Clin Soc Work J (2007) 35:5766 DOI 10.

1007/s10615-006-0060-6

ORIGINAL PAPER

Karen Horney and Psychotherapy in the 21st Century

Wendy B. Smith

Published online: 8 August 2006 Springer Science+Business Media, Inc. 2006

Abstract Many ideas currently circulating in the psychological and psychoanalytic communities have correspondence with the theories put forth by Karen Horney during the rst half of the twentieth century. This paper provides an overview of Horneys theoretical departures from Freud and an introduction to her then controversial views of motivation and relationship. Compatibility between Horneys ideas and attachment theory, self-psychology, intersubjectivity, and the person in the environment is discussed. Two clinical cases are presented, illustrating Horneys theory and approach. Keywords Karen Horney Theory of neurosis Basic anxiety Neurotic trends Attachment theory Self-psychology

Introduction The work of Karen Horney, who died 50 years ago, is remarkably relevant to the problems faced by psychotherapists in the twenty-rst century. Anxiety, a central and organizing theme in her work, is present in todays world at a level which would have been unimaginable to Horney and her contemporaries. Her
An earlier version of this paper was presented at the 2004 National Meeting of the Committee on Psychoanalysis of the Federation of Societies for Clinical Social Work in New York. W. B. Smith (&) School of Social Work, University of Southern California, Los Angeles, CA 90089-0411, USA e-mail: wsmith@usc.edu

recognition of the role of the family in both engendering and mediating anxiety as well as in shaping the individuals response to it is today reected in systems and developmental theories. Many of her ideas are not only deeply compatible with theories currently circulating in schools of psychoanalysis, but may also be seen as early versions of notions thought to be newly emerging in the areas of motivation, behavior, and development as well as in the theory and practice of psychoanalytic psychotherapy. This paper provides an overview of some of Horneys fundamental departures from Freudian theory, such as her construct of neurosis and neurotic strategies and her view of the analysts role. In the contemporary context, I will discuss the ways in which her thinking is compatible with attachment theory, self-psychology, intersubjectivity, and the social work perspective of understanding the person in his environment. I then will offer some clinical material as seen through a Horneyan lens.

Social Historical Context Karen Horney was born in 1885, in Hamburg, Germany, to a Protestant upper middle class family. Her Norwegian father was a sea captain and a Bible reader. Her mother was a free-thinking Dutch woman who encouraged her daughter to pursue medical studies, still a fairly unusual career for women at that time (Kelman, 1967). According to Horneys daughter, Marianne Eckardt, her mother pursued her professional development with a remarkable sureness of aim. She knew early in her medical studies that she would study psychoanalysis (Natterson, 1966, p. 451).

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Horney studied medicine at the universities of Freiburg, Gottingen, and Berlin and, after entering analysis with Karl Abraham, became a founding member of the Berlin Psychoanalytic Institute. In 1932, Franz Alexander asked her to become Associate Director of the Chicago Psychoanalytic Institute; she stayed 2 years before moving to New York and joining the New York Psychoanalytic Institute. There, her unorthodox views created controversy, and in 1941 she was disqualied from teaching at that institute. In the same year, she founded the American Institute for Psychoanalysis, serving as its dean until her death. Nineteenth century science had been based on closed systems and determinism; it was in this intellectual atmosphere that Freud began to develop his ideas. The early twentieth century saw the beginning of shifts toward less tightly structured views in which degrees of determinism might be recognized and moral and aesthetic values might have a place (Kelman, 1967). This more open, less concrete way of thinking informs and, indeed, characterizes some of the differences I shall outline between Freuds ideas and those of Karen Horney.

Horney and Freud In Freuds schema, the present can only be understood in terms of infantile experience. It is determined by the biological development of the psychosexual structure, which is molded to some degree by environmental forces. Human behavior is seen as the result of the interaction of instinctual and counter instinctual forces within the person, who has a xed quantity of energy. The three structures of the id, the ego, and the superego comprise the person, and neurosis is seen as the result of conicts among these three structures (Kelman, 1967). In a major departure from Freud, Horney proposed that the person was ruled not by the pleasure principle but by the need for safety (Horney, 1945). She rejected the idea that the instincts were the source of all motivation; she saw instead a mixture of forces, both internal and external, at work in creating behavior. Like Freud, Horney believed that the past is always contained in the present. Unlike Freud, she viewed people as conditioned by early experience rather than xated at a given point or stage (Paris, 1999a, b). She focused more on the current character structure than on infantile experience, and she was particularly interested in the strategies the person developed and employed to cope with what she called basic anxiety. According to Horney, basic anxiety results when

pathogenic conditions in childhood cause children to feel unsafe or unloved, leaving them with a sense of helplessness in a potentially hostile world (Paris, 1999a, b). Horney advocated a focus on understanding neurotic character structure and defenses in terms of their current function for the individual. Underlying her notion of basic anxiety is another fundamental difference between her view and Freuds. Freud postulated a destructive instinct present within us all; Horney believed that people were not inherently either good or bad, but could become destructive as a result of negative environmental circumstances that caused the constructive forces within them to be blocked. The defensive strategies that people adopt to fend off anxiety can and often do eventually become selfdefeating or self-destructive. Freud emphasized biology as the source of instincts and therefore of behavior. Since biology is universal, he assumed that the course of development and the conicts among people he observed were likewise universal. The result of this assumption was an undervaluing of the important roles played by other factors such as the immediate environment, the larger culture, the plasticity of human development, and the continuation of signicant aspects of human development past the age of puberty. These other factors are now much more widely acknowledged as being central to the course of development. In contrast to Freud, Horney focuses on the world in which the child nds him or herself: the family, which is the most important component of the childs environment (Horney, 1950, p. 159), peers, and the larger societal surround. Like such other Neo-Freudians as Fromm and Sullivan, she believed that the drives were given meaning by interpersonal, social, and cultural forces rather than the other way around (Eckardt, 1984). Sexual difculties, in her view, were the result, rather than the cause of personality disorders.

Feminine Psychology The impact of culture is perhaps nowhere so clear in Horneys departures from Freud as it is in her work on feminine psychology. Indeed, her collected papers on this subject were published posthumously in 1967, and it was this work which returned Horney to the public eye. These papers were written over a 14-year period during which her ideas about feminine psychology evolved and crystallized. As early as 1922, Horney was beginning to examine and to question the classical analytic view of women. In 1926, in The Flight from Womanhood, she pointed out that the psychology of

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women was described from mens point of view, and as such, represented ...a deposit of the desires and disappointments of men (Horney, 1926, p. 56). She noted that women unconsciously yield to these notions and that it is necessary to try to free our minds from this masculine mode of thought... (p. 59). I will not review here her exhaustive unpacking of the logic (or illogic) of the classical view, including penis envy, as that has occupied many papers and books in feminist literature over the past three decades. It is perhaps most important to note that her conviction that cultural factors exert a powerful inuence on our ideas of gender and development has passed into mainstream thought, but was radical for her time. Her comments about ideologies functioning to reconcile women to subordinate roles by presenting these roles as innate and unalterable likewise seem obvious now. Yet Horney was telling us 70 years ago that women presenting the traits specied by menpassivity, compliance, masochism, dependency, for exampleare more frequently chosen by men, so that their erotic chances in life depend on conformity to the image of what constitutes their true nature as outlined by men (Horney, 1933). While much has changed in the status and understanding of women today, one need only glance at the fashion and mens magazines on any news stand to see how these classical conceptions by men of men and women continue to have pervasive presence and inuence in our culture.

I shall describe the strategies or solutions in some detail, both to convey the power and applicability of the model and to set the stage for discussing the relationship of the model to other current theories, and eventually, to the clinical examples that follow. First, however, an introduction to Horneys view of the self will provide a foundation.

Horneys Conception of the Self Horney conceptualizes three versions of the self: real, ideal, and actual. The real self (see above) refers to the panoply of possibilities existing within each person, including temperament, talents, capacities, and predispositions. This is the self that is the source of values, a healthy conscience, and a sense of vitality. The real self, which is a possible self, cannot develop fully without a positive environment (Horney, 1950; Paris, 1999a). The ideal self arises in response to the anxiety generated by a problematic environment. The child becomes alienated from his/her real self when it does not evoke sufciently positive or growth-afrming responses from signicant others. He/she attempts to address feelings of isolation and/or hostility via a fantasied idealized self that holds the imagined promise of a felt positive identity and the satisfaction of inner needs for security and safety. Energies are shifted from true self-realization to the aim of actualizing the idealized self, which of course, cannot be actualized and is therefore an impossible self. Horney refers to the pursuit of the ideal self as the search for glory. That search involves the need for perfection, neurotic ambition, and, often, the need for vindictive triumph (Horney, 1950). It is important to note that the ideal self also contains the despised self who cannot live up to the fantasied and impossible expectations. The despised self or image results from failure to meet the exaggerated compensatory demands of the idealized self. Self-hatred is the rage of the idealized self toward the actual self for not being what it should be. Horneys concept of the tyranny of the should (Horney, 1950), describes the powerful need to live up to a grandiose self-conception, thereby avoiding the unbearable awareness of helplessness and weakness in a hostile or indifferent world. Thus, the shoulds are often extreme, as in I should always be understanding of others, or I should never feel hurt by others. Finally, the actual self is the mixture of strengths and weaknesses, strategies and strivings that describe the

Horneys Theory of Neurosis Horney believed that each person has a central inner force which is common to all people, yet possesses unique character in each individual. This force, she argues, is the source of growth. She calls this force the real self (Horney, 1950, p. 18). Each person needs both love and friction or frustration in order to develop healthily. If people in the environment cannot love the child or even conceive of him as the particular individual he is, (p. 18), he becomes alienated from his real self and develops basic anxiety. All people develop strategies to deal with the environment, but in the usual casein Winnicotts term the good enough environmentthese can be exibly taken up or discarded according to the situation. In the child who develops basic anxiety because of a pernicious or indifferent environment, strategies become extreme and rigid, giving rise to internal conicts between and among strategies. The child attempts resolution of the conict by making one strategy predominate, usually to his or her detriment.

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persons current being in the world. In a good situation, the real and actual selves are close to each other; in a less positive situation, great disparities exist between the two (Paris, 1999a).

Horneys Schema of the Neurotic Trends The neurotic trends are the ad hoc strategies we all have at our disposal to cope with the worlds we nd. Each strategy has a different emphasis, and all are present as potentials. The neurotic individual is unable to use them in exible and situation-specic ways. Each basic attitude has a positive, as well as a negative value (Horney, 1945). The rst strategy is moving toward people; it emphasizes compliance and helplessness. The individual wants to be liked, wanted, accepted, protected, and has an insatiable need to feel safe. Self-sacrice may be involved. The positive value here lies in the capacity to create a friendly relationship to the outside world. The second strategy, moving against people, emphasizes hostility and aggression. Life is seen here as a struggle of one against all; the individual has a need to control others, possibly to excel and to win recognition. This person chokes off feelings for the sake of expediency and must ght the softer feelings within. As with the person who moves toward people, however, the center of gravity lies outside oneself. The positive side of this strategy is that it enables the person to equip him/herself for survival in a competitive society. The third and last strategy is that of moving away from people, with an emphasis on isolation. This strategy addresses the desire for independence and self-sufciency. The person becomes neurotically detached and attempts to prevent anyone or anything from mattering. The positive value here is that the individual may attain integrity and serenity in a disturbing world. These were the versions of the three basic strategies delineated by Horney in 1945 in Our Inner Conicts. In 1950, she published Neurosis and Human Growth, in which she further elaborated and eshed out each of the neurotic solutions. In the later elaboration, moving toward people was described as the self-effacing solution, involving the appeal of love. The idealized self in this case glories suffering and martyrdom, and in the extreme, leads to a morbidly dependent relation to others. Moving against people was called the expansive solution and its main appeal was the sense of mastery. The idealized self here is superior, grandiose; it requires admiration.

Finally, moving away from people was described as resignation; a sense of freedom is its goal. Horney saw this as the most radical solution to conict because it restricts life and growth most severely. In every individual, all trends are present; in neurotics, one trend predominates in a self-destructive way. This truncated overview of some of the main points of Horneys theory of neurosis shows evidence of compatibility with both self-psychology and attachment theory. At least two other writers have noted these afnities, as described in the following sections.

Horney and Kohut In 1988, Jack Danielian published a fairly thoroughgoing analysis of the differences and similarities between Kohut and Horney (Danielian, 1988). He points to the remarkable resemblance between Horneys trends and the three selfobject transferences of idealizing, mirroring, and twinship. The wish to merge with the idealized parent or analyst selfobject is much like the compliant or self-effacing solution. The mirroring transference, in which the grandiose-exhibitionistic self is mobilized, is comparable to the expansive solution. And the twinship/alter ego transference, requiring ego alikeness and conveying a sense of anonymity in the midst of loneliness, has elements of the solution of resignation. Danielian also highlights the similarity between Kohuts concept of empathic immersion (as an application of vicarious introspection) and Horneys view that the analyst must embody wholeheartedness in his approach to the patient. I will discuss this further in a section below on the analysts role. Both Kohut and Horney recognize self-healing or curative forces within the human psyche, but where Horney suggests that once obstructions to self-realization have been diminished, growth can and will continue, Kohut returns to a mechanistic meta-psychology, namely that the child does not grow by unfolding his potentialities, but rather by internalizing external qualities (Danielian, 1988, p. 12). Another difference between the two is that Horneys theory is conict-based, whereas Kohuts is a decit model in which there must be restoration or structure-building, as opposed to resolution of conict.

Horney and Attachment Theory Attachment theory is increasingly in the foreground of psychological and psychoanalytic thinking. It draws on ethology, evolution theory, cognitive psychology, and

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object relations theory, and it emphasizes the primary status and biological functions of the intimate emotional bonds between people from birth forward. As I have noted, Karen Horney also accorded centrality to human relationships, especially those in the family, as fundamental shapers of motivation, behavior and, indeed, character structure. An ethological basis can be seen for her formulation of the strategies of aggression, withdrawal, and compliance, which are as noted by Paris (1994) complex human versions of the basic mechanisms of defense in the animal kingdom: ght, ight, and submission. Attachment theory suggests that individuals organize their behavior and their self and world views (internal representations) in relation to their experience of the early caregivers in their lives. These characteristic views and behaviors become enduring and have continuity. Like Horneys trends or solutions, they tend to lose exibility: in both theories, what begins as an adaptive response becomes a characteristic of the person. It is true that Horney, whose theories emerged from her clinical observations, observed adult neurotics, whereas attachment theory grew out of observations of infants and their caregivers. Interestingly, the strategies described in both theories have remarkable correspondence, and in both, the goal of the strategy is security. In both systems, healthy development depends on the ability to use the full range of strategies. In attachment theory, this translates as being able to use the secure base and being able to explore the environment apart from the base (Feiring, 1983). The child with a secure attachment (Group B in the literature) may belong to any of four subtypes, from those with most ability to explore and least need for proximity to those needing the most proximity and having least ability to explore comfortably. Although most of the securely attached would not be considered neurotic in Horneys schema, this last group at the edge of the range and moving toward being overly compliant might be close to demonstrating a selfeffacing solution. Group C, those with anxious resistant attachments, sound much like individuals who employ Horneys expansive solutionsthat is, moving against people. They are ambivalent about the caregiver, distressed by separation, and yet not comforted by contact. They may be hostile and controlling, and are conicted in their longings. Group A, those with avoidant attachments, are clearly similar to Horneys solution of detached resignation. They avoid proximity or interaction with the caregiver, exploring the world, but moving away from

people. They expect little from others, choosing to avoid conict rather than to experience or resolve it. What might we say about Group D, those with a disorganized, disoriented attachment pattern, in relation to Horneys model? The attachment theorists regard these as individuals who cannot develop a coherent strategy (Main & Solomon, 1985), so no one strategy can be said to predominate. Unable to use any of the strategies successfully, they can nd no real solution. They can neither form relationships, nor avoid them entirely. They may be hypervigilant and compulsively compliant, so in some senses self-effacement may be dominant, yet avoidance and attempts to be invisible interrupt these behaviors. Such people probably cannot construct an ideal self in any direction: they ail.

Horney and Psychotherapy However contemporary her understanding of the interpersonal and intrapsychic underpinnings of human behavior, Horneys views on the psychotherapeutic enterprise are no less so. Her conception of the therapeutic relationship and the analysts role within it are so compatible with current intersubjective and relational views as to make one wonder why she is not taught and spoken of regularly and with respect today in training institutions. Horneys ideas about therapy were based on her understanding of the cultural/interpersonal contributions to neurosis, the continuing nature of development, and the nature and functions of the patients current defensive strategies as displayed in the interaction with the therapist. The purpose of therapy, she suggested, was to lessen the patients anxiety to the extent that he or she is able to give up the neurotic trends and abandon the drive to actualize the idealized self, thus permitting further self-realization and growth to take place (Paris, 1999b). She placed great importance on self-realization and growth. Freud had emphasized the removal of neurotic symptoms and increasing the capacity for enjoyment and work. Sullivans goal was to help the patient to establish good human relationships. Horney added to these the improvement of relations not only with others but also with the self, as well as greater freedom, inner independence, and self-realization in every way (Horney, 1956a). The patients motivationthe desire to suffer less and to unfold ones true potentialis crucial: the therapist must foster the patients initiative and resourcefulness in an exquisitely cooperative enter-

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prise (Horney, 1946 in Paris, 1999b). The patients tasks are to express him/herself as completely as possible, to become aware of unconscious driving forces and their effects, and to change those patterns of behavior that disturb the patient and others (Paris, 1999b). The unconscious forces, in a Horneyan sense, have less to do with repressed drives from early childhood, and much more to do with conicts between neurotic trends pressing for dominance (Paris, 1994). Transference and countertransference likewise arise from and are expressions of character structure and, as such, can provide insight into the nature of the persons defenses and conicts (Horney, 1939). Symptoms are seen as arising from the character neurosis, which is the focus of attention and treatment (M.H. Eckardt, unpublished). Horney describes the therapists tasks as observation, understanding, interpretation, help with resistances, and something called general human help, a phrase that refers to an attitude of friendliness and serious interest that helps the patient to regard his/her own growth as important and to accept his/her less than perfect self (Paris, 1999b, p. 80). Horney includes interpretation as an analytic task, but she is referring more to the interpretation of the unconscious aspects of the neurotic character or patterns than to interpretation of transference or dreams, which are rarely mentioned (M.H. Eckardt, unpublished). In a paper entitled What Does the Analyst Do? (Horney, 1946 in Paris, 1999b), Horney comments on the analysts stance in a way that can only have been revolutionary at the time and provides a dramatic illustration of her ability to think outside the analytic box. She describes the special nature of the analysts attention: it must be wholehearted. ...It can be productive only if he enters into the task completely and without reservation... letting his own emotional reactions come into play. She goes on to argue that analysts should not try to suppress their emotions because they play an important role in the therapeutic process; indeed, analysts feelings are the most alive part of themselves (p. 98). This is quite a different picture from the so-called blank screen and sounds much more like contemporary relational analysts. There is, today, greater attention to affect, in both patient and analyst, than there was when Horney lived and wrote. Yet she includes affect explicitly in her description of the analysts role, discussing it as an aspect of optimal analytic behavior. Perhaps this reected an implicit recognition of the need for full or complete participation by both members of the dyad if therapeutic healing is to occur.

Horney dened understanding as a process of moving toward another persons position while still maintaining our own (Horney, 1956b). This suggests that the analyst, in the optimal situation, is able to feel into the other person with all of his/her own self (p. 199). She might be regarded as a conservative intersubjectivist in that she clearly acknowledges the presence, importance, and irreducibility of the two subjectivities in the room; yet, for her they remain separate. A more radical intersubjective view assumes a continuously coconstructed realityone in which, while the analysts subjectivity is subordinated to the needs of the patient, there is always some measure of contribution by both, instead of an immersion by only one party, the analyst, into the patients reality.

Case examples from a Horneyan Perspective Case #1: Ms. H When she came for treatment, Ms. H was a single, 26year-old woman of English and Scottish descent. She grew up in a middle-class suburb of San Diego and moved to Los Angeles in her early twenties to pursue a retail business opportunity. She was a middle child and only girl, with a brother 9 months older and a brother 1 year younger. Ms. H was a strikingly attractive young woman of above-average intelligence who nished 1 year of college before deciding it was not for her. She was successfully working in a retail business with plans to open a business of her own in the future. Ms. Hs reasons for seeking treatment were problems in a love relationship, lack of self-condence, difculty with confrontation, family issues, and intense negative feelings about her own body. I saw her for 3 years, initially twice a week and then three times per week. Ms. Hs mother, described as immature and mercurial in mood, was divorced when Ms. H was 5 years old. Her father sought the divorce; the mother was both devastated and enraged. She remarried 3 years later, but her bitter competitiveness with her ex-husband regarding the affections of the three children continued. Father had an active social life until he remarried 10 years later; during his single years, he was an inattentive and erratic parent. Stepfather, by contrast, was deeply but destructively involved with the children, on the one hand spending enjoyable time with them, and on the other, physically and verbally abusing the boys, and sexually abusing Ms. H from the time she was 8 until he and her mother divorced when Ms. H was 13. Mother remarried twice,

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and had at least two other engagements. She was preoccupied with her love relationships or depressed and isolated in her room, on one occasion overdosing on pills while the children were in the house. Between men, she could be a sporadically involved or demonstrative mother, but more frequently was angry, unhappy, or simply not present. When in their midteens, the children chose to live with their father and his new wife. Mother fought this in court and lost. Following the change of custody, mother refused all contact with the children for years. During childhood and early adolescence, Ms. H successfully repressed awareness of her stepfathers molestation of her; after moving to her fathers home, however, troubling dreams led to the therapy that resulted in a report to the authorities. The stepfather was red from his job, but the case was not prosecuted, as Ms. Hs mother stated she would be a hostile witness. The police told my patient it would be a matter of her word against his and was likely to be a very difcult experience. As an infant, Ms. H entered a problematic world. She had two siblings so close in age that her mother barely had time to recover from one pregnancy and childbirth before the next, and none of the children had a period of being alone with her. That marriage was unhappy, and it ended unhappily. It is likely that the needs of three very small children overwhelmed the recently divorced mother. The basic anxiety of Ms. Hs life was intense from the moment of birth, perhaps from conception. What gifts she had could not possibly blossom in an environment in which, in Horneys terms, her parents were too wrapped up in their own neuroses to love her or even to conceive of her as the person she was (Horney, 1950). In addition, her stepfather, experienced by her as the most attentive of her parents, invaded and abused her over a period of years. What was Ms. Hs solution to the powerful anxieties generated by the circumstances of her childhood? What became of her real self? It is unlikely that she had the requisite space and care to begin the development of her real self in early childhood. The lack of a dependable source of care and response compromised her development from the outset. She could not begin to construct any condence, in herself or in others, and the world must have seemed indifferent at best. It would soon become hostile and dangerous. Ms. H was encouraged early on to concentrate on her feminine and body attributes. Her appearance was the aspect of her that her mother, father, and stepfather paid most attention to, and was, in fact, what differentiated her from her brothers. She was constantly reinforced for her cuteness, prettiness and later

her lovely skin and body. Stepfather told her, even as he made use of her, Your mother is jealous of your body. This was both exhilarating and alarming, providing fertile ground for the development of her own body preoccupations. A strong component of Ms. Hs idealized self has to do with bodily perfection and the striving to obtain it through exercise and diet. Horney (1950) points out that the difference between healthy strivings and neurotic drives for glory is the difference between spontaneity and compulsion, between wanting to and having to. We can see in Ms. H the presence of all three of the Horneyan strategiesmoving toward, moving against, and moving away from people. Her predominating strategy is the self-effacing solution, or compliance and moving toward. Her longing for love and protection are expressed in her attempts to please the signicant others in both her early and current life. She has difculty with assertiveness and aggression; problems with confrontation had been one of her expressed presenting problems. Her relationships with men are characterized by the attention she and they pay to her idealized selfif she looks perfect enough, the man will/does love her, and she feels condent and worthwhile. If she does not look good enough, she feels guilty, inferior, or contemptible. It is worth noting that what she regards as her out-ofshape self would look to anyone else like a physical self to be admired. There are also elements of withdrawal and resignation, or moving away. Ms. H struggles with a tendency to self-isolate, spending many weekends alone in her apartment, avoiding social contact. The idea of not needing or depending on anyone is appealing to her, as her disappointments have been manifold. She similarly fears investing herself in new achievements; she behaves as if she can protect herself from pain only by avoiding longing for anyone or anything. This represents a further restriction of her real self in favor of a desired totally self-sufcient self. Traces of the expansive solution are less apparent, but may make more of an appearance as Ms. Hs angry feelings emerge more fully. The neglect and brutality of some of her childhood experiences are bound to have engendered considerable rage. Her femaleness is bound up with interpenetrating strategies as well, in that it was a source of inferiority (to her brothers) and vulnerability as well as a source of potential perfection and power. Ms. H provides a good illustration of Horneys view that the familial and cultural views of gender play crucial roles in determining the meaning of sex, ones sexual equipment, ones sexual role. Ms. H reported wanting a penis when she was little; in her

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family, being a boy looked safer and freer. It would have protected her from the way in which she was dened and exploited. At the same time, she feels that being female is her most important advantage. The Horneyan therapeutic goals with Ms. H would involve reducing the anxiety over safety and security so that she can relinquish her compulsive focus on bodily perfection as a substitute source of security. Because her self-effacing trends (longing for love via compliance) are in conict with her expansive trends (longing for mastery via grandiose triumphs), the expansive and aggressive aspects have been subordinated. The reduction of the need to quash all aggressive feelings should permit a less rigid reliance on self-effacement. The relaxation of the drive to actualize her idealized self through physical perfection could make room for her real self to emerge and unfold, in turn allowing for the development of goals and relationships that reect her inner longings and abilities rather than more rigidly adopted stereotypically feminine behaviors and modes. Her human relations might then evolve more exibly so that they can comfortably include aggressive as well as compliant aspects. In the relationship with me, there was an unavowed idealizing transference, tempered by fears of dependency and disappointment. In Horneyan terms, my impression was that Ms. H tried to be motionless in the transferencemoving neither toward nor away, and certainly not against me. It was as if she were holding herself as still as she could, watching me carefully without seeming to watchperhaps not even allowing herself to know she was watching. In early life, she had known no truly benign yet caring gures; it is unlikely that she could conceive of me other than as an idealized fantasy of the perfect mother. On occasions when I attempted to take this up, Ms. H could respond only minimally; she seemed to need me not to be too real a person. In a lecture on The Quality of the Analysts Attention (Horney, 1959), Horney gives us a piercingly sensitive admonitionone that has general application and that in the case of Ms. H has special relevance: We must be careful not to let the intensity of our attention convert a mutual analytic situation into one where the patient is in the brilliant spotlight on a clinical stage while we are in the darkened audience. With both of us sharing more subdued light in the same room, we can become more open and real to one another (p. 189). A more muted exchange, necessitated by Ms. Hs understandable wariness, may have led to the problems I shall describe. At the time I wrote (and presented) an earlier version of the paper, Ms. H was deeply engaged in the

treatment. Some months later, Ms. H changed jobs and reduced the frequency of her appointments to two sessions/week because of her new work schedule. After several months at this job, Ms. H decided to change careers, from retail sales to becoming a physical trainer, again an indication of the high valuation of the body and its appearance and properties. As the training required was costly, she moved in with a friends family in an informal au pair arrangement. The family lived much of the time in a community some distance away; Ms. H withdrew even further from therapy, coming in only once each week, and eventually discontinuing altogether. Ms. Hs departure from therapy was both more complicated, and from my point of view, more precipitous, than these facts suggest. During the course of the therapy, Ms. H had explored and experimented with her relationship with her mother. When she began therapy, there had been no contact for many years; about 1 year into the therapy she made telephone contact, and followed that with sporadic additional phone calls, many of which were disappointing to her because of her mothers substantial self-involvement. Her mother wanted very much to have a photograph of her, yet showed no real desire to actually meet or be with her. The pain of her mothers preoccupations during early life reverberated again. I too had a powerful reaction to her mothers renewed, but apparently limited interest in a real relationship with her, and probably unconsciously conveyed to her my own sense of disappointment and anger, putting more psychological burden on her. Horney believed that repressed hostility was the early affect which we most fear and most need to contact (Paris, 1994). Ms. Hs rage, which emerged powerfully in her dreams, had begun to surface more consciously during the last year of her treatment. Shortly before discontinuing therapy, Ms. H had what she described as a wonderful telephone conversation with her mother, in which they were able to talk openly about some of the events of Ms. Hs childhood and adolescence. She then told me, with considerable anger, that I had failed to push her strongly enough to reconcile with her mother. Indeed, I had not pushed in this direction. I had told myself that this was a path which must be traveled as it unfolded and that I could not/ should not inuence it. After the fact I could recognize that not doing something is also a way of inuencing events and behavior. It is likely that my unspoken disapproval of her mothers abandonment did play an unrecognized part in the intersubjective unfolding of events. While I may have internally, as Horney suggests, been letting my own emotional reactions come

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into play (Horney, 1946 in Paris, 1999b), I had not fully recognized what they were and how they might be entering into the encounter. As a result, Ms. H may have felt me to be inattentive to her true needs and feelings, much as her mother had been. She may have ed from me much as she ed her mother at age 16. In Horneyan terms, the compliant solution had weakened its neurotic grip enough to make way for her repressed aggression, which now rose to the fore. In a more grandiose state perhaps, she no longer needed me and could be in control of our situation. Unfortunately, the work was interrupted before the events and responses could be analyzed and understood, and a true exibility of responses achieved. Case #2: Mr. Y Mr. Y, a 40-year-old accountant, came in for couples therapy with Ms. X, his live-in girlfriend of 5 years who had been in treatment with another therapist for many years. His girlfriends real wish was that Mr. Y have individual therapy, but while he was (barely) willing to have couples therapy, he had no desire at all to come on his own. I saw the couple weekly for several months. When their relationship had begun, both had needed considerable distance. Ms. X had progressed in her own therapy and development to the point where she longed for greater communication and closeness, but Mr. Y was as closed off as he had always been and their lives were more parallel than emotionally interwoven. In the joint sessions, Ms. X spoke at length about her feelings, but Mr. Y was almost completely unable to do so. She could not tolerate the snail-like pace of the conjoint therapy and wished Mr. Y to continue on his own. Despite deep ambivalence, Mr. Y correctly sensed that his relationship with her depended on his doing this, and so he began individual therapy. After the rst few months of individual sessions, during which Mr. Y related to me in a most guarded fashion, he began to open up, remembering and speaking about intensely painful and isolating experiences of his childhood for the very rst time in his life. Mr. Y was the youngest, by several years, of four children from a depressed industrial town in the Pacic Northwest. Both parents were alcoholics, and an older sister who also became alcoholic committed suicide when Mr. Y was a young adult. The family was poor, requiring welfare at times, and marginal at best. Family life was chaotic and emotionally barren. Mr. Ys parents fought frequently and violently, and divorced when Mr. Y was in junior high school. After the divorce, contact with father was sporadic and, when it did occur, had a dead quality. Mr. Ys mother remarried,

but her alcoholism and resulting arguments continued in the new marriage. The stepfather was somewhat more available to Mr. Y than his own father had been. Due to the unpredictable and highly charged atmosphere at home, Mr. Ys siblings were out as often as possible, and all three left home by late adolescence. Mr. Y recalls a childhood lived largely by himself, either at home alone while parents were out drinking or lying still in his room, hoping they would not ght. He spent his adolescence experimenting with drugs, up to and including IV drugs. His one great strength was his intelligence, and he resolved to leave home and attend collegethe only member of his family to do so. Mr. Y provides a poignant example of the strategy of withdrawal from the battleeld of human emotions and relations. Though he maintained formal social and work relations, he never spoke of his feelings to other people. He wanted neither to be touched nor to touch others, and cultivated as much detachment as he could. His relationship with Ms. X had been possible for him only because she too had been incapable of intimacy when he met her. The couple shared a house and social engagements, but nothing elsenot money, not meals, not communication, very little sex. Mr. Ys idealized self was one that needed no one and never felt anything. He tried not to be aware of his own conicts, and concerned himself as entirely as possible with material things. He focused on cars, sports, recreational activities, did a fair amount of drinking, and had the most minimal contact with family members. A conicting trend for Mr. Y, however, is moving against peoplehe would be deeply troubled at moments when he felt the surfacing of the rage and hostility within. This occurred in trafc, sometimes at work, occasionally in relationship to Ms. X. Indeed, Mr. Ys deep anger, and his fear of exploding unpredictably and uncontrollably as people in his family so often did, contend powerfully with his longing to feel nothing. The squelching of the more expansive angry trends resulted, in the treatment, in the tight, at quality of relating that so frustrated his girlfriend. It was only marginally less frustrating in the consulting room. His early transference to me was indicative of both avoidant and combative trends. Sometimes he appeared to feel utterly neutral, while I struggled to locate some affect in the room. At these times I felt it was all I could do to maintain some feeling of connectedness to Mr. Y. At other times, it seemed as if he experienced me as an enemy at the gate, threatening to attack him. In both modes, the atmosphere was deadening, reecting his need to render the environment less

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dangerous to him. For me, the struggle was between fully experiencing the deadness (surrendering to or weathering it) and provoking some contact just to feel more alive in the room. After some months, he began to arrive in a more open state, having thought about something he actually wanted to talk about. His basic anxiety had diminished to the point where I could be experienced as a benign presence who would maintain an even and predictable attentiveness to his process. In his relationship with Ms. X, who of course has an agenda and needs of her own, his comfort in sharing has come much more slowly. The couple shares more time and more varied mutual experiences than when they rst came to see me, and Mr. Y has developed greater range of feeling and expression. He now welcomes his awareness of his inner state, where before he tried to be as far removed from it as possible.

unending human potential for growth is supported by recent and current brain and infant research. Perhaps the most impressive aspect of Karen Horneys work is that it was conceived and propounded by a woman in a time and place that were professionally and culturally steeped in a male-dominated paradigm. To think these thoughts and then to proclaim them publicly were extraordinary acts of imagination and courage.

References
Danielian, J. (1988). Karen Horney and Heinz Kohut: Theory and the repeat of history. American Journal of Psychoanalysis, 48, 1. Eckardt, M. H. (1984). Karen Horney: Her life and contribution. American Journal of Psychoanalysis, 44, 3. Feiring, C. (1983). Behavioral styles in infancy and adulthood: The work of Karen Horney and attachment theorists collaterally considered. American Journal of Psychoanalysis, 44, 2. Horney, K. (1926). The ight from womanhood. In K. Horney (Ed.), Feminine psychology. New York, NY: W. W. Norton & Co., 1967. Horney, K. (1933). The problem of feminine masochism. In K. Horney (Ed.), Feminine psychology. New York, NY: W. W. Norton & Co., 1967. Horney, K. (1939). New ways in psychoanalysis. New York, NY: W. W. Norton & Co. Horney, K. (1945). Our inner conicts. New York, NY: W. W. Norton & Co. Horney, K. (1950). Neurosis and human growth: The struggle toward self-realization. New York, NY: W. W. Norton & Co. Horney, K. (1956a). Aims of analytic therapy, lecture I. In B. Paris (Ed.), Karen Horney: The therapeutic process: Essays and lectures. Yale University Press: New Haven, 1999. Horney, K. (1956b). Understanding the patient, lecture 5. In B. Paris (Ed.), Karen Horney: The therapeutic process: Essays and lectures. Yale University Press: New Haven, 1999. Horney, K. (1959). The quality of the analysts attention, lecture 3. In B. Paris (Ed.), Karen Horney: The therapeutic process: Essays and lectures. Yale University Press: New Haven, 1999. Kelman, H. (1967). Karen Horney on feminine psychology. In K. Horney (Ed.), Feminine psychology. New York, NY: W. W. Norton & Co. Main, M., & Solomon, J. (1985). Discovery of an insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton, & M. Y. Yogman (Eds.), Affective development in infancy (pp. 95125). New Jersey: Abbey. Natterson, J. (1966). Karen Horney: The cultural emphasis. In F. Alexander et al. (Eds.), Psychoanalytic pioneers (pp. 450 456). New York: Basic Books. Paris, B. (1994). Karen Horney: A psychoanalysts search for selfunderstanding. New Haven: Yale University Press. Paris, B. (1999a). Karen Horneys vision of the self. In A. Horner (Ed.), Visions of the self. American Journal of Psychoanalysis, 59, 2, 1999. Paris, B. (1999b). Karen Horney: The therapeutic process: Essays and lectures. New Have: Yale University Press.

Conclusion There are many alternative ways to describe both Ms. H and Mr. Y psychologically: one might speak of internalized bad objects and the compromises necessitated by the unavoidable splitting, managing, and/or projecting of these internalizations. One could discuss the anxious attachment resulting from Ms. Hs early motherinfant experiences or the avoidant attachment pattern of Mr. Y. One could discuss the selfobject functions desperately needed by Ms. H, and the idealizing transference, followed by the devaluing transference which accompanied her exit from treatment. Certainly, one could discuss Mr. Ys problems in affect regulation, and the sparsity of his internal life. What Karen Horney offers us is a glowingly human set of constructsconstructs that allow us to situate our patients in relation to their inner and outer worlds within a positive, growth-minded and open system. Her conception of the person affords the individual his or her unique, even if yet unrealized qualities, while recognizing the more common ways in which people arrange themselves to accommodate otherwise shattering experiences in early life. Born over 100 years ago, Karen Horney was in many ways a woman ahead of her time. Her ideas about human behavior and about psychotherapy have a remarkably contemporary feel. Her appreciation of the impact of environment and culture on development, long a staple of social work thinking, has acquired more and more currency in analytic circles. Her optimistic view of the plasticity of development and the

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