Years ago I worked with alcoholic men on the Manhattan Bowery, where 10 minutes per patient was the norm. I prescribed medication and attempted psychotherapy. I relied on energetic engagement and kept track of my patients’ idiomatic verbal usages, corrected wrong cognitions, and recommended better behaviors. I incorporated psychoanalytic principles—Freudian principles as modified by Karen Horney (pronounced Horn-eye). With rueful affection, my patients, recently discharged from the drying-out unit, called my treatment turnstile psychiatry.
As the drafts of DSM-5 suggest, we are moving still more forcefully to knowing our patients through symptoms that cut across constellations of disorders. Yet despite our sophisticated nosologies and psychopharmacological remedies, our patients still want us to know them. In this, they are no different from patients who see an internist or surgeon. We are psychiatrists; our patients expect more from us. But our time with each of them is short. Horney can help.
Karen Horney (1885-1952), an early follower of Freud, was trained in Berlin. In 1932, she relocated to Chicago to become Associate Director of the newly formed Chicago Institute for Psychoanalysis. Several years later, she joined the New York Psychoanalytic Institute. Yet all through the 1920s and 1930s, she was becoming disenchanted with Freudian orthodoxy—chiefly its lofty regard of penis envy and the Oedipus complex. She hammered away at Freud’s endorsement of a conservative cultural belief system that gave male superiority an endorsement from biology. She began her own school, which energized what would soon play a major role in the Neo-Freudian orientation to psychoanalytic or, more inclusively, “psychodynamic” thinking.
The who of the patient is foremost in psychodynamic psychiatry. Who this person is precedes as foundational the complaints and the treatments we later recommend. It includes unconscious elements that interact beyond the patient’s awareness and that contribute to personality organization and symptom development. In the usually brief sessions we have with our patients, we want to engage them. We want them to feel engaged with us.
Many readers of Horney’s books find themselves in her pages. They feel that someone out there knows them. In applying the tenets of her orientation and the simple humanity that runs through her work, we become engaging to our patients. They find themselves through the treatment we offer, even when we are constrained by the turnstile psychiatry that so many of us now find ourselves practicing.
For Horney, a child grows freely and well to the extent that he or she feels security and genuine self-esteem. To the extent that the child falls prey to adverse influences, he or she develops a deep insecurity, what Horney called basic anxiety—the feeling of being helpless and alone in a world experienced as potentially hostile.
Basic anxiety is intolerable if it is intense and sustained. The child must act to allay it. He may feel the need to see things differently to reduce the sense of threat. Horney framed these efforts at reorientation as interpersonal moves. The child may move toward others by showing a clinging neediness, dependency, and self-effacement if loving submission appears to be the safest strategy. Or, the child may move against others by showing aggression, expansiveness, grandstand behavior, competitiveness, control, contempt, and exploitation of others. Included within this general orientation are tendencies toward narcissistic grandiosity, perfectionism, arrogance, and vindictiveness. Finally, the child may move away,or detach himself, from others, showing efforts to disengage and thereby avoid conflict between the tendency to submit and the tendency to dominate.