I can now come to the positive suggestions which I wish to make for discussion at this preliminary stage. Let it be understood that I recognize the immense value of classical psychiatric
classifications.
My concern is with the effect on classification of some of the newer ideas (or perhaps these are old ideas given new emphasis, or wrapped up in new language?). I shall choose matters which I
personally have studied and have tried to elucidate in various papers. The same ideas have been introduced independently into the literature by other analysts, but it would confuse the issue if I were to attempt to quote, or to compare the various terms used by these other writers with those used by myself.
I give special consideration to:
ii. The idea of delinquency and psychopathy as derivations of perceived, actual emotional deprivation.
iii. The idea of psychosis as related to emotional privation at a stage before the individual could perceive a deprivation.
(i) False Self
The concept of the false self (as I call it) is not a difficult one. The false self is built up on a basis of compliance. It can have a defensive function, which is the protection of the true self.
A principle governing human life could be formulated in the following words: only the true self can feel real, but the true self must never be affected by external reality, must never comply. When the false self becomes exploited and treated as real there is a growing sense in the individual of futility and despair. Naturally in individual life there are all degrees of this state of affairs so that commonly the true self is protected but has some life and the false self is the social attitude. At the extreme of abnormality the false self can easily get itself mistaken for real, so that the real self is under threat of annihilation; suicide can then be a reassertion of the true self.
Only the true self can be analysed. Psycho-analysis of the false self, analysis that is directed at what amounts to no more than an internalized environment, can only lead to disappointment. There may be an apparent early success. It is being recognized in the last few years that in order to
communicate with the true self where a false self has been given pathological importance it is
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necessary for the analyst first of all to provide conditions which will allow the patient to hand over to the analyst the burden of the internalized environment, and so to become a highly dependent but a real, immature, infant; then, and then only, the analyst may analyse the true self. This could be a present-day statement of Freud's anaclitic dependence in which the instinctual drive leans on the self-preservative. Dependence of the schizoid patient or of the borderline case on the analyst is very much a reality, so much so that many analysts prefer to avoid the burden and they select cases carefully. In selecting cases for analysis analysts must therefore take into account the common existence of a false self. Selection requires in the clinician an ability to detect the false-self defence, and when this is detected the clinician must then decide whether this is likely to be a positive help in the analysis, or whether in a particular case it is pathologically powerful and indicates so severe an initial handicap in emotional development that psycho-analysis had better be left out of
consideration.
I suggest that ‘false self’ is a valuable classificatory label, one that almost absolves us from further diagnostic effort. It is in this type of case, not uncommon, that psycho-analysis can be dangerous, that is if the analyst is taken in. The defence is massive and may carry with it considerable social success. The indication for analysis is that the patient asks for help because of feeling unreal or futile in spite of the apparent success of the defence.
A special case of the false self is that in which the intellectual process becomes the seat of the false self. A dissociation between mind and psyche-soma develops, which produces a well-recognized clinical picture. In many of these cases there is probably an especially high intellectual endowment, and this may contribute to the building up of the syndrome although the high I.Q. on test may result from the dissociation.
(ii) Psychopathy
First, I must try to define the word psychopathy. I am using the term here (and I believe I am justified in doing so) to describe an adult condition which is an uncured delinquency. A delinquent
is an uncured antisocial boy or girl. An antisocial boy or girl is a deprived child. A deprived child is one who had something good-enough, and then no longer had this, whatever it was, and there was sufficient growth and organization of the individual at the time of the deprivation for the deprivation to be perceived as traumatic. In other words, in the psychopath and the delinquent and the antisocial child there is logic in the implied attitude ‘the environment owes me something’. I personally believe
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that in every case of antisocial organization there was a point at which a change occurred, with the individual able to appreciate the fact. This appreciation of course is not usually conscious, but the point of deprivation may be remembered, unless it has become lost among innumerable successive deprivations.
The main thesis here is that the maladjustment and all the derivatives of this type of disorder consist essentially in an original maladjustment of the environment to the child, the maladjustment not having occurred early enough to produce psychosis. The accent is on environmental failure and the pathology is therefore primarily in the environment and only secondarily in the child's reaction. The classification of delinquents and psychopaths ought logically to be in terms of the classification of environmental failure. It is for this reason that there is a confusion immediately if an attempt is made to bring psychopathy and recidivism and the antisocial tendency into line with other labels such as neurosis and psychosis.
This argument leads to:
(iii) The Question of Psychosis and Classification
If it be true that the disorders which come under the wide heading of psychosis (and which
comprise the various types of schizophrenia) are produced by environmental deficiency at a stage of maximal or double dependence, then the classification has to be adapted in order to meet this idea. Such a development would certainly have surprised psycho-analysts of thirty years ago, most of whom, in considering psychosis, would have started off with an assumption that very primitive mechanisms were aetiologically significant in such illness. Today, I suggest, we are coming round to the view that in psychosis it is very primitive defences that are brought into play and organized, because of environmental abnormalities. We can of course see the very primitive mechanisms at work in psychotics as also in our ‘normal’ patients, and indeed in all people. We cannot diagnose psychotic illness by finding primitive mental mechanisms. Of course, in psychotic illness it is the primitive defences that we meet with, defences which do not have to be organized if in the earliest stages of near-absolute dependence the good-enough environmental provision does in fact exist. Justice can be done to all the factors by the statement that the individual's maturational processes (including all that is inherited) require a facilitating environment, especially in the very early stages. Failure of the facilitating environment results in developmental faults in the individual's personality development and in the establishment of
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the individual's self, and the result is called schizophrenia. Schizophrenic breakdown is the reversal of the maturational processes of earliest infancy.
I am suggesting that in a study of psychosis the attempt must be made to classify the environment and the types of environmental abnormality, and the point in the development of the individual at which these abnormalities operate, and that to attempt to classify sick individuals on the basis of the clinical pictures that they present leads to no useful result. I repeat: the environmental deficiencies
which produce psychosis belong to the stage prior to that at which the developing individual has the equipment to be aware of either the environmental provision or its failure (cf. the antisocial
tendency). It will be seen that in attempting to date the onset of psychosis I am therefore referring to the degree of the individual's dependence and not to the individual's pregenital instinctual life, nor to the stage of the infant's erotogenic zone primacy.
The argument has been developed here on the basis of extremes. In our clinical work we meet mostly with patients who are to some extent or under certain conditions healthy, but who can be ill, so that it can be said that they bring their illness to us for treatment as a mother might bring a sick child.
Inherent Conflict
Let us now look at the internal factors, those which concern us as analysts. Apart from the study of healthy persons, it is perhaps only in psycho-neurosis and reactive depression that one may get near to the truly internal illness, the illness that belongs to intolerable conflict which is inherent in life and in living as whole persons. It might be a definition of relative psychiatric health that in the healthy one can genuinely carry the difficulties that the individual encounters back to the inherent struggle of individual life, the (unconscious) attempt of the ego to manage the id and to use id- impulse in the fullest possible way in relationship with reality. It is important for me to make this clear because some may feel that in putting forward a method of classifying which includes a classification of environment I am leaving aside all that psycho-analysis has gained in the study of the individual.
Without attempting to review the literature I wish to refer to the writings of two of my teachers, Rickman and Glover. Rickman's 1928 lectures had a big influence on the development of my thought but I am not aware that Rickman dealt with the importance of dependence.
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In Edward Glover's On the Early Development of Mind (1956) there are many references to
classification. I think there are only two references in this book to the environment of the kind that I am developing into a main theme. On page 174 there is the sentence: ‘An instinct that requires a true external object, such as the mother's nipple, is unmasterable unless with the collusion of the real object.’ This is from a 1932 lecture, entitled ‘A Psycho-Analytic Approach to the Classification of Mental Disorders’. The other reference comes in his 1949 statement in the British Medical Bulletin on ‘The Position of Psycho-Analysis in Great Britain’ (Glover, 1949). After painting rather a gloomy picture of the state of affairs in the British Society he puts forward the following
comment: ‘But when all is said, the present is an interesting phase in the history of psycho-analysis. However absurd some of the hypotheses recently advanced may have been, there is no doubt that the focusing of interest on problems of early ego-development and on the organization of mind during the phase of “primary identification” (i.e. at the stage before the “self” and the “not-self” are accurately differentiated), will in the long run produce results of value both diagnostically and therapeutically.’
I wish also to refer to Ackerman (1953), who however does not seem to concern himself with the special feature of dependence at a very early date.
Classification According to Environmental Distortion
I think it might be valuable to classify according to the degree and quality of the environmental distortion, or deficiency, that which can be recognized as aetiologically significant. It is necessary to look at this point of view, even if only to reject it.
things: At one extreme there is heredity; at the other extreme there is the environment which supports or fails and traumatizes; and in the middle is the individual living and defending and growing. In psycho-analysis we deal with the individual living, defending and growing. In
classification, however, we are accounting for the total phenomenology and the best way to do this is first to classify the environmental states; then we can go on to classify the individual's defences, and finally attempt to look at heredity. Heredity, in the main, is the individual's inherent tendency to grow, to integrate, to relate to objects, to mature.
Classification in terms of environment would require a more
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accurate knowledge than at present exists, as far as I know, of the stages of dependence. For the time being I find it valuable to use the concepts which I have put forward in other papers, of independence arising out of dependence, which in turn arises out of double dependence. By double dependence I mean dependence which could not at the time be appreciated even unconsciously by the individual, and which therefore cannot be communicated to an analyst in a patient's analysis. As I have said elsewhere (Chapter 9), the analyst has to reclothe the patient's material, using his or her imagination in so doing.
Summary
By my way of looking at things at the beginning we see a concentration of environmental
phenomena in which there crystallizes out a person, a mother, and it is in the mother that the infant begins to appear first as an anatomical and a physiological unit, and then gradually, at about the birth date, becomes a male or a female person. This infant member of ‘the nursing couple’ develops in his or her own right in so far as the environment does not fail in its various essential functions, functions which change in their emphasis and develop in their quality as the growth of the individual proceeds.
Under the most favourable conditions, where continuity is preserved externally and the facilitating environment allows the maturational process to act, the new individual really starts and eventually comes to feel real, and to experience life appropriate to his or her emotional age. This individual can be described and typed, defences can be classified, and value or lack of value in the personality can be noted. In such cases we may find depressive or psycho-neurotic defences or we may find a normality. If we like we may attempt to group individuals according to types, and according to the ways the hereditary elements gather together in individuals in relation to specific environments; and (in maturity) we may go on to take note of the capacity of the individual to take part in the creation and maintenance of the local environment.
All this assumes a good enough beginning, with the true self operative, protected by a false self which is no more than a social manner.
The alternative is psychotic illness, with organization of primitive defences. Here the illness is aetiologically secondary to environmental failure, although the illness shows clinically in a more or less permanent distortion in the personality structure of an individual. In between these two is the antisocial tendency, in
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which the environment fails at a later stage, a stage of relative dependence, a stage at which the individual child has the equipment to perceive the fact of an actual deprivation.
personality structure. Our immediate need, however, is for a classification and a re-evaluation of the environmental factor in so far as this affects in a positive or negative way the maturational
development and the integration of the self. Postscript 1964:
A Note on Mental Breakdown
Some patients have a fear of mental breakdown. It is important for the analyst to keep in mind the following axiom:
Axiom
The breakdown that is feared has already been. What is known as the patient's illness is a system of defences organized relative to this past breakdown.
Breakdown means a failure of defences, and the original breakdown ended when the new defences were organized which constitute the patient's illness pattern. The patient can remember the
breakdown only in the special circumstances of a therapeutic setting, and because of ego-growth. The patient's fear of breakdown has one of its roots in the patient's need to remember the original breakdown. Memory can only come through re-experiencing. Hence the positive use that can be made of a breakdown if its place in the patient's tendency towards self-cure be recognized and used practically.
The original breakdown took place at a stage of dependence of the individual on parental or maternal ego-support. For this reason work is often done in therapeutics on a later version of the breakdown—say a breakdown in the latency period, or even in early adolescence; this later version occurred when the patient had developed ego-autonomy and a capacity to be a person-having-an- illness. Behind such a breakdown there is always, however, a failure of defences belonging to the individual's infancy or very early childhood.
Often, the environmental factor is not a single trauma but a pattern of distorting influences; the opposite, in fact, of the facilitating environment which allows of individual maturation.
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