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The Ego and Analysis of Defense
An important element-if not the most important element-in comparing one analyst's technical approach with that of another lies in identifying, in more than usual detail, the manner or choice of the analyst's forms of attention during the conduct of the analysis. In a previous essay (Gray 1973) I examined and described elements of such focus--by the analyst and in due time by the analysand--that have evolved in the course of the developing practice and theory of analysis of the neuroses, or to express it more realistically, might well be expected to have evolved.
The first significant and far-reaching step toward modern ego-involving psychoanalytic technique was abandoning the use of hypnotic trance (Freud 1910). This step was decisive; classical analysis has not returned to the full use of hypnotic influence, primarily because "results were capricious and not lasting" (Freud 1917b, p. 292). As we know, coinciding with and contributing to this development was the discovery that the patient's conscious, voluntary cooperation could be enlisted to overcome repression. Although the initial manifestation of this cooperation was essentially the patient's attempt to free-associate, it soon became technically important to call the patient's attention to the existence of a resistance to do so. A brief transition period occurred, during which a supplementary laying on of hands was part of the persuasive method; nevertheless, the trend was definitely in the direction of making more use of the relatively autonomous aspects of the patient's psyche, in effect avoiding bypassing important components of the ego.
Now let us, by a flight of imagination, suppose that Rome is not a human habitation but a psychical entity with a similarly long and copious past--an entity, that is to say, in which nothing that has once come into existence will have passed away and all the earlier phases of development continue to exist alongside the latest ones. [He then lists many coexisting structures.] And the observer would perhaps only have to change the direction of his glance or his position in order to call up the one view or the other. [Freud 1930, p. 70]While trying to find special implications in certain inconsistencies and ambiguities in Freud's statements relevant to technique, one also ought to keep in mind the sometimes offered
explanation that Freud hesitated to write about technique because he wished to avoid putting such knowledge in the hands of unqualified individuals. Could this have contributed to an illusion of lag? I believe a more significant element is involved than either a reluctance to abandon a cherished position or some measure of restraint in spelling out details of technique. I believe that Freud was in fact ambivalent about the trend of involving more of the patient's ego during the analysis--a trend in technique for which he was, of course, responsible.
Freud (1913), in discussing the nature of communications to the patient and speaking of sources of information about what exists in the patient's repressed unconscious, says, "It is not difficult for a skilled analyst to read the patient's secret wishes plainly between the lines of his complaints and the story of his illness." However, Freud condemns analysts who through early direct interpretations "arouse ... violent opposition in [the patient]"; further, "As a rule the therapeutic effect will be nil; but the deterring of the patient from analysis will be final." Of himself, he states, "In former years I often had occasion to find that the premature communication of a solution brought the treatment to an untimely end, on account not only of the resistances which it thus suddenly awakened, but also of the relief which the solution brought with it." He includes an apparently unequivocal precept: "Even in the later stages of analysis one must be careful not to give a patient the solution of a symptom or the translation of a wish until he is already so close to it that he has only one short step more to make in order to get hold of the explanation for himself' (pp. 140-14 1, passim). Here the trend to work with material near the surface is so clear that the recommended interpretations even bear resemblance to what Bibring (1954) was eventually to call a "clarification."
Freud's main point here is the futility, and often harm to analysis, of an emphasis on the imparting of "knowledge" to patients about their repressed unconscious. He nails this point down by implying similarity between technical reliance on direct interpretations of the analyst's impressions of the repressed contents and that of telling the patient factual information about traumas, which has been gleaned from relatives. Following a clinical illustration, Freud concludes he had "no choice but to cease attributing to the fact of knowing, in itself, the importance that had previously been given to it and to place the emphasis on the resistances.... Conscious knowledge was ... powerless against those resistances" (italics added). Freud then overrides the trend he has just been espousing by adding, "For the sake of complete accuracy, however, it should be added that the communication of repressed material to the patient's consciousness is nevertheless not without effect. It does not produce the hopedfor result of putting an end to the symptoms; but it has other consequences. At first it arouses resistances, but then, when these have been overcome, it sets up a process of thought in the course of which the expected influencing of the unconscious recollection eventually takes place" (p. 142). In an inconsistency here, Freud has maintained room for his previous approach of establishing by interpretation a "record" or impression, in consciousness, of what is presumed to exist as a separate record in the repressed unconscious (Freud 1910, p. 42), and in so doing, he again gives credibility to "deep" interpretations.
Later, Freud (1914) indicates that making interpretations "from the patient's free associations, what he failed to remember" is a technique of the past. Now the analyst contents
himself with studying whatever is present ... on the surface of the patient's mind, and he employs the art of interpretation mainly for the purpose of recognizing the resistances which appear there, and making them conscious to the patient. From this there results a new sort of division of labour: the doctor uncovers the resistances which are unknown to the patient; when these have been got the better of, the patient often relates the forgotten situations and connections without any difficulty. [p. 147; italics added]The "two-records" approach and deep. interpretations have apparently now been laid to rest. Strachey's classic contribution in 1934 was a brilliant attempt to summarize and synthesize almost everything up to that time pertaining to the therapeutic action of psychoanalysis. It contained many technical implications and recapitulates Freud's progress beyond the earlier technical practices of approaching the id more directly. Strachey referred to the early approach of naming in order to establish a registration in the consciousness of an otherwise repressed trend of "objectionable" thought, stating that "It was only if these two impressions could be `brought together' (whatever exactly that might mean) that the unconscious trend would be `really' made conscious." He then reviewed the progress made in giving more attention to the resistance, indicating that ". . . it was at this point that the practical lesson emerged: as analysts our main task is not so much to investigate the objectionable unconscious trend as to get rid of the patients' resistance to it" (p. 276; italics added).
Despite an extraordinary capacity for grasping the extent to which various lines of psychoanalytic thought had progressed at that time, Strachey failed to make the decisive observations Anna Freud made soon after. I think that his failure to do so was another measure of the elusiveness of the applications to technique of the pertinent ego concepts.
Hartmann (1951) provides one of the most explicit statements in the literature on the existence of a lack of integration between psychoanalytic theory and psychoanalytic technique. His central point, "the lag is ... on the side of technique [rather] than on the side of theory and of psychological insight" (p. 143), refers to insight about the ego. Apropos Freud's technical papers under discussion above, Hartmann regards the occurrence of Freud's explicit attention to the priority of working with resistance "without at first realizing all its implications for ego psychology" as indicating one time when theory lagged behind technique. It is true that Freud's conclusion that the analyst contents himself with studying what is on the surface of the patient's mind, and uses interpretation mainly for dealing with resistance, was to be conceptually enhanced with the eventual formation of the structural theory. However, his concurrent theory provided adequate support for this technical advance. Freud (1915) states, "indeed ... if [an idea] is not inhibited by the censorship, it regularly advances from one position [Ucs.] to the other [Cs.]" (p. 175). Here is a theoretical concept sufficient to support any developing priority for analytic attention to the resistances.
Twenty-three years after the important 1914 technical statement, however, Freud resurrects the earlier approach in his paper, "Constructions" (1937b), when he describes communicating to the patient extensive reconstructions to create an impression in the patient's consciousness "so that it may work upon him" (p. 260). It is almost as though the refinements of ego analysis, which by then had been elaborated from Freud's own observations by Wilhelm Reich, Anna Freud, Richard Sterba, Otto Fenichel, and others, had never taken place. To my knowledge, only Stone (1973) has taken notice of this major inconsistency, when he spoke of "Freud's early, never fully relinquished biphasic process" (p. 47).
Since those resistances, which in Freud's writings later became the mechanisms of defense, had early been assigned to some version of the ego, it follows that whenever he did give precedence to working on the resistance he was of course speaking of working on or dealing with the ego. Many of his descriptions or recommendations sound almost modern (i.e., post-Anna Freud), if one fails to realize that Freud was not speaking of analyzing the ego in the manner eventually conceptualized. To "work upon," to "overcome," to "deal with" the resistances involves technical measures that are often different from those used in analyzing defenses. Yet Freud was unequivocal in his recognition that the key to effective, lasting therapeutic results lay in reversing the pathological alterations that the defense mechanisms had wrought on the ego. This is illustrated by his observation: "Indeed we come finally to understand that the overcoming of these resistances is the essential function of analysis and is the only part of our work that gives us an assurance that we have achieved something with the patient" (Freud 1917b, p. 291; italics added).
What was it that Freud, if he was not analyzing the defenses, had primarily relied on to influence the ego? I have touched on the persistence of the biphasic technical device of interpretatively establishing "two records." There is a more fundamental factor that should be explored.
Dropping full-scale hypnosis or hypnotic trance from psychoanalytic technique did not result in the exclusion of suggestion--a partial hypnosis--to influence the patient. Just as strong positive transference was the earlier vehicle for the trance-hypnosis which entirely excluded the ego's participation, so positive transference became the vehicle for influencing the patient's participation in the analytic process. The authoritarian element, although applied with a different emphasis, was nevertheless preserved. In lieu of a not yet developed technique for analyzing the defenses, Freud retained the force available for "influencing" and "overcoming" them, namely the power of
suggestion: no longer utilizing the trance, but using the related device of relying on the ego-disarming quality of the positive transference. Freud (1917b) acknowledged this:
If the patient is to fight his way through ... resistances which we have uncovered ... he is in need of a powerful stimulus which will influence the decision in the sense we desire.... At this point what turns the scale ... is ... simply and solely his relation to the doctor. In so far as his transference bears a `plus' sign, it clothes the doctor with authority and is transformed into belief in his communications ... [p. 445; italics added]. The change which is decisive for a favourable outcome is the elimination of repression.... This is made possible by the alteration of the ego which is accomplished under the influence of the doctor's suggestion. [p. 455; italics added]
Prior to a more detailed grasp of the ego's mechanisms in its defensive role, the continued use of a partially hypnotic influence was a necessary technical adjunct. Judging from the last quotation, the use of suggestion to overcome resistances appears to have continued for Freud, and has to the present time continued for many analysts as an accepted part of their work, giving further evidence of the lag in integrating knowledge of the ego into psychoanalytic technique. I would not dispute that suggestive influence may be to some degree inevitable in any human interaction, but I am referring to dependence on it and a fostering of it in the analytic situation. Many practitioners who may not be particularly interested in sorting out therapeutic factors in their analytic work and who do not knowingly use suggestion might object to any implication that they were doing so. However, the analyst who makes interpretative remarks referring to unconscious matters of which the patient cannot become aware--instead of referring to "... a preconscious derivative which can be recognized as such by the patient merely by turning his attention toward it" (Fenichel 1941, p. 18; italics added)--has left the patient to take the interpretation "on faith" and is still making use of the "two-record," biphasic method. This is an authoritative approach that relies heavily on suggestion to influence rather than on analysis of the resistance. Recent critical examinations of some of the processes and factors subsumed or hidden under references to "therapeutic alliance" (Brenner 1979) should help clarify this little-discussed area of persistent hypnotic-suggestive influences in analytic technique.
It is my impression the importance of this newest addition to our science has not been sufficiently recognized and that it has not yet penetrated the thinking and therapeutic technique of most analysts. It is easy to understand why this is so. We are still very much impressed, even fascinated by the id contents which psychoanalysis enables us to discover. The working of the ego is so inconspicuous and silent that we are hardly aware of it.... We never can catch [the unconscious defenses] at work; we can only reconstruct them from the result. While one can listen with the "third ear" to the utterances of the id, it needs a most refined instrument to register the workings of the ego defenses. It has been my observation that it is a most difficult task to teach students to pay attention to these mute and subterranean workings of the ego. Even the experienced analyst must constantly exercise self-discipline in order to remain aware of the ego's defense measures in therapy.... Judging from my experience as a teacher, from our scientific meetings and from the current literature I find too little real influence of Anna Freud's studies, although often lip service is paid to them. "Mechanism of defense" is used glibly to indicate the advanced state of one's analytic thinking, and "identification with the aggressor" is mentioned in order to display consideration of the ego. I believe it will require a great deal of time and effort on the part of training analysts to make Anna Freud's discoveries of the silent activities of the ego penetrate general analytic thinking and improve psychoanalytic technique so that it will consist of id-plus-ego analysis, applied alternatingly. [Sterba 1953, pp. 17-181
Sterba could validly make these same observations today.
If the patient starts his treatment under the auspices of mild and unpronounced positive transference it makes it possible at first for him to unearth his memories just as he would under hypnosis, and during this time his pathological symptoms themselves are quiescent. But if, as the analysis proceeds, the transference becomes hostile or unduly intense and therefore in need of repression, remembering at once gives way to acting out. From then onwards the resistances determine the sequence of the material which is to be repeated. The patient brings out of the armoury of the past the weapons with which he defends himself against the progress of the treatment-weapons which we must wrest from him one by one.... We have ... made it clear ... that we must treat his illness, not as an event of the past, but as a present-day force. [Freud 1914, p. 151; italics added]Fenichel refers to the general inertia in translating observations regarding resistance into technical development. He stated, "One of the stimuli to the development of so-called `analytic ego psychology' was insight into the fact that resistance [author's italics] analysis is the real therapeutic agent ... the volume of the literature concerning the newly gained psychological insight is incomparably greater than the number of papers which seek to utilize this insight to contribute to an improvement of psychoanalytic technique" (Fenichel 1941, p. 106; italics added). In addition to referring to Anna Freud's work, he spoke of one paper by Nina Searl (1936) which attempted to "clarify what it means to analyze a resistance in contradistinction to refuting a resistance." Since then it continues to be just as rare to find papers specifically concerned with that issue.
Freud's treatment of the developments in defense analysis in the mid-thirties deserves special attention. When Anna Freud spoke in Philadelphia in 1973, she said she had prepared her (1936) monograph in honor of her father's 80th birthday. She indicated it was to be a summary of her father's ideas on the subject. Kris and others would of course see it otherwise. Freud himself made reference to this work in only two of his papers. First, there was a brief comment in anticipation: "An investigation is at this moment being carried on close at hand which is devoted to the study of [the ego's] methods of defence: my daughter, the child analyst, is writing a book upon them" (Freud 1936, p. 245).
After the monograph appeared, Freud had time to write six more papers. In only one of these-"Analysis Terminable and Interminable" (1937a)--does he speak of her work (pp. 236, 238), seemingly crediting her with the essential ideas she expresses. Section V of Freud's (1937a) paper, if read carefully, reveals evidence of a change in Freud's way of regarding the analyst's approach to observing ego resistance as compared with the approach that characterized some of the important developments within his outstanding early technical statements. Let us compare his earlier and later comments.
"The patient's resistance is of very many sorts, extremely subtle and often hard to detect" (Freud 1917a, p. 287, italics added). This opinion is quite in keeping with Anna Freud's eventual
description of the ego's defenses, activities so subtle that they "can only be reconstructed" (A. Freud, 1936, p. 2) after the mechanism has taken place. And this is in keeping with Sterba's remarks that "it needs a most refined instrument to register the working of the ego defenses" (Sterba 1953, pp. 17-18). Later, however, we find Freud (1937a) saying of resistances, "The analyst recognizes them more easily than he does the hidden material in the id" (p. 239); 1 regard this as a lapse.
The most revealing evidence that at this time in his life Freud did not see eye to eye with Anna Freud's clarifying and probably original concepts concerning the technique of defense analysis--more exactly, the analysis of transference of defense--lies in his discussion of the "alterations of the ego" which have been brought about by the mechanisms of defense. Here is where he elaborates upon the idea of "resistance against the uncovering of resistances." Freud had said for so long that mechanisms of defense are automatic, dynamically unconscious activities of the ego, that to some extent his phrase was redundant. However, Freud uses the phrase in the context of discussing massive increases in resistance on the part of the patient when the analyst approaches dealing with the resistances:
One might suppose that it would be sufficient to treat them [the ego's defenses] like portions of the id [italics added] and, by making them conscious, bring them into connection with the rest of the ego.... But what happens is this.... The ego ceases to support our efforts at uncovering the id .... negative transferences may now gain the upper hand and completely annul the analytic situation. The patient now regards the analyst as no more than a stranger who is making disagreeable demands on him, and he behaves towards him exactly like a child and does not believe everything he says. If the analyst tries to explain to the patient one of the distortions made by him for the purpose of defence, and to correct it, he finds him uncomprehending and inaccessible to sound arguments [italics added]. Thus we see that there is a resistance against the uncovering of resistances.... [Freud 1937a, p. 239]I would argue that what Freud describes is a classic example of an analytic patient who has experienced an interpretation thathas been too "deep." Freud has described the reactions of an ego that has had to cope with the threatened emergence of frightening degrees of id derivatives too soon. This is, in fact, one of the very problems that led Freud (1913) earlier to recognize and emphasize the value of working from the surface and withholding interpretation of symptoms or wishes until the patient "is already so close to it that he has only one short step more to make in order to get hold of the explanation for himself' (p. 140). This trend led eventually to the contemporary concept of the ego.
Following Inhibitions, Symptoms and Anxiety (1926a), Freud's interest in detailed attention to the nature--not the existence--of resistance appears to have diminished. As described above, he later shows an apparent recurrence of a predilection for the earlier "two-impressions" interpretative approach, which depended strongly on the authoritative, hypnotic-suggestive influencing potential of transference in overcoming resistance.
Individuals influenced by Freud during his time have shown that they could evolve differing technical approaches, offer theory to support their approaches, and yet maintain that they were strictly following Freud's guidelines. Reich (in his early phase), Anna Freud, Sterba, and Fenichel all chose to emphasize rather similar perspectives, clearly deriving from certain of Freud's contributions. Nunberg, also as a bona fide Freudian, developed a technical and theoretical approach that differs in important respects from these others. He placed less confidence in an ego-analytic approach intended to facilitate and develop in the analysand an autonomously cooperating and participating observing ego. On the contrary, Nunberg (1937) continued to take the persistence of the hypnotic type of influence as the necessary component of the analytic process:
For ... making conscious what has been reproduced in repetition [in analysis], the patient obviously needs the cooperation of... that part of his ego which in the transference is siding with the analyst. In obedience to the analyst's request to remember--to repeat--experiences from the past, the patient's ego braces itself for the readmission of the repressed into consciousness.... The ego's reaction is similar to that which occurs in hypnosis, where, in obedience to our compliance with the hypnotist, even unpleasurable suggestions are accepted and carried out. The obedience is reproduced owing to libidinal ties belonging to the oedipus complex. [p. 169, italics added]
Nunberg, appearing to follow a practice of facilitating removal of resistance by authoritative reinforcement, is described by former supervisees as having encouraged the use of direct, deep
I borrowed the phrase "developmental lag" to characterize a puzzling reluctance to apply certain ego concepts to the method of psychoanalytic technique. I shall now take further advantage of the metaphor and examine the implied "conflicts" in terms of particular "fixations" at earlier periods of development in analytic theory and practice. I shall also consider the resulting "resistances" to progress in this area in the face of certain burdensome consequences encountered by the analyst who makes ego analyzing a constant part of his technique. Selected are only four so designated fixations: (1) fascination with the id; (2) predilection for an authoritative analytic stance; (3) preoccupation with external reality, including past as external reality; and (4) counterresistance to transference affects and impulses.
Freud's "regressive development" may have been manifested by the return, in some of his very late writings, to forms of interpretation he had ostensibly set aside over twenty years before and thereby contributed significantly to the developmental lag. Here I am referring, among other things, to his use of the large-scale, direct interpretation reconstructions. This is not to be taken as an across-the-board antireconstruction position on my part. There are varieties of reconstructions that I find quite compatible with and essential to the technique of competent analysis of defenses against specific drive derivatives.
Counterresistance to Transference Affects and Impulses
Counterresistance refers here to ways of the analyst's perceiving and conducting an analysis so as to stimulate or reinforce resistance beyond that degree which occurs due to the internal conflicts mobilized by the task of free association. In a strict sense, counterresistance might well be confined to ways that are unconsciously motivated within the analyst. Some counterresistance, of course, exists chiefly because of less than skillful technique. Be that as it may, it is the unconsciously motivated form directed against the full emergence of analyst-cathected affects and impulses that I include as one of the fixations that contribute to relative neglect of analyzing the ego and its defenses.
Historically, it was not uncommon for the analyst to make genetic interpretations of observed unconscious material relating to the analyst, without providing the patient with an opportunity to work through the full awareness of those affects or impulses toward the analyst. The patient's resistance to this particularly advantageous experience was thus supported.
This resistance-supporting tendency persists, although to a lesser degree. We see it whenever the analyst interprets the genetic aspects of barely or newly, yet cautiously conscious, transference of id derivatives (as distinguished from interpreting genetic aspects of transference of defense) without having made sure that the patient had worked through virtually all of the defenses against experiencing those derivatives in their immediate form, toward the analyst and others (see Gill 1979). The analyst who does provide the latter experience will, of course, have to be subjected to drive derivatives of a more detailed and intense variety. Inevitably this will expose all of the ways in which the analyst has been or is being perceived, fantasied and real. It is, therefore, gratuitous to make a special technical point of getting the patient to verbalize his observations of and reactions to "the real relationship" (Greenson 1967). Actually, it is especially because the patient's "real" perceptions of the analyst will be included in the material, particularly as defenses against the act of perception (Lustman 1968) are diminished, that the analyst's counterresistance to observing and analyzing the ego's activities is easily aroused. It is difficult for analysts to overcome narcissistic self-protection against having their actual characteristics--appearance, ways of speaking, ways of thinking (as these become apparent), and so on--accurately perceived by the patient as a part of effective analytic process. It is a challenge, when this problem occurs in supervision, to transmit this principle successfully without inflicting a narcissistic wound.
Freud's phrase, "There is resistance to uncovering resistances" could well refer to an ubiquitous reluctance to consider, perceive, and conceptualize--both to oneself and to one's analysand--the detailed workings of the ego in its defensive measures against specific drive derivatives.
Many obstacles the analyst meets in making observations about the ego's defensive activity occur because of, or are reinforced by, the fact that there is something to be gained by the analyst--as distinct from the patient--in not making such observations. The gains range from enhanced instinctual satisfactions to relief from conflicts. Some of the conflicts have to do with the analyst's narcissistic vulnerability to the patient's id; some are superego-induced conflicts within the analyst which compromise his neutrality. Essentially the conflicts resemble the intrapsychic conflicts of neurosis itself and qualify often as a form of countertransference. A burdensome byproduct of the widening-scope applications of analysis is increasing emphasis on the therapeutic uses of countertransference. Given the trying aspects of the work with many such cases, this trend has often been a matter of attempting to make a virtue out of a necessity, and historically has made an appearance whenever analysis moved toward the treatment of nearer-psychotic pathology.
I have reserved one obstacle until last because I do not think it lends itself to the metaphor of a fixation and because there is not much to say about it. This obstacle concerns an inner tendency to maintain a natural or at least a maturely typical state of virtual ignorance of those functions of the ego that potentially enable it to observe itself. Freud (1900) first called attention to the fact when he discussed analyzing one's dreams: "Practice is needed even for perceiving endoptic phenomena ... from which our attention is normally withheld; and this is so even though there is no psychical motive fighting against such perceptions" (pp. 522-523, italics added). Over thirty years later, addressing his unseen "Lecture" audience, Freud (1933b) wrote more specifically about the ego:
I must ... let you know of my suspicion that this account of mine of ego-psychology will affect you differently from the introduction into the psychical underworld which preceded it. I cannot say with certainty why this should be so.... I now believe that it is somehow a question of the nature of the material itself and of our being unaccustomed to dealing with it. In any case, I shall not be surprised if you show yourself even more reserved and cautious in your judgement than hitherto. [p. 58; italics added]
Evolution has provided man, in spite of repression, with numerous ways of becoming aware of much about his unconscious id activity-through dreams, art, literature, etc. Eventually, to these was added psychoanalysis. To borrow a concept from Jonas Salk's Survival of the Wisest (1973), the capacity of Freud's ego for certain new perceptions brought forth a "metabiological mutation" that speeded the evolutionary change of man in ways which, for better or worse, have transcended those changes brought about by the course of "biological" mutations. It is an interesting question and relevant to this discussion whether, were it not for an interest in analyzing neurotic conflicts, there would have been occasion for man to try to perceive his own unconscious ego activity and make it part of his consciousness. In the evolution of our capacity to perceive demonstrable ego mechanisms in their detailed roles in neurotic conflict, we are not assisted as with the "cooperative" qualities of the drive derivatives, which strive to find us. The workings of the id are, in many ways, available for those who wish to study them--even in settings that are not analytic situations; the defensive activities of the ego can hardly be captured in "closeup" except in an analysis that includes a consistent attempt to develop an increasingly autonomous capacity for an ever-freer intrapsychic spontaneity, reflectively observed and verbalized. Let us not be dissuaded by limiting factors from further evolution of our psychoanalytic technique in the realm of neurotic conflict.
The Ego In Session
For some analysts ego psychology has a bad name, whether because of psychoanalytic politics (a wish to disavow the so-called classical position) or because it appears to leave the "depths" of the mind behind or because-as a nonexperiential concept-"ego" does not have the appeal of, say, sexual or aggressive urges, affects, repetitive object relationships, or subjective states. "Ego" is an indispensable concept, however, and central to all clinical work. At the very least, the concept helps us in any assessment of a person's capacity to enter and participate in the analytic task. But much more is addressed by the concept "ego." In this chapter I use clinical vignettes to illustrate three of the ways in which the ego makes its appearance in sessions: first, in terms of the achievements and failures in its developmental history; second, in terms of its participation in the work of the analytic process; and third, in its more frequently described role in defense in relation to some intrapsychic disturbance. Each discussion will center on clinical judgments within the session.
"Oh, I don't know," she said. "I suppose it comes from his dyslexia, his learning disability. That made it very difficult for him in school--until he found rowing, which was something he could do well. The others he went to school with who had that problem had to face it earlier, but because of Steve's rowing he never had to, and now it's a bigger problem, because he put it off that long. Rowing's given him an avenue away from facing it."His wife interprets in terms of the past. Redgrave himself says, in effect, that rowing has aims, values, and pleasures in the present. Analytically, we are often aware of both and have to guide our intervention (or nonintervention) according to the success of or intrusions on ego function as experienced by the patient at the moment.
Issues around the loss of autonomy in what should be the primary autonomous ego apparatuses of perception, memory, thought, motility, or affect also come directly into sessions. I illustrate this with material from two adult analyses where there were intrusions on the autonomy of an entire mental function, not just anxiety or blocking around specific mental contents.
Arthur was an isolated, obsessional, and affectively dry graduate student in engineering who was, in spite of these traits, devoted to his analysis and made good use of it. Here and there, when a question came up about spontaneous fantasies or daydreams, he showed himself to be averse to them. Even more striking was that the same aversion applied to spontaneous memories. Of course he had memory; he remembered how to get to my office each day, for example, and how to speak the English language. But a concrete memory spontaneously appearing in his mind was greeted aversively, and he generally denied having any. He rationalized this pathetically: "I'm young. I live in a neighborhood filled with young people. We look towards the future; we're not interested in the past." I shall not go into this in any detail except to describe the turning point that culminated in its resolution--that is, a gradual return of the ability to permit spontaneous memories and fantasies. We were speaking one day of this aversion to memories when a memory burst forth from him. He recalled having worked as a dishwasher at a nearby luncheonette while in college. One day, late in the lunch hour, the dishes from the noontime rush were being carried in by the trayload by the waiters. "They were coming so fast I was afraid I'd be buried by the slop." That was it. Not a memory of some early trauma, but an indicator of, or a metaphor for, what the fear of memory was about: that memories would come so fast (and be so awful) that he would be "buried by the slop." By drawing on this now explicitly verbalized fear and fantasy, I was able over time to enable him to have spontaneous memories and daydreams and to work with them analytically.
In another patient, it was independent thought that was interfered with. Though his work as a high school teacher obviously required planning and communicating and thinking, in the analysis he disclaimed any of his own quite significant contributions to the process, reattributing his thoughts to me. It turned out that, among other things, thinking on his own had come to signify being alone. Fears and sadness regarding object loss (his mother had died when he was a young child) underlay much of the blocking in the use of an entire ego function: independent thought.
One last clinical illustration of the utility in the session of a concept of the ego and its developmental failure derives from when I was supervising a therapist-in-training who was working with Aaron, a ten-year-old boy. I thought at second hand that Aaron seemed phobic and essentially in the neurotic range. But his anxiety did not come under control through what seemed like good therapeutic work, and his fears spread now to this and now to that in a panphobic way. To get the feel of the child, I arranged to meet him through the premise of being a consultant who would work with the boy and his mother jointly for a few sessions. I was not with Aaron twenty minutes before I became convinced that his anxiety was of the overwhelmed panicanxiety sort, not a bound phobia with some affective spillover. There had not been, as I could then formulate it, the development of a successfully working anxiety signal that could trigger in-place defenses. Rather, anxiety "signaled" only that more anxiety was on the way, and it escalated to a flood almost instantaneously. In the session, when his anxiety grew and disruptive, frantic activity developed along with it, his mother started scolding him. I intervened and told her (in his presence) that he could not control himself at the moment, that he was overwhelmed and needed her help, and that her scolding was not useful. (As an aside, our exchange was interesting. The mother immediately became indignant. "You mean I shouldn't express my feelings?" she said. I responded: "Exactly. At least not right now. He needs your help." She instantly replied: "I'm in therapy myself and so are a lot of my friends and we're all learning to express our feelings, to let them out." "Yes, but not right now;" I said. "Aaron is overwhelmed and needs to feel you are in control and can help him get under control." Her final reply: "I never heard of such a thing!") In a subsequent session, when the anxiety again began to flood and his mother again began to scold, Aaron (in a voice desperate, pleading, and in pain) said to her over and over: "You heard what Dr. Pine said. You heard what Dr. Pine said. You heard what Dr. Pine said." Unfortunately, although he did, she did not.
My point in this first part of this chapter has been that, as illustrated by the case of Billy and the eventual emergence of a sublimated activity, the analyst or therapist is aided by having a concept of the ego and its development, that is, of the evolution and workings of the anxiety signal and defense and sublimation, of the maintenance of the primary autonomy of the ego apparatuses, and of the achievement of secondary autonomy in some activities--or failures in any of these. Modes of understanding are enhanced by such concepts, and interventions and their timing are in turn shaped by the understandings.
The Patient's Participation in the Analytic Exchange
The clinical examples I have been describing, involving recognition of achievements and failures in the developmental history of the ego as evidenced within the session, are specific and not always a focus of the work. By contrast, in this section I want to discuss a problem of general significance in sessions: the person's readiness, in ego psychological terms, to hear, work with, and contribute to the interpretive process. I again start with an example from the treatment of a child: eight-year-old Sophie.
Sophie had come to me some two and a half years before the events I recount. The only child of recently divorced parents, she was both lonely and, as her parents described it, "overexcitable." The parents were on good terms with respect to the handling of their child, and both expressed concern about the impact on her of the divorce and of the events that preceded it--events I need not go into. She also was said to create sadomasochistic games with her pet cat and her Raggedy Ann doll; her parents were worried about this--rightly so, I thought. From my first contact with Sophie it seemed clear to me that her "overexcitability" was an expression of her tendency to leap into excited action with overelevated mood the moment she had the slightest hint of any uncomfortable feeling; it was a form of defense through action.
In the first two years of the treatment, my main work was to enable her to experience feelings, to know them mentally, which again is ego development work, as I discussed in the prior section. We had made considerable progress in this area, though it was variable. About three months prior to the events I describe next she had come in reporting a nightmare. I explained to her how we could work as detectives, using the dream and her thoughts about it as clues to figure out what the dream was about. By this point she was able to participate in this work, even saying, "But what about this part of it?" halfway through the work on the dream, and greeting my final interpretation with, "Now I think you got it!" (Recall that she was only eight years old.) The dream led to her reporting a childhood secret (whether it had been available as a memory before and withheld, I do not know) and the related unraveling of a longstanding severe situational anxiety response, which has shown no sign of its presence since that work.
Now for the material I wish to report. Remember, this child formerly, and still at times, fled into excited action at the slightest distress. Reference to the sadomasochistic games and anything even close to sex or bodies was met with immediate flight. My aim is to discuss a patient's signaling readiness--conceptualized as an ego activity--to participate in the work in some particular area.
Sophie came in one day armed with a new joke. "Why did the man swim in the ocean?" "Why?" I asked. "To make peepee in it." End of joke, but the start of a long series of events in the sessions. She spent the rest of the session making drawings. One of them had what seemed to me a clear representation of male genitals; a second led to spontaneous verbalization on the same theme. I had simply made note of each one aloud as we went along; she listened but did not flee. At the end I recounted the common theme in the joke, the drawing, and the verbalization. She clearly saw it, expressed a mix of curiosity and distress in the tone of her "I don't know why," and hid her face in contained and focal embarrassment and without flight into activity.
In the next two sessions there was much related material, which I need not review. My point is only that she stayed with it, though she did say toward the end of one session: "You're a crazy man." I asked why. "To talk with a little girl about things like this." I heard real trust and affection in her statement, though puzzlement and concern also. I said with a smile: "It must seem strange, but it's something that's on your mind for some reason."
Sophie spent alternate weekends with one or the other parent, and the following weekend was her father's turn. He called me at about 7:30 on Monday morning to say that Sophie had had a bad dream and wanted to tell it to me. I was impressed that she wanted to bring it to me, and we spoke right then on the phone. Here is the dream as reported: "I was in bed with my daddy and a bad guy came in and shot me. The bullet went through my arm and stuck in my clothing between my elbow and my shoulder. I had to do a somersault to get it off. And then I woke up." I told her I was glad that she called to tell it to me, and that we could work on it in her session (later that day), just as we did with the other dream.
We did work on it. I need not describe her associations or my questions and interpretations. My aim is to detail her ability to participate in the work. The talk went to nakedness, to intercourse ("My parents don't do it!"), and to my interpretation of an overall sexual meaning. I did not bring anything into the transference. Her response to the interpretation, with playful mockery and yet recognition, was: "You solved it (the dream that is), but I don't like it!" Nonetheless she came back the next day (the last in this sequence) and said: "We didn't get it all yet. Why did he shoot me?" This led us into the sexual meaning of the shooting and a punishment meaning. She greeted this with: "Now we got it! [pause] Oh! I wish I had never told you that joke!" (about peeing in the ocean). With this remarkable statement she was showing that she had a grasp of the continuity of the whole sequence of the work though spread over several sessions, was feeling the discomfort, and was containing it.
To top this, after a pause she said spontaneously: "You're torturing me with talk about sex. I'm going to cut off your peepee and my daddy's:" I told her I could hear in her voice that sex talk was like torture and said it reminded me of the games she played with her cat and her Raggedy Ann doll. I wondered if she thought sex was like torture (there was a specific basis for my asking this, which I shall not give here). Her response: "No! [pause] Is it? [pause] For who? Both people or just one?"
Altogether a remarkable sequence in an eight-year-old who formerly had fled all discomfort, was unable to mentalize things, and instead rushed into action. She showed a well-functioning ego and a capacity to participate in the work at each step along the way: in her recognition of the sexuality in her drawings ("I don't know why"), in her playful and trusting comment (in spite of discomfort) that I was a crazy man "to talk about such things with a little girl," in her calling me to tell me the dream, in her recognition of when we "got" the understanding of the dream, and in her capacity then to ask, "Is it torture? For whom?" And, of course, her capacity was also shown by her staying with these themes for some five sessions spread over two weeks.
Many things lead to the decision to interpret: the expressive content itself, some optimal level of anxiety, the presence of some transference manifestation in the material. But I am here focusing on just one aspect: the indicators of a patient's capacity to self-observe and to hear and take in the analyst's words--ego functions. The same kind of assessment may result in quite different intervention decisions, and next I illustrate some of those briefly.
Several years ago I was working with a forty-year-old man, a mediator by profession and not by chance. He played, or sought to play, the mediator role in his physically violent family during his growing-up years. For the first couple of years of treatment, his own anger was notable by its absence. But then, in a half-dozen widely spaced sessions in our third year of work, I felt sure I was hearing explicit references to his anger, past or present. Each time I addressed it with a question or comment, however, he vigorously criticized me for pushing my own agenda and reading it into what he was saying, and then he withdrew. Only later did an understanding of the situation develop between us. He had, he later came to realize, semi-consciously made a pact with himself as a child: he would survive by mediating and never entering the fray himself. What I thought I heard as indirect communications about anger with an inner sense of (ego) control he experienced as alien and dangerous slip-ups, at least at the point at which I took note of them. Only after we spent considerable time on the childhood pact he had made with himself--that is, the defense aspect (to be the mediator only)--could his self-observation and analytic participation come into play in relation to the anger itself.
A second kind of situation involves observation of intact ego function signaling to the treating person a nonreceptivity rather than a readiness to explore. Some years ago, before pharmaceuticals rapidly cooled off psychotic processes in patients entering psychiatric hospitals, one would not infrequently see a therapist who had become fascinated by the exploration of bizarre psychotic thought processes and would feel the loss of it and find the work less interesting when the patient reinstituted what were often tight controls and became quite dry. Not infrequently a therapist would try to reach back into the psychotic thinking with the unsurprising result that the patient withdrew, got angry, got frightened, or, in the worst instances, slipped back into the disordered thought. Here, a surface of intact ego function signified not the readiness to explore, but an effort to blot out all mental dangers. Time enough to explore when the patient, without prodding by the therapist, began to slip; at such times, some patients, frightened by the possible return of the psychotic thinking, could welcome exploratory interventions that had the intent of clarifying things in order to reestablish control.
A third kind of example occurs sometimes when we are working in the midst of an intensely rageful, sexual, envious, or other transference struggle that is paralyzing the work. We work in the transference because it has the most immediacy and therefore the most heat, but if it is too hot work can be impossible. No work gets done when the observing ego is swamped and loses its autonomy in the face of whatever passion is active. Often it is useful in such a situation to move the work elsewhere, to the past or the outside present (around the same issue), to cool off the situation enough to make self-observation possible. This is a variant of something I wrote about earlier under the heading "strike while the iron is cold" (Pine, 1984). There I referred to fragile patients or to moments in any treatment when interpretations could not be received (during conditions of great affective intensity) because the experienced danger to intact ego function was too great; interpretation in the form of education-like clarification could sometimes be made in a subsequent session--looking back--after the storm had quieted. In the instance of moving interpretation out of the transference, we could say we strike where the iron is cooler. In all my examples I am trying to show how an assessment of ongoing ego function, particularly in the form of the observer capacity, guides intervention or helps us refind our bearings when we go astray.
A final, more general point, at the level of theory of technique, further entails addressing the patient where his or her observer function can be operative. In his central body of work, Paul Gray (1994) stresses the importance of staying close to the analytic surface and thus working where the patient can become aware of what is going on. He does this by proposing that we listen for the drive derivatives in the patient's associations and then taking note to ourselves and to the patient of his or her flight from, undoing of, reaction against, or other resistance to that content. I am here addressing that same technical point. My disagreement with Gray is that he narrows the field of the work too much in assuming that the relations between drive derivatives and defenses are the principal contents of mind for analysis. Fred Busch (1995) working similarly to Gray, broadens the field by suggesting that we keep an eye on the analytic surface for any sign of distress, without presuming that it is in response to drive derivatives. This leaves room, in my terms, for distress also in relation to repetitive object relations growing out of strain trauma from the childhood era, or painful subjective states of self around deficits in parental care, or feelings of humiliation or helplessness in relation to defects in ego function. But the overall thrust of the discussion is the focus on the area of mental function with respect to which the patient can come to see and know what is going on inside.
A discussion related to both Gray's and Busch's points took place between Theodore Jacobs and Andre Green at the Congress of the International Psychoanalytic Association in 1993. Jacobs had presented process notes of a session. Green, the discussant, was critical of Jacobs for not going deep enough, not interpreting various things that had been implied in the patient's associations. Jacobs's response was to the point. He said, in effect, that "going deep" means going where the patient can still recognize what you are saying and where it draws from (self-observation); Dr. Green's "deep" interpretations, Jacobs suggested, would be mere words, in essence promoting intellectualization and not "deep" at all.
Eleven-year-old Johnny, whose presenting problems at a city hospital clinic included clowning behavior sufficiently compulsive that it had contributed to school failure, was seen by a supervisee of mine in twice-weekly psychotherapy. The clowning behavior and other symptoms had erupted after a series of separations. The first separation was brought about by the child's removal from his home by a city agency following maternal neglect and paternal abuse. He went to one foster home and then to the homes of a series of relatives, none of whom kept him for long, in large part because of his other symptoms--encopresis and collecting things from street garbage cans that he would store under his bed. He was now living with his maternal grandmother, who was also threatening to move away with another grandchild, leaving him behind. The incident that follows addresses the clowning behavior and the separation issue.
Johnny had rapidly grown attached to his female therapist and, in numerous ways, demonstrated his wish to make the office his permanent home. Now, several months into the treatment, in the session I draw from, his therapist had asked him to tell her about his memories of his several shifts of home and what these homes and the shifts had been like for him. Johnny spoke articulately and with surprising readiness; he had not been very expressive before. He focused especially on his time with his mother and father. The details are not necessary for the point I wish to make, except to note that he reached the point of saying, quite movingly: "I'd give anything to be back with my mother!" This was immediately followed, his therapist told me, by a plunge into a joking, clowning attitude. The high point of the clowning was his rapidly pulling any available junk from his pockets while saying: "I'd give anything--even these paper clips, even this spool, even these candies!" The therapist told me that she immediately saw the clowning here as his driven effort to escape the pain of longing consequent upon his recalling his life with his mother and expressing his wish to be back with her. It is of interest (though a side point) that this beginning therapist also told me that she chose to say nothing to the boy, in large part because (as she recognized) she was herself uncomfortable with the degree of his pain and longing.
Thus far we see a simple and straightforward example of defense against inner distress. While the defense concept initially came into use to describe defense against drive derivatives (such as fantasies or wishes), Anna Freud (1936) explicitly extended the concept to include defense against affect; and later, Arnold Modell (1984) extended it to include defense against object relations. Perhaps the strongest and most unifying formulation in this domain was offered by Jacob Jacob
son (1994). He suggested that the common conceptual ground that binds diverse psychoanalytic theories of mind together is the centrality of theories of painful affect. From this perspective, psychoanalysis centers on a view of the mind as beset by painful affect that has to be coped with (defended against, managed) in some way. Psychoanalytic theories differ in terms of what they see as the nature and source of the painful affect and the means of dealing with it, but the task--defense against affect, as seen in eleven-year-old Johnny--is essentially the same in all psychoanalytic models.
Johnny's session continued. About ten minutes later, he started talking about videotapes. He said that he and his mother used to watch videotapes together. To the therapist's "Tell me more;" he added: "We would watch and joke around; we had a lot of fun when we did that; we would get silly together:' The student therapist did not pick up the link until I pointed it out, but what have we here? Suddenly the joking as a defense against painful longing appears in a different light. Now it is readily seen as a repetition of a (perhaps only imagined, perhaps real) pleasurable part of the lost object relationship with mother, a means of actualizing in the present the memory of "joking around" with his mother. So, if we go back, the sequence is as follows. He says, "I'd give anything to be back with my mother" and then, via his joking ("even these paper clips, even this spool"), he
transports himself (probably without full awareness, perhaps marginal awareness--we do not know) back into the situation of the imagined and longed-for relation to his mother. He has simultaneously protected himself from his pain and, in this clowning way that is quite automatic for him, fulfilled his wish; clowning has placed him back with his mother.
Is one of these two views of his "joking around"--the defense view or the object connection view--more "true" than the other? In this instance, I think not. I believe he could have responded well to interventions from both points of view, experiencing their intrapsychic "rightness." If they were worded properly, I believe they could have become usable for him without simply worsening his pain. I shall suggest some interventions in a moment, but first some further discussion of the intrapsychic defense aspect of the ego in the session.
Ordinarily, we think of defense in the session not as something having "thing" quality, not a defense "mechanism," but as a moment in a process, a way the clinical material can be organized at that moment. It is not the case that the possibilities for such organization are unlimited; "anything goes" does not go well. But there is usually more than one way to understand the associative material of the session that can be useful in moving the treatment forward. Interpretation in terms of defense, as modulating unpleasant affect or fleeing or disguising thought content, is often one of those ways.
We no longer think of defense as simply a sign of "resistance" that must be gotten through in order to get to the "real" content. Defense is understood now as a reflection of the person's mode of coping, of functioning in relation to the internal world. As such, it is at least equal in significance to any other part of mental life that is to be explored in a therapy or analysis. While Breuer fled analysis after his experiences with transference (his patient's falling in love with him), it was one of Freud's great achievements to turn the view of transference upside down and find it to be not a problem requiring flight, but one of the invaluable routes into the exploration of the patient's psyche. Concepts of resistance and defense followed a parallel path of development in the theory of technique. At first they were seen as something to be gotten out of the way in order to reach the unconscious fantasies and wishes reflective of infantile sexual drives. Later, with the development of an ego psychology, defense and resistance came to be seen as direct expressions of core features of the person that were themselves to be understood. And, with Wilhelm Reich's (1949) work on character analysis, they came to be seen as central features of characterology. Today, when most analysis is character analysis, defense and its expression in the so-called resistance are at the center of what analysis helps the analysand to see in all its functions, its rigidities, its maladroit self-defeating efforts at adaptation (when these are indeed the case), and its history.
When Johnny said, "I'd give anything to be back with my mother" and immediately shifted into his joking mode, and considering that he was an abandoned and neglected child and that the loss was real, I would have intervened in a way to enable him to hold onto his wish to at least some degree by simultaneously helping him bear his pain. The wish was, after all, a tie to the only mother he had. Bearing in mind that he was quite trusting of and attached to his therapist at this point in the treatment, I proposed that she could have said something like: "I know you started joking because of how hard it was for you when you said you'd give anything to be back with your mother; of course you would like to be back with her; I understand that." Remember that at this point in the session we do not yet know that "joking around" was a way of being with his mother. Let me make clear the aim of the intervention as stated. Clowning behavior was getting him into difficulty, including school failure; it was problematic. Though intrapsychically an effort at defense, symptomatically it was maladaptive. Here my intervention has the intention of indicating my understanding of the function of clowning (clowning started because the expression of the wish to be with mother was painful) and offering another mode of managing the affect (a defense equivalent) through the current object relation to the therapist ("of course you would like to be back with her; I understand that").
Later, when Johnny's associations went to the video experiences with his mother ("We would watch and joke around; we had a lot of fun when we did that; we would get silly together"), and the "defense" turned out also to be a significant means of actualizing the past relation to his mother in the present, I would probably have made that clear to him as well, seeing this as an opportunity to give him back a piece of his relation to his mother, showing him that he does carry her with him. Thus, I might have said (right after his "we would get silly together"): "Oh! Now I understand something else, Johnny!" (this by way of alerting his attention). "When you started joking before, after you said you'd give anything to be back with your mother, the joking was one of the good ways you really could be with her. I guess there are some good memories, and you can hold them with you by joking around." I imagine it would only be a matter of time after this that the treatment could also turn to the compulsive quality of the joking--the clowning behavior--and at least one of its functions revealed here, in order to begin the process of enabling him to give it up in its maladaptive form.
Like the question of the patient's readiness to participate in the analytic work, the issue of intrapsychic defense is relevant at all times and in all sessions. Defense (the modulation of inner distress) is an ongoing part of mental life. Whether it becomes the central focus of the work depends on many factors, including the degree to which it is seen as obstructing the analytic work, the degree to which it is seen as revealing something important about the patient, and altogether its relation to whatever seems the central issue of the session. Defense is always present; whether it becomes the interpretive focus depends on its place in the hierarchy of affective significance at the moment.
The wealth of intrapsychic issues potentially reached through paying attention to (rather than getting past) defense and its expression as "resistance" in the session is well illustrated in the following treatment of a woman in analysis. She was thirty-five years of age, married and childless, when she came for treatment. She sought help because she both wanted to have a child and feared it. The fear was paralyzing, and it took the form of anxiety-driven obsessive thought: "It will be too much" or "I'll get overwhelmed" or "I'll be out of control" or "It will be too confusing." She had been stuck with this thought for years and could not bring herself to try to conceive. Now, having reached age thirty-five and very much wishing to have a baby, she came into treatment.
Two things became clear as the work progressed. The first was her thinking style in the sessions. Her thoughts would come in a flood. Her ideas seemed dynamically rich, her delivery insightful, but one idea would follow the other, tumbling out in confusing array. There was never a quality of looseness or thought disorganization, but rather of rushing away from each idea, and presumably its attendant dangers, soon after she had given voice to it. In this sense her thinking was quite well organized; she had a reliable and predictably utilized defensive mode available in the face of intrapsychic distress: mental flight. She would come back to many ideas in her later sessions, but they were not built upon and were therefore for the most part useless to her. (There were of course exceptions, but those are not my focus here.) Though the ideas would reappear in subsequent sessions they still seemed not to be "held"; rather, they seemed to "occur" to her, almost to "happen," again and again, before once more being left behind. Excess and flight served as her defense; it was the functional "resistance" in the session that made progress slow.
The second thing that became clear as the work progressed was the nature of her life history as she experienced it. Here too the quality was one of flooding, of "too much." Was this colored by her mode of telling about it? Was there something about her that led to her experiencing it that way in the first place? While neither of these two possibilities can be entirely ruled out, the internal feature of the analytic process strongly supported the view that she was indeed subjected to too much knowledge, too much overhearing of things, too much seeing. As the only child in a household that included her parents, two Don Juan-like maternal uncles, various governesses and other servants, and highly flamboyant maternal grandparents, each of whom had had active and publicly known sexual affairs throughout her growing-up years, she was overloaded with sexual knowledge long before she could assimilate it even minimally. Add to this her own fantasy elaborations and wishes, and the picture of hyperstimulation was complete. So the history, the style in the sessions, and the presenting problem all revolved around the quality of "too much": too much confusion, overstimulation, and experience beyond what she could control. One can see immediately that the "resistance" is the life story. Whether it is treated as defense-resistance or as expressive content to be kept in center stage would depend on the analytic moment and how the analyst thinks it would be best approached at that particular time.
To date (the analysis is still in process), the style of flight from ideas (not flight of ideas) has been understood in a number of ways: (1) as a protection against being overstimulated by seeing too much, knowing too much, the flight now from her own thoughts about the overstimulating memories, but also directed against thought in general; (2) as a turning of the passive to active with respect to overstimulation, now drowning the analyst as she had felt drowned as a child; (3) as an expression in (verbal) action (on the analyst) of her experience of the overstimulation as an assault; (4) as a mode of being stupid, of maintaining stupidity, of not knowing--something that affected her day-to-day functioning in widespread and limiting ways--and of having this "stupidity" set in especially when she was angry (suggesting her own anger at the overstimulating intrusions, the other side of the experience of being assaulted); and (5) as a participation in the familial mode of denial of what is in fact being revealed and communicated, this denial serving as self-protection and, more idiosyncratically for her, as a way to preserve her idealized view of her father as well as to identify with him and protect him against her own jealousy and rage.
Analysis of "resistance" in a case like this is not intended merely to get past it to something else but to analyze it, to understand its component parts and their history and its place in the patient's life.
Let me give one last example of a focus on defense, in this instance a misplaced focus, stemming from the analyst's misunderstanding of what were the patient's primary concerns at that particular point. The analyst's intent was, in effect, to say, "You are talking about this because it is safe and keeps you away from something else." Only in time did the analyst come to believe that the patient was talking about what mattered in a way that mattered, and that she (the analyst) had been endeavoring to impose a particular view of mind on the patient's material (see Chapter 7 for further examples of this kind of error).
I enter this analysis in midstream without giving its history or the patient's history. I do this because my aim is to illustrate a point; I recognize that without full backup material, the reader cannot truly make an independent judgment about it.
The patient, a forty-year-old man who had graduated from law school but never managed to pass the bar examination and was now working in a family business, would regularly come to sessions and talk about films he had seen and things about himself that they had reminded him of. Often these were memories of anger and associated guilt; equally often they were memories of sexual experiences with attendant shame. This material seemed significant to the analyst, though it had no apparent relation to the problems that had brought the patient to analysis (which I shall not go into here). In numerous sessions, the patient would turn from these film-stimulated memories and confessional reports to speaking of his unhappiness with his work in the family business, where (he said) he never got sufficient praise and recognition. He would go into elaborate detail about moments in his life when such recognition had been forthcoming, especially from his many girlfriends, and how precious that had been to him. He would bemoan the lack of recognition that he felt when his analyst was silent, but spoke of how he would feel a glow when his analyst would (as he experienced it) find something of value in what he had been saying (indicated by her making some interpretation).
The analyst had been thinking of these shifts in the session (from anger-guilt and sex-shame to the search for recognition and praise) as a form of backing off, of seeking to feel valued in spite of the "confessions," of shifting to safer areas--in short, as a resistance that the analyst would interpret to enable the patient to "get beyond" it and arrive at some other place (the anger-guilt and sex-shame issues). Only gradually did the analyst turn her understanding around a full 18o degrees. The analysis took a decisive step foward when she came to the belief that the self-esteem issues (reflected in the search for recognition and praise) were the primary ones and that the reports about sex and anger reflected the patient's attempt to please the analyst and get "recognition" and "praise" from her.
The concept of intrapsychic defense evolved within a particular theory, Freud's theory. I have already suggested that it must have a place in every psychoanalytic theory of mind; each of those theories includes a central focus on psychic pain, however that is understood within the theory, and therefore the human mind will be understood in part through its efforts to cope with that pain (Jacobson, 1994). But when the mind is viewed single-mindedly, around one set of issues that are seen to be necessarily the main ones (whether this be sexuality or interpersonal experience in the here-and-now or internalized object relations), failures to understand become a real danger. In the reported instance, my guess is that the anger-guilt and sex-shame issues will eventually find their place onto center stage in this analysis, although they are not there at this point. The analyst, working within a particular theoretical model, was seeking to put them there, thereby ignoring the central thrust of the patient's material; hence her view of the self-esteem material as resistive rather than expressive. "Defense interpretation" is central in analytic work, but it is only one part of the full story of an analysis.
What I have been attempting to show is that, seventy-five years after its formal origins (Freud, 1923, 1926) and sixty years after its flowering (Freud, 1937; A. Freud, 1936; Hartmann, 1939), an ego psychological point of view can be--I would say should be--a living presence in the analytic hour. It provides tools for comprehending aspects of what is going on and how and when to approach it. It spawns concepts like ego defect (Pine, 1985, 1990), alerting us to unreliable or distorted or delayed development of defense, the anxiety signal, affect modulation, impulse control, a sense of separateness (which is a part of reality testing), object constancy--all significant achievements subsumed under the concept "ego:' It alerts us to one of the ways in which pathology is organized--in incursions on the ego's autonomy--whether these incursions come via object need (as in the patient who feared the consequences of independent thought) or via the "slop" of sexual and aggressive memories (as in the patient with the aversive response to spontaneous memories and daydreams) or in numerous other ways.
Though not illustrated here, ego psychology offers us the concept of the ego's relative autonomy--not either-or--such that the autonomous function of memory, thought, or the like may be seen as present at one moment and absent at another, a concept with major implications for the timing and focus of interpretation. It can alert us to another aspect of the relativity of autonomy (also not illustrated here)--the "how much" dimension: not too hot, not too cold, but just right. We have all seen instances where the "autonomy" of thought, for example, is so complete (so separated from affective and wishful sources) that the thought process is dead and dried out, with all affective energy eliminated from it (a caricature of autonomy), or where it is so animated, so suffused with wish and urge, that it suffers distortion. An ego concept also gives us tools for distinguishing between well-functioning defenses, sublimations, or other adaptations and their breakdown, again with implications for the when and how of intervention. It supplies a multitude of ways to recognize when the patient has enough observing ego to receive what is offered interpretively. And, in its most familiar role, it offers a conception of intrapsychic defense and of resistance within the analytic process, now seen to be equally significant for what they reveal and what they obscure.
Work in these ways, around and with a concept of the ego and its functions, is not what I believe analysis is. It is not the interpretation of defense before impulse. It is not the finding of creative ways to work with ego defect (Pine, 1990; Fleming, 1975). It is not interpretation in the transference. It is not reconstruction. It is not the processing of countertransference reactions or the interpretation of transference-countertransference enactments. It is not a focus on the here-and-now relationship of two people in interaction. And it is not a focus on the patient's current psychic reality or subjectivity. It is all of these things at some times, and any one or more of them at particular times and with particular patients.
An ego psychology is a necessary part of all theories of contemporary psychoanalysis, even though it had its conceptual birth in relation to a particular theory. Whether we view the mind as powered by sexual and aggressive urges and fantasies, internalized object relations, painful subjective states, or something else, problems of defense in relation to intrapsychic life, of adaptation to the outside world, and of reality testing all remain. An ego psychology addresses them. And we have conscious minds, capable of planning and anticipating and judging. So we have to recognize that we are powered not only by what is in the depths but also by rational thought, and that too is recognized in our concept "ego."
Ego psychology retains a firm place in the psychoanalytic pantheon in relation to both the multiplicity of current theories and the central current focus on technique. Having illustrated that here and having also previously discussed relational components of the therapeutic impact '(in Chapters 3 and 4), I now turn to a subject that draws on both aspects: questions regarding (ego) defect and (object relational) deficit in development and treatment.