Along with narcissistic vulnerability and related affects of shame, helplessness, or reactive anger, conscious or unconscious guilt often cripples depressed patients. Some patients reveal deep-seated feelings that they are bad or unworthy and are prone to attacking themselves—through self-criticisms or punishments—when they sense that they are behaving in an aggressive, competitive, or overly sexual manner. Examples of this are the cases of Ms. G in Chapters 4 ("Getting Started With Psychodynamic Treatment of Depression") and 6 ("Addressing Narcissistic Vulnerability"), who felt devastatingly guilty about aggressive thoughts concerning her mother and boyfriend, and of Ms. V in Chapter 7 ("Addressing Angry Reactions to Narcissistic Injury"), who worried that she was harsh when expressing vindictive feelings toward her father.
Other patients seem to be unaware of guilty feelings, yet the therapist may infer them from these patients' self-punishing behaviors or self-criticisms. Some of these patients feel justified in their anger at their parents or others. As described below in this chapter (see the case of Ms. AA in "Case Example 2"), the therapist must be tactful in bringing evidence of unconscious guilt to patients' attention.
To best understand the depressive patient's guilt, it is important to review the theoretical concept of a harsh, or overly severe, superego (Arlow 1996). This concept is clinically useful in understanding patients who experience an uncontrollable inner sense of condemnation, those who experience no guilt and whose self-punishment is only inferred, and those whose guilty feelings emerge in the course of psychotherapeutic exploration.
The superego is seen by some psychoanalysts (e.g., Milrod 1972) as a complex inner structure having three functions (Table 8-1): 1) ajudging
Table 8-1. Functions of the superego
1. Judging: Evaluating thoughts, desires, and fantasies as acceptable or harmful; can induce guilt
2. Limiting: Contains or limits impulses; inhibits behaviors
3. Punitive or rewarding: Punishes or praises the self, often by way of affects of guilt and depression or pleasure and pride function, which evaluates behaviors, thoughts, desires, and even fantasies as either acceptable or as morally harmful to the self or to others and which can often stimulate the conscious experience of guilt; 2) a limiting function, which contains or limits impulses and inhibits behaviors judged to be unacceptable; and 3) a punitive or rewarding function, which is responsible for actually punishing a patient for unacceptable thoughts or impulses or rewarding praiseworthy actions. Punishment can occur in the form of tormenting guilt or other depressive affects or can be accomplished by way of stimulating self-destructive behaviors. Often the self-punitive aspect of these behaviors occurs outside of the patient's awareness or is only minimally understood.
Severity in the superego can have many different etiologies. For example (see discussion about Ms. AA in "Case Example 2"), a harsh, judging superego can be based, at least partly, on internalizing the accusations of a parent perceived as excessively punitive, blaming, or demanding. Many depressed patients, however, may have had parents who were far from harsh but who were experienced rather as neglectful, frustrating, or even overindulgent. Aggressive fantasies about frustrating, withdrawn, or neglectful parents may stimulate the development of a harsh, limiting superego, if patients imagine that their aggression can get out of control and will damage others. When this is the case, patients may limit or excessively inhibit any behavior or thought that is unconsciously linked to these fantasies and thus perceived as dangerously aggressive. Further, hostile or competitive impulses toward parents who are perceived as psychologically or physically fragile can stimulate an excessive sense of guilt, through the fear that one can, or even has, damaged this parent. For some patients whose parents are overindulgent, the fantasy that they might "get away with murder" can result in an excessive limitation of aggressive or sexual impulses, due to the development of a compensatory, excessive inner scrutiny.
In working with depressed patients, then, understanding and interpreting the different functions of a harsh superego can contribute to alleviating conscious and unconscious guilt, to diminishing self-punishment by way of destructive behaviors and tormenting depressive affects, and to relieving excessive inhibitions based on guilt and on an excessively limiting
Table 8-2. Working with the harsh superego: middle phase of treatment
1. Helping patients recognize hidden guilt and self-punishment in their behaviors and feelings
3. Exploring guilt and punishment embedded in character: severe inhibitions and sadomasochistic character traits superego (Table 8-2). The latter outcome, in turn, allows patients greater opportunity for self-expression and for behaviors that will enhance their self-esteem and diminish feelings of narcissistic vulnerability.
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