Psychoanalytic Explanations of Pathology

An important debate in modern psychoanalytic circles is this: what causes psychopathology/symptoms? A good student of Freud would recognize that the patient’s inability to manage conflicts (particularly libidinal) result in compromise formations/symptoms. Of course, certain patients were understood to be fixated at various levels of psychosexual development: schizoid/depressive (oral), paranoid/obsessive (anal), and hysterical (phallic). Brenner argued that individual is in conflict, trying to manage various intrapsychic conflicts (wishes vs. fears) that give rise to unpleasure (anxiety/depressive affect), and the individual’s use of defenses result in compromise formations (sometimes symptoms if pathological). Kleinians stress that individuals, from birth, have to manage the overwhelming terror and destructiveness of the death drive that threatens to destroy the infant’s self and objects. An individual’s ability to manage this aggressive drive and integrate loving and aggressive feelings towards others (objects) is a sign of health.

What I find particularly troubling is the environmentalist shift in psychoanalytic thinking (i.e. rejection of drive theory & Freud’s model of the mind) and an exclusive focus on the child’s attachment to important caregivers. Fairbairn was most revolutionary in rejecting the pleasure principle and Freud and Abraham’s theory of psychosexual development. He stressed that the libido is not pleasure seeking but rather object-seeking (i.e. humans ontologically seek out relationships and other humans are not just vehicles for pleasure). Invariably, these theorists only ever consider the impact the mother has on the child. We are told if the mother is not a good-enough (Winnicott), if she cannot manage her anxiety (Sullivan), or if she is depriving (Fairbairn) then the infant fails to develop a healthy or true self. Mahler likewise suggested that the mother must facilitate the child’s separation from her, and if she fails certain pathologies will emerge (e.g. borderline personality). Kohut was adamant that caretakers (again presumably the mother) must provide the child with adequate mirroring (validation) and must be worthy of idealizing to help foster the child’s  robust sense of self. Again and again these theorists seem to assume that the most important happenings occur in the first two years of life, and that the mother has to provide an excellent environment to properly allow the child to develop normally. Not surprisingly, the third (usually the father) is generally missing from these theories; hence, the Oedipus complex is displaced by the preoedipal infant’s attachment to mother.

Of course, the technical implications are obvious. If environmental deficits are responsible for pathology then a new environmental/relational experience or what Alexander called a corrective emotional experience must be provided to rectify matters. This leads to the classic interpersonal vs. intrapsychic debate, i.e. what is mutative the therapeutic relationship or the analyst’s interpretations? I tend to think of the relationship as the means through which the patient can take in and listen to the clinician’s interpretation of the patient’s unconscious conflicts.

Why is this troubling? It seems to place all the blame on the mother’s capacity to tolerate the infant, and she is presumed to have made a mistake if pathologies develop. What I think is problematical is that it fails to assume that other people and events can produce major problems. For instance, mothers can be rejecting/depriving, but fathers tend to abuse and/or seduce children. For instance, I recently read Ellman’s (2010) When Theories Touch on various psychoanalytic theories (I highly recommend it, even though he excluded Lacan), and he noted that homo sapiens have the worst track record when it comes to child abuse (1-5) compared to other primates. And it goes without saying that fathers are generally responsible for child abuse.

Another problem with the mother-blaming strategy is that it is extremely dis-empowering. I’m not denying that mothers can be at the root of some pathologies, but I think the field has given undue attention to maternal influence. Children eventually become adults and they make decisions, often self-destructive decisions (which is why they end up in therapy). Of course, the goal is to understand why the person is attached (unconsciously) to their symptoms and to understand the various reasons why they refuse to give them up. Moreover, another problem with this environmentalist approach is that it’s not as if the way someone is treated as a child directly translates into adult functioning. Some folks are extraordinarily resilient (e.g. people who are abused don’t all become psychotic) while others with relatively “normal” backgrounds seem to be very vulnerable to developing symptoms.

One more thing. Something that I have been particularly struck by in my clinical work is the extent to which masochism and repetition compulsion are at the heart of pathology. People continue to do self-destructive things and yet they cannot help themselves (hence unconscious determinants are driving behavior). There are multiple ways to explain such phenomena: Oedipal conflicts, unconscious guilt, wish for punishment, etc, but I’ve found that the death drive is indispensable here. This fall I’m planning to write a paper on repetition compulsion and death drive, as it seems to be one of Freud’s most profound and darkest discoveries. It’s not surprising that most of the field (save for Kleinians and Lacanians) has disavowed the death drive, believing it to be too speculative.

13 thoughts on “Psychoanalytic Explanations of Pathology

  1. I’m a big fan of Andre Green who emphasizes the infants active participation in his environment, one of his bug bears with Lacanians is precisely the point you articulated in the post. Another great thing I find with him is that he touches on the authors you mentioned but approaches them in a systematic way – opposed to treating the authors as providing useful conceptual tools and drawing on them in a haphazard way (ready/present-to- hand).

    I think the privileging of environmental factors is a consequence of a) fear of wild analysis, b) the fear that psychoanalysis is simply hocus pocus. Environmental factors tend to be more easily quantifiable as opposed to ‘speculating’ about the motivations of an infant who cannot even ‘self-report’.

    I am equally aware of the opposite danger of enantiodromia, as a response to widely perceived perception that Freud ‘blamed mommy’ that she now gets a free ride. I think that this can be ameliorated to some extent by emphasizing the bisexuality of the subject, that the masculine third is always already there even in pre-opedipal relationships.

    My thesis in this regard: The stakes of the Oedipal phase (structure or state?) is less to do with ‘enter stage: third’ in which the arrival of the incorporeal third (primordial father) takes place at the same time as the corporeal third (infants actual father), but opening the horizons of the infant from the dramas of the primary care giver (and their personal – if they are lucky – triangulations, or otherwise bi-polar relations).

    With respect to causality, I think the subject is a distorted screen which reflects linear causality into-itself. If what I said previously seems to confirm the primacy of object relations, the subject as a distorting screen reserves a place for the infant that is other than floatsam of adult desires.

  2. I’ve recently seen the film “We Need to Talk About Kevin” – great film btw- that deals with the thematic concerns of this post.

  3. Interesting you bring up Andre Green. I’ve been meaning to read his book on affects, and I recently read a chapter he wrote in Kirshner’s Between Winnicott and Lacan (2011). The book is really worth checking out. I certainly have my major sympathies in the intersection between object relations (particularly Klein/Winnicott) and Lacan. I’d also suggest Charles’ Working with Trauma: Lessons from Bion and Lacan (2011) – my review of this text will be coming out next year in Psychodynamic Psychiatry

    To bring this into more focus, we could revisit the debate that Greenberg and Mitchell put forward in their text on object relations. They claim that there are two incompatible metapsychologies: drive/structure vs. relational/structure. I don’t tend to think of things in such a binary way. I believe there are ways to bridge the gap between drive and object relations, but certain authors like Fairbairn, Sullivan, and Kohut destroy that possibility by rejecting the notion of drives and the primacy of aggression. It’s clear that Freud emphasized object relations, especially in his metapsychological papers.

    My thesis is simply this: we’ve swung to far in privileging the environment. Anna Freud’s repudiation of Bowlby and attachment theory was ridiculous and extremely rigid. Analytic thinkers have certainly learned from that literature, and you’re right that it provides the necessary empirical validation to the Big Other (because apparently nobody grants validity to psychoanalytic data, which is simply ridiculous). Embracing attachment theory does not necessitate a rejection of drives, despite all of the arguments that Mitchell makes. I also worry that attachment has become so in vogue that infantile sexuality has been all but ignored/repressed. Unlike other Lacanians I don’t appreciate the exclusive focus on Freud/Lacan, as if every other analytic think is worthless. This may not be a fair generalization, but it’s certainly the rest of the field’s fantasy about Lacanians.

    Regarding the speculative comment, I tend to think that many of these thinkers have been rather speculative. Mahler’s work was founded on solid research. In term of treatment, I’m always amazed by these analyst’s ability to interpret nonverbal material (which they assume is the only way to access prelinguistic/preoedipal trauma) through the analysis of countertransference. That strikes me as wildly more speculative than listening to a string of associations.

  4. Thanks for the reading tips. There is so much good stuff I want to read atm, and I’m gonna try and be disciplined and focus on Andre Green and Object Relations for a bit. If you ever get round to reading his book on affects, please do post some thoughts up on it. I’ve dipped into it a few times but found it both intimidating and hard going – it seems to require a familiarity with a wide range of background material – so any morsels given will be received with gratitude! I’m trying to situating his thinking on affects in relation to Lacan’s jouissance – it seems to me that he quite rightly rails against early-mid (Imaginary/Symbolic) Lacan but is largely unsympathetic to later Lacan when I suspect they are closer but ultimately differ regarding Green’s integration of Winnicott/re-evaluation of Freudian corpus in terms of life/death drives.

    “They claim that there are two incompatible metapsychologies: drive/structure vs. relational/structure. I don’t tend to think of things in such a binary way. I believe there are ways to bridge the gap between drive and object relations, but certain authors like Fairbairn, Sullivan, and Kohut destroy that possibility by rejecting the notion of drives and the primacy of aggression. It’s clear that Freud emphasized object relations, especially in his metapsychological papers.”

    Yeah exactly. I’m in the middle of reading an essay by AG “The intuition of the negative in Playing and Reality” which – going on first impressions – focuses on the transitional object bridging precisely this divide. May be worth a look.

    “I’m always amazed by these analyst’s ability to interpret nonverbal material (which they assume is the only way to access prelinguistic/preoedipal trauma) through the analysis of countertransference.”

    Linking this back to comments regarding empirical validity, the relationship between Analyst/Analysand I think is ultimately singular and a state of exception which renders it problematic in terms of ‘data’. But I am bullshitting here as I have precisely zilch experience of the analytical setting which may otherwise give me a different perspective on it.

  5. Green’s on my radar, but right now I’m backed up preparing some articles and conference presentations. I’ll try to post something once I get some free time. I regret to say that I haven’t read enough of Winnicott. Last month I read his ‘The Use of an Object’ which is just brilliant. I have some books that I intend to read over the next year. I find some ideas of Winnicott to be brilliant and other notions of Winnicott (e.g. ‘what matters is not what the analyst says but how he says it’) to be awful.

    Yes, I will say that my understanding of all of these matters has greatly increased through my clinical experience (as patient and therapist). I’m guessing you’re not working as a clinician, presumably?

  6. From the little I have read on him I really like his formulations on Psychosis, I forgot the actual quote but it rendered vivid for me the Psychotic’s violent imposition of his phantasy onto others.

    You presume correctly, lay analysis on myself out of necessity!

  7. It’s funny cause my friend and I are right now preparing a paper on schizophrenia and psychoanalytic theory. Some of Winnicott’s formulations are interesting (the notion that they fear a breakdown that has already occurred), but other ideas strike me as really wrong headed (e.g. psychosis is due to maternal deprivation which causes the infant to develop a ‘false self’ and the treatment of choice is causing a massive regression in which the analyst re-parents the patient). I’ve never been a big fan of the regress, restore, repackage approach. Lacan was likewise critical of this approach, believing it was much too risky.

  8. Yeah I am uncomfortable with the talk of authentic ‘Self’, on a superficial level it smacks me as too much of ego psychology a la Kohut. TBH that’s what has stopped me reading Winicott in the past.

    “I’ve never been a big fan of the regress, restore, repackage approach.”

    I agree, I understand the positive role phantasy may have for psychotic subjects but I think it is irresponsible for the analysis to uncritically support it – which I assume is what would be involved at some stage of the RRR model. For when the psychotic subject is not in the analytical setting and comes across individuals/family members that refuse/challenge his or hers perspective the consequences are not very pleasant.

    Will you be making the paper available for public consumption? I would like to get a better idea of the distinction between schizophrenia and psychosis.

  9. Kohut, in all honesty, was an idiot. All psychopathology is someone else’s fault, and deprivation is the source of everyone’s problems. Sounds like bullshit to me.

    My doctoral work addresses how I worked with a psychotic patient in long-term work. I’m hoping that paper as well as my paper on psychoanalytic theory and schizophrenia will be available hopefully in the next year. The distinction between schizophrenia and psychosis has a long history. Obviously, schizophrenia is a psychotic disorder. In the comments section, we discuss this question here: https://itself.wordpress.com/2011/11/24/the-psychoanalytic-psychotherapy-of-schizophrenia-and-psychosis-syllabus/

  10. Kerberg FTW!

    Thanks, I chased up the ver Eecke artical. So to chuck around some rough (negative) definitions, Psychosis = failure of symbolic, Autism = failure of imaginary, shizophrenia = failure of symbolic + imaginary?

  11. Yes, Kernberg is better, although he is theoretically inconsistent (unable to integrate Klein+ego psych).

    I believe that’s correct. Do you wanna give me your email so I can send a rough draft of my paper? I explore all these issues of psychosis/schizophrenia from various analytic schools: Freud, interpersonalists, Kleinians, ego psychologists, Lacanians, etc.

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