiety to permit the learning of new functions.
But I strongly suspect that for all patients help in the recognition and resolution of conflicts is a primary means of promoting increased feelings of intactness and self-cohesiveness. As adults, we are not simply frozen at "arrested" points in childhood. Hence, it is not at all clear as to what is meant by permitting arrested configurations to unfold as they would have in the normal course of development. No process, physiological or psychological, unfolds in an adult as it would have when we were 1, 2, or 3 years of age.
What can such talk mean or refer to? After all, as Loewald reminds us,. That we do not, as adults, simply resume a developmental growth that was arrested at an earlier period does not mean that growth in adulthood is not possible. As adults, we can experience a deepening and increase in self-understanding and self-knowledge; we can alter our attitudes and our irrational and grim unconscious beliefs; we can become more self-confident and less plagued with anxiety; we can become more forgiving and self-accepting and less self-castigating; and so on.
Furthermore, many of these outcomes may follow a renewed struggle with developmental issues which were left unresolved. However, all these changes are age-appropriate ones that occur in the lives of adults. The fate of borderline patients. The longitudinal pattern of suicidal behaviour in borderline personality disorder: A prospective follow-up study. Borderline Personality Disorder as an impulse spectrum disorder. Serotonergic studies in patients with affective and personality disorders. Correlates with suicidal and impulsive aggressive behavior. Prospective studies of outcome.
DEVELOPMENTAL DEFECT VERSUS DYNAMIC CONFLICT
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Alprazolam, carbamazepine, trifluoperazine and tranylcypromine.
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