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Giovacchini, P.L. (1973). Character Disorders: Form and Structure. Int. J. Psycho-Anal., 54:153-160.
(1973). International Journal of Psycho-Analysis, 54:153-160
Character Disorders: Form and Structure
Peter L. Giovacchini
Two aspects of patients suffering from characterological disorders have been stressed: (1) the patient's primitive, preverbal fixations allow the therapist to contribute to the form of the patient's psychopathology as he attempts to conceptualize psychic mechanisms and ego defects in secondary process communicable terms, and (2) the specific type of ego defect encountered in such patients leads to a frantic pursuit of reassurance that they are capable of being helped,
although fundamentally they constantly prove to themselves that such a pursuit is fruitless and hopeless.
These two factors have opposite effects upon the therapeutic response. The first makes the patient more amenable to therapy if the analyst continues to respect the fundamental nature of the patient's productions, and does not distort, misunderstand or attempt to impose his preconceived concepts. In other words, the clothing the analyst uses to dress the patient's productions must fit, although styles may vary. To use Winnicott's felicitous expression, the analyst's secondaryprocesses must not 'impinge' upon the patient's primaryprocesses(Winnicott, 1954).
Such patients are often not easily understood, and in his need to be helpful, the analyst sometimes introduces ideas to the patient which stem from his need to do something rather than from true understanding. Creative listening, as is true of all creativity, involves a tolerance of ambiguity, an ability to wait until the analyst can understand and the patient is ready to be understood. Only then can the form of the patient's disorder be determined by non-intrusive, synthesizing elements of the analyst's psyche. Such moments, however, cannot be hurried; otherwise, one is imposing something extraneous upon the patient.
Such premature closure may cause the patient to despair further. We often hear of such situations misinterpreted as examples of the unfeasibility of the psychoanalytic method. On other occasions, the patient responds with eager acceptance but ego integration is not achieved. Again I find one of Winnicott's concepts useful in explaining this apparent harmony between patient and therapist: the patient's 'false self' (Winnicott, 1949) is relating to the analyst's false perspective, while the patient's agonizing inner core is, for the moment, submerged by a mutually shared delusion. I refer to the analyst's perspective as false because it represents the therapist's false analytic self. The true analytic self derives understanding from what the patient reveals rather than from elements of the analyst's value system and other aspects of his self-representation. Letting the patient remain in the foreground is an inherent attribute of the analytic identity. Being assertive obliterates one's analytic identity, although other nonprofessional aspects of the self-representation might be enhanced by such an active orientation. Respect for another's autonomy increases analytic autonomy.
The first factor, then, referring to the analytic setting contributing to the form the patient's psychopathology will take, is, in general, a positive therapeutic element. The second aspect discussed, the way patients suffering from characterological problems experience and express the need to be helped, creates complications and has often been responsible for failure.
Recognizing why these patients are so desperate has been of some help in dealing with them by helping us recognize why we cannot deal with them at the manifest level of their demands. If the picture of intrinsic and preordained frustration is viewed from a therapeutic perspective rather than reacted to with counter-frustration (which is also to some extent a projection of the patient's frustration) or by a reactive attempt to show him that he can be helped, there is hope for further integration. Concentrating upon the adaptive significance of the patient's characterological defences lessens the therapist's frustrations and makes it somewhat easier for him to deal with this group therapeutically.
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