Judging: Evaluating thoughts, desires, and fantasies as acceptable or harmful can induce guiltĢ. The superego is seen by some psychoanalysts (e.g., Milrod 1972) as a complex inner structure having three functions (Table 8-1): 1) ajudgingġ. This concept is clinically useful in understanding patients who experience an uncontrollable inner sense of condemnation, those who experience no guilt and whose self-punishment is only inferred, and those whose guilty feelings emerge in the course of psychotherapeutic exploration. To best understand the depressive patient's guilt, it is important to review the theoretical concept of a harsh, or overly severe, superego (Arlow 1996). AA in "Case Example 2"), the therapist must be tactful in bringing evidence of unconscious guilt to patients' attention. As described below in this chapter (see the case of Ms. Some of these patients feel justified in their anger at their parents or others.
Other patients seem to be unaware of guilty feelings, yet the therapist may infer them from these patients' self-punishing behaviors or self-criticisms. V in Chapter 7 ("Addressing Angry Reactions to Narcissistic Injury"), who worried that she was harsh when expressing vindictive feelings toward her father.
G in Chapters 4 ("Getting Started With Psychodynamic Treatment of Depression") and 6 ("Addressing Narcissistic Vulnerability"), who felt devastatingly guilty about aggressive thoughts concerning her mother and boyfriend, and of Ms. Some patients reveal deep-seated feelings that they are bad or unworthy and are prone to attacking themselves-through self-criticisms or punishments-when they sense that they are behaving in an aggressive, competitive, or overly sexual manner. Along with narcissistic vulnerability and related affects of shame, helplessness, or reactive anger, conscious or unconscious guilt often cripples depressed patients.
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