Abstract
Freud (1926) described obsessional neurosis as “the most interesting and repaying subject of analytic research” (p. 112). In spite of the simplicity of his theory of an anal fixation, he did not believe that psychoanalysis had arrived at a satisfactory explanation of its origin or structure. While the advantage of the disorder lay in the obsessive patient’s verbal presentation—in contrast with the hysteric’s more obscure bodily pains—the difficulty lay in the “variety” of its forms, in the sweeping range, that is, of the problems we regard as obsessive (p. 155).
In a scholarly and wide-ranging contribution, Moshe Marcus and Steven Tuber seek to explain just one of the core features of obsessive mental functioning—doubt. The obsessive subject lacks a feeling of certainty in cases (e.g., repeatedly makes sure the door is locked) where certainty would seem warranted. Although the cognitive and neuropsychological literature has emphasized the problem of failure to achieve what Marcus and Tuber term affective certainty (Reed 1977; Dar et al. 2000; Taillefer et al. 2016), we lack a developmental theory to account for it. The authors seek to provide a theory, one grounded in ego psychological and Winnicottian thinking, along with a description of the mental processes that underlie this capacity.
After a comprehensive review of the empirical literature, which establishes the central place of doubt or indecision in obsessive functioning, Marcus and Tuber home in on the question of judgment. The person who repeatedly checks the door, to make sure it is locked, can learn nothing new from yet another turn of the doorknob. The question is what he does with what he already knows—what “judgment” he makes, in the authors’ terms, with the information he has.
Marcus and Tuber rely on Kant to dissect the mental processes at play in the capacity for judgment. To judge an object, for Kant, means to decide whether it falls under a general rule or category. In what he terms a determinative judgment, the rule or category is given (e.g., this wooden thing is a table). In a reflective judgment, the person must generate a new rule or concept, a term to capture a new or untheorized aspect of clinical experience. Marcus and Tuber are most interested in one type of reflective judgment—the judgment of beauty or taste. When we assert that an object is beautiful, we base our judgment on a subjective feeling of aesthetic pleasure and yet hold, as Kant shows, that our feeling points to a universal truth. We believe others should agree with us. If they don’t, they are simply missing something. The authors take this type of judgment, which refers to an affective experience (yet makes a claim to universal truth), as paradigmatic of the kind of judgment the obsessive fumbles over.
To clarify, Marcus and Tuber do not mean that obsessive people are unusually preoccupied with questions of beauty. They broaden Kant’s analysis of aesthetic judgment to include any judgment with an affective reference point. An obsessive patient might ruminate, for example, over whether or not her partner is a loving person (or, for instance, a selfish one), whether or not her babysitter is a good babysitter, whether or not her city is a good place to live, whether or not the local school is a good place to send her children, etc. The authors suggest that these judgments, like judgments of beauty, require her to check in with her feelings as the index of whatever truth she might find. Because she mistrusts her feelings, the obsessive can’t make this kind of judgment. She compulsively seeks external rules or guidelines where none exist, or where, if they do exist, they simply refer her back to her feelings. What does she feel, for example, makes for a good learning environment? This, for the authors, lays bare the anatomy of doubt.
To use one’s own’s affective state as a reference point, one must, Kant held, have common sense, a sense of how others would see the same object. Marcus and Tuber take up the question of internalization in the establishment of a general other in the mind. This question, which provides a bridge to ego psychology, leads to the issue of authenticity. Psychoanalysis complicates the philosopher’s picture, they suggest, by asking whether we internalize the other in an authentic way or in a self-alien way. The obsessive, they argue, internalizes the other in an alien way. He lacks a personalized experience of common sense, finding himself, instead, beholden to a set of alien standards or demands that prevent him from trusting his own impressions.
The authors’ discussion of internalization relies primarily on Roy Schafer’s classic treatise (1968). To “introject” an object, Schafer explains, is to establish “an inner presence with which one feels in a continuous or intermittent dynamic relationship” (p. 72). To “identify” with an object is to go further, modifying one’s own motives, attitudes, and behaviors “in order to increase one’s resemblance to an object” (p. 16). The authors focus primarily on superego formation. The child reorganizes his motives and attitudes, particularly those around restraint and renunciation, so thoroughly that his moral code becomes independent of his parental introjects. He thereafter experiences that code—at least in health—as a feature of his “subjective self,” as a source of conscience, no longer tied to his perception or representation of parental attitudes (p. 178).
When developmental problems result in the incomplete internalization of a parental figure, we find, according to Marcus and Tuber, the structural conditions for an obsessive-compulsive disorder. Even though the obsessive-compulsive patient might have the cognitive capacity to make judgments, he doesn’t trust himself. He still relies on external authority figures—or on introjects who represent them—to make choices for him in a way he experiences as self-alien. He checks compulsively to make sure he has turned off the stove, for instance, or locked the front door, because, on an unconscious level, he does not believe he can make those determinations. Only an outside authority can confer a sense of rightness and safety on his actions. Paradoxically, when he does get external reassurance, it typically fails to resolve his doubt, because, the authors hold, its very “externality” renders it unable to resolve his inner conflict.
It is important to emphasize the harsh and mysterious quality of the introjects that fill in for a faulty superego in the authors’ rendition of the compulsive doubter. The introjects to which he appeals, in the absence of his own judging capacity, are not only external; they are impossible to satisfy:
Nothing is ever good enough to meet the approval of this introject, which is set up to judge the “rightness” of every action using the most exacting standards of performance. And when inevitably the subject is found wanting, the introject commands for the action to be repeated, again and again, until some unknowable and undefinable point has been reached, and the introject is mysteriously and finally content with the state of things [p. 56].
These introjects persist unchecked in “their” demands in part because the obsessive-compulsive subject does not trust in his authority to evaluate their messages. He can only try to quiet them. Each failure evokes their criticism and reinscribes the mystery of what it would take to feel secure.
Pausing at this point, one might wonder how complete an account the authors have given us of obsessive compulsions. While the internalization of a harsh, self-alien introject is one pathway, another might be the identification with one’s introjects, so that they no longer feel alien (see Rizzolo 2023). Leib (2001), for example, describes the case of Rachel, a young woman with a disabling case of OCD, who spent her analytic sessions railing at the selfishness of dog owners who let their animals defecate on the street. Once an attractive and successful professional, she had become thin, drawn, and unable to work for fear of encountering their excrement. The analysis uncovered an unconscious identification with her mother’s selfish and imperious attitudes, which threatened the patient’s conscious sense of self, and which she had thus located in others. The problem was not a self-alien authority in the mind; the problem was that she feared she was her mother. The authors’ account has the most force, then, if we consider it as but one of several potential pathways to development of an obsessive-compulsive presentation.
Having established the problem in obsessive-compulsive doubt (the inability to make aesthetic/affective judgments), and having traced it to problems in internalization (i.e., the failure to internalize a personal sense of one’s own values/standards), the authors seek to nuance their argument by integrating core concepts from George Herbert Mead and Lev Vygotsky. While Mead and Vygotsky are of significant interest to psychoanalysis, and while the authors provide a masterful, chapter-length introduction to each one, the reader can’t help but feel that these links remain undeveloped. The Mead chapter is eighteen pages long, but it devotes just a single page to comparing Mead and Schafer. Of the twelve-page chapter on Vygotsky, four pages address psychoanalysis directly, but the payoff is unclear. The authors suggest that in a Vygotsky-inspired approach to OCD compulsions, “one part of the mind is perpetually attempting to compel behavior . . . and the other part of the mind is in a perpetual state of feeling compelled” (p. 93). While this description is no doubt accurate, we have arrived here already through Schafer’s work on internalization. It might be that the authors require a second book or series of papers to elaborate how Mead or Vygotsky can take psychoanalysis further than it has gotten by its own lights.
The authors’ use of Mead, in particular, suggests unexplored links between the authors’ largely ego psychological perspective and the Sullivanian tradition on obsessive-compulsive problems. Sullivan (1973) and later interpersonal theorists (e.g., Salzman 1980; Mallinger 1984) have conceptualized the obsessive’s emphasis on control—what Mallinger terms the “obsessive myth of control”—as a defense against an early environment in which a veneer of sweetness and light masks the parents’ latent hostility. Unlike Schafer, who draws on Freud’s structural model, Sullivan (1953) and the interpersonal tradition draw explicitly on Mead’s conception of the “I” and the “me.” I have argued that we find a third pathway here—neither identification nor introjection—but the repudiation of or dissociation from the potential for chaotic or disruptive experience (Rizzolo 2023). In these cases, we do not hear an identification with a critical parent. Nor do we hear an internal dialogue with a critical introject. We find, rather, a tenuous and rigidly maintained state of calm on the premise that the subject has managed to control his interface with the chaotic or potentially disruptive forces that operate in the not-me world.
After their foray into Mead and Vygotsky, which, again, opens interesting and important directions (even if they remain undeveloped), Marcus and Tuber seek to ground their theory in Winnicott’s depiction of the early infant-mother dyad. They argue, in essence, that an anxious parent might unconsciously transmit her overwhelm to her infant, who, in turn, will begin to experience “flashes of worry and concern” and the context of mundane everyday routines. If the parent is not only anxious, but also critical, the child might develop a sense of alienation from his own initiatives. Whose worry is he perceiving? His or his mother’s? To what extend does he guide his own activities? To what extent do his goals and motives revolve around his parent’s emotionality? The authors might develop this direction further through Masud R. Khan’s brilliant paper, “Infantile Neurosis as a False-Self Organization” (1971). One might wonder here if the authors would hold to the idea that all obsessive patients feel alienated from themselves, or if, as in the Winnicottian tradition, they might find value in a differential diagnosis: a differentiation between obsessives who feel authentically at home in their obsessive style and those who operate, by contrast, in a lifeless or false-self adaptation to the world.
In sum, this book will prove of great interest to scholar-clinicians who want to see what Kantian ideas might offer to psychoanalytic theory and, in particular, to an ego psychological conceptualization of obsessive states. While the chapters on Mead, Vygotsky, and Winnicott remain undeveloped, the creative reader will appreciate them nonetheless for their suggestive potential. The authors have shown the clinical importance and the intellectual excitement that we can still derive from grappling with the original neurotic structures that occupied Freud’s attention.