Classic psychoanalytic theory was developed by Sigmund Freud (1856–1939), who based his theories on his psychoanalytic work with adult patients. In his efforts to understand the human mind, Freud proposed several hypotheses. First, the topographic model (Fig. 2.1) posits that most mental life occurs in the unconscious , and that preconscious and conscious life is rather limited. Later, in revising the topographic model, Freud developed the structural model (Fig. 2.2). In this model the unconscious is comprised of several intrapsychic agencies: (1) the id , which embodies the instinctual sexual and aggressive drives; (2) the superego , which consists of the cultural and societal norms that have been incorporated into the person’s psyche; and (3) the ego , which moderates conflict between the id (which desires free reign) and the superego (which urges civility). Still later Freud wrote about the importance of the sexual drive theory in the form of psychosexual developmental phases determined by the organ of predominant interest to the infant/child for pleasure. Freud posited that the key developmental task of children involved “taming the instinctual drives ” of the id through the development of the superego and ego (Freud 1916–1917). As can be seen in Table 2.1, there are three phases (oral , anal , and phallic) of the developmental process—often referred to as psychosexual development —and each requires that conflicts from the previous phase be successfully resolved. Freud emphasized that during the phallic phase, between the ages of 4 through 6 years, the intrapsychic conflict centers on the important oedipal complex , part of a longitudinal process of psychosexual development. When the anxieties of the oedipal complex are resolved, the person achieves the healthy psychological genital phase of normal heterosexuality (Freud 1924). According to Freud, pleasurable heterosexual intercourse was the goal of his psychosexual theories: “the subordination of all the component sexual instincts under the primacy of the genitals” (Freud 1905).

For Freud, unresolved conflicts of the oral , anal , or oedipal phase lead the person to have a neurotic fixation that, when he or she is under stress, manifests in a regression of ego functions to behaviors of the phase fixated in. Additionally, classic Freudian theory posits that a given personality is determined (or defined) by the ego functions that he or she utilizes and is continually influenced by the superego , which inhibits the unconscious drives’ press for gratification.

A summary of Freud’s theories and their importance to psychoanalysis can be found in An Elementary Textbook of Psychoanalysis by Charles Brenner (1974) and in the more recent work, Freud and Beyond, by Mitchell and Black (1995).

Heinz Hartman (1894–1970), a psychiatrist and psychoanalyst, often described as one of Freud’s favorite students, developed the school of ego psychology. Holding that the ego has a biological substrate that includes perception, memory, concentration, motor coordination, and learning, he believed these innate ego capacities had autonomy from the sexual and aggressive drives of the id and were not products of frustration or conflict. Hartman coined the term “autonomous ego functions” (Hartman 1958), and his ideas share much with recent concepts concerning implicit memory systems and internal working schema stored in non-declarative memory systems (Mancia 2006).

The window into a personality style can be created through the study and understanding of the ego defense mechanisms an individual employs in coping with daily-life anxiety and threats to self-esteem from intrapsychic conflicts. Though Sigmund Freud was the first to describe such defense mechanisms, our contemporary understanding of these processes comes from his daughter, Anna Freud (1895–1982), who systematically classified these defenses, compiling a comprehensive catalog in her classic work The Ego and the Mechanisms of Defense (Freud 1937/1966). Sometimes we might consciously know which defense mechanisms we use in relation to others—as in humor to manage family conflict or denying or overlooking a colleague’s negative comments—but in most cases they occur unconsciously. Defense mechanisms usually are adaptive and can have a salutary effect, allowing an individual to function normally. Importantly, however, when used in a repetitive fashion, defense mechanisms can become maladaptive and induce further anxiety. In this regard, a diabetic patient who unconsciously and routinely uses denial may avoid following through with the treatment team ’s recommendations regarding monitoring blood sugar and administering insulin, and thus his or her diabetes may be poorly controlled. This distinction between adaptive and maladaptive defense mechanisms was thoroughly evaluated by George Vaillant, MD (1934–) in his seminal work Ego Mechanisms of Defense: A Guide for Clinicians and Researchers (Vaillant 1992), in which he hierarchically categorizes defense mechanisms as mature, neurotic, immature, and pathological (Table 2.2). More recently, these defense mechanisms have been categorized dichotomously into mature and immature based on the degree to which they are considered pathologic.

Having briefly discussed Freud’s psychoanalytic models and related ego -psychological models, which will be of practical relevance to the psychiatrist working with difficult consultations, we will now discuss three important concepts: introjection , transference , countertransference . These concepts subtend classical psychodynamic and contemporary psychodynamic theories and are central to approaching the consultation with complex psychiatric patients.

From the 1940s to the 1960s, psychoanalytic theorists increasingly recognized the importance of the patient’s early interactions with parents and caregivers, given that these developmental experiences were crucial to the formation of the individual’s ego . As a result, in the 1940s a natural transition from ego psychology to object-relations theory evolved. Melanie Klein (1882–1960), a student of Freud, is thought to be the first object-relations theorist, noting that object relations were at the center of a person’s emotional life (Klein 1932). Object relations refers to the capacity to have a stable and rewarding relationships based on the internalization (a process closely related to introjection as described above) of the early childhood representations of others in the form of “objects.” However, internalization of these objects is not a mere imitation. Filtered by the child’s wishes and needs (Delgado and Songer 2009), these objects are attributed an individualized significance. The variability in what an infant innately happens to internalize from his or her parents as “objects” supported later psychodynamic theories that incorporated temperament and attachment styles into what has recently been termed “intersubjectivity .” Clinically, this concept—intersubjectivity—has been defined as “the capacity to share, know, understand, empathize with, feel, participate in, resonate with, enter into the lived subjective experience of another” and “interpreting overt behaviors such as posture, tone of voice, speech rhythm and facial expression, as well as verbal content . . . which assumes that [the therapist] can come to share, know, and feel what is in the mind of the patient and the sense of what the patient is experiencing” (Stern 2004).

Melanie Klein posits that the infant, as part of a normative developmental phase, from 0 to 4 months of age, possesses a primitive fear. During this period, which Klein refers to as the paranoid position , internalized representations of caregivers are experienced as part objects that are split into “good” and “bad” objects (e.g., the loving mother, nurturing mother, and the depriving mother). In the early stages, the child maintains the self and object split to avoid the distress in recognizing that there are aggressive and depriving aspects of the self as well as the other. Then, from 4 to 12 months of age, the child learns to integrate and tolerate that a person has both “good” and “bad” parts and enters a healthy phase that Klein describes as the depressive position (Klein 1932). Having psychologically achieved the depressive position, the child proceeds to develop a capacity of concern for others and guilt about one’s actions and thoughts about others, with desire for reparation (Winnicott 1965). Klein believed that individuals who are unable to work through the depressive position in their childhood continue to struggle to relate to others in adult life. More recently, the contemporary object relations theorist and psychoanalyst Otto Kernberg, MD (1928–), has suggested that when the patient’s internal representation of others remains “split,” they primarily use low-level defense mechanisms including splitting , projection , and projective identification (Kernberg 1976). According to Kernberg, these patients were best understood as exhibiting a borderline level of organization, with poor capacity for affect regulation, and are prone to impulsive actions, including suicide (Kernberg 2000). Those with borderline-level organization have tumultuous relationships with others, unconsciously experiencing them as “bad objects” that evoke early internalized frightening and chaotic experiences, usually at the hands of a critical parent or caregiver. They often display maladaptive defense mechanisms—splitting, projection and projective identification, and these are commonly linked to patients with longstanding patterns of difficult/feisty temperaments, poor cognitive and affective flexibility (see Chap. 3), and insecure attachment styles (described below). In turn, these patients are unable to navigate the back-and-forth complex adjustments to different affective states of the other. Further, they have a limited capacity to have genuine concern for others and little or no guilt about their thoughts and interactions with them.

It would be beyond the scope of this book to provide a full description of all the object-relation processes of individuals with character pathology. We focus instead on the theory’s most relevant clinical contributions in working with difficult psychiatric consultations. To this end, we define splitting , projection and projective identification .