Contemporary practitioners are besieged with suffering people who need intensive, long-term care (Can anyone convincingly argue that psychopathology is decreasing in the context of contemporary social, political, economic, and technological changes?). They may be expected to see patients every 2 weeks, or even less frequently, and to carry caseloads so large that genuine connection with and concern for one’s individual clients is impossible.

An indirect source of the widespread contemporary devaluation of the psychoanalytic tradition may be the expanding gulf between academics and therapists. Some degree of tension between these two groups has always existed, largely because of the different sensibilities of the individuals attracted to one role or the other.

the paucity of randomized controlled trials of open-ended psychodynamic therapy has cost us dearly. In addition, the arrogance of many analysts in the heyday of psychoanalysis, especially their belief that what they experienced with each patient was too idiosyncratic to be researchable, contributed to negative stereotypes held by nonclinical colleagues.

The increasing shaping of clinical psychology into a positivist “science,” the cost-containment efforts by insurance companies, the economic interests of the pharmaceutical industry, and the dismissive reaction of some analysts to outcome research of any kind have generated the “perfect storm” leading to the devaluation of psychodynamic psychology and psychotherapy.

pertinent material will eventually surface.

A bulimic woman who develops her eating disorder as a first-year college student and who recognizes her behavior as driven and self-destructive is a very different patient from a woman who has had binge–purge cycles since elementary school and who considers her behavior reasonable. Both would meet the DSM criteria for bulimia, but one could reasonably expect the first client to change her behavior within a few weeks, while a realistic goal for the second would be that after a year or so she would clearly see the costs of her eating disorder and the need for change.

My patients who are therapists themselves often express brutal self-criticism about their “lack of empathy” when they are having a hostile or frightened reaction to a client. They wish they did not feel such disturbing affects; it is unpleasant to acknowledge that therapeutic work can include primitive levels of hatred and misery that no one warned us about when we decided to go into the business of helping people. Clinicians in this condition may be actually suffering from high rather than low levels of empathy, for if they are really feeling with a patient, they are feeling his or her hostility, terror, misery, and other wretched states of mind. Affects of people in therapy can be intensely negative, and they induce in others anything but a warm response. That one should try not to act on the basis of such emotional reactions is obvious even to a completely untrained person. What is less obvious is that such reactions are of great value. They may be critical to making a diagnosis that allows one to find a way to address a client’s unhappiness that will be received as genuinely tuned in rather than as rote compassion, professionally dispensed regardless of the unique identity of the person in the other chair.

Someone who strikes an interviewer as manipulative, for example, may have, among other possibilities, an essentially hysterical character or a psychopathic personality. A therapeutic response would depend on the clinician’s hypothesis. With a hysterically organized person, one might help by commenting on the client’s feelings of fear and powerlessness. With the psychopathic person, one might instead convey a wry appreciation for the client’s skills as a con artist. If the therapist has not gone beyond the “manipulative” label to a deeper inference, it is unlikely that he or she will be able to offer the client any deep hope of being understood. If one overgeneralizes—seeing all manipulative clients as hysterics, or, alternatively, as psychopaths—one will make therapeutic contact only part of the time.

Another instance of the value of diagnosis in enabling the therapist to convey empathy involves the common situation of a patient with a borderline personality organization contacting an emergency service with a threat of suicide. Emergency mental health workers are ordinarily trained in a generic crisis-intervention model (ask about the plan, the means, and their lethality), and that model usually serves them well. Yet people with borderline psychologies tend to talk suicide not when they want to die but when they are feeling what Masterson (1976) aptly called “abandonment depression.” They need to counteract their panic and despair with the sense that someone cares about how bad they feel. Often, they learned growing up that no one pays attention to your feelings unless you are threatening mayhem.

People are more comfortable when they sense that their interviewer is at ease. A therapeutic relationship is likely to get off to a good start if the client feels the clinician’s curiosity, relative lack of anxiety, and conviction that the appropriate treatment can begin once the patient is better understood.

Therapists may underestimate the importance of this settling-in process, during which they may learn things that will become hard for the patient to expose later in treatment. Most adults can answer questions about their sexual practices or eating patterns or substance use with relative frankness when talking to someone who is still a stranger, but once the therapist has started to feel familiar and intimate (perhaps like one’s mother) the words flow anything but easily. When a parental transference has heated up, the client may be encouraged to push on by remembering that in an early meeting with this person whose condemnation is now feared, all kinds of intimate matters were shared without incurring shock or disapproval.

Once borderline clients start to have real hope of change, they often panic and flirt with suicide in an effort to protect themselves from the devastation they would feel if they let themselves hope and then were traumatically disappointed.

If one knows that one’s depressed patient has a borderline rather than a neurotic-level personality structure, one will not be surprised if during the second year of treatment he or she makes a suicide gesture. Once borderline clients start to have real hope of change, they often panic and flirt with suicide in an effort to protect themselves from the devastation they would feel if they let themselves hope and then were traumatically disappointed.

I have seen many gifted, devoted therapists lose confidence and find rationalizations for getting rid of an ostensibly suicidal patient at precisely the moment when the person is expressing, in an identifiably provocative borderline way, how important and effective the treatment is becoming. Typically, in the session preceding the suicide gesture the patient expressed trust or hope for the first time, and the therapist became excited after so much arduous work with a difficult, oppositional client. Then with the parasuicidal behavior the therapist’s own hopes crumble.

Therapists, whose personalities are often rather depressive (Hyde, 2009), are quick to turn any apparent setback into self-censure.

that careful assessment is most important at two points: (1) at the beginning of treatment, for the reasons given above; and (2) at times of crisis or stalemate, when a rethinking of the kind of dynamics I face may hold the key to effective changes in focus. Once I have a good feel for a person, and the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client. If I find myself preoccupied with issues of diagnosis in an ongoing way, I suspect myself of defending against being fully present with the patient’s pain. Diagnosis can, like anything else, be used as a defense against anxiety about the unknown.

people exist for whom the existing developmental and typological categories of personality are at best a poor fit. When any label obscures more than it illuminates, the practitioner is better off discarding it and relying on common sense and human decency, like the lost sailor who throws away a useless navigational chart and reverts to orienting by a few familiar stars. And even when a diagnostic formulation is a good match to a particular patient, there are such wide disparities among people on dimensions other than their level of organization and defensive style that empathy and healing may be best pursued via attunement to some of these.

Diagnosis should not be applied beyond its usefulness. Ongoing willingness to reassess one’s initial diagnosis in the light of new information is part of being optimally therapeutic.

My favorite book on interviewing, mostly because of its tone, remains Harry Stack Sullivan’s The Psychiatric Interview (1954). Another classic work that is full of useful background and wise technical recommendations is The Initial Interview in Psychiatric Practice by Gill, Newman, and Redlich (1954).

Babies, and therefore the infantile aspects of self that live on in adults, were seen as uninhibited seekers of instinctual gratification, with some individual differences in the strength of the drives.

Drive theory postulated that if a child is either overfrustrated or overgratified at an early psychosexual stage (as per the interaction of the child’s constitutional endowment and the parents’ responsiveness), he or she would become “fixated” on the issues of that stage.

The id is entirely unconscious. Its existence and power can, however, be inferred from derivatives, such as thoughts, acts, and emotions. In Freud’s time, it was a common cultural conceit that modern, civilized human beings were rationally motivated creatures who had moved beyond the sensibilities of the “lesser” animals and of non-Western “savages.” (Freud’s emphasis on our animality, including the dominance of sex as a motivator, was one reason for the degree of resistance his ideas provoked in the post-Victorian era.)

The Freudian ego operates according to the reality principle and is the seedbed of sequential, logical, reality-oriented cognition or “secondary process” thought. It thus mediates between the demands of the id and the constraints of reality and ethics. It has both conscious and unconscious aspects. The conscious ones are similar to what most of us mean when we use the term “self” or “I,” while the unconscious aspects include defensive processes like repression, displacement, rationalization, and sublimation.

With the structural theory, analytic therapists had a new language for making sense of some kinds of character pathology; namely, that we all develop ego defenses that are adaptive within our particular childhood setting but that may turn out to be maladaptive later in the larger world.

“therapeutic split in the ego” (Sterba, 1934) was seen as a necessary condition of effective therapy. If the patient is unable to talk from an observing position about less rational, more “gut-level” emotional reactions, the first task of the therapist is to help the patient develop that capacity.

Another clinical contribution of the ego psychology movement was the conclusion that psychological health involves not only having mature defenses but also being able to use a variety of defenses (cf. D. Shapiro, 1965).

(Note that Freud wrote in simple, non-jargon-laden language: Id, ego, and superego translate as “it,” “me,” and “above me,” respectively [see Bettelheim, 1983].

Freud believed that the superego was formed mainly during the oedipal period, through identification with parental values, but most contemporary analysts regard it as originating much earlier, in primitive infantile notions of good and bad.

The superego is, like the ego from which it arises, partly conscious and partly unconscious. Again, the assessment of whether an inappropriately punitive superego is experienced by the patient as ego alien or ego syntonic was eventually understood to have important prognostic implications. The client who announces that she is evil because she has had bad thoughts about her father has a significantly different psychology from the one who reports that a part of her seems to feel she is evil when she entertains such thoughts. Both may be depressive, self-attacking people, but the magnitude of the first woman’s problem is so much greater than that of the second that it was considered to warrant a different level of classification.

Psychoanalysis as a movement—and Freud as a person—was emphatically not hedonistic, but the taming of tyrannical superegos was one of its frequent goals.

We were learning that efforts to expose the operations of the id, to bring a person’s unconscious life into the light of day, have little therapeutic benefit if the patient regards such illumination as exposing his or her personal depravity.

Sigmund Freud’s original ideas had included the notion that anxious reactions are caused by defenses, most notably repression (unconsciously motivated forgetting). Bottled-up feelings were seen as tensions that press for discharge, tensions that are experienced as anxiety. When Freud made the shift to the structural theory, he reversed himself, deciding that repression is a response to anxiety, and that it is only one of several ways human beings try to avoid an unbearable degree of irrational fear. He began construing psychopathology as a state in which a defensive effort has not worked, where the anxiety is felt in spite of one’s habitual means of warding it off, or where the behavior that masks the anxiety is self-destructive.

W. R. D. Fairbairn (e.g., 1954), for example, rejected Freud’s biologism outright, proposing that people do not seek drive satisfaction so much as they seek relationships. In other words, a baby is not so much focused on getting mother’s milk as it is on having the experience of being nursed, with the sense of warmth and attachment that goes with that experience.

Psychoanalysts influenced by Sandor Ferenczi (such as Michael and Alice Balint, sometimes referred to as belonging to the “Hungarian School” of psychoanalysis) pursued the study of primary experiences of love, loneliness, creativity, and integrity of self that do not fit neatly within the confines of Freud’s structural theory. People with an object relations orientation put their emphasis not on what drive had been mishandled in a person’s childhood, or on what developmental phase had been poorly negotiated, or on what ego defenses had predominated. Rather, the emphasis was on what the main love objects in the child’s world had been like, how they had been experienced, how they and felt aspects of them had been internalized, and how internal images and representations of them live on in the unconscious lives of adults. In the object relations tradition, oedipal issues loom less large than themes of safety and agency, and separation and individuation.

The conviction that the emotional connection between therapist and client constitutes the most vital curative factor in therapy is a central tenet of contemporary analytic therapists (Blagys & Hilsenroth, 2000). It is also supported by considerable empirical work on psychotherapy outcome (Norcross, 2002; Strupp, 1989; Wampold, 2001; Zuroff & Blatt, 2006) and seems to apply to nonpsychodynamic as well as psychodynamic therapies (Shedler, 2010).

Freud had regarded strong emotional reactions to patients as evidence of the analyst’s incomplete self-knowledge and inability to maintain a benign, physicianly attitude toward the other person in the room. In gradual contrast to this appealingly rational position, analysts working with psychotic clients and with those we now diagnose as borderline or traumatized or personality disordered were finding that one of their best vehicles for comprehending these overwhelmed, disorganized, desperate, tormented people was their own intense countertransferential response to them.

For example, one of my patients once seemed to be going nowhere for several sessions. I noticed that every time he mentioned someone, he would attach a sort of verbal “footnote,” such as “Marge is the secretary on the third floor that I eat lunch with on Tuesdays”—even if he had often talked about Marge before. I commented on this habit, wondering whether someone in his family had not listened to him very carefully: He seemed to assume I didn’t remember any of the main figures in his current life. He protested angrily, insisting that his parents had been very interested in him—especially his mother. He then commenced a long defense of her, during which I began, without really noticing it, to get very bored. Suddenly, I realized I had not heard a thing he had said for several minutes. I was off in a daydream about how I would present my work with him as a case study to some eminent colleagues, and how my account of this treatment would impress them with my skill. As I pulled myself out of this narcissistic reverie and started listening again, I was fascinated to hear that he was saying, in the context of defending his mother against the charge of lack of attentiveness, that every time he was in a play in elementary school, she would make the most elaborate costume of any mother in the grade, would rehearse every line of dialogue with him over and over, and would sit in the front row on the day of the performance, radiating pride. In my fantasy, I had become startlingly like the mother of his childhood years, interested in him mainly as an enhancer of my own reputation.

The transformation of countertransference from obstacle to asset is one of the most critical contributions of object relations theory (see Ehrenberg, 1992; Maroda, 1991).

Defenses were reconceptualized as existing not only to protect a person from anxiety about id, ego, and superego dangers but also to sustain a consistent, positively valued sense of self (Goldberg, 1990b).

People become organized on dimensions that have significance for them, and they typically show characteristics expressing both polarities of any salient dimension. Philip Slater (1970) captured this idea succinctly in a footnote commentary on modern literary criticism and biography:   Generations of humanists have excited themselves and their readers by showing “contradictions” and “paradoxes” in some real or fictional person’s character, simply because a trait and its opposite coexisted in the same person. But in fact traits and their opposites always coexist if the traits are of any intensity, and the whole tradition of cleverly ferreting out paradoxes of character depends upon the psychological naiveté of the reader for its impact. (pp. 3n–4n)   Thus, people with conflicts about closeness can get upset by both closeness and distance. People who crave success the most hungrily are often the ones who sabotage it the most recklessly. The manic person is psychologically more similar to the depressive than to the schizoid individual; a compulsively promiscuous man has more in common with someone who resolved a sexual conflict by celibacy than with someone for whom sexuality is not problematic. People are complicated, but their intricacies are not random. Analytic theories offer us ways of helping our clients to make sense out of seemingly inexplicable ironies and absurdities in their lives, and to transform their vulnerabilites into strengths.

For self psychological sources, Kohut’s The Analysis of the Self (1971) is almost impenetrable to beginners, but The Restoration of the Self (1977) is easier going.

Morris Eagle (2011) has recently published a brilliant historical review and critique of evolving psychoanalytic theory.

For coverage of empirical contributions to psychoanalytic personality theory, there are several excellent reviews in the Psychodynamic Diagnostic Manual (PDM Task Force, 2006). Morris Eagle (2011) has recently published a brilliant historical review and critique of evolving psychoanalytic theory. For a vivid exposure to how a practicing analyst applies theory (especially Winnicott, Lacan, and Klein) to practice, read Deborah Luepnitz’s (2002) account of five cases in Schopenhauer’s Porcupines, a gem of a book that is as absorbing as a good novel.

When Freud developed the structural model of the mind, this distinction took on the quality of a comment on a person’s psychological infrastructure: Neurotic people were viewed as suffering because their ego defenses were too automatic and inflexible, cutting them off from id energies that could be put to creative use; psychotic ones suffered because their ego defenses were too weak, leaving them helplessly overwhelmed by primitive material from the id. The neurotic-versus-psychotic distinction had important clinical implications. The gist of these, considered in light of Freud’s structural model, was that therapy with a neurotic person should involve weakening the defenses and getting access to the id so that its energies may be released for more constructive activity. In contrast, therapy with a psychotic person should aim at strengthening defenses, covering over primitive preoccupations, influencing realistically stressful circumstances so that they are less upsetting, encouraging reality testing, and pushing the bubbling id back into unconsciousness.

Trying too quickly to take on what the therapist sees as obvious problems may damage the alliance and impede the process of change.

With some patients, this process of building an alliance can take more than a year. Trying too quickly to take on what the therapist sees as obvious problems may damage the alliance and impede the process of change.

Freud’s contention that the proper goal of therapy is the removal of inhibitions against love and work applies to this group; some neurotic-level people are also looking to expand their capacity for solitude and play.

They are deeply confused about who they are, and they usually struggle with such basic issues of self-definition as body concept, age, gender, and sexual orientation. “How do I know who I am?” or even “How do I know that I exist?” are not uncommon questions for psychotically organized people to ask in earnest. They cannot depend on a sense of continuity of identity in themselves and do not experience others as having continuity of self either: They live in fear of “malevolent transformations” (Sullivan, 1953) that will turn a trusted person abruptly into a sadistic persecutor. When asked to describe themselves or other important people in their lives, they tend to be vague, tangential, concrete, or observably distorting.

People with psychotic tendencies have trouble getting perspective on their psychological problems. They lack the “reflective functioning” that Fonagy and Target (1996) have identified as critical to cognitive maturation.

The critical thing for therapists to appreciate is that close to the surface in people with psychotic-level psychologies, one finds both mortal fear and dire confusion. The nature of the primary conflict in people with a potential for psychosis is literally existential: life versus death, existence versus obliteration, safety versus terror. Their dreams are full of stark images of death and destruction. “To be or not to be” is their recurrent theme.

The downside of these patients’ poignant dependence on our care is the burden of psychological responsibility they inevitably impose. In fact, the countertransference with psychotic-level people is remarkably like normal maternal feelings toward infants under a year and a half: They are wonderful in their attachment and terrifying in their needs. They are not yet oppositional and irritating, but they also tax one’s resources to the limit. I should not work with a schizophrenic, a supervisor once told me, unless I was prepared to be eaten alive.

This “consuming” feature of their psychology is one reason that many therapists prefer not to work with individuals with schizophrenia and other psychoses. In addition, as Karon (1992) has noted, the access of psychotic patients to deeply upsetting realities that the rest of us would prefer to ignore is often too much for us. In particular, they see our flaws and limitations with stunning clarity.

One of the most striking features of people with borderline personality organization is their use of primitive defenses. Because they rely on such archaic and global operations as denial, projective identification, and splitting, when they are regressed they can be hard to distinguish from psychotic patients. An important difference between borderline and psychotic people, though, is that when a therapist confronts a borderline patient on using a primitive mode of experiencing, the patient will show at least a temporary responsiveness. When the therapist makes a similar comment to a psychotically organized person, he or she will likely become further agitated.

Devaluation is an unconscious strategy that is often intended to preserve self-esteem, but which does so at the expense of learning. An effort to address that defense might go something like “You certainly love to cherish all my defects. Maybe that protects you from admitting that you might need my help. Perhaps you would be feeling ‘one down’ or ashamed if you weren’t always putting me down, and you’re trying to avoid that feeling.” A borderline patient might scorn such an interpretation, or grudgingly admit it, or receive it silently, but in any event, he or she would give some indications of reduced anxiety. A psychotic person would react with increased anxiety, since to someone in existential terror, devaluation of the power of the therapist may be the only psychological means by which he or she feels protected from obliteration. The therapist’s discussing it as if it were optional would be extremely frightening.

In nonregressed states, because their reality testing is fine and because they may present themselves in ways that compel our empathy, they do not look particularly “sick.” Sometimes it is only after therapy has proceeded for a while that one realizes that a given patient has a borderline structure. Usually the first clue is that interventions that the therapist intends to be helpful are received as attacks. In other words, the therapist keeps assuming a capacity for reflective functioning that the patient mostly lacks. (In older language, the therapist is trying to talk with an observing ego, something the client cannot access, especially when upset.)

Masterson saw borderline patients as fixated at the rapprochement subphase of the separation–individuation process (Mahler, 1972b), when the child has attained some autonomy yet still needs reassurance that a caregiver remains available and powerful. This drama unfolds around age 2, when children typically alternate between rejecting mother’s help (“I can do it myself!”) and dissolving in tears at her knees. Masterson (1976) believed that borderline patients have had mothers who discouraged them from separating in the first place or neglected them when they needed to regress after attaining some independence.

With a neurotic-level person in a paranoid state, it may be enough to interpret the transference, that is, to comment on how the patient is mixing one up with some negative person from the past or some projected negative part of the self. Interpretation of this sort is useless with severely disturbed people; in fact, they are likely to consider it a diabolical evasion.

Take irritation, for example. It is natural for the therapist to feel irritated with any patient at various points, especially when the person seems to be behaving self-destructively. A perception that one’s therapist looks annoyed would be upsetting to any client, but it is mortally terrifying to more deeply troubled ones. If a neurotic-level person asks, “Are you mad at me?” one helpful response would be something along the lines of “What are your thoughts and feelings about what it would mean if I were mad at you?” If the same query is made by a potentially psychotic patient, the therapeutic reply might be “You’re very perceptive. I guess I am feeling a little irritation. I’m a bit frustrated that I can’t seem to help you as fast as I would like. What was your reason for asking?”

My own style with most psychotic-level people is quite self-disclosing. I have been known to talk about my family, my personal history, my opinions—anything to put the person at ease with me as an ordinary human being. Such an approach is controversial; not every therapist is temperamentally comfortable with exposure. It also has certain hazards, not the least of which is that some aspect of the therapist’s revealed person will incite a psychotic response in the patient. My rationale lies in the contrast between symbiotically organized people and more individuated ones. The former have such total, encompassing transferences that they can only learn about their distortions of reality when reality is painted in stark colors in front of them, whereas the latter have subtle and unconscious transferences that may surface only when the therapist is more opaque.

In many vulnerable people, feelings are not so much unconscious as they are fundamentally unformulated (D. B. Stern, 1997).

This kind of active, educative stance is vital to the emotional equilibrium of a psychotically anxious person because it mitigates the terror that he or she harbors about going crazy. It also welcomes the client into a world of greater psychological complexity and implicitly invites him or her to “join the human race.”

Often, the source of the distress is only peripherally related to the topic of the rant; it may be, for example, some life circumstance involving a separation (the client’s child is entering kindergarten, or a brother announced his engagement, or the therapist mentioned vacation plans). Then one empathizes actively with how disconcerting separations can be.

By definition, the borderline client lacks an integrated observing ego that sees things more or less as the therapist does; instead, he or she is subject to shifting chaotically between different ego states, with no capacity yet for putting disparate attitudes together.

therapist. By definition, the borderline client lacks an integrated observing ego that sees things more or less as the therapist does; instead, he or she is subject to shifting chaotically between different ego states, with no capacity yet for putting disparate attitudes together. Whereas the psychotic person tends to fuse psychologically with the clinician and the neurotic one to keep a clear separate identity, the borderline person alternates—confusingly to self and others—between symbiotic attachment and hostile, isolated separateness.

By definition, the borderline client lacks an integrated observing ego that sees things more or less as the therapist does; instead, he or she is subject to shifting chaotically between different ego states, with no capacity yet for putting disparate attitudes together. Whereas the psychotic person tends to fuse psychologically with the clinician and the neurotic one to keep a clear separate identity, the borderline person alternates—confusingly to self and others—between symbiotic attachment and hostile, isolated separateness.

When borderline patients could tell me off about my rigid, selfish rules, I noticed that they did a lot better than when I was trying to put them into a state of gratitude for my generosity—an inherently infantilizing position.

Therapists new to work with borderline patients often wonder when all the preconditions of therapy will finally be worked out, a working alliance created, and the actual therapy begun. It may be painful to realize that all the work with the conditions of treatment is the therapy. The beginner wonders when the borderline patient will “calm down.” The intensity of borderline patients will characterize the work throughout, and it is critical that the therapist be able to tolerate or “contain” that intensity, even when it involves verbal attacks on the therapist (Bion, 1962; Charles, 2004). Once a neurotic-type alliance is achieved, the patient by definition will have taken a giant step developmentally.

One way around this problem is to appreciate that the borderline client lacks the reflective capacity to process an interpretation as additional information about the self, and that consequently one must provide that function within the interpretation.

appreciate that the borderline client lacks the reflective capacity to process an interpretation as additional information about the self, and that consequently one must provide that function within the interpretation. So one would have a better chance of being heard as empathic if one said, “I can see how much Mary means to you. Is it possible, though, that there is also a part of you—a part that you would not act upon of course—that would like to get rid of her because she’s in some ways in competition with you?” Or, “You certainly have established that you have a very independent, self-reliant streak. It’s interesting that it seems to coexist with some opposite tendencies, like a sensitivity to what I think of you.” Such interventions lack the punch and beauty of an economy of words, but given the particular psychological problems of borderline people, they are much more likely than more trenchant formulations to be taken in as intended.

The kind of interpretation that may reach a borderline person in such a predicament is something like “You seem to have a conviction that you are bad. You’re angry about that, and you’re handling that anger by saying that I am the one who is bad, and that it’s my anger that causes yours. Could you imagine that both you and I could be some combination of good and bad and that that wouldn’t have to be such a big deal?”

It is important in such interventions to talk from the perspective of one’s one own motives rather than the patient’s inferred motives. The value of “I-statements” is as great here as when one argues with a lover or friend. There is a huge difference between being on the receiving end of “You’re putting me in a bind” or “You’re setting it up so that whatever I do is wrong” and hearing “I’m trying to do right by you as your therapist, and I find myself feeling in a bind. I worry that if I do X, I’ll be unhelpful in one direction, and if I do Y, I’ll disappoint you in another.”

People with borderline psychologies need empathy as much as anyone else, but their mood changes and ego-state fluctuations make it hard for clinicians to know how and when to convey it. Because they tend to evoke loving countertransferences when they are depressed or frightened, and hateful ones when they act antagonistically, one may find oneself inadvertently rewarding them for regression and punishing them for individuation.

Because separateness is eventually empowering, Masterson urged therapists to behave with borderline patients conversely from the way their mothers purportedly had; namely, to confront regressive and self-destructive behaviors actively (e.g., “Why would you want to pick up men at bars?”) and to endorse empathically any efforts toward autonomy and competence (e.g., “I’m glad to see you can tell me off when I make you angry”). He advised us not to reward the clinging that gives the patient no basis for self-esteem, and to take pains to see the forward-moving, adaptive elements in even aggravating manifestations of self-assertion.

provoked by a patient’s incursions on our equanimity.

Decades of clinical work suggests that countertransference, like transference, is a mixture of internally generated and externally stimulated material, sometimes weighted more in one direction, sometimes more in the other (Gill, 1983; Jacobs, 1991; Roland, 1981; Sandler, 1976; Tansey & Burke, 1989). In our therapeutic role we should be insightful about our own dynamics and take responsibility for our reactions, even when they are being provoked by a patient’s incursions on our equanimity.

For example, a paranoid man, in treatment with a young woman, is in a state of self-righteous indignation about mistreatment by some authority. The therapist notices that she feels weak, small, fearful of the patient’s criticism, and distracted by fantasies of being attacked. She should consider the possibility that what she is feeling is a split-off, disowned part of the patient that is being projected into her in an almost physical way. If that idea seems reasonable after some reflection, it may be therapeutic (to both parties!) for her to say something like “I know that you are in touch with feeling angry and energized, but I think there may also be a part of you that feels weak, anxious, and fearful of being attacked.”

When one suddenly feels bored, or in a rage, or panicky, or overwhelmed with the wish to rescue, or diverted by sexual images, something is probably going on that says something important about the client’s internal state. For example, a paranoid man, in treatment with a young woman, is in a state of self-righteous indignation about mistreatment by some authority. The therapist notices that she feels weak, small, fearful of the patient’s criticism, and distracted by fantasies of being attacked. She should consider the possibility that what she is feeling is a split-off, disowned part of the patient that is being projected into her in an almost physical way. If that idea seems reasonable after some reflection, it may be therapeutic (to both parties!) for her to say something like “I know that you are in touch with feeling angry and energized, but I think there may also be a part of you that feels weak, anxious, and fearful of being attacked.”

It might help her to contain defensive reactions, an achievement not to be disdained, but it would not guide the therapist toward what she could actively do to help the patient. The worst thing that can happen if we mistake our own feelings for a client’s is that we will be wrong, and if interpretations are made in a tone of hypothesis rather than pronouncement, the patient will be glad to point out our errors.

I have learned that it is not helpful to say, as if one could be dispassionate, “So tell me about your fantasies about my reaction,” as one might with a neurotic-level person who had acted out and feared disapproval. Instead, it is better to say something like “Well, you know it’s my job to try to help you be less self-destructive, so when I hear that you’ve been more self-destructive, it does get to me. What’s it like for you when I get irritated at your behavior?” As Karen Maroda (1999) has emphasized, it does not usually close the patient down when the therapist is able to show some emotion—especially borderline patients, who know they are difficult.

But in treatment, it is important to remember the psychological equivalent of the Heisenberg principle: When we are observing something, we are part of what is being observed.

when he first encountered the most dramatic and memorable examples of processes that we now call defenses (repression, conversion, dissociation) he saw them when they were operating in their defensive function. The emotionally damaged, predominantly hysterical people he first became fascinated by were trying to avoid reexperiencing what they feared would be unbearable pain. They were doing so, Freud observed, at a high cost to their overall functioning. Ultimately it would be better for them to feel fully the overwhelming emotions they were afraid of, thereby liberating their energies for getting on with their lives. Thus, the earliest context in which the defenses were talked about was one in which the doctor’s task was to diminish their power.

The person using a defense is generally trying unconsciously to accomplish one or both of the following: (1) the avoidance or management of some powerful, threatening feeling, usually anxiety but sometimes overwhelming grief, shame, envy, and other disorganizing emotional experiences; and (2) the maintenance of self-esteem.

Psychoanalysts assume, although this is seldom explicitly stated, that we all have preferred defenses that have become integral to our individual styles of coping. This preferential and automatic reliance on a particular defense or set of defenses is the result of a complex interaction among at least four factors: (1) one’s constitutional temperament, (2) the nature of the stresses that one suffered in early childhood, (3) the defenses modeled—and sometimes explicitly taught—by parents and other significant figures, and (4) the experienced consequences of using particular defenses (in the language of learning theory, reinforcement effects).

Defenses have been extensively researched. Phoebe Cramer (2008) has reviewed empirical findings supporting seven core psychoanalytic observations; namely, that defenses (1) function outside of awareness; (2) develop in predictable order as children mature; (3) are present in normal personality; (4) become increasingly used in times of stress; (5) reduce the conscious experience of negative emotions; (6) operate via the autonomic nervous system; and (7) when used excessively, are associated with psychopathology.

Ever since Kernberg (e.g., 1976) called attention to borderline clients’ use of archaic forms of projection and introjection (a precursor of identification), however, many therapists have followed him in identifying the following defenses as intrinsically “primitive”: withdrawal, denial, omnipotent control, primitive idealization and devaluation, projective and introjective identification, and splitting.

The so-called primitive defenses are ways we believe the infant naturally perceives the world. These ways of experiencing live on in all of us, whether or not we have significant psychopathology; we all deny, we all split, we all have omnipotent strivings.

It is the absence of mature defenses, not the presence of primitive ones, that characterizes borderline or psychotic structure.

On the healthier end of the schizoid scale, one finds people of remarkable creativity: artists, writers, theoretical scientists, philosophers, religious mystics, and other highly talented onlookers whose capacity to stand aside from ordinary convention gives them a unique capacity for original commentary.

The obvious disadvantage of withdrawal is that it removes the person from active participation in interpersonal problem solving. People with schizoid partners are frequently at a loss as to how to get them to show some kind of emotional responsiveness. “He just fiddles with the TV remote control and refuses to answer me” is a typical complaint

Most of us occasionally use denial, with the worthy aim of making life less unpleasant, and many people use it frequently in dealing with specific stresses. A person whose feelings get hurt in situations in which it is inappropriate or unwise to cry is more likely to deny the hurt feelings than to acknowledge them fully and inhibit the crying response consciously.

the defense of reaction formation, in which an emotion is turned into its opposite (e.g., hatred into love), constitutes a specific and more complex type of denial of the feeling being defended against than a simple refusal to feel that emotion.

The clearest example of psychopathology defined by the use of denial is mania. In manic states, people may deny to an astonishing degree their physical limitations, their need for sleep, their financial exigencies, their personal weaknesses, even their mortality.

He noted that at the infantile stage of primary omnipotence or grandiosity, the fantasy that one controls the world is normal; that this naturally shifts, as the child matures, to a phase of secondary or derived omnipotence in which one or more caregivers are believed to be all-powerful; and that eventually, the maturing child comes to terms with the unattractive fact that no one’s potency is unlimited.

many people who rarely break the law have personalities driven by the defense of omnipotent control, as in the corporate “snakes in suits” described by Babiak and Hare (2007). They use conscious manipulation as a primary way of avoiding anxiety and maintaining self-esteem.

“Getting over on” others is a central preoccupation and pleasure of individuals whose personalities are dominated by omnipotent control (Bursten, 1973a). Such people are common in enterprises that require guile, a love of stimulation or danger, and a willingness to subordinate other concerns to the central objective of making one’s influence felt. They can be found in leadership roles in business, in politics, in covert operations, among cult leaders and evangelists, in the advertising and entertainment industries, and in other walks of life where the potential to wield raw power is high.

Normal idealization is an essential component of mature love (Bergmann, 1987). And the developing tendency over time to deidealize or devalue those to whom we have childhood attachments seems to be a normal and important part of the separation–individuation process.

the more dependent one is or feels, the greater the temptation to idealize.

Some people spend their lives running from one intimate relationship to the next, in recurrent cycles of idealization and disillusionment, trading the current partner in for a new model every time he or she turns out to be a human being.

Projection is the process whereby what is inside is misunderstood as coming from outside. In its benign and mature forms, it is the basis for empathy. Since no one is ever able to get inside the mind of another person, we must use our capacity to project our own experience in order to understand someone else’s subjective world.

others). A person who uses projection as his or her main way of understanding the world and coping with life, and who denies or disavows what is being projected, can be said to have a paranoid character.

A person who uses projection as his or her main way of understanding the world and coping with life, and who denies or disavows what is being projected, can be said to have a paranoid character.

Introjection is the process whereby what is outside is misunderstood as coming from inside.

In its problematic forms, introjection can, like projection, be highly destructive. The most striking examples of pathological introjection involve the process that has been labeled, somewhat inappropriately in view of its primitivity, “identification with the aggressor” (A. Freud, 1936). It is well known, from both naturalistic observations (e.g., Bettelheim, 1960) and empirical research (e.g., Milgram, 1963), that under conditions of fear or abuse, people will try to master their fright and pain by taking on qualities of their abusers. “I’m not the helpless victim; I’m the powerful perpetrator” seems to be the unconscious attraction to this defense.

Introjection is also implicated in some kinds of depressive psychology (Blatt, 1974, 2004). When we are deeply attached to people, we introject them, and their representations inside us become a part of our identity (“I am Tom’s son, Mary’s husband, Sue’s father, Dan’s friend,” etc.). If we lose someone whose image we have internalized, whether by death, separation, or rejection, not only do we feel that our environment is poorer for that person’s absence in our lives but we also feel that we are somehow diminished, that a part of our self has died. An emptiness or sense of void comes to dominate our inner world. We may also, in an effort to feel some sense of power rather than helpless loss, become preoccupied with the question of what failure or sin of ours drove the person away. The critical, attacking voice of a lost object can live on in us as a way of keeping that person internally alive.

If one regularly uses introjection to reduce anxiety and maintain continuity in the self, keeping psychological ties to unrewarding objects of one’s earlier life, one can reasonably be considered characterologically depressive.

Similarly, children in destructive families prefer to believe there is something wrong with them (preserving hope that by changing, they can improve their lot), than to take in the terrifying fact that they are dependent on negligent or abusive caregivers. Fairbairn (1943) called this process the “moral defense,” noting that it is “better to be a sinner in a world ruled by God than to live in a world ruled by the Devil” (pp. 66–67). If one regularly uses introjection to reduce anxiety and maintain continuity in the self, keeping psychological ties to unrewarding objects of one’s earlier life, one can reasonably be considered characterologically depressive.

Ogden (1982):   In projective identification, not only does the patient view the therapist in a distorted way that is determined by the patient’s past object relations; in addition, pressure is exerted on the therapist to experience himself in a way that is congruent with the patient’s unconscious fantasy.

Kernberg (1975) has described this aspect of projective identification as “maintaining empathy” with what has been projected.

Somatization is what analysts have called the process by which emotional states become expressed physically.

Analysts in the relational movement emphasize that enactments are inevitable in therapy, as the unconscious worlds of both patient and therapist create mutually enacted dynamics, which the therapist is responsible to turn into speech and reflection.

“Acting out” or “enactment” thus properly refers to any behavior that is assumed to be an expression of transference attitudes that the patient does not yet feel safe enough, or emotionally articulate enough, to bring into treatment in words.

People may sexualize any experience with the unconscious intention of converting terror or pain or other overwhelming sensation into excitement—a process that has also been referred to as instinctualization.

In 1994 I wrote that dissociation seemed different from the other lower-order defenses because it is so clearly a response to severe trauma, from which many of us are thankfully spared while growing up (the other processes, in contrast, represent normal modes of operating that become problematic only if one hangs onto them too long or to the exclusion of other ways of dealing with reality).

One must have attained a sense of the wholeness and continuity of the self before one is capable of handling disturbing impulses by repression. For people whose early experiences did not foster identity integration, troublesome feelings tend to be handled with more primitive defenses, such as denial, projection, and splitting (Myerson, 1991).

repression becomes problematic only when it (1) fails to do its job of keeping disturbing ideas out of consciousness so that we can go about the business of accommodating to reality, or (2) gets in the way of certain positive aspects of living, or (3) operates to the exclusion of other more successful ways of coping.

This process, labeled by Mowrer (1950) the “neurotic paradox,” whereby attempts to quell one anxiety only generate others, is the core characteristic of what was once (in a much more comprehensive use of the term than is typical now) called neurosis.

Regression is a relatively uncomplicated defense mechanism, familiar to every parent who has watched a child slide backward into the habits of a prior maturational stage when tired or hungry.

Intellectualization handles ordinary emotional overload in the same way that isolation handles traumatic overstimulation.

Thus, the parent who hits a child rationalizes aggression by allegedly doing it for the youngster’s “own good”; the therapist who insensitively raises a patient’s fee rationalizes greed by deciding that paying more will benefit the person’s self-esteem; the serial dieter rationalizes vanity with an appeal to health.

People rarely admit to doing something just because it feels good; they prefer to surround their decisions with good reasons. Thus, the parent who hits a child rationalizes aggression by allegedly doing it for the youngster’s “own good”; the therapist who insensitively raises a patient’s fee rationalizes greed by deciding that paying more will benefit the person’s self-esteem; the serial dieter rationalizes vanity with an appeal to health.

When one is rationalizing, one unconsciously seeks cognitively acceptable grounds for one’s direction; when one is moralizing, one seeks ways to feel it is one’s duty to pursue that course. Rationalization converts what the person already wants into reasonable language; moralization puts it into the realm of the justified or morally obligatory. Where the rationalizer talks about the “learning experience” that some disappointment provided, the moralizer will insist that it “builds character.”

As for individuals on the more pathological end of the compartmentalization continuum, there are people who are great humanitarians in the public sphere yet defend the abuse of their children in the privacy of their homes.

Upon confrontation, the person using compartmentalization will rationalize the contradictions away.

“Undoing” is a term that means exactly what one would think: the unconscious effort to counterbalance some affect—usually guilt or shame—with an attitude or behavior that will magically erase it. An everyday example would be a spouse’s arriving home with a gift that is intended to compensate for last night’s temper outburst.

In describing character, which may be highly adaptive and healthy, “obsessive” applies to thinking styles; “compulsive” to acting modes of adaptation.

For children, who have no choice about where they live and who may pay a high price for offending a touchy caregiver, the defense of turning against the self can distract them from the much more upsetting fact that their well-being depends on an undependable adult (Fairbairn, 1954).

The term “displacement” refers to the redirection of a drive, emotion, preoccupation, or behavior from its initial or natural object to another because its original direction is for some reason anxiety ridden.

It is typical of reaction formation that some of the disowned affect “leaks through” the defense, such that observers can sense there is something a bit excessive or false in the conscious emotional disposition. With a preschool girl who has been displaced by a younger brother, for instance, there may be a distinct flavor of her “loving the baby to death”: hugging him too hard, singing to him too loudly, bouncing him too aggressively, and so on. Most adult older siblings have been told a story about their pinching the new baby’s cheeks until the child screamed, or offering some delicacy that was actually poisonous, or committing some similar transgression that was allegedly motivated by love.

We can hate the person we love or resent the person to whom we feel grateful; our emotional situation does not reduce to one or the other position. (Freud felt that there is one exception to universal ambivalence—the love of a mother for a male baby—but one suspects his narcissism distorted his perception.) It is a common fear that analysts delight in exposing the fact that one seems to feel x but really feels y; in fact, we take the view that while one may feel x, one also (unconsciously, perhaps) feels y. In reaction formation, one persuades the self that all that is felt is one polarity of a complex emotional response.

It is a basic psychoanalytic premise that no disposition is totally unmixed. We can hate the person we love or resent the person to whom we feel grateful; our emotional situation does not reduce to one or the other position. (Freud felt that there is one exception to universal ambivalence—the love of a mother for a male baby—but one suspects his narcissism distorted his perception.) It is a common fear that analysts delight in exposing the fact that one seems to feel x but really feels y; in fact, we take the view that while one may feel x, one also (unconsciously, perhaps) feels y. In reaction formation, one persuades the self that all that is felt is one polarity of a complex emotional response.

The term “displacement” refers to the redirection of a drive, emotion, preoccupation, or behavior from its initial or natural object to another because its original direction is for some reason anxiety ridden. The classic cartoon about the man bawled out by his boss, who goes home and yells at his wife, who in turn scolds the kids, who kick the dog is a study in displacement.

Another way that one can cope with feelings that present a psychological threat to the self is by enacting a scenario that switches one’s position from subject to object or vice versa. For example, if one feels that the yearning to be cared for by someone else is shameful or dangerous, one can vicariously satisfy one’s own dependency needs by taking care of another person and unconsciously identifying with that person’s gratification in being nurtured.

Freud (1923) was the first to suggest a distinction between nondefensive and defensive identification by differentiating what he called “anaclitic” identification (from the Greek word meaning “to lean on”) from “identification with the aggressor.” The first type he considered to be motivated by an uncomplicated wish to be like a valued person (“Mommy is generous and comforting, and I want to be just like her”). The second he regarded as an equally automatic but defensively motivated solution to the problem of feeling threatened by the power of another person (“I’m afraid of Mommy’s punishment for my hostile impulses; if I become her, her power will be inside rather than outside me”). Freud assumed that many acts of identification contain elements of both a straightforward taking in of what is loved and a defensive becoming like what is feared.

major part of the process of psychotherapy is the rethinking of old and now problematic identifications that were entered into automatically, resolved a conflict for the child at the time, and are now causing conflict in adulthood.

The yearning of adolescents to find icons to emulate in their effort to address the complex demands of looming adulthood has been noted for centuries; in fact, the dissatisfaction of contemporary teenagers with the heroes now offered by Western culture has been connected by some psychoanalytic observers with the alarming increase in adolescent suicides over recent decades (e.g., Hendin, 1975).

The capacity of human beings to identify with new love objects is probably the main vehicle through which people recover from emotional suffering, and the main means by which psychotherapy of any kind achieves change. Repeatedly, research on the treatment process finds the emotional quality of the relationship between patient and therapist to be more highly correlated with outcome than any other specifiable factors (Norcross, 2002; Strupp, 1989; Wampold, 2001, 2010).

Freud’s (e.g., 1938) repeated warning to analysts to avoid falling into the temptation to present themselves in a grandiose way as saviors, healers, or prophets to their patients remains a guiding maxim in the field;

The original idea was that sublimation was the “good” defense, the one that by definition represented a creative, healthful, socially acceptable or beneficial resolution of internal conflicts between primitive urges and inhibiting forces.

Sublimation was the label Freud (1905) originally gave to the expression of biologically based impulses (which to him included urges to suck, bite, mess, fight, copulate, look at others and be looked at by them, inflict injury, endure pain, protect the young, etc.) in a socially valuable form. For example, Freud would have said that a periodontist may be sublimating sadism; a performing artist, exhibitionism; a lawyer, the wish to kill one’s enemies.

The traditional definition of reaction formation involves this conversion of a negative into a positive affect or vice versa. The transformation of hatred into love, or longing into contempt, or envy into attraction, for example, can be inferred from many common transactions.

In contrast to a common misunderstanding that the object of psychotherapy is to rid oneself of infantile strivings, the psychoanalytic position about health and growth includes the assumption that the infantile parts of our natures remain alive throughout adulthood. We do not have the choice to divest ourselves of them; we can only handle them in better or worse ways. The goals of analytic therapy include the understanding of all aspects of the self, even the most primitive and disturbing ones, the development of compassion for oneself (and others, as one’s need to project and displace one’s previously disowned qualities lessens), and the expansion of one’s freedom to resolve old conflicts in new ways. They do not include purging the self of its loathed aspects or obliterating primitive desires. That sublimation is considered the apogee of ego development says a great deal about the basic psychoanalytic attitude toward human beings and our inherent potentials and limits, and about the implicit values informing psychoanalytic diagnosis.

Some humor clearly maximizes our capacity to tolerate psychological pain. The extreme version of this process is the “gallows humor” that has been noted for centuries as a mechanism for surviving life’s grimmest realities. Much humor is defensive in a positive way, performing welcome functions such as holding objects of fear up to ridicule, acknowledging harsh realities with a light touch, transforming pain into pleasure. A sense of humor, especially a capacity to laugh at one’s own idiosyncrasies, has long been considered a core element of mental health. The emergence of humor in a previously dour or anguished patient is often the first indication of significant internal change.

All of us have powerful childhood fears and yearnings, handle them with the best defensive strategies available at the time, and maintain these methods of coping as other demands replace the early scenarios of our lives

That is, a therapist can help a depressive client to be less destructively and intransigently depressive but cannot change that client into a hysterical or schizoid character. People maintain their “inner working models” (Fonagy, 2001): core internal scripts, conflicts, expectations, affects, and defenses. Yet with new experience and insight they may vastly expand their sense of agency and realistic self-esteem. The increased sense of freedom comes from mastery and choice in behavior that previously was automatic; the self-acceptance comes from understanding how they got their particular combination of tendencies.

Bursten’s (1973a) criterion for diagnosing a psychopathic person, that his or her organizing preoccupation is “getting over on” or consciously manipulating others, captures the essence of psychopathic psychology. Conceived this way, the diagnosis of characterological psychopathy has nothing to do with overt criminality and everything to do with internal motivation.

Early neglect, abuse, and maltreatment can affect the development of the orbitofrontal cortex, which seems to be the moral center of the brain (Damasio, 1994; Martens, 2002; Yu, 2006). Thus, the biological substrate for the high levels of affective and predatory aggression in antisocial people may not directly implicate their genetic heritage, but may still be essentially “hardwired” by the interaction of experience and genes. Antisocial personalities have low serotonin levels, of whatever origin (Coccaro, 1996), and diagnosed psychopaths have remarkably low reactivity of the autonomic nervous system (Intrator et al., 1997; Lykken, 1995), a fact that may explain their sensation-seeking and long-noted “failure to learn by experience” (Cleckley, 1941, p. 368).

The primary defense in psychopathic people is omnipotent control. They also use projective identification, dissociation, and acting out. The need to exert power takes precedence over all other aims.

Law enforcement agents are repeatedly astounded at how readily criminals will confess to homicide yet will hide lesser offenses (sexual compulsions, taking a few dollars from a murder victim’s handbag), evidently because these are seen as signs of weakness (N. Susalis, personal communication, May 7, 1993).

Early observers noted, and more recent research confirms (Robins, Tipp, & Przybeck, 1991), that many psychopathic people—those who have escaped self-destruction and incarceration—“burn out” in middle age, often becoming surprisingly upright citizens.

(I suspect that one reason psychopathy is more common in men is that females confront realistic limitation earlier: We are less physically strong; we live with the nuisance of menstruation and the danger of pregnancy; we are at greater risk of rape and physical abuse, and as primary caregivers, we are humbled by the discrepancy between our images of ideal maternal effectiveness and the emotional challenges of trying to rear civilized children.)

As long as omnipotent defenses are unthwarted by limits, a person’s motivation to develop more mature adaptations is minimal. Older adolescents and young adults of all personality types, especially healthy young men, typically have omnipotent feelings: death is far away, and the prerogatives of adulthood are at hand. Infantile grandiosity is reinforced.

Confusing amalgams of harsh discipline, overindulgence, and neglect have long been noted in the clinical literature (Abraham, 1935; Aichhorn, 1936; Akhtar, 1992; Bird, 2001; Greenacre, 1958; Redl & Wineman, 1951). Especially in the histories of violent psychopaths, one can find virtually no consistent, loving, protective influences. Weak, depressed, or masochistic mothers and explosive, inconsistent, or sadistic fathers have been linked with psychopathy, as have alcoholism and other addiction in the family.

Children who become psychopathic have often been indulged materially and deprived emotionally.

Like all character types, psychopathy can be “inherited” in that the child imitates the defensive solutions of the parents

When outside objects fail, the only object to invest in emotionally is the self and its personal power. Self-representations may be polarized between the desired condition of personal omnipotence and the feared condition of desperate weakness

Anyone whose fondest images of self reflect unrealistic notions of superiority, and who runs into evidence that he or she is only human, may attempt to restore self-esteem by exerting power.

One other feature of self-experience in the psychopathic patient that deserves mention is primitive envy, the wish to destroy that which one most desires (Klein, 1957).

Awareness that devaluing messages constitute a defense against envy is cold intellectual comfort in the face of a psychopath’s unmitigated scorn, but it helps.

The fact that these perpetrators are palpably relieved to confess to someone who wants to incarcerate them suggests that even an incorrigible felon may have a primitive sense of accountability and can gain something from a relationship.

The sadistic murderer Carl Panzram (Gaddis & Long, 1970) had a lifelong friendship with a prison guard who once showed him ordinary kindness. Rigorous tough-mindedness and rock-bottom respect seem to be a winning combination with antisocial people.

The overall aim of work with a psychopathic individual is to help the patient move toward Klein’s depressive position, in which others are seen as separate subjects worthy of concern (Kernberg, 1992). Over the course of treatment, as the psychopathic person’s omnipotent control, projective identification, domination by envy, and self-destructive activities are dispassionately examined in an atmosphere of consistency and respect, the patient will in fact change. Any shift from using words to manipulate to using them for honest self-expression is a substantial achievement, one that may occur simply through the antisocial person’s repeated exposure to someone with integrity. Any instance where the client inhibits an impulse and learns something about pride in self-control should be seen as a milestone. Since even a small movement toward human relatedness in a psychopath may prevent an immense amount of human suffering, such progress is worth every drop of sweat the practitioner secretes in its service.

The term “narcissistic” refers to people whose personalities are organized around maintaining their self-esteem by getting affirmation from outside themselves.

Many have noted that in every vain, grandiose narcissist hides a self-conscious, shame-faced child, and in every depressed and self-critical narcissist lurks a grandiose vision of what that person should or could be (Meissner, 1979; A. 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 (Cooper, 1984).

Alice Miller (1975) suggested, for example, that many families contain one child whose natural intuitive talents are unconsciously exploited by his or her caregivers for the maintenance of their self-esteem and that this child grows up confused about whose life he or she is supposed to lead. Miller believed that such gifted children are more likely than untalented youngsters to be treated as “narcissistic extensions” of their caregivers and are hence more apt to become narcissistic adults.

Self psychologists have coined the term “selfobjects” for the people in our lives who support our self-esteem by their affirmation, admiration, and approval (see Basch, 1994).

The communication that “unlike me, you can have it all” is particularly destructive, in that no one can have it all; every generation will face its own constraints. For self-esteem to be contingent on such an unrealistic goal is a crippling inheritance.

this countertransference sense of having been obliterated, of having been made invisible as a real person, is diagnostic of a probable narcissistic dynamic.

The psychoanalytic explanation for these phenomena relates to the special kind of transference characteristic of narcissistic people. Rather than projecting a discrete internal object such as a parent onto the therapist, they externalize an aspect of their self. Specifically, instead of feeling that the therapist is like mother or father (although sometimes one can see aspects of such transferences), the client projects either the grandiose or the devalued part of the self.

Any non-narcissistic person can sound arrogant or devaluing, or empty and idealizing, under conditions that strain his or her identity and confidence. Medical school and psychotherapy training programs are famous for taking successful, autonomous adults and making them feel like incompetent children.

The approach advocated by Kernberg (e.g., 1984)

Kohutian efforts at empathic relatedness, at least as they are conventionally put into practice, would be ineffective with psychopathic people because they do not emotionally understand compassionate attitudes; they scorn a sympathetic demeanor as the mark of weakness. The approach advocated by Kernberg (e.g., 1984) centering on the confrontation of the grandiose self, would be more respectfully assimilated by a psychopathically organized person, and is consistent with the recommendations of therapists such as Greenwald (1974), Bursten (e.g., 1973a, 1973b), Groth (e.g., 1979), and Meloy (e.g., 2001), who have specialized in working with psychopathic clients.

Heterosexual women whose hysterical presentation includes considerable exhibitionistic behavior and a pattern of relating to men in which idealization is quickly followed by devaluation may appear to be basically narcissistic, but their concerns about self are gender specific and fueled by anxiety more than shame. Outside certain highly conflicted areas, they are warm, loving, and far from empty (see Kernberg, 1984).

Because the defense that defines the schizoid character is a primitive one (withdrawal into fantasy), it may be that healthy schizoid people are rarer than sicker ones, but I do not know of any research findings or disciplined clinical observations that support this assumption empirically.

The psychoanalytic concept of the schizoid person has a lot in common with the Jungian concept of the introvert, specifically the kind of individual who would test as an introverted, intuitive, feeling, judging type (INFJ) on the Jungian-derived Myers Briggs inventory. INFJs constitute only about 1% of the overall population in the areas where personality distribution has been studied, and are understood as having strengths as “mystics” or “confidants.”

Albert Einstein (1931) wrote about himself:   My passionate sense of social justice and social responsibility has always contrasted oddly with my pronounced lack of need for direct contact with other human beings and human communities. I am truly a “lone traveler” and have never belonged to my country, my home, my friends, or even my immediate family, with my whole heart; in the face of all these ties, I have never lost a sense of distance and a need for solitude. . . . (p.

But people who are diagnosably autistic often report an internal inability to imagine what others are thinking and feeling and being motivated by, whereas schizoid people, despite their withdrawal, are more likely to be preternaturally attuned to the subjective experience of others. I have heard Asperger-diagnosed parents say that they had to be taught that their children need to be hugged. Even if he had trouble getting himself to hug his child, a schizoid father would have no difficulty understanding the child’s need. Schizoid people are more likely to describe themselves as overwhelmed by affect than as lacking it. So in these areas there seems to me a significant difference in the territory under consideration.

Schizoid people do not seem to struggle quite the way narcissistic people do with shame or introjectively depressive people do with guilt.

Schopenhauer’s famous parable about porcupines on a cold night (see Luepnitz, 2002) captures the dilemma of schizoid people: When they move close for warmth, they prick one another; when they move away from the pain, they get cold. This conflict can be enacted in the form of intense but brief connection followed by long periods of retreat.

some schizoid people crave unattainable sexual objects, while feeling vague indifference toward available ones.

One way of understanding these apparently deliberate preferences for eccentricity and defiance of custom is to assume that the schizoid person is assiduously warding off the condition of being defined—psychologically taken over and obliterated—by others.

since human beings are often drawn to those with opposite and envied strengths, schizoid people tend to attract (and to be attracted to) warm, expressive, sociable people such as those with hysterical personalities. These proclivities set the stage for certain familiar and even comic problems in which the nonschizoid partner tries to resolve interpersonal tension by continually moving closer, whereas the schizoid person, fearing engulfment, keeps moving farther away.

Where the psychopath pursues evidence of personal power, or the narcissist seeks admiring feedback to nourish self-regard, the schizoid person wants confirmation of his or her genuine originality, sensitivity, and uniqueness. This confirmation must be internally rather than externally bestowed, and because of their high standards for creative endeavors, schizoid people are often rigorously self-critical.

Because schizoid people may withdraw into detached and obscure styles of communication, it is easy to fall into a counterdetachment, in which one regards them as interesting specimens rather than as fellow creatures. Their original transference “tests,” as per control–mastery theory, involve efforts to see whether the therapist is concerned enough for them to tolerate their confusing, off-putting messages while maintaining the determination to understand and help. Naturally, they fear that the therapist will, like other people in their lives, withdraw from them emotionally and consign them to the category of hopeless recluse or amusing crackpot.

The therapist must keep in mind that the aloofness of the schizoid client is an addressable defense, not an insurmountable barrier to connection. If the clinician can avoid acting on countertransference temptations either to prod the patient into premature disclosure, or to objectify and distance him or her, a solid working alliance should evolve.

Once a therapeutic relationship is in place, certain other emotional complexities may ensue. In my experience, the subjective fragility of the schizoid person is mirrored in the therapist’s frequent sense of weakness or helplessness. Images and fantasies of a destructive, devouring external world may absorb both parties to the therapy process

Schizoid people have a tendency, with which an empathic therapist may unwittingly collude, to try to make the therapy relationship a substitute for, rather than an enhancer of, their lives outside the consulting room. Considerable time may go by before the therapist notices that although the patient develops rich insights in nearly every session, he or she has not gone to a social function, asked anybody out, improved a sexual relationship, or embarked on a creative project.

Schizoid psychology is usually easy to recognize, given the relative indifference of schizoid people to making a conventional impression on the interviewer.

The essence of paranoid personality organization is the habit of dealing with one’s felt negative qualities by disavowing and projecting them; the disowned attributes then feel like external threats. The projective process may or may not be accompanied by a consciously megalomanic sense of self.

the defense that defines paranoia may derive from a time before the child had clarity about internal versus external events, where self and object were thus confused. Paranoia intrinsically involves experiencing what is inside as if it were outside the self.

paranoiagenic situations that are humiliating

Because they see the sources of their suffering as outside themselves, paranoid people in the more disturbed range are likely to be more dangerous to others than to themselves

Even the most grandiose paranoid person lives with the terror of harm from others and monitors each human interaction with extreme vigilance. Analysts have long referred to the kind of fear suffered by paranoid clients as “annihilation anxiety” (Hurvich, 2003); that is, the terror of falling apart, being destroyed, disappearing from the earth.

Paranoid anxiety tends not to be quelled by serotonin reuptake inhibitors, but is instead responsive to benzodiazepines, alcohol, and other “downer” drugs, which may be why paranoid patients often struggle with addiction to those chemical agents.

People with narcissistic character structures are afraid of revealing their inadequacies; those with paranoid personalities are afraid of other people’s malevolence.

Projection, and disavowal of what is projected, dominate the psychology of the paranoid person.

This is projective identification: The person tries to get rid of certain feelings, yet retains empathy with them and needs to reassure the self that they are justified. The borderline paranoid person works to make what is projected “fit” the target. Thus the woman who disowns her hatred and envy announces to her therapist in an antagonistic manner that she can tell that the therapist is jealous of her accomplishments; comments made in a sympathetic spirit are reinterpreted by the client as evidence of envy-driven wishes to undermine and control, and soon the therapist, worn down by being steadily misunderstood, is hating the patient and envying her freedom to vent her spleen (Searles, 1959).

Because of the combination of denial and projection that constitute paranoia, causing the repudiated parts of the self to be extruded, therapists of paranoid patients often find themselves consciously feeling the aspect of an emotional reaction that the client has exiled from consciousness.

The therapist’s unflustered acceptance of intense hostility fosters the patient’s sense of safety from retribution, mitigates fear that hatred destroys, and exemplifies how aspects of the self that the patient has regarded as evil are simply ordinary human qualities.

Thus, when the patient is in an unrelenting, righteous, powerful rage, and the therapist feels resultingly threatened and helpless, it may be deeply affirming for the client to be told, “I know that what you’re in touch with is how angry you are, but I sense that in addition to that anger, you’re coping with profound feelings of fear and helplessness.” Even if one is wrong, the client hears that the therapist wants to understand what is creating such severe upset.

if one can tap into underlying grief and bear gentle witness to the client’s pain, paranoia may evaporate.

one can make repeated distinctions between thoughts and actions, holding up the most heinous fantasies as examples of the remarkable, admirable, creative perversity of human nature. The therapist’s capacity to feel pleasure in hostility, greed, lust, and similar less-than-stellar tendencies without acting them out helps the patient to reduce fears of an out-of-control, evil core.

It is much more therapeutic for a paranoid person to rage and grieve about the limits of the relationship than to worry that the therapist can actually be seduced or frightened out of his or her customary stance.

Consistency is critical to a paranoid person’s sense of security; inconsistency stimulates fantasies that wishes have too much power. Exactly what the individual therapist’s boundaries are (e.g., how missed sessions or phone calls to the therapist’s home are handled) matters less than how reliably they are observed. It is much more therapeutic for a paranoid person to rage and grieve about the limits of the relationship than to worry that the therapist can actually be seduced or frightened out of his or her customary stance.

They need to know that the person treating them is stronger than their fantasies. Sometimes what matters more than what is said to a paranoid person is how confidently, forthrightly, and fearlessly the therapist delivers the message.

Depressive people are agonizingly aware of every sin they have committed, every kindness they have neglected to extend, every selfish inclination that has crossed their minds.

Freud (1917a) noted that people in depressed states aim negative affect away from others and toward the self, hating themselves out of all proportion to their actual shortcomings.

Sadness, the dominant feeling in anaclitic depressives, is the other major affect of people with a depressive psychology. Evil and injustice distress them but rarely produce in them the indignant anger of the paranoid, the moralization of the obsessive, the undoing of the compulsive, or the anxiety of the hysterical person.

Unless they are so disturbed that they cannot function normally, most depressive people are easy to like and admire. Because they aim hatred and criticism inward rather than outward, they are usually generous, sensitive, and compassionate to a fault. Because they give others the benefit of any doubt, and strive to preserve relationships at any cost, they are natural appreciators of therapy.

In working with introjectively depressive patients, one can practically hear the internalized object speaking. When a client says something like, “It must be because I’m selfish,” a therapist can ask, “Who’s saying that?” and be told, “My mother” (or father, or grandparent, or older sibling, or whoever is the introjected critic). Often the therapist feels as if he or she is talking to a ghost, and as if therapy, to be effective, will have to include an exorcism. As this example shows, the kind of introjection that characterizes depressive people is the unconscious internalization of the more hateful qualities of an old love object. That person’s positive attributes are generally remembered fondly, whereas negative ones are felt as part of the self (Klein, 1940).

Children project their reactions onto love objects who desert them, imagining that they left feeling angry or hurt. Then such images of a malevolent or injured abandoner, because they are too painful to bear and because they interfere with hopes for a loving reunion, are driven out of awareness and felt as a bad part of the self. A child may thus emerge from experiences of traumatic or premature loss with an idealization of the lost object and a relegation of all negative affect into his or her sense of self.

If one emerges from painful separations believing that it is one’s badness that drove the beloved objects away, one may try very hard to feel nothing but positive affects toward those who are loved.

Introjection as a concept covers the more total experience of feeling incomplete without the object and taking that object into one’s sense of self in order to feel whole, even if that means taking into one’s self-representation the sense of badness that comes from painful experiences with the object. Turning against the self gains a reduction in anxiety, especially separation anxiety (if one believes it is one’s anger and criticism that ensure abandonment, one feels safer directing it against the self), and also maintains a sense of power (if the badness inheres in me, I can change this disturbing situation).

Children are existentially dependent. If those on whom they must depend are unreliable or badly intentioned, they have a choice between accepting that reality or denying it. If they accept it, they may generalize that life is empty, meaningless, and uninfluenceable, and they are left with a chronic sense of incompleteness, emptiness, longing, futility, and existential despair. This is the anaclitic version of depressive suffering. If instead they deny that those they must depend upon are untrustworthy (because they cannot bear living in fear), they may decide that the source of their unhappiness lies within themselves, thereby preserving hope that self-improvement can alter their circumstances. If only they can become good enough, can rise above the selfish, destructive person they know themselves to be, life will get better (Fairbairn, 1943).

Clinical experience attests resoundingly to the human propensity to prefer the most irrational guilt to an admission of impotence.

diminution, feeling inferior to those objects,

lament

In researching characterological altruism (McWilliams, 1984), I found that the only times my charitable subjects had experienced depression were when circumstances had made it temporarily impossible for them to carry on their humanitarian activities.

Male children consequently attain a sense of gender identity from being different from the mother, and females derive it from identification with her. An outcome of this imbalance in early parenting is that men use introjection less, as their masculinity is confirmed by separation rather than by fusion, and women use it more, because their sense of femaleness comes from connection. When feeling internally empty, men may be more likely to use denial and to behave counterdependently than to experience themselves anaclitically as needy and longing.

As anaclitically oriented clients progress, they tend to get critical, too, because they have to confront the painful fact that even though they now have a warm connection, there are things they have to work on. I have noticed that the more their complaints are welcomed, the more likely they are afterward to take positions on their own behalf outside the treatment room.

Before the discovery of the antidepressive properties of lithium and other chemicals, many patients with borderline and psychotic structure were so firmly convinced of their badness, so sure of the therapist’s inevitable hatred of them, or so despairing of real devotion, that they could not tolerate the pain of attachment. Sometimes they would commit suicide after years of treatment because they could not bear to start feeling hope and thereby risk another devastating disappointment.

Countertransference with depressive individuals runs the gamut from benign affection to omnipotent rescue fantasies, depending upon the severity of the depressive issues.

The most important condition of therapy with a depressed or depressively organized person is an atmosphere of acceptance, respect, and compassionate efforts to understand.

Blatt and Zuroff (2005) discovered, in an analysis of data collected for an ambitious National Institute of Mental Health (NIMH) study of major depression, that improvement in the introjective patients was centrally related to the therapist’s addressing the patient’s presumed internal beliefs about badness and its role in any losses they had had.

In the case of anaclitic patients, Blatt and Zuroff (2005) found that they got better quite quickly in therapy almost no matter what they talked about with their therapists. Not surprisingly, given that their experience of depression centered on the need to attach, as soon as they felt safely connected with a caring person, their symptoms diminished. The bad news with this group was that when the relatively brief therapy covered by the NIMH study ended, they became symptomatic again.

In working with depressive clients under conditions that force termination, it is especially important to predict preemptively the patient’s expectable interpretation of the meaning of the loss.

Depressive people are deeply sensitive to abandonment and are unhappy being alone.

“You must be going away because you’re disgusted with me,” or “You’re leaving to escape my insatiable hunger,” or “You’re taking off to punish me for my sinfulness” are all variants on the depressive theme of basic unlovability.

Most of us in the field probably started out being neurotically flexible and generous in an effort to protect our depressive patients from suffering. But what depressive people really need is not uninterrupted care. What they need is the experience that the therapist returns after a separation. They need to know that their anger at being abandoned did not destroy the relationship and that their hunger did not permanently alienate the therapist. One cannot learn these lessons without enduring a loss in the first place.

It may come as a revelation to depressive individuals that the freedom to admit negative feelings increases intimacy, unlike being false or out of touch.

If support backfires, as it almost always will, especially with introjective clients, what can one do to improve the self-esteem of a depressive person? The ego psychologists had a useful prescription: Don’t support the ego; attack the superego. If a man is berating himself for the crime of envying a friend’s success, and the therapist responds that envy is a normal emotion, and that especially since the patient did not act it out, he might congratulate himself rather than running himself down, the patient may respond with silent skepticism. But if the therapist says, “So what’s so terrible about that?” or teases him for trying to be purer than God, or tells him good-naturedly to “Join the human race!” the patient may be able to take the message in.

Depressive people work so hard to be good that they are usually exemplary in the patient role—so much so that their compliant behavior may be legitimately considered part of their pathology. One can make small dents in a depressive mentality by interpreting a client’s cancellation or temporary nonpayment as a triumph over the fear that the therapist will retaliate at the slightest sign of opposition.

Overall, therapists of characterologically depressive patients must accept and even welcome the client’s removing their halo. It is nice to be idealized, but it is not in the patient’s best interest. Therapists in the earliest days of the psychoanalytic movement knew that it signified progress when a depressed patient became critical or angry or disappointed with the clinician;

People with hypomanic personalities have a fundamentally depressive organization, counteracted by the defense of denial. Because most people with manic tendencies suffer from episodes in which their denial fails and their depression surfaces, the term “cyclothymic” has sometimes been used to describe their psychology.

Because the person experiencing mania literally cannot slow down, drugs like alcohol, barbiturates, and opiates that depress the central nervous system may be highly attractive.

The core defenses of manic and hypomanic people are denial and acting out.

isomorphic with the depressive tendency to idealize,

One’s primary concern with a hypomanic patient must be the prevention of flight.

A good history should highlight the disparity; narcissistically structured people lack the turbulent, driven, catastrophically fragmented backgrounds of most hypomanic clients.

The person who behaves masochistically endures pain and suffering in the hope, conscious or unconscious, of some greater good.

I want to stress that the term “masochism” as used by psychoanalysts does not connote a love of pain and suffering. The person who behaves masochistically endures pain and suffering in the hope, conscious or unconscious, of some greater good.

Most unconsciously driven, self-defeating actions include the element of an effort to master an expected painful situation (R. M. Loewenstein, 1955). If one is convinced that, for example, all authority figures will sooner or later capriciously punish those who depend on them, and if one is in a chronic state of anxiety waiting for this to happen, then provoking the expected punishment will relieve the anxiety and provide reassurance about one’s power: At least the time and place of one’s suffering is self-chosen.

When one has had a frightening, negligent, or abusive background, the need to recreate those circumstances in order to try to master them psychologically can be both visible and tragic.

As memories came back, and as she grieved over her prior helplessness and began discriminating between present and past realities, her self-mutilation gradually ceased.

Youngsters who have lost a parent tend to worry that their badness drove that parent away. Preferring a sense of guilty power to helpless impotence, they try to convince themselves and others that it is the substitute parent who is bad, thus deflecting attention from their own felt wrongdoing. They may provoke until the stepparent’s behavior supports their conviction.

it is often hard to influence a stepfamily system in a purely behavioral way. The agenda of an angry and guilt-driven party may have much more to do with continuing to suffer (so that someone else is seen as culpable) than with improving the family atmosphere.

Usually the history of a masochistic person sounds like the history of a depressive one, with unmourned losses, critical or guilt-inducing caregivers, role reversals where the child feels responsible for the parents, instances of trauma and abuse, and depressive models (Dorpat, 1982). Yet if one listens carefully, one also hears a theme of people having been responsive when the client was in deep enough trouble. Whereas depressive people feel that there is no one there for them, masochistic ones may feel that if only they can demonstrate sufficiently their need for sympathy or care, they may not have to endure complete emotional abandonment.

Esther Menaker (e.g., 1953) was one of the first analysts to describe how the origins of masochism lie in unresolved dependency issues and fears of being alone. “Please don’t leave me; I’ll hurt myself in your absence” is the essence of many masochistic communications,

It is not uncommon to learn from masochistic patients that the only time a parent was emotionally invested in them was when they were being punished. An association of attachment and pain is inevitable under these circumstances. Teasing, that peculiar combination of affection and cruelty, can also breed masochism (Brenman, 1952). Especially when punishment has been excessive, abusive, or sadistic, the child learns that suffering is the price of relationship.

Nydes (1963) argued (cf. Bak, 1946) that people with masochistic personalities have certain commonalities with paranoid people, and that some individuals swing cyclically from masochistic to paranoid orientations. The source of this affinity is their common orientation to threat. Both paranoid and self-defeating people feel in constant danger of attacks on their self-esteem, security, and physical well-being. The paranoid solution in the face of this anxiety is something like “I’ll attack you before you attack me,” whereas the masochistic response is “I’ll attack myself first so you don’t have to do it.” Both masochistic and paranoid people are unconsciously preoccupied with the relationship between power and love.

People with a moral–masochistic personality structure often impress others as grandiose and scornful, exalted in their suffering and scornful of those lesser mortals who could not endure equivalent tribulation with so much grace. Although this attitude makes moral masochists look as if they are enjoying their suffering, a better formulation would be that they have found a compensatory basis in it for supporting their self-esteem (Cooper, 1988; Kohut, 1977; Schafer, 1984; Stolorow, 1975).

For those who tilt toward moral masochism, they may be fighting back by not fighting back, exposing their abusers as morally inferior for showing their aggression, and savoring the moral victory that this stratagem achieves.

When self-esteem is enhanced, and/or a relationship is felt to be reinforced, by bearing misfortune courageously, and when these goals are seen as less achievable if one acts on one’s own behalf (“selfishly”), it is difficult to reframe an unpleasant situation as requiring corrective measures.

Masochistic clients can be infuriating. There is nothing more toxic to a therapist’s self-esteem than a client who radiates the message, “Just try to help me—I’ll only get worse.” This negative therapeutic reaction (Freud, 1937) has long been related to unconscious masochism, but understanding that intellectually and going through it emotionally are two different things.

Self-destructive people do not need to learn that they are tolerated when they smile bravely; they need to find out that they are accepted even when they are losing their temper. Moreover, they need to understand that anger is natural when one does not get what one wants and can be simply understood as such by others. It does not have to be fortified with self-righteous moralism and exhibitions of suffering. Masochistic people may believe they are entitled to feel hostility only when they have been clearly wronged, a presumption that costs them countless hours of unnecessary psychological exertion.

for. Self-destructive people do not need to learn that they are tolerated when they smile bravely; they need to find out that they are accepted even when they are losing their temper. Moreover, they need to understand that anger is natural when one does not get what one wants and can be simply understood as such by others. It does not have to be fortified with self-righteous moralism and exhibitions of suffering. Masochistic people may believe they are entitled to feel hostility only when they have been clearly wronged, a presumption that costs them countless hours of unnecessary psychological exertion. When they feel some normal disappointment, anger, or frustration, they may either deny or moralize in order not to feel shamefully selfish. When therapists act self-concerned, and treat their masochistic patients’ reactive outrage as natural and interesting, some of these patients’ most cherished and damaging internal categories get reshuffled.

Self-destructive people do not need to learn that they are tolerated when they smile bravely; they need to find out that they are accepted even when they are losing their temper. Moreover, they need to understand that anger is natural when one does not get what one wants and can be simply understood as such by others. It does not have to be fortified with self-righteous moralism and exhibitions of suffering. Masochistic people may believe they are entitled to feel hostility only when they have been clearly wronged, a presumption that costs them countless hours of unnecessary psychological exertion. When they feel some normal disappointment, anger, or frustration, they may either deny or moralize in order not to feel shamefully selfish. When therapists act self-concerned, and treat their masochistic patients’ reactive outrage as natural and interesting, some of these patients’ most cherished and damaging internal categories get reshuffled.

In the same vein, one should not buy into guilt and self-doubt. One can feel powerful pressure from masochistic clients to embrace their self-indicting psychology. Guilt-provoking messages are often strongest around separations. A person whose self-destructiveness escalates just when the therapist is about to take a vacation (a common scenario) is unconsciously insisting that the therapist is not allowed to enjoy something without agonizing over how it is hurting the patient.

One finds in most religious practices and folk traditions a connection between suffering and reward, and masochistic people often support their pathology uncritically with these ideas.

The predominantly depressive person needs above all else to learn that the therapist will not judge, reject, or abandon, and will, unlike the internalized objects that maintain depression, be particularly available when the client is suffering. The more masochistic person needs to find out that self-assertion, not helpless suffering, can elicit warmth and acceptance, and that the therapist, unlike the parent who could be brought to reluctant attention if a disaster was in progress, is not particularly interested in the details of the patient’s current misery.

The idealization of reason and the faith in progress through human action that were hallmarks of Enlightenment thinking still permeate our collective psychology. Western civilizations, in conspicuous contrast to some Asian and Third World societies, esteem scientific rationality and “can-do” pragmatism above most other attributes.

Where both thinking and doing propel someone psychologically, in marked disproportion to feeling, sensing, intuiting, listening, playing, daydreaming, enjoying the creative arts, and other modes that are less rationally driven or instrumental, we may infer an obsessive–compulsive personality structure.

The “workaholic” and the “Type A personality” are popularly acknowledged variations on the obsessive–compulsive theme.

Professors of philosophy sometimes have obsessional but not compulsive character structure; they get pleasure and self-esteem from mentation, and feel no press to implement their ideas. People drawn to carpentry or accounting frequently have compulsive but not obsessive styles; their gratifications come from accomplishing specific and detailed tasks, often with little cognitive elaboration.

As symptoms, obsessions (persistent, unwanted thoughts) and compulsions (persistent, unwanted actions) can occur in anyone, not just in those who are characterologically obsessive and compulsive. And not all obsessive and compulsive individuals suffer recurrent intrusive thoughts or engage in irresistible actions.

As was true for masochism as an overall concept, most behavior that we tend to see as pathological is by definition compulsive: The doer seems driven to act again and again in ways that prove futile or harmful. The schizoid person is compelled to avoid people, the paranoid to distrust, the psychopath to use, and so on

Freud reasoned that toilet training usually constitutes the first situation in which the child must renounce what is natural for what is socially acceptable.

The basic affective conflict in obsessive and compulsive people is rage (at being controlled) versus fear (of being condemned or punished). But what especially strikes those of us who work with them is that affect is unformulated, muted, suppressed, unavailable, or rationalized and moralized (MacKinnon et al., 2006). Many contemporary writers construe the obsessive allergy to affect as a type of dissociation (e.g., Harris & Gold, 2001).

Obsessive–compulsive individuals idealize cognition and mentation. They tend to consign most feelings to a devalued realm associated with childishness, weakness, loss of control, disorganization, and dirt. (And sometimes femininity; men with obsessive and compulsive personalities may fear that expressing tender emotions regresses them to an early, disowned, premasculine identification with Mother.)

One of my patients, a married oncologist who knew very well that AIDS is not easily transmitted by mouth-to-mouth contact, felt helplessly compelled to get tested repeatedly for HIV antibodies after she had kissed a man with whom she was tempted to have an affair. Even some compulsions that are manifestly free of a sense of guilt can be found to have originated in guilt-inducing interactions; for example, most people who compulsively clean their plates were made to feel guilty as children about rejecting food when, somewhere in the world, people are starving.

Compulsive actions often have the unconscious meaning of undoing a crime.

Freud believed that the conscientiousness, fastidiousness, frugality, and diligence of obsessive–compulsive people were reaction formations against wishes to be irresponsible, messy, profligate, and rebellious, and that one could discern in the overresponsible style of such individuals a hint of the inclinations against which they struggled.

People who are strongly preoccupied with being upright and responsible may be struggling against more powerful temptations toward self-indulgence than most of us face; if this is so, it should not surprise us when they are only partially able to counteract their darker impulses.

One route by which individuals emerge with obsessive and compulsive psychologies involves parental figures who set high standards of behavior and expect early conformity to them.

Introjectively oriented obsessive and compulsive people are deeply concerned with issues of control and moral rectitude. They tend to define the latter in terms of the former; that is, they equate righteous behavior with keeping aggressive, lustful, and needy parts of the self under strict rein. They are apt to be seriously religious, hard-working, self-critical, and dependable.

Anaclitically oriented obsessive individuals worry a lot, too, though the focus of their concern is more external: The “perfect” decision is one that no witness can criticize.

This paralysis is one of the most unfortunate effects of the reluctance of obsessional people to make a choice. Early analysts christened this phenomenon the “doubting mania.” In the effort to keep all their options open, so that they can maintain (fantasied) control over all possible outcomes, they end up having no options.

The “Yes, but” stance of the obsessive person may be seen as, at least in part, an effort to avoid the guilt that inevitably accompanies action.

Where the obsessive person postpones and procrastinates, the compulsive one speeds ahead. People with compulsive psychologies have a similar problem with guilt or shame and autonomy, but they solve it in the opposite direction: They jump into action before considering alternatives.

As I mentioned earlier, obsessive people support their self-esteem by thinking; compulsive ones by doing.

obsessive people support their self-esteem by thinking; compulsive ones by doing.

It is typical for obsessional clients to experience the therapist as a devoted but demanding and judgmental parent, and to be consciously compliant and unconsciously oppositional.

But 2 years later he came back to tell me that he had thought a lot about feelings since he had seen me, particularly about his anger and sadness at being so far from his native country. As he had let in those emotions, his obsessions and compulsions had waned.

Doubts about whether anything is being accomplished in therapy are typical for the therapist as well as for the obsessive or compulsive client, especially before the person is brave enough to express such worries directly.

A third component of good treatment with obsessionally and compulsively structured people is the practitioner’s willingness to help them express their anger and criticism about therapy and the therapist.

Because it can feel like a power struggle (to both parties) for the therapist to keep harping on the question “But how do you feel?” one way to bring a more affective dimension into the work is through imagery, symbolism, and artistic communication. Hammer (1990), in exploring how obsessional people use words more to fend off feeling than to express it, mentions the special value to this population of a more poetic style of speech, rich in analogy and metaphor.

To be useful to obsessive and compulsive people, one needs not only to help them find and name their affects but also to encourage them to enjoy them. Psychoanalytic therapy involves more than making the unconscious conscious; it requires changing the patient’s conviction that what has been made conscious is shameful.

Occasionally, one can appeal to the practical nature of obsessive and compulsive people when they flee their feelings; for example, some scientifically minded patients find it helpful to know that crying rids the brain of certain chemicals associated with chronic mood disturbances.

Ordinarily, obsessive and compulsive dynamics are easy to differentiate from other kinds of psychology. Isolation and undoing are usually pretty visible; compulsive organization is particularly conspicuous, since the person’s drivenness to act cannot be easily masked.

As with obsessive–compulsive individuals who lack obsessions and compulsions but who operate on the same principles that produce them, there are many of us who have never had hysterical outbreaks but whose subjective experience is colored by the dynamics that create them.

People with hysterical personalities have high anxiety, high intensity, and high reactivity, especially interpersonally. They are warm, energetic, and intuitive “people people,” attracted to situations of personal drama and risk. They may be so addicted to excitement that they go from crisis to crisis. Because of their anxiety level and the conflicts they suffer, their own emotionality may look superficial, artificial, and exaggerated to others, and their feelings may shift rapidly (“hysterical lability of affect”). The great actress Sarah Bernhardt (Gottlieb, 2010) seems to have had many hysterical features, as did the fictional Scarlett O’Hara. People with hysterical characters may like high-visibility professions, such as acting, performing, preaching, teaching, and politics.

Many have suggested that hysterically organized people are by temperament intense, hypersensitive, and sociophilic. The kind of baby who kicks and screams when frustrated but shrieks with glee when entertained may well have the constitutional template for hysteria.

Some highly intelligent people with hysterical personality organization are remarkably creative; their integration of affective and sensory apperception with more linear, logical approaches to understanding produces a rich integration of intellectual and artistic sensibility.

People with hysterical personalities use repression, sexualization, and regression. They act out in counterphobic ways, usually related to preoccupations with the fantasied power and danger of the opposite sex. They also use dissociative defenses, about which I say more in the next chapter.

Freud’s first constructions of repression as an active force rather than an accidental lapse derived from his work with people who under hypnosis recalled and relived childhood traumas, often incestuous ones, and then lost their hysterical symptoms. In his earliest therapeutic attempts, first with hypnosis and then with nonhypnotic suggestion, he put all his energies into undoing repression, inviting his patients to relax and exhorting them to let their minds be open to recollection. He observed that when traumatic memories returned with their original emotional power, a process he labeled “abreaction,” hysterical disabilities would disappear.

A woman who, for instance, had been reared to regard sexual self-stimulation as depraved might lose feeling and movement in the hand with which she would be tempted to masturbate. This phenomenon, known as “glove paralysis” or “glove anesthesia” because only the hand was affected (which cannot be of neurological origin because nerve damage that paralyzes the hand would also paralyze the arm), was not uncommon in Freud’s time, and it begged for an explanation. It was symptoms like glove paralysis that inspired Freud to conceive of hysterical ailments as achieving a primary gain in resolving a conflict between a wish (e.g., to masturbate) and a prohibition (against masturbating), and also secondary gains in the form of concern from others.

People who repress erotic strivings and conflicts that seem dangerous or unacceptable tend to feel both sexually frustrated and vaguely anxious.

Acting out in hysterical people is often counterphobic: They approach what they unconsciously fear. Behaving seductively when they dread sex is only one example; they may also exhibit themselves when they are unconsciously ashamed of their bodies, make themselves the center of attention when they are feeling inferior to others, throw themselves into acts of bravery and heroism when they are unconsciously frightened of aggression, and provoke authorities when they are intimidated by their power.

It has often been observed (e.g., Easser & Lesser, 1965; Herman, 1981; Slipp, 1977) that the fathers of histrionic women were both frightening and seductive. Men may easily underestimate how intimidating they are to their young female children; male bodies, faces, and voices are harsher than those of either little girls or mothers, and they take some getting used to. A father who is angry seems particularly formidable, perhaps especially to a sensitive female child.

The greater frequency of hysteria in females seems to me to be explicable by two facts: (1) men have more power than women in the larger culture, and no child fails to notice this; and (2) men do less of the primary care for infants, and their relative absence makes them more exciting, idealizable, and “other” than women. The outcome of an upbringing that magnifies simplistic gender stereotypes (men are powerful but narcissistic and dangerous; women are soft and warm but weak and helpless) is for a woman thus reared to seek security and self-esteem from attaching herself to males she sees as particularly powerful. She may use her sexuality to do this and then find she has no satisfactory sexual response to physical involvement with such a person. She may also, because his power scares her, seek to evoke the more tender side of a male partner and then unconsciously devalue him for being less of a man (i.e., soft, feminine, weak). Some hysterically organized people, male as well as female, thus go through repetitive cycles of gender-specific overvaluation and devaluation, where power is sexualized but sexual satisfaction is curiously absent or ephemeral.

The hysterical sense of self is that of a small, fearful, defective child coping as well as can be expected in a world dominated by powerful and alien others. Although people with hysterical personalities may come across as controlling and manipulative, their subjective state of mind is quite the opposite. Manipulations carried out by individuals with hysterical structure are, in marked contrast to the maneuvering of psychopathic people, secondary to their quest for safety and acceptance.

Attachment to an idealized object—especially being seen with one—may create a kind of “derived” self-esteem (Ferenczi, 1913): “This powerful person is part of me.” The psychology of groupies who idealize artists or politicians has this feel. Sexual acting out may be fueled by the unconscious fantasy that to be penetrated by a powerful man is somehow to capture his strength.

Freud’s whole conception of hysteria revolved around the observation that what is not consciously remembered remains active in the unconscious realm, finding expression in symptoms, enactments, and reexperiences of early scenarios. The present is misunderstood as containing the perceived dangers and insults of the past, partly because the hysterical person is too anxious to let contradictory information in.

Because hysterical personality is a psychology in which gender-related issues may dominate the patient’s way of seeing the world, the nature of the initial transferences may differ as a function of the sex of both client and therapist. With male practitioners, heterosexual female clients with hysterical dynamics may be excited, intimidated, and defensively seductive. With female therapists, they are often subtly hostile and competitive. With both, they may seem somewhat childlike. The transferences of male hysterical patients will vary depending on whether their internal cosmology assigns greater power to maternal or paternal figures

Still, it is surprising how many clinicians accept the hysterical invitation to act out omnipotence. The appeal of playing “Big Daddy” to a helpless, grateful young thing is evidently quite strong. I have known otherwise disciplined practitioners who, when treating a hysterically organized woman, could not contain their impulse to give her reassurance, consolation, advice, or praise, despite the fact that the subtext in all these messages is that she is too weak to figure things out on her own, or to develop the capacity to give herself her own reassurance or comfort.

Trying and failing to seduce someone is profoundly transformative to histrionic people, because—often for the first time in their lives—they learn that someone they depend on will put their welfare above the opportunity to use them, and that the direct exertion of their autonomy is more effective than defensive, sexualized distortions of

What hysterical clients need, as opposed to what they may feel they need when their core conflicts are activated in treatment, is the experience of having and giving voice to powerful desires that are not exploited by the object of those desires. Trying and failing to seduce someone is profoundly transformative to histrionic people, because—often for the first time in their lives—they learn that someone they depend on will put their welfare above the opportunity to use them, and that the direct exertion of their autonomy is more effective than defensive, sexualized distortions of it.

Standard psychoanalytic treatment was invented for people with hysterical personality structure, and it is still the treatment of choice with healthier clients in this group. By standard treatment, I mean that the therapist is relatively quiet and nondirective, addresses process more than content, deals with defenses rather than what is being defended against, and limits interpretation mostly to addressing resistances as they appear in the transference.

Comments with any trace of the attitude “I know you better than you know yourself” may, in the imagery that often dominates the internal representational world of the hysterical person, feel castrating or penetrating to the client. Raising gentle questions, remarking casually when the patient seems stuck, and continually bringing him or her back to what is being felt, and how that is understood, comprise the main features of effective technique.

It is important to rein in one’s narcissistic needs to be valued for making a contribution; the best contribution one can make to a histrionic person is confidence in the client’s capacity to figure things out and make responsible adult decisions.

We now know (Solms & Turnbull, 2002) that glucocorticoids secreted during traumatic experience can shut down the hippocampus, making it impossible for episodic memory (the memory of being there) to be laid down in the first place.

Along with many other therapists who have treated dissociative patients, I have found myself construing the controversy about “whether dissociative identity disorder exists” as a pervasive social countertransference to a condition that can be unbearable to imagine.

People who use dissociation as their primary defense mechanism are essentially virtuosos in self-hypnosis. Movement into an altered state of consciousness when one is distressed is not possible for everybody; you have to have the talent.

With respect to affect, however, the picture is clear: Dissociative people have been overwhelmed with it and have gotten virtually no help processing it. Their affect is consequently in a state of chronic dysregulation (Chefetz, 2000a). Primordial terror, horror, and shame are foremost among the emotions that provoke dissociation in any traumatic situation; rage, excitement, and guilt may also be involved.

Bodily states that may instigate trance include intolerable pain and confusing sexual arousal. While it is possible to develop a dissociative identity in the absence of early sexual trauma and abuse by caregivers, empirical studies have established this relationship in the vast majority of cases in hospital settings severe enough to be diagnosed as dissociative identity disorder (Braun & Sacks, 1985; Putnam, 1989). More and more, neglect is emerging as equally pathogenic (Brunner, Parzer, Schuld, & Resch, 2000; Teicher et al., 2004); the child who is sexually used by a parent and otherwise ignored (by both the exploitive parent and other caregivers) suffers unbearably and must resort to dissociative solutions. Bullying and peer aggression (Teicher, Samson, Sheu, Polcari, & McGreenery, 2010), emotional abuse, and—probably most pathogenic of all—witnessing of domestic violence (Wolf, Gales, Shane, & Shane, 2000) are found in the histories of people with severe enough dissociation to meet DSM criteria for dissociative identity disorder.

Herman (1992) and Liotti (1999, 2004) have elaborated on the internal presence in traumatized people of perpetrator, victim, and rescuer images—the “drama triangle” originally noted by Karpman in 1968. Others have noted witness and bystander roles as well (Davies & Frawley, 1994; R. Prince, 2007). Therapists can expect to find themselves cast in such roles, and to face dramatic eruptions of traumatic themes.

Because of the power of the traumatic transferences, one must tolerate being used by the patient in ways that feel “distorting.” This requires swallowing one’s defensiveness and engaging in what Sandler (1976) called “role responsiveness” and Lichtenberg (2001) has called “wearing the attributions” of the client. Chefetz (personal communication, October 11, 2010) offers an example of this kind of response: “So, you’re feeling like you’re at risk of being hurt by me? Tell me about what you imagine might happen. What comes to mind as you consider this? Does that match any scenes from the past? Are there other ways of being you in the background, close by, who are really engaged in a lot of this thinking and feeling? Why do you think they are so present?”

one factor that should alert a diagnostician to a possible dissociative identity problem is the presence of several prior, serious, and/or mutually exclusive diagnostic labels in a person’s treatment history.

Data suggesting the possibility of a dissociative process include a known history of trauma; a family background of severe alcoholism or drug abuse; a personal background of unexplained serious accidents; amnesia for the elementary school years; a pattern of self-destructive behavior for which the client can offer no rationale; complaints of lost time, blank spells, or time distortion; headaches (common during switching); referral to the self in the third person or the first-person plural; eye-rolling and trance-like behaviors; voices or noises in the head; and prior treatment failures.

Saying “Last Monday you were furious at me and thought I was worthless, but today you’re saying I’m wonderful” may evoke defensiveness in either a dissociative or a generically borderline person. But saying “I’m noticing that today you are clear that I am really on your side. Do you recall how you felt about me in last Monday’s session?” may permit the dissociative client to admit to having forgotten the Monday session. The person with borderline dynamics is more likely to rationalize moving back and forth from love to hatred, idealization to devaluation.

The therapeutic ramifications of this differential revolve around the importance with hysterical people of interpreting their recurrent impulses, fantasies, and unconscious strivings, as opposed to an emphasis with dissociative clients on reconstructing a traumatic past. If one does the former with a basically dissociative client, one will reinforce denial, increase guilt, and fail to deal with the pain that a terrible history has created. If one does the latter with a histrionic client, one may prevent the flowering of the sense of agency that comes from acknowledging internal dynamics and redirecting one’s energies in directions that are genuinely satisfying.