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Shuren, I. (1967). A Contribution to the Metapsychology of the Preanalytic Patient. Psychoanal. St. Child, 22:103-136.
(1967). Psychoanalytic Study of the Child, 22:103-136
A Contribution to the Metapsychology of the Preanalytic Patient
I have described a specific structural ego pathology that appears in a wide grouping of varied clinical syndromes. The ego deficiencies are found in patients who fall within "the widening scope of psychoanalysis" (Stone et al., 1954). They begin treatment in a chronic state of partial ego regression. The ego has attempted to stabilize at the ego organization of the separation-individuationphase and has failed, in part, to do so. Although the paper limits itself to a metapsychological study of this specific mental structure, some inferences
are drawn which also contribute to a theory of technique. The technique of therapy involves "preparation for analysis," in which adequate emotional separateness must first be laboriously achieved before controlled regression can occur "in the service of the ego." The ego pathology is correlated with an inability to sustain secondaryautonomy, so that the ego is prone to regression and is overly dependent on environmental stimuli. It is theorized that paramount among these ego deficiencies are an unstable capacity for neutralization and for integration and a special sensitivity toward traumatic anxiety. Also depicted as defective are memory, signal function, frustration tolerance, emotional capacity, and the capacity to cathect objects. Genetic and dynamic distinctions are drawn between integration and synthesis, in presenting them as two separate ego functions.
The failure in secondaryautonomy is correlated with the clinical fact that defense has become the prime concern of this ego, thus creating an impoverished personality. The defenses are depicted as rigid and brittle and as continually failing under increase in pressure from the drives, the superego, and the external world. When this occurs, the ego structure eventually splits between its cognitive functions and its experiencing functions. Splitting is seen as following along lines of an earlier split derived from a rupture of the stimulus barrier during the first year of life. The earlier split is understood as having been covered over by reactive defenses, such as turning against the self. Poorly controlled behavioral discharges are ascribed to a loss of the ego's capacity to integrate these two sets of functions when defenses fail. Under conditions of splitting, the ego is depicted as being passive and helpless, because of a regressive loss of its control functions.
These ego deficiencies appear in an identifiable subcategory of a large grouping of patients referred to as "preanalytic." This designation encompasses a clinically heterogeneous variety of patients, whose psychopathology falls between, and to a certain extent overlaps, neuroses and psychoses. This paper also contributes some of the foundation for a theory of technique of these patients, by delineating the metapsychology of the ego deficiencies and defenses held in common by this subcategory. The decisive fixation points of the subcategory appear to fall in the symbiotic and separation-individuation phases. They begin in infancy and extend to the onset of the oedipal
phase, at about age three. The ego pathology seems best understood as the effect of serious and unresolved conflicts around the developmental needs of the ego for object constancy and emotional separateness.
The differential factors that determine the severity of individual cases are the developmental age when fixations occurred, the intensity of these fixations, and the quantitative ratio between fixation and regression. Those patients who tend more in a psychotic direction, the borderline states, are understood as cases of actual arrested development, in which libidinal resources and some early ego functions failed to develop further. Those patients who tend more in a neurotic direction are seen as illustrating the loss of functions through regression. The level of differentiation of individual ego functions and the capacity of the ego to sustain these functions without regression define the strength of the ego in an individual case and also appear to determine the prognosis.
All of these patients appear to be in a chronic state of impoverished libidinal object cathexes. This applies mainly to representations of current external objects and to representations of the current self. This phenomenology is a major factor behind the generalized complaints that bring them into treatment. There also appears to be a deficit of cognitive object cathexes that is correlated with the widespread use of denial. The explanation is offered that cathexes have been withdrawn from objects, bit by bit, whenever disappointments were experienced in the past. The energies that have been withdrawn are understood to have been reinvested in an unconscious nuclear defense that is based on an illusion of symbiotic connectedness and on an omnipotent self image. Since objects are still decathected whenever these illusions are threatened in the present, it is concluded that this defense is still current and that these energies are also used to reinforce the defense.
Clinically, the illusory omnipotence is removed gradually in the course of therapy as self-esteem is increased along realistic lines. This occurs within the context of a basically positive transference, which helps the patient rebuild a sustained capacity for libidinal objectcathexis, through a sense of trust. Only the achievement of secondary ego autonomy will sufficiently protect the patient from regression and finally permit him to relinquish his pathological illusions. The
nuclear defense that consists of omnipotent expectations, characterological passivity, and separation-individuation attitudes of connectedness to objects will remain a major focus throughout the course of therapy. These factors will appear intermittently, even to the end of an analysis itself. As their gradual resolution slowly completes the process of preparation for analysis, this simultaneously makes further analysis proper possible.
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