Psychiatric Annals

book reviews 

THE ANALYSIS OF THE SELF: A SYSTEMATIC APPROACH TO THE PSYCHOANALYTIC TREATMENT OF NARCISSISTIC PERSONALITY DISORDERS

Rebecca Z Solomon, MD

Abstract

Kohut. Heinz THE ANALYSIS OF THE SELF: A SYSTEMATIC APPROACH TO THE PSYCHOANALYTIC TREATMENT OF NARCISSISTIC PERSONALITY DISORDERS. New York: International Universities Press, Ine 1971 368 pp.. $12.50

In his approach to the treatment of narcissistic personality disorders, Dr. Kohut focuses on the analysis of the self, because he believes that the central psychopathology in these disturbances is a defective self image. The defect is due to the incomplete differentiation of self and object which results in the persistence of archaic self-objects. Because his libido is deployed to maintain his fragile self, the narcissistic personality, unlike the neurotic, is unable to invest objects with libido. While the neuroticfears the loss of love of the object, the narcissistic personality fears the loss of the object.

The narcissistic personality results from experiences with parents who treat their children as extensions of themselves and are unable to allow them to develop independently. They do not respond appropriately to the phase specific needs of the child for encouragement and approval. The child of such parents grows into an adult who does not view himself or his parents realistically as he has not had the opportunity to either modify his granthose notions of himself or deal with over-idealization of parents.

In the course of work with these patients a transference develops which differs from the transference which occurs in the treatment of neurotics. In the latter, conflicts about instinctual striving toward objects from the past are revived and transferred to the therapist. In the treatment of the narcissistic personality, either the therapist is idealized and strength sought from him, or the patient uses him as a mirror for the purpose of self-definition. The idealization of the therapist is a reflection of the persistence of the image of the omnipotent and perfect parent on whom the patient depends for supplies and guidance. His expectations from the therapist are exaggerated. Separations from the therapist cause severe anxiety because of the primitive nature of the patient's tie to him. The mirror transference is evidence of the patient's need for approval from an object whom he perceives as part of himself.

The therapeutic approach to the patient's unrealistic expectations and demands is neither to gratify the demands nor to dismiss the expectations. The transference is allowed to develop so that the patient may become aware of the primitive nature of the images with which he struggles. When the therapist believes the patient is sufficiently cognizant of the primitive nature of his problem, he indicates to the patient that the transference - as well as the resistances which have occurred - are defenses against anxiety because of anticipated severe rebuff and rejection. The anxiety is not related to fear of castration but is generated by pre-oedipal memories of serious losses and disappointments. These patients fear abandonment. Some have actually lost parents, but in all, emotional abandonment is the major issue. Memories are permeated with feelings of helplessness and profound shame in themselves and their parents. Gradually, the therapist introduces reality considerations which the patients can integrate to transmute their exaggerated and unattainable goals and ideals, which are the basis for their feelings of shame and helplessness, into realistic expectations. Thus, archaic narcissistic strivings which are doomed to failure are modified into mature narcissistic aims which can be gratified.

Dr. Kohut's theoretical approach to the problem of narcissism is unique. Unlike many analysts who view narcissism and object love as being reciprocally related, Dr. Kohut postulates that object love and mature narcissism, which both have their origin in autoerotism, develops along parallel lines. His argument is based largelv on energie considerations…

Kohut. Heinz THE ANALYSIS OF THE SELF: A SYSTEMATIC APPROACH TO THE PSYCHOANALYTIC TREATMENT OF NARCISSISTIC PERSONALITY DISORDERS. New York: International Universities Press, Ine 1971 368 pp.. $12.50

In his approach to the treatment of narcissistic personality disorders, Dr. Kohut focuses on the analysis of the self, because he believes that the central psychopathology in these disturbances is a defective self image. The defect is due to the incomplete differentiation of self and object which results in the persistence of archaic self-objects. Because his libido is deployed to maintain his fragile self, the narcissistic personality, unlike the neurotic, is unable to invest objects with libido. While the neuroticfears the loss of love of the object, the narcissistic personality fears the loss of the object.

The narcissistic personality results from experiences with parents who treat their children as extensions of themselves and are unable to allow them to develop independently. They do not respond appropriately to the phase specific needs of the child for encouragement and approval. The child of such parents grows into an adult who does not view himself or his parents realistically as he has not had the opportunity to either modify his granthose notions of himself or deal with over-idealization of parents.

In the course of work with these patients a transference develops which differs from the transference which occurs in the treatment of neurotics. In the latter, conflicts about instinctual striving toward objects from the past are revived and transferred to the therapist. In the treatment of the narcissistic personality, either the therapist is idealized and strength sought from him, or the patient uses him as a mirror for the purpose of self-definition. The idealization of the therapist is a reflection of the persistence of the image of the omnipotent and perfect parent on whom the patient depends for supplies and guidance. His expectations from the therapist are exaggerated. Separations from the therapist cause severe anxiety because of the primitive nature of the patient's tie to him. The mirror transference is evidence of the patient's need for approval from an object whom he perceives as part of himself.

The therapeutic approach to the patient's unrealistic expectations and demands is neither to gratify the demands nor to dismiss the expectations. The transference is allowed to develop so that the patient may become aware of the primitive nature of the images with which he struggles. When the therapist believes the patient is sufficiently cognizant of the primitive nature of his problem, he indicates to the patient that the transference - as well as the resistances which have occurred - are defenses against anxiety because of anticipated severe rebuff and rejection. The anxiety is not related to fear of castration but is generated by pre-oedipal memories of serious losses and disappointments. These patients fear abandonment. Some have actually lost parents, but in all, emotional abandonment is the major issue. Memories are permeated with feelings of helplessness and profound shame in themselves and their parents. Gradually, the therapist introduces reality considerations which the patients can integrate to transmute their exaggerated and unattainable goals and ideals, which are the basis for their feelings of shame and helplessness, into realistic expectations. Thus, archaic narcissistic strivings which are doomed to failure are modified into mature narcissistic aims which can be gratified.

Dr. Kohut's theoretical approach to the problem of narcissism is unique. Unlike many analysts who view narcissism and object love as being reciprocally related, Dr. Kohut postulates that object love and mature narcissism, which both have their origin in autoerotism, develops along parallel lines. His argument is based largelv on energie considerations as he repeatedly refers to the investments with and transformations of object and narcissistic libido. The self is conceptualized by Dr. Kohut as a content of the mind, not a structure like the id, ego and superego, but as he discusses the self, its importance to the psyche seems at least co-equal to that usuallv attributed to psychic structures. Dr. Kohut's formulations stimulate many questions. In addition to issues involved in his concept of self a major issue is the extent to which energie concepts are useful in understanding psychological phenomena.

To adequately deal with the complex theoretical matters which Dr. Kohut's book calls to our attention would take far more space than that allotted to this review. Although one may differ with the theories he proposes, the book is valuable because of the insights it offers both into the narcissistic personality and into narcissistic phenomena which are encountered in varying degrees in all persons. Not only does Dr. Kohut delineate the manifestations of pathological narcissism but he also describes the constructive aspects of mature narcissism which are expressed in the attributes of empathy, creativity, humor and wisdom.

10.3928/0048-5713-19730801-06

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