Working with the Core Relationship Problem in Psychotherapy: A Handbook for Clinicians / Edition 1

by Althea J. Horner

Overview

A clinician's Rosetta Stone for understanding and treating presenting problems

"I highly recommend this book to therapists of all persuasions."—Allan N. Schore, department of psychiatry and biobehavioral sciences, University of California at Los Angeles School of Medicine

In this important book, noted author, teacher, and psychologist Althea J. Horner shows how to reveal, understand, and use the powerful core relationship problem — which is formed from earliest childhood and creates an image of the self in relation to others — so it can act as a Rosetta stone for understanding the underlying conflict that repeatedly plays out in a client's behavior. Once this essential element is uncovered, clinicians learn how to work with their clients to successfully resolve common presenting problems.

Product Details

ISBN-13:	9780787943011
Publisher:	Wiley
Publication date:	08/14/1998
Series:	Psychology Series
Pages:	224
Product dimensions:	6.32(w) x 9.37(h) x 0.75(d)

About the Author

ALTHEA J. HORNER is a distinguished author, teacher, psychologist, and author of many classic and award-winning books including Object Relations and the Developing Ego in Therapy, Being and Loving, The Wish for Power and the Fear of Having It, Treating the Neurotic Patient in Brief Psychotherapy, and Psychoanalytic Object Relations Therapy.

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Introduction

The Unconscious and the Archaeology of Human Relationships

I come to my thoughts about mental development and the nature of the unconscious as a biological scientist. The marriage between biology and philosophy may appear strange and unnatural, but insofar as all aspects of being are integrated within a cohesive self in healthy development, a person's biology, psychology, and philosophy must inevitably and permanently be wedded.

Because that which we call the unconscious cannot be directly perceived, it must be considered a theoretical construct. Adler (1980), referring to the electron in nuclear physics and to the black hole in astronomy, notes that modern science legitimately and validly deals with objects that lie outside the range of ordinary experience because they cannot be directly perceived. He describes the unconscious in psychology as a similarly legitimate and valid object of study (p. 67). He also reminds us of Ockham's assertion that "we are justified in positing or asserting the real existence of unobserved or unobservable entities if-and only if-their real existence is indispensable for the explanation of observed phenomena" (p. 98).

Strachey (1957) wrote that the basis of Freud's repression theory of hysteria and the cathartic approach to treatment "cried out for a psychological explanation," noting that it was "only by the most contorted efforts that they had been accounted for neurologically" (p. 164). The neurological explanation disappeared in Freud's Interpretation of Dreams ([1900] 1953b), and what Freud had written previously about the nervous system he now translated into mental terms. Strachey says that here "the unconscious was established once and for all" (p. 164). Nevertheless, the neurological-psychological controversy still flourishes today (as discussed in Chapter Seven).

Freud ([1915] 1957c) saw the difficulties of "psycho-physical parallelism" as insoluble, the physical characteristics of "latent mental states" being totally inaccessible to us. "No physiological concept or chemical process can give us any notion of their nature" (p. 168). "On the other hand," he adds, with respect to these mental states, "we know for certain that they have abundant points of contact with conscious mental processes." Setting his role as neurologist aside, he says that "every endeavor to think of ideas as stored up in nerve cells and of excitation as traveling along nerve fibers, has miscarried completely" (p. 174).

Despite findings of recent brain research concerning the functioning of neurotransmitters and involving direct visualization of the brain at work, we are really no further along than Freud in our understanding of the physical correlates of what we call mind. But as long as we speak as scientists, we must assume that like the black hole, they are there. And as long as they remain unknowable, the theoretical construct we refer to as the unconscious allows us to bridge what is unknown with what is known.

The Stages of Object Relations

When they work from an object relations point of view, therapists and patients seek to discover the content of the unconscious that most directly affects the experience of the self, the experience of the other, and the complex relationships between them.

A developmental approach to the understanding of these experiences of self and other (experiences that include ideas, perceptions, feelings, wishes, and impulses) has taken us back further and further in the life of the child, with most recent research highlighting the interactional basis of their evolution from the start of life. As genetically patterned as the hunting and mating behaviors of other species is the neonate's readiness to respond to, and also to initiate, that interaction. Also built into the healthy central nervous system is the readiness to respond to patterns and actively to construct and synthesize new patterns.

The patterning of the mental schema we call self and the patterning of the mental schema we call object take place in predictable, hierarchical stages. We use the term object rather than mother because this particular mental schema is in part created by the child in accord with its own limited mental capabilities and unique experience of the early caretaking environment. The child creates a kind of metaphor and images for the significant other from its interpersonal experiences. This metaphor then reciprocally shapes the child's perception and expectations of the interpersonal environment, along with the child's behavior toward it. Herein lies the relevance of unconscious mental schemata for conscious experience and behavior and for the psychological treatment of disturbances in that sphere.

It is the child's ability to synthesize patterns out of experience and to register, as memory, those that occur repeatedly and regularly that leads from a process of interaction to what we call psychic structure-that is, to the enduring memories that will build and evolve over time to form the mental schemata of self and object. These patterns are built up out of the child's entire universe of experience, including what originates from within its own body as well as what originates from the external world with which it interacts.

The failure to distinguish between process and structure has led to some popular misconceptions about attachments, or what is often referred to as bonding. Rather than being understood as a process that leads eventually to structure, attachment is being understood as an event. Parents-to-be, as well as delivery-room personnel, espouse what might be characterized as the epoxy theory of attachment, believing that this is an event that takes place immediately in the first minutes of life, analogous to the imprinting experienced by Lorenz's ducks ([1935] 1957).

But we are not ducks, and although attachment-seeking behavior begins in the early hours with the maintenance of eye contact by the baby, the actual structuring of the enduring mental tie with the primary caretaker takes several months to develop fully. During this time, the child builds or synthesizes the experience of himself or herself in such a way as to include the primary caretaker (usually the mother) and the salient qualities of their interaction.

That the expectant mother who wants her baby is bonded to it long before it is born is clearly evident in the grief of women who miscarry. Yet the faddish furor over the critical nature of bonding and the near hysteria surrounding it has meant that some women who are unable to deliver by natural childbirth or who for some reason are unable to have immediate skin-to-skin contact with their new baby are inflicted with undue anxiety or guilt about themselves as mothers or about the future of their child.

As the child negotiates a series of developmental processes, beginning with the process of attachment, each stage brings him or her to a higher level of structural organization. The schemata of self and object-self representation and object representation in psychoanalytic terms-become increasingly complex and increasingly differentiated from each other. At the same time, disparate aspects of the organization of the self become increasingly integrated within a single self-schema while a similar process takes place with disparate aspects of object representation. Gradually, a single, integrated self representation evolves, as does a single, integrated object representation. However, even though we may speak of a single, integrated self representation, that self is exceedingly complex and various aspects may be in conflict with each other. In Chapter Eight, I describe working with dissociated self-states and address the current controversy over the nature of integration. Each level of psychic organization determines to a large extent the nature of the child's experience of himself or herself and of the other, along with the interaction between the two. This psychic organization is not directly observable, and for the most part it remains beyond conscious awareness, although what derives from it is conscious. Edith Jacobson (1964) defines identity as the conscious experience of the self-representation.

From the object relations point of view, the unconscious is highly organized, being characterized by a discoverable structure with its own dynamics, comparable to the dynamics of conscious experience. Discovering the link between them in the course of psychoanalytic therapy is the first step toward the remediation of pathological development and its consequent pathology of structure. Sandler (1981) notes that "every wish comes to include a representation of the person's own self and a representation of the object who also has a role to play in the fulfillment of the wish. The wish contains representations of self and object in interaction" (p. 183). The fact that such wishes are rooted in unconscious structure is what makes them so tenacious, to be acted out over and over even when the relationship may appear to the observer to be highly unsatisfactory.

Elsewhere (Horner, [1979] 1984) I have described the stages and processes in the development of early object relations and have related the pathology of each developmental way station to specific pathology of the personality. Particularly relevant to this discussion is the work of Mahler (1968; Mahler, Pine, and Bergman, 1975) and of Bowlby (1969), Winnicott ([1960] 1965a), and Kohut (1971). The remainder of this chapter describes these developmental stages, which are defined in terms of the self and object representations and their relationship to one another. Each stage leaves its traces in the unconscious, and even in the fully evolved individual, these traces may be reactivated under stress and regression or in dream or fantasy. As I noted in the Preface, my focus in this book is on what is dynamically relational as an interpersonal manifestation in the here and now of this intrapsychic representational world.

Preattachment Stage

At birth the child is in a state of what Mahler (1968) refers to as normal autism (p. 7). This term has been criticized because the newborn is clearly not in a chronic withdrawn state, as in pathological autism. Indeed, the child actively seeks contact from the very start. Here again the distinction between process and structure is important. Despite the immediate activation of the process of attachment, there is as yet no enduring, structured internal representation of the object. The experiences and their patterning and resultant memory traces are yet to come.

Grotstein (1990) wrote about "nothingness, meaninglessness, chaos and the 'black hole,'" traumatic states reported by patients that related to early infancy when the caretaking other failed in her holding capacity and when there was, as yet, no structured internal object to sustain the self. Some might argue that the infant's innate preference for the pattern of a facial configuration over a geometric or other nonhuman-type pattern (Fantz, 1966) indicates an innate object structure. However, although the precursors of self- and object representations may be present at birth in the form of preference, readiness, and potential, the cognitive development necessary for the structuring of the mental schemata and for the development of structure, as we use the term, has not yet occurred.

The most clearly stage-related pathology is that of early infantile autism, in which the child remains at the infantile stage of life and makes no move toward attachment. Along with the absence of attachment-seeking behavior, there appears to be a basic cognitive defect in these children that interferes with the organizational processes themselves. Before these discoveries, the mothers of such children were branded icebox mothers, on the assumption that the failure of attachment in these children was the direct consequence of the failure of the mother to facilitate the process. In situations in which the environment is grossly pathological, disrupting the organizing capacities of the child, there may be a retreat into secondary autism. Autistic withdrawal in response to severe stress in an adult suggests that similar failures of the environment date back to the earliest months of life. Similar autistic withdrawal in reaction to environmental failures would constitute the core relationship problem for that individual.

Process of Attachment Stage

Over the earliest months of life, we see the innate attachment-seeking behavior of the infant interacting with maternal behavior and response in a manner that, optimally, brings about the subsequent stage of normal symbiosis (Mahler, 1968), when the child has synthesized the experience of himself or herself in such a way as to include the primary caretaker and the salient qualities of their characteristic interaction. It is here that the basis for an affectional relationship and for what Erikson (1950) calls basic trust is laid down. The mother's emotional availability and her capacity for empathic response are essential to this process.

At the most primitive level, failure of attachment may carry with it severe deficits in the early organization of the self. The failure to develop an attachment and to achieve a satisfactory symbiosis because of environmental factors such as institutionalization or an unstable foster home situation may lead to the development of characteristic disturbances, such as an inability to keep rules, a lack of capacity to experience guilt, and an indiscriminate friendliness with an inordinate craving for affection and no ability to make lasting relationships (Rutter, 1974). Also, the affectionless psychopath (Bowlby, 1946) is characterized by the failure to develop the affectional bond that goes with attachment.

In Chapter One, I refer to the work of Alan Schore (1996) that demonstrates the neurological basis for the failure to develop a cohesive self in the first year of life and the critical nature of mother-infant interaction during that period, particularly eye contact. If there is a disruption of attachment due to separation and loss, subsequent development then depends upon the availability of a satisfactory substitute attachment object. Such interruption may lead to a lifelong schizoid detachment. Rutter says that "many (but not all) young children show an immediate reaction of acute distress and crying (... the period of 'protest'), followed by misery and apathy (the phase of 'despair')." There may be "a stage when the child becomes apparently contented and seems to lose interest in his parents ('detachment')" (p. 29). Rutter concludes that this syndrome is probably due to the disruption or distortion of the bonding process itself. At a later time in treatment the effects of such separations and losses can be identified as the core relationship problem.

Bowlby (1960) notes that the persistent longing of a young child for the lost love object is often suffused with intense generalized hostility: "There is no experience to which a young child can be subjected that is more prone to elicit intense and violent hatred for the mother than that of separation" (p. 24). The detachment is not permanent if the separation is not too long, but, Bowlby states, there is reason to believe that after prolonged and repeated separations during the first three years of life, detachment can persist indefinitely.

The quality of the child's experience during the attachment process and during subsequent separations and losses in the first three years of life builds into his or her inner world the unconscious feelings and expectations about the interpersonal world that will color all later developmental stages as well as future interpersonal relationships.

Normal Symbiosis Stage

Midway between the process of attachment and the separation-individuation process (Mahler, 1968) stands the primitive mental structure, the undifferentiated self-object representations. Owing to the young child's immature cognitive abilities, the undifferentiated images of the self and object are not yet integrated into single images. Instead, they are organized on the basis of the predominant feelings that go with the interactions between the self and the other. The good self- and object images are linked by positive feeling and mood. The bad self- and object images are linked by negative feelings and mood. Not until the cognitive development that will come toward the end of the second year of life will the disparate images be integrated into single cohesive representations of the self and of the other. If the good-bad split persists into adult life, it leads to an inability to hold on to relationships. When the other fails to be all good because of a failure to meet the wishes or needs or demands of the self, he or she then becomes all bad and is discarded or becomes the object of intense hatred.

Insofar as the primary caretaker has been able to lend herself to the child's unfolding, the experience vis-ˆ-vis the other is part of the child's positive and trusting experience of the self. Herein lies the archaic unconscious basis for the experience of oneness that at times comes with a loved other. But whatever the ecstasy of that experience, it may also carry a charge of anxiety at the felt loss of separateness of the self.

The bipolarity of experience-that which is directed toward the self and that which is directed toward the other-exists from the beginning of life. It starts with the infant's alternating attention to what is happening within its own body and to the interpersonal environment that it seeks to engage. All through life, these conflicting pulls will be felt in one way or another, the intensity of the conflict dependent upon the security of the sense of self and the security within the interpersonal situation. The conflict is often expressed as existing between "being myself" (identity) and "being in a loving relationship" (intimacy) (Horner, 1990). Sometimes these two states are believed to be mutually exclusive, especially when the mother reacts to the child's growing separation and individuation from her as if they were an assault and destructive to her well-being.

No sooner is the symbiotic structure established intrapsychically with the organization of the undifferentiated self-object representations, than the child moves toward a new process, that of separation and individuation (Mahler, Pine, and Bergman, 1975).

Hatching Stage: The Beginning Step of Separation

Mahler (1968) emphasizes the importance of the optimal symbiosis for subsequent differentiation of the self schema, or self representation, from the object representation. "The more the symbiotic partner has helped the infant to become ready to 'hatch' from the symbiotic orbit smoothly and gradually-that is, without undue strain on his own resources-the better equipped has the child become to separate out and to differentiate his self representations from the hitherto fused symbiotic self-plus-object representation" (p. 18). During this process the mother functions as a frame of reference, a point of orientation for the individuating child. If this security is lacking, there will be a "disturbance in the primitive 'self-feeling' which would derive or originate from a pleasurable and safe state of symbiosis, from which he did not have to hatch prematurely and abruptly" (p. 19). That is, while the self representation remains intertwined with the object representation, the loss of the object and the sense of connection with that person evoke a sense of disorganization and dissolution of the self of which the object and the sense of connection are still a part.

When a person's unconscious psychic structure is dominated by this picture, the person may experience severe separation panics. These separations can be due to a break in the emotional connection with the significant other as much as to an actual physical separation. It is the sense of inner connectedness that remains critical and that is so insecure. (Later I describe an individual who clings to his object no matter what the personal cost.) Agoraphobia may develop when the individual's house or apartment serves as a kind of prosthesis, standing unconsciously for the needed object. In therapy we will understand this lack of security as the core relationship problem.

Practicing Stage:
The Second Step of Separation and Individuation

During the period when the child is approximately ten to sixteen months of age, his or her focus shifts increasingly to those functions that develop as a consequence of the maturation of the central nervous system, such as locomotion, perception, and learning. These are referred to as the autonomous functions of the ego. The child is also increasingly confronted with the experience and awareness of separateness from the mother. Her ready availability when the child needs her and the pleasure the child derives from the mastery of new abilities make small separations tolerable for the child. With the culmination of the practicing period around the middle of the second year, the toddler appears to be in an elated mood. This accompanies the experience of standing upright and walking alone. This peak point of the child's belief in his or her own magic omnipotence, Mahler (1968) tells us, "is still to a considerable degree derived from his sense of sharing in his mother's magic powers" (p. 20).

At this point in development the inner representation of self and the other are still in great part undifferentiated, and this can be the anlage of the pathological structure referred to as the grandiose self. If things go wrong in the child's subsequent relationship with his or her caretakers, at a time when the child has come to realize how relatively helpless and dependent he or she really is, the grandiose self is a defensive fallback position. The adult that the child becomes can deny anxiety and dependency wishes as long as this inflated omnipotent self is in charge. The other is no longer of any emotional consequence. Of course the person must go to great lengths to protect this illusion, and if it is threatened, as by poor grades in school or the loss of a job, the reaction will be severe, with the development of symptoms such as depression or suicidal behavior. Sometimes others must be debased or demeaned to protect this state of being. An attack on the grandiose self, as by an ill-advised interpretation, may evoke a paranoid reaction inasmuch as this illusion functions to hold the self together and in that way protects survival.

Echoes of the practicing period and its magic omnipotence in the unconscious sometimes lead to persisting beliefs about the magical nature of one's abilities. Learning to walk and talk does indeed come as by magic, unlike the conscious effort one must make to learn the vocabulary of a foreign language at school. I have worked with some patients who were clearly of superior intelligence and to whom early learning was effortless throughout the grade school years; paradoxically, they were far less secure about their abilities than people of lesser innate ability. They did not connect their abilities with that sense of conscious effort that can give a person a feeling of some control over what he or she can and cannot do. What comes by magic can also disappear by magic-one cannot rely on it.

Rapprochement Stage and the Rapprochement Crisis

At around the age of eighteen months the toddler becomes increasingly aware of his or her separateness from the mother and the mother's separateness from him or her. The child's experiences with reality have counteracted his or her overestimation of omnipotence, self-esteem has been deflated, and the child is vulnerable to shame. Furthermore, through dependence on the object, who is now perceived as powerful, the child is confronted with the relative helplessness of the self. There is an upsurge of separation anxiety and depressed mood. If on the one hand the other uses power in a benign and helpful manner, that power is the basis for the child's sense of security. If on the other hand parental power is experienced as being against the self, as something that is not only given but also withheld, the child learns to both hate and envy the power and will develop techniques to control it. Behind such controlling behavior lie insecurity and anxiety. This is a core relationship conflict that may be acted out in therapy vis-ˆ-vis the therapist. The patient needs the therapist to be strong and to have the power to help him or her, but the patient may hate and envy that power as well.

The major concern of the person who struggles with problems associated primarily with this stage of development is the loss of the support, love, and approval of the other that is feared to result from the assertion of the person's own wishes or feelings. Still vulnerable to feelings of helplessness and shame, the person tends to idealize the other and see that other as having the power to protect the self from these painful feelings. The other may be a parent or perhaps a spouse or friend. This persisting dependent way of seeing the self and the other, and the expectations and demands that go with it, puts a strain on interpersonal relationships. Although the other may be idealized, he or she is also envied and feared and is blamed when things do not go well.

The rapprochement crisis is the developmental switch point that marks the shift from a sense of omnipotence to a sense of helplessness-from a sense of perfection to a sense of shame. When prior development has not gone well, the conscious awareness of the reality of separateness and the loss of omnipotence may be very traumatic. If there are deficits in the structural organization of the self and object representations, either as the result of unfavorable circumstances and experiences or as the result of some failure in the child's synthesizing capabilities, these deficits become evident at this time. The child, and the adult he or she becomes, is unable to negotiate the developmental demands, and symptomatic behavior such as anxious clinging develops.

The response of the environment to the child's growth has to allow for the child's strivings toward autonomy that conflict with the intensely felt dependency needs. The term rapprochement suggests the alternating moving away from the mother and returning to her for emotional refueling. Healthy parents do not have a need for the child to stay dependent and helpless or to be completely self-reliant. They can shift their way of relating to the child, being empathically in tune with the child's conflicting impulses and needs. Echoes of the rapprochement crisis are heard in adolescence, and the setup in the unconscious left over from the earlier childhood phase of development will affect the manner in which the young person negotiates the later developmental tasks. Anxiety over self-assertion or at the prospect of moving out of the parental home may come from the activation of unconscious rapprochement factors. The sense of self and other is still being determined by the unconscious self and object representations that were in existence at that early time and are still making themselves felt. In the course of psychotherapy with this person as an adult, this rapprochement crisis will be recognized as the core relationship conflict.

Achievement of Identity and Object Constancy Stage

The child is now developing language, and so the concepts of "Mama" and "Baby" are established at the start of the rapprochement period. This conceptual capability has an organizing and integrating effect. Unintegrated islands of disparate self representations become unified cognitively and structurally under each specific label, or symbol. Disparate object representations are similarly unified. There is a single self who may be good or bad, happy or angry, and a single object who may also be experienced in a number of different ways. This cognitive and structural integration sets the stage for an integrated sense of self, or identity, and an integrated view of the other. Although the child may be angry at his or her mother for some felt deprivation or failure of empathy, she is still mother, loved and valued in her own right and not only for what she can do for the child's self. In the earlier stage of development, before the cognitive achievement that brought the recognition that there is really just one self and one emotional mother, the self and object representations were split on the basis of the quality of feeling and emotion that went into the interaction. Mother was all good, idealized, and adored, or she was all bad and hated. The self in interaction with her was also split. With integration the complex, differentiated self and the sense of having a single identity come into being and provide a foundation for an unfolding individuality.

This is the point at which the capacity for ambivalence comes into being. Although ambivalence may be a developmental achievement, it can be emotionally painful and may be defended against by a defensive splitting, despite the integration that has taken place.

In healthy development, where there is a realistic picture of the other, relationships are increasingly defined on the basis of here-and-now interaction, although certain wishes, attitudes, and expectations, as well as the quality of emotion, are still colored by the forgotten past. Although archaic self and object representations persist in the unconscious, their impact is mitigated by the ascendency of reality-dominated perception and thought. The unconscious images may appear in dreams or in fantasy or may be recreated in artistic productions. The fairy godmother and the wicked witch of the fairy tales of childhood strike a familiar chord in children and adults alike, resonating with the now unconscious split images that dominate the earliest months of life. At times we may yearn for the blissful oneness of symbiosis or chafe under what feels like engulfment in a relationship. But by and large our reality perceptions keep us firmly rooted in our own individuality and that of the other.

Identification and Emotional Autonomy Stage

With the final stages of differentiation of self from object, certain identifications with the object remain as part of the self. These become part of the internal constant object. The baby needed the mother to comfort it and relieve its anxiety. Now the capacity to comfort oneself and to relieve one's own anxiety with a variety of psychological mechanisms is part of the self, derived from what once came from outside. This transformation can be observed in process in the toddler's relationship with his or her teddy bear or Linus blanket-the so-called transitional object (Winnicott, [1951] 1975).

The parents' "Good for you!" which reflected their pleasure in the child's accomplishments, now is voiced by the part of the self referred to as the superego (Freud, [1923] 1961b), which is composed of both the ego-ideal and the conscience. Not only does the superego criticize the self for transgressions, it also praises the self when the individual lives up to his or her ego-ideal, and it is the source of a healthy and secure self-esteem. These identifications with the parents allow the person to do for himself or herself what once could be done only by parental figures; they are necessary to the development of full emotional autonomy.

And Now the Eternal Triangle

With the full differentiation of self from object, there is also a firmer differentiation of mother from father. The primary caretaker-mother-is the linchpin of the psyche. Still, there is an attachment to the father even though dependency is vested primarily in the mother. Although the quality of the attachment to the mother as the primary caretaker of infancy is central to the build-up of the earliest self and object representations, an attachment to the father develops as well. Early on he is accepted as a substitute for the absent mother. Then his role becomes increasingly important. He supports individuation from the mother, not only as a substitute for her but also as a provider of different and unique experiences for the developing child. Up to now the child's relationship with each parent has been discrete and dyadic. Now, more and more, the individuality of each parent is recognized and valued differentially. The child becomes aware of the triangle that includes the self and both mother and father. The conflict inherent in that triadic relationship emerges. This is the point at which the conflicts of the Oedipus complex (Freud, [1913] 1953c, p. 129) come to the fore. What was a dyadic view of the interpersonal world now must include two significant others. A two-way competitiveness within the triangle generates new wishes, anxieties, and defenses. The child wants to be preferred by mother over father and by father over mother. Along with envy, the child now experiences jealousy of a rival who is also loved, and an uncomfortable ambivalence is generated. With patients who complain of the inability to make choices, we may discover that the core relationship conflict originated at this developmental point, where the child expects that to choose one object of the heart's desire is to cause the loss of the other who is equally desired. In some families this expectation may actually be the case; in others it will be only the child's fear or a projection of his or her own jealousy and wish to possess the object.

The relative ease or difficulty of this period will be strongly influenced by prior development and by the nature of the inner, unconscious representational world. The oedipal period tends to overlap with the latter part of the rapprochement phase of the separation-individuation process, so that rapprochement anxieties are aggravated by oedipal strivings. As the child moves closer to father, will mother abandon him or her? The child's ability to negotiate this troublesome period will also be affected by parental attitudes toward the child, who now presents the parents with an increasingly complex little person. The anxiety-generating wishes and feelings of the oedipal period may be repressed, taking their place in the unconscious along with the archaic images of earlier development.

The Unconscious and Psychoanalysis

The consistent and predictable presence of the primary mothering person throughout the early months of life ties the infant's experience together in a particular way. It is through her that the child's body, impulse, feeling, action, and eventually thought become organized as part of the self and integrated not only with each other but also with external reality, of which she is a representative. She is a bridge between the child's inner world of experience and the outer world of reality. Not only does the mothering person mediate the process of organization and of relating to reality but her image is part of what is organized and is the basis for the development of object relatedness as well. Thus her role in the evolution of the self and object representations is critical. When early development within the maternal matrix goes well, the outcome is the achievement of a cohesive, reality-related, object-related self.

Character pathology results from failures in this process of organization and may take the form of deficits of cohesion or integration, deficits of reality relatedness, or deficits of object relatedness. With the interruption or distortion of the development of early object relations, the individual does not arrive at a healthy outcome of the separation-individuation process-namely, a well-secured identity, object constancy, and a superego that regulates self-esteem. When structural pathology derives from failures within the relationship sphere in early development, those same core relationship failures will be manifest in here-and-now relationships as well and will be the focus in psychotherapy.

The therapeutic matrix can be viewed as analogous to that provided by the good-enough mother of the early years. It is a relationship within which repair of the defects of character structure, of the unconscious representational world, may take place. In an accepting, understanding, and safe relationship, various split-off aspects of self can be experienced, expressed, and integrated. The therapeutic matrix facilitates the attachment process, which will eventually provide the basis for the internalization of maternal-therapist functions, responses, and interactions, that is, for the further integration of the self within a context of human relatedness. The therapeutic matrix facilitates differentiation, the structuring of the boundaries of the self, the achievement of identity coupled with the achievement of object constancy, and the structuring of a guiding and loving superego. With structural repair and growth, the archaic images of the self and object, which have been playing out in adult interpersonal relationships, will loosen their grip on the individual's life and will fade into the realm of the unconscious.

With a secure sense of identity the adult can explore the repressed, unconscious conflicts of the oedipal period without undue anxiety and thus can finally renounce the wishes of childhood, being free to find suitable adult love objects and to strive for mature goals.

Now that this overview of the stages and processes of early object relations development from a structural perspective has been laid out as a reference point, the following chapters look at some of the specific core relationship problems that may emerge at various places of derailment along this developmental continuum. We always want to know how much healthy development was laid down before the derailment in order to assess the resources and strengths of the individual as well as his or her vulnerabilities. In the event of trauma we need to ask, Who is the child to whom this happened?

How to go about changing our focus from what is structural to what is relational is discussed throughout the chapters in Part One, "The Core Relationship Problem."

Table of Contents

Foreword ix
Samuel Slipp

Preface xi

Introduction: The Unconscious and the Archaeology of Human Relationships xvii

Part One: The Core Relationship Problem 1

1 Construction of the Developmental Hypothesis: The Hypothesis

2 Construction of the Developmental Hypothesis: Method of Data Gathering 11

3 The Place of the Signifier in Psychoanalytic Object Relations Theory 23

4 The Contribution of Family System Pathology to Core Relationship Problems 35

5 Belief Systems and the Analytic Work 45

Part Two: some Common Clinical Problems and Issues 51

6 Deciphering the Compromise Formation: A Psychological Rosetta Stone 53

7 OCD: The Medicalization of Psychopathology and the Importance of Preserving a Psychology of the Mind 59

8 Working with Dissociated Self-States 69

9 Cherchez la Mere: Disturbances of Object-Seeking Behavior in the Wake of Early Abandonment Experiences 77

10 Money Issues and Analytic Neutrality 83

11 Religion, Values, and Clinical Issues 93

12 The Therapist’s Core Relationship Problem: Countertransference Resistance 99

13 Moments of Decision: What Do I Say? What Do I do? 107

Part Three: Difficult Patients and Clinical Problems 115

14 Interminable Therapy and Transference Resistance 117

15 When Helping doesn’t Help: The Negative Therapeutic Reaction 123

16 The Masochistic Personality Disorder – A Diagnosis worth Keeping: Working with the Good Girl and the Good Boy 129

17 “Those Wrecked by Success” Revisited: Envy and the Fear of Being Envied 143

18 Managed Care as a Clinical Issue 149

Part Four: For Supervisors Only 155

19 Core Relationship Problems and the Supervision Process 157

References 165

About the Author 173

About the Foreword Author 175

Index 177

Editorial Reviews

"In this important book, Dr. Althea Horner, a remarkably skilled theoretician, continues to expand her developmental object relational model, a perspective that is solidly grounded in very recent findings in developmental psychopathology and neurobiology. But in addition, as a master clinician, she then demonstrates how an understanding of early- forming core relationship problems can offer penetrating insights into working with characterological disturbances. Due to her integrative contributions and extraordinary ability to explain complex clinical phenomena in clear and accessible language, I highly recommAnd this book to therapists of all persuasions." —Allan N. Schore, department of psychiatry and biobehavioral sciences, University of California at Los Angeles School of Medicine

"Once again, Althea Horner demonstrates that she is a master of the theory and practice of psychodynamic psychotherapy. In her latest book, Horner goes directly to the heart of the treatment. She clarifies the importance of identifying the core relationship problem early in treatment as it is the organizing principle for understanding the many layers of adaptive/defensive elaboration that accrue over the years. . . .The Core Relationship Problem in Psychotherapy is full of material that all clinicians—beginner and seasoned practitioners alike—will find thought provoking and rewarding." —Marion Solomon, author of Narcissism and Intimacy

"A testament to concision, wisdom, and instruction in psychotherapy. . . . My own experiences with patients flickered constantly through my thoughts as I read, and I was pleased to find new insights into clinical encounters about which I had previously been complacent. The handling of specific. . . . clinical issues all are considered with nondogmatic sensitivity." —Douglas H. Ingram, dean, American Institute for Psychoanalysis and clinical professor of psychiatry, New York Medical College

"Dr. Horner does it again! Her clear, concise style and compassionate tone draws the reader effectively through an education in the theory, art, and practice of psychodynamic psychotherapy, utilizing the core conflictual model. Every aspect of this most difficult of professions is elucidated by a elegant and common sense approach that leaves the student of psychotherapy with the feeling of having been touched by a master clinician." —William H. Rickles, M.D., private practice, Los Angeles, CA

From the Publisher

This handbook is designed to assist therapists in identifying the patient's core relationship problem early in the treatment and to use this understanding of the problem as a basis for therapy. Topics include the place of the signifier in psychoanalytic object relations theory, the contribution of family system pathology to core relationship problems, common clinical problems associated with the author's approach, the negative therapeutic reaction, and interminable therapy and transference resistance. Annotation c. by Book News, Inc., Portland, Or.

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