Martin Burgy
Freud's intrapersonal concept of anal-sadistic regression isset against the interpretation of obsessive-compulsive neurosis as astructural ego deficit. The interpersonal dimension that comes to the fore as a result of this, becomes clear if we focus on obsessive-compulsive behavioral disorder: Persons suffering from obsessive-compulsive neurosis lack the self-assessment factor. It needs another person as part of their own ego who accepts and supports them in their behavior. A clinical example illustrates this narcissistic function of compulsion together with the changes in the psychodynamic approach and resulting therapy. Against DSM-classification with the concept of obsessive-compulsive disorder, which contains an unspecific symptomatology that occurs both in neurosis, schizophrenia, melancholia, and organic psychosis, this article advocates the specific and differentiated concept of obsessive-compulsive' neurosis.
In "Inhibition, Symptom and Anxiety," Freud, as early as 1926, pointed at the narcissistic gratification that the obsessive-compulsive symptom offers the patient: "The systems which the obsessional neurotic constructs flatter his self-love by making him feel that he is better than other people because he is specially clean or specially conscientious" (1, p. 99).
This secondary gain from the disorder supports the striving of the ego at assimilating and thus establishing the symptom as part of the personality's character. In Freud's opinion characteristics like tidiness, cleanliness, politeness, accuracy, and economy are in fact reactions set up to fend off anal-sadistic impulses. The personality traits are not what they seem, but point at an underlying unconscious or intrapsychic conflict (2, 3).
Most subsequent authors adopted this view. Hoffmann, for example, comments on obsessive-compulsive neurosis as follows: "There are hardly any recent publications on phenomenology, nosology and psychodynamics, rather, the well-known positions are repeated all over" (4, p. 45). And in his book on psychodynamics of obsessive-compulsive neurosis, Benedetti writes: "Freud's model continues to be the basis of all psychodynamic thinking. It is only when summarizing the literature that one can see just how modest the subsequent publications are as compared to the brilliance of Freud's model" (5, p. 16). Notwithstanding the acknowledgment of Freud's merits, Benedetti is critical of the fact that Freud's successors as a matter of course continue to adopt his theory and to hand it down without questioning it in any way.
FREUD'S INTRAPSYCHIC VIEW
The Oedipal conflict is at the center of Freud's thinking. Once the genital phase has been reached, the ego's defense struggle sets in, fuelled by the suppressed castration complex. Using a whole series of defense mechanisms, such as isolation, denial, magic thinking, intellectualization, and rationalization, the ego withdraws to the former anal-sadistic level of development. Regression is seen as the successful defense of a mature and stable ego structure. From the point of view of structural dynamics, regression of the ego leads to increasing severity and lack of love on the part of the superego, as more and more id-impulses have to be fended off. These impulses are anal-sadistic (antisocial, aggressive), anal-libidinous (pleasurable soiling) and genital (onanism, homosexual and heterosexual desires). The ego develops obedience towards the superego and identifies itself by reacting accordingly with the traits of the anaclitic character as indicated above. The compulsive symptom develops into the ego's compromising symbolic way of solving conflicts between the superego and the id. Freud, therefore, is of the opinion that in the form of obsessive-compulsive actions "the masturbation that has been suppressed approaches ever more closely to satisfaction" (1, p. 115).
In 1996, Joraschky takes up this view by describing the symbolism of ablutomania in the following way: "Thus washing one's hands, on the one hand, cleans off magically guilt, but can, on the other hand, be a new form of onanism that is inconspicuous to one's conscience" (6, p. 56).
Attention is focused on the intrapsychological structure and conflicts, so that Freud's theory of an internal dependence on the superego instead of the external dependence on people around continues to prevail in obsessive-compulsive neurosis (7).
INTERPERSONAL VIEW AND NARCISSISM
As psychoanalysts continue to hold on to the concept of one-person psychology, they tend to lose sight of the interpersonal and interactive processes in obsessive-compulsive neurosis, although Freud described them, albeit without going into any further detail, in his introduction to the treatment of the Rat-Man. The first comments his patient made to him at the initial analysis session were as follows: He had a friend, he told me, of whom he had an extraordinarily high opinion. He used always to go to him when he was tormented by some criminal impulse, and ask him whether he despised him as a criminal.His friend used then to give him moral support by assuring him that he was a man of irreproachable conduct, and had probably been in the habit, from his youth onwards, of taking a dark view of his own life. At an earlier date, he went on, another person had exercised a similar influence over him. This was a nineteen-year-old student (he himself had been fourteen or fifteen at the time) who had taken a liking to him, and had raised his self-esteem to an extraordinary degree, so that he appeared to himself to be a genius. (8, p. 159)
The element of relationships in compulsion can clearly be seen here, the psychodynamic background of which is described by Quint (9) in the disturbance of the obsessive-compulsive neurotics' actions: Obsessive-compulsive personalities can rely neither on their actions nor on their thoughts, as they lack the self-evaluating function. They need the other person, who will acknowledge and confirm their actions. In the clinical field this shows in the incessant questions that these patients address to the most important persons they relate to. Thus, in the case of ablutomania, they want to know if their hands are really clean, in order to stop washing them. Tormented by the thought of having, for instance, infected or soiled someone (even without touching) they try, with the help of the other person, to turn the magic experience into a generally acceptable reality. In this process the other person has the function of a self-object. In terms of relationships, it is the narcissistic hunger for the other person, who enable neurotics, incomplete in themselves, to acquire recognition and esteem to repair their structural ego deficits (10). As regards the genesis of the disorder, there is reason to believe that in childhood,neurotics had been unable to experience their parents as a part of themselves and were thus not able to experience their own value and ability to achieve something.
Janssen (11) takes a somewhat similar approach, describing the psychodynamic function of obsessive-compulsive symptoms as a way to cope with a conflict of symbiosis and separation, namely that, on the one hand, the symptom tries to prevent blending with the primary object, and, on the other, to compensate for a threatening object loss. Rudolf (12) calls it the neurotic's fragile ego in need of an object whose compulsory mechanisms serve the purpose of emotionally soothing and stabilizing an aggressively agitated self that fears above all the disintegration and destruction of its object relationships.
From this viewpoint, obsessive-compulsive neurotics strive to hold onto and control the other person as a part of themselves, in order to establish a feeling of undividedness, while at the same time secretly rebelling against it. They want to establish the narcissistic symbiosis in which postmaturing can become possible (13). The successful mother-child symbiosis is, according to Mahler (14), the precondition for a basic feeling of self-identity, while according to Winnicott (15), the infant's experience of controlling the mother and the possibility of experiencing her as a part of one's own self is a precondition for all future object differentiations. This view is complemented by clinical findings made by Quint (16, 17) and Lang (18). The following case study is aimed at illustrating the theoretical approach described for psychodynamics and therapy of obsessive-compulsory neurosis.
CASE STUDY
INTERVIEW
At the preliminary interview before inpatient psychodynamic psychotherapy, Ms. A. would not shake hands. One reason was that it was painful, because her hands were sore from washing, and the other, that she was afraid of being soiled by touching the other person. Sitting there, her mouth half open, she looked like a disabled child.
Her speech was clumsy and later on became more and more pressured.
Ms. A. started by saying that she had only come to the clinic because her mother had insisted on it, feeling she could no longer stand the situation with Ms. A. at home. At the age of 11, she had come home from playing being dirty all over. Her mother scolded her and called her dirty and revolting. Theses words triggered a washing and cleaning compulsion. Ms. A. can no longer tell herself when exactly her hands or the kitchen are clean. She needs her mother's confirmation that everything is clean. She also needs her mother's assurance when buying clothes, in order to know if a certain pullover, for example, goes well together with a certain pair of trousers. Ms. A. says that her mother is, therefore, the most important person in her life, although she can never really do things right for her. She feels worst when her mother is away for the weekend. She would then constantly clean and wash her hands, until they start bleeding. In her mother's absence, she has the feeling that people outside the house can notice her anxiety and are attracted by it. She would keep checking the front door all night for fear of being killed. She thus cannot live without her mother. She has tried five times to undergo psychotherapy as an outpatient, but it did not help her in any way.
BIOGRAPHICAL BACKGROUND
Ms. A. was born one year after her sister. She states that she was not a welcome child and that she should have been a boy and been born two years later. In the mother's opinion she had been a restless and disturbed child. The father played no role in the family and did not want to have anything to do with the family's problems. When there were arguments, he would sneak out into the garden. All in all, Ms. A.'s development was delayed by two years. Due to enuresis, she only started nursery school when she was five, and entered first grade at the age of seven. In her opinion nobody at school could stand her. After leaving school she continued to be an outsider as she was notable to take criticism. Therefore her mother was the only person she could relate to. When the mother came for the interview, she was apprehensive and unsure of herself. She reproached herself for her failure in raising her daughter. She said that the fact that the second daughter was born so soon after the first had been too much for her right from the start. And even today, she still feels that her daughter's incessant washing, asking questions, and making obstinate demands are almost unbearable for her. The daughter would go on for hours asking her to lend her the car, so that even though she needs it herself, she would finally give in to her.
THE NARCISSISTIC FUNCTION IN SYMBOLS, MAGIC THINKING, AND SADISM
The characteristic feature of obsessive-compulsive behavior is that in spite of numerous repetitions, there is no guarantee of success. As self-feeling and the self-assessing function are not sufficiently developed, persons suffering from obsessive-compulsive neurosis need the endorsement of another person. Thus Ms. A. is unable to judge whether her washing and cleaning have been successful, nor can she Indepedently decide on questions regarding her clothes. Hence she is excessively dependent on her mother.
The onset of the illness at the age of 11 already shows the existential importance of the mother: The mother's criticism concerning her dirty appearance cannot be faced, so that Ms. A. starts to wash herself compulsively. This compulsion is aimed at closing the apparent rift. It does not have the meaning of a symbol but rather that of an attempt at bonding. When left alone by the mother at weekends, Ms. A. washes her hands until they start bleeding and she is afraid of death. Asked about the meaning of her washing her hands, Ms. A. at no point of the therapy talks about guilt or pleasure and masturbation, but only about her fear of dirt, bacteria, and poison that might find its way into her body and kill her. As regards its contents, compulsive behavior is, therefore, more a paranoid concretism than a symbol. In addition, in Ms. A.'s case, the underlying fragility of the boundary between the ego and the world around becomes apparent both in a "tactile taboo" that Freud first described in obsessive-compulsive neurosis in 1913 (19) and in the opinion that her fear would attract her killer. Magic thinking clearly describes the illusionary-narcissistic attachment to the object. While Freud's concept of neurosis sees the child as a clearly defined uniform ego, magic thinking is characterized just by the nonexistence of a clear dividing line between the ego and the object. The thoughts acquire independence and a material nature against the patient's will. Genetically speaking it is possible to establish a connection between the magic loss of control over one's thoughts and Winnicott's development phase of narcissistic omnipotence: Infants believe that they can control their environment, i.e., the mother, but that is just what they cannot do. As the narcissistic unity is fragile, the inadequate reflective behavior on the mother's part leads to a situation in which the connection between internal condition and external reality is not established or only inadequately so.
Successful symbiosis, by contrast, is a necessary precondition for a separation of the self from the non-self and thus also for the bridging of the resulting difference between mother and child by the symbol. The example of Ms. A.'s biography, which was extended by the mother's anamnesis, shows that Ms. A. was not a welcome child. Right from the start she was too much of a burden for the mother, so that no adequate resonance and symbiosis could ensue. Sufficient experience in controlling the object is lacking. Ms. A.'s existence still fully depends on the mother who represents security to her. The fear of not achieving the symbiotic relationship correlates with the fear of self-disintegration. Self-will, aggressivity, spontaneity, sexuality, and sadism must be suppressed. As a rule, the families of origin of obsessive-compulsive neurotics are described as severe and rigid: The omnipotent parent insists on slavish obedience. The originally external compulsion turns into an internal compulsion, the cruel other turns into the interiorized cruel other in the form of a punishing superego. The reactive equivalents of the superego are sadistic, despotic, antisocial id-impulses.
As regards interpersonality, the opposite point of view must be adopted: The severe superego is not the genetically primary element that suppresses the id and thus makes it sadistic. Much rather, the sadistic impulses are there first and are reactively confronted with a rigid superego in order not to jeopardize the vital object relationships. Ms. A.'s case shows that the mother is in fact a woman who is not tough, cruel, and persecuting, but actually highly accommodating. However, the second child, i.e., Ms. A., was far too much for her to cope with. As Ms. A. cannot exact her mother's love, she forces her at least to take notice of her by tormenting her with her compulsions. Like many other patients, Ms. A. admitted in the course of the therapy that at times she deliberately used her compulsions to have her way with her mother.
Winnicott (20) describes this antisocial tendency as the child's attempt to force the environment to look after it. In his opinion, uncleanliness, ablutomania, and demanding behavior, as can be found in Ms. A., point in this direction. The child wants to bring about the mother's attention by force. An important element here is the illusion of omnipotence, of magic control and manipulation of the mother, which has already been described, that serves to control and express the original existential fears. In Winnicott's opinion there is no primary narcissism as postulated by Freud, but a primary dependence on the mother. If this step in development is not successful, the most important subsequent relationships must be controlled like seals, in the sense described by Morgenthaler (21), in order to counterbalance the structural ego defect. This also seems to be the reason why in obsessive-compulsive neurotic personalities love and hate are so close together. Particularly people who are close to one, are treated with extreme sadism. The dividing line between good and bad is inadequate, a fact that induces Quint (16) to assume that there is a disorder in differentiating between good self and object images, on the one hand, and bad self and object images on the other. This split prompts Janssen (11) to establish a connection between obsessive-compulsive neurosis and borderline organization. At the root of sadism there is,in fact, the desire to be taken notice of.
RESULTS AND THERAPEUTIC CONSEQUENCES
The concept of obsessive-compulsive neurosis, developed by Freud and widely accepted until the present day, should be enhanced by the interpersonal and narcissistic dimension. In this view, narcissism does not mean an original independence of the environment, but man's need for wholeness that exists right from the start (22). Given the lack of symbiotic experience and resonance, obsessive-compulsive neurotics cannot rely on their actions but continue to require the other as self-object. They struggle for narcissistic symbiosis, that is a precondition for separation and autonomy. Whereas in successful symbiosis, symbolization serves as bridge between the resulting distance to the primary object, the actions of obsessive-compulsive neurotics do not have the function of a symbol but constitute a makeshift attempt at bonding. Magic thinking and sadism also point at the attempt to achieve narcissistic control of the object or at least to be taken notice of.
In Ms. A.'s case this became obvious both in her behavior towards her mother and during the therapy: The initial reluctance to enter therapy can be connected to Ms. A.'s fear of separation from her mother. Her thoughts continually revolve around the home and she adopted a contemptuous attitude towards the therapy. With the therapist tolerating her contempt, Ms. A. started to torment him with endless questions and reports regarding her compulsions, professional future, medication, clothes, etc., in the same way as she did with her mother. For instance, she secretly changed the medication and tried to make additional therapy appointments. The secret pleasure for her derives from this struggle, in which she is taken notice of, in which she can bring something about, and in which a difference in viewpoints can arise. Just like in the therapy of borderline patients, it is important here that therapists have a supporting function. At the same time a struggle for clear limits that connote security takes place (11). Given the lack of symbolizing abilities described, interpreting the compulsory symptoms, for instance, must be dispensed with. Quint (9) points out that there are cases where confronting and interpreting strategies lead to symptoms with autistic withdrawal, depersonalization, paranoid experiencing, severe depressive reaction, and diffuse anxiety. Once Ms. A. embarked on the therapy, her washing compulsion at weekends was interpreted as aggression towards her mother. She reacted by developing massive paranoid fears of being discharged from the hospital. This shows that her washing compulsion was in fact not symbolic "make-believe" but rather an attempt at bonding that degenerated into repetition and that, at the same time, served the purpose of relieving diffuse fears and aggressive tension. It is a technical error to interpret aggressivity in such a case, a strategy which, given the existing structural deficiency, brings about fears of object loss and self-loss. In the traditional terminology, Quint draws the therapeutical conclusion that the therapist must intervene in such a manner that obsessive-compulsive patients experience in transference the effect of their actions, i.e., the ability to act effectively. When the therapist has the feeling that in the course of a therapeutic interview obsessive-compulsive patients direct feelings, emotions, affects to her/him and they can empathically make her/him understand that she/he feels touched, affected, moved, then this means that: 1. a repressed instinct demand has been revived in transference and been brought nearer to conscience, and 2. these patients have been exposed to the experience that they have the ability to make something happen, that they have acted successfully. This is the beginning of a new self-understanding and a new narcissistic orientation.
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extracts from ( American Journal of Psychotherapy, 2001, Vol. 55 Issue 1, p65,9p. ,Item Number: 4255519)
