Você está na página 1de 17

See

discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/227077551

Therapy of the Conscience: Technical


Recommendations for Working on the Harsh
Superego of the Patient
ARTICLE in CLINICAL SOCIAL WORK JOURNAL NOVEMBER 1998
Impact Factor: 0.27 DOI: 10.1023/A:1022821903579

DOWNLOADS

VIEWS

13

99

1 AUTHOR:
William Meyer
Duke University Medical Center
22 PUBLICATIONS 30 CITATIONS
SEE PROFILE

Available from: William Meyer


Retrieved on: 30 July 2015

Clinical Social Work Journal


Vol. 26, No. 4, Winter 1998

THERAPY OF THE CONSCIENCE: TECHNICAL


RECOMMENDATIONS FOR WORKING ON THE
HARSH SUPEREGO OF THE PATIENT
William S. Meyer, M.S.W., B.C.D.

ABSTRACT: An indispensable goal of intensive psychotherapy is to modify


areas of the superego which are unreasonably harsh and punitiveyet, surprisingly little is written on this topic. In this paper, after discussing various
aspects of the superego, I recommend an active treatment technique which involves educating the patient, over time, about how pervasive and punitive is
for lack of a better wordthe conscienceof his or her mind. During this process, one can expect a softening and lessening of the patient's punitive superego
and an expansion of the patient's benign or benevolent superego, as the patient
begins to identify with and introject more of the compassionate attitudes which
have been imparted and experienced in the intimate relationship of psychotherapy.
KEY WORDS: super-ego; conscience; psychotherapy; psychotherapy technique.

Therapeutic work on the super-ego of the patient constitutes such a


vital and significant portion of clinical work that most would agree that
an intensive psychotherapy cannot be successful unless the superego of
the patient undergoes a demonstrable change. So critical is this particular focus that it is perplexing that more is not written specifically on this
topic.
What constitutes the superego? For purposes of discussion, the superego can be divided into three component parts: the ego ideal, the
benign or benevolent superego, and the prohibiting superego (Kramer,
1958). Briefly, the ego ideal represents what the person wants to be; the
The author wishes to thank Charles Keith, MD, for his mentorship, review of an earlier draft of this paper, and many helpful suggestions.
353

<B 1998 Human Sciences Press, Inc.

354

CLINICAL SOCIAL WORK JOURNAL

benign superego relates to the ego with love; and the prohibiting superego, (and it will be mostly this aspect of the superego I will be referencing), is that function of the mind which is demanding, harsh, and often
punitive. In health these three internal components of 1) ideals, 2) support and 3) prohibitions or criticisms, usually maintain a cooperative,
reality-based balance with each other, although conflict is inevitable.
Psychopathology, on the other hand, offers many examples of disproportion and extreme discord among the three parts.
The prohibiting superego involves memories of parental caretakers
when they were experienced as frustrating or angryin other words, or
in another paradigm, a representation of the bad object. It is that function of the mind which evolves into what is commonly referred to as
one's conscience. Internalized in each individual, the prohibiting superego, (working along side the ego ideal and the benign superego), can be
conscious or unconscious; it can whisper or it can roar.
The superego provides the harbor for an individual's morality and
ideals (Rothstein, 1994). Such moral values develop, in large part,
through identifications with parents, but also through identifications
with the larger family, community, religion, and the greater culture.
Such identifications may be harsh and cruel or tender and loving
(Blanck and Blanck, 1994). It is the part of the mind that induces feelings of pride and satisfaction or shame and guiltthose affective states
which refer to fantasied types of internalized and externalized parental
approval and disapproval.
The affective state of shame is linked to a mental representation of
an externalized shaming object. This is the experience associated with
feeling humiliated or mortified. Such affects are accompanied by a psychological state which is experienced as, "I am being scrutinized by a
parent-like other who disapproves, loathes, or is disgusted by me."
While shame has an interpersonal quality, "Others will think me bad,"
in guilt, the disapproval is experienced as a mental representation of the
self pronouncing the negative judgment, "I am bad."
While all people harbor at least a moderate amount of such attitudes within themselves, (indeed ours would be a frightful society if we
were composed of individuals who were guiltless and shameless), our
consulting rooms are frequented by individualsfrom the neurotic to
the borderline to the psychoticwhose inner lives are subjected to the
unrelenting tyranny and brutality of harsh consciences. So important is
the assessment of super-ego functioning that Kernberg (1976) states
that the quality of superego functioning [emphasis added] and the quality of object relations are the two most important prognostic criteria in
patient evaluations.
The work of Kernberg (1976, 1986) allows us to distinguish varying
levels of super-ego functioning. For instance, the more mature superego

355

WILLIAM S. MEYER

of the healthy individual is noteworthy for its relative lack of harshness.


Consequently, the healthy individual is able to partake of life's pleasures without debilitating guilt and is able to maintain a predominantly
positive sense of self over time. Even so, the healthier individual will be
susceptible to intense rumblings of conscience resulting in mild mood
swings, experiences of sadness and modulated feelings of shame and
guilt; but such feelings are transitory and are rarely oppressive over
long periods of time.
Also, the superego of the psychologically healthy individual contains
an internal sense of morality such that the individual does not exploit or
mistreat others, even in the absence of external controls. Internalized
morality can only occur in the person who has achieved object constancy, which includes the capacity for feelings of remorse (Arlow, 1996),
and allows for the person to feel an empathic, compassionate identification with the experience of the other. Furer (1967), in writing of this
critical developmental milestone, coined the phrase "identification with
the comforter." I can think of no good reason why this poignant phrase
has not taken its rightful place alongside its far more familiar counterpart of identification with the aggressor.
Although we can distinguish those who have an internalized sense
of morality from those who do not, it is beyond question that even the
relatively healthy individual has a significant capacity for rationalizing
and indulging in questionable behavior. All people are susceptible to
moral lapses, at least temporarily, particularly when some combination
of circumstances, temptations, personal vulnerability, and influential
figures of authority (see, for instance, Milgram, 1965), provide enticements for the individual to suspend temporarily the values that are an
internalized part of his or her moral code.
Moving from the super-ego of health to the other end of the continuum we can see a bold contrast by looking at the individual who suffers
from a severe borderline, psychopathic, or anti-social personality. The
severely anti-social patient presents with one of the most extreme forms
of superego pathologyfor not only is the superego unusually harsh,
but the individual has a strong propensity to project and punish that
which is experienced as bad, making it appear that there is no superego
functioning at all. The person with severe anti-social personality may
pay lip service to the morality that others have internalized but has no
real grasp of what this morality is or means. He or she is unable to
experience any authentic investment of love in or from others, and given
the severity of psychopathology, psychotherapy with these patients is
usually unsuccessful or minimally successful, at best.
The superego of the severe borderline, according to Kernberg, lacks
integration partly due to the patient's tendencies toward projection,
splitting, primitive dissociation, and an over-reliance on projective iden-

356

CLINICAL SOCIAL WORK JOURNAL

tification. The patient's inner view of him or her self is a chaotic mixture
of intensely shameful, threatened, or exalted images, and is dominated
by an excessively cruel superego. Consequently, the patient is vulnerable to severe depressive moods. His or her capacity for experiencing
concern and guilt is seriously impaired, and there is a tendency toward
impulsive action which is followed by self-inflicted psychological or physical punishment. As character pathology is more severe, the superego is
even more punitive. In fact, in so many patients who possess weak ego
strength, we also find a tyrannical, bombastic superego.
In the absence of a balanced, well-modulated superego the person
functioning on a severe borderline level is also deprived of the rewarding and approving functions of the superego, i.e. the benevolent superego. This leads to over-dependence on others for self-esteem regulation
(Edward, et al. 1991). Yet, because relationships with others are dominated by intense needs, intimacy is experienced as threatening. Most
often the prognosis for psychotherapy is guarded and goals of the therapist should be realistic, e.g. there may be extended periods of time
where the only achievable goal may be to help the patient avoid decompensation or remain alive. As noted by Freud (1940), the final outcome
of the therapeutic struggle depends upon the amount of energy "which
we can mobilize in the patient to our advantage, in comparison with the
amount of energy of the forces working against us. Here once more God
is on the side of the big battalions. It is true that we do not always
succeed in winning, but at least we can usually see why it is that we
have not won." (p. 78).
Between these extremes of health and pathology there is a middle
group of patients whom Kernberg designates as having intermediate to
high levels of organization of character pathology. It is this group of
patients, described below, which so often seek and can be successfully
treated by analytically informed psychotherapy, particularly when there
is an active focus on superego pathology, especially during the early
phases of psychotherapy.
At this higher level of character pathology the patient has a relatively well-integrated, but severe and punitive superego. Although the
ego is well-integratedthere is a relatively stable concept of self and
others and the patient is capable of experiencing guilt and mourningit
is the superego which dominates because of its sadistic, harsh, and perfectionistic nature. Demands to be great, powerful, and physically attractive co-exist with strict demands for moral perfection. The patient
may show some dissociative trends and a tendency toward projection
and denial, yet object relations are relatively stable in that there is a
capacity for lasting, deep involvement with others. It is these patients
who provide us with the greatest opportunity to make use of our thera-

357

WILLIAM S. MEYER

peutic interventions precisely because of their capacity to avail themselves, over time, of what we have to offer.
If we are sensitive to feelings or attitudes emanating from the superego of the patient we can observe their impact in most therapy hours.
A characteristic feature of the punitive superego is that it is readily and
regularly externalized and experienced as coming from outside the self.
In treatment such attitudes are routinely attributed to the psychotherapist (Kris, 1990).
For example: the patient doesn't make eye contact, the patient
changes topics to avoid a sensitive issue, or the patient becomes silent.
That this intra-psychic phenomena becomes manifest interpersonally is
familiar to all cliniciansbut how has this come about, what happens
and why, and what can we do to therapeutically intervene? Before we
attempt to address these clinical questions let us focus further on the
development of the superego per se.
SUPEREGO DEVELOPMENT
How do we explain why the super-ego develops as moderate or severe? While classical psychoanalytic theory emphasized how the resolution of the oedipal conflict results in crystallization of the superego, it is
now beyond debate that the superego has been in development since
early infancy.
The infant, with its unique temperament, interacts with and by increments takes in the provisions offered by the people of his of her environment. Responses to the infant are critical in shaping the beginnings
of the infant's mental images and representations. Mothers of infants at
high risk were observed repeatedly making statements regarding their
babies such as, "You're so bad," "You're a stinker," "I feel like giving him
away," and "Can't you leave me alone." This was contrasted with mothers of low-risk infants who made statements like, "Who's the pretty girl
in the mirror?" (Broussard, 1979).
So many factors influence these representations which are central
to the developing superego. To name a few, how much time elapses between an infant expressing his or her need and the caregiver's response?
What is the quality of the response, the look on the caregiver's face, and
the tone of the caregiver's voice? In one of Kohut's early papers (1957) he
notes that the tone of the parental voices take root as the precursors of
conscience in the child. "An important sector of our superego develops
from the parental commands, censures and approvals, transmitted by
the sounds of the parents voices, which may be piercing or cutting, heatedly angry or coldly killing . . . ," which goes on to form the basis for

358

CLINICAL SOCIAL WORK JOURNAL

what "could be called the sound or the tone of the voice of conscience
Similar considerations apply also to the approving parental introjects." (p. 396).
It is in this matrix of the infant's constitution interacting with the
representations of voices and experiences of his or her environment
where the template of personality structure takes its formative shape. If
temperament and environmentnature and nurturecombine to provide mostly positive experiences then a preponderance of positive images of self and other representations begin to define the individual's
inner life. If experiences are mostly negative then there will be a preponderance of negative self and object images. It is here that super-ego
precursors develop and set the stage for the type of personalityself
and object representations of good and badwhich will evolve over the
individual's lifetime.
However even when all goes well, the child's primitive defenses and
magical thinking, tend to make the superego of early childhood excessively harsh. Every observant parent has seen his or her child expect
severe retribution for the most minor of infractions demonstrating that
the inner parental representations can be experienced as far more severe than the parents have actually ever been. It is a maturational task,
particularly during the latency years, for the child to modulate this
harshness. Active interventions by the parents are required to facilitate
this modulation, so the child can be more accepting of sexual and aggressive impulses as they emerge in adolescence.
Such adolescent upsurges however, induce renewed super-ego pressures, thus heralding another round of intensified conflict. Because such
conflict is inherent in the human condition, no one is immune from suffering under the demands of super-ego criticism, and thus struggling
with problems of a "neurotic" nature, leading to excessive repressions,
inhibitions, and depressed mood. It is not rare for individuals, who have
undergone psychotherapy and become more tolerant of themselves, to
then re-work certain aspects of parental images, such that parents are
remembered in a more favorable light, more charitably, than they once
were.
Although "neurotic" struggles with one's superego are ubiquitous,
we would be remiss if we did not consider whether classical psychoanalytic thinking, with its strong emphasis on instinct, defense, and internal conflict, had underemphasized the extent to which the external
environment shaped the superego. Clinical practice repeatedly demonstrates that so many individuals with an overly harsh conscience, a preponderance of negative introjects, and severe feelings of guilt and shame,
were raised in households by disturbed parents who often mistreated
their children and whose own troubles rendered them grossly unattuned
to the needs of their developing children.

359

WILLIAM S. MEYER

If the parents were "good enough", if they had been reasonably attuned and available and reasonably consistent in what they permitted
and prohibited, then the child will have the greatest hope of growing
into the adult who has the same internalized conscience of morality and
moderation.
To be sure, every child is partly a "bad" child. That is, every child
does naughty things and thinks naughty thoughts. To the child (and
variably imbedded in the mind of many an adult) the thought is equal to
the deed. Given this magical thinking of childhood and the child's propensity to operate under the talion principle (an eye for an eye), many
children fear, yet feel deserving, of cruel punishments.
Do the parents attempt to temper such harshness with love or do
they weigh in on the side of severe retribution? To sight an extreme
example, one could look at the punishment of washing a child's mouth
out with soap. Such a punishment is consistent with the child's primitive notions of good and evil in which the mouth's "bad" language must
be "cleansed." Such experiences become internalized. Through experience, through identification with the aggressor, a part of the child's
super-ego becomes one with the severe super-ego of the parent.
Contrast this with the loving parent who observes his or her child
unintentionally send a glass crashing to the floor. The child is frightened
by the loud noise and fearfully looks to the parent with every expectation that the parent will offer a swift and severe scolding. The loving
parent realizes that the child is already frightened and guilt-ridden and
offers the child comfort and reassurance, thus contributing to the modification of the super-ego's punitive tendencies. Such benevolent reassurances, particularly in times of acute stress or trauma are critical to
healthy emotional development.
For the child who routinely endures a hostile or absent echo from
the environment the child comes to feel that the "bad" part of him or her
self is both accentuated and becomes more than ordinarily unacceptable.
The child may experience ever-greater parts of the self as "bad", including the normal but darker side of feelings such as greed, jealousy, anger,
lust, or sadness (Kramer and Yachter, 1988).
One 45 year old woman patient told me that her demanding mother
would punish her by not speaking to herliterallyfor days, sometimes weeks, at a time. In one treatment session the patient spoke in a
matter-of-fact manner about her inability to eat the high-priced chocolate candy her boss had given her last Christmas. She would feel too
guilty. Although it was the woman's good fortune to marry a supportive
husband, she has struggled with depression all her life.
Although the memories of interactions with caretakers form the
template of superego identifications, superego development extends beyond these interactions and has the potential for modification after

360

CLINICAL SOCIAL WORK JOURNAL

childhood with influences from individuals outside the family, religious


institutions, literature, and the greater culture at large. What gives us
hope for the child and for the adult in treatment is that the superego is
capable of taking in the influences of those who have stepped into the
place of parentseducators, role models, teachers, and, of course, psychotherapists.
DYNAMICS AND TREATMENT
Analytic technique has evolved considerably from the days in which
Freud, rather than analyze the substance of the patient's resistance and
internal criticism, would attempt to use his authority to circumvent the
patient's superego. Freud (1913) forewarned his patients that there
would be times in which they would feel uneasy about stating what was
on their mind. "You must never give in to these criticisms," he told them,
"but must say [whatever you are thinking] in spite of themindeed, you
must say it precisely because you feel an aversion to doing so. ... never
forget that you have promised to be absolutely honest, and never leave
anything out because, for some reason or other, it is unpleasant to tell
it." Subsequent analytic developments have demonstrated that not only
is it unnecessary and counter-therapeutic to strong-arm the patient into
divulging any and every passing thought, but the reasons behind the
patient's reluctance to speak freelyi.e. the super-ego, are as worthy of
analysis, if not more so, than the content which they are defending.
One of the first papers to elucidate technical aspects of the treatment of superego pathology is the classic paper of James Strachey, "On
the Therapeutic Action of Psychoanalysis," first published in 1934. It is
remarkable that this clinical paper written 60 years ago, by Freud's
translator and Winnicott's analyst, could maintain such relevance to
contemporary practice. Let me summarize his thinking:
The super-ego, containing the "bad" introjected object, is a portion of
the patient's mind which is primitive, out-of-date, and out-of-touch with
reality, and which operates automatically as would a reflex. When the
patient engages someone (in the therapeutic relationship for example),
there is a tendency to project his or her critical super-ego (bad-object
representation) onto the other and fantasize the external object to be
dangerous.
For example, suppose we have a patient, Mrs. Smith, who states in
her first therapy appointment that she cries frequently for no apparent
reason. During the course of the hour she reveals that her husband
rarely speaks to her, is preoccupied with sports on television, doesn't
help her with housework or child-care, and is largely inattentive to what
she is wanting or needing. Yet, she says, her husband is a good provider,

361

WILLIAM S. MEYER

doesn't beat her or run around, andshe looks down at her shoesshe
knows she is just being selfish to complain.
We can safely presume that she is projecting certain thoughts onto
the therapist. Her thoughts will go something like this, "Listen to me
rattle on about nothing. This therapist must think I'm selfish. Why did I
come here in the first place. Why am I bothering him with these petty
problems, especially when there are people who really need help?'"
It would be of little help to tell the patient that she has as much
right to psychological help as others, because a lecture about how one
should or shouldn't feel only adds to superego pressure and is never
therapeutic. Further it would be foolhardy and detrimental to the therapeutic alliance to insist that her problem is that she's angry at her husband (Meyer, 1988). While she would be angry at her husband if she
were free to experience her feelings, which she is not, the most compelling therapeutic issue related to anger is not her anger, but the superego
judgments about her anger. Further, it is likely that this same tyrannical attitude toward her anger oversees and dominates many other aspects of her self-experience. Her judgments are projected and re-introjected, thereby undermining her inter-personal relationships, including
the as-yet-to-be-developed relationship with her therapist.
What can the therapist do? Let us return to Strachey.
If a breach could somehow or other be made in the vicious circle [of
projection and re-introjection], the processes of development would
proceed upon their normal course. If, for instance, the patient could
be made less frightened of his super-ego . . . , he would project less
terrifying images . . . ; the object which he then introjected would in
turn be less savage ... In short, a benign circle would be set up
instead of the vicious one. (p. 367)

How to establish such a breach? How can the patient be made less
frightened of his or her super-ego?
First, the therapist must put into words what the patient is experiencing. In the case mentioned above the therapist will focus mostly with
Ms. Smith on her embarrassment and shame, and feeling that she has
no right to be dissatisfied with her husband or to receive psychological
assistance. The therapist, by illuminating what she is experiencing, will
acquaint her with the shaming, punitive aspect of her mind, and will
continue to do so non-judgmentally, patiently, and tactfullyover time
until Ms. Smith begins to observe this dynamic without the therapist's
assistance. As part of the process of working through, some of the factors which contributed to Ms. Smith's severe judgments will become apparent: memories of parental disapproval, religious beliefs, and childlike expectations of severe retribution, to name a few. Again, such
dynamics are operative to some extent in all of us. Over time Strachey's

362

CLINICAL SOCIAL WORK JOURNAL

"benign circle of projection and introjection" will become activated and


Ms. Smith will achieve a stable reduction in self-criticism, as she identifies with the gentler, more loving superego of the therapist.
Sandier and Sandier in more recent papers (1983,1984) provide further elaboration of this topic. They note that the adult patient was once
the developing child who experienced pain when, either by actual occurrence or projective distortion, he or she felt shamed or humiliated by
others. As a means of psychological protection, the child became able to
anticipate the shaming and humiliating reactions of others. In order to
avoid pain, the child would become his or her own disapproving audience. The child would only speak, or later even think, about content
which did not seem ridiculous or silly.
That child, now grown, brings to treatment a resistance to conscious
awarenessa censorshipover what is felt to be unacceptable preconscious thoughts, impulses, and feelings. This censorship which functions just below the level of consciousness serves to protect him or her
from shame, embarrassment, humiliation, and other forms of internalized social anxiety. The therapist must focus on illuminating the process of the patient's attempt at censorship, while taking care neither to
criticize the patient nor to push the patient to do things differently. The
priority is to analyze and, when possible, interpret what is occurring in
the here and now of the clinical situation (Stone, 1981).
During this extended process, the patient should begin to feel freer
to acknowledge some of the feelings and ideas which feel "bad" or disturbing. One patient, in this type of situation, began for the first time to
talk with me about certain homoerotic fantasies about which he felt intense shame. He later told me that during this interaction he had scrutinized my face for any trace of disapproval or disgust. That none was
discernable was, for him, tremendously relieving, and no doubt began a
process of easing the strict standards of his superego. Another patient
required months of the type of interventions described above that highlighted the cruel nature of her conscience, which seemed to demand that
she suffer severe deprivation and self-punishment. Then after equivocating for weeks she revealed that she had an abortion years earlier.
The unearthing of this fact stimulated therapeutic momentum which
interrupted a long-standing therapeutic stalemate.
It is often a moment of great consequence when patients can muster
the courage to speak of a dark secret, and then feel heard, understood,
and accepted by the therapist. The patient, after a prolonged period
of keeping quiet due to expectations that the therapist will react as
harshly and unsympathetically as did remembered objects from the
past, takes a chance with a new object. Should the therapist realize the
poignancy and significance of this effort and respond accordingly, the

363

WILLIAM S. MEYER

patient will take in, appropriate, and internalize, the gentler superego of
the therapist.
A CLINICAL CASE
Dr. A was a scientist in his mid-40's when he entered treatment complaining
of chronic feelings of a low-level depression, a loveless marriage, low self-esteem,
and periodic bouts of excessive drinking. Dr. A. very much looked the part of the
eccentric professor with his unkempt hair, mismatched clothes, and sweatstained under arms. He seemed to be sending a silent but unmistakable message
that others should keep their distance.
Among his strengths, however, Dr. A. had a deep and abiding love for his
two latency aged sons, had a history of enduring friendships with women, and
felt passionately about issues of social justice. He was also intensely motivated
to get help for his intense psychological pain, even though he did not feel worthy
of psychological treatment.
Dr. A. grew up as the middle child of a Catholic family of five children. His
mother had ten pregnancies and lost five to miscarriages. She was a warm, although not demonstrative, caretaker of the children. Dr. A. has vivid memories
of mother's heavy sighs which were perpetual reminders to the children that she
felt under-supported and over-burdened. Dr. As father was remembered particularly for his growing bitterness and excessive drinking as his various businesses ventures failed, one after another. Positive interactions between father
and the children became as scarce as the household income, and he was given to
unprovoked torrents of rage which were punctuated by sadistic verbal and physical humiliations of any child who committed the most minor of infractions. To
this day Dr. A. finds it inexplicable and inexcusable that his mother never sided
with the children against their father and that she did not move the children out
of the house as their father's behavior became increasingly hurtful and unpredictable.
Although Dr. A. was given to feeling like a misfit among his boyhood peers,
he believes his saving grace was his outstanding intellect which won him muchneeded attention and praise from the nuns and priests who provided his grammar and high school education. They became the surrogate parents to whom he
felt indebted.
Twice weekly treatment was begun and immediately there was a pronounced negative transference. I was relentlessly assailed as someone who must
be exploitative, because after all I was merely making money on other people's
misery. I must have been someone who grew up in the "in crowd", he said
jeeringly, and consequently could not possibly understand what it felt like to be
rejected by one's peers. Last, what could I possibly offer that would be of benefit.
Whatever I could give, he said, would be feeble and insufficient when compared
with the depth of his need.
I began by suggesting that these types of attacks probably served some purpose. I suggested that he might want me to be on the defensive because he felt
vulnerable with me. Perhaps he was afraid that if he let his guard down, I might
somehow hurt him. I also pointed out the inescapable fact that Dr. As attitude
toward me was, in part, a variant of the harshness he usually reserved for himself. I was able to bring to Dr. As attention that many of the accusations he was

364
CLINICAL SOCIAL WORK JOURNAL

directing toward me, stemmed from a deep fear that if he relaxed his defensive
posture, I would be as harshly critical of him as he was of himself.
His self-punitive attitude was pervasive. For instance, he had the most difficult time purchasing anything for himself, and if he forced himself to buy something this act aroused so much guilt that he could not enjoy his purchase. A
similar dynamic could be seen in his eating habits. He was somewhat overweight
and snacking took on qualities of a ritual. He would procure a sizeable quantity
of some high calorie snack and then find an isolated spot where his treat could
be quickly and voraciously devoured. Thus Dr. A. would experience the mixture
of glee, dread, and punishment associated with the feeling that he had partaken
of some forbidden pleasure.
Perhaps it was in Dr. A's sexual fantasy life that his over-riding sense of
guilt and his primitive conscience could be seen so blatantly. In spite of Dr. A.'s
superior intelligence he felt a powerful conviction that sexual enjoyment was
criminal, morally reprehensible, and something that, for him, should be subjected to severe penalty. Dr. A. rarely had sex with his wife over their decadelong marriage and recalled that there were years, even during adolescence,
when he had refrained from all sexual activity including masturbation. Dr. A felt
that this was what the nuns and the priests wanted of him and that it was his
duty to complybut there was more. He had always loathed his body and from
the age of five felt he was physically grotesque. It should be noted that there was
absolutely nothing physically unattractive about Dr. A., and it can only be surmised that this feeling can be partially explained by the fact that his mother
rarely touched him.
The only masturbatory fantasy Dr. A. had ever allowed himself was as follows: He is in a room with a woman. She does not look at him, because if she did
she would feel revulsion. Yet she is active and aggressive. He fears he will be
hurt. He must be completely passive while she quickly brings him to orgasm.
This fantasy, of course, has multiple determinants, and the dynamics of fantasies, like dreams, can be understood on many levels and from many perspectives. For the purpose of this discussion, I wish only to point out the patient's
severe superego which allows minimal pleasure, even in fantasy and only under
the most excruciating and fleeting of circumstances, and it is the patient's superego that became a central focus of this therapy.
Repeatedly, as gently as I could, I would say to him, "Here it is again. Look
at this attitude you have toward yourself. You have such a harsh conscience. You
can't allow yourself to enjoy things. You don't let up on yourself. You feel anything short of what you view as perfection is terrible, etc."
At first, Dr. A. would say, "I'm so stupid that I do this to myself. You must
think I'm an idiot." I would say the following: "You're doing it again. Here is a
situation in which we are beginning to see how pervasive, how brutal is this
attitude of self-criticism, and your only response is to use this as yet another
piece of information with which to pummel yourself."
I cannot count the many times there were variations of this dialogue. Frequently, as we would identify an area of self-condemnation, Dr. A's associations
would help to explain its origin. Guilt about purchases brought forth memories
of his father's spending sprees, while the family was nearly destitute. Dr. A's
rejection of sexuality elicited his feeling of allegiance to the strict values of special teachers in his Catholic high school, and so forth. As we visited and revisited the theme of Dr. A.'s harsh conscience, we identified his expectation that
I would condemn him, ridicule him, or precipitously react explosively toward
him. It was not hard to trace the (primarily) father transference origins of this

365
WILLIAM S. MEYER

expectation, which, in fact, Dr. A. transferred to all males. Yet, by my reliable


consistent presence, by my demonstrating to Dr. A. how his mind worked and by
our exploration of the transference, it was my hope that Dr. A. would be able to
identify with and incorporate the more benevolent superego represented in the
therapeutic setting.
Bit by bit, over several years, there was ample evidence that the super-ego
of Dr. A. was indeed softening. Dr. A. began to purchase new clothes, and expressed a newfound desire to see himself as "elegant." He stopped drinking, began to exercise, and lost weight. He took pride in his appearance. He began to
take stands in both his work and personal relationships, and after heroic measures to salvage what could only be called a hopeless marriage, he acted on his
only healthy option which was to leave his wife without abdicating the responsibilities of caring for his children. He spoke with pleasure of creative sexual
fantasies which were no longer restricted to fleeting acts of pain and humiliation. He and I developed a warm closeness within the confines of the therapeutic
relationship, in a way familiar to therapists who have had the pleasure of seeing
their patients over time. He began having close relationships with other men,
and by the time treatment ended he and a woman were becoming seriously involved in what appeared to be a healthy, reciprocal, promising romance.
It is worth noting that in the course of therapy he began to recall the loving
interactions between him and his father in the years prior to his father's severe
alcoholism. He was surprised at the tender feelings which emerged, which until
then, had long been unfelt and denied. Also, near the end of treatment he commented that his image of God, the ultimate super-ego projection, had changed
from a picture of a harsh and severe angry male to that ofa subjective feelingwhich conveyed a sense that there was the benevolent presence of a higher
power which was hopeful and encouraging.

CONCLUSION
If we are attentive to the communications of those who come to us
for psychological assistance we can often recognize individuals who are
filled with self-loathing and labor under the demands of oppressive superegos. Indeed many treatment failures may be caused by insufficient
attention paid to this critical dynamic. Or even worse, as noted by Anton
Kris (1990), by not taking a more active role against the severe superego, analysts have regularly, though unintentionally, sided with the self
punitive attitudes of the patient. Anton Kris (1993) states that of eleven
patients he has seen for reanalyis, ten had presented themselves with
profound punitive, unconscious self-criticism that had been untouched
or actually increased in the previous analytic relationship.
This paper recommends an active treatment technique which, as
but one part of an intensive psychotherapy, involves tactfully educating
the patient about how pervasive and punitive isfor lack of a better
wordthe conscienceof his or her mind. In the process of this treatment, which necessitates a sufficient period of time, one can expect a
softening and lessening of the patient's punitive superego, leading to a

366

CLINICAL SOCIAL WORK JOURNAL

decrease in pathological shame and guilt and an expansion of the patient's benign or benevolent superego, as the patient begins to identify
with and introject more of the compassionate, consoling, and benevolent
attitudes which have been imparted and experienced in the intimate
relationship of psychotherapy.
I will conclude this paper with a poem, written from the perspective
of a patient. In a few brief paragraphs, which highlight first the projective, and ultimately the introjective qualities of her therapeutic experience, this woman describes the change which occurred during her
treatment.
She begins by describing her therapist as the eyes of an x-ray machine which will mercilessly expose all her badness. Over time, as the
therapist and "his eyes" remain constant, she comes to internalize the
true perspective of the therapist who sees her as a good person who is
suffering from the effects of an unhappy childhood. Her own view of
herself evolves from a preponderance of self-recriminations over her
badness tothe therapist's perspective: a compassionate, loving view of
herself as a lonely child in pain. In so doing, she describes the arduous,
sometimes excruciating, but ultimately curative journey of her psychotherapy.
The Sinner*
Pierced by the strength of the eyes which pinion me to the x-ray machine, exposing my soul beyond nakedness, I squirm in guilt.
Relentlessly scanning this mass of slime
They'll not flinch in pursuing my crime.
"Guilty," I plead for peace and release,
"Guilty," I cry, "Please let me appease!"
And always the eyes with their piercing ray,
Always the eyes never looking away.
"What is your crime?" asks the voice of the eyes,
"What is this shame for which your soul dies?"
"Guilty," I cry, of my crimes I confide,"
And always the eyes from which I can't hide.
"What is your guilt?" asks the voice of the eyes.
"Why do you joke in this cruel exercise?
You've seen for yourself through your x-ray machine.
* I am most grateful to a former patient who has graciously permitted me to use her
poem in this article. It has not been published previously.

367

WILLIAM S. MEYER

You know very well that I'm unclean.


"Look for yourself, and tell what you see,"
Say the eyes through the voice from the x-ray machine.
I tremble, I quiver, I flinch, I cry.
In terror I struggle; I know I must die!
"What do you see," asks the voice from the eyes,
Rejecting my offers, my pleading, my lies.
I look at the eyes, the power they wield,
The soft gentle eyes that never will yield.
I steal a glance, hoping to please,
Hoping the stare will eventually ease.
"What do you see?" asks the voice from the eyes,
The loving, caressing significant eyes.
"I see a child, afraid, alone.
I see a child I've never known."
I look at the eyes, looking at me,
Healing, caring, enveloping me.
I look at the eyes, the soft gentle eyes,
The loving, caressing, significant eyes
Touching my soul, showing the way,
Always the eyes never looking away.

REFERENCES
Arlow, J.A. (1996), "The structural model," in Textbook of Psychoanalysis.
Blanck, G. and Blanck, R. (1994), Ego Psychology: Theory and Practice, 2nd Edition, Columbia University Press, New York.
Broussard, Elsie R. (1979), Assessment of the Adaptive Potential of the mother-infant
system: the neonatal perception inventories. Seminars in Perinatology, Vol. 3, Pp. 91100.
Edward, J., Ruskin, N. Turrini, P. (1991), Separation /Individuation: Theory and Application, 2nd Ed., Gardner Press.
Freud, S. (1913), "On beginning the treatment (further recommendations on the technique
of psychoanalysis. The Standard Edition, Vol. 12 Streak, J., London, Hogarth Press.
Freud, S. (1940) An Outline of Psychoanalysis. W. W. Norton & Co.
Purer, M. (1967) Some developmental aspects of the superego. International Journal of
Psychoanalysis. 48: 277, pp.277-280.
Kernberg, 0. (1986), Severe Personality Disorders. New Haven, Yale University Press.
Kernberg, 0. (1976) Object Relations Theory and Clinical Psychoanalysis. New York, Jason
Aronson.
Kohut, H. (1957) The psychological functions of music. Journal of the American Psychoanalytic Association. 5:389-407.
Kramer, P. (1958) Note on one of the preoedipal roots of the superego. Journal of the
American Psychoanalytic Association. 6:38-46.

368

CLINICAL SOCIAL WORK JOURNAL

Kramer, S. and Yachter, S. (1988) The developmental context of preoedipal object relations:
clinical applications of Mahler's theory of symbiosis and separation-individuation. The
Psychoanalytic Quarterly. Vol. 62, No. 4, 547-576
Kris, A. (1990) Helping patients by analyzing self-criticism. Journal of the American Psychoanalytic Association. Vol. 38, No. 3 Pp. 605-636.
Kris, A. (1993) Support and psychic change. In: Psychic Structure and Psychic Change, ed.
M.J. Horowitz, O.F. Kernberg, & E.M. Weinshel. Madison-Connecticut: International
Universities Press, pp. 95-115.
Meyer, W.S. (1988) On the mishandling of 'anger' in psychotherapy. Clinical Social Work
Journal. Vol. 16, No. 4, Pp. 406-417.
Milgram, S. (1965) Some conditions of obedience and disobedience to authority. Human
Relations, 18, P. 57-76.
Rothstein, A.M. (1994) Shame and the superego: clinical and theoretical considerations.
Psychoanalytic Study of the Child, 49: 263-277.
Sandier, J. & Sandier, A.M., (1983). The "second censorship," the "three-box model" and
some technical implications. International Journal of Psychoanalysis. 64:413-425.
Sandier, J. & Sandier, A.M. (1994). The past unconscious and the present unconscious: a
contribution to a technical frame of reference. Psychoanalytic Study of the Child. 49:
278-291.
Stone, L. (1981). Some thoughts on the "here and now" in psychoanalytic technique and
process. Psychoanalytic Quarterly, 1:699-709, 720-721.

William S. Meyer, M.S.W., B.C.D


Duke University Medical Center
Box 3812
Durham, NC 27710