Good Breast/Bad Analyst: False Dichotomies in Understanding Aggressive Patients

To explain the prevalence of aggression and destruction in human life, Freud (/1955) put forth the idea of the death instinct (thanatos), a primary drive aimed at achieving nothingness and the complete loss of tension. Since that time, various schools of psychoanalytic thought have been interested in the origins of aggression, its etiology and its intrapsychic underpinnings.

This interest involves an ongoing debate within psychoanalysis as to whether aggression is a primary drive or a by-product of early caretaking failures. This distinction is important in that it carries profound implications for how we conceptualize our patients' problems (particularly those of our more difficult patients), and for how we determine the optimal response to aggression from a patient. In addition, where we draw this distinction carries many implicit and explicit ideas about what is the optimal analytic surround. This last point is of considerable debate within contemporary psychoanalytic schools of thought, particularly the intersubjective, relational, and self-psychological schools.

There has been some tendency towards reductionism in views of aggression. A misuse of theory can defensively protect the analyst from any responsibility for creating or exacerbating a patient's aggressive responses and affect, be this in examining countertransference reactions, empathic failures, or ill-timed interpretations, and so forth. Much of contemporary psychoanalytic thought, particularly self psychology, has argued against viewing aggression as an intrinsic attribute or primary drive of the individual, instead viewing aggression as a by-product of failures in early caretaking that are re-created and re-experienced in the analyst/analysand dyad. Adhering to this view, the analyst's primary task is to attend to this process and adjust her stance and interventions accordingly, while also making the process more conscious for both the analyst and the analysand.