Basic Fault, Balint (1968)
Chapters 1-6: The Three Areas of the Mind
- There’s a whole lot that analysts still don’t know. We don’t know, for example, what we’re supposed to do with the id, don’t know if we’re even able to influence the id. And although we know a few things about the superego — e.g., that it primarily forms when the child introjects her parents and that it can be changed when the patient introjects her analyst — we don’t know how to help the patient get rid of parts of her superego.
- Freud based psychoanalysis on his work with obsessional and melancholic patients. These patients possess certain characteristics that other individuals don’t possess, and consequently, it’s no guarantee that the techniques which work for these patients will work for other patients.
Balint goes on to describe two different types of patients. Oedipal patients primarily struggle with internal conflict. One one to put this is to say that their problems occur in a triangular relationship, one in which there is a subject and two additional objects; an example of this would be an individual (subject) who has conflict between her superego (internalized parent) and her id (desire to attain some gratification).
Oedipal patients are plagued by problems that originated during the Oedipus period, roughly between the ages of 3 and 5. Children at that age are very adult-like; their emotions, desires, and instinctual urges are similar to those of adults, and they’re able to use adult language to understand and describe their experiences. Because the origin of their problems goes back to the Oedipal period (and not earlier), they possess the ego strength needed to withstand “the tensions caused by internalization without breaking down” and without resorting to more primitive defenses like acting-out, projection, and denial. Moreover, they’re able to make use of language and thus analytic interpretations, taking in the analyst’s interpretation.
Others are not able to make use of interpretations, and Balint writes that for these patients “the root of their illness goes further and deeper than the Oedipus conflict.” He writes that they have been disturbed at the level of the “basic fault.” Whereas those at the Oedipal level have internal conflict, those at the basic fault have a deficiency. Such patients feel that there is a fault within them, and they have a strong feeling that someone has failed them. Because their injury occurred when they were pre-verbal, adult language — and thus interpretations — is often useless them.
Chapters 7-13: Primary Narcissism and Primary Love
Balint next discusses Freud’s conception of narcissism. Freud wrote that the mother’s breast is our first sexual object. When we lose access to this object, we enter a state of auto-eroticism that lasts throughout latency. Primary narcissism is the intermediate stage from auto-eroticism to allo-eroticism. Secondary narcissism is the state “in which some, or even a very large part, of the libido that has previously cathected external objects, is withdrawn from them and cathects to the ego.”
What Freud meant by narcissism seems better captured by the term schizoid. He believed that schizophrenia is a form of narcissism, but Balint argues that schizophrenics are actually “highly sensitive to the analyst's moods, and the more regressed the patient is, the more sensitive he becomes; what a normal or neurotic patient would not even notice usually affects or, more correctly, disturbs a regressed patient deeply.”
Balint proceeds to argue that there is evidence for the existence of secondary narcissism but not primary narcissism. Rather than being in a state of primary narcissism, Balint believes the infant enters into a state of primary love. He notes that the fetus has an extreme dependence on its environment, implying that its libido cathects to the environment. [To cathect means “to focus one’s emotional energies on someone or something.”] That said, the fetus’ perception of the environment is probably undifferentiated, no objects existing, the fetus and environment “penetrat[ing] into each other,” existing in “a harmonious mix-up.”
Birth is a traumatic experience, and the infant might cathect its libido to its ego “in an attempt to regain the previous feeling of oneness.” However, the infant will soon experience a different type of cathexis. It might be an ocnophlic cathexis in which she cathects to her mother; the mother is felt to be “safe and comforting while the spaces between them are threatening and horrid.” Or the infant might experience a philobatic cathexis; here “the objectless expanses retain the original primary cathexis and are experienced as safe and friendly, while the objects are felt as treacherous hazards.” In the former state, the infant clings to its mother and introjects her, and in the latter state, the infant develops skills “to maintain himself alone with very little, or even no, help from his objects.”
The young infant is only capable of a primitive two-person relationship. If her relationship to her mother becomes disturbed, her reaction will consist of “loud and vehement symptoms suggesting processes either of a highly aggressive and destructive, or profoundly disintegrated, nature.” On the other hand, “if the harmony is allowed to persist without much disturbance from outside, the reaction amounts to a feeling of tranquil, quiet well-being which is rather inconspicuous and difficult to observe.”
Chapters 14-18: The Gulf and the Analyst’s Response to ItBalint next discusses Freud’s conception of narcissism. Freud wrote that the mother’s breast is our first sexual object. When we lose access to this object, we enter a state of auto-eroticism that lasts throughout latency. Primary narcissism is the intermediate stage from auto-eroticism to allo-eroticism. Secondary narcissism is the state “in which some, or even a very large part, of the libido that has previously cathected external objects, is withdrawn from them and cathects to the ego.”
What Freud meant by narcissism seems better captured by the term schizoid. He believed that schizophrenia is a form of narcissism, but Balint argues that schizophrenics are actually “highly sensitive to the analyst's moods, and the more regressed the patient is, the more sensitive he becomes; what a normal or neurotic patient would not even notice usually affects or, more correctly, disturbs a regressed patient deeply.”
Balint proceeds to argue that there is evidence for the existence of secondary narcissism but not primary narcissism. Rather than being in a state of primary narcissism, Balint believes the infant enters into a state of primary love. He notes that the fetus has an extreme dependence on its environment, implying that its libido cathects to the environment. [To cathect means “to focus one’s emotional energies on someone or something.”] That said, the fetus’ perception of the environment is probably undifferentiated, no objects existing, the fetus and environment “penetrat[ing] into each other,” existing in “a harmonious mix-up.”
Birth is a traumatic experience, and the infant might cathect its libido to its ego “in an attempt to regain the previous feeling of oneness.” However, the infant will soon experience a different type of cathexis. It might be an ocnophlic cathexis in which she cathects to her mother; the mother is felt to be “safe and comforting while the spaces between them are threatening and horrid.” Or the infant might experience a philobatic cathexis; here “the objectless expanses retain the original primary cathexis and are experienced as safe and friendly, while the objects are felt as treacherous hazards.” In the former state, the infant clings to its mother and introjects her, and in the latter state, the infant develops skills “to maintain himself alone with very little, or even no, help from his objects.”
The young infant is only capable of a primitive two-person relationship. If her relationship to her mother becomes disturbed, her reaction will consist of “loud and vehement symptoms suggesting processes either of a highly aggressive and destructive, or profoundly disintegrated, nature.” On the other hand, “if the harmony is allowed to persist without much disturbance from outside, the reaction amounts to a feeling of tranquil, quiet well-being which is rather inconspicuous and difficult to observe.”
Balint next discusses regression, which involves the client communicating in more and more primitive ways. He writes about regression in such an illuminating way that I feel the need to quote him at length:
In a way, the process of maturation and civilization amounts to moving less and less physical mass, i.e. using less and less muscular energy, for the expression of the same idea, effect, or message. That means that as fewer and fewer muscles are involved, the movements become finer and subtler. Of all the skeletal muscles perhaps the speech muscles have the smallest mass and are the subtlest and finest; consequently, moving them uses less energy than moving any other. The maturation process, however, does not stop here. The child, or the primitive, first substitutes shouting or screaming in place of acting, then he learns to shout and scream less, i.e. to express the same intensity of emotion by using smaller amounts of physical mass and muscular energy.
All psychoanalytic patients undergo some regression, becoming childish and experiencing “intense primitive emotions in relation to the analyst; all this, of course, is a constant part of what is generally called transference.” Although all patients regress, some regress further than others. In the case of more disturbed patients, words and thus interpretations lose their meaning, the patient becomes inordinately attached to and attentive to the analyst.
Balint next turns to the limits of language. He points out that some words cannot be accurately translated from one language to another. More to the point, although the child at the Oedipal level can use adult language, the child at the level of the basic fault cannot; rather, all her communications are non-verbal. It is therefore up to the analyst to translate her non-verbal communications into adult language; it is also up to the analyst to inform the patient what her communications mean.
Balint then discusses how different schools of psychoanalysis treat patients at the level of the basic fault. Classical analysts fail these patients by talking to them as though they’re organized at the Oedipal level. Kleinians use adult language to describe what happens at the level of the basic fault, although they use terms that are unfamiliar to most clients, words like contents, part-objects, split off, take in, incorporate, and project. Many Kleinian patients have the experience of their analyst forcing “mad thoughts” into them. Moreover, there remain many pre-Oedipal experiences that lie “beyond the realm of words,” even these Kleinian words.
Balint next turns to Winnicott, who wrote that when a child has an inadequate early environment, she copes by developing a false self. In analysis, Winnicott argue, the patient must be allowed to regress to the state before they developed their false self. Moreover, as the patient regresses, the analyst must provide “management,” a “very delicate piece of work, consisting of nursing, protecting, mediating, looking after, etc.” Only then, Winnicott believed, can an atmosphere develop in which the patient can hear and accept interpretations.
Balint argues that management is difficult. These such patients, he writes, “are wont to develop exacting demands, often amounting to addiction-like states.” If the analyst gives into the patient’s demands to create the environment the patient lacked when younger, the analysis will not succeed. One reason for this is that it’s generally not possible to sustain such an environment “long enough for the patient to develop new ways of development which will avoid the repetition of the original trauma and lead to a healing-off of the basic fault.”
Chapters 19-23: The Benign and the Malignant Forms of Regression
Freud wrote that when the patient regresses the analyst should respond by maintaining his stance of abstinence and only respond to the regression by making interpretations. Ferenzi took a different view and believed that the patient’s wishes in regression should be gratified. Balint wants to make room for both approaches and distinguishes between malignant regression (which Freud encountered, thus informing his position) and benign regression (which Ferenzi encountered, thus informing his position).
Patients with benign regression respond well to gratification and quickly emerge from this “primitive world” and start to feel better. Balint notes that gratifying these patients wishes is a supplement to interpretation but that it does not replace it. Patients with malignant regression can never get enough; “as soon as one of their primitive wishes or needs was satisfied, it was replaced by a new wish or craving, equally demanding and urgent,” often leading “to the development of addiction-like states which were very difficult to handle.”
Chapter 24-26: The Regressed Patient and His Analyst
The two most important factors in psychoanalysis are interpretations and the analyst-patient relationship. Those patients who do not benefit from interpretations must be allowed to regress to the object-relationship state in which his deficiency originally occurred. Only after this has happened can the patient “begin anew” and develop new, healthier patterns of object relationship. The ideal analyst-patient relationship has been described in different ways by different writers; e.g., Bion wrote about the “container” and the “contained,” Winnicott wrote about the “good enough environment.” Balint refers to the ideal relationship as one based on the pattern of primary love.
Before telling us how we can go about establishing this type of relationship, he tells us things that we must not do. First, we must not turn into “mighty and knowledgeable objects for our patients,” thus encouraging them to regress into an ocnophilic world. “In this world, there are ample opportunities for dependence but very meagre ones for making independent discoveries.” Put differently, we cannot let patients think that we are omnipotent. Second, the analyst must try not to behave as “a separate, sharply-contoured object. In other words, he must allow his patients to relate to, or exist with, him as if he were one of the primary substances. This means that he should be willing to carry the patient, not actively but like water carries the swimmer.”
Sometimes these patients simply need silence. He adduces a time he used silence with a patient:
The patient remained silent right from the start of the session for more than thirty minutes; the analyst accepted this and, realizing what possibly was happening, waited without any attempt whatever at interference; in fact, he did not even feel uncomfortable or under pressure to do something. I should add that in this treatment silences had occurred previously on several occasions, and patient and analyst had thus had some training in tolerating them. The silence was eventually broken by the patient starting to sob, relieved, and soon after he was able to speak. He told his analyst that at long last he was able to reach himself; ever since childhood he had never been left alone, there had always been someone telling him what to do.
During times in which the patient cannot make use of words, the analyst must function “as a provider of time and of milieu.” Balint elaborates:
This does not mean that he is under obligation to compensate for the patient's early privations and give more care, love, affection than the patient's parents have given originally (and even if he tried, he would almost certainly fail). What the analyst must provide — and, if at all possible, during the regular sessions only — is sufficient time free from extrinsic temptations, stimuli, and demands, including those originating from himself (the analyst). The aim is that the patient should be able to find himself, to accept himself, and to get on with himself, knowing all the time that there is a scar in himself, his basic fault, which cannot be ‘analysed’ out of existence; moreover, he must be allowed to discover his way to the world of objects — and not be shown the ‘right’ way by some profound or correct interpretation. If this can be done, the patient will not feel that the objects impinge on, and oppress, him. It is only to this extent that the analyst should provide a better, more ‘understanding’ environment, but in no other way, in particular not in the form of more care, love, attention, gratification, or protection.
In the book’s final chapter, Balint writes beautifully about how the analyst should relate to the basic level patient, and so I will quote him at length:
[T]he analyst should bear in mind that on the whole he should try to avoid penetrating defences or undoing splits by incisive and correct interpretations since these might be felt by his regressed patients as disbelieving the justification or validity of their grievances, recriminations, and resentment. Instead, the analyst must sincerely accept all complaints, recriminations, and resentments as real and valid, and allow ample time to his patient to change his violent resentment into regret. This process must not be hurried by interpretations, however correct, since they may be felt as undue interference, as an attempt at devaluing the justification of their complaint and thus, instead of speeding up, they will slow down the therapeutic processes...
Provided the analyst is able to fulfill most of the requirements sincerely and unreservedly, a new relationship may develop which will enable the patient to experience a kind of regret or mourning about the original defect and loss which led to the establishment of the fault or scar in his mental structure. This mourning differs fundamentally from that caused by the loss in reality of a beloved person or that caused by the damage to, or destruction of, an internal object, characteristic of melancholia. The regret or mourning I have in mind is about the unalterable fact of a defect or fault in oneself which, in fact, has cast its shadow over one's whole life, and the unfortunate effects of which can never fully be made good. Though the fault may heal off, its scar will remain for ever; that is, some of its effects will always be demonstrable.
The period of mourning must be allowed to run its course which, in some patients, may be exasperatingly long. Although this process cannot be hurried, it is most important that it should be witnessed; since it belongs to the area of the basic fault, apparently it is impossible to go through this mourning by oneself; it can be done only in the framework of a two-person relationship, such as the analytic situation. If the analyst can provide a sufficiently long, unhurried period for this mourning, and maintain the necessary primitive atmosphere by his tolerance and non-interfering interpretations, the patient begins to cooperate in a somewhat different way from before, as if he had become willing and able to re-assess his position vis-à-vis his objects and of re-examining the possibility of accepting the often unattractive and indifferent world around him.
In the book’s final chapter, Balint writes beautifully about how the analyst should relate to the basic level patient, and so I will quote him at length:
[T]he analyst should bear in mind that on the whole he should try to avoid penetrating defences or undoing splits by incisive and correct interpretations since these might be felt by his regressed patients as disbelieving the justification or validity of their grievances, recriminations, and resentment. Instead, the analyst must sincerely accept all complaints, recriminations, and resentments as real and valid, and allow ample time to his patient to change his violent resentment into regret. This process must not be hurried by interpretations, however correct, since they may be felt as undue interference, as an attempt at devaluing the justification of their complaint and thus, instead of speeding up, they will slow down the therapeutic processes...
Provided the analyst is able to fulfill most of the requirements sincerely and unreservedly, a new relationship may develop which will enable the patient to experience a kind of regret or mourning about the original defect and loss which led to the establishment of the fault or scar in his mental structure. This mourning differs fundamentally from that caused by the loss in reality of a beloved person or that caused by the damage to, or destruction of, an internal object, characteristic of melancholia. The regret or mourning I have in mind is about the unalterable fact of a defect or fault in oneself which, in fact, has cast its shadow over one's whole life, and the unfortunate effects of which can never fully be made good. Though the fault may heal off, its scar will remain for ever; that is, some of its effects will always be demonstrable.
The period of mourning must be allowed to run its course which, in some patients, may be exasperatingly long. Although this process cannot be hurried, it is most important that it should be witnessed; since it belongs to the area of the basic fault, apparently it is impossible to go through this mourning by oneself; it can be done only in the framework of a two-person relationship, such as the analytic situation. If the analyst can provide a sufficiently long, unhurried period for this mourning, and maintain the necessary primitive atmosphere by his tolerance and non-interfering interpretations, the patient begins to cooperate in a somewhat different way from before, as if he had become willing and able to re-assess his position vis-à-vis his objects and of re-examining the possibility of accepting the often unattractive and indifferent world around him.
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