Psychoanalytic Views of Mental Health

Freud once wrote, “But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health you will be better armed against that happiness” (Breuer & Freud, Studies on Hysteria, p. 306). Freud was clearly no optimist when it came to mental health. For Freud, society generally serves to discourage our natural libidinal and aggressive wishes through the creation of various social prohibitions that demand our drives be sublimated into healthy, socially acceptable channels. Freud never believed that psychoanalysis promised happiness. Instead, psychoanalysis is a quest for truth through the analysis of the patient’s unconscious wishes and beliefs.

Ego psychologists (such as Hartmann) believed that the reduction of drive tension (in accordance with the pleasure principle) was a sign of mental health. Ideally, the subject can develop conflict-free autonomous ego functions that can function relatively unimpeded by intrapsychic conflicts. Ego psychologists believed that the strengthening of the ego’s capacities and defenses enabled the ego to mediate between various forces (id-superego-external reality). Ultimately, Hartmann argued that healthy adaptation to reality was the gold standard of mental health.

Kleinians conceive of the child, at birth, as having to cope with annihilation anxiety in response to the child’s death drive during the paranoid-schizoid position (0-6 months). In this position, the Kleinian infant experiences others as part-objects (non-integrated, i.e. either as bad breast or good breast) and resorts to using primitive defenses (splitting, projection, projective identification) in response to overwhelming anxiety. Later, the Kleinian infant moves into the depressive position, and the infant experiences others as integrated whole objects (both good and bad); hence the child can experience both hating and loving feelings towards the mother at the same time. Klein once said that a split in the object is a split in the ego. In other words, as the individual develops a more integrated, realistic view of others, she will develop a more integrated view of self. Hence, the capacity for conflict resolution (integration), the management of anxiety and the capacity to view others as integrated wholes are signs of mental health for Kleinians.

Winnicott argued that the development of a true self allows one to discard the false self, a self that is created in response by inhospitable caretakers that do not foster the child’s sense of creativity, spontaneity, and authenticity. This false self is a necessary armor the pre-Oedipal child develops if it is not provided an adequate holding environment by the inadequate mother. I can’t find the reference but Winnicott once said that when the individual develops a true self she is able to enjoy being purposeless (capacity to play). I like that idea.

Kohut, the founder of self psychology, believed that mental health was based on the individual’s capacity to develop an integrated, creative and vital self. The goal of self psychological treatment is to facilitate this development of a healthy self, which can be facilitated by improving the patient’s selfobject functioning (an intrapsychic capacity to regulate self-esteem based on one’s experience with early caregivers). The self psychological analyst provides empathy, strengthening the patient’s selfobjects and healthy sense of narcissism. Basically, Kohut thought that mental health was equivalent to healthy, realistic self-esteem.

Brenner, the founder of modern conflict theory (an American revision of classical psychoanalysis), argued that the individual’s capacity to develop healthy compromise formations (resolutions between intrapsychic conflicts due to competing wishes from the libidinal and aggressive drives) was the gold standard for mental health. For Brenner, conflicts are never resolved but constantly mediated through various compromise formations (solutions). Pathological compromise formations are symptoms, and the distinction between healthy compromise formations and symptoms is difficult to define.

Lacan rejected social adaptation (a la ego psychology) as the goal of psychoanalytic treatment. Instead, Lacan suggested that individual’s fidelity to her desire (Sem VII) was the way to get beyond the false identifications of the ego. For Lacan, the ego is a symptom (a defense), an attempt to bring together fragmentary, unintegrated subjective experiences. The unconscious (the discourse of the Other) irrupts the false sense of wholeness and coherence of the patient’s ego (ego ideal). The patient’s capacity to take responsibility for her unconscious (where the id was there the ego shall be) is a sign of psychological health and authenticity (although Lacan would undoubtedly reject the way these terms are normally used by analysts).

Finally, object relations and relational analysts (from Fairbairn to Mitchell) stress the individual’s capacity to develop holistic, fulfilling relationships with others. Too often, patients suffer from painful repetitive relational experiences with others, due to neglectful and abusive caregivers. The goal of treatment is for the analyst to offer a corrective emotional experience to the patient. This enables the patient to set aside ingrained, pathological patterns of relating and to develop the ability to view others in new, satisfactory ways. In the final analysis, the ability to have new relational experiences and the creation of a new healthy object relationship fosters change.

Mental health is based on the analyst’s view of human nature (Fromm). I would argue (following Freud and Lacan) that neutrality has to be the guiding analytic posture for treatment. Clinicians should not tell patients what to do (lest we slip into suggestion, a technique Freud rejected based on his experience with Charcot), as we do not want to tell the patient how to resolve their conflicts. Otherwise we might end up implicitly siding with the status quo and endorsing society’s current arrangements.

In the end, a discussion of pathology, diagnosis, and symptoms must be re-thought. The majority of psychiatric diagnoses are based on the individual’s inability to conform to normative societal expectations. For instance, many patients are diagnosed with a personality disorder. What is a personality disorder? Basically, it’s a fancy term clinicians use to label patients who are difficult to get along with. However, what is the proper standard for such diagnoses? Don’t these type of diagnoses betray a belief in the ‘health’ of society and the goodness of adaptation? I’m not trying to romanticize ‘mental illness’ (a term fraught with controversy) because many people genuinely suffer. Instead, I’m trying to raise the important question of how we distinguish between ‘health’ and ‘sickness’. Some would be quick to say that whatever causes an individual undue, unmerited suffering is ‘sick’. However, this assumes that a symptom is causing the individual distress, which is not always the case. Symptoms can be ego-syntonic (i.e. they are normative and not rejected by the patient).

Recently Nancy McWilliams, a prominent American analyst, presented at my graduate program. Here’s her list of mental health. Let me know what you think.

Signs of Mental Health based on McWilliams’ Presentation at GWU (March 2012):
1) Capacity to Love (Freud)
2) Capacity to Work (Freud)
3) Capacity to Play (Winnicott)
4) Secure Attachment (Bowlby)
5) Sense of Agency/Autonomy (Erikson)
6) Self Constancy/Identity Integration (Stern)
7) Object Constancy (Stern)
8) Ego Strengths (Westen/Shedler)
9) Realistic/Reliable Self-esteem (Kohut)
10) Sense of Values (Superego) (Cleckley)
11) Affect/Thought Tolerance/Frustration (Tomkins)
12) Insight (Reality Testing) (Fenichel)
13) Mentalization (Reflective Functioning) (Fonagy)
14) Good Coping Strategies/Defensive Flexibility (A Freud)
15) Balance between Self-Definition & Self-in-Relationships (Balint)
16) Passion/Vitality/Purpose (Winnicott)
17) Acceptance & Capacity to Mourn/Suffer (Klein)

Notice, the absence of sex and aggression!

29 thoughts on “Psychoanalytic Views of Mental Health

  1. Peter, that’s the entire list. Anything you’d care to add?

    Will, healthy aggression is the capacity to have honest, non passive-aggressive conflicts and confrontation. In other words, healthy self-assertion that is neither too timid nor too destructive.

  2. A relatively benign superego is certainly a sign of health (would likely be covered by #9-10). That’s a good point about self-sabotage. Reptition compulsion and self-sabotage is key for the relational idea of destructive, repetitive relational experiences and the necessity of forming new habits and ways of relating to others. However, I’m surprised it didn’t make it onto McWilliams’ list.

  3. Thanks.

    I took PA ‘s comment as being sarcastic due to the length of the list. It does seem to lack an internal consistency.

    “However, this assumes that a symptom is causing the individual distress, which is not always the case.” – Exactly! Neurotic symptom can be compensatory in BPD imo, no wonder they get pissed off if you try to relieve the neurosis.

  4. Could you say a bit more about symptoms being compensatory in BPD (borderline PD?)?

    Symptoms also aren’t merely a source of suffering. Good clinicians know you can’t take away a symptom or defense away before you have something to put in its place. Also, symptoms cause both pain and are also a source of pleasure (jouissance). This is why people don’t just automtically give up their symptoms. Symptoms are compromises and a source of ambivalence.

  5. “Good clinicians know you can’t take away a symptom or defense away before you have something to put in its place.” Does the “you” in that sentence refer to the clinician or to the patient? If it’s the former, how does that square with neutrality? And how does it differ in substance from CBT or approaches that focus straightforwardly on interrupting destructive/unwanted habits?

  6. The you was referring to the clinician, although the patient is obviously implicated in the process. All I meant to say was that you have to be aware of the timing of treatment and defenses and symptoms have to be respected because they can be quite difficult to give up. That’s not to say that symptoms can be easily sacrificed, and we all know suggestion (CBT) doesn’t have the long-lasting effects of psychonanalytic work.

    You raise a good question about neutrality and suffering. Psychoanalysis is a response to suffering. I think of neutrality as a mindframe I have when I approach treatment. I do not want to be narcissistically invested in the outcome, although I clearly want the suffering to cease (to feel useful, the desire to be loved/idealized, etc). I do not have my own imaginary desires (marry this person or take this job) but rather am infinitely curious (Bion said analysts should ‘eschew memory and desire’ every session) which is a fancy way of saying that clinicians should be forever vigilant about what you are listening to and stay focused on all aspects of what is going on in the room. I would argue that symptoms can be sacrificed only once the person understands how the symptom both causes pain and also bring enjoyment, in other words there is an attachment to the symptom that has to be understood (could be a mask for masochism, ucs guilt, etc). One thing that I’ve thought about recently is how therapists need to set aside their neurotic desire to be helpful or cure (Freud & Lacan discussed this). Too often, clinicians want to be helpful but it’s often an implicit demand to the patient to change because it is hard to be around someone who is suffering. The clinician’s capacity to be useless might be the only way for the patient to fully investigate how they both desire to change and also do not want to change. Hence, you have to get towards the ambivalence and a helping attitude might be a simple defense against ‘sitting with the shit’. Brenner once said all clinicians are motivated by their desire to see others suffer (a sadistic, voyeuristic wish). This strikes me as right on, and of course, it is heavily defended against by those claiming that their sole motivation is to alleviate suffering.

  7. RE: Compensatory symptom in BPD’s

    Broadly construed, BPD narcissistic wounding due to treacherous primary object the subject tries to make good a patched breast over the hole in the ego. For example productive intellectualization (an obsessional symptom) may fulfil this function.

    This is particularly problematic as ostensibly the analysand may present as an obsessional and the analyst may act on that basis and encounter a negative therapeutic reaction, or else the analyst may succeed in reliving the neurotic symptom only to uncover annihilation anxiety.

  8. I’ll be honest I’m not following you. BPD is borderline personality disorder, no?
    Sure, splitting is a common defense observed (others are eithe idealized/devalued) and the person narcissistically benefits from associating with grandiose others. Symptoms can often mask deeper more profound pathology. I think that’s what you’re getting at. Often, psychotic individuals might present with OCD symptoms or other more classically neurotic symptoms (hysterical psychosomatic symptoms) that only cover deeper psychotic pathology.

  9. Ok I’ll elaborate further as I fear I have simplified too much. I’m basing this on Andre Green’s dead mother complex, which I consider to be a complex that arises in BPD’s which is itself a intermediary category between neurosis and psychosis. How does ‘patched breast’ differ from the mere masking of symptoms? As you state splitting is one of the more primitive defence mechanisms of BPD, the patched breast is a possibility that arises after splitting when one of the split off parts comes to fulfil a triangular relation. Andre Green calls this premature opedipalization; premature precisely because it does not involve a paternal object. Andre Green in a bid to avoid confusion sometimes drops opedipalization and simply refers it as a triangulation.

    This forestalls psychosis tout court because of the triangulation, but it is not a neurosis because it also falls short of identification with the paternal object. My previous comment was misleading in that I called the patched breast an obsessional symptom whereas if I was being more careful I would have stated that it seems to imitate obsessional symptom (hence why it is problematic for the analyst) when in fact strictly speaking it is different due to the triangulation as distinct from Oedipalization.

    How to tell the difference? The aversion to object dependence (which side steps castration anxiety as the object is not catheterized) in favour of autoerotic satisfaction.

    Is that any clearer?

  10. I should like to add that I am not clear if ‘triangulation’ generalizable for all BPD’s or whether it is specific to dead mother complex. I suspect the former, if so I think we can chalk one up for Andre Green making another essential contribution to psychoanalytical theory/practice.

  11. Yes, the word oedipalization seems misleading. I’m not sure I follow his notion that triangular relation does not represent an Oedipal triangle because no parental object is involved. Isn’t the maternal breast implicated in this relationship? Also, why is this called the dead mother complex? I’m aware of borderline diagnosis as being an intermediary between neurosis and psychosis in the work of Kernberg. Maybe I’m being dense but I feel like you haven’t properly defined the patched breast and how this relation doesn’t involve a parental object for BPD individuals.

  12. To be clear, I believe that all symptoms function in the way I described earlier in the comment post, not just those found in borderline individuals.

  13. No you are right, I may be editing out information which may be pertinent and that I undervalue myself as well as being imprecise with my language – so I am finding your questions in that respect and for revealing gaps in my own knowledge useful. Green is basically channelling Lacan, Klein, Winnicolt, with Kernberg in the background and then synthesizing them.

    Firstly why dead mother? It is based on a contrast with the ‘dead father’ of the sons that performs a structuring role i.e. the sons respect the function he once played in a kind of continuing deference. In a Lacanian sense this is a form of masculine pleasure.

    Contrast this with the mirroring function that the mother performs for the infant. A gap in my knowledge here is the specific difference between Lacan and Winnicolt on the topic of mirroring as I know AG also takes the latter into account – and you may find my explanation unsatisfactory until this is resolved. I’m all ears if you (or any lurkers!) could help me out on this. The etiology of the dead mother complex specifically is a sudden event in the mothers life which results in the sudden decathexis of the infant causing the breaking down of the mirroring function essential for the holding environment. Note that this does not imply that the mother herself dies as an external object, but at the level of feminine jouissance as it essentially pertains to the infants relationship to the mother this decathexis is registered as a narcissistic wounding. This is the essential distinction between dead father and dead mother, the former is abstract and installed as the result of the mother’s failure at providing an answer to the Real of the infants drive despite trying to; the latter is immediate in the sense that the mother gives up trying to provide an answer before we can get to the Oedipal situation.

    The patched breast is the subjects attempt to make good diffuse identity that precedes Oedipal relations. AG departs from the Klenian’s in that the patched breast whilst an attempt at reparation (for example in artistic pursuits), it is doomed to fail as it is essentially conservative and so constitutes a fixation in which the patched breast enshrines the decathexis (the dead mother) and fails as a substitution. Why this failure? Because of the maladaptive relationship to the name of the father that underwrites the possibility of such a substitution. This is to be distinguished from psychosis tout court as this does not constitute a foreclosure as such.

    So to answer your questions, no the breast essentially pertains to dyadic relationships in the orbit of feminine pleasure in the subject. It is called the dead mother complex because the subject enshrines the violent decathexis which constitutes her ‘deadness’, but there is a live attachment to this dead mother imago which is the source of ongoing suffering. It essentially pertains to the intrapsyhic relations of internal objects which colour object relations proper.

    How we doing?

  14. I would like to also add that I suspect AG is in dialogue with Lacan’s concept of the sinthome, but my knowledge does not reach all the way to late Lacan yet and don’t feel I can comment.

  15. The dead father has some resonance with Lacan’s name-of-the-father if I’m reading you right. Winnicott’s mirroring mother has more to o do with being responsive and loving towards the infant (attunement). Lacan’s notion has more to do with providing a narcissistic function and putting the infant in the economy in the desire of the mother.

    So the dead mother (for whatever reasons) de-cathects from the child and withdraws her libidinal investment in the child. The mother rejects the child, which results in a narcissistic injury for the child. The pre-Oedipal mother in Winnicottian term is not-good-enough, in others, she sucks. Kohut has a similar idea about narcissitic failures for borderline patients, as does Kernberg.

    You should check out Fairbairn’s notion of the internalization of bad objects and how it is related to Green’s theory. Celani has written a good text on Fairbairn’s object relations theory. There’s some overlap, particularly with the dead mother notion.

    I think I follow you, although the language is fairly dense and somewhat alien to my ears. Then again, Lacan isn’t particularly user-friendly.

  16. Best place to start is Greenberg and Mitchell’s (1983) Object Relations in Psychoanalytic Theory. Other theorists who integrate object relations are drive theory well are Joseph Sandler, Otto Kernberg, Klein, Bion, and other Kleinians

  17. I should say that I strongly disagree with the thesis of their book, namely, that two antagonistic metapsychologies exist in psychoanalysis that cannot be integrated. They push the reader into false choices, in my opinion For one, there are more than just drive and relational models. Second, I’d suggest reading S Ellman’s When Theories Touch (2010) which attempts to offer a more synthetic, integrated account of various theories. Unfortunately, neither book covers Lacan.

  18. From what I have read of it so far I tend to agree with your comments, though the advantage with the method they adopted is that whilst it lacks nuance it provides a clear basis of comparison. I kind of like it like that as I have my own pet thinkers in which to add my own nuance to the topics they touch upon. Are you aware if the second book you recommended covers Bion? Alternatively could you suggest any good secondary literature that covers Bion?

    The Fairbairn chap is interesting though I am more inclined to incorporate object seeking in line with drive theory and find it frustrating relational/structure models tend to dismiss drives as an atavistic through-back to to the 19th century – which is an all to immediate dismissal.

  19. Fairbairn was clever but not that clever. Also, it is any surprise that the British and American analysts have been the most squeamish about sexuality and the libidinal drive? You might check out Bleandonu’s book on Bion as well as Mawson’s text on Bion that came out last year.

  20. Cheers. My take on the squeamishness regarding drives? It is symptomatic of the the all pervasiveness of phallic jouissance in psychoanalysis. This is, for me, what is at stake in Andre Green’s return to affect in which he evaluates the Freudian corpus in light of inter-phallic jouissance (hence the importance of Winnicott for him) and circumscribes where Freud (and Lacan!) fell short of their own insight. Far from the relational/structure model being abstractly opposed to drive/structure model of Freud, in my mind relational/structure models is in continuity with a tendency found in Freud himself.

  21. Obviously drive theory is intersubjective but the relational/structural model advanced by Greenberg and Mitchell diminishes the importance of sexuality (a move Freud would certainly object to). Again, I haven’t read Green but I don’t think ‘affect’ is some ‘royal road’ to the unconscious or to truth. I might be reacting to the sentimentality and moralism of contemporary psychodynamic theory and practice, but there is a real fetishization of affect, as if emotions are what make us who we are. Unfortunately, catharsis and emotional expressions only take us so far because everything has to symbolized in language. This probably also explains why so many clinicians these days act as if their feelings and reactions to the patient (countertransference) are really important and should be a major guide to the ways they conduct treatment.

  22. I was specifically thinking along the lines of scopic drive more than drives in general. I think the Real-Symbolic is (wrongly) much maligned, and taken seriously you would have to factor in synchronicity and retroactivity which renders problematical any reference to a sense of affect being primary. But then ever time Lacan refers to the drives in terms of signification I cringe inside – here I am much more sympathetic to the concerns which motivate Derrida regarding the trace.

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