Psychoanalytic Character Diagnosis

Psychoanalytic Character Diagnosis

Classical psychoanalytic theory approached personality in two different ways, each deriving from an early model of individual development. In the era of Freud's original drive theory, an attempt was made to understand personality on the basis of fixation (At what early maturational phase is this person psychologically stuck?). Later, with the development of ego psychology, character was conceived as expressing the operation of particular styles of defense (What are this person's typical ways of avoiding anxiety?). This second way of understanding character was not in conflict with the first; it provided a different set of ideas and metaphors for comprehending what was meant by a type of personality, and it added to the concepts of drive theory certain assumptions about how we each develop our characteristic adaptive and defensive patterns.

These two explanatory sets are the basic elements of my own visualization of character possibilities. I try to show also how relational models in psychoanalysis (British object relations theory, American interpersonal psychoanalysis, self psychology, and contemporary relational ideas) can illuminate aspects of character organization. In addition, my understanding of personality has been enriched by less clinically influential psychodynamic formulations such as Jung's archetypes, Henry Murray's "personology," Silvan Tomkins's "script theory," control-mastery theory, and recent empirical work, especially attachment research and cognitive and affective neuroscience.

Readers may note that I am applying to the diagnostic enterprise several different paradigms within psychoanalysis that can be seen as mutually exclusive or essentially contradictory. Because this book is intended for therapists, and because I am temperamentally more of a synthesizer than a critic or distinction maker (I share this sensibility with other clinical writers such as Fred Pine and Lawrence Josephs), I have avoided arguing for the scientific or heuristic superiority of any one paradigm. I am not minimizing the value of critically evaluating competing theories. My decision not to do so derives from the specifically clinical purpose of this book and from my observation that most therapists seek to assimilate a diversity of models and metaphors, whether or not they are conceptually problematic in some way.

Every new development in clinical theory offers practitioners a fresh way of trying to communicate to troubled people their wish to understand and help. Effective therapists-and I am assuming that effective therapists and brilliant theorists are overlapping but not identical samples- seem to me more often to draw freely from many sources than to become ideologically wedded to one or two favored theories and techniques. Some analysts adhere to dogma, but this stance has not enriched our clinical theory, nor has it contributed to the esteem in which our field is held by those who value humility and who appreciate ambiguity and complexity.

Different clients have a way of making different models relevant: One person stimulates in the therapist reflections on Kernberg's ideas; another sounds like a personality described by Horney; still another has an unconscious fantasy life so classically Freudian that the therapist starts to wonder if the patient boned up on early drive theory before entering treatment. Stolorow and Atwood have shed light on the emotional processes underlying theories of personality by studying how the central themes in the theorist's life become the issues of focus in that person's theories of personality formation, psychopathology, and psychotherapy. Thus, it is not surprising that we have so many alternative conceptions. And even if some of them are logically at odds, I would argue that they are not phenomenologically so; they may apply differentially to different individuals and different character types.

Having stated my own biases and predilections, I now offer a brief, highly oversimplified summary of diagnostically salient models within the psychoanalytic tradition. I hope they will give therapists with minimal exposure to psychoanalytic theory a basis for comprehending the categories that are second nature for analytically trained therapists.

CLASSICAL FREUDIAN DRIVE THEORY AND ITS DEVELOPMENTAL TILT

Freud's original theory of personality development was a biologically derived model that stressed the centrality of instinctual processes and construed human beings as passing through an orderly progression of bodily preoccupations from oral to anal to phallic and genital concerns. Freud theorized that in infancy and early childhood, the person's natural dispositions concern basic survival issues, which are experienced at first in a deeply sensual way via nursing and the mother's other activities with the infant's body and later in the child's fantasy life about birth and death and the sexual tie between his or her parents.

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. Appropriate caregiving was construed as oscillating sensitively between, on the one hand, sufficient gratification to create emotional security and pleasure and, on the other, developmentally appropriate frustration such that the child would learn in titrated doses how to replace the pleasure principle ("I want all my gratifications, including mutually contradictory ones,

right now!") with the reality principle ("Some gratifications are problematic, and the best are worth waiting for"). Freud talked little about the specific contributions of his patients' parents to their psychopathology. But when he did, he saw parental failures as involving either excessive gratification of drives, such that nothing had impelled the child to move on developmentally, or excessive deprivation of them, such that the child's capacity to absorb frustrating realities was overwhelmed. Parenting was thus a balancing act between indulgence and inhibition-an intuitively resonant model for most mothers and fathers, to be sure.

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. Character was seen as expressing the long-term effects of this fixation: If an adult man had a depressive personality, it was theorized that he had been either neglected or overindulged in his first year and a half or so (the oral phase of development); if he was obsessional, it was inferred that there had been problems between roughly one and one half and three (the anal phase); if he was hysterical, he had met either rejection or overstimulating seductiveness, or both, between about three and six, when the child's interest has turned to the genitals and sexuality (the "phallic" phase, in Freud's male-oriented language, the later part of which came to be known as the "oedipal" phase because the sexual competition issues and associated fantasies characteristic of that stage parallel the themes in the ancient Greek story of Oedipus). It was not uncommon in the early days of the psychoanalytic movement to hear someone referred to as having an oral, anal, or phallic character.

Lest this oversimplified account sound entirely fanciful, I should note that the theory did not spring full-blown from Freud's fevered imagination; there was an accretion of observations that influenced and supported it, collected not only by Freud but also by his colleagues. In Wilhelm Reich's Character Analysis, the drive theory approach to personality diagnosis reached its zenith. Although Reich's language sounds archaic to contemporary ears, the book is full of fascinating insights about character types, and its observations may still strike a chord in sympathetic readers. Ultimately, the effort to construe character entirely on the basis of instinctual fixation proved disappointing; no analyst I know currently relies on a drive-based fixation model. Still, the field retains the developmental sensibility that the Freudian construct set in motion.

One echo of the original drive model is the continuing tendency of psychodynamic practitioners to think in terms of maturational processes and to understand psychopathology in terms of arrest or conflict at a particular phase. Efforts of contemporary psychoanalytic researchers to rethink the whole concept of standard developmental stages have inspired enthusiasm for less linear, less universalizing models, but these new ways of thinking coexist with general tendencies to view patients' problems in terms of some aborted developmental task, the normal source of which is seen as a certain phase of early childhood.

In the nineteen fifties and nineteen sixties, Erik Erikson's reformulation of the psychosexual stages according to the interpersonal and intrapsychic tasks of each phase received considerable attention. Although

Erikson's work is usually seen as in the ego psychology tradition, his developmental stage theory echoes many assumptions in Freud's drive model. One of Erikson's most appealing additions to Freudian theory was his renaming of the stages in an effort to modify Freud's biologism. The oral phase became understood by its condition of total dependency in which the establishment of basic trust (or lack of trust) is at stake. The anal phase was conceptualized as involving the attainment of autonomy (or, if poorly navigated, of shame and doubt). The prototypical struggle of this phase might be the mastery of toilet functions, as Freud had stressed, but it also involves a vast range of issues relevant to the child's learning self-control and coming to terms with the expectations of the family and the larger society. The oedipal phase was seen as a critical time for developing a sense of basic efficacy ("initiative vs. guilt") and a sense of pleasure in identification with one's love objects.

Erikson, influenced by experiences such as having lived with Native American Hopi tribes, extended the idea of developmental phases and tasks throughout the lifespan and across cultures. In the nineteen fifties, Harry Stack Sullivan offered another stage theory (of predictable childhood "epochs"), one that stressed communicative achievements such as speech and play rather than drive satisfaction. Like Erikson, he believed that personality continues to develop and change well beyond the first six or so years that Freud had stressed as the bedrock of adult character.

Margaret Mahler's work on subphases of the separation-individuation process, a task that reaches its initial resolution by about age three, was a further step in conceptualizing elements relevant to eventual personality structure. Her theory is basically object relational, but its implicit assumptions of fixation owe a debt to Freud's developmental model. Mahler broke down Freud's oral and anal stages and looked at the infant's movement from a state of relative unawareness of others (the autistic phase, lasting about six weeks) to one of symbiotic relatedness (lasting over the next two or so years-this period itself subdivided into subphases of "hatching," "practicing," "rapprochement," and "on the way to object constancy") to a condition of relative psychological separation and individuation.

Other clinically relevant developmental observations emerged from British analysts. Melanie Klein wrote about the infant's shift from the "paranoid-schizoid position" to the "depressive position." In the former, the baby has not yet fully appreciated the separateness of other people, while in the latter, he or she has come to understand that the caregiver is outside the child's omnipotent control and has a separate mind. Thomas Ogden later posited a developmentally earlier "autistic-contiguous position," a "sensory-dominated, presymbolic area of experience in which the most primitive form of meaning is generated on the basis of the organization of sensory impressions, particularly at the skin surface." He emphasized how, in addition to viewing these positions as progressively more mature stages of development, we need to appreciate that we all move back and forth among them from moment to moment.

Such contributions were greeted eagerly by therapists. With the post-Freudian stage theories, they had fresh ways of understanding how their patients had gotten "stuck" and could appreciate otherwise puzzling shifts in self-states. They could now also offer interpretations and hypotheses to their self-critical clients that went beyond speculations about their having been weaned too early or too late, or toilet trained too harshly or with too much laxity, or seduced or rejected during the oedipal phase. Rather, they could wonder to patients whether their predicaments reflected family processes that had made it difficult for them to feel security or autonomy or pleasure in their identifications (Erikson), or suggest that fate had handed them a childhood devoid of the crucially important preadolescent "chum" (Sullivan), or comment that their mother's hospitalization when they were two had overwhelmed the rapprochement process normal for that age and necessary for optimal separation (Mahler), or observe that in the moment, they were feeling a primitive terror because the therapist had interrupted their thought processes (Ogden).

More recently, Peter Fonagy and his colleagues have offered a model of the development of a mature sense of self and reality characterized by a capacity to "mentalize" the motives of others. Mentalization resembles what philosophers have called "theory of mind" and what Klein called the depressive position: the appreciation of the separate subjective lives of others. He observed that children move from an early "mode of psychic equivalence," in which the internal world and external reality are equated, to a "pretend mode" around age two, in which the internal world is decoupled from the external world but is not governed by its realities (the era of imaginary friends), and the achievement of the capacity for mentalization and reflective functioning around ages four or five, in which the two modes are integrated and fantasy is clearly distinguished from actuality. I talk more about this formulation in Chapter three in connection with borderline personality organization.

For therapists, such models were not just interesting intellectually; they provided ways of helping people to understand and find compassion for themselves-in contradistinction to the usual internal explanations that we all generate about our more incomprehensible qualities ("I'm bad," "I'm ugly," "I'm lazy and undisciplined," "I'm just inherently rejectable," "I'm dangerous," etc.). And clinicians could keep their own sanity better when they ran into otherwise incomprehensible responses to their attempts to understand and help. For example, a client's sudden verbal assault on the therapist could be seen as a temporary retreat into the paranoid-schizoid position.

Many contemporary commentators have noted that our propensity to construe problems in developmental terms is too reductive and only questionably supported by clinical and empirical evidence. L. Mayes, for example, notes that "maps that orient us to the developmental terrain are quite useful, but such maps should not be taken literally." Others have pointed to different patterns of psychological development in non-Western cultures. Contemporary developmental psychologists are leery of simple stage formulas, given that development is a dynamic, ever-shifting process. As my colleague Deirdre Kramer has noted, it is probably more accurate to speak of a "range of developmental possibilities" than "a" developmental "level."

Still, the tendency of therapists to see psychological phenomena as residues of normal maturational challenges persists-perhaps reflecting the fact that developmental models have both an elegant simplicity and an overall humanity that appeals to us. There is a generosity of spirit, a kind of "There but for fortune go I" quality, to believing there is an archetypal, progressive, universal pattern of development, and that under unfortunate circumstances, any of us could have gotten stuck at any of its phases. It is not a sufficient explanation for personality differences, but it feels like an important part of the picture. One of the axes on which I have aligned diagnostic data contains this developmental bias in the form of relatively undifferentiated (symbiotic-psychotic), separation-individuation (borderline), and oedipal (neurotic) levels of personality organization.