Learning Disability in Adulthood. Daniel Gensler

(1993).
Contemporary Psychoanalysis, 29:673-692

Learning Disability in AdulthoodPsychoanalytic
Considerations1
Daniel Gensler, Ph.D.
LEARNING DISABILITIES ARE GENERALLY considered issues for
children as they go through school. Yet their effect continues into adulthood in
a person's cognitive style, use of defenses, interpersonal relations, character,
self-image, and career development. With a few exceptions (Bellak, 1979) ;
(Gardner, 1980), the study of the impact of learning disabilities on
personality has been extended beyond childhood and adolescence only in the
last ten years. Recent analyses of learning problems among young adults in
college (Cohen, 1983), patients with personality disorders (Dorr, 1990), and
adult dyslexics (Migden, 1990) all confirm the lasting effects on personality
of learning disability into adulthood. This article examines these effects on
adult character, defensive style, and relationship patterns.
The term "learning disability" may be a misnomer for adults who are no
longer formally learning in school settings. What are called learning
disabilities in childhood often become for adults difficulties in exercising
higher cognitive capacitiesin intentional problem-solving, in language, or
in the purposeful use of symbolic or material tools. These difficulties arise
from inefficiencies in the auditory or visual taking in of information (despite
intact auditory and visual acuity); in reflecting upon, conceiving of,
remembering, and organizing this information cognitively;

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Contemporary Psychoanalysis, Vol. 29, No. 4 (1993)
1 I appreciate the encouragement and support given me in this project by the
late John Schimel, M.D. I am also grateful to Don-David Lusterman, Ph.D.,
for his helpful comments regarding an earlier draft of this paper. Earlier
versions of this paper were delivered at the William Alanson White
Institute, the Postgraduate Center for Mental Health, and the Department of
Child and Adolescent Psychiatry at Roosevelt Hospital-St. Luke's Medical
Center, New York City.
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and/or in verbal or motor response to a particular situation regarding the use
of such information.
The category of learning problems is a broad one. Sanders (1979) divides
the field into three areas: social determinants (family, culture, school);
biological determinants (mental retardation, learning disabilities,
maturational delays); and psychological determinants. This paper addresses
the mutual influences of psychological and biological determinants of learning
problems. I will not make reference to mental retardation, and I will not
address learning disorders of simply psychogenic origin. Rothstein et al.
(1988) note that
it is entirely possible for a child with a learning disorder of
psychogenic etiology to be unimpaired neuropsychologically.
However, the converse cannot be as readily concluded.
Neuropsychologically impaired children frequently develop
psychodynamic elaboration of their difficulties, particularly when
they remain undiagnosed for lengthy periods of time (p. 269).
We will also see that people with learning disorders "of psychogenic
origin" can become impaired neuropsychologically when the learning
disorder leads to a lasting distortion of cognitive development.
Constitutional Influences on Personality
The body motivates action in many ways. Breathing, sex, hunger,
elimination, and the use of the muscles create imperatives which develop
their own meaning. The body influences the mind and development through the
effective or ineffective functioning of the cognitive and sensory apparatus;
through the maturation of various ego functions; through individual differences
in temperament; through individual styles of attachment, initiative, and social
responsiveness visible from infancy on; and through genetic influences on
personality. All these, along with chronic disease, extremes of physique, and
disability (innate or acquired) create the limits and possibilities of
experience.
For example, Neubauer and Neubauer (1990) used studies of identical
twins to document the powerful influence of genetics on personality
development. Genetically identical twins raised separately, and in very
different environments, share more than eye color and propensity to genetic
disease. They show unmistakably
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similar rates of maturation, levels of perceptual sensitivity, degrees of
curiosity and social engagement, orientation to people versus objects, and
degree of overall ego strength and adaptability. They are much more likely to
develop similar problems such as shyness, compulsiveness, phobias, sleep
disorders, language disorders, schizophrenia, depression, and addictive
disorders. All of these traits and outcomes become visible, are lived out, and
are understood by each twin in the context of different environments and
primary relationships. But, the authors write,
We can ask whether problems in development are caused by these
relationships, as is often supposed, or whether they are merely
expressed in them and by them (pp. 8990).
In this paper I focus on the influence on adult relations and development of
learning disability seen as a constitutional fact of the organism.
The Influence of Annemarie Weil
Using the findings of child psychoanalysis and developmental psychology,
ego psychologists examined autonomous functions of the egostimulus
barrier, attention, perception, motion, memory, language, integration, reality-
testing, defense, and adaptation. These ego functions came to be seen as
maturational factors, constitutionally based in the growth of the human
organism and also developing in interaction with the important others in a
child's life. Delays, weaknesses, or even variations in the rate of development
of these ego functions were found to have profound consequences for
personality functioning.
With the theoretical vantage point of Hartmann and Mahler, Weil (1978)
examined the psychological effect on development of delays and variable
rates of maturation of perception, motility, and language. She gave particular
attention to the developmental consequences of low or high stimulus
thresholds on perceptual sensitivity. She also emphasized the development
and importance of integration and the capacity for inner organization, which
she saw as an autonomous ego function. Weil found that if maturational
variations from the norm occur before the emergence of speech, they affect
primarily the later potential for levels of anxiety and aggression, in interaction
with poorly-attuned or well-attuned parents. If variations or delays in rate of
maturation occur
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after the emergence of speech, resulting problems most often contribute to
concurrent neurotic developments.
Weil's comments on the influence of language delays are relevant for this
presentation. She described the importance of language for causal thinking,
categorical thinking, abstraction, awareness, and introspection. She noted
Katan's (1961) analysis of the importance of language for the control of drives
and the modulation of affects. Language allows trial action and cognitive
anticipation, leading to greater capacity for delay and for reality testing. The
parents' involvement is crucial in stimulating this development; but so is the
innate and unfolding capacity of human intelligence to organize sounds into
phonemes and to integrate repeated experiences into morphemes. She writes,
maturational rates, maturational achievements, or styles of
performance, reflect maternal investment within the blueprint of
constitutionally given limits (p. 473).
Delays or inefficiencies in language development in toddlerhood lead to a
prolonging of preverbal mother-child interactions, and so can interfere with
the process of separation-individuation. Later in childhood, delays in the
development of language can interfere with the development of secondary-
process thinking, even in the presence of good-enough, well-attuned parents.
For example, if it is difficult to distinguish the relevant from the irrelevant
because of a weakness in the capacity to organize ideas, one can get flooded
with multiple impressions. There are then excessive digressions and it is
harder to pursue a main line of thought. This kind of thought disorder in
childhood arises from a language disorder related to the capacity to structure
and organize verbal input and output.
Once a child gets to school, Weil notes, it is common for disorders of
language to lead to disorders of reading, reading comprehension, and writing.
These disorders interact with the parents', teachers' and the child's own
anxieties and pressures, causing humiliation and disturbances of self-esteem.
Diminished motivation, avoidance, and procrastination often follow,
combining with preexisting or emerging neurotic problems. As such children
grow up, they may withdraw from tasks of school or work, with feelings of
inferiority and envy. Apathy, negativism, helpless rage, and angry acting-out
of frustration, are all common. One relational outcome
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can be the tendency to sadomasochistic relations which allow the living out of
the familiar themes of helplessness, control, humiliation, and provocative
withdrawal. Weil found that without attention to this whole process,
psychoanalysis or psychotherapy often fails to improve the symptoms.
Visible, Invisible and Overlooked Constitutional Factors
Some constitutional factors are easily visible to others, and some are less
visible. Most clearly in blindness and deafness, there are known and visible
defects in sensory equipment. In hypersensitive children and adults, there are
deficiencies in the stimulus barrier, and one can see a startle or avoidant
reaction to intense stimuli. In autism there is a failure in the ability to become
emotionally involved and in the capacity for communication. These failures
are today seen as constitutionally based and lead to obvious pathology.
However, the bodily origins of factors which can profoundly influence a
person's functioning are often less than obvious to others and even to oneself.
Some examples are basic underlying mood as a temperamental given,
adaptability to change, very mild cerebral palsy, undiagnosed Tourette's
syndrome, memory weakness, or longstanding expressive language disorder.
If significant others remain ignorant of such conditions, they may be likely to
attribute the person's oddness or weakness in functioning to psychodynamic
factors such as hostility, motivated inattention, or neurotic conflict.
When as clinicians we are the significant others, we take histories. Usually
histories uncover these less obvious conditions. Yet because of ignorance or
discomfort, able-bodied people often discount or overemphasize the
disabilities of others. This social psychological fact can extend to able-
bodied clinicians. Poznanski (1979) describes therapists'
countertransferential reactions to disabled patients. She writes that the
therapist
is likely to be threatened by his own feelings of helplessness in the
situation. As a result, the interview with the patient can be distorted
in several ways. One way this can happen is for the therapist, who
is not in touch with his own feelings, to gloss over the degree and
extent of the handicapping situation (the therapist does not clearly
ascertain what the handicapped person is and is not able to do). In
order to be effective, it is absolutely necessary for the therapist to
recognize the environment
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and constraints that act upon the patient. Nonetheless, the
handicapped patient often enters into a conspiracy of silence with
the therapist by not volunteering practical information about the
extent of the disability. Sometimes the patient does not provide
clear and correct answers even when directly asked about his
limitations. Rather than avoiding discussion of the patient's
disabilities, the therapist and patient may unconsciously focus on
narrow, concrete, and somewhat isolated areas of the patient's
ability to function while avoiding the central issues of total
adaptation. This, too, serves a defensive function for both the
patient and the therapist and helps avoid the anxiety associated with
the handicap (p. 642).
When even the patient is ignorant of an underlying conditionwhich is
frequently the case when a learning disability has gone undiagnosed into a
person's adulthoodthen a major blind spot can persist in understanding that
patient.
The Work of Richard Gardner
Gardner (1980) finds that minimal brain dysfunction (an earlier term for
learning disability) in childhood can have neurological and emotional
consequences in adulthood. Coordination deficits may lead to trouble working
adequately with one's hands. Reading and especially map reading may
continue to be hard into adulthood. Impairments in conceptualization or
abstract thinking may make it difficult to appreciate subtle nuances of many
situations. Gardner cites Piaget and Inhelder (1948), who found that normal
children can determine how a scene looks from someone else's point of view
by the age of nine or ten. Gardner speculates that developmental defects in
this perceptual ability may lead to trouble into adulthood in appreciating
another person's point of view, thoughts or feelings. In therapy, Gardner
warns us not to assume that any of these reactions are psychogenic until we
are sure that there is no organic defect.
He also delineates the emotional reactions of adults to a history of having a
learning disability. People fear involvement, even marriage, lest their defects
be revealed. There can be self-loathing, anticipation of rejection, fear of
trying new things. A history of learning disability can contribute to immaturity
when, after a childhood with overprotective parents, an adult comes to expect
others to satisfy needs on demand.
Gardner draws some implications for psychoanalytic work with learning-
disabled adult patients. Patients with auditory processing
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problems might do better face-to-face than on the couch, in order to be able to
use the visual aspects of face-to-face communication to compensate for the
auditory processing problem. Patients with longstanding difficulties in
sequencing and organization may have difficulty with the lack of structure in
the experience of free association. Gardner believes that it can be useful to
demonstrate to the patient through teaching or persuasion how ego defects are
interfering with functioning.
In his article, Gardner does not go on to examine how these kinds of
interventions can also represent a countertransferential enactment or a role
induction. Nor does he mention the necessity of dealing with the inevitable
character defenses which are called forth when the patient is faced with the
fact of ego defects. Yet these dimensions are crucial in analytic work with
learning-disabled adults. For example, in helping a patient to read a train
schedule, or in pointing out the effects of a patient's dependent reaction to a
learning disability, a therapist may well be repeating a parental role with the
patient as child. This leads patient and therapist to re-enact all the feelings
and consequent character defenses of being in that position. Such participation
and re-enactment can be invaluable in giving the therapist an accurate view of
the patient's inner world, and in allowing the therapist a way to interpret that
inner world to the patient in an emotionally vivid manner. Therefore it is vital
to be aware of countertransferential feelings and to work with the patient's
character defenses as the learning disability is being clarified.
Here is some clinical material from psychotherapy and psychological
evaluations to illustrate some of these points.
Mr. A
Over the course of years of work I realized that this patient had substantial
learning problems when he was a child. He had not thought of his history in
this way. He was in the lower track of classes when he went through school
and he had felt poorly about himself as a student. His presenting problems had
to do with depression, his relationship with his girlfriend, and disturbing
dreams. Then we started to learn of his trouble in verbal expression. He
stuttered. His grammar and word usage were poor. As he put it, he "butchered
words." He had trouble finding the right word. Talking on the phone was
particularly hard for him. With
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no visual cues regarding the other's response, his anxiety over making verbal
sense worsened. Indeed he would not make phone calls, and panicked when
he had to. His mother made his calls for him. In so doing she encouraged him
to continue to depend on her, rather than to seek some way for him to handle
calls himself. Her relation with the patient's father was not a good one. My
patient believed that she fostered his and his siblings' dependence because
she was afraid of her children growing up and leaving her.
When I met Mr. A, his verbal expressive problems were visible in an
occasional stammer; in long pauses between phrases; and in vague and
confusing references to "it" and "that" without pointing back more clearly to
what he was referring to in the last few minutes of his comments. There was
an effort to package fine verbal deliveries. He told me that during his pauses,
he would edit what he was about to say so as not to sound stupid.
As a child Mr. A also read poorly. He changed words as he read; he
panicked when he saw italics and he skipped those words; he reversed words
as he read. In writing he was a poor speller; he could not get his grammar
correct; and he had trouble organizing his ideas. As a consequence he
procrastinated in his writing assignments and engaged in much anxious
correcting and redoing. Because of these weaknesses, he thought of himself as
stupid.
Financially Mr. A depended on low-paying temporary or part-time jobs,
and also on his girlfriend's income. These jobs were not in the field of his
career aspiration. Despite his difficulty in verbal expression, Mr. A aspired
to a career which involved a great deal of public speaking. When he spoke his
ideas were considered creative, original, and interesting. However, there
were problems with his expression, his organization, and his conclusions. He
spent days and months reworking drafts of his speeches in the effort to
improve his work.
In the meantime Mr. A procrastinated making phone calls related to hunting
for a higher-paying job. His procrastination provoked his girlfriend and kept
them fighting. Yet his reluctance to make phone calls was also a continuation
of his lifelong phone anxiety. Unlike his mother, his girlfriend would not help
him with his phone calls (for example, by rehearsing them beforehand with
him). Rather, she was impatient with him for putting off making the calls.
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Reworking drafts of oral presentations and speeches preoccupied Mr. A
and became an obsessional substitute for finding steady or higher-paying
employment. His dependence on his girlfriend for financial support led to
much conflict. She would demand that he seek more income. He would
become passive-aggressive, oppositional, or withdrawn and cold with her.
For her own reasons she was repelled but then attracted to him in this cycle,
and their relation was a stable alternation of storminess and calm.
There was a great deal of work on his hostility toward his father, a
narcissistic and self-preoccupied man with whom Mr. A had first learned to
be so passive-aggressive and oppositional. Mr. A also had a
developmentally-disabled younger brother. He shunned this brother, who
reminded him of his own learning problems and of his own financial
dependence. We also analyzed his relations with idealized older siblings or
mentors (of which I was one), and realized his self-abasement, idealization,
envy, and dissociated rage.
The anxiety over using the telephone became one nucleus for the accretion
of characterological, interpersonal, and vocational issues. We examined his
motives for using the phone phobia to withhold, vacillate, provoke, punish his
girlfriend and punish himself. But in addition to analyzing these interpersonal
motives, Mr. A needed empathy for the experience of living with the fear of
making phone calls. He needed this understanding even as we recognized his
ability to use the associated procrastination in hostile or manipulative ways.
We learned how his ambition to succeed in public speaking arose, after an
earlier career, in his ambivalent effort to break away from his dependence on
his mother. In his childhood Mr. A had felt little sense of his own
individuality or worth. Now an adult, he hoped to say something effective,
something which people felt was worth hearing, and to feel confirmed in that
way as an individual of worth. As long as his girlfriend would support him,
allowing him freedom from full-time employment, he was determined to
devote his time to developing his public speaking skills. To him, this was
worth the cost of all the conflict with her.
This position became more and more untenable for Mr. A as we clarified
the sadomasochism in his way of trying to repeat, in his relation with his
girlfriend, his childhood dependence on his mother. Once the nucleus of
feeling around the phone anxiety
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was addressed, we could make some progress recognizing the humiliation and
rage which he was trying to ignore in his relation with his girlfriend. He had
allowed his determination to overcome the verbal-expressive disability, and
the associated low feelings about himself, to develop into an attitude of
irresponsibility and entitlementmuch on the model of his hated father.
Realizing this identification horrified him, especially in the context of feeling
ashamed in the transference. He began to make work phone calls, despite the
anxiety. He began to speak with his girlfriend about their vicious pattern of
relating, during moments of calm. And he reached out to his disabled younger
brother, after years of avoiding him. Without the analysis of his phone anxiety,
I do not think that he would as readily have been able to start to break out of
the entrenched sadomasochistic cycle of meanness and avoidance. We could
not have analyzed the anxiety over the use of the telephone without following
the thread of the verbal-expressive disability and his reactions to it, back into
childhood.
Mr. B
I worked with a man in his mid-twenties who was enrolled in a grueling
program of graduate study. Mr. B doubted his ability to get through school,
and he was anxious over the pressure. His wife was in the same school as he,
training for the same career. But she handled the grueling schedule with less
strain. Although he felt he had no right to be angry, he resented her for not
slowing herself down in order to let him feel less overshadowed by her
success. In these feelings he was repeating an old pattern of relating with his
highly accomplished older sister, who had died in an accident when they
were teenagers.
Mr. B's father was a well-known professional in the very same field he
was studying. The father openly doubted his son's ability to make it in that
field. Both his parents used to call him stupid and inept, which enraged him,
but also kept his own self-doubt alive.
As the therapy moved along, Mr. B started to see me as impatient,
disdainful, self-centered, and demandingsimilar to his father. It became
apparent to us both how ready he was to misinterpret my behavior and intent.
That was an area of early agreement, and allowed the good will for a
therapeutic alliance which carried us (for a while) through much storminess.
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After inquiring closely into the nature of his difficulties in school, I raised
the possibility of a learning disability. Mr. B agreed to undergo a
psychological assessment to evaluate his difficulties in spelling and writing.
The assessment found a substantial handicap in the areas of fine-motor
coordination, visual organization in space, visual discrimination, and word
finding. An additional ophthalmological problem was discovered
(overconvergence). He got corrective lenses; he began weekly remediation
with a specialist; and he continued in therapy.
In part Mr. B was excited about the possibility of improving his
functioning through remediation. However, to accept the fact of his handicap
depressed him. It was a substantial blow to his self-regard. It was also a
blow to his ambition someday to match or even outdo his father's
accomplishments. He longed to deny the major impact which the learning
disability had had on his lifelong career as a student. He often preferred, with
his parents, to blame his own laziness, supposed stupidity, or "self-sabotage."
Yet he always had known of his difficulty in schoolwork. He knew that he
needed to start preparing for his final exams and papers weeks before his
classmates. Fearing failure, he would obsess about a project and
procrastinate until a deadline loomed. Then he would become determined to
"show them" (parents, school, wife) that he could do the workwhich
eventually would get done more or less adequately, although usually late.
A pattern appeared, first in the transference and countertransference and
then as a fundamental part of his character. Mr. B would procrastinate, appear
helpless, upset and needy, and set me up to tell him to be more disciplined.
He then resented me and rebelliously refused to work at his studiesas if his
freely-chosen commitment to school were an unwanted obligation foisted
upon him by me. We realized that this pattern was characteristic of his
relation with his father and his teachers. He set himself up as inept or
irresponsible, even when he was capable of acting more competently or
responsibly. This would provoke the other person into helping him in a
patronizing or infantilizing way, by telling him or showing him what he
already knew. Rage and self-hatred would follow. He would resent the
other's superiority as well as his own self-denigration. He would become
bitter, hostile, withdrawn, and depressed. As we examined these patterns, he
cycled between grudging insight and devaluation of the whole process
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of examining such patterns. Several times he considered leaving the therapy
with me, hoping that another therapy (behavior therapy or marital therapy)
could provide a speedier and less painful solution.
Mr. B was inclined to depend on his wife for help in his studies. He had
relied on his parents and sister when he was younger. He developed a similar
dependent relation with his female tutor. He would defer to her ideas and
discard his ownor he would not develop his own in the first place. He
considered his deference and dependence to be an unavoidable consequence
of his learning problem. I responded with empathy for the difficulty of
adjusting to a handicap, and for the bitterness he felt at his parents' apparent
malice. I recognized his need for help. But I also noted how accustomed he
was to emphasizing his inability. He would act counter-productively and then
feel entitled to his outrage at the other's response.
The therapy with Mr. B started to founder after a defensive splitting of his
feelings developed. The remedial tutor came to be seen as supportive and
giving and understanding; I was seen as cold and uncaring. When I would not
adjust my policy regarding fees for missed sessions and regarding honesty in
filling out insurance forms, he felt justified in his perceptions of me as
withholding and rigid. The hostility toward me allowed him to spare himself,
his parents, and his tutor. He felt too angry and vulnerable to maintain a self-
reflective attitude. Matters were made worse when his insurance company
took longer than usual to reimburse him for the cost of the therapy. Money was
short and he terminated treatment.
I have since learned that he continued the tutoring, successfully finished his
graduate studies, and began a career in his field. He considers the
identification, working through, and remediation of the learning disability to
be a turning point in his life.
The eventual polarization and termination of treatment which occurred
with Mr. B probably derived from several factors: no coordination between
the remedial tutor and myself; the strain of an intense negative transference;
and the hurt, rage, and realistic anxiety over receiving a diagnosis of a
substantial learning disability while still being an adult in school training for
a career.
I offer both of these cases to illustrate ways in which learning disability
can become enmeshed in adult relationship styleshere
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in passive-aggressive, irresponsible, pseudo-incompetent or hostile-
dependent ways. Certainly symptoms and character traits are multidetermined.
The influence of an early and lasting problem in learning is one determinant
among many. Yet to overlook the influence of a learning disability on
character deprives the therapy of one crucial component for empathy; for
understanding affect, identity, and self-regard; and for analyzing dependence
and rage, in or out of the transference.
Assessment is useful once a therapist suspects that a patient has been living
with a learning disability. I suggested psychological evaluation and possible
remedial work to both Mr. A and Mr. B. Mr. B agreed; Mr. A did not. I
believe that Mr. B was desperate enough to seek assessment and remediation
because the learning disability was interfering with his current daily work at
school. For Mr. A, public speaking was not his financial bread and butter. An
adult's decision to undergo a psychological evaluation for learning disability
is not an easy one. A patient may be more likely to accept the recommendation
to seek evaluation if the learning disability is seen as interfering with
activities that are vital to current income or education.
The recommendation for psychological testing certainly becomes grist for
the mill of therapy. But when it leads to an actual evaluation, the results offer
a more accurate guide to the patient in therapy, in remediation, and in career
planning. Therapist and patient have to combine the results of an evaluation
into everything else that is known about the patient. An evaluation of an adult
patient specifically for learning disability should not overemphasize the
influence of learning disability on personality development. It should aim at
integrating whatever is found regarding a learning disability into a more
general picture of functioning.
Here are two vignettes from psychological testing, demonstrating the
effects of weaknesses, respectively, in visual information processing and in
verbal memory.
Mr. C
A successful lawyer in his fifties was referred to me by his therapist, who
suspected a learning disability. The request was for an investigation into its
possible existence and effects. Mr. C gave a history which included difficulty
in college math and biology,
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poor handwriting, and a tendency to lose his way as he was going about town.
Mr. C doubted he had a learning disability. He attributed the history of
difficulty in math to lack of effort; he attributed the trouble with biology to the
influence of his mother's squeamishness; he saw his poor penmanship as
another manifestation of his sloppy life. He had entered therapy because of
problems relating to members of his family, and because of panic attacks.
Psychological evaluation found substantial weaknesses compared to the
norm in a variety of visual skillsin visual reasoning, visual spatial
relations, and visual memory. There was a heavy use of verbal self-cueing to
compensate for these visual weaknesses.
Mr. C had also developed an impressionistic style of visual perception.
On the Rorschach he explained his responses by referring largely to the sense
of movement or symmetry he saw on the card. He gave relatively little
attention to form. Form refers to the "goodness of fit" between his response
and the actual visual contours of the area of the inkblot to which he was
responding. For example, on Card VI he saw "a bearskin; maybe a totem
pole." Both are common responses and easy to see. In keeping with
Rorschach protocol I later asked him what made the card look like a bearskin
and a totem pole. Most people explain such responses to this card with
reference to the form or the shading of the blot as they explain (e.g., "the
shape of an animal flattened out" or "the shading makes it look furry"). But for
"bearskin" Mr. C answered, "the outline, bulk, how it's divided" and for totem
pole he could only explain "straight-upgives me a general feeling of that."
This impressionistic style probably arose out of his relative weakness in
dealing with visual material. With such a weakness, what is seen cannot be
formulated in precisely articulated visual detail. It would be an error to
attribute Mr. C's vaguely-explained perceptions to defensive avoidance, to
poor reality testing, or to the effects of repression. Security operations can
certainly latch onto constitutional inclinations and use those inclinations for
the purpose of defense. But long analysis of any possible defensive use of
vague explanations for what he sees would probably not have freed this man
to perceive the visual world with more precisely articulated detail.
Another effect of Mr. C's weakness in the processing of visual
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information was a performance anxiety when dealing with visual material. As
a consequence he developed certain work habits. He would rush, or become
cocky, alternating with periods of perseverance. He also felt inadequate and
occasionally out of control. There was a quick tendency to disdain and
sarcasm; he would maintain his self-esteem by denigrating others in
comparison to himself. During the evaluation this way of relating was more
visible when he was dealing with visual material; it was less visible when he
was dealing with verbal material.
I do not claim that these interpersonal, defensive, characterological, and
emotional findings all derive from the relative weaknesses in dealing with
visual information. For example, Mr. C grew up in a household full of hostile
ways of relating. But when a psychological evaluation turns up a central
finding, I would suggest that the central finding can be cited in partial
explanation of other observed aspects of the patient's performance.
Psychodynamics are interwoven with cognitive capacities. Even as a delay or
failure in cognitive development becomes visible, it becomes part of one's
identity, and part of one's interpersonal and defensive repertoire. It generates
feelings within oneself and reactions from others. But it is inaccurate to say
that such failures are motivated or functional. Their functional utility may
encourage the person not to challenge or struggle with them more. Yet the
hardwired aspect of these failures presents a non-psychodynamic organic
limit, an outer boundary for functioning, which psychodynamics can then pick
up on.
Mr. D
In the case of another patient referred for psychological evaluation, a
weakness in verbal memory had a major effect. Mr. D was an accomplished,
reflective, creative man of 35, with superior intelligence. Because of a
longstanding difficulty in fine-motor coordination, he changed careers to one
which required less manual work than his former job. Although successful in
his new job, he was concerned about a variety of problems: trouble absorbing
and retaining written material; trouble articulating ideas under pressure, with
a fear of ridicule for not being comprehensible; trouble resuming writing after
a short break; trouble taking in directions; and trouble evaluating how long a
task would take.
The evaluation revealed a substantial weakness in auditory attention
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and verbal memory. To compensate, Mr. D had developed a mental habit of
mulling things over in order to gain access, through a series of mental
associations, to a fact or learned piece of data which he could not summon
directly to mind. This habit of mulling over, itself, could distract him from
attending to the ongoing flow of conversation. However, he could focus
attention on the current task when urged to do so. His mulling-over habit was
adaptive to the defect in verbal memory, in that with its help, he often
succeeded in retrieving the missing information.
Nonetheless, there were several effects of the weakness in auditory
attention and verbal memory. First, he tended not to follow directions. He
would plunge into a task and orient himself to its requirements only after he
started itan exception to his usual reflective style. Second, at least partially
because of his trouble retrieving and using verbal information, he had trouble
marshalling his thoughts under the pressure of the moment. As a consequence
he would freeze up when asked for specifics. He adapted or compensated by
preferring to focus on the general, the abstract, or the symbolic, tending to
miss the trees for the forest. Often this had the positive effect of leading to
productive and creative thinking. However, it prevented him from returning to
the detailed data of a problem in order to take a fresh look.
If the weakness in verbal memory were unknown, it would be tempting to
attribute the findings to other sources altogether. Mr. D's tendency not to
follow directions could be attributed to issues regarding authority or social
participation. Indeed, he associated the experience of listening to directions
with memories of rebellion while sitting at the Passover Seder table
rebelling against the authority of the ritual, and against its expectations for
conduct. His tendency to mull things over could be seen as an obsessive
defense against anxiety or angerand indeed he did mull things over more
when he was angry. His tendency not to come forth with specifics could seem
stubborn, withholding, or retentive. Since the psychological evaluation
revealed a number of obsessional defenses, it would not be hard simply to
add these traits to that list. Without ruling out the possibility that these traits
also acted as obsessional devices, I want to note their likely origin in the
weakness in verbal memory, via the compensatory habit of mulling over.
Character traits can develop at least in part from efforts to cope with
organically-based problems in purposeful functioning.
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Causes and Effects
There are alternating, interwoven layers of psychogenic and neurological
influence, and the distinction between neuropsychological origins and
psychogenic origins is not so absolute. The concept of ego defect is relevant
here. Pine (1990) notes that "defect" connotes that something has not
developed well, and that this can occur for a number of reasons. There could
be a deficit in parenting, an inborn biological condition, early trauma, pain or
illness, or early conflict resolution. For example, he notes that reliable
parental care ordinarily produces the capacity for trust, the expectation of
satisfaction, and so the ability to delay. Therefore a deficit in such reliable
parental care might produce a defect in the capacity for delay, leading to
impulsivenessan apparent ego defect.
Pine (1985) also cites a case of early conflict resolution through infantile
thinking and infantile ego organization, leading to pseudoimbecility in a ten-
year-old boy. This boy presented himself as an inane, grinning fool, using his
dumbness to torture his parents and also to continue a gratifyingly dependent
relation with them. This adaptation to life distorted the whole of his
subsequent cognitive development so profoundly that even after therapy
ameliorated his self-limiting defensive organization, substantial defects
remained.
Pine (1990) notes that such defects are not independent of conflict. But he
emphasizes that
the very fact that defects are thus tied up with conflict may, I
believe, at times blind us to the defect aspectbecause one more,
and then again still one more, interpretation of a conflictual
derivative or source will forever be possible, and may result in a
failure to give recognition to the fact of a defect with whatever
implications for technique (if any) that fact may have (p. 202).
From a different perspective, Stern (1985) describes how constitutional
defects and capacities unfold in interaction with early experiences. He
examines the clinical ramifications of defects in the maturation of
constitutional capacities. In one baby, constitutional weakness in the capacity
to transfer information from one modality to anotheran ego defectmay
lead directly to learning disabilities, since learning so often requires
transposition of information back and forth between vision and hearing. In
another baby, low tolerance for stimulation or poor capacity to regulate
arousal
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can lead to withdrawal or disorganization, undermining the capacity calmly to
focus attention.
Stern emphasizes the importance of the attunement or the temperamental
style of the parent. This factor increases or decreases the chances that the
baby's constitutional vulnerability will lead to an actual disorder of function.
Under good circumstances, the first baby's parent might sense that the child
prefers one sensory mode rather than another, and would respond
accordingly. If the second baby were lucky, its parent's temperament would
be such that the parent would stimulate the baby no more than the baby could
handle, rather than overwhelm the baby's low stimulus threshold. Under these
circumstances there is less chance for the development of fixed patterns of
withdrawal, or disorganized attentional states, or uncompensated difficulties
in cross-modal perception. Just as the body's immune system normally
protects us from disease, there is an interpersonal immune system which, at its
best, can function to reduce innate propensities to precursors of ego disorders
(including learning disability).
In the psychotherapy of adults with learning disabilities, it is most
practical to treat the defects as givens and to address their elaboration in
character, defense, and relational style. Even when ego defects originally
arose (for example) from very early conflict resolutions leading to
pseudostupidity, or from very early, intolerable overstimulation leading to a
dampening of focused attention for new things, the only way to bring these
origins closer to the level of consciousness is through recovery of memories
via analysis of transference over long periods of time. In the meantime, it is
the analysis of the conflictual and interpersonal elaboration of the early
defectstheir psychogenic effects rather than their possible psychogenic
causeswhich will lead to the more practical, near-term benefits for the
patient.
Analytic attention to the influence of learning disability on character and
defense should occur in the context of everything that is known about the
patient. The therapist should not overemphasize learning disability compared
to other influences on the patient. If the influence was truly minor or
irrelevant, or if it is has always been a clear fact to which the patient has
adapted well, then the analysis of the learning disability can remain a minor
part of the work. If its influence is substantial but the patient is not ready to
address it, then tact and timing are as crucial here as
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anywhere else in the therapy. The patient's coping style must be respected:
some patients turn towards stresses and others turn away. Minor defects may
appear exaggerated if the patient or the family has fixed on them as
unacceptable; major defects may be minimized if the patient or the family
finds them congenial, or denies them.
The benefit to analysis is considerable once a learning disability is
identified, assessed and worked through. Issues of shame, self-esteem,
dependence, envy, and competition can become more clear. Sadomasochistic
and passive-aggressive relationships can be understood more fully. Academic
and vocational difficulties are more comprehensible, and so are family
reactions. Unusual motivation can be understood from a more informed
position. If the patient enters into remedial work, analyst-tutor contact can
benefit both the remedial work and the therapeutic work as long as issues of
consent and confidentiality are worked out and the meaning of the contact is
explored analytically. Character, defense, affect and relation take on a clarity
that would be impossible if the learning disability were not identified and
analyzed.
REFERENCES
Bellak, L., ed. 1979 Psychiatric Aspects of Minimal Brain Dysfunction in
Adults New York: Grune and Stratton.
Cohen, J. 1983 Learning disabilities and the college student: Identification
and diagnosis In: Adolescent Psychiatry 11 177-198 E. C. Feinstein (ed.).
Chicago: University of Chicago Press.
Dorr, D. 1990 Personality disorders linked to neuroperceptual learning
disorders Psychiatric Times (February), 50-52
Gardner, R. 1980 What every psychoanalyst should know about minimal brain
dysfunction Journal of the American Academy of Psychoanalysis 8 403-
426 []
Katan, A. 1961 Some thoughts on the role of verbalization in early childhood
Psychoanal. Study Child 16:184-188 []
Migden, S. 1990 Dyslexia and psychodynamics: A case study of a dyslexic
adult Annals of Dyslexia 40 107-116 []
Neubauer, P. and Neubauer, A. 1990 Nature's Thumbprint: The New
Genetics of Personality New York: Addison-Wesley.
Piaget, J. and Inhelder, B. 1948 The Child's Conception of Space New York:
W. W. Norton.
Pine, F. 1985 Developmental Theory and Clinical Process New Haven:
Yale University Press.
Pine, F. 1990 Drive, Ego, Object, Self: A Synthesis for Clinical Work New
York: Basic Books.
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Poznanski, E. 1979 Handicapped children In: Basic Handbook of Child
Psychiatry 3 641-650 S. Harrison and J. Noshpitz (eds.). New York:
Basic Books.
Rothstein, A., Benjamin, L., Crosby, M. and Eisenstadt, K. 1988 Learning
Disorders: An Integration of Neuropsychological and Psychoanalytic
Considerations Madison, Connecticut: International Universities Press.
Sanders, M. 1979 Clinical Assessment of Learning Problems: Model,
Process, and Remedial Planning Boston: Allyn and Bacon.
Stern, D. 1985 The Interpersonal World of the Infant: A View From
Psychoanalysis and Developmental Psychology New York: Basic Books.
[]
Weil, A. Maturational variations and genetic-dynamic issues J. Am.
Psychoanal. Assoc. 26:461-491 []
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Article Citation [Who Cited This?]
Gensler, D. (1993). Learning Disability in AdulthoodPsychoanalytic
Considerations1. Contemp. Psychoanal., 29:673-692

Learning Disability in Adulthood. Daniel Gensler

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Contemporary Psychoanalysis, 29:673-692

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