Trauma, Inner Conflict and The Vicious Cycle of Repetition

Wurmser, L. (1996). Trauma, inner conflict, and the vicious cycles of repetition*. Scand. Psychoanal. Rev., 19:17-45.
(1996). Scandinavian Psychoanalytic Review, 19:17-45
Trauma, inner conflict, and the vicious cycles of repetition*

Lon Wurmser
This paper deals, first theoretically with the concepts of trauma, narcissism, and conflict causality, then clinically with the recurrent sequences of compromise formations which form characteristic vicious circles of a narcissistic, masochistic, and addictive kind, and ends with some technical conclusions and a psychological and philosophical reconsideration of the concept of repetition compulsion. The repetition compulsion, reflected in those vicious cycles, is viewed as an attempt to attain in symbolic ways affect regulation and conflict resolution which proves blocked because the affects and the drive needs evoked by them and closely connected with them, the forms of defense, and the superego demands, are all of a global quality and therefore irreconcilable with each other. Therefore, the consistent endeavors to express them in symbols also have to be defeated. Narcissistic crises, loyality conflicts, and shame-guilt dilemmas have a commanding position in the triggering of those sequences, of the ensuing impulsive actions, and of the splitting of consciousness and identity. It is just 100 years ago that Freud and Breuer's Studies on Hysteria (1893, 1895) appeared and opened a radically new epoch in the understanding of the human mind. I would like to proceed from this historical event, and with that from the concept of hysteria, in order to explore some issues central to the work with severe neuroses. At first, more precisely: What meaning does hysteria still have today? If we restrict the diagnostic concept of hysteria to conversion symptoms, i.e., the transformation of unconscious inner conflicts into bodily expressive symbolism, it is hard still to find patients of this kind in our practice.
An earlier version of this paper was presented at the Czech and Norwegian Psychoanalytic Societies.
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I hardly remember an example from my experience which would fully correspond to this prototype. This compels us to reflect on its essence: What does it mean descriptively, phenomenologically? Before I try to answer this I will make a brief detour to obsessive-compulsive neurosis. There, it is an issue of thoughts and actions which are ego-dystonic, seem meaningless and involuntarily recur in stereotypical form. They appear strange, as it were, split off, from context and feelings. Dynamically, i.e., in deeper understanding (as opposed to the phenomenological view), it is the fear of feeling and sensing, the forms of defense against touching, which determine symptomatology and character structure: especially isolation, and with that intellectualization and generalization, undoing, reaction formation and displacement. Returning now to hysteria, it is, again phenomenologically speaking, intensive affects that are egodystonic, meaningless and yet intrude, against one's will, with compelling force and impact on perception, motor action, and state of consciousness, even self-identity. We at once recognize that, understood in this way, this type of neurosis retains unchanged its importance and frequency. And we find just as indispensable terms which led Freud to its analysis and therapeutic resolution: trauma, conflict, compulsiveness, splitting, and especially repetition compulsion. Dynamically, we find the fear of knowing and remembering, and, with that, as forms of defense, repression, negation and denial, sexualization and condensation as well as manifold reversals. The form of expression is especially important: the dramatic acting out of primitive affects as defense against rational thinking. And thus, we also have what we might call hysteria of everyday life, not even necessarily in a pathological sense: much in popular culture, particularly today's music, sport and demagogy can be expressions of mass hysteria, where such elemental affects have become presentable. It also becomes evident with this that very many patients counted today in the borderline category, represent new editions of what was seen as hysterical problematic: drug addiction, eating disorders, masochistic love addiction, multiple personalities, and states of depersonalization. In what follows, I shall explore more the themes of trauma, inner conflict and repetition compulsion, first briefly theoretically trauma, narcissism, and conflict causality, then clinically the recurrent sequence of compromise formations which form characteristic vicious circles of a narcissistic, masochistic, and addictive kind, and finally in the form of some
technical conclusions and a psychological and philosophical reconsideration of the concept of repetition compulsion.
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Trauma
The Greek word signifies wound, injury, also defeat, from the words troein, to wound, to pierce, to charm, and terein, to rub, to torment, to torture. In the Preliminary Communication (1893), Freud notes that the causation of hysteria usually lies in psychical trauma, and he defines this as: Any experience which calls up distressing* affects such as those of fright, anxiety, shame or emotional pain may operate as a trauma of this kind (S.E., 2, p. 6). He adds that often instead of a single, major trauma, we find a number of partial traumas forming a group of provoking causes. These have only been able to exercise a traumatic effect by summation (l.c.). It is then of the greatest importance whether there has been an energetic reaction to the event that provokes an affect . If the reaction is suppressed, the affect remains attached to the memory the injured person's reaction to the trauma only exercises a complete cathartic effect if it is an adequate reaction as, for instance, revenge. However, language serves as a substitute for action; by its help, an affect can be abreacted almost as effectively (p. 8). In the Discussion (Epikrise) of the case of Frau Emmy von N., he and Breuer state: we regard hysterical symptoms as the effects and residues of excitations which have acted upon the nervous system as traumas. Residues of this kind are not left behind if the original excitation has been discharged by abreaction or thought-activity (p. 86). Conversion is being defined as the transformation of psychical excitation into chronic somatic symptoms. Usually, such a transformation occurs incompletely; at its place we encounter alterations of mood (anxiety, melancholic depression), phobias and abulias (inhibitions of will). These symptoms are seen by Freud as due to trauma, not, as claimed at the time by French psychiatry, as stigmata of neurotic degeneracy (p. 87)**. In the case description of Miss Lucy R., Freud takes a decisive step ahead when he refers to experiences in which opposing affects had been in conflict with each other and states poignantly: The conflict between
In German: peinlich; its translation would be more like embarrassing, damaging to self-esteem, shameful.
her affects had elevated the moment into a trauma, and the sensation of smell that was associated with this trauma persisted as its symbol (p. 115/6). The actual traumatic moment, then, is the one at which the incompatibility forces itself upon the ego and at which the latter decides on the repudiation of the incompatible idea. That idea is not annihilated by a repudiation of this kind, but merely repressed into the unconscious. The result is a splitting of consciousness which is a deliberate and intentional one. At least, it is often introduced by an act of volition (p. 123) He notes later that it was a peculiar state of knowing and at the same time not knowing a state, that is, in which a psychical group was cut off (p. 165). It is theoretically crucial that the traumatic moment is one in which the conflict is conscious (pp. 167f.). 30 years later (Freud, 1926), he calls a situation of helplessness that has been actually experienced a traumatic situation, distinguishes between physical helplessness if the danger is real and psychical helplessness if it is instinctual (the former being traumatic), and adds that anxiety is on the one hand an expectation of a trauma, and on the other, a repetition of it in a mitigated form The ego, which experienced the trauma passively, now repeats it actively in a weakened version, in the hope of being able itself to direct its course (pp. 166f.). The repetition refers here not only to the anxiety signal (reproduced as a signal of help), but to the much more general changing from passivity to activity, which is now equated with the earlier understanding of abreacting a trauma (p. 167). In regard to the current use of the trauma concept, I refer to The Psychoanalytic Glossary's definition: The disruption or breakdown that occurs when the psychic apparatus is suddenly presented with stimuli, either from within or from without, that are too powerful to be dealt with or assimilated in the usual way. A postulated stimulus barrier or protective shield is breached, and the ego is overwhelmed and loses its mediating capacity. A state of helplessness results, ranging from total apathy and
By the way, this was the general, so-called scientific view in the Victorian age. Frederick R. Karl (1995) cites this view in his biography of George Eliot that because of the female sexual and reproductive systems, women's cerebral evolution had been arrested at a certain undeveloped point she lacked the element that was thought to contain the will . Therefore, it was held that women were more subject to diseases of excitement, that is, hysteria and related nervous ailments. This, too, was held as scientific, despite evidence that men outnumbered women in such nervous diseases (p. 324).
withdrawal to an emotional storm accompanied by disorganized behavior bordering on panic. Signs of autonomic dysfunction are frequently present (Moore & Fine, 1990). Krystal asserts more incisively: trauma refers to an overwhelming, paralyzing psychic state, which implies a loss of ego functions, regression, and obligatory psychopathology (1988, p. 145). We could also define it as an overwhelming, unsolvable external conflict between self and environment, whereas Freud, as we found, saw it as moment of a conscious inner conflict. I do not believe that these two are contradictory, but they are two sides of the same coin. In the trauma, the conflict between self and outside changes to a conscious, but unsolvable inner conflict. The affects battling each other overwhelm the capacity of the ego to master them, a failure that leads to the split between the groups of ideas, to the act of making the connections unconscious, about which Freud was originally speaking.
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If we look outside the confines of psychoanalysis, we see that at present, this question of psychic trauma has assumed new actuality with the controversies swirling around the alleged frequency of repressed sexual abuse. On the one side, there are those who believe in the almost ubiquitous occurrence of severe sexual traumatization which, although repressed, is said to exert an uncanny power. On the other hand, there are critics who want to destroy the concept of repression altogether and, with it, deny psychoanalysis its right to exist. In the first group, the zealots of repressed memory, who are convinced that they can infer from superficial symptoms and single dreams, the suffered sexual seduction and violation of their patients. They then impose those interpretations with great suggestive powers upon their patients and induce them to accuse their fathers and mothers of heinous crimes. While Andrea Dworkin and Susan Brownmiller were hypothesizing that American fathers regularly rape their daughters in order to teach them what it means to be inferior, Bass and Davis set about to succor the tens of millions of victims who must have repressed that ordeal (quoted by Crews (1994)). Families are torn apart, marriages destroyed, men and occasionally women sent for decades to prison, without recourse to further evidence. Wright says therefore: whatever the value of repression as a scientific concept or a therapeutic tool, unquestioning belief in it has become as dangerous as the belief in witches (quoted by Crews). In the second camp, we find non-clinicians, like Crews and Grnbaum,
who assert that the concept of repression is without empirical support; the power of suggestion is such that all the claims of psychoanalysis for scientific truth are without basis and its character not much better than demonology. Obviously and unfortunately, the criticisms of the practices of the first camp are only too justified; they can very well be counted within the realm of mass hysteria. The polemics by the second group induce us again and again to reflect on the epistemological foundations of our own work and understanding, although their anankastic quibbling and pars pro toto reasoning leaves them strangely uncomprehending as to what really goes on in psychoanalytic work and hence makes them remarkably irrelevant, in spite of their clamor for attention. How does the question of repressed trauma relate with my own experience with severe neuroses, with an approach where I am particularly careful with interpretations, particularly cautious with the factor of suggestiveness? Most importantly, how can we understand the consequences of severe traumatization and their treatment? Almost all my patients with severe neuroses (and even those with less severe manifest pathology) have been massively traumatized, often chronically, throughout childhood, and even later on. But it has not been my experience that even with these patients, those traumata have become unconscious, and that their lifting out of such amnesia would have been the decisive mutative factor. I don't claim that this does not exist, but it has not been my observation. It was rather so that the main affects and the attempts to gain control over them, the main anxieties and wishes, engendered by those traumata, and with that the conflicts derived from them, have become or remained largely unconscious and are at the center of our therapeutic work. Their transformation into words (and other symbols) and the partial resolution of those conflicts, have clearly had the mutative effect and justify the psychoanalytic endeavor. The causality relevant to a psychoanalytic approach to problems of psychopathology is that of the centrality of unconscious inner conflict. The entire structure of psychoanalytically relevant causality could be reformulated in the following way. The more severe the traumata, the more overwhelming the affects. The more radical and overwhelming the affects, the more intense the conflicts. The more intense and extreme the conflicts, the more encompassing (global) the defenses and the more totalitarian the contradictory demands of the inner judge, that sadistic version of conscience.
Thus, the trauma lives on in the severity and pitiless character of the conscience as well as in the split character of the superego (conscience, ideals, values, loyalties). The more extreme the aggression of the superego, the more life-determining are the fantasies and the more prominent the core phenomena of the neurotic process (compulsiveness, globality and polarization), meaning: the broader the problems of narcissism, of splitting of identity, and of compulsiveness. And in reverse order, the psychoanalytic path from description to explanation proceeds from the core phenomena of the neurotic process, compulsiveness, polarization and absoluteness, as they are typically reflected in preconscious conflicts, affects and self-protective behaviors. It uses with particular benefit the bridges of the core fantasies in order to reach the unconscious core conflicts. The recognition of them and the new attempt to resolve them brings about the effective change; their place in the inner chain of causal connection is at the very center. Beyond the conflicts, we deal with core affects of a traumatic or physiologic origin, often determining the severity of the conflicts we deal with. The core fantasies and core conflicts are specifically set up to deal with, to defend against, central affects of a primary and global nature. Behind those 4 layers of psychopathology described (core phenomena, core fantasies, central conflicts, and main affects) there looms like a monster, in every case of severe neurosis, the fatal power of trauma. In that context there are several particular aspects that have more-and-more captured my interest: (1) the issue of double reality and double-self, i.e., of split identity and of the breaking apart of the experience of the outside world; (2) the phenomena of masochism, narcissism, and compulsive drug use as central ways of dealing with such chronic traumatization; (3) the existence of characteristic circular sequences of ego states, of compromise formations of conflicts, that can be reconstructed for the current inner life, for the current transactions in transference and immediate environment, but also for the past. Such reconstructions of ego
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states assumed much greater relevance than the restoration of narrative continuity by reconstruction of repressed trauma. These vicious circles also show a certain specific regularity for different pictures of pathology. I shall develop all 3 groups of phenomena in the form of characteristic circuli vitiosi, with the help of one especially instructive case. At the end, I shall say a little bit about the technique with these severely traumatized patients. Yet, before I enter into the case report, I would like to state what is meant by narcissism.
Term and Concept of Narcissism

Sidney Pulver (1970) distinguishes the use of the word narcissism in a purely descriptive sense, term, from its supposedly explanatory use, concept. First, as to its use as term narcissism: (1) as sexual perversion, the direction of the conscious sexual interest onto the self, e.g., as masturbation in front of the mirror; (2) as a postulated early stage of development where the child uses fantasies of omnipotence and grandiosity, or of idealization, of wishes for merger and union; (3) as object relation marked by a hypercathexis of the self and a hypocathexis of others, shown as exploitation and using, what we also know as soulblindness and soul murder; (4) it refers generally to self esteem and its conflicts: measured against an ideal state of well-being and the conflicts about this. The ostensibly explanatory concept narcissism refers to it as a drive, investing any aspect of the self with any form of libido (fused, neutralized, desexualized, resexualized). On this concept rests also the theoretically important distinction of primary versus secondary narcissism and the developmental derivation from certain phases in which the narcissistic drive would rule. Similarly, the basic concepts of Kohut, the bipolarity of idealized self-object versus grandiosity are part of this fundamental schema of the explanatory use of the drive concept narcissism. The Psychoanalytic Glossary defines narcissism very broadly as a concentration of psychological interest upon the self (Moore & Fine, 1990). I will now summarize very briefly my own use of the term. I see it as a purely descriptive word, an excellent summarizing term, collecting and subsuming many dynamically related, but seemingly disparate phenomena. By itself, it explains nothing; it requires further empirical analysis, just as it is true for the concepts of masochism, sadism, repetition compulsion, or splitting. How do I use it? (1) In the meaning of the narcissistic character: haughty, arrogant, exploitative, entitled. (2) A set of narcissistic fantasies and wishes: transgressing and wiping out the boundaries and limitations of any kind. (3) For narcissistic defenses, namely fantasies of omnipotence or magical power and overvaluation of symbols of power, very much including fantasies of total responsibility with an exaggerated sense of guilt and
an ego ideal of perfection, in order to defend against helplessness and impotence. (4) Closely connected with this, a set of character traits serving defensive aims: of idealization of the other or of grandiosity of the self, but also a pervasive attitude of resentment, i.e., an overblown feeling of suffered injustice; a prominent tendency of shame reactions, of embarrassment, of being wounded, of blaming others. (5) The narcissistic dimension of being human: everything relating to self-esteem, to value of self and others. (6) Affects that are strongly relating to the ego ideal or the ideal self: shame and resentment, pride and the sense of honor. (7) Narcissistic conflicts: conflicts about self-esteem and self-respect, especially shame conflicts and those about resentment. (8) As narcissistic stigma the overvaluation, hence the absoluteness and globality of judgment and feeling. (9) The consequence of this absoluteness is the typical split of one's identity, feeling torn asunder, the experience of double reality and double self. All these relate more-or-less directly to the value of the self, and with that to the boundaries of the self. Behind these important groups of phenomena can be found unconscious conflicts, overwhelming affects, and ultimately traumata in the sense of unsolvable outer conflicts. It is with some of these that I would like to deal with here. For this, I select a particularly instructive case, in which the problems of compulsive drug use, masochistic character pathology, and the whole panoply of narcissistic phenomena all converge. Since I have dealt with the issues of masochism elsewhere (Wurmser, 1993), I focus on the dynamics underlying relapses, and with that, the issues of narcissism as well.
Rape was the Metaphor for my Whole Life

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Sonya is a now 39-year-old unmarried white woman, very slim, finely built and pretty, still almost girlish in appearance and dress. She sought help for a severely self-destructive life pattern, which had entailed about 20 years of compulsive substance abuse (opiates, mostly heroin, and with particular abandon cocaine, at times also alcohol), episodically crippling chronic depression and anxiety since early childhood, with suicide impulses, and, in the last few years, an extreme risk-taking behavior, skirting
death, with homelessness and prostitution on the Westcoast. A number of times she was raped, often severely abused and not paid. About four years ago, she contracted the HIV infection, most likely when she was living with a pimp with whom she was sharing drugs and needles. This was after having lived with another drug addict whom she had been in a masochistic love bondage with and who mistreated her severely. He was the father of her daughter which is now 3 years old. Sonya was in various treatment programs, for a longer period quite successfully in a therapeutic community, where she complied with what she experienced as very degrading and humiliating practices, until she had another of her serious relapses. It was in the wake of that relapse that she lost her, at that time, 2-year old child; her parental rights were being removed, and the child is now being considered for adoption. After having suffered shipwreck in everything she had undertaken, she decided to return home in December 1993 and eventually to get to the bottom of her pathology. She enrolled in a methadone program and stopped taking cocaine and other drugs, but realized that her problems were far deeper than could be dealt with by such symptom removal. She decided, after a particularly life-threatening relapse, to enter psychoanalysis with me at the end of February 1994, convinced by a friend of hers and patient of mine who had successfully done so (he too is HIV-positive). In the 2 years since she has been in analysis, she has had one serious relapse with cocaine, lasting 48 hours (in June 1994), and two brief ones of a few hours duration. She was very deeply involved in her psychoanalytic work, though with increasing ambivalence, came regularly and on time, and was, in spite of her history, astonishingly articulate and introspective. As of the beginning of 1996, she has decided to come only once a week, largely under pressure of her parents and of the insurance.
Background
The patient comes from a quite dysfunctional background: an explosive, despotic father, a very submissive mother operating with much denial, a family life oriented towards showing a good faade, a lot of fighting and screaming at home. Toward the outside, her father was, however, a very successful factory owner, one who had built up the enterprise on his own, from very modest beginnings. Yet when he came home he would make himself a Scotch and begin screaming, every night. He had been a war
hero in WW II, saving people from a burning airplane in the Far East and ferrying supplies over the Himalayas. There was a radical conflict in her between the two images of her father: cold, furious, cruel loving, warm, the one to whom she jumped every morning into bed, on whose lap she sat and with whom she was bathing. The image of him is double; it is split, and so is her self-image. The mother was a housewife, socially very shy. She was very cold, could not express herself . There are always these mixed message with her. She says everything is allright, but you know it isn't. I tell her: You say one thing, I feel something else. She is comfortable with her fake smile, pretending what one should. And I pull the curtain away. I have a thing about honesty: that people say what they mean. The family gave me a lot of double messages. The entire family, of immigrant, mostly German background, was entirely oriented toward becoming socially accepted, making it with the golf and country club set, showing the proper faade, catching up with the Joneses. Yet, Sonya's identity was that of the loser. She is the youngest of 4 children. The oldest brother, about 15 years her senior, was a very unruly, explosive child, suffering from diabetes, and causing his parents a lot of worry. He became an unstable, drug-abusing and self-destructive man. Eventually he was murdered by another addict whom he had sheltered. The next older brother, about 8 years her senior, forced the patient a couple of times to have oral sex with him in front of his friends when she was 7 or 8, after repeatedly having had sex with Sonya's sister. He knew I would do everything for him. He knew he could talk me into giving him head and make me the laughing stock of his friends. Now he is a successful professional and happily married. Maggie, her sister, is about 5 years older than the patient. At first, in childhood, she was Sonya's protector, much beloved and admired by her. Later on she became an alcoholic. There is a mighty stream of jealousy, envy, and resentment flowing in both directions between Sonya and her older sister, leading at times to violent outbursts on both sides, and this since their childhood. It focussed at times on the much greater attractiveness of Sonya, the ease she had to establish sexual relationships with men, and later on Sonya's pregnancy: She smacked me across the face that I had the nerve of having a child. She freaked out on me. She wanted me to abort it. She tried to kill me in the car, by driving it into a tree, after hitting about 15 cars. She was in a blackout from vodka and pills. I was
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sick and wanted to go to a hospital, but she refused to let me out of the car, locked all the doors, crashing in all those cars, driving without a windshield. It was a death ride. Finally we hit and flipped. The door flew open and I ran away, into the pouring rain. I thought I would never see her again alive. She tried to kill herself and to take me with her. I was the object of her hatred. It was when I fled barefoot from her that I got infected with AIDS. An old black junkie took me in. I used his needles. He had AIDS; he had lied to me . I welcomed the virus in. I must have wanted to kill myself, and now I have to live with all the damage I have caused. Sonya describes herself as having always been a very shy and frightened child, constantly trying to be very good and kind, to be the mediator and saviour of her family, attempting to pacify father's rage and heal mother's unhappiness, to please her brothers and to look up to her sister. Yet she also remembers from the beginning of therapy how, in early childhood, she was very frightened that her mother would actually kill her at night or in the car. In adolescence, another side of her broke through that wanted to burst out from the confines of her overly strict conscience and compliance and escape from the sense of despair, loneliness and worthlessness. Ever since, she has oscillated between these two identities almost to the extent of a multiple personality: that of a very conscientious and honest self, trying to please and to rescue her family, basically quite anxious and shy, compliant, yet fearful of social contact and the other self that wants to break all limits, burst out of the chronic sense of guilt, shame, and anxiety by defying convention and daring death and humiliation, have fun with the wild kids and excitement regardless of the consequences: going from caring so much about every smallest thing to not caring about anything. There is a strong sexual-masochistic component to the search for tragedy and danger. All her heterosexual relationships were to brutal men who abused or exploited her severely. Many times, she risked her life: I was always attracted by these murderous guys; I was blind to it, in denial, when they kicked me, and I would sacrifice everything for them. And when they left, it was as if the whole world died . My life is driven by destructive sexuality, in form of drugs and men. The turn on was the danger, something about living life on the edge. Guys who were safe did not have that magnetism. The attraction was always to men who seemed not vulnerable to shame, a kind of anti-shame-heroes.
She felt attracted only to men who showed power, not nice guys whom she saw as wimps: When they see how I dealt with my shame, it turned them off, because they wanted women with power. And then my shame about the rejection was overwhelming. I was the most worthless shit, lower than low, pathetic . I kept saying: beat me up more, metaphorically. The rape was the metaphor for my whole life; everything was about humiliating and punishing me, because I was so pathetic . I sought out as much punishment as I could. I turned it against myself, I went to war against myself: because I felt so humiliated, for being such a zero, such a loser, I took it out on myself.
The triangle
Very early in our work, she states, almost without distortion and with little prompting on my side, the oedipal conflict. When I was little, my father gave me a lot of attention. He was everything for me. He is a very expressive person, did hug me. I was sitting on his lap in bed; we were cuddling. I remember I had a recurrent dream then that I never forgot: that my mother tried to kill me. It was so weird. There was a big garden outside the window. There would be little men standing outside, an army, and they would get me. They were sent by my mother. They would come in, and she would direct them to have me killed. And this dream came over and over again. We had a Cadillac with an electric window. I pulled my arm back, feared that my mother would hurt me When I look at the three of us: my mother was over there, very asexual, my father was warm and loving, and I was very physical. He loved to hug me. There was a time when the father was everything for me. That was the same time when I had the dream that my mother would hurt me, there was something evil in her. You wanted to hurt her and get her out of the way, but these wishes were very frightening. You wanted to have the father for yourself. At the same time, you wanted to love mother. You were afraid that she would now turn against you, and you felt: I'm a bad person for having this anger against her. It is the same now with B. (her girlfriend). I want her out of the way to have V (her husband) for myself. There is a lot of tension now between us. There we have the repetition. In all her dreams, she is self-destructive, is being punished for these wishes: to have father for herself and to get rid of mother.
A dark cloud hangs over the house. This may have been a big reason why you had to destroy your life and punish yourself, particularly every step toward
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independence and every accomplishment. Every piece of happiness she has to buy with much torment: How can I be happy when they are so unhappy?! This needs to cast a dark shadow also over the therapy, in the form of the negative therapeutic reaction in fact, in every therapeutic endeavor she has undertaken: it is not the fear of failing, but the prohibition against success. In the whole family, there is, under the appearance of propriety and self-sacrifice, an underground of murderous rage and disdain, leading to the sense of the double message. Yet it is likely that the parents themselves suffer under the crushing weight of their conscience, that they, in different ways, have constantly to prove to themselves and others that they are good after all, and should not be so harshly judged. They need to justify themselves. There was extreme loneliness and terror, and yet there was also overstimulation and seductive intimacy. The children looked for relief and closeness with each other, ultimately in form of incest.
Relapse and the Role of Narcissism

A practically most relevant question is: What leads to the momentary breakdown of the apparently adjusted identity, an identity obviously very much embodying a false self, and with that to the return to drug use, with its immediately catastrophic spiraling down. I have so much shame which kept me relapsing. The drugs were easier than dealing with shame; they were the only escape from the shame. It is like a soul death. We witnessed how it was usually an intolerable pressure from the side of her conscience, either in form of overwhelming feelings of guilt or of shame, especially the latter, connected with a deep disappointment in herself and in others, which led at first to furious rage, then to a bold invalidation of the rules of reality and morality, to a short-lived state of pleasure with the help of the drug, and then to a renewed violent crash. It is very difficult to interrupt this devil's circle once it has started. Working it through in thought and affect, before its wild force has been unleashed, is an essential part of our daily work. We find in it a vicious cycle of narcissism: (1) the absoluteness of expectations: her perfection, her self-image as
Goddess or princess, as angel and Savior, as Daddy's good little girl; the grandiosity of her ego-ideal and of her responsibility; (2) the absoluteness of inner and projected, but also provoked criticism, especially in form of shame; the cruelty of the anal-sadistic superego; (3) the absoluteness of her rebellion abainst those expectations and the criticism, with the fantasy of invincibility and invulnerability, her victory over death and humiliation, her entitlement, her furious claiming her rights, her vindictiveness, her jealous rage; (4) the absoluteness of the punishment which she inflicts on herself or which she invites; (5) the absoluteness of the absolution: the total acceptance, the drama of sin and redemption, the merging with spirituality, with the idealized other. And with that the resumption of the circle. The following two circles are modifications of this.
The Vicious Cycle in Masochism

Narcissistic crisis
At issue is a much exaggerated expectation, especially in the form of her own grandiosity, her perfection, her capability to heal the unhappiness of her family and to reconcile the adversaries as well as the opposite values. Reality can never come close to this grandiose expectation. This means an abrupt collapse of her very brittle self-esteem. This phase of the process we may call the narcissistic crisis. This narcissistic crisis reflects, even repeats, the original, lifelong traumatization, consisting in her case in the severe conflicts at home between pretended righteousness and piety and the real atmosphere of rage, hate and disdain, exaggerated demand and humiliation. Moreover, we find the massive and unpredictable back and forth of severe overstimulation and frustration, of sexual seductiveness and cruelty by her father and her brother. Take to this, her mother's double-bind messages of overt saintliness and renunciation, of hidden devaluation and contempt, her craving for purity and her severe reproof of everything sexual or emotional. One more polarity will come up shortly. Consequently, the traumata are those of soul blindness and soul murder, of invisibility of the personal needs and emotions of the child, and the alternation of overstimulation in the form of seductiveness, even incest, and verbal violence and abuse; the house of fear, the house of shame: Nobody saw me, nobody could see who I was. Nobody did care
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whether I was hurt. Nobody felt how I was hurt. They could do not wrong, and I could do no right.
Affect regression and attachment to pain

The next step consists in the breakdown of the affect defense, in the form of what Krystal described as affectregression. In connection with the theme of her HIV-infection and the profound dread of death, she speaks of her deep fear of separation from mother, all through her childhood: I was so sad and missed her so much, and I was so afraid without her . I hung onto Momie, needing her and on the other side, fearing her killing you. Deep down she is very dependent and needy, hating it and liking it at the same time. It is in this context that she speaks of how her feelings, once roused, very rapidly become global (dedifferentiated), beyond symbolization (deverbalized), and experienced, as if they were physical (resomatized): affectregression (Krystal, 1988). I feel overwhelmed by emotions in the dreams. It's like waves, an overwhelming dark stuff. These feelings overpower me and make me different from the others. I feel not grounded, swept off by my feelings, my fears. and shame, and rage, and sadness, and guilt; but I agree: especially anxiety. And much of your shame has to do with it: not having control over your feelings. And taking drugs was an attempt to take control of these overwhelming feelings, and what we try here is somewhat similar: to gain control by putting them into words, although this is much more slowly than with drugs. throughout my life my feelings have run me, instead of my running my life. Why are the feelings so overwhelming for me, and not for others? This flood of feelings has to be seen against the pervasive atmosphere of dread at home: There was always this pressure; to say and do the right thing and to make everybody comfortable. I could not be myself. There was this silence, and I felt so awkward . I blame part of it on the anxiety in my house. There was tremendous anxiety at home, in the whole family, a house of fear. Of particular importance for her masochism is what Valenstein (1973) called the attachment to the painful affect: the pain and the grief stand for the lost object. She clings to the suffering, as if it were her idealized, yet lost mother.
Sexualization
At the same time, with the affect regression, we notice the translation of such global affect into sexual tension. It is reflected in the following archaic equation: sexuality and sexual exitement=violence, cruelty, explosive bursting=painful, intolerable tension = overwhelming, unbearable feelings. I dealt with the humiliation in a sexual way, all the anxiety and frustration. I wanted to get it off sexually, to relieve myself of the anxiety. The thought of humiliation made me climax, e.g., seeing the guy with somebody else or just feeling the humiliation. That was a central theme in my sexuality It shaped her entire sexual orientation: all men with whom she got involved developed humiliation to an art. Thus was the relationship with her father: both deeply shaming and intensily erotized. The frustration becomes like sexual energy. I want to crawl out of my skin, being angry, but unable to say it. This aggression became something physical with me. I used to masturbate to get rid of the frustration. I cannot put it in words. Also, when I hated myself, when I was jealous or irritated, I wanted to get rid of the energy. It's all bottled up in me. It was translated into something physical. I was very ashamed at myself for masturbating. It made me feel weird, this physical thing in me. It relieved the intolerable tension. Exactly. A restlessness and frenzy. For me, it was irritation; it comes out of my skin, I will burst. I try to control it, in order to be appropriate. I'm afraid to express it. And at the end, it is as if there were two Sonyas.
Reversal, fantasy of omnipotence, and double self

This is on the one side a turning of passive into active (she speaks of turning the tables), ego-psychologically speaking, an identification with the aggressor or with the trauma. This may occur in the form of rage and indignation, directed against the outside, or it is a helpless attempt to change suffering into doing or at least a provoking. Or it is in the form of very intense envy and jealousy. She relates a persistent quest for power which should undo the helplessness and shame about her weakness. Especially the description of her prostitution fits into this picture: There is much manipulation: getting as much money as possible and doing as little as possible, playing on their
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horniness. I liked that aspect. And then there is that other image of myself: I'm totally vulnerable, totally in love, and sex plays a big rle; I'm totally powerless, because I'm in love, and he makes me feel like a piece of shit, is shaming me. Where is that in-between? I'm either at the bottom or on top. When I play the game as prostitute I feel nothing. Except power. Right. And then there is that other me: there is no power and total emotion and hurt, total shame. Split in two. Part of this omnipotent turning of passive into active is the attitude of active dehumanization of the other: that she uses the others in the same way as tools and part objects as she had felt objectified, dehumanized, manipulated, depersonalized. In general, perversion is after all dehumanized sexuality or sexualized dehumanization (Cooper, 1988, 1991). On the other side it is decisive that this means a doubling of the self (again well described by her in regard to the doubleness of omnipotence in prostitution versus powerlessness in love, often simultaneously, or in very rapid transition, also within a given sequence of thought). It is a magical transformation, in the hope that protectedness and a transcendence of anxiety and particularly of shame could be reached when the true self is split off from its masks, when it could be hidden, abducted, removed to some other, strange place, eventually to re-emerge in powerful disguise. Especially this type of fantasy and much of the doubleness of many patients with multiple personalities is an important protective fantasy in the face of overwhelming traumatization: It is not me who suffers something so horrible. It is my alter ego, my body, my shell. In reality, I am somewhere else and am somebody different. This splitting or doubling requires a massive denial of inner reality, mostly a blocking of those overwhelming affects mentioned. Such denial is supported by an invalidation fantasy set up to make the perception of reality inoperative.
Introjection
The next station or layer is the internalization of the trauma: The cruelty of trauma and abuse becomes part of the superego parallel to the turning of the rage, the envy, and the contempt against the self. Thus, this figure of the inner judge reflects (as we know from Freud) not only the aggression of the traumatizing object, but the aggression of the subject to be contained by this inner authority.
This is one meaning of the cruelty of this inner judge: as a guardian against her own murderous aggression. We shall encounter another meaning shortly.
Conflict in the superego

What is crucially important in this, however, is the intrinsically contradictory, split nature of the values enforced by this inner judge. It is as if he were following opposite laws, opposite values which still command though absolute adherence. She faces an irreconcilable value conflict: With my sister and my mother it's so: when I am doing too well, they resent me. With my brother and my father, it is the reverse: when I'm not good enough, they resent me. Mother and sister are jealous and resentful of my independence and success, and my brother and my father are disgusted when I'm not successful enough. On the one side, there is the envy of her success with mother and sister: on the other, the contempt for her failure with brother and father. For my father, I should be totally powerful, and for my mother, totally self-disciplined, without drive, pure. These two value systems, one based on power, the other based on purity, are irreconcilable, but both converge in the one point where their respective antitheses of weakness and dirtiness are prime causes for shame. She feels herself to be the scapegoat of her parents: for her father, who wants to be an aristocrat, and for her mother, who wants to be a saint.
Absoluteness the narcissistic stigma

In light of the globality and absoluteness of the previous stations, responsibility and self-ideal assume similar totality. Thus we find a grandiose ego-ideal as pendant to the cruel conscience-judge-superego. It is a totalitarian superego, often with opposite demands of irreconcilable totality. Generally speaking, the narcissistic fantasies serve in traumatic situations, as we saw before, as protection against helplessness. There exists, however, a particularly important version of such protective omnipotence, a fantasy, almost a delusion: the omnipotence of responsibility, as if to say; If I would only be strong and good enough, all these awful things would not happen. Whatever abuse occurs, it is all my fault. At the price of enormous guilt, the patient protects herself (or himself) against the even more frightening helplessness. The more I'm in touch with things, the more I sense how ill at ease my mother is. I would like to fix it, run in and help her, to heal her. I hate
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seeing her suffering. Just like in childhood: how the father was yelling at her. I heard it in the night. They argued often about the other children. I thought: When I'll be older, I'll be a perfect child and never cause problems; and they will be so proud of me. I'm the scapegoat, her daughter the drug addict, and she is the saint. She has to be the rescuer. Her selfimage depends on it. Sonya's own ego ideal is that of the Savior: When I was 5-years-old, I was dreaming: to be an angel, in a spiritual world, to help mother, to be the perfect daughter, to rectify this house full of commotion. It was a heavy responsibility for a little child to take on! Thus, throughout the material, goes the absoluteness both of her conscience and of her ideal: she herself must be perfect and behave accordingly; her self-condemnation is correspondingly totalitarian: I'm aware of the part that has to be perfect in contrast to the person who suffers, as a result of the abuse from men, humiliated over and over again.
Re-externalization of the cruel conscience

Others are being treated with the same scorn and are punished with the same pitiless harshness, as the inner judge deals with everything one does and feels. Thus, one becomes the cruel judge of others: sadism disguised as morality. Simultaneously with this turning of the superego's aggression against the outside world, we encounter the narcissistic attitude of arrogance and entitlement. This cause of sadistic and narcissistic behavior, as a protective faade, hiding the whole masochistic sequence described, is clinically enormously important. Berliner called this defensive attitude countermasochism (1940, 1947).
Provoked victimization
The patient ends up, again and again, in the position of the victim. This is the masochistic side dominating the surface appearance and marking the symptomatology. The masochistic core fantasies relive traumatic experiences in staged scenarios of managed suffering and shame, with the primacy not of the mechanisms of perverse sexuality, but of fantasy equations of sexualization of violence, centrally repeated in the submission to the tormenting, rigidly judgmental, anal-sadistic superego, with the aim of the magical, omnipotent transformations, hidden within the masochistic beating fantasy (Freud, 1924): through suffering and humiliation, the patient tries to achieve love and respect on many developmental levels: Only
through pain is it possible for me to preserve attachment, love and sensuality. Most poignantly, the patient tries to alter magically, omnipotently, reality and bring about a series of massive denials and reversals: By the suffering provoked, brought about, re-enacted by me, I transform passively-endured pain into pleasure, anxiety into sexual excitement, hatred into love, separation into fusion, helplessness into power and revenge, guilt into forgiveness, shame into triumph and, most of all, passivity into activity, in the words of another patient: the alchemist's dream (Wurmser, 1993). The masochism is understandable on the basis of the premise of power through suffering (Novick & Novick, 1987, 1991). Yet this aim remains unconscious, remains self-defeating. The end is suffering and often catastrophe. The vicious circle is closed. So far, the masochistic cycle. The vicious circle of drug addiction will only briefly be sketched. It more-or-less coincides in the first 4 stations; but then it continues in the following way:
Externalization
Part and parcel of the turning to activity and the rle of omnipotence, described as the 4th step, is a wild drivenness to action, the search for a concrete external solution for the inner and now denied conflict. A magical means is sought on the outside, that should heal the inner wound.
Aggression
Both previous steps require a violent breaking out, the violation of the boundaries and limits, the destruction of the social bonds. It is a very destructive attack upon others and the self, a wish to humiliate and torment others and to disgrace herself.
Defense against the superego, flight from conscience

Reliability, conscientiousness, obligations towards others are acknowledged, but at the same time deprived of their emotional relevance and validity, treated as if they had absolutely no meaning. This means a very deep splitting of the experience of inner authority, reflecting a deeper conflict within the superego, e.g., in the form of opposite value obligations and value systems (power versus saintliness, appearance versus being loyal to herself, very often loyalty conflicts between her parents). The drug use is a direct flight from conscience: I'm drawn back into
it: that time could stand still, that I could get high for a few days and immediately step back into that reality where I would have no responsibility, where I would be anonymous, free, shooting Coke, an escape from responsibility, only having the pleasure of the
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drug. I become this other person, tough and cool my identity as a drug addict. For many years, I was thriving on being an outcast, being part of the counterculture. It empowered me my expressing something by hurting myself, that I got rid of something within me. It was killing me, the active expression of something: perhaps my anger and hurt turned inward. It was powerful. She clearly describes the simultaneity of both meanings of the drug use: as revolution against her sense of guilt and as punishment for this revolution; the same can be said about her sense of shame. With the drugs, she overthrows the inner judge.
Narcissistic triumph
The drug brings various forms of pleasure, but the most important is the narcissistic gratification, especially in the form of an exaggerated sense of entitlement and the enormous rush in self-esteem and orgastic fulfillment. Yet with that, the crashing down into a renewed and deepened narcissistic crisis is inevitable. The circle is closed again.
Technique
Now, I would like to summarize some principles of the psychoanalytic therapy with these severely traumatized patients. In that, I proceed from Edward Bibring (1954) and Paul Gray (1994). Bibring describes 5 basic kinds of psychotherapeutic interventions: suggestion, abreaction, manipulation, clarification, and interpretation. He distinguishes the technical from the curative use of therapeutic procedure. In the technical sense, such a procedure is used as a means, tactically, in an auxiliary way. E.g., even in the most rigorous work of psychoanalysis, it cannot be avoided to use occasional suggestion or abreaction. The supposed effectiveness of psychoanalysis does not, however, lie in them, but in the process of clarification and interpretation e.g., in the way alluded to in the work with Sonya: that, to a large measure, she herself is able to find the interpretation, thanks to the clarifications I am employing. We may call suggestion the use of our authority in order to communicate what we believe. With Sonya it is, e.g., my conviction that her illness
by no means has to be terminal, that there is still long-term hope, and that the analytic treatment is able to resolve to a large extent the issues underlying her emotional illness its causes. Abreaction or catharsis, the 2nd therapeutic principle according to Bibring, assumes a huge space in this treatment, in the form of the emotionally intense expression, the storms of affect, mainly of pain, anxiety, shame, grief, and rage. The 3rd principle, that of manipulation, not meant in a pejorative way perhaps plays a rle in a subtle way, e.g., in the encouragement given that she take over more responsibility for her life, or in my assuring her that insight and action are both and at the same time necessary, also in the affirmation of her creative capabilities and in the toleration of her emotional outbursts, all this in order to facilitate and confirm the continuation of the analysis. Another action on my side that could be seen in this category, was the offer at the time when the insurance payments seemingly ceased for good and her father was only willing to pay for 2 sessions a week to continue our analytic work on the level of 4 times/week, regardless of the payment. Clarification, the 4th form of intervention, means to put into words what is preconscious, not truly repressed anymore, but also not explicit enough, or connecting what still seems separate, but belonging together and not blocked anymore by palpable resistance. A good example is the demonstration of the oedipal conflict which she had already largely brought out herself. And finally, interpretation is the uncovering of truly hidden connections. In this, it is our art to enable the patient's observing ego as much as possible to develop these interpretations on her own, as I have just mentioned in regard to the oedipal connections. Analysis is not seen as much anymore as uncovering of what is unconscious, but to help the self-observing part of the ego to learn to recognize and resolve inner conflict. Thus, it is more of a conjoint interpretative process than an explicit interpretation as intervention by the analyst. If we now generalize to severely traumatized patients, we find the following. (1) With regard to the centrality of affect regression and attachment to pathogenic affect, the therapeutic modus of abreaction, of catharsis, has special relevance. Long stretches of psychoanalytic treatment are also, in some patients, accompanied by expression and outbursts of intense affectivity.
(2) The restoration of broken connections, insight by the patient, remains decisive for any lasting success. As examples, I gave those vicious cycles, for 3 frequent and significant patterns of such inner connections. Their presence again can be shown rather by clarification than by interpretation. With this work of insight, we have to remember Gray's words that the analyst's primary goal is always the analysis of the patient's psyche, not the patient's life (1994, p. 9), that the focus in the work lies in what goes on within the analysis, not on events and details outside, and that the examination deals above all with the inner life, not his behavior (p. 18). Thus, it offers the patient the opportunity to develop her self-observing abilities to their greatest potential. (3) Special care has to be taken not to let suggestions intrude unawares, especially with regard to possible traumata. Suggestions in general are hardly always and entirely avoidable; at times, they may be indispensable. Still, the entire technique is on the one side so structured that we do not become an external authority, specifically in the direction of
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what value systems or ideology the patients ought to believe in, nor that we are judgmental, critical. The transference of the superego rather needs to be approached analytically than to be used suggestively. On the other side, it often turns out to be required with these more severely ill patients that the analyst does not question the permissive functions of the superego in the transference, the fantasy of the analyst as an affectionate, approving, and protective authority (p. 133) in contrast to the critical, condemning aspects. With that, he lets stand a certain measure of suggestion, especially the permission of abreaction. It is the difference between whether it is the broad therapeutic aim of reducing the patient's potential for anxiety or of merely reducing anxiety itself (p. 91). That means that in the given instance, we may prefer a more psychotherapeutic approach over one that is psychoanalytic in the narrower sense. What is crucial is that we know what we do: that in this case, at this time, the choice between these two principal ways of approach is taken as a more-or-less, not as an either-or. It is as if our field of work is determined all the time by these two coordinates: the resolution of inner conflict by insight in the psychoanalytic method sensu strictiori and that of the more direct influence upon the dynamic equilibrium by the therapist's authority the more psychotherapeutic approach. Thus, it is the art to know what the patient can tolerate, and when. (4) In the same meaning of a psychotherapeutic rather than a psychoanalytic
approach, there may at times be intellectual explanations and interpretations downward, away from the here and now, away from the transference, and into the distant past. These may also be considered a kind of manipulation in Bibring's understanding. They may become necessary during severe affect regressions and serve a momentary relief of anxiety, a reduction of tension in the analysis, and thus can protect the continuation of our work. Here, the distancing, even intellectualization, may mean a kind of guard-rail at the edge of the abyss. To the same intent, we may count considerable flexibility as to the setting up of sessions (when and how often), which may even allow the very beginning or the continuation of the analysis. (5) With Kohut, it has also been my experience that we have to use particular caution with regard to the narcissistic vulnerability of these patients, that we have to be particularly careful in dealing with their propensity to shame, and that the interpretation of idealization and grandiosity in the transference (e.g., as defense against underlying aggression or those overwhelming affects) cannot be forced. Often I don't evade direct questions. Still, they may give me the opportunity to give real interpretations, couched as supportive interventions, or perhaps, the other way around: supportive suggestions given as interpretations. Thus, Sonya very recently, in a storm of rage and devaluation, demanded from me to know: When I am stuck in this shit, I cannot think. Only afterwards, only after I've cooled down. I ask your help. What would give me in the midst of this avalanche the tools to deal with it? That is what I ask you. I responded: To see that this rage goes back to the shame, and the shame comes from the absoluteness of the expectations and the judgment, from within and from without. That helps in the avalanche. Formally, it is true, this is an interpretation; but basically, it is an authoritatively given word of supportmostly a kind of suggestion and manipulation, but clearly provided to assure the continued analytic work. Her response was at once: That makes sense; the relapse is over. (6) The intensity of those storms of affect may often require the employment of specific medication in particular of antidepressives. It is better, although not an absolute necessity, if somebody else prescribes them. Again and again, I have found it very helpful when other treatment modalities are combined with insight oriented, analytic therapy. Just as in somatic medicine, the simultaneous, judicious use of different agents may also be crucial here.
Conclusion
I would like to end with some more deeply theoretical, even philosophical considerations. With all patients suffering from severe neurosis, we (and they) are impressed by the compelling force of certain feelings, thoughts, and actions. It was held by Kubie (1954; cf also Wurmser 1994) that the decisive criterion marking the neurotic process is precisely this character of stereotypical, compulsive repetition. The more severe the neurotic conflicts are, the deeper is this subjective sense of compulsion and the more drastic are also the objective manifestations of compulsiveness. This seemingly compelling drive to repeat certain mental processes in an old, stereotypical fashion was looked at, metapsychologically, as a primary force of the psyche repetition compulsion as manifestation of a supposed death instinct and of primary masochism (Freud, 1924), or as an elementary power of its own (Waelder, 1930). If we stay, however, entirely within the realm of what is psychological, we recognize that this repetition compulsion aims at the resolution of inner conflicts which are largely unconscious and therefore not solvable. Because the attempt fails, it has to be renewed time and again, and this manifests itself, as we just have seen, in characteristic sequences of attempted solutions that all fail and yet have to be repeated in vicious circles that are specific for the various syndromes. The reason for this is that their real goal, the removal of the original conflicts and of the traumata connected with them, is not reachable, since these affects battling each other are themselves unknown; their qualities are cut off from consciousness.
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However, chronically unsolved conflicts contradict the need for inner unity, i.e., the ego's striving for synthesis. The repetition serves the conquest of the inner conflicts in order to enhance the synthesis of the inner world; it may also be used to resolve the conflict with the outside world in order to facilitate the re-integration into the community. Yet, as mentioned before, this attempt in form of a series of compromise formations has to fail, because the connections are torn and, in this form, cannot be tied together again. Why are those connections torn? Why is there repression, or defense more generally? I believe that the answer has to be seen in the absolute, overwhelming, and hence traumatic nature of what assaults the self at first from the outside, afterward from within, urgently requiring working-through
and adequate response whether those outer traumatizations come in the form of condemnation and brutality, or complete misrecognition or overstimulation, i.e., soul blindness and soul murder, or whether the problem lies in those inner reactions of a global and total nature that try to deal with those dangers and damages. In other words, the defense directed against the trauma or the chronically traumatic environment is just as radical and uncompromising as the traumatization itself. The result is an inability of the ego to integrate these affects symbolically. Thus, it is evident that the repetition compulsion very prominently not only serves the resolution of conflict, but also the mastery and regulation of affect. The more massive the polarities of affects and the higher the accompanying affective tensions are, the stronger is the necessity to find regulation with the help of a repetitive effort to reconcile what is irreconcilable and thus to restore inner unity. Since the goal of a possible solution lies outside the realm of word representations, and, with that, is usually barred from the symbolic process in general, the attempt at resolution by repetition keeps failing, as long as those polarities are not opened up to the symbolic processes. The repetition compulsion is, therefore, an attempt to attain in symbolic ways regulation and conflict resolution, which proves blocked because the affects and the drive needs evoked by them and closely connected with them, the forms of defense, and the superego demands are all of a global quality and therefore irreconcilable with each other; therefore, also the consistent endeavors to express them in symbols have to be defeated. Narcissistic crises, loyality conflicts, and shame-guilt dilemmas have a commanding position in the triggering of those sequences, of the ensuing impulsive actions, and of the splitting of consciousness and identity. In spite of this recurrent defeat, the attempt cannot be given up, since it lies in the nature of the ego to attain inner unity, to overcome the inner rent, the inner contradictoriness, the doubleness of self and world experience. The need for synthesis, i.e., for psychical self-preservation is so important and so preeminent, that, in intensity and penetrating power, it corresponds to an instinctual drive*.
The biological baggage connected with this English term, lacking in the German Trieb, lets me express my reservations by quotation marks.
Ultimately, the conflict nature of the human being is unresolvable; it belongs to human existence, to man's very essence, as we read in Plato's Phaidros: There is imposed on the soul pain and extreme conflict entha de ponos te kai agon eschatos psyche prokeitai.
References
Berliner, B. (1940). Libido and Reality in Masochism. Psychoanal Q. 9:322-333 [] Berliner, B. (1947). On Some Psychodynamics of Masochism. Psychoanal Q. 16:459-471 [] Bibring, E. (1954). Psychoanalysis and the Dynamic Psychotherapies. J. Amer. Psychoanal. Assn. 2:745-770 [] Cooper, A. M. (1988). The narcissistic-masochistic character. In: R. A. Glick & D. I. Meyers (eds.): Masochism. Current Perspectives. Hillsdale, N J: Analytic Press, pp. 117139. Cooper, A. M. (1991). The unconscious core of perversion. In: G. I. Fogel & W. A. Myers (eds.): Perversions and Near-Perversions in Clinical Practice. New Haven: Yale Univ. Press. pp. 1735. Crews, F. (1994). The Revenge of the Repressed. New York Review of Books, 17 November and 1 December. Freud, S. & Breuer, J. (1893, 1895). Studies on hysteria. Standard Edition 2. [] Freud, S. (1924). The economic problem of masochism. Standard Edition 19, 157172. [] Freud, S. (1926). Inhibitions, symptoms and anxiety. Standard Edition 20, 77174. [] Gray, P. (1994). The Ego and Analysis of Defense. Northvale, NJ: Jason Aronson. Karl, F. R. (1995). George Eliot. Voice of a Century. New York: Norton. Krystal, H. (1988). Integration and Self-Healing. Affect, Trauma, Alexithymia. Hillsdale, NJ: Analytic Press. Kubie, L. S. (1954). The Fundamental Nature of the Distinction Between Normality and Neurosis. Psychoanal Q. 23:167-204 [] Moore, B. E. & Fine, B. D. (1990): Psychoanalytic Terms and Concepts. New Haven: Yale University Press. Novick, J. and Novick, K. K. (1987). The essence of masochism Psychoanal. Study Child 18:353-384 []
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Novick, J. and Novick, K. K. (1991). Some Comments on Masochism and the Delusion of Omnipotence from a Developmental Perspective. J. Amer. Psychoanal. Assn. 39:307-331 [] Pulver, S. E. (1970). NarcissismThe Term and the Concept. J. Amer. Psychoanal. Assn. 18:319-341 [] Valenstein, A. F. (1973). On Attachment to Painful Feelings and the Negative Therapeutic Reaction. Psychoanal. Study Child 28:365-392 [] Waelder, R. (1930). The principle of multiple function: observations on overdetermination. In: Psychoanalysis: Observations, Theory, Application. Guttman (ed.), 1976; pp. 6883. New York: Int. Univ. Press. Wurmser, L. (1993). Das Rtsel des Masochismus, Heidelberg: Springer.
Wurmser, L. (1994). A Time of Questioning Annual Psychoanal. 22:173-207 []

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Wurmser, L. (1996). Trauma, inner conflict, and the vicious cycles of repetition*. Scand. Psychoanal. Rev., 19:17-45
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Trauma, Inner Conflict and The Vicious Cycle of Repetition

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Trauma, Inner Conflict and The Vicious Cycle of Repetition

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Wurmser, L. (1996). Trauma, inner conflict, and the vicious cycles of repetition*. Scand. Psychoanal. Rev., 19:17-45.

(1996). Scandinavian Psychoanalytic Review, 19:17-45

Trauma, inner conflict, and the vicious cycles of repetition*

Term and Concept of Narcissism

Rape was the Metaphor for my Whole Life

Relapse and the Role of Narcissism

The Vicious Cycle in Masochism

Affect regression and attachment to pain

Reversal, fantasy of omnipotence, and double self

Conflict in the superego

Absoluteness the narcissistic stigma

Re-externalization of the cruel conscience

Defense against the superego, flight from conscience

Wurmser, L. (1994). A Time of Questioning Annual Psychoanal. 22:173-207 []

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