Alan Sugarman

borderline and Schizophrenic Patients : a Comparative Study of Defensive Structure

&NA; Historically unresolved diagnostic questions regarding the borderline diagnosis and its relationship to schizophrenia are explored. Is the borderline syndrome a subvariant of schizophrenia or does it constitute a distinct diagnostic entity in its own right with specific, common, and identifiable features which set this group of patients off from others? Based on recent developments in psychoanalytic object relations theory, a Rorschach scoring manual designed to assess the primitive defenses that are conceptualized to underlie as well as organize the borderline patient was applied to independently selected samples of hospitalized borderline (DSM‐III criteria) and schizophrenic (Research Diagnostic Criteria) adolescent and young adult patients. Consistent and significant differences were found between groups on the basis of defensive functioning. Borderline patients were found to use test measures of splitting, primitive devaluation, idealization, denial, and projective identification significantly more than schizophrenic patients. The levels of inter‐rater reliability and the direction of the results in discriminating borderline from schizophrenic patients on the basis of defensive functioning indicate that the Rorschach Scoring System is a reliable and valid instrument. The implications of the results in terms of the differential diagnostic issues, the nature of borderline defenses, and the utilization of the Rorschach as a research instrument are considered.

Fantasizing as Process, Not Fantasy as Content: The Importance of Mental Organization

It is suggested that the traditional way of thinking about and working with unconscious fantasy inadvertently retains outdated topographical approaches to analytic technique. Shifting our analytic emphasis to the process of unconscious fantasizing better accounts for the importance of mental organization in understanding psychopathological phenomena and guiding analytic technique. This reformulation has two significant implications: (1) It highlights the importance of making the process of fantasizing conscious because access to this process can facilitate the analytic process and the attainment of insightfulness; and (2) it also emphasizes the need eventually to explore the reasons that a patient chooses fantasy over abstract, symbolic modes of experiencing and communicating internal phenomena.

Psychoanalyzing a Vulcan: The Importance of Mental Organization in Treating Asperger's Patients

The opinion that psychoanalysis is of little value in treating patients suffering from Aspergers syndrome is a relatively common one, even among fellow psychoanalysts. Several reasons have been suggested to account for this including the discrediting of psychoanalytic treatment for patients in the autistic spectrum because of Bettelheims (1967) mistaken blaming of the condition on poor parenting or the assumption that a biochemically based disorder cannot benefit from a psychologically oriented treatment. This article suggests that a third reason has to do with the underlying model of mutative action used by many current day psychoanalysts. Implicit in most modern day Freudian work is a model of mutative action that prioritizes verbal interpretation and emphasizes the gaining of insight into unconscious mental content. Viewing the psychoanalytic task as deciphering the unconscious meaning of the patients verbalizations ignores the problem that Aspergers patients have with mentalizing or developing a theory of mind. This article suggests that psychoanalysts shift their emphasis to promoting a process of insightfulness defined as the equivalent of mentalization as it occurs in the psychoanalytic situation. Insightfulness is similar to the Kleinian emphasis on promoting higher order symbolic thinking. The psychoanalytic treatment of a patient suffering from Aspergers syndrome is described to illustrate how the psychoanalyst works to promote insightfulness and how this approach differs from trying to uncover the hidden, unconscious content presumed to lie at the depths of the psyche. The patient described also illustrates the higher end of the Aspergers spectrum and the need not to let the character defenses that develop to cope with such a debilitating disorder not obscure the essential constitutional basis of the patients difficulties even though, of course such limitations will become components of compromise formations.

The Centrality of Beating Fantasies and Wishes in the Analysis of a Three-Year-Old Girl

Freuds (1919) classic paper, “A Child Is Being Beaten,” with its introduction to masochism, offers an excellent example of how child psychoanalytic data can clarify his ideas, correct those where he went astray, and check whether ones that seem speculative are supported by developmental data. Toward these ends, the analysis of a three-year-old girl with prominent beating fantasies is presented. Her analytic material suggests that it is unimportant from a treatment or pathogenesis perspective to differentiate between different types of sadomasochistic content in such fantasies. That is, the phenomenological distinction between beating fantasies and beating wishes does not seem to have much practical utility. All such fantasies have the same essential structure and are compromise formations in which pain is sought to maintain the complex equilibrium provided by them. Her material also indicates that such phenomena do not require oedipal stage engagement or dynamics to develop, although they will, of course, be colored by this stages issues as the child engages it. Even sexualization, the so-called hallmark of beating fantasies, can arise as a means to deal with various cumulative traumas and does not require access to the sexual stirrings of the oedipal stage to occur.

The Place of Internalization of the Analyst in Analyses That Emphasize the Mutative Priority of Insight: A Developmental Perspective.

Despite the extensive debate about the role that internalization of the analyst plays in analyses conducted from a more traditional perspective, and the increasing acknowledgment that both insight and the relationship with the analyst are important and coexisting mutative factors, most analysts who value insight continue to see interventions that influence the patient via the relationship as lamentable and leading to less stable change than insight alone. This continued belief ignores all that we have learned about the role that interaction and identification play in the development and modification of psychic structure throughout the developmental process. The historical origin of this belief is reviewed along with the evolution of views in analysts prioritizing verbal interpretation leading to insight as a mutative element. This paper also reviews the role of internalization in the formation and transformation of psychic structure during development. Finally, that role is applied to understanding the role of insight in therapeutic action in order to demonstrate that internalization is a crucial part of insight. Its importance is based on a recasting of insight as a process so that patients learn to observe and understand their mental processes, not just to decode latent mental content.