Self-psychology is considered a descendent of Freudian psychoanalysis and was developed by, among others, Heinz Kohut. Richard Ulman and Doris Brothers (1988) present a treatment approach from the Kohutian self-psychology perspective. At the core of self-psychology is the notion that the structure of the self is created through relationships. Each of us possesses the psychic structure, the self-object, to refer to someone who is important in satisfying our basic, narcissistic-oriented needs. Self-objects are in the service of the self. The self is developed through the mirroring processes of the parents and primary caregivers. This sense of self develops and progresses from grandiosity and being the center of the world into a more healthy sense of self-esteem and ambition. Failures in mirroring result in an inadequate sense of self. In future relationships, the self-object is used to symbolize other people, and such people are expected to respond to you in a way that your self-object-mirroring experience has determined.
From the perspective of therapy, this self-object transference serves as a vehicle for working through the unconscious meanings of trauma. Similarly to Horowitz and other psychodynamic thinkers, trauma will inevitably activate unconscious material and will need to be differentiated from current issues in order to facilitate adjustment. Kohut is cited as viewing the self-object transference as the "primary therapeutic medium within which to restore and transform . . . archaic narcissistic fantasies" (Ulman & Brothers, 1988, p. 216). Therapy helps bring to consciousness the existence and action of "shattered and faultily restored archaic narcissistic fantasies" (Ulman & Brothers, 1988, p. 218), and eventually working through these helps further the patient's psychic growth. These shattered experiences must be transformed in order to restore a sense of safe centrality in the patient. Each patient will be reenacting and playing out the script of fantasies around which they have organized their psychological functioning. These may be grandiose fantasies, idealization, merger, or numerous others. The important thing to note here is that the therapist must be aware of the action of these within the context of the therapeutic relationship and interaction.
Ulman and Brothers (1988) organize treatment into three phases: initial, reconstructive, and working through. They provide a very good summary as follows:
The initial phase of treatments focuses on the vacillations between resistance to and establishment of self-object transference fantasies. . . . The reconstructive phase centers on the analysis of resistances to self-object transference fantasies as well as both traumatic and genetic reconstruction. Finally, the working through phase involves the consolidation and analysis of self-object transference fantasies. The therapeutic transformation of these fantasies as part of the resolution of a traumatic transference-neurosis leads to further psychic structuralization of the patient's subject world and to increased introspection or insight into the unconscious meanings of trauma. (p. 223)
Ulman and Brothers (1988) point out several important issues for the initial phase of treatment. They warn that it is important not to push too hard for the establishment of a self-object transference too soon as this may further fragment and disorganize the patient. Further, the clinician wants to be careful not to create a false transference based on a fantasy bond between patient and therapist. Resistance to the establishing of a transference fantasy of self in relation to a positive mirroring and idealizing object may occur as well. This resistance needs to be analyzed. Kohut cites two types of resistance that the therapist might encounter: nonspecific narcissistic resistance, in which the patient resists loss of independence and autonomy by the act of coming to someone else for help, and specific narcissistic resistance, which is related to the patient's disturbed self and unconscious fear of disintegration. A focus on symptoms and the more technical aspects of PTSD help focus the patient without too much stimulation. There may also be projections of inadequacy and incompetence upon the therapist.
The reconstruction phase involves reviving the self-object transference that imbues the current trauma with unconscious meaning. It is important to pay attention to the organizing fantasies of self at this stage, as they will shape the nature of patient defenses and the nature of the therapeutic interaction within the context of the relationship. Ulman and Brothers (1988) state, "the therapeutic objective of reconstruction is to arrive at valid empathic inferences about the unconscious meaning of trauma" (Ulman & Brothers, 1988, p. 225). In this phase of treatment, the therapist should monitor the patient's attempts to recapitulate the faulty fantasies. Nightmares are important symptoms of PTSD that play an important role in this form of treatment. Nightmares present an opportunity for interpretation of the patient's shattered narcissistic fantasies. As treatment progresses, nightmares that depict victimization might turn into dreams of triumph, signaling the transformation of the shattered fantasies to healthier organized fantasies. Also, narcissistic rage might emerge that can be directed at either the therapist or the patient him- or herself as the patient becomes more aware. This rage can be a reaction to the experience of the environment having failed to provide support, or it may be a reaction to a failure of the self to live up to grandiose expectations of "omnipotent control of basic mental and physical processes" (Ulman & Brothers, 1988, p. 222), or even a reaction to the self failing to, or not being able to, enlist environmental support.
The final phase, working through, is divided into three subphases: consolidating a selfobject transference fantasy in order to restore damaged archaic narcissistic fantasies, increasing insight into the unconscious meaning of psychic trauma as "encoded in PTSD symptoms," and analyzing the transference and advancing development toward a more mature sense of self.
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