The As-If Patient and the As-If Analyst

Patients who seek out psychoanalysis but lack the capacity for selfobservation have been a challenge for classical theory and technique from early on. In 1919, Abraham described a group of apparently analyzable patients who could not tolerate interpretation. Freud (1920) rethought basic theory when confronted with patients who repeat traumatic experiences without sufficient “aloofness” (p. 18). Helene Deutsch's paper on as-if personalities, “Some Forms of Emotional Disturbance and Their Relationship to Schizophrenia” (1942), belongs to this series. She, too, is describing patients who do not see what the problem is. This clinical/theoretical difficulty has produced some of the largest debates in our field. What accounts for the inability to observe oneself? What is effective in dealing with this problem—interpretation or the relation to the analyst? Deutsch's paper raises these questions tangentially; it is known more for its delineation of a syndrome than for any major clinical/ theoretical contribution. Today, it is best reconsidered via its limitations, particularly when Deutsch comes up against the question of interpretation versus relation.

Superficially, Deutsch says, the as-if personality appears “normal.” But the people in the patient's environment typically have a feeling of unease, an “intangible and indefinable” sense that something