The person evolves an idealized image. The orientation selected is elevated to a status of utter grandiosity. The person is not merely a kind person, but the kindest person; not merely a tough person who can negotiate any business deal, but the toughest son of a bitch you can imagine; not merely a person who enjoys freedom, but one who is—like the song says—“King of the Road.” This leads to a search for glory. The actual self is in profound conflict with the glorified self—the self one yearns to be. One may hate the actual self for falling so far short of the idealized self.
The quest to actualize the idealized self, like so much else, is largely unconscious. At any moment, the individual or the observer may catch sight only of its shadow. One critical way by which we recognize the neurotic process is in the irrational claims or entitlements the neurotic person makes on others and, importantly, on himself. These claims on self constitute inner dictates, a tyranny of the shoulds. Guilt, self-recrimination, compulsive behavior, critical attitudes toward others, fear of critical attitudes from others, inhibitedness, loss of spontaneity in feeling and action, and specific Axis I disorders may, with consideration of biological factors, result from such inner tyranny.
Beyond what we now consider organic determinants, in Horney’s terminology, our patient seeks help because the unconscious dynamic forces—a mix of feelings, thoughts, and customary behaviors—are not working. With medications and one or another form of psychotherapy, the psychiatrist is supposed to help fix matters. Sometimes that is possible, and it may even lead to an excellent outcome. Knowing from the start how a personality is organized, especially as theorized by Karen Horney—appreciating the primary and repressed moves of the patient, inner dictates, claims, idealized image, and intrapsychic defensive maneuvers—makes the help we offer most likely to succeed.