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The clinical material for this report is based on three and a half years of analytic work (approximately 750 hours) with a young woman. For the first two and a half years, progress was slow and the analysis was very stormy. During the last year, the analyst acquired a clearer understanding of one aspect of the material, namely, the relationship between unconscious guilt and certain disturbances in ego function of the patient. This understanding resulted in a more consistent and systematic interpretative technique and the patient responded by making dramatic and unexpected progress.
This clinical experience raises a number of questions in the psychoanalytic theories of ego function and technique, and illustrates some problems in relating theory to practice. In the first place, the patient falls into the group which has been called "the borderline states." There was marked invasion of secondary process by primary process, with impaired reality testing, and a restriction in the capacity to postpone gratification of impulses so that the ego's observing and integrating functions were jeopardized. Knight (6), discussing some therapeutic considerations regarding "borderline states, " describes how, in the analytic situation, these patients will bring forth misleading "rich" material but that often the analytic interpretations of it cannot be utilized by the patient's ego. He says, "For the sake of accurate diagnosis, realistic prognosis, and appropriate therapy, therefore, the clinician must be able to locate the position, movements, and possibilities of synthesis of the main ego forces and functions, and not be misled by all the shooting in the forward holding point." Knight points out