PATHOLOGICAL ORGANIZATION: AN EXTREMELY PROBLEMATIC DEFENCE
My experience in thinking about the concept of ‘defence’ is rapidly to become tired. It could be argued that all of psychoanalysis is about defences. According to Freud we seek to remain in a state of equilibrium, always trying to avoid stimuli. Our defences are the weapons we use to maintain this equilibrated state. Repression, the unconscious mechanism by which we drive thoughts into the unconscious, is a major defence. It is one of the ego’s mechanisms of defence about which Anna Freud wrote her most important book, The Ego and the Mechanisms of Defence, published in 1936. There are thirteen. Here is her list:
1. PROJECTION
2. INTROJECTION
3. REPRESSION
4. REGRESSION
5. DENIAL
6. ISOLATION OF AFFECT
7. RATIONALISATION
8. UNDOING
9. REACTION FORMATION
10. TURNING AGAINST THE SELF
11. REVERSAL
12. SUBLIMATION
13. CONVERSION
This list was later modified and extended, principally by Joseph Sandler in a book of dialogues with her entitled The Analysis of Defense (1985). They concluded that the list might be extended to up to nineteen defence mechanisms. My point in listing the ego’s mechanisms of defence is to say, ‘That just about covers it’. What else is there, at least in classical Freudian and neo-Freudian theory? I would add two points. First, these are normal mechanisms. They help us to get through everyday life. However, each one has a benign and a virulent form. More precisely, there is a continuum from normal to pathological intensities of each one. We project all the time -- every time we encounter another person and have an intuition about them, for example. But the mad person who walks up to you and shouts accusations is at the other end of that continuum. Consider some of the others. Sublimation, as Freud tells us, is essential to civilization. We go to films and read books and play sports rather than raping and murdering other people. We rationalize in harmless ways, but there are also psychopathic ways of doing so. Repression, the most general of the mechanisms in the list, keeps us from being overwhelmed by experience: we drive a great deal into the unconscious. When we do so consciously it is called suppression. We all experience conversion when we express distress in physical ways -- headaches, forms of tiredness, disturbed sleep, for example, but psychosomatic disease is an altogether more serious form of conversion, and, though more prevalent in Freud’s time than ours, conversion hysteria could lead to paralysis, blindness and other serious disabilities. In our own time, anorexia nervosa has been called the paradigm illness for somatization.
So, you see, defences are ubiquitous and have many degrees and manifestations. In lay terms we often call people defensive when they over-react to a real or imagined accusation. I suppose we could say that at the other extreme of defensiveness is mass scapegoating when we kill thousands, tens of thousands or even millions of people, be they blacks, El Salvadorians, Kurds or Jews, people perceived as threats to our own group or nation.
I want to say something else about Anna Freud’s list of the ego’ mechanisms of defence. I memorised it when I was a medical student in the same spirit that I memorised symptoms and diseases. I now believe that in so doing I was making a philosophical mistake. I have come to believe that good psychoanalytic psychotherapy does not involve lots of naming of mechanisms or syndromes, as if a list of defences is a list of natural kinds. I also think that naming of disorders in psychotherapy is not like naming natural kinds. Going further, medical diagnoses are not really natural kinds, either; they are constellations of physiological processes that we deem diseases because they trouble us. A natural kind is the name of a fundamental physical particle, an amino acid, a species of plant or animal. To equate diseases, much less mental diseases, to categories in physics or biology is a risky business, even a reifying one. Reification is treating the relations between human relations as if they were relations between things. It is dehumanising. I say this, because in a moment I am going to tell you about a diagnostic category in psychoanalysis called ‘pathological organization’, and I want to prepare you for not taking it too literally, even though I will argue that it is a useful way of thinking about extreme defences. (In case you have found this last bit a trifle cryptic and difficult to take in, I refer you to two essays of mine on the internet, one concerned with a critique of the concept of psychopathology and the other with scrutinising psychiatric diagnoses in contrast with psychodynamic ways of thinking about mental distress: Young, 1997, 1998; see also Young, 1999 .)
As a prerequisite to talking about pathological organizations, there is a very important distinction between Freudian and neo-Freudian theory which we need to have in hand. Freud was much more inclined to draw attention to the dark side of human nature than his daughter was. If you read his Civilization and Its Discontents, one of Freud’s last writings, published the year before he died from a sixteen-year struggle with cancer, you will find that is an essay on the theme ‘Man is a wolf to other men’ (a quote from Freud). Anna Freud, by contrast, believed that psychoanalysis was not a struggle with daemonic force in human nature but was a process of education and did not dwell, relatively speaking, on human aggression and destructiveness. In fact, if you read the so-called ‘Controversial Discussions’ between the followers of Anna Freud and Melanie Klein in the mid-1940s, you will repeatedly find the Freudians shocked by the picture of the child’s mind painted by the Kleinians. Winnicott considered Klein’s concept of the depressive position second only in importance to Freud’s discovery of the Oedipus complex, but he notoriously balked at Klein’s concept of the paranoid-schizoid position and the death instinct, though, I should remind you that she was I this matter a loyal follower of Sigmund Freud. Other tendencies in psychotherapy, humanistic ones, for example, argue that humans are essentially good-natured. They deplore the pessimism and negativism in Freudian theory and find Kleinian theory horrific, a libel against human decency. Freud and Klein maintained that they were just being realistic.
There is more on the destructive side of human nature in recent psychoanalysis, and its basis is the claim that human nature is Manichean, that is, it is made up of more or less equal parts of Eros and Thanatos, love and hate or aggression, constructive and destructive. Some psychoanalysts, Freud’s contemporary, Wilhelm Reich, for example, believed that the negative side of human nature is only the result of what people suffer. Remove repression, he argued, and you get happy people. The famous libertarian progressive school Summerhill is run on this basis. Dartington was also, though to a lesser extent, and Bedales was to an even lesser one. Kleinians think that what you get if you pay insufficient attention to the aggressive and destructive aspects of human nature is chaos. As Bruce Springsteen so aptly put it, ‘There’s things that’ll knock you down that you didn’t see coming’.
I turn now to my main topic, pathological organizations. You can read about this concept by laying your hands on three or four documents, The first is volume one of Melanie Klein Today, edited by Elizabeth Bott Spillius, the last section of which, consisting of eight chapters, contains all the main papers on the concept. Second is John Steiner’s monograph entitled Psychic Retreats, where he generalizes his paper in the Spillius volume an spells out benign and virulent forms of a mental position which lies between the paranoid-schizoid and depressive positions (concepts I’ll describe anon). Finally, there is an important paper by Michael Sinason in volume seven of the journal Psychoanalytic Psychotherapy entitled ‘Who Is the Mad Voice Inside?’, in which he argues that each and every one of us at all times has two distinct personalities, a sane self and a mad self - called the cohabitee -- living simultaneously in our minds, a Dr. Jekyll and a Mr. Hyde, with each in the ascendant while the other is in eclipse, rather like a Swiss weather clock. Joscelyn Richards writes about the cohabitee in the same issue of that journal. Finally, if you want to examine the relationship between the concept of pathological organization, on the one hand, and the categories of psychiatric classification, on the other, Alex Tarnopolsky argues in an excellent paper that pathological organization does for Kleinian psychoanalysis what the concept of borderline personality disorder does for psychiatry (Tarnopolsky, 1992, 1992a).
Turning now to the features of a pathological organization, although you may think I am putting the cart before the horse, I want to begin with the locus classicus, a paragraph by Harold Rosenfeld which I consider to be one of the most profound passages in all of the psychoanalytic literature. He writes, ‘The destructive narcissism of these patients appears often highly organised, as if one were dealing with a powerful gang dominated by a leader, who controls all the members of the gang to see that they support one another in making the criminal destructive work more effective and powerful. However, the narcissistic organization not only increases the strength of the destructive narcissism, but it has a defensive purpose to keep itself in power and so maintain the status quo. The main aim seems to prevent the weakening of the organization and to control the members of the gang so that they will not desert the destructive organization and join the positive parts of the self or betray the secrets of the gang to the police, the protecting superego, standing for the helpful analyst, who might be able to save the patient. Frequently when a patient of this kind makes progress in the analysis and wants to change he dreams of being attacked by members of the Mafia or adolescent delinquents and a negative therapeutic reaction sets in. This narcissistic organization is in my experience not primarily directed against guilt and anxiety, but seems to have the purpose of maintaining the idealization and superior power of the destructive narcissism. To change, to receive help, implies weakness and is experienced as wrong or as failure by the destructive narcissistic organization which provides the patient with his sense of superiority. In cases of this kind there is a most determined chronic resistance to analysis and only the very detailed exposure of the system enables analysis to make some progress’ (Rosenfeld, 1971, reprinted in Spillius, 1988, vol. 1, p. 249). It occurred to me that you can keep all this in mind if you think that patients with a pathological organization have the dynamics of the group in television’s ‘The Sopranos’ in their minds.
I have had four patients who seem to me to fit this picture. Some of my work with one of them was supervised by the distinguished psychoanalyst, Arthur Hyatt Williams, who spontaneously pointed out that she fitted this diagnosis, so I have some sense that I can recognise one when I am unlucky enough to have one in my consulting room. He said early on, ‘Don’t despair, with these people the first ten years are the hardest, and some don’t improve until after they leave you’. He was in his eighties at the time, and I was pushing sixty and had not yet acquired his stoicism. She was stuck and could not allow herself to move forward. She was at the top of her profession and for part of the time she was with me held a post in the nation’s best institution for training people in one of the arts. She also had credits in some well-known products. But nothing worked; in particular, no relationships worked. She trusted no one, despised practically everyone, was long-faced and morose. Although comely, she showed no vivacity and was unable to deploy a smidgen of charm or friendliness. She also suffered from near-psychotic experiences. For example, she lived in fear that someone would drive up next to her car and throw a bin bag full of shit and offal through her window, so it was kept tightly closed. She also experienced garden hoses and electrical flexes as likely to rise up like snakes and strangle her. She had little to say and holds the record in my practice for long silences, one of which lasted for a whole session. Everything was bleak. On one occasion, after several years of analytic interpretations including reflections in the dynamics of her family of origin, she made a lively remark, the nature of which was completely dismaying: ‘Why do you keep mentioning my parents as if they have something to do with how I am?’ We worked together several times a week for, I think, nine years, and she left. I can say no more. I recently learned that she moved on in her job to another prestigious cultural setting.
I had a man who was her match. He had a good education including a first from Oxbridge and was a professional who had held jobs in prestigious firms, but he kept resigning and moving down the pecking order and then moved on to being a head-hunter for people in his profession, ending up doing that job in-house for one of the world’s leading firms. He was convinced that he was no good at any of those jobs, hence the resignations and the sideways move out of practicing it. His personal life was similar. When he first came to me he was in an unsatisfactory relationship with a woman with a chronic, periodically life-threatening, disease. He was devoted to him and he was trying to get out of the relationship, which he eventually did, only to embark on a series of unsatisfactory relationships. ‘Relationships’ is perhaps the wrong word, since hey all ended so quickly. Each one was quickly discovered to have a completely unacceptable attribute: too hairy, too small breasts; one was expelled for being ‘too Celtic’, whatever that is. At the end he was doing telephone dating and getting rid of several potential lady fiends per evening of diligent rejecting. His previous therapist, a Jungian, had wound up their work, because he found my patient too full of hatred for the work to progress. I was also not good enough, and he was always threatening to leave. In fact, at one point he got himself another therapist with whom he worked in parallel for a time. This connected to another serial process. I believe that he holds the record for taking introductory courses in London psychotherapy trainings. I can recall five -- all not good enough. He finally quit his head-hunter’s job, sacked me and went off in search of a good training in America.
We had a lot to work on, and we did. In fact, I fancy that I made some of my best interpretations with him, and he better I thought it was, the more completely and sarcastically it was rejected, from ‘not quite right’ to ‘hopeless’ (thought never Celtic). His father was an entrepreneur and property developer and an unsuccessful member of my patient’s profession. His mother was always finding fault with him. Each failing was corrected by a course, a tutor or some other remedial regime, bringing him up to scratch, only to discern some other failing and start the process over again. You will see that in his development and in his interactions with me there was plenty of material for good interpretations. In fact, he was very effective at projecting his hopelessness into me, so much so that I had to stop accompanying my partner up the block to get our daughter at the end of my session with him, because I would always be so unpleasant and rejecting and would spoil a shared experience which was delightful as long as it wasn’t after seeing him. I had to be by myself a while to assimilate my countertransference.
My other two cases are women. One was the daughter of a prominent owner of an emporium. She had no qualifications, though her brothers had good degrees and were successful and married with children. She had no husband and no children and no job. Her partner was a refugee who had no job and was impotent. She lived rent-free in a family-owned flat and, though she received a monthly remittance, she was forever overspending and pawning her valuables. She was always going to write or sculpt but never did, except for a bronze figure she often described which was of a woman with her legs spread with a large threaded screw where her head should be. We worked together for several years, then she decided to stop and gave me her one highly-symbolic creation at the end of her last session.
I am still seeing the last of my patients who I believe has a pathological organization. She is my longest-term patient. I believe we have made some progress, though it is of the sort of which I am the least proud. That is, she has not changed her external life, but she is less distressed about it. She has a job in the service sector of a university. She remains an assistant, because she never got the qualification that would allow her to move further up the hierarchy, a qualification which her husband, who works in another university, has. She took the course but was unable to write the dissertation. In the end they said they would give it to her if she would just describe her job, but she couldn’t entitle herself to do that. She and her husband love each other, but their sexual life is limited, and they never felt confident enough to have children, and now it’s too late. They have a rich cultural life and travel widely, but she is very shy, indeed, and does not make friends, and they rarely entertain. Moreover, they come from another country and have spent almost all of their time here pining to return home to live and work, but they only manage holidays and never make the move. He has a higher-ranking job than she does, but they are both stuck and unable to move in any way except toward greater stoicism. She is in no sense a nasty or lazy person and frequently gets praise for her work, but she is, to put it mildly, unfulfilled. We have worked hard interpreting her past and her ‘here and now’, but nothing has properly shifted.
Kleinian theory says that we have two basic modes of psychic being, the paranoid-schizoid position and the depressive position. John Steiner describes them as follows: ‘As a brief summary: in the paranoid-schizoid position anxieties of a primitive nature threaten the immature ego and lead to a mobilisation of primitive defences. Splitting, idealisation and projective identification operate to create rudimentary structures made up of idealised good objects kept far apart from persecuting bad ones. The individual’s own impulses are similarly split and he directs all his love towards the good object and all his hatred against the bad one. As a consequence of the projection, the leading anxiety is paranoid, and the preoccupation is with survival of the self. Thinking is concrete because of the confusion between self and object which is one of the consequences of projective identification (Segal, 1957).
‘The depressive position represents an important developmental advance in which whole objects begin to be recognised and ambivalent impulses become directed towards the primary object. These changes result from an increased capacity to integrate experiences and lead to a shift in primary concern from the survival of the self to a concern for the object upon which the individual depends. Destructive impulses lead to feelings of loss and guilt which can be more fully experienced and which consequently enable mourning to take place. The consequences include a development of symbolic function and the emergence of reparative capacities which become possible when thinking no longer has to remain concrete (Steiner, 1987, pp. 69-70; see also Steiner, 1993, pp. 26-34).
Steiner argues that there is a place between these two fundamental positions, a third one he calls a ‘psychic retreat’. In its benign form it can act as an emotional space for reflection or contemplation, on the analogy to a religious retreat. In its virulent or malign form, however, one can get stuck there, with one’s life on hold, leading to the dreaded diagnosis of ‘pathological organization’ (Steiner, 1993). I think this perfectly describes the four patients whose problems I have sketched above. One can say that in important ways, they cannot ‘get on’. Their lives are ‘on hold’. They are unfulfilled. The first two, the cultural worker and the professional man, are miserable and furious with life and with their parents. The other two, though much less angry with life or their parents, are unfulfilled in work and also have no children, though the last of them has a lot of the aspects of a good marriage, companionable, if not very sexual. I failed dramatically with three of them and made modest progress with the fourth, who I still see.
The initial kernel of this way of thinking was Klein’s stress on the central and ongoing role of primitive processes, both constructive and destructive, in human nature. The particularization of this which led to the concept of pathological organization was Bion’s short but powerful paper on ‘Differentiation of the Psychotic and Non-Psychotic Parts of the Personality’, in which he argued -- or, some say, was taken to argue -- that all of us all the time have both psychotic and non-psychotic forces at work in our inner lives. How we are is the outcome of the resolution of the forces at work. Other Kleinians enriched the role of baleful forces in the inner world - Henrķ Rey on schizoid phenomena in borderline states; Donald Meltzer on terror, persecution and dread in paranoid anxieties; Eric Brenman on cruelty and narrow-mindedness; Leslie Sohn on narcissism and virulent projective identification; Edna O'Shaughnessy on extreme defences; Betty Joseph on addiction to near-death. In my view the papers of Rosenfeld and Steiner, from which I have quoted, are the best at gathering together these elements. The title of each conveys a lot. Rosenfeld’s is ‘A Clinical Approach to the Psychoanalytic Theory of the Life and Death Instincts: An Investigation into the Aggressive Aspects of Narcissism’ and Steiner’s is ‘The Interplay between Pathological Organizations and the Paranoid-Schizoid and Depressive Positions’.
You will have noted that I did not get very far with the patients I suggest have pathological organizations. The literature I have cited tells us why this is likely to be the case. In particular, Betty Joseph stresses the attraction of being near to death to these patients and emphasizes that we have to make careful and very precise interpretations over and over in order to have any hope of shifting the powerful structure, amounting to a gang, which we are up against. It is, in my experience, disheartening work.
Elizabeth Spillius summarizes the intractable features of this syndrome as follows: domination of the bad self over the rest of the personality (Spillius, 1998, p. 197) with an idealization of the bad self (p. 198-99); a perversion of internal reality (p. 200). These patients are neither neurotic nor psychotic but in a frontier state (p. 197) that is hugely difficult to reach. I am sorry I cannot bring you better news. I hope Valerie Sinason [who gave a talk on the same evening] can.
Text of a talk delivered in the CONFER series on ‘Problematising Defences’, given at the Tavistock Centre, London, 8 December 2003.
REFERENCES
(Place of publication is London unless otherwise specified.)
Bion, Wilfred R. (1957) ‘Differentiation of the Psychotic from the Non-Psychotic Personalities’, Inernat. J. Psychoanal. 38, Parts 3-4; reprinted in Second Thoughts: Selected Papers on Psycho-analysis. Heinemann, 1967 and Maresfield, 1984, pp. 43-64.
Freud, Anna (1936) The Ego and the Mechanisms of Defence. Hogarth Press; reprinted, 1966.
Richards, Joscelyn (1993) ‘Cohabitation and the Negative Therapeutic Reaction’, Psychoanal. Psychother. 7: 223-39.
Rosenfeld, Harold (1971) ‘A Clinical Approach to the Psychoanalytic Theory of the Life and Death Instincts: An Investigation into the Aggressive Aspects of Narcissism’, Internat. J. Psychoanal. 52: 169-78; reprinted in in Spillius, ed., 1988, vol. 1, pp. 239-55.
Sandler, Joseph with Anna Freud (1985) The Analysis of Defense: The Ego and the Mechanisms of Defense Revisited. N. Y.: International Universities Press.
Sinason, Michael (1993) ‘Who Is the Mad Voice Inside?’, Psychoanal. Psychother. 7: 207-21.
Spillius, Elizabeth B., ed. (1988) Melanie Klein Today, 2 vols. Routledge. Vol. I - Mostly Theory, Part Four: Pathological Organizations, pp. 193-342; her Introduction is on pp. 195-202.
Steiner, John (1987) ‘The Interplay between Pathological Organizations and the Paranoid-Schizoid and Depressive Positions’, Internat. J. Psychoanal. 68: 69-80; reprinted in Spillius, ed., vol. 1, pp. 324-42.
______ (1993) Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients. Routledge.
Tarnopolsky, A. (1992) ’The Validity of the Borderline Personality Disorder’, in D. Silver and M. Rosenbleuth, eds., Handbook of Borderline Disorders.. Madison, CT: International Universities Press, pp. 29-52.
______ (1992a) ‘Borderline Disorders: A British Point of View’, in Ibid., pp. 177-202.
Young, Robert M. (1997) 'The Concept of
Psychopathology: a Critique', on-line at
http://human-nature.com/rmyoung/papers/paper63.html
______ (1998) 'Descriptive versus Dynamic
Concepts of Psychopathology', on-line at
http://human-nature.com/rmyoung/papers/pap111.html
______ (1999) ‘Between Nosology and
Narrative: Where Should We Be?’, on-line at
http://human-nature.com/rmyoung/papers/pap120.html
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