Self psychology and the psychotherapy of psychotic patients: A case study

Self psychology has previously been employed in describing the treatment of narcissistic personality disorders. This article discusses the clinical application of concepts of self psychology to the psychotherapy of a psychotic patient. Empathy and the concept of empathic failure were very helpful in conceptualizing the therapeutic process. The two selfobject transferences of mirroring and idealization were both present in this case, and the recognition and interpretation of these transferences were critical in understanding the therapeutic process. The patient's delusional experiences receded and began to be less disruptive as the selfobject transferences emerged and remained in place. The resurgence of delusional material was usually indicative of a failure of empathy and a disruption of the selfobject transference. This patient's ability to regulate his anxiety and calm himself was considerably enhanced during the course of treatment. Self psychology and the understanding it provides proved to be of great value in the treatment of this patient and has wide applicability to the psychotherapy of psychosis.     

Reviving the stalemated treatment through a self psychology re-analysis

Stalemated psychoanalytic treatment can be sustained for hears when patient and analyst work in an experience-distant analytic mode. When this occurs patients feel misunderstood, despairing and hopeless, yet, are unable to change their situation. The case of a patient who undertook a reanalysis with a self psychologist is presented to demonstrate how the empathic, experience-near treatment mode enabled the patient to overcome the stalemated problems of the first analysis. The experience of feeling understood was crucial for the deepening of the analytic work, for the furthering of the selfobject transference and for the working through of the fixations and arrests in development.Presented on November 2, 1990, at the Third National Clinical Conference of the Committee on Psychoanalysis of the National Federation of Societies for Clinical Social Work.     

The uninterpreted rage: Protecting the therapeutic alliance in the treatment of borderline patients

After reviewing differing approaches to the treatment of the borderline patient, this paper describes the treatment of a patient whose negative transferences are not interpreted by the therapist; rather, the focus is on maintaining the therapeutic alliance via the awareness of the kinship selfobject function of the therapist and merger with the idealized selfobject.There is no end unless the bottom of the trough has been reached, unless the thing feared has been experienced. (Winnicott in Casement, 1991, pp. 129–130). As a matter of fact in these cases it is of decisive importance for the psychotherapist to remain clearly differentiated from the core of psychopathology—if he cannot achieve this separation and becomes drawn into the patient's delusions, he loses his tie to the healthy remainder of the patient's psyche and thus his therapeutic leverage. The maintenance of a realistic, friendly relationship with the psychotherapist is thus of crucial importance in the treatment of the psychoses and borderline states ... (Kohut, 1971, p. 30).     

Toward a More Optimal Selfobject Milieu: Family Psychotherapy from the Perspective of Self Psychology

This paper applies the theory of self psychology to the understanding and treatment of families. The healthy family is viewed as a reliable source of selfobject experience for its members, while problems in or between family members are seen as due to a lack of adequate selfobject experience for one or more members. Causes of selfobject failures or misattunements in the family are examined, with an emphasis on the influence of previous relational experiences on current needs, capacities, and experiences of others. Curative factors in this form of family therapy are then outlined, and a treatment approach designed to help family members become better able to provide empathically attuned responses to each other is described, with a case example used to illustrate key points.     

The Desomatizing Selfobject Transference: Analysis of an Eating Disorder

This article documents the manner in which psychological treatment, with its attentiveness to the vicissitudes of the unfolding selfobject transference, gradually enabled a patient to contain and articulate painful affect states. The patient's passionate relationship with food, strikingly illustrated in the clinical material, including her dreams, endowed eating with the functions of an idealized selfobject. Over the course of treatment, she seemed to traverse a psychic bridge that took her from an isolated reliance on food through a more focal awareness of her body and her feelings, to an investment in, and capacity for, deepened relationships with other people.     

Using psychodynamic interventions to engage in trauma-informed practice

In recent years, trauma-informed practice has received increased attention in the social work literature. Although the adoption of trauma-informed practice is necessary for preparing social workers to practice effectively with clients, these frameworks do not necessarily provide social workers with the specific skills for doing so. Therefore, we argue that using interventions grounded in contemporary psychodynamic theory can help transform them into trauma-informed practitioners. Psychodynamic psychotherapy interventions, especially from object relations and self psychology, align with many of the principles of trauma-informed practice (e.g. establishing an atmosphere of safety and acceptance, relying upon relational collaboration). We begin by discussing trauma-informed practice and then discuss how the use of psychodynamic psychotherapy interventions (holding environment, containment, and selfobject transferences) can facilitate the application of trauma-informed principles. We conclude with a case illustration of how to incorporate psychodynamic interventions into trauma-informed practice.     

Creativity and the Self: A Self Psychological Approach to Art and Healing

This paper explores the contributions of Heinz Kohut and self psychology to the conceptualization of art and healing on an individual and cultural level. The roles of normative narcissistic development, selfobject experience, and empathy are emphasized in the formation and maintenance of creative expression. Crayton Rowe’s addition of the undifferentiated selfobject is also explored. The lives and work of legendary artists, as well as a case example from the ongoing clinical treatment of a creative professional, provide illustration.     

Perplexing or distressing episodes in supervision: How they can help in the teaching and learning of psychotherapy

Difficult times in the supervision of psychotherapists are shown to have the potential for making positive contributions to the teaching/learning process. The concept of parallel process is central to this paper, along with emphasis on the supervisor's self-awareness and use of her inner experience, positive and negative countertransference, and Kohut's concept of the selfobject transferences. A number of case examples illustrate these ideas.An earlier version of this paper, entitled Parallel Processes and the Impact of Supervision on Treatment, was delivered at the Psychotherapy Institute Symposium in Berkeley, California, on November 4, 1984.     

Integration and alternatives: Some current issues in psychoanalytic theory

The first great bridge between psychoanalysis and social work came with the concepts of ego psychology which provided a synthesis between the worlds of the social order and the psychological depths. Current psychoanalytic theorists now question whether any one psychological theory is sufficient to describe the complexity of human experience, and suggest that each theory has a piece of the truth because it states something that is correct about the patient at a particular time in the treatment. Adherence to multiple theories makes a complex problem for the clinical practitioner, who must decide from which perspective to respond to the clinical material of the moment. Psychoanalytic theorists are also questioning the degree to which it is actually the content of the therapist's interpretations which brings about change in the patient. This article suggests that these developments in psychoanalysis, with their emphasis on therapeutic flexibility and the importance of the relationship will renew and reinvigorate the bridge between psychoanalysis and clinical social work.An earlier version of this paper was presented at the First Clinical Conference of the National Federation of Societies for Clinical Social work.     

Extending Kohut’s Concept of Selfobject: The Undifferentiated Selfobject

This paper highlights and adds to the understanding of the undifferentiated selfobject, an extension of Kohut’s contributions of mirror, twinship and idealizing selfobjects. Introduced by Rowe in (2005), the undifferentiated selfobject follows Kohut’s teaching that there are still selfobjects that have not been discovered and which, therefore, have remained unanalyzed. This paper offers an understanding of the importance of the undifferentiated selfobject in the treatment of a depressed and potentially suicidal woman.     

Survival dilemmas: Case study of an adult child of a schizophrenic parent

This article describes aspects of the treatment of an adult child of a schizophrenic parent. Many theories on irrationality in the family setting illuminate the range of impingement on the child's reality when a parent is disturbed in this way. Current research has absorbed itself in interpretations of data on risk, vulnerability, disorder, and early trauma, which have implications for prevention as well as therapeutic treatment of the adult survivor. Profound effects on Ms. P's early development are elaborated in the therapy, in which the treatment stance is influenced by Kohut's theories of the self, particularly as applied to the establishment within the holding environment of specific transferences that facilitate reconstructive work.     

Supervision of trainees: Tending the professional self

This article seeks to demonstrage how self psychological concepts can be applied to the process of training psychotherapists in a variety of clinical and community settings. The author examines the role of clinical supervision in the development, consolidation, and maintenance of a cohesive professional self. The role of selfobject experience, needs, transference, and countertransference as manifested in the supervisory relationship is elaborated. Supervisor and supervisee form a self-selfobject unit, through which the trainee's anxieties and vulnerabilities can be managed. This selfobject matrix enables maintenance of self-esteem, expansion of cognitive understanding, and structure building in the arena of the professional self. To achieve these ends, the supervisor forms an empathic alliance with the internal, subjective experience of the therapist. The importance of focusing on the self experience and selfobject needs of the therapist in training via an empathic mode of observation is illustrated by several examples and vignettes. The application of theory to practice is emphasized, with examples chosen from a variety of clinical settings and modalities.     

God as Selfobject and the Therapeutic Potential of Divine Failure

Although early psychoanalytic theorists took a disapproving stance towards religious belief, later theorists recognized the critical support that a relationship with God provides the believer. This shift has allowed social workers to continue utilizing psychodynamic theory without taking a condescending attitude towards their clients’ religious beliefs. Kohut’s articulation of selfobject needs that persist throughout adulthood provided a prism through which to understand the support for the underlying structures of the self that a connection with the divine offers. However, Kohut’s identification of God as a selfobject limits itself to only its supportive element. This article explores the potential for psychological growth inherent in a relationship with God. The ability to acknowledge and mentally process divine failure—those moments where for the believer God does not offer sought after support—seem to be the primary catalyst for exercising this potential growth. Clinical examples are provided to demonstrate how a relationship with God can be addressed in a therapeutic context.     

Selfobject functions of the family: Implications for family therapy

The application of Self-Psychology theory to family functioning adds to our models of understanding and intervention in family therapy. This article develops a theory of the family as a supraordinate selfobject and explores diverse clinical applications of the theory. The family as a selfobject matrix enhances the self development of the child by the provision of continuity through the maintenance of proximity over time, and by an enhanced quality and quantity of selfobject responsiveness for the individual. This application of Self Psychology theory has wide implications for family therapy with children in foster care, family therapy with elderly couples coping with dementia in one spouse, and family therapy as a component of treatment with suicidal adolescents.     

“Supportive” psychotherapy: A contemporary view

In this paper, a brief review of social work literature regarding the technique of psychotherapy serves as a bridge to introduce the way in which self-psychology and the systematic use of empathy as a mode of listening and responding, had effected the conduct of psychoanalytic psychotherapy. A clinical sample, taken from the treatment of a patient who was diagnosed as having a Borderline Condition, is being used to demonstrate that feeling understood firms up the self in a way that enhances introspection and permits the use of interpretations as the therapist's primary mode of communication. The clinical example also demonstrates that when the therapist maintains an empathic position, the patient, even in once weekly therapy, is likely to develop one of the selfobject transferences. Further, that when empathic interpretations are used as the therapist's primary interventions, structural changes are likely to occur in such a way that treatment results in true healing rather than in the fostering of a life-long dependency on the therapist. Only a brief reference is made to the usefulness of self-psychology to the treatment of patients with higher level psychic organization and the important part that anger plays in the process of psychoanalytic psychotherapy.The Shirley Greenberg Memorial Lecture, Delivered at Simmons College, School of Social Work, Boston, Massachusetts on June 9, 1983.     

A self psychological approach to the treatment of gay men with AIDS

This paper applies the concepts and techniques of the self psychological approach to the treatment of gay men with AIDS. The psychosocial impact of AIDS on the maintenance of self and identity for gay men is explored with an emphasis on the implications for selfobject needs being met. The author illustrates through four case vignettes attempts at satisfying the mirroring, idealizing, and alterego selfobject needs of such clients. Individual, relational, and family-focused clinical concerns are addressed.     

Transference and countertransference reactions in the psychotherapy of pathological gamblers

Traditionally, in psychodynamic forms of treatment, the patient's relationship with the therapist is central to eliciting and exploring the patient's characteristic ways of thinking, feeling and behaving. Research has increasingly demonstrated the significance of the therapeutic relationship to the treatment outcome. Since little has been written about the therapist-patient relationship in the treatment of pathological gambling, we shall describe what we have found to be some of the common and problematic transference and countertransference reactions and interactions. Both positive and negative transferences and countertransferences will be discussed not only as obstacles to successful therapy, but as tools for understanding patients' conflicts, defenses and reasons for gambling.     

Chronic Fatigue Syndrome: A self psychological perspective

Chronic Fatigue Syndrome, an illness with debilitating effects on both the body and mind, has received increased attention in the last several years. Yet there has been hardly any documentation of the psychotherapy of afflicted individuals. The author suggests that self psychology is a useful approach in such cases, not only in addressing the effects of the illness, but in facilitating the patient's maintenance of much needed selfobject ties and the ability to follow the complex and difficult medical treatment program. A case illustration demonstrates these dynamics. Self experience of such individuals is then explored with specific reference to nuclear vs. peripheral selves. The author catalogues disruptions in selfobject ties as a result of the illness and offers treatment recommendations.I wish to thank Susan Sands, Ph.D., and Karen Rogers, MFCC, for their support and editorial contributions.     

Selfobject intervention in brief treatment with patients inappropriate for traditional brief psychotherapy models

This article discusses brief psychodynamic intervention with patients who are likely not to benefit from a primarily verbal, insight-oriented or explorational treatment. The major models of brief psychodynamic psychotherapy and their range of effective applicability are discussed. The function of selfobjects throughout the life-cycle are explored. Interventions designed around these selfobject functions are presented for patients unlikely to benefit from a more traditional approach. These interventions are developed through a thorough assessment of the patient's difficulties and include the setting of time limits for treatment (i.e. both within sessions and for the treatment as a whole). Interventions specifically directed toward reestablishing effective selfobject functioning in the mirroring, idealizing and twinship/alterego spheres are also presented. Vignettes are used to illustrate such interventions.     

A self psychological study of dehumanization in Eugene O'Neill'sThe Hairy Ape

Experiences of isolation, alienation, and self-fragmentation have been expressed by literary artists throughout this century. Many of the plays of Eugene O'Neill depict human suffering in these terms. Applying the constructs of self psychology, particularly those relating to selfobjects and the selfobject milieu, these experiences in O'Neill's plays can be described as shifts in self-cohesiveness. O'Neill'sThe Hairy Ape depicts a man with a fragile sense of self who suffers a disruption of the selfobject milieu which had sustained him. As a consequence of this change in his social embeddedness, the character Yank experiences a sense of fragmentation and ultimately feels that he does not belong to the human race. The play depicts in a powerful way the necessity of a selfobject milieu in sustaining one's sense of self.