How Does Analysis Cure?

Heinz Kohut, Arnold Goldberg

• Publisher: University of Chicago Press
• Year: 2009
• Print ISBN: 9780226006000, 9780226450346
• eBook ISBN: 9780226006147
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Austro-American psychoanalyst Heinz Kohut was one of the foremost leaders in his field and developed the school of self-psychology, which sets aside the Freudian explanations for behavior and looks instead at self/object relationships and empathy in order to shed light on human behavior. In How Does Analysis Cure? Kohut presents the theoretical framework for self-psychology, and carefully lays out how the self develops over the course of time. Kohut also specifically defines healthy and unhealthy cases of Oedipal complexes and narcissism, while investigating the nature of analysis itself as treatment for pathologies. This in-depth examination of "the talking cure" explores the lesser studied phenomena of psychoanalysis, including when it is beneficial for analyses to be left unfinished, and the changing definition of "normal."

An important work for working psychoanalysts, this book is important not only for psychologists, but also for anyone interested in the complex inner workings of the human psyche.

Part One

The Restoration of the Self: Responses and Afterthoughts

Not surprisingly, some of the ideas contained in my recent book The Restoration of the Self (1977) have evoked a variety of responses from colleagues. On many occasions, in consultative sessions, seminars, and correspondence, I have been asked to clarify certain thoughts that I had apparently not elaborated sufficiently in my book. In addition to this external stimulation from the side of colleagues and friends, I have continued to pursue certain lines of thought a bit further and have arrived at new insights that I would like to communicate. Although the various topics that I wish to take up in Part I are to a certain extent interconnected, they do not form a truly cohesive whole. They belong together mainly insofar as they are all responses and afterthoughts to The Restoration of the Self.

1

Analyzability in the Light of Self Psychology

Should Some Analyses of Severe Personality and Behavior Disorders Remain Incomplete?

Although the majority of comments elicited by The Restoration of the Self (1977) have been supportive of the psychoanalytic psychology of the self set forth in that work, one aspect of my presentation that seems to require further discussion has been constructively brought to my attention by a colleague. In a letter that was favorably disposed toward self psychology in general and warmly approving of The Restoration of the Self in particular, this colleague took exception to what he understood to be one implication of my recent work. Specifically, he believed I advocate “that one will have to break off treatment before the analysand gets into too disturbing material.” While conceding that “a regression can be in certain cases difficult to control,” he voiced the opinion, which he felt was in opposition to my view, that “slow and cautious work and especially the ability to verbalize the experiences” would counteract the danger sufficiently. These statements disturbed me. I had not realized that my views concerning this issue, particularly as they were presented in The Restoration of the Self, would be interpreted in the way in which my friendly colleague had. And there are undoubtedly other readers who similarly misunderstood my therapeutic attitude toward those conditions which the colleague in question characterized as “real deficiencies of the self.” In the following I will try to explain my actual position.

The essential therapeutic conclusion of all my contributions to the understanding of the self and its development can be formulated as follows: it is the defect in the self that brings about and maintains a patient’s selfobject (narcissistic) transference, and it is the working through of this transference which, via transmuting internalization, that is, via a wholesome psychic activity that has been thwarted in childhood, lays down the structures needed to fill the defect in the self. Indeed, I take the emergence of this process, and especially its persistent engagement, as evidence that the treatment situation has reactivated the developmental potential of the defective self. This central hypothesis, clearly set forth in The Analysis of the Self (1971) and many other publications, was not contradicted by my presentation in The Restoration of the Self.

The misunderstanding that I am advocating incomplete analyses for analyzable disorders of the self, that, in particular, I am advising that certain structural defects in the self should in such cases be allowed to remain unhealed, stems perhaps from the fact that I did not succeed in impressing upon some readers the significance of certain theoretical refinements concerning the development of the self in childhood and the significance of certain correlated shifts in the definition of psychological health and psychoanalytic cure that now supplement my earlier hypotheses.

But I must proceed slowly and present my views concerning early development, mental health, and cure not in isolation but within the fundamental context from which all explanations derive: the empathic observation of the experiences of my analysands in the analytic situation. I will start by affirming once more my central claim with regard to the cure of the self: in the analysis of narcissistic personality disturbances all existing defects in the self become spontaneously mobilized as selfobject (narcissistic) transferences. And I will only add, to prevent a possible misunderstanding, that when I speak of the spontaneous mobilization of the transference in this context, I am fully aware of the fact that transference resistances which oppose this development exist and must be recognized and then dealt with by interpretation (see Kohut 1978b, 2:547–61). But acknowledgment of the existence of forces that oppose the unfolding of these transferences does not contradict my central claim that, given the actuating matrix of the psychoanalytic situation, the defective self of the patient with a narcissistic personality disturbance will mobilize its striving to complete its development, that is, that it will try again to establish an uninterrupted tension arc from basic ambitions, via basic talents and skills, toward basic ideals. This tension arc is the dynamic essence of the complete, nondefective self; it is a conceptualization of the structure whose establishment makes possible a creative-productive, fulfilling life.

If a self has attained such nondefective structural completeness but is still unable to enact its intrinsic program because its energies are consumed by unresolved oedipal conflicts, then oedipal conflicts will be mobilized in the psychoanalytic situation, and an oedipal transference will offer itself to be worked through. The self psychological approach to those psychic disturbances that Freud called the “transference neuroses” is, prima facie, the same as that advocated by traditional analysis: the facilitation of the unfolding oedipal transference via systematic defense-analysis and the avoidance of premature transference interpretations (see Kohut 1971, p. 266) followed by a protracted phase of interpretation and working through. The differences between the traditional and the self psychologically informed therapeutic approaches to the classical transference neuroses relate to their different conceptions of the basic pathogenesis. The classical position maintains that we have arrived at the deepest level when we have reached the patient’s experience of his impulses, wishes, and drives, that is, when the patient has become aware of his archaic sexual lust and hostility. The self psychologically informed analyst, however, will be open to the fact that the pathogenic Oedipus complex is embedded in an oedipal self-selfobject disturbance, that beneath lust and hostility there is a layer of depression and of diffuse narcissistic rage. The analytic process will, therefore, not only deal with the oedipal conflicts per se but also, in a subsequent phase or, more frequently, more or less simultaneously (though even then with gradually increasing emphasis), focus on the underlying depression and the recognition of the failures of the child’s oedipal selfobjects. In view of the fact that the flawed selfobject matrix that is the breeding ground for the pathogenic Oedipus complex in childhood will be extensively discussed later in the present work, I will now leave the topic of the analysis of the oedipal neuroses and turn to the analyzable self disorders in the narrow sense of this term, that is, to the narcissistic personality and behavior disorders.

With regard to the analysis of narcissistic personality disturbances in the narrow sense, I want to emphasize the essential importance of such patients reexperiencing and working through the lethargies, depressions, and rages of early life via the reactivation and analysis of their archaic traumatic self-selfobject relationships in the transference. While, as I noted above, all properly conducted analyses of oedipal neuroses will eventually reveal a layer of depression and diffuse rage concerning the failures of the selfobjects of the oedipal period, with the narcissistic personality disorders the remobilization of the analogous experiences of early and earliest childhood must occupy the center of the analytic stage for prolonged periods. If, that is, the insufficiently coherent or enfeeblement-prone self of the analysand suffering from a severe narcissistic personality disorder requires the working through of the lethargies and rages of earliest infancy on the way toward its rehabilitation, then these archaic experiences will be mobilized in the psychoanalytic situation and worked through. I might add here that these primeval experiences usually manifest themselves in the transference via the “telescoping” of archaic needs and archaic responses to their frustration on the one hand (such as the need for a primitive merger and primitive forms of rage and lethargy), with analogous needs and frustration-responses of later developmental stages on the other (such as the wish for closeness via perfect empathy and the feeling of disappointment when the empathic response is imperfect).

Having now corrected with, I hope, unmistakable clarity the misunderstanding to which I initially referred—I do not, in other words, advocate “that one will have to break off treatment before the analysand gets into too disturbing material”—it behooves me also to clarify the point made in The Restoration of the Self that led my friendly critic astray. The crucial point that I stressed in that work but apparently did not succeed in illuminating sufficiently was this: If during its development in early childhood the self succeeds in disentangling itself from a seriously pathogenic selfobject and creates a new pattern for itself via a new developmental route, nearly reaches its goal in this second attempt at taking shape but ultimately fails again, though not by as wide a margin, then given the renewed chance for further self development in adult life made possible by psychoanalysis, the spontaneously unrolling sequence of transferences will ultimately come to rest at the point at which those needs begin to be remobilized that had not been responded to in the child’s second and more promising attempt to build up its self. It is in the analyses of these cases—and of these cases only, I will stress—that the transference, after briefly touching early depressions and rages, will spontaneously move on and settle at a different, later point in development. And it is in the analyses of these cases—and of these cases only, I reiterate (see in this connection my discussions of Mr. X. in Kohut [1977, pp. 199–219] and of Mr. Z. [1979])—that experience has taught me that it is an error to attempt to guide the patient to the analysis of archaic traumata. It is the pivotal point in later development when for the second time the self sought the cohesion-firming responses of a selfobject that is revived in the crucial transferences of such analyses. And the working-through processes that are then set in motion will ultimately bring about a true cure of the disease of such a self, that is, they will establish a structurally complete self. I will only add that when I speak of the “cure” of the self in this context, my statement is in harmony with my conviction that the psychological health of this core of the personality is always best defined in terms of structural completeness, that is, that we should speak of having achieved a cure when an energic continuum in the center of the personality has been established and the unfolding of a productive life has thus become a realizable possibility.

The healthy self that may ultimately establish itself may deviate from norms derived from the assumption that every analytic cure is defined either—according to the traditional Freudian outlook—by the engagement and ultimate resolution of oedipal conflicts or—according to the Kleinian view—by the reexperiencing and ultimate overcoming of the most archaic layers of depression, suspicion, and rage. However rough-hewn the definition of mental health on the basis of the structural and functional completeness of a sector of the self may be, I believe it is not only more meaningfully applicable to human life in general, but more specifically relevant to the psychic disturbances that are prevalent today than definitions which, following the traditional Freudian and Kleinian norms, equate mental health with the attainment of a specific psychological task of early development: the attainment of postoedipal genitality, of the capacity for post-paranoid-depressive object love, of object constancy, or of any other number of specific developmental successes that are deemed to be crucial. I am opposed to these definitions neither because of their perfectionism—all standards are ideals—nor because to a certain extent they set up self-fulfilling prophecies—all value judgments share this limitation—but because I believe they are in error. Although the attainment of genitality and the capacity for unambivalent object love have been features of many, perhaps most, satisfying and significant lives, there are many other good lives, including some of the greatest and most fulfilling lives recorded in history, that were not lived by individuals whose psychosexual organization was heterosexual-genital or whose major commitment was to unambivalent object love.¹

All in all, then, I am fighting two orthodoxies: one decrees that every cure rests on the analysis of the Oedipus complex, the other legislates that every cure rests on the analysis of the depressions and rages of earliest infancy. Furthermore, I must emphasize at this point that I am not fighting these orthodoxies on the basis of considerations that spurn idealistic perfectionism in therapy and advocate the need for compromise.

In fact, I am not disregarding the necessity for making compromises with regard to the goals of the psychoanalytic practitioner. I fully acknowledge that disorders that are in principle analyzable are encountered, though not as frequently as some believe; I tend to be on the side of courage here and find that, with caution and patience, it will be rewarded by success—in which analyst and analysand will rightly decide to let sleeping dogs lie—even though the decision means that the analysis remains incomplete, that areas will be avoided which would have to be activated and examined in order to heal the essential defect in the self. But these issues are irrelevant in the present context, and they were similarly irrelevant in the context in which I contemplated them in The Restoration of the Self (1977). The basis on which my therapeutic conclusions rest is not expediency, however laudable, in instances carefully selected by the seasoned clinician, but a new definition of the essence of the self and a new conceptualization of its structural development.

I will now, at the risk of appearing pedantic, present a schematic survey of the therapeutic possibilities vis-à-vis each of the three genetic-structurally defined classes of disorders—the psychoses, the narcissistic personality disturbances, the classical transference neuroses—in which the functional freedom of the self is impaired.

The Three Classes of Psychic Disorder and Their Analyzability

The Psychoses

In the psychoses, including those covertly psychotic personality organizations (central hollowness, but a well-developed peripheral layer of defensive structures) for which I reserve the term borderline states, a nuclear self has not been shaped in early development.² Although my analytic experience with such patients is very limited, I have reached the conclusion that in these cases the psychoanalytic situation does not bring about the long-term activation of the central chaos of the self within a workable transference that is a precondition for setting in motion the processes that would lead to the creation, de novo, of a nuclear self. In order to lead to a causal cure, the therapeutic process would have to penetrate beneath the organized layers—the defensive structures—of the patient’s self and permit the prolonged reexperience of oscillations between prepsychological chaos and the security provided by primitive merger with an archaic selfobject. It is certainly imaginable that, even in adult life, the repeated experience of optimal frustration in an archaic homeostatic selfobject environment brought about in the analytic situation would lead, as in earliest infancy, to the birth of a nuclear self. But I cannot imagine that an individual would submit himself to the dissolution of defensive structures that have protected him for a lifetime and voluntarily accept the unspeakable anxieties accompanying what must seem to him to be the task of facing a prepsychological state that had remained chaotic because the selfobject milieu in early life lacked the empathic responsiveness that would have organized the child’s world and maintained his innate self-confidence. I am aware of the fact that I may simply be describing my personal limits as a psychoanalyst and thus my acceptance of the existence of psychoses and borderline conditions. (I am a diagnostic relativist here: to my mind the terms “psychosis” and “borderline state” simply refer to the fact that we are dealing with states of prepsychological chaos which the empathic instrument of the observer is unable to comprehend.) Be that as it may, however, my clinical experience suggests that the analytic dissolution of defensive structures that have formed around a persisting hollowness in the center of the patient’s self cannot be achieved—even in cases where this central hollowness is experienced as painful by a would-be analysand. Perhaps the basis of my conviction, as I implied before, is the feeling that I would not be able to maintain a reliable empathic bond with the patient when, at the end of his journey toward the basic transference, he would have to tolerate the protracted experience of prepsychological chaos and, not just temporarily but for long periods, borrow the analyst’s personality organization in order to survive. Of course, the fact that a therapist cannot accompany his patient into the lands of prepsychological chaos does not mean that he cannot be of help to him. While a nuclear self cannot be created by the therapy, the patient can still use the therapist as a selfobject to build up new defensive structures and, especially, to firm already existing defensive structures. A selfobject transference establishes itself, in other words, in which the threatened defensive structures are offered to the selfobject therapist for his mirroring approval, or in which the selfobject therapist’s personality is used, via a twinship merger or goal-setting idealizations, to strengthen the patient’s defensive structures. As the result of straightforward educational activities from the side of the therapist, moreover, the patient can learn how to manage his defensive structures to his best advantage.

The Narcissistic Personality and Behavior Disturbances

In the narcissistic personality and behavior disturbances, in contradistinction to the psychoses and borderline states, the outlines of a specific nuclear self have been established in early development. The structuralization of the pattern of the self has remained incomplete, however, with the result that the self reacts to narcissistic injuries with temporary break-up, enfeeblement, or disharmony (see Kohut and Wolf 1978). In contrast to the psychoses, however, the psychoanalytic situation here does provide a matrix in which the defects in the structure of the self—even severe defects that lead to the temporary appearance of serious, quasi-psychotic symptoms—are filled in via reactivation of the needs for narcissistic sustenance (i.e., the need for mirroring and the need to merge with an ideal) that had not been provided in childhood.

The Structural-Conflict Neuroses

With regard to the psychoses and narcissistic personality disturbances, a definition of the essence of the disorder and of the correlated therapeutic approach could be stated unambiguously. With regard to the structural neuroses, however, we unfortunately cannot be equally positive at this time. If we had to formulate the traditional outlook on the structural neuroses in self psychological terms, we would simply say that in the structural neuroses a nuclear self has become more or less firmly established in early childhood but that the self is ultimately unable to realize its creative-productive potential (its nuclear program of action) because its ...

Table of contents

• Cover
• Copyright
• Title Page
• Dedication
• Contents
• Preface
• Introduction
• Part One. The Restoration of the Self—Responses and Afterthoughts
• Part Two. The Nature of the Psychoanalytic Cure
• Notes
• References
• Index