In this guest column, Tih-Shih W. Lee, MD, PhD, and Oscar F. Hills, MD, focus on love relationships, an aspect of our patients' lives to which we often pay little attention. The authors describe a number of personality-driven relational structures together with the defense mechanisms that underpin them from a psychodynamic viewpoint. They suggest that studying these relational structures can help us as therapists develop a better understanding of our patients' intrapsychic anguish and psychosocial difficulties and achieve enhanced therapeutic alliances, more focused selection of psychological interventions, and a keener awareness of countertransferences.
Norman A. Clemens, MD
Although love relationships are an extremely important dimension of the lives of our patients and ourselves, they are not often the focus of clinical psychiatric attention. Love relationships are usually not explicitly dealt with in psychiatric texts or training and do not often appear in the psychiatric literature, as shown by the dearth of references found using medical literature search engines. In fact, the word "love" seems to be rather underutilized in the medical literature, despite the universality of the phenomenon, as if it were an unscientific concept. But love relationships are a major part of our patients' lives-a source of both angst as well as satisfaction and security. In the latest version of the Diagnostic and Statistical Manual of Mental Disorders, DSM IV, problems in relationships are listed under a V code, Partner Relational Problem, V61.10, described as "a pattern of interactions between spouses or partners characterized by negative communication (e.g., criticisms), distorted communication (e.g., unrealistic expectations), or non-communication (e.g., withdrawal) that is associated with clinically significant impairment in individual or family functioning..." (p. 737).1 In the current version of the World Health Organization's International Classification of Diseases, ICD-10, they are listed as a Z code, Z63.0 "Problems in relationship with spouse or partner."2 These sections are probably among the least referenced parts of these diagnostic classification systems.
In psychiatric practice, we learn about patients from what they tell or do not tell us, what we observe, and the psychosocial context. Understanding their love relationships gives us a better and more holistic appreciation of the individual. By studying external manifestations of relational issues, we get a glimpse into patients' internal worlds, much like the ophthalmologist who, using the ophthalmoscope, catches a glimpse of the central nervous system. In clinical practice, issues pertaining to love and relationships are often left to be dealt with by psychologists, couples' therapists, and counselors. In the process, psychiatrists may miss the opportunity to gain a better insight into the patient's mental life and to empathically connect with the patient in an authentic manner.
We therefore propose a limited classification of underlying personality-driven modes of relatedness, which we term "relational structures" of patients. Understanding the defense mechanisms that are employed in the service of these relationships can help therapists gain a deeper understanding of the patient's problems, and can enhance the therapeutic alliance. In this column, we describe and discuss a few relational structures that affect interpersonal relationships from a dynamic point of view, and we propose a way of better understanding patterns of interaction. We also cite a few fictional characters from popular movies for illustrative purposes.
To fully understand what is going on in a relationship, we need to understand the personality structure of the individuals (i.e., from the perspective of one person), the character of their relationships (i.e., from the perspectives of two or more persons), and the stressors and strains of the existing dynamic. This column primarily addresses the individual's relational structures, which refer to the form and mode of relatedness towards the partner. Even though some terms that we use here are similar to those used in Axis II of DSM IV, their use does not imply that the patient has the corresponding personality disorder. In general, personality disorders are pervasive, persistent, and maladaptive patterns of inner experience and behavior that affect multiple areas of social and occupational functioning, whereas, in our use of the term "relational structures" here, we are limiting the analysis principally to the dyadic dimension. For example, a patient whose relationship typifies a narcissistic relational structure and employs narcissistic defense mechanisms3 may not meet criteria for narcissistic personality disorder. While there is always the temptation to pathologize, we want to emphasize that relational structures exist on a continuum between well functioning and pathological and that different structures can, in fact, co-exist at the same time. We do not present an exhaustive list of all relational structures, and we are not aware of the existence of such a list. Rather we highlight a few of the main relationship structures we have observed and discuss potential problems they can engender.
Narcissistic Relational Structures
Individuals with prominent narcissistic personality traits often wish for unconditional caring and ministration, but do not readily see such wishes as recapitulations of early parental, caregiving relationships. In the service of these needs, their model of reality is somewhat compromised, especially in matters of personhood. They tend to experience partners as part-objects rather than as whole people with lives of their own. Highly narcissistic persons cannot tolerate the intrusion of others' wishes, desires, demands, and requirements in their lives. Hence the partners are not seen as separate entities but rather as extensions of themselves. The primary defense mechanisms described as narcissistic are denial, distortion, and projection.3
Otto Kernberg characterizes narcissistic individuals as having a limited capacity for a deep investment in a love object.4 They may be promiscuous and have intense feelings of frustration and impatience when desired sexual objects are not immediately available to them. Kernberg also notes that, if the partner is considered attractive or desirable by other people, it stirs up unconscious envy and greed in narcissistic patients and fills them with the need to take possession and eventually to devalue and spoil that which is envied, leading to disappearance of both excitement and desire.
Hence, narcissistic individuals often "fall in love" but are not able to "be in love." In the extreme, they may harbor antisocial elements, as are found in serial daters of both sexes who are emotionally uninvested or unavailable and who use lies or half-truths to get whatever they want. They usually feel little remorse or compunction for their behavior and are unable to find fulfillment in relationships. This is nicely illustrated in the character of Alfie in the eponymously titled movie (starring Michael Caine in 1966 and Judd Law in 2004) and by the cad (played by Hugh Grant) in Bridget Jones's Diary (2001).
Sadomasochistic Relational Structures
Individuals with sadomasochistic relational structures are more externally oriented but are still impelled by undifferentiated internal forces. In analytic terms, it can be said that their libidinal and aggressive impulses are played out primitively in the relationship. Sadomasochism reveals two sides of the same coin, with sexually charged aggression directed towards the partner in sadism and directed inwards towards the self in masochism. Common defense mechanisms encountered in such relationships are acting out, turning aggression on the self, reversal, externalization, projection, and rationalization.
Sadism in a relationship can be seen when the patient obtains gratification in engaging in abusive behavior towards the partner. The abuse could be physical abuse, verbal slights, or even merely withholding care and affection. However, the same individual or partner could at the same time be subject to similar types of abuse and also obtain some perverse gratification from being the victim of such abuse. Glenn and Bernstein5 argued that masochists often attempt, consciously or unconsciously, to exert control through their behaviors and to encourage people to attack them-but titrate the degree of provocation so as to regulate the amount of pain inflicted. They propose that in difficult situations, masochists may serve to reverse states of helplessness and passivity by actually creating such situations and experiences in which they are the victims of abuse. When they achieve "victory" through their own defeat, narcissistic and aggressive urges are gratified. In the movie Love Actually (2003), the best man (played by Andrew Lincoln) who falls in love with the bride (played by Keira Knightley) and ends up holding a placard professing love from his "wasted heart," possibly demonstrates underlying masochistic traits. There is also the long-suffering wife (played by Emma Thompson) who endures her husband's infidelity with stoicism but perhaps "gains" some paradoxical gratification as the wronged woman.
"Neurotic" Relational Structures
"Neurotic" is a term that is no longer used in the DSM system, but is still found in the ICD-10 in the categories F40-F48, Neurotic, stress-related and somatoform disorders.2 Here we use it, without prejudice towards any diagnostic taxonomy and for want of a better term, to describe a wide range of structures but retain the quotation marks. "Neurotic" in this context can be broadly used to describe the unconscious repetition and reliving of past relationships and problems in current relationships. Hence, "neurotic" structures are probably the most common and poorly defined relational structures. Unless functionally disabling, they may not even be considered pathologic. In fact, most successful love relationships entail a certain level of "neuroticism." It is in the more extreme cases that individuals are overwhelmed by insecurities, doubts, and anxieties, and feel unworthy, entitled, envious, discontented or all of the above at the same time. This in turns leads to ambivalence, indecision, or "commitment phobia." To paraphrase Groucho Marx, "I wouldn't want to be in love with anyone who could love me." It is as though to admit and accept love, in reality, is to take the first step towards its destruction. The common neurotic defenses are rationalization, intellectualization, displacement, isolation of affect, and controlling.3 The bachelor-protagonist (played by Hugh Grant) in the movie Four Weddings and a Funeral (1994) and the newly elected Prime Minister (also played by Hugh Grant) in Love Actually are examples of characters whose neurotic structures come into play, but who eventually manage to achieve happy outcomes.
Mature Relational Structures
Mature structures are realistic but not problem-free. They require the ego strength to tolerate the vicissitudes of relationships, including the ability transiently to hate the person who is loved without destroying the love object. This also entails the practical understanding that "it likely wouldn't be much better with anyone else" and hence having to learn to trust others and oneself with a consistent outlook. The mature defense mechanisms employed are anticipation, humor, sublimation, and altruism.3 Mature love can therefore be said to include a limited projection of a reality-tempered ego ideal onto the idealized love object, and a simultaneous enhancement of narcissistic investment from the sexual gratification of the love object. However, all relationships, including mature and successful ones, have elements of other more primitive structures at various times. In the movie On Golden Pond (1981), the couple (played by Katherine Hepburn and Henry Fonda) probably exemplify mature relational structures. In mature relationships, the ideal synthetic goal is the dynamic integration of family life, social interactions, and companionship.
The complications in relationships that can result from the presence of personality traits and pathologic structures do not in any way detract from the fact that love is a truly splendid and inexplicable psychic phenomenon that comes in many shapes and guises. Personality structures in an individual interact and transform over time and in different environments, often in apparently inexplicable ways. The role of the psychiatrist is to appreciate these personality structures and recognize how they pertain to the very real distress and struggles our patients experience in their lives. Such an appreciation is also relevant for psychiatrists themselves who may have relationship issues in their own lives that contribute to countertransference.
With greater awareness and comfort with the subject, psychiatrists can go beyond treating the anxious and depressive symptoms that are usually the manifestations of relationship difficulties. The relationship difficulties themselves can become a focus of clinical attention. Various psychotherapeutic interventions can be instituted; for example, time-limited interpersonal therapy may be indicated to deal with specific interpersonal deficits, whereas long-term psychodynamic therapy may be more appropriate for enduring personality problems that repeatedly affect love relationships.
Love and relationships have been around throughout, and in fact are responsible for, the history of humanity, and hence continue to delight and confound us in every society today. As the opening lines of the movie Love Actually suggest, "love actually is all around."
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:737.
2. The ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organization; 1992:242.
3. Meissner W. Theories of personality and psychopathology: Classification of defenses. In: Saddock B, Saddock V, eds. Kaplan & Sadock's comprehensive textbook of psychiatry, 7th edition, volume I. Philadelphia: Lippincott Williams & Wilkins; 2000; 721.
4. Kernberg, O. Love relations: Normality and pathology. New Haven: Yale University Press; 1998.
5. Glenn J, Bernstein I. Sadomasochism. In: Moore B, Fine B, eds. Psychoanalysis, the major concepts. New Haven: Yale University Press; 1995: 252-65.