My patient, Dr. White, a research scientist, has been in treatment for nearly three years. He is a short, very slightly built man. His pale, heavily lined forehead and graying beard are in sharp contrast to his very lean body and extremities, which look as if they belonged to a 12-year-old boy rather than to a 45-year-old man. He has all the symptoms associated with a severe case of anorexia, except that of a distorted body image: he feels thin and is fully aware of the dangers involved in keeping his weight barely above acceptable limits. Like others with this disorder, Dr. White is preoccupied with food all the time. He weighs himself several times a day, engages in lengthy exercises every day, and is compelled to deprive himself of anything that could potentially give him pleasure. The patient sets his alarm for 2:30 A.M. but frequently gets up before that in order to complete a lengthy routine of weightlifting and running. With his near-starvation diet, strenuous exercises, and chronic sleep deprivation, he is always exhausted and has to take several short naps during the day.
The patient first came to see me because he feared that his marriage was on the brink: he feared that his wife would soon ask him to leave because he had not been able to be a father to his children, or a husband to her. His own parents had divorced before he was 3 and he had not seen his mother since then; he does not have any memory of her and does not know what she looked like. He only knows that his mother was alcoholic and that, after the divorce, his father did not permit her to visit him and his sister (who is two years younger). Only recently did he learn from his father that he was repeatedly hospitalized for broken bones, bruises all over his body, and burns on his hands and feet, injuries that his mother had inflicted on him. His father, also a scientist, had extremely high standards for the children’s behavior and raised them with strict puritanical methods. Dr. White was always an “A” student, but he does not recall having ever felt satisfaction, nor that his father ever expressed satisfaction with him or with his accomplishments: he was always left with the feeling that he could have done better. In spite of the fact that he has been able to secure prestigious and good-sized grants over the years, he is constantly worried that he will be asked to leave his current job because he does not meet the high standards of the institution where he works.
Dr. White had been a chubby child, and his father, in order to teach him good eating habits and self restraint, did not allow him to enter the kitchen before going to school. Instead, he would bring the patient an orange for breakfast to his room. Father also stressed the importance of athletic activities, and the patient became a successful long-distance runner, earning several trophies.
Dr. White does not recall any time when he was able to ask for physical or emotional comfort freely and directly. As far as he can remember, he has been living with a wall firmly erected around his emotions. He no longer experiences the longing for close emotional contact in its original form; this is now mixed with shame, and it finds expression in a behavior pattern in which he presents himself in a pitiful, sorrowful way: he walks with his shoulders hunched, frequently emits a deep sigh, and whenever he has the opportunity he makes degrading remarks about himself or about his work. This is a behavior pattern in which the masochist’s bid for affection expresses hidden sadism (Berliner 1958). Predictably, this sadomasochistic behavior (in which sadism is expressed indirectly by making “others,” his current transference objects, responsible for his mental suffering) does not produce compassion in those who witness it. Instead, the opposite is true—friends and family turn away from him.
Because of this indirect communication of displaced rage, Dr. White suffered repeated rejections by the very people whose accepting and validating responses he needed and wanted most urgently. Eventually he realized that, even when others were responsive to his indirect appeals for emotional comfort, he could not reciprocate. For while he had an enormous need for affection he was unable to give any.
Since his wife became Dr. White’s most important transference object, he was strongly motivated to display this behavior in her presence. In the course of treatment, he began to pay closer attention to this feel-sorry-forme behavior and to recognize the importance of the context in which it was likely to emerge. For example, one day when he was particularly successful at work and was looking forward to going home in a reasonably good mood, he realized that as he was nearing his home he became increasingly more irritable and depressed. By the time he reached the house, he convinced himself that the good feelings of the day were nothing but an illusion. He realized then, he said to me, that “presenting myself as a failure is the best way for me to communicate my despair. I am afraid she [his wife] will see me feeling good.”
The longing for a caring and accepting response became associated not only with shame, but also with jealousy and envy of those whom he experienced as receiving attention while he felt excluded or dismissed. In his jealous rages he would humiliate and verbally abuse his 4-year-old son, the recipient of his mother’s affection. The patient was convinced that it was the birth of this child that “pushed [him] over the brink,” and he dated his depression, his suicidality, and the anorexia to the birth of this child. Not long ago he told of an episode in which he literally tore the child away from his mother because he was touching her breast. Apparently the son touching the wife’s breast had activated an intense need for physical comfort and intimacy. Once the need for the hug and the touch was activated, so was his sense of frustration that caused him either to strike out impulsively or to withdraw in hurt and anger. The angry and guilt-provoking retreat would say in essence: “You are depriving me; you are a bad, withholding mother, and even if you tried to give to me, I know it would not be enough—or not exactly what I need.”
After a rageful outburst at his son for his ordinary 4-year-old behavior, Dr. White would experience intense shame and he would become acutely suicidal. In order to protect himself as well as his family from his outbursts and the shame and guilt that would follow them, he frequently remained at work until late at night and left the house before the children woke up in the morning. He rarely participated in family activities, and in fear that his fantasy of a “perfect holiday” would not be fulfilled, he would take on extra assignments and would stay at work during the holidays. At these times he would be filled with self pity and a renewed determination to kill himself before the next major holiday.
Beside their 4-year-old son, the couple has an 8-year-old daughter; his love for his daughter and feeling loved by her at first kept him from thinking about suicide. Following the birth of the son, however, he came to believe that the daughter, too, would be better off without him. He has kept a vial of a highly toxic substance in his drawer for the last four years. When he feels particularly desperate, he finds solace in knowing that he could put an end to his mental anguish anytime he wanted to. However, he complains of lacking courage to kill himself: “I’m tired of living, but too scared to die,” he says frequently.
Because of the severity of his depression and the suicide risk, the patient was put on an anti-depressant that, after some time, began to relieve the symptoms of anorexia and gave him some relief from the depression. However, the medication did not alter the sadomasochistic behavior pattern and he continued to feel emotionally isolated.
How do we understand the self-degrading behavior, the suicidal depression, and the periodic outbursts of rage from a self-psychological perspective? Self psychology, like all other psychoanalytic theories, has to be able to explain the nature of the psychopathology in keeping with its theory of development. The development of this form of psychopathology (as with all other forms of personality disorder) reaches deep into childhood. In cases of self-degrading, suicidal behavior, we postulate two interrelated traumata: one is the absence or partial absence of phase-appropriate caretaker responsiveness to infantile grandiosity and exhibitionism, and the second is the possible coupling with physical and/or emotional abuse of caretaker indifference to the child’s legitimate need for affirmation.
The developmental theory of self psychology asserts that it is the phaseappropriate validation of infantile grandiosity and exhibitionism by caretakers that makes possible the transformation of narcissistic structures into pride and pleasure in one’s self and in one’s activities. Self-esteem is gradually built by the caretakers’ unambivalent responsiveness to the child’s uniqueness and his/her accomplishments. When caretaker responsiveness is absent or faulty, infantile grandiosity persists in the adult psyche and patients will cling to a sense of absolute perfection with tenacity. Failure to develop adequate transformation of infantile grandiosity and exhibitionism is also responsible for a lack of vigor and aliveness, a form of characterological depression. The faulty consolidation of the nuclear self results in extreme vulnerability to slights and to any indication of nonacceptance or rejection, to which patients react with unforgiving rage or withdrawal. When physical abuse is added to this scenario, the result is that the child—and later the adult—experiences him/herself as evil and undeserving of love. The suicidal ideas that these patients express appear to be the consequence of self loathing and a feeling that what they are experiencing cannot be understood by others and cannot be shared. Since they feel emotionally isolated, death offers relief and suicide acquires a tremendous appeal.
In Dr. White’s case, the neglect and physical abuse by one parent (the mother) was coupled with conditional acceptance by the other. When acceptance and appreciation are thus conditional, the child grows up with a nagging sense of self doubt, doubt about his intellectual and/or physical abilities and attractiveness. Though these are frequently bright and accomplished individuals, their achievements are not accompanied by a sense of satisfaction, pride, and contentment.
In childhood, the frustrations related to the developmentally needed responses and the suffering due to the physical abuse are endured silently, the reactive rage remaining unconscious in order to preserve an already precarious connection to the rejecting or abusive caretakers. The defensive psychological structures that protect the poorly developed, fragmentation-prone self from retraumatization are also the very ones that constitute the building blocks of the now evolving symptomatic behavior. Defensive psychological structures with unarticulated rage at their core are responsible for chronically embittered, paranoid attitudes, and for various degrees of depression, criminality and suicidality. In severe self disorders, all these personality features may be present with one or the other taking center stage.
While it is not possible to describe in a few observations a therapeutic process that sometimes takes years to evolve, I shall try to convey its essence by citing a brief segment from Dr. White’s treatment.
More often than not, the patient would arrive for our twice-weekly sessions profoundly depressed. He would enter the office with a sigh, lower himself into the chair as if that were too much of an effort, and express a sense of profound hopelessness. In this particular session, the patient told me about a poem that touched him deeply. He was particularly impressed by a line that went: “No one knows the depth of his fellow man’s suffering.” I said to him that he probably liked this line because it expressed his own feeling that nobody could possibly know what it is like to go through life feeling the way he does. The patient nodded in agreement, and I added that we understood from previous discussions that the pitiful, feel-sorry-for-me behavior that he cannot stop from repeating was intended to demonstrate his mental suffering so that those around him, especially his wife and myself, could have an idea of what he was experiencing. He was convinced, I said to him, that if others knew how he felt this would make him feel better, that sharing the pain was the only thing that could possibly relieve his mental anguish. “Yes,” he said, “I don’t know how others feel about it, but this is the most important thing to me: I want others to know what it’s like for me. I also think Joan [his wife] is responsible for the way I feel. She never puts her arms around me. She is never affectionate.” There was silence, since we both knew that even when his wife expressed affection he would fend her off because he would perceive a flaw in the way she expressed it; he experienced her as cold and withholding of affection, rather than as someone who could, potentially, compensate him for past deprivation.
After a brief silence, Dr. White asked, “Why can’t I accept her efforts? Why do I constantly find fault with her and what she tries to do for me?” I said that the way I understood this was that his wife had become his mother in his mind. As a child he probably felt deserving of mistreatment, believing that if he were a “good boy” his mother would love him. Now, as an adult, he wanted to rid himself of the feeling that he was bad and wanted others, primarily his wife, to take the responsibility for his sense of deprivation and misery. I understood, I said, that it was difficult for him to consider that the way he felt today might have more to do with the past than with the present.
This was the first time that I had made a connection between his childhood experiences and his holding his wife responsible for his past deprivations and abuses. Dr. White greeted my comments with a sigh and another silence. He left saying that he would have a great deal to think about between then and our next meeting.
When he returned, he said that while my explanation of his behavior made sense to him, he now felt worse because he could see more clearly the childishness of his feelings and his behavior. In an effort to help him accept his “childish” feelings, I added that I could see how after the birth of his son the longings for unconditional acceptance, love, and attention from his wife had become more imperative. Dr. White then remembered that he had had similar problems after the birth of his daughter but was able to overcome them.
In my clarifying and interpretive comments I continued to emphasize that, for an adult, these feelings are very hard to accept and this was why he had adopted a feel-sorry-for-me mode of behavior: conveying his emotional misery in this manner, he hoped for a caring, compassionate response. Dr. White hung his head and made a barely audible comment about the unreasonableness of his behavior, saying that it was he, himself, who had the greatest difficulty accepting the childishness of his needs.
While the transferential nature of his relationship with his wife reactivated his infantile longings, a recent therapeutic conversation revealed the nature of the patient’s transference expectations in relation to me. He began the hour by telling me that the day before he had felt good. He had gone home at a reasonable hour and had had dinner with his family, something he hadn’t done for a long time. He had not run off to the basement to do his exercises as he usually does. But now he was already worried that this was not going to last, that tonight something might set him off, and once that happened he would not be able to stop himself from repeating his old pattern in which, once he feels hurt, he has to retaliate immediately or withdraw in fear of abusing his family.
The patient then told me two stories which he had heard on the radio. The first one was an account given by one of Nureyev’s dance partners. The woman was describing Nureyev’s magnetism, how at times she was so enthralled by him that she would miss her cue as she was waiting in the wings for her turn. The patient was struck by the fact that, though she was almost at the end of her dancing career, Nureyev’s presence had started a new life for her. (I thought his telling me this story was likely to be related to a feeling on his part that our relationship has had a profound impact on him.)
Since I did not say anything, the patient went on to tell the second story. He had heard a man describing the sexual experiences of another person. At first he had thought that it was a gay man describing the sexual experience of another man, but then he realized that the man was talking about the sexual experiences of a woman. How could a man know anything about the sexual experience of a woman? Though I could not be sure, I said, I did have an idea why these stories came to his mind now and why he may have wanted to tell me about them. I thought these stories had to do with what we were discussing earlier: how important it was for him that others know how he felt. The story he had just related to me, about a man who knew what a woman experienced sexually, made me think that he must be wondering how I could know what he was feeling, since, after all, my life experiences had to be different from his. “Yes,” he said, “I’ve often wondered about that. “As a matter of fact, he added, he often worried that, should he doubt my understanding and appreciation of how much he was suffering emotionally, then in this relationship too he might feel compelled to resort to doing something drastic in order to convince me. For example, imagining that I would become upset and distraught upon hearing about his suicide, he would feel elated: Could he actually go that far to assure that I knew the extent of his mental anguish? He had thought about this the other day and had realized that, though I had never discussed his suicidal intent with him directly or tried to talk him out of it, he felt that my understanding the depth of his despair—my being able to put into words feelings that he himself could not articulate—made his inner world more accessible to him. His feelings had become less mysterious, and he now believed that they might be alterable.
He went on to say that what was particularly useful to him was that I helped him understand the reasons why he tried to get attention from his wife with his feel-sorry-for-me behavior, and how it was this behavior that finally alienated her from him. He added: “You are my last hope that what I feel can be known. Otherwise, being miserable is my ‘lifeline’ to others.”
With the help of a clinical example, I described the developmental precursors of a severe form of self pathology in which the clinical picture was dominated by depression, anorexia, and suicidality. In presenting a few highlights of the treatment process, I underlined the healing potential of the feeling of being understood. I hope to have demonstrated that it is important not to address the manifest symptoms in isolation but to recognize and interpretively respond to the underlying vulnerability of the self. In the course of treatment the patient demonstrated, in small but significant ways, structural changes that enabled him to reflect on his emotions, so that he no longer became instantaneously enraged in such a way that he felt compelled to retaliate or withdraw, a behavior that was intended to make his environment feel responsible for the psychological pain that was inflicted on him. Dr. White no longer considers suicide to be an option for him—not because he thinks that he is too cowardly to undertake it, but because, with increasing frequency, he enjoys his work and spending time with his children. Since he has put on weight, he has become increasingly more resilient physically and emotionally.
Berliner, B. (1958). The role of object relations in moral masochism. Psychoanalytic Quarterly 26:358–377.