The shifting emphasis in clinical studies from primary to secondary narcissism reflects both the shift in psychoanalytic theory from study of the id to study of the ego and a change in the type of patients seeking psychiatric treatment. Indeed the shift from a psychology of instincts to ego psychology itself grew partly out of a recognition that the patients who began to present themselves for treatment in the 1940s and 1950s “very seldom resembled the classical neuroses Freud described so thoroughly.”
In the last twenty-five years, the borderline patient, who confronts the psychiatrist not with well-defined symptoms but with diffuse dissatisfactions, has become increasingly common. He does not suffer from debilitating fixations or phobias or from the conversion of repressed sexual energy into nervous ailments; instead he complains “of vague, diffuse dissatisfactions with life” and feels his “amorphous existence to be futile and purposeless.” He describes “subtly experienced yet pervasive feelings of emptiness and depression,” “violent oscillations of self-esteem,” and “a general inability to get along.” He gains “a sense of heightened self-esteem only by attaching himself to strong, admired figures whose acceptance he craves and by whom he needs to feel supported.” Although he carries out his daily responsibilities and even achieves distinction, happiness eludes him, and life frequently strikes him as not worth living.
Psychoanalysis, a therapy that grew out of experience with severely repressed and morally rigid individuals who needed to come to terms with a rigorous inner “censor,” today finds itself confronted more and more often with a “chaotic and impulse-ridden character.” It must deal with patients who “act out” their conflicts instead of repressing or sublimating them. These patients, though often ingratiating, tend to cultivate a protective shallowness in emotional relations. They lack the capacity to mourn, because the intensity of their rage against lost love objects, in particular against their parents, prevents their reliving happy experiences or treasuring them in memory. Sexually promiscuous rather than repressed, they nevertheless find it difficult to “elaborate the sexual impulse” or to approach sex in the spirit of play. They avoid close involvements, which might release intense feelings of rage. Their personalities consist largely of defenses against this rage and against feelings of oral deprivation that originate in the pre-Oedipal stage of psychic development.
Often these patients suffer from hypochondria and complain of a sense of inner emptiness. At the same time they entertain fantasies of omnipotence and a strong belief in their right to exploit others and be gratified. Archaic, punitive, and sadistic elements predominate in the superegos of these patients, and they conform to social rules more out of fear of punishment than from a sense of guilt. They experience their own needs and appetites, suffused with rage, as deeply dangerous, and they throw up defenses that are as primitive as the desires they seek to stifle.