Reply to Jennifer Downey

Dr. Downey is concerned that physical disability or defect not be regarded as just a fantasy. She warns, appropriately, of the analyst's countertransference potential for denial of the painfulness and severity of patient's physical abnormalities. I agree completely with her. Either/or understanding of concepts can lead to oversimplification. Dr. Downey misunderstands my position as one of oversimplification—that physical defects are to be regarded as only psychological, ignoring or minimizing the actual physical defect. Exclusive emphasis on either extreme, the actual physical reality or only inner fantasy, would miss the interplay and integration we psychoanalysts seek between external reality and intrapsychic meanings and constructions.

I do not want to be misunderstood as implying that the sense of defect is a compromise formation unrelated to, or minimizing patients' bodily reality. Bearing in mind fully such bodily reality, I emphasized the usefulness of the concept of sense of defect as a compromise formation crucial for the progress of an analysis, that is, as something to be understood and analyzed. My case material, unlike Dr. Downey's, included patients who once had severe physical abnormalities or defects, which now had far less "actual" impact on their lives, and patients with "realistically trivial" defects who, nevertheless, felt themselves to be defective.

Sense of defectiveness had not, to my knowledge, been written about in detail previously. My aim was to understand this sense of defectiveness psychoanalytically and to consider how to analyze it. The opposite countertransference risk, of collusion with the patient that the feelings of defectiveness are realistic or appropriate, can minimize the patient's capacity for growth out of severe feelings of defectiveness. We certainly do need to maintain balance in our perspectives toward bodily reality and its limitations and the possibilities for better resolution of neurotic conflict. Also, whe