On the Sense of Defect

May 28, 1986

I am writing in response to Dr. Coen's (1986) very interesting article published in the Journal of the American Psychoanalytic Association (34:47-67)↗.

The sense of defect is a useful concept in work with patients with a variety of defects, as Dr. Coen points out. The fantasies a patient develops with the defect as a nidus are of great importance whether the defect is a physical or emotional one, visible to others or not, limiting capacity or life-span or not.

However, Dr. Coen elects to deal with all these defects as psychological only—a fantasy—and then proceeds to discuss the motivations for the persistence of the fantasy. This is an oversimplification which by encompassing so many kinds of defect is confusing rather than helpful. Further, the suggestion that we view the disability or defect as just a fantasy is misleading. A patient's body may impose limitations that must be dealt with just as the mind does. By analogy, we do not consider level of cognitive ability a fantasy, although many fantasies may be elaborated about it and inhibitions may make it seem less than it is. Whether or not one has a physical appearance normal enough not to attract attention is important, just as it is important whether or not one has a basic capacity like the ability to see or to walk. It is particularly important that we as analysts consciously endeavor not to deny abnormalities of capacity and appearance, because they can be so painful that it is quite tempting to do so.

I would like to offer an illustration from my own practice. I work in a medical center where I treat patients with a variety of serious physical problems including genetic abnormalities, disorders of sexual differentiation, and the like. A patient with dwarfism consulted me for help with social withdrawal of many years' standing. In order to be able to visit my office, she obtained a driver's license and a specially equipped car. She then made a test run and found that she could not park the