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Kohut's The Two Analyses of Mr. Z is
an extrordinary document, one that has not gotten the attention it deserves.
It is a scathing critique of classical id analysis, so cleverly couched
that it can hardly be rebutted. Kohut hit on the device of exposing the
way that classical id analysis is unempathic by showing how unempathic he
himself was when working from that model, following that by showing
how he corrected for this problem in a second analysis with the same patient,
Mr. Z.
Strozier,
in his biography of Kohut, says that although "there is no smoking gun,"
the case was an elaborate hoax—although
an inspired one. The first analysis of "Mr. Z." was based on Kohut's own
analysis with Ruth Eissler 20 years earlier, which Strozier describes as
"stupefying" (2001, p. 421n3). Strozier speculates that the second analysis
was entirely fictional (being an account of how Kohut thought he should
have been treated). No one has yet speculated further about Kohut's motive,
but Eissler's interpretations enraged him and he must have craved this final
refutation, especially as he now saw that her painfully unempathic interpretations
were entirely representative of classical psychoanalysis. This meant portraying
himself as the "stupefying" analyst, a fascinating move which put his reputation
at some risk, but allowed him to savage the classical model by using himself
as a human shield. To simplify the exposition I here play it straight.
The classical analyst almost literally
laid siege to patients, using the rule of frustration and abstinence to
starve them out—to intensify their repressed wishes (see A
Key to Where the Bodies are Buried). Kohut argued, in essence, that
this only threatened an already vulnerable ego, and that empathy was a necessary
condition for insight and change. His central point in The Two Analyses
is that the classical model makes the analyst unempathic. He or she
may be sympathetic and may want to be empathic (able to identify with, experience
being in the place of, the patient), but the id analytic model makes you
automatically unempathic.
The first analysis was five-times-a-week for four years. Then about five
and a half years later, Mr. Z returned for another four year five-times-weekly
analysis.
At the center of both analyses was Z's narcissism. He "became self-centered,
demanding, insisting on perfect empathy, and inclined to react with rage
at the slightest out-of-tuneness with his psychological states, with the
slightest misunderstanding of his communication." In the first analysis
Kohut says that he had "at first tolerated it [Z's narcisissm] as unavoidable
[but had] later increasingly taken a stand against it. " Which meant confronting
him with "interpretations concerning his narcissistic demands and his arrogant
feelings of 'entitlement'."
In this first analysis, Kohut's interpretation was that these reactions
came from an attachment to his mother that "he was unwilling to break."
Note "unwilling." He was "opposing maturation because he did not want to
relinquish childish gratifications." Note "did not want."
"The patient opposed these interpretations with intense resistances. He
blew up in rages against me, time after time." But Z eventually accepted
Kohut's views and the analysis came to a mutually agreed-upon, reasonably
successful termination.
This is the classical view of resistance: that it is a reluctance to give
up gratifications. An "unwillingness." This is why classical psychoanalysis
is identified as a drive psychology. This means that people act,
and do what they do, because they want to. So Mr. Z was seen as
narcissistically fixated on an "overgratifying" mother.
Kohut says that, in the first analysis, he thought of Mr. Z as responsible
for his reactions. "I had therefore expected that analytic insights would
enable him to see his path clearly, to relinquish his narcissistic demands
and
grow up." [emphasis added]
By the time of the second analysis, Kohut realized that Mr. Z was distressed
because he hated Kohut's interpretations, not because they were right and
not because he could not tolerate insight, but because it hurt his feelings
to be called immature—a momma's boy. Of course, Kohut was well aware of
that in the first analysis, but he just thought he was a momma's
boy.
By the time of the second analysis, Kohut knew that his interpretations
hurt because they were attacks on Mr. Z's self-esteem that were dictated
by the drive theory. His Self Psychology is intended to correct for the
drive fallacy.
What this actually meant was that the patient's behavior was not always
the expression of wishes. It was almost like a Papal dispensation. Patients
did not always have to be held responsible for their behavior.
Kohut's correction was to argue that what looks like drive-induced behavior
is often the expression of developmental arrests. What this means is that
Mr. Z couldn't help it.
Kohut's idea was that if you think of us as fundamentally driven by wishes,
then it is hard to avoid thinking that how we act betrays our real aims—and
it is hard to
avoid thinking of defenses as a
cover up, an evasion of responsibility for these aims. |
In the second analysis of Mr. Z Kohut took the position that the patient's
grandiose self was not a defense and, also, did not represent the gratification
of a wish or need. Rather, it represented a developmental arrest, at a
normal developmental phase—an arrest resulting from a maturational
failure, not from Z's unwillingness to take responsibility for his reactions.
This was vastly different from seeing Z's reactions as representing a fixation
caused by maternal overgratification.
Kohut now saw him as ungratified—and, listen to this—he now described
Z as "desperately—and often hopelessly—struggling to disentangle himself
from the noxious selfobject [his term for an internalized object—using
this term to make clearer how what we call the self is you as you experience
yourself reflected by an internal other], to delimit himself,
to grow,
to become independent." Kohut went from seeing Z as unwilling to give
up his dependency and to grow up—to struggling to be independent and to
grow!
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So this is a story about resistance, about how what Kohut had seen
as Z's resistance was his own resistance to Z's struggles,
a resistance created by the drive/defense theory, that is, the id
analytic model. In all the subsequent arguments about the Z case,
this key reversal is hardly mentioned. Kohut was actually working
through the concept of resistance itself. He came to see it, in our
terms as loss of voice , and in gaining his own, he helped Mr. Z gain
his. |
There were a lot of criticisms of the Two Analyses. He didn't quite
get away with blaming himself for the faults of classical analysis. Kohut
was faulted for simply doing a poor job of his first analysis of Z, for
being technically inadequate and also unempathic! He was accused of having
some personal difficulty coping with Z's narcissism. His critique of drive
theory was dismissed as his discomfort with the drives. Another criticism
accepted the idea that he was the one who was resisting, but in contrast
to his idea that the drive/defense model created his resistance to Z, the
criticism was that he was resistant to the "austere and demanding discipline
of psychoanalytic practice." Analysts have always distinguished themelves
by reaching for the ad hominem argument, the irony being that this only
makes Kohut's point for him; just as classical (id) analysts pathologize
patients' complaints, so they pathologize their critics.
More friendly analysts suggested that maybe Kohut made himself look bad
in the first analysis as a foil for presenting his new approach. They believe
that he could not have been as moralistic as he sounded.
To Kohut's credit, he answered all his critics, including me, in his second
and third books. When I was asked by Contemporary Psychology to
review Kohut's first book, I said I didn't think I could do an unbiased
review since I knew Kohut as one of the more rigid and orthodox classical
analystic thinkers. I was told to go ahead anyway, and so there I was with
an advance copy of The Analysis of the Self. I'd like to be able
to say that I predicted that it was the opening contribution to a whole
new approach to psychoanalysis, but far from it; I predicted the book would
be largely ignored, as too abstract and unreadable, as well as by the fact
that he overlooks crucial superego effects. What I had not anticipated
was how much Kohut's focus on empathy would appeal to the whole community
of therapists, whether or not they understood his message or even read
his book. Self Psychology has become the rubric under which a sizeable
number of therapists practice.
In answering his critics, he stayed on their level—sort of the "No, I didn't,"
"Yes, I did," kind of answers. In his rebuttals to criticisms of the Z
paper, he did not acknowledge that it launched the most thoroughgoing attack
on basic psychoanalytic assumptions that has ever been made by an experienced
and sophisticated analyst. (He only acknowledged this much later, in his
last writings. At the time he still preferred the veiled approach.) Some
analysts even insist that Kohut said nothing new, that analysts have always
known how to deal with narcissistic resistances and have always known of
the necessity to be empathic.
But what Kohut means by empathy is that the classical stance is adversarial.
To appreciate that you have to translate his theoretical revisions into
plain language. His most well-known revision is that narcissism has its
own separate line of development from object love. He was arguing against
Freud's idea that narcissism is a stage in the development of object love,
as I mentioned above. Kohut saw that according to Freud's conception, narcissism
is developmentally inferior to object love. Therefore analysts working
from Freud's conception are likely to feel all the more left out by a patient's
narcissism, seeing it as a defense against the therapeutic relationship
and as an obstacle to growth—a refusal to grow up, as Kohut had seen it.
Seeing it as a refusal makes it inevitable that the therapy relationship
will be adversarial, no matter how benign the therapist.
It is hard not to be adversarial in our instinctive ways of thinking
about patients. We feel responsible for everything. That's what AA is about
in requiring people to recognize that they are not responsible for their
problem. We have learned not to blame rape or abuse victims, but this is
recent. A common example nowadays is the kid who won't leave home after
high school or college and who is seen as "refusing to grow up." Even some
therapists will take that view. Like people really don't want to work;
they'd rather lie around and watch TV and play video games. It isn't just
Republicans who look at things that way.
So Kohut came to see the conception of narcissism as itself an obstacle
to therapeutic empathy. He proposed that narcissism has its own line of
development, separate from object love. So that even a mature adult
was entitled to it. That was a really clever move, so clever that the
point can be overlooked if you just take it as an abstract theoretical
innovation.
With this formulation, when you look at grandiose or self-absorbed patients,
you think they need to be this way. You don't think you're being
a bad or weak therapist if you let them get away with it. In a word, you
can be forgiving. But Kohut never actually said this. He just said that
narcissism has its own line of development. This automatically made
you forgiving, just as the old view automatically made you disapproving.
Kohut made being forgiving just seem like being objective.
What I'm saying is that Kohut couched his innovations in such abstract
language that he could almost get away with being "revisionistic" without
seeming to be (a goal of most major analytic theorists, cf. Greenberg and
Mitchell).
Another seemingly purely abstract idea of Kohut's was that drives are part
of the self rather than outside the self, that the self is superordinate
to drive. What this meant was that the drives, aggression and sex, are
normally
in the service of self-consolidation. He then went on to propose
that what we see as libidinal and aggressive drives, separate from and
in conflict with the self, are actually "the breakdown products of self-fragmentation."
In other words, he saw the drives as reinforcing an intact self, and as
ego-alien only to a disorganized self.
This is a remarkably sterile and opaque way to put a pretty simple idea
that would even be obvious to begin with if it had not been for Freud's
special take on it. Applying this idea to Mr. Z, it is only saying that
he has to defend against the analyst or to attack him, not because he needs
to compete with him or to humiliate him or to triumph over him, but because
he is vulnerable to feeling erased by him. (One patient who had come to
be more self-empathic about his narcissism, said, "It feels erasive around
here.")
So it was Kohut's genius to tinker with the classical model in such a way
as to make the analyst more empathic and less likely to see the therapy
as a power struggle—less liable to feel the need to be tough. To put it
another way, Kohut exposed, as no one else had, the way that the classical
model (and in many ways the standard dynamic model most therapists have
been taught, that derives from the analytic model) makes the therapist
prone to feel manipulated and tricked, with patients out to defeat the
therapist and sabotage the therapy. So what Kohut meant by empathy is not
necessarily perfect attunement, but just undoing the unempathic effect
of the classical model.
Kohut is saying that patients need to have their narcissistic states.
Like Z, they need to be "self-centered" and "demanding," to insist on "perfect
empathy," and to become enraged at slights, without having this interpreted
as resistance. When Kohut argues that their behavior is not the expression
of drives or defenses, what he actually means is that, despite how it might
seem, they are not being fundamentally competitive, depreciating, envious,
or hostile. You might say that they are just doing what they are supposed
to do—trying to put together ("consolidate") a self.
Kohut argues that much of the intensity of the narcissistic patient's rage
at slights is iatrogenic. It expresses the patient's frustration at the
therapist's resistance to being a selfobject. This is to say that patients
need the therapist to tolerate being shoved into the background and allowed
only limited participation, maybe having to simply be a yes-person.
Equipped with this new model in the second analysis of Z, Kohut was able
to experience Z's grandiosity, with none of his previous need to counter
it, to interpret it away, or to get Z to renounce it.
Instead of getting Z to give up his narcissism, Kohut says, "I relinquished
the health-and-maturity morality that had formerly motivated me." He says,
"I had acquired a more dispassionate attitude." And "I now focused on [Mr.
Z's grandiosity] with the analyst's respectful seriousness." (That memorable
sentence captures the spirit of Kohut's contribution. )
THE THIRD ANALYSIS: INTERSUBJECTIVITY
Now, I want to add a third and
a fourth analysis to the first two. The first is not of Mr. Z, although
it could be, since it takes a further step in the direction Kohut pointed.
The fourth is a hypothetical ego analytic version.
The third version is the intersubjective model, with its best known contributor
being Robert Stolorow, a Harvard PhD who was Contemporary Psychology's
choice to review Kohut's second book, The Restoration of the Self,
which he not only reviewed enthusiastically, but took as the inspiration
for his own work. His approach is also called "relational," or "perspectivist,"
and he sees himself as part of this self-conceived new wave of social constructivists.
What this all means is more modest than it sounds. It just means that when
the patient experiences a failure of empathy, it can really be a failure
of empathy on the therapist's part. It seems as if Kohut was saying the
same thing, but his stress was on how a therapist's theory predisposes
him or her to be unempathic. The intersubjectivists stress how the therapist's
personal vulnerabilities, as well as the classical model, make him or her
vulnerable to being unempathic or, in more usual language, defensive.
This is why it is called "intersubjective. " These writers make a point
of how therapy is a two-person situation, not one person and an infallible
therapist. What this all amounts to is hard to pin down without a case,
so here is one from the book The Intersubjective Perspective; Stolorow
in the senior author.
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This is
the case of Henry (pp. 128-130). This was from the fourth year of
therapy with Peter Thomson. "One morning, after a long silence, Henry
said: 'It is upsetting to have to say this. Rob died over the weekend'."
(Rob had leukemia.) The therapist responded: "You must have a lot
of feelings about that, and I guess it is difficult to talk about
them." The therapist then says to the reader,
I believed
myself to have been compassionate, but as this conversation transpired,
his view was vastly different. He remained silent for several days
[the frequency of sessions is not given, but this makes it sound like
three or four times-a-week], and all efforts to encourage him to speak
were of no avail [Thomson does not say what else he may have done,
or why he tried to encourage him to speak].
Finally,
four days [sessions?] after the aforementioned exchange, I said, "I think
you are angry with me." Henry responded, "Yes, I needed a more intuitive
response to my experience. My reaction has been to withdraw and to do things
on my own."
I noted myself feeling defensive and I wished to protest that I had done
my best to empathize with him. Henry went on: "You did not seem to understand
how upset I was. I felt you were very distant and harsh. You sounded technical,
not genuine or sympathetic. I would have appreciated a more simple and
personal comment." For some time he continued to chide me.
I had to work quite hard to decenter [this an intersubjective term
describing their key move] from my pressing need to believe that I had
only been kind. I then made a number of remarks that I considered to be
understanding of his feelings, but they were not accepted as such. For
example, I said: "I truly appreciate your feeling so mistrustful and that
you need the right kind of response." When Henry said that I was of no
use to him, I responded, "Perhaps you could help me to become more usable."
(Thomson says that he realizes that such remarks were generated by his
feeling of failure, and) ...a concretization of my sense of responsibility
for his disappointment in me. I was thereby prevented from pursuing a genuine
empathic inquiry into the source of his experience with me.
Henry's feeling that it was futile to talk to me, along with his anger
and negativism, continued for two or three more weeks. Henry said, "If
the quality, the tone and language, of your response isn't exactly right,
it leaves me enraged. My sense is that you are far away from what I am
experiencing. You suggested at one point that I fear to let you come closer
to me. That infuriates me, it is so far removed from where I am."
Gradually Henry's rage dissipated. My concretized sense of guilt and responsibility
failed to take into account of how Rob's death had triggered in Henry a
heightened sensitivity to a traumatic response.
Upon self-reflection, I recognized the influence of my classical training,
which induced in me a prereflective [another intersubjectivist's
term] need to regard Henry's silence as resistance. This aversive attitude
caused me at times to match his silence with my own, and at other times
to make excessive efforts to push Henry to speak.
My response to his news of Rob's death must be understood in the light
of my prereflective attitude. Although I thought I had been compassionate,
the intersubjective field had already been colored by my response to his
continued silence. (This is how the intersubjectivists' talk.]
Henry continued for another two or three weeks to feel that it was futile
to talk to me, that I was far away from his experience. Why did his rage
finally dissipate? I have no definitive answer, but I think as Henry sensed
I was more in touch with his experience, this began to change the intersubjective
"weather." I also have the strong impression that Henry's negative feelings
gave expression to healthy adversarial strivings. A little later on, he
commented on how he was pleased to, as he put it, have attained the freedom
to "rant and rave."
I believe that the material I described illustrates the complex mutual
regulation and dysregulation of intersubjective interplay to be an organizing
theme of analysis. |
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In my opinion, what Peter Thomson's case presentation shows is that intersubjectivity
theory does not adequately protect the therapist against the countertransference.
The case also shows how decentering doesn't work. It only resulted in the
therapists having symptoms, that is, expressing his defensiveness indirectly.
When Henry accused Thomson of being cold and unfeeling, Thomson had to
take too much responsibility for it, as he himself points out. Also, Henry's
silence clearly did worry and distress Thomson, as if the patient just
should be talking.
More to the point, you can see from Thomson's rather painful efforts to
get on Henry's side, that his framework gave him no way to accomplish this.
He can only do his best to convey solicitude, managing only, in each instance,
to dig himself in deeper, with Henry feeling all the more caught in the
clutches of Thomson's performance anxiety. The ego analytic framework is
all about how to get on Henry's side, and how to get him on his own side,
without having to role-play being empathic, and with the issue of the therapist's
fallibility being either irrelevant or taken for granted.
If Mr. Z had come in for a third analysis with an intersubjective analyst,
what happened would have been even more of a contrast from the first analysis.
Kohut did still feel that at some point he had to confront the patient's
narcissism. This is illustrated in his equal famous case of Miss F (which
see). Kohut never actually gave up
the drive theory, and he thought of narcissism as unneutralized narcissistic
libido. Eventually it had to be painfully confronted, Kohut thought, although
with her did this as gently and as gradually as he could.
There is no such idea in the intersubjective approach. No drive theory and
no idea that there is any necessity for painful confrontations. So Mr. Z
would have gotten even more of a break from a relational analyst than he
got from Kohut the second time around.
THE FOURTH ANALYSIS: EGO ANALYSIS
Which bring me to the fourth analysis
of Mr. Z. Both Kohut's work and Stolorow's revisions are thought of as
re-evaluations of the idea of resistance. But, more than that, they represent
a recognition that therapy can be damaging, not primarily because of
therapist's vulnerabilities, but because of how those vulnerabilities get
intensified by standard dynamic assumptions.
Evidence of this appears right away, in Peter Thomson's opening comment
to Henry: "I think you are angry with me." That's a good example of an
unempathic interpretation. It has a shaming effect, inevitably conveying
disapproval. A more empathic interpretation would have taken account of
what eventually gets recognized: Henry's inability to "rant and rave,"
that is, his silence. When he is angry he has to withdraw—the response
of the shamed.
"I think you are angry with me" is an example of a "naming" interpretation.
In Fred Pine's sense it is too "open ended." As Pine would put it, the
patient does not know what the interpretation means. Henry would
not know "what it means in terms of his own badness, dangerousness, babyishness;
what he is supposed to do with it, whether he should act on it or not,
and what attitude the therapist has toward it." To put it more simply,
it can sound like a reproach, maybe even is a reproach. It does not sound
encouraging. The patient is not going to think he is being encouraged to
be more at home with his anger. If it does not sound like a reproach, it
at least sounds regretful, even a bit mournful. "I'm sorry to see that
you are angry with me" can be even harder to hear than anything else.
More intact patients can take such interpretations with a grain of salt.
You can say practically anything to them and they will take it in the
way you want them to. But more vulnerable patients are not such good sports.
It seems to me that a more empathic interpretation would have been, not
"I think you are angry with me," but "I think you are struggling with
some angry feelings toward me." Or, "I think you are feeling angry at
me, but you are afraid that if you express it it will upset me, and only
get us into a wrangle, like I'll have to prove how empathic I really am."
(For another discussion of this kind of intervention, see The
Shame-Blame Reflex ).
Paradoxically, this new responsibility for the intersubjective field made
Thomson feel he just had to empathize with Henry, which made it hard to
let himself react to the ways Henry made him feel unempathic, and then
to use these as a clue to Henry's internal dialogue.
What both Kohut and the intersubjectivists are concerned about is therapist
vulnerability and defensiveness. Kohut's remedy is to recognize that the
patient is suffering and can't help acting provocative. Stolorow adds that
it is helpful to decenter and reflect. We add that these are only partial
solutions although they point the way. Our view is that both Kohut and
Stolorow are right, that therapist vulnerability and defensiveness have
more to do with what we have been trained to think than who we are. Our
theory
should protect us from who we are, rather than intensify our anxieties.
Therapists want to be empathic. It feels much better; it feels more
powerful. But the classical analyst is afraid to be; it can just mean being
weak. The relational analyst feels bad and incompetent about not being
able to be fully empathic. But what we think makes it possible to be
empathic is to recognize that you want to be and that something is stopping
you. In Henry's case what stops you is Henry.
Our way of putting it is to say that Henry can't "speak from his position."
He can't say. "I'm having trouble expressing myself, or knowing what to
say." Or,"I don't feel like talking." Or, "I feel like you want me to talk,
and that if I don't you'll feel like a failure." So you then need to help
him to be able to articulate his position in this way. The mark of success
is that once he is able to do that, you automatically feel empathic.
Back to Mr. Z
Kohut exposed the drive/defense fallacy, but risked committing what can
be called the "developmental fallacy." As we see it, the contemporary
scene is characterized by the overuse of developmental explanations in
reaction to the still prevalent overuse of drive/defense explanations.
As we also see it, what looks like drive-induced or developmental
phenomena are actually attempts to cope. There is always a hidden rationality
at work, and the therapeutic key is to show this to the patient.
Going back to Mr. Z, as we understand such patients, he would have no
confidence about being able to control the give and take in the relationship.
Once the therapist speaks, Z would feel the hour is lost to him, because
then the therapist's ego is on the line. So he would try to fill up the
time and to avoid giving the therapist an opportunity to speak, in order
to get his experience across. And that has to be done in considerable
detail because the therapist's attention is fickle, as he or she waits
for the next opportunity to take over.
Our finding is that if you really get into narcissistic patients' theory,
they see the therapist as narcissistic, as always trying to take
the stage, or having to suppress trying to take the stage. They are especially
sensitive to therapists' need to have their comments acknowledged and
accepted, to be appreciated, to feel competent and caring. It feels risky
to get the therapist's ego going. Narcissistic patients are not confident
of their ability to take care of the therapist's narcissism.
Now the big accomplishment, from this ego-analytic point of view, is for
therapist and patient to be able to talk on this level. Being able
to talk on this level means that the patient would get to the point of
being able to talk about worrying about the therapist's narcissism. Like
to say that "Once you begin talking, I feel like it isn't safe to ignore
you, like I have to show respect by following your lead. Also, I'm afraid
to say that because it might make you mad, or make you have to prove it
isn't so."
So that's the funny part—or let's call it the ego-analytic part—that the
accomplishment for the narcissistic patient is to be free to ignore you.
That's funny because it supposedly is the problem: that the narcissistic
patient tries to monopolize the hour—and even gets enraged if you try
to say something.
Kohut said that Mr. Z "blew up in rages against me, time after time."
This was in the first analysis, and Kohut later decided that this anger
was justified, that it expressed the patient's frustration at the therapist's
not being a selfobject. But that is not all it expressed. It also expressed
the patient's difficulty being able to articulate a complaint.
Apparently, in the second analysis, Mr. Z did not have these tantrums.
This had to be what conclusively convinced Kohut although, mysteriously,
he makes no mention of what must have been a dramatic contrast.
What I mean is that undoubtedly there were times in the second analysis
when Z felt slighted, even if in that analysis Kohut was able to respond
in such a way as to defuse rather than exacerbate this reaction. But it
clearly never became a goal for the patient to be able to say "I
feel slighted." Or to say that he felt ignored when Kohut talked. Maybe
to say that "It feels like when you talk, you're taking over, with your
own impressions of what I was saying, and that what you say is more about
you than about me." There is no suggestion that even in the second analysis
Z ever got to organize this complaint.
Our idea is that Z does not only need to have his narcissistic demands
and rage tolerated or accepted, he needs help to better express his position.
It's almost like saying he needs help to be better at being narcissistic.
So let's think for a minute about what it means to be narcissistic. And
let's take the simplest version, which Z represents. Kohut is famous for
his formulation that the narcissistic patient experiences the therapist
as if the two of them are "one body and mind," and then when the therapist
misses a cue, the patient can't stand the separation and goes into a rage.
For the classical analyst this was a defense against genuine closeness.
The idea was that the patient is afraid of closeness, and experiences
it as a loss of self. Modern analysts would agree with Kohut that Z's
rage was a reaction to suddenly feeling separate, or as it is now more
likely to be put, his feeling suddenly abandoned. But this does not go
deep enough—or is not superficial enough.
The key defiiciency that characterizes narcissism is the inability to
regulate give and take in a relationship. Once the therapist speaks, Z
could feel the hour is lost to him, bexause as I said earlier, such patients
see the therapist (and everyone else, I should add) as the narcissistic
one. So once the therapists speaks his ego is on the line. This
would infuriate Z in just the same way that his own behavior could infuriate
others. And narcissistic people tend to be among the most intolerant of
narcissism. Indeed, that is their problem.
When we get further into the heads of patients like Mr. Z, we find some
surprises. First, we are likely to find that Z is puritanically opposed
to narcissism. In other words, once we stop being opposed to it and holding
patients responsible for it, we find that they are opposed to it, and
even that that is their problem.
We find it common for the narcissistic patient to be an expert at picking
up other people's narcissism and feeling especially vulnerable to it,
as well as very disapproving of it. As I noted earlier, the therapist
is seen as always trying to take the stage, or having to suppress trying
to take the stage. So Z would try to fill up the time in order to get
himself heard. As I also noted earlier, that has to be done in considerable
detail because the therapist's attention is seen as fickle, waiting for
the next opportunity to grab the stage.
But since being so self-centered is, for these patients, the worst thing
to accuse anyone of and since everyone seems to be that way, they are
not likely to ever reveal this view on their own.
This makes it a big accomplishment for a narcissistic patient to say,
once the therapist has begun to speak, "Well, there goes my hour."
This is being free to be narcissistic. Maybe even to enjoy it.
That's what narcissistic gratification would really look like.
If the narcissistic patient has this kind of freedom, then narcissistic
rage at slights is much less likely.
This is what makes the CBT discoveries relevant. If we really take a close
look at what is going on in patients' minds, a lot of the guesses therapists
make about what patients are doing don't hold up. For example, the narcissistic
patient who is enraged and denounces the therapist can sound like a little
child. And that itself is important, because partly it is a repetition
of childhood tantrums (any adult who has tantrums will have had tantrums
as a child, or at least I have not found any exceptions to that rule).
But, as I put it earlier, there always is an ego and superego at work,
even though it can be hard to detect. Freud did not "discover" the superego
until he had been doing psychoanalysis for 25 years, and even thought
his life work was complete (see Analyzing,
Not Psychoanalyzing ).
So it is hard to see that when Z had his tantrums he was condemning himself
for it, and also feeling that he was making Kohut hate him. If you keep
the self-talk paradigm in mind then you do not need to "decenter," because
then you really don't see the patient as doing anything that unified.
Then you take the Kohut revolution one step further, seeing Z as highly
divided, and as likely to be more condemning of himself than Kohut. Or
seeing Henry as strugging with his anger at the therapist.
Remember how Henry's therapist reported Henry as saying that "he was pleased
to have attained the freedom to 'rant and rave'." "Ranting and raving"
is a self-mocking expression. It is not like having the fun of getting
to really put the therapist down, like for Henry to be able to stop being
polite and to say to Thomson: "Thomson, I'm sick and tired of you moaning
and groaning about how I'm making it so hard for you to be helpful."
Henry really did not feel he had much of a right to be angry. And for
the therapist to take Henry's silence as simply anger is really
leaping over the fact that Henry is sitting there, or lying there, immobilized.
The literal fact is that Henry can't be angry.
So the fourth analysis of Z would need to get into more of the details
of what was going on inside him. To use a contemporary analytic
buzz word, each of Z's analyses was getting more "experience near. " The
first analysis was the one most distant from his experience.
Now, what is all this saying about insight and about interpretations?
First, that we assume that interpretations really do promote insight.
But do they? Here is what Kohut finally came out and said in one of his
last papers (How Does Analysis Cure, p. 208):
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I believe that drive theory and
the theory of the movement from dependency to autonomy and from narcissism
to object love are, or have gradually become, a moral system in scientific
disguise; I therefore believe, verbal disclaimers to the contrary, that
the actual practice of analysis is burdened by hidden moral and educational
goals. |
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In other words, what we can call the standard dynamic model is prone to
be moralistic, which in simple terms means condemnatory—that interpretations
often are putdowns, sometimes subtle, sometimes not. So when we ask "Do
we have time for insight?" the answer is "No, not for a lot of what we
think of as insights." They often are hidden putdowns, as Kohut is saying
here.
Or, another lesson from all the analyses of Mr. Z, is that interpretations
are often not experience near. They often do not strike an immediate chord,
and often, as in Z's first analysis, they even violate a patient's experience.
It is hard to accept patients' experience enough to really help them have
it. Even Kohut never got that far. He could forgive Z for being touchy and
difficult, but he never went so far as to help him to be better at convincingly
expressing such feelings. Like for Miss F (see Ego
Analysis Vs. Self Psychology) to put the shrillness into words, as to
say:
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When you speak I just suddenly
get furious, and then you get careful with me and that makes me feel even
more furious. I feel like I'm really getting something across ("controlling
your mind") and then I suddenly find you're someplace else. |
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Maybe she would even get to the point of being able to enjoy complaining,
really making Kohut sit up and take notice.
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