116 LETTERS TO THE EDITOR

concept rejected by Homey. Rather than view one child as fixated at the symbiotic subphase and the other at the rapprochement subphase, a Horney perspective might envision the first as struggling to prove his illu- sion of being fused with the mother, and the second as clinging in a rigid and indiscriminate quest to secure omnipotence over the idealized mother.

I value Lemer's paper despite these differences. Homey wrote well before Mahler, Bowlby, and writers in object relations had prominently entered the psychoanalytic scene. In their emphasis on the interpersonal and the self, and in their comparative deemphasis of drive theory and clas- sic psychic structures, they clearly do invite comparison with Horney's views.

Douglas H. Ingram, M.D.

REFERENCES

1. Lerner, J. Homey theory and mother/child impact on early childhood, Am. J. Psychoanal., 43: 149-156, 1983.

2. Pine, F. On the pathology of the separation-individuation process as manifested in later clinical work: an attempt at delineation. Int. J. Psychoanal., 60: 225-242, 1979.

3. Rosenthal, H. On early alienation from the self. Am. J. Psychoanal., 43: 231-243, 1983.

To the Editor:

I appreciate Dr. Ingram's thoughtful comments on my paper, "Homey Theory and Mother/Child Impact on Early Childhood." His letter chal- lenges me to further clarify my thinking about Homey theory and early development. My concern about the broader usage of basic anxiety stems from two sources. First, the actual experience of anxiety in the neonate is different from that of the toddler. I think that it is useful to recognize this difference in our psychoanalytic concepts. Second, overwhelming anxiety, experienced at different developmental stages, will lead to different psychic consequences. If the anxiety is experienced very early, it may lead to borderline conditions or psychosis, rather than neurotic process.

Winnicott dubs the earliest form annihilation anxiety, or unthinkable anxiety. He asks us to think of the baby, "as an immature being who is all the time on the brink of unthinkable anxiety" (1). The varieties of unthink- able anxiety are: going to pieces, falling forever, having no relation to the

LETTERS TO THE EDITOR 117

body and having no orientation. Annihilation anxiety differs both in char- acter and in substance from the experience of being alone and helpless in a hostile world. Horney used basic anxiety specifically to describe the lat- ter state. Annihilation anxiety, which I would equate with what I have called Horney's manifest anxiety, leads to the most severe forms of pathol- ogy, including the organization of a compliant false self, a condition that originates before the infant is capable of developing the neurotic trends that could be marshalled on the level of basic anxiety. When Horney and Winnicott speak of the real self and the true self, respectively, they refer to the center of uniqueness and spontaneity in each of us. Mahler uses the concept of self differently. She refers to an organized, experiencing struc- ture, which is composed of self and object representations. In early infancy, Mahler's "self" is not yet fully developed. While I agree that alienation from Horney's real self can arise before the rapprochement subphase of the separation-individuation process, I do not believe that it can result in "cer- tain trends that become rigid ~nd indiscriminate, and that require mal- adaptive defenses, all perpetuating the neurotic process," unless Mahler's "self" is also present and somewhat separate and individuated. If we speak of neurotic process, I think we are talking about phenomena that develop later.

Dr. Ingram feels that I imply the concept of fixation in my discussion of two hypothetical clinging children. My purpose was, in fact, to distinguish between the Freudian concept of fixation, on the one hand, in which libido is concentrated on a stage of psychosexual development which is either too gratifying or too frustrating, in either case resulting in an investment in staying with the issues of that stage (i.e., oral, anal, phallic, oedipal), and the concept of developmental lack, on the other hand. Where I refer in my paper to a developmental lack, the infant was not provided at a wery early time with what was required for further growth. The infant is stuck, but gets no "instinctual" relief from where he or she is. Rather, the infant, and later the adult, is seriously handicapped in relations with others and in feelings about himself or herself in ways that differ from those of the neurotically fixated person.

While Dr. Ingram indicates that a Horney perspective might envision a child who has not moved beyond symbiosis as "struggling to prow.~ his illu- sion of being fused with the mother," in my view, for the child who has not been able to adequately move on from the symbiotic phase, it is not an illusion that he or she is fused with the mother. It is the child's actual psychic predicament. The idea that the child might be attempting to prove this "illusion" suggests that this position is defensive. I think that iit is only at the rapprochement subphase or beyond that one can use that kind of defense. The prerapprochement child has available only much more

118 LETTERS TO THE EDITOR

primitive, more poorly organized, and much less successful defenses, which may be rigid and indiscriminate, but are not neurotic trends.

If, theoretically, we recognize that anxiety experienced at different levels of development actually generates different states and fuels different pro- cesses, we must also look at the implications for psychoanalytic technique. The lack of full scale individuation in some patients brings about a dis- torted perception of self and others that is not amenable to a standard psychoanalysis. Lacking in these people may be the ability to form mean- ingful relationships, to be in contact with feelings, to tolerate anxiety and conflict, to take pleasure in living and to be productive. Usually, they are severely alienated from self and externalize extensively. Psychoanalysis generally calls for the patient to be able to distinguish between experience and reality and "to split off his experiencing ego from his observing ego" (2).

Horney's theory, with its recognition of the value of human help, its emphasis on eliciting constructive forces, its appreciation of the real rela- tionship between analyst and patient, and its concept of the real self, while also giving the greatest weight to unconscious forces, contains the ele- ments necessary to develop what Winnicott calls the "holding environ- ment," a psychoanalytic situation in which patients who did experience unbearable amounts of the earliest anxiety and its consequences, and who are not able to be analyzed through our usual approaches, can be treated. Should we instead think exclusively in terms of neurotic trends, we may exclude these patients from our practices or tend to treat them in a way that does not recognize their developmental deficits and special needs. Perhaps our work with Horney's theory should move in the direction of developing its application beyond neurosis. To do that, certain concepts may have to be reexplored. Essential in this process is such dialogues as the one Dr. Ingram has initiated.

Joyce A. Lerner, M.S.W., C.S.W.

REFERENCES

1. Winnicott, D.W. Ego integration in child development. In The Maturational Processes and the Facilitating Environment. New York: International Universities Press, 1982, p. 57.

2. Greenson, R. The Technique and Practice of Psycho-Analysis. London: Hogarth, 1981, pp. 172-173.

To the Editor:

I was delighted that Joyce Lerner's thoughtful paper on "Homey Theory