Martin Burgy
Freud's intrapersonal concept of anal-sadistic regression isset against the interpretation of obsessive-compulsive neurosis as astructural ego deficit. The interpersonal dimension that comes to the fore as a result of this, becomes clear if we focus on obsessive-compulsive behavioral disorder: Persons suffering from obsessive-compulsive neurosis lack the self-assessment factor. It needs another person as part of their own ego who accepts and supports them in their behavior. A clinical example illustrates this narcissistic function of compulsion together with the changes in the psychodynamic approach and resulting therapy. Against DSM-classification with the concept of obsessive-compulsive disorder, which contains an unspecific symptomatology that occurs both in neurosis, schizophrenia, melancholia, and organic psychosis, this article advocates the specific and differentiated concept of obsessive-compulsive' neurosis.
In "Inhibition, Symptom and Anxiety," Freud, as early as 1926, pointed at the narcissistic gratification that the obsessive-compulsive symptom offers the patient: "The systems which the obsessional neurotic constructs flatter his self-love by making him feel that he is better than other people because he is specially clean or specially conscientious" (1, p. 99).
This secondary gain from the disorder supports the striving of the ego at assimilating and thus establishing the symptom as part of the personality's character. In Freud's opinion characteristics like tidiness, cleanliness, politeness, accuracy, and economy are in fact reactions set up to fend off anal-sadistic impulses. The personality traits are not what they seem, but point at an underlying unconscious or intrapsychic conflict (2, 3).
Most subsequent authors adopted this view. Hoffmann, for example, comments on obsessive-compulsive neurosis as follows: "There are hardly any recent publications on phenomenology, nosology and psychodynamics, rather, the well-known positions are repeated all over" (4, p. 45). And in his book on psychodynamics of obsessive-compulsive neurosis, Benedetti writes: "Freud's model continues to be the basis of all psychodynamic thinking. It is only when summarizing the literature that one can see just how modest the subsequent publications are as compared to the brilliance of Freud's model" (5, p. 16). Notwithstanding the acknowledgment of Freud's merits, Benedetti is critical of the fact that Freud's successors as a matter of course continue to adopt his theory and to hand it down without questioning it in any way.
FREUD'S INTRAPSYCHIC VIEW
The Oedipal conflict is at the center of Freud's thinking. Once the genital phase has been reached, the ego's defense struggle sets in, fuelled by the suppressed castration complex. Using a whole series of defense mechanisms, such as isolation, denial, magic thinking, intellectualization, and rationalization, the ego withdraws to the former anal-sadistic level of development. Regression is seen as the successful defense of a mature and stable ego structure. From the point of view of structural dynamics, regression of the ego leads to increasing severity and lack of love on the part of the superego, as more and more id-impulses have to be fended off. These impulses are anal-sadistic (antisocial, aggressive), anal-libidinous (pleasurable soiling) and genital (onanism, homosexual and heterosexual desires). The ego develops obedience towards the superego and identifies itself by reacting accordingly with the traits of the anaclitic character as indicated above. The compulsive symptom develops into the ego's compromising symbolic way of solving conflicts between the superego and the id. Freud, therefore, is of the opinion that in the form of obsessive-compulsive actions "the masturbation that has been suppressed approaches ever more closely to satisfaction" (1, p. 115).
In 1996, Joraschky takes up this view by describing the symbolism of ablutomania in the following way: "Thus washing one's hands, on the one hand, cleans off magically guilt, but can, on the other hand, be a new form of onanism that is inconspicuous to one's conscience" (6, p. 56).
Attention is focused on the intrapsychological structure and conflicts, so that Freud's theory of an internal dependence on the superego instead of the external dependence on people around continues to prevail in obsessive-compulsive neurosis (7).
INTERPERSONAL VIEW AND NARCISSISM
As psychoanalysts continue to hold on to the concept of one-person psychology, they tend to lose sight of the interpersonal and interactive processes in obsessive-compulsive neurosis, although Freud described them, albeit without going into any further detail, in his introduction to the treatment of the Rat-Man. The first comments his patient made to him at the initial analysis session were as follows: He had a friend, he told me, of whom he had an extraordinarily high opinion. He used always to go to him when he was tormented by some criminal impulse, and ask him whether he despised him as a criminal.His friend used then to give him moral support by assuring him that he was a man of irreproachable conduct, and had probably been in the habit, from his youth onwards, of taking a dark view of his own life. At an earlier date, he went on, another person had exercised a similar influence over him. This was a nineteen-year-old student (he himself had been fourteen or fifteen at the time) who had taken a liking to him, and had raised his self-esteem to an extraordinary degree, so that he appeared to himself to be a genius. (8, p. 159)
The element of relationships in compulsion can clearly be seen here, the psychodynamic background of which is described by Quint (9) in the disturbance of the obsessive-compulsive neurotics' actions: Obsessive-compulsive personalities can rely neither on their actions nor on their thoughts, as they lack the self-evaluating function. They need the other person, who will acknowledge and confirm their actions. In the clinical field this shows in the incessant questions that these patients address to the most important persons they relate to. Thus, in the case of ablutomania, they want to know if their hands are really clean, in order to stop washing them. Tormented by the thought of having, for instance, infected or soiled someone (even without touching) they try, with the help of the other person, to turn the magic experience into a generally acceptable reality. In this process the other person has the function of a self-object. In terms of relationships, it is the narcissistic hunger for the other person, who enable neurotics, incomplete in themselves, to acquire recognition and esteem to repair their structural ego deficits (10). As regards the genesis of the disorder, there is reason to believe that in childhood,neurotics had been unable to experience their parents as a part of themselves and were thus not able to experience their own value and ability to achieve something.
Janssen (11) takes a somewhat similar approach, describing the psychodynamic function of obsessive-compulsive symptoms as a way to cope with a conflict of symbiosis and separation, namely that, on the one hand, the symptom tries to prevent blending with the primary object, and, on the other, to compensate for a threatening object loss. Rudolf (12) calls it the neurotic's fragile ego in need of an object whose compulsory mechanisms serve the purpose of emotionally soothing and stabilizing an aggressively agitated self that fears above all the disintegration and destruction of its object relationships.
From this viewpoint, obsessive-compulsive neurotics strive to hold onto and control the other person as a part of themselves, in order to establish a feeling of undividedness, while at the same time secretly rebelling against it. They want to establish the narcissistic symbiosis in which postmaturing can become possible (13). The successful mother-child symbiosis is, according to Mahler (14), the precondition for a basic feeling of self-identity, while according to Winnicott (15), the infant's experience of controlling the mother and the possibility of experiencing her as a part of one's own self is a precondition for all future object differentiations. This view is complemented by clinical findings made by Quint (16, 17) and Lang (18). The following case study is aimed at illustrating the theoretical approach described for psychodynamics and therapy of obsessive-compulsory neurosis.
CASE STUDY
INTERVIEW
At the preliminary interview before inpatient psychodynamic psychotherapy, Ms. A. would not shake hands. One reason was that it was painful, because her hands were sore from washing, and the other, that she was afraid of being soiled by touching the other person. Sitting there, her mouth half open, she looked like a disabled child.
Her speech was clumsy and later on became more and more pressured.
Ms. A. started by saying that she had only come to the clinic because her mother had insisted on it, feeling she could no longer stand the situation with Ms. A. at home. At the age of 11, she had come home from playing being dirty all over. Her mother scolded her and called her dirty and revolting. Theses words triggered a washing and cleaning compulsion. Ms. A. can no longer tell herself when exactly her hands or the kitchen are clean. She needs her mother's confirmation that everything is clean. She also needs her mother's assurance when buying clothes, in order to know if a certain pullover, for example, goes well together with a certain pair of trousers. Ms. A. says that her mother is, therefore, the most important person in her life, although she can never really do things right for her. She feels worst when her mother is away for the weekend. She would then constantly clean and wash her hands, until they start bleeding. In her mother's absence, she has the feeling that people outside the house can notice her anxiety and are attracted by it. She would keep checking the front door all night for fear of being killed. She thus cannot live without her mother. She has tried five times to undergo psychotherapy as an outpatient, but it did not help her in any way.
BIOGRAPHICAL BACKGROUND